Damage Control in Penetrating Liver Trauma: Fear of the Unknown
The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.
- Penetrating Hemodynamically Unstable Liver Trauma.
- blood loss Surgical
- hospital emergency service
- abdominal injuries
Zago TM, Pereira BM, Nascimento B, Alves MSC, Calderan TRA, Fraga GP. Trauma hepático: Uma experiência de 21 anos. Rev Col Bras Cir 2013;40:318-22. https://doi.org/10.1590/S0100-69912013000400011.
Petrowsky H, Raeder S, Zuercher L, Platz A, Simmen HP, Puhan MA, et al. A quarter century experience in liver trauma: A plea for early computed tomography and conservative management for all hemodynamically stable patients. World J Surg 2012;36:247-54. https://doi.org/10.1007/s00268-011-1384-0.
MacGoey P, Navarro A, Beckingham IJ, Cameron IC, Brooks AJ. Selective non-operative management of penetrating liver injuries at a UK tertiary referral centre. Ann R Coll Surg Engl 2014;96:423-6. https://doi.org/10.1308/003588414X13946184901524.
Asensio JA, Roldín G, Petrone P, Rojo E, Tillou A, Kuncir E, et al. Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: Trauma surgeons still need to operate, but angioembolization helps. J Trauma 2003;54:647-54. https://doi.org/10.1097/01.TA.0000054647.59217.BB.
Doklestić K, Djukić V, Ivančević N, Gregorić P, Lončar Z, Stefanović B, et al. Severe blunt hepatic trauma in polytrauma patien - Management and outcome. Srp Arh Celok Lek 2015;143:416-22. https://doi.org/10.2298/SARH1508416D.
Kalil M, Amaral IMA. Avaliação epidemiológica de vítimas de trauma hepático submetidas a tratamento cirúrgico. Rev Col Bras Cir 2016;43:22-7. https://doi.org/10.1590/0100-69912016001006.
Prichayudh S, Sirinawin C, Sriussadaporn S, Pak-Art R, Kritayakirana K, Samorn P, et al. Management of liver injuries: Predictors for the need of operation and damage control surgery. Injury 2014;45:1373-7. https://doi.org/10.1016/j.injury.2014.02.013.
Chien LC, Lo SS, Yeh SY. Incidence of liver trauma and relative risk factors for mortality: Apopulation-based study. J Chinese Med Assoc 2013;76:576-82. https://doi.org/10.1016/j.jcma.2013.06.004.
Ordoñez CA, Parra MW, Salamea JC, Puyana JC, Millán M, Badiel M, et al. A Comprehensive Five-Step Surgical Management Approach to Penetrating Liver Injuries That Require Complex Repair. J Trauma Acute Care Surg 2013;72:207-11. https://doi.org/10.1097/TA.0b013e31829de5d1
Kozar RA, Crandall M, Shanmuganathan K, Zarzaur BL, Coburn M, Cribari C, et al. Organ injury scaling 2018 update: Spleen, liver, and kidney. J Trauma Acute Care Surg 2018;85:1119-22. https://doi.org/10.1097/TA.0000000000002058
Chen RJ, Fang JF, Lin BC, Hsu YP, Kao JL, Chen MF. Factors determining operative mortality of grade V blunt hepatic trauma. J Trauma - Inj Infect Crit Care 2000;49:886-91. https://doi.org/10.1097/00005373-200011000-00016
Kaptanoglu L, Kurt N, Sikar HE. Current approach to liver traumas. Int J Surg 2017;39:255-9. https://doi.org/10.1016/j.ijsu.2017.02.015.
Ditzel RM, Anderson JL, Eisenhart WJ, Rankin CJ, DeFeo DR, Oak S, et al. A review of transfusion- And trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg 2020;88:434-9. https://doi.org/10.1097/TA.0000000000002570
Biffl WL, Moore EE. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-17. https://doi.org/10.1097/MCC.0b013e32833f52d2.
Di Saverio S, Sibilio A, Coniglio C, Bianchi T, Biscardi A, Villani S, et al. A proposed algorithm for multimodal liver trauma management from a surgical trauma audit in a western European trauma center. Minerva Anestesiol 2014;80:1205-16.
Lin BC, Fang JF, Chen RJ, Wong YC, Hsu YP. Surgical management and outcome of blunt major liver injuries: Experience of damage control laparotomy with perihepatic packing in one trauma centre. Injury 2014;45:122-7. https://doi.org/10.1016/j.injury.2013.08.022.
Lamb CM, Garner JP. Selective non-operative management of civilian gunshot wounds to the abdomen: A systematic review of the evidence. Injury 2014;45:659-66. https://doi.org/10.1016/j.injury.2013.07.008.
Yu WY, Li QJ, Gong JP. Treatment strategy for hepatic trauma. Chinese J Traumatol - English Ed 2016;19:168-71. https://doi.org/10.1016/j.cjtee.2015.09.011.
Kobayashi LM, Costantini TW, Hamel MG, Dierksheide JE, Coimbra R. Abdominal vascular trauma. Trauma Surg Acute Care Open 2016;1. https://doi.org/10.1136/tsaco-2016-000015.
Di Saverio S, Catena F, Filicori F, Ansaloni L, Coccolini F, Keutgen XM, et al. Predictive factors of morbidity and mortality in grade IV and v liver trauma undergoing perihepatic packing: Single institution 14 years experience at European trauma centre. Injury 2012;43:1347-54. https://doi.org/10.1016/j.injury.2012.01.003.
Beitner MM, Suh N, Dowling R, Miller JA. Penetrating liver injury managed with a combination of balloon tamponade and venous stenting. A case report and literature review. Injury 2012;43:119-22. https://doi.org/10.1016/j.injury.2011.08.028.
Ordoñez C, Pino L, Badiel M, Sanchez A, Loaiza J, Ramirez O, et al. The 1-2-3 approach to abdominal packing. World J Surg 2012;36:2761-6. https://doi.org/10.1007/s00268-012-1745-3.
Misselbeck TS, Teicher EJ, Cipolle MD, Pasquale MD, Shah KT, Dangleben DA, et al. Hepatic angioembolization in trauma patients: Indications and complications. J Trauma - Inj Infect Crit Care 2009;67:769-73. https://doi.org/10.1097/TA.0b013e3181b5ce7f.
Manzano-Nunez R, Herrera-Escobar JP, DuBose J, Hörer T, Galvagno S, Orlas CP, et al. Could resuscitative endovascular balloon occlusion of the aorta improve survival among severely injured patients with post-intubation hypotension? Eur J Trauma Emerg Surg 2018;44:527-33. https://doi.org/10.1007/s00068-018-0947-2.
Ordoñez CA, Herrera-Escobar JP, Parra MW, Rodriguez-Ossa PA, Puyana JC, Brenner M. A severe traumatic juxtahepatic blunt venous injury. J Trauma Acute Care Surg 2016;80:674-6. https://doi.org/10.1097/TA.0000000000000979.
Rezende-Neto JB, Al-Kefeiri G, Strickland M, Prabhudesai V, Rizoli SB, Rotstein O. Three Sequential Balloon Catheters for Vascular Exclusion of the Liver and Aortic Control (one REBOA and two REBOVCs): A Hemorrhage Control Strategy in Suprahepatic Vena Cava Injuries. Panam J Trauma, Crit Care Emerg Surg 2018;7:114-22. https://doi.org/10.5005/jp-journals-10030-1214.
Coccolini F, Coimbra R, Ordonez C, Kluger Y, Vega F, Moore EE, et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020;15. https://doi.org/10.1186/s13017-020-00302-7.
Ordoñez CA, Khan M, Cotton B, Perreira B, Brenner M, Ferrada P, et al. The Colombian Experience in Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): The Progression from a Large Caliber to a Low-Profile Device at a Level I Trauma Center. Shock 2020. https://doi.org/10.1097/SHK.0000000000001515.
Ordoñez CA, Parra MW, Manzano-Nunez R, Herrera-Escobar JP, Serna JJ, Rodriguez Ossa P, et al. Intraoperative combination of resuscitative endovascular balloon occlusion of the aorta and a median sternotomy in hemodynamically unstable patients with penetrating chest trauma: Is this feasible? J Trauma Acute Care Surg 2018;84:752-7. https://doi.org/10.1097/TA.0000000000001807.
Ordonez CA, Nunez RM, Parra MW, Herrera Escobar JP, Rodriguez F, Vidal M, et al. Common Complications after the Use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). J Am Coll Surg 2017;225:S52-3. https://doi.org/10.1016/j.jamcollsurg.2017.07.102.
Ordoñez CA, Rodríguez F, Parra M, Herrera JP, Guzmán-Rodríguez M, Orlas C, et al. Resuscitative Endovascular Balloon of the Aorta is feasible in penetrating chest trauma with major hemorrhage: Proposal of a new institutional deployment algorithm. J Trauma Acute Care Surg 2020;Publish Ah. https://doi.org/10.1097/TA.0000000000002773
Copyright (c) 2020 Universidad del Valle
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
The copy rights of the articles published in Colombia Médica belong to the Universidad del Valle. The contents of the articles that appear in the Journal are exclusively the responsibility of the authors and do not necessarily reflect the opinions of the Editorial Committee of the Journal. It is allowed to reproduce the material published in Colombia Médica without prior authorization for non-commercial use