LIVER TRAUMA. Jonathan R. Hiatt, MD
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1 Jonathan R. Hiatt, MD
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6 HISTORY MORTALITY OF LIVER INJURY MODERN CONCEPTS PACKS, RESECTION PRINGLE WW II 27% KOREA 14% VIETNAM 8.5% URBAN TRAUMA CTRS.
7 EPIDEMIOLOGY CLASSIFICATION THERAPEUTIC STRATEGY NONOPERATIVE OPERATIVE MULTIDISCIPLINARY PORTA HEPATIS INJURY
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9 INJURY PATTERNS COMMON BLUNT PENETRATING
10 PATIENTS BY MECHANISM HOSPITAL n STAB WD GSW BLUNT HOUSTON DETROIT NEW ORLEANS SAN FRANCISCO
11 MORTALITY BY MECHANISM HOSPITAL STAB WD GSW BLUNT HOUSTON DETROIT NEW ORLEANS SAN FRANCISCO SAN ANTONIO DENVER MOORE, CONTEMP SURG '79
12 INJURY PATTERNS ASSOCIATED INJURIES COMMON AFFECT MORTALITY
13 MALHOTRA, ANN SURG 2000 LIVER TRAUMA ASSOCIATED INJURIES (BLUNT)
14 MORTALITY BY NO. OF INJURIES NO. OF ASSOC. INJURIES n MORTALITY, % 0 (LIVER ONLY) or > 9 67 MIKESKY, SGO 1956
15 MORTALITY (n = 1842) TOTAL / LIVER RELATED RICHARDSON, ANN SURG 2000
16 MORTALITY: CAUSES TIME % < 48 HR. BLEEDING 8.2 > 48 HR. ORGAN FAILURE 2.3 FELICIANO, ANN SURG 1989
17 MORTALITY: RISK FACTORS 20-FOLD INCREASE WITH: BASE DEFICIT < - 6 OPERATIVE BLOOD LOSS > 5 l
18 CLASSIFICATION: AAST ORGAN INJURY SCALE Freq, % MOORE, J TRAUMA 1979 & '94
19 MORTALITY BY INJURY CLASS MORTALITY, % HEPATIC MORTALITY, % III IV V COGBILL, J TRAUMA 1988
20 OPERATIVE PRINCIPLES MOST NONBLEEDING GRADED APPROACH TAILORED TO INJURY MULTIPLE TECHNIQUES
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22 LIVER TRAUMA
23 NONOPERATION: CURRENT STATUS ATTEMPT IN > 80% SUCCEED IN > 70% (90% OF ATT.) FAILURES: HIGHER INJURY GRADE HEMOPERITONEUM OUTCOME IMPROVED LOS, INFECTION, TRANSFUSION
24 NONOPERATIVE MGMT. J TRAUMA 12
25 NONOPERATIVE MGMT. (Blunt injury) Level 1 1. Urgent laparotomy: Hemodynamically unstable Diffuse peritonitis J TRAUMA 12
26 NONOPERATIVE MGMT. (Blunt injury) Stable w/o peritonitis: 1. No routine laparotomy Level 2 2. Abdominal CT w/ IV contrast 3. Transient responder: Consider angio/embolization as adjunct to operation 4. Grade, hemoperitoneum, neuro status, age>55y, associated injuries are not absolute contraindications 5. Angio/embolization with active contrast blush on CT 6. Environment: Monitoring, serial exams, available OR J TRAUMA 12
27 NONOPERATIVE MGMT. (Blunt injury) Level 2 Stable w/o peritonitis: 1. No routine laparotomy 2. Abdominal CT w/ IV contrast Angiography/embolization: 3. Consider as adjunct to op. for transient responder 5. With active contrast blush on CT 4. Grade, hemoperitoneum, neuro status, age>55y, associated injuries are not absolute contraindications J TRAUMA Environment: Monitoring, serial exams, available OR
28 NONOPERATIVE MGMT. (Blunt injury) Level 3 1. Repeat CT: persistent SIR, pain, jaundice, Hgb drop 2. Interventional modalities incl.ercp, angio, laparoscopy, IR drainage for complications (bile leak, biloma, bile peritonitis, liver abscess, bilious ascites, hemobilia) 3. Pharmacologic VTE prophylaxis can be used w/o increasing failure rate, but timing of safe initiation not determined J TRAUMA 12
29 NONOPERATIVE MGMT. (Blunt injury) Cannot make recommendations 1. Frequency of Hgb measurements 2. Frequency of abdominal exams 3. Intensity and duration of monitoring 4. Time to resuming oral intake 5. Duration/intensity of activity restriction (hospital and DC) 6. Optimal length of ICU and hospital stay 7. Timing of initiation of DVT prophylaxis J TRAUMA 12
30 NONOPERATION: PRINCIPLES MECHANISM BLUNT Tangential penetrating STABLE, EVALUABLE MINIMAL TRANSFUSION ICU MONITORING RESPONSIBLE SURGEON
31 669 pts; nonop 65% BP < 90 10% 23 deaths (5%) LIVER TRAUMA Nonoperation: Morbidity Risk Factors 2 hepatic deaths (MSOF) 87 hepatic complics. in 61 pts. (13%) Kozar, Arch Surg 2006
32 Nonoperation: Morbidity Risk Factors Post-injury day Kozar, Arch Surg 2006
33 Nonoperation: Morbidity in Children 185 nonop; successful in 90% 10 died (5.4%): CNS 7, MOSF 3, hepatic 0 Complications 7(3.8%) Giss, J Trauma 2006
34 CLASSIFICATION: LIMITATIONS MORBIDITY / MORTALITY related to: PARENCHYMAL DAMAGE INITIAL INJURY OPERATIVE INTERVENTIONS HEPATIC VEINS
35 OPERATIVE APPROACH WIDE PREP LONG MIDLINE INCISION CONTROL HEMORRHAGE MOBILIZE LIVER DIVIDE HEPATIC LIGAMENTS FIXED RETRACTOR
36 INITIAL HEMORRHAGE CONTROL
37 SCORE, ACS Surg
38 PRINGLE OCCLUSION STOPS FORWARD FLOW HEPATIC ARTERIAL PORTAL VENOUS? EXCLUDES HEPATIC VENOUS BLEEDING? DURATION
39 Portal Occlusion - Elective (Portal triad clamping) (ischemic preconditioning) Richardson, HPB 2012
40 EXTENDED INCISION
41 OPERATIVE APPROACH WIDE PREP LONG MIDLINE INCISION CONTROL HEMORRHAGE MOBILIZE LIVER DIVIDE HEPATIC LIGAMENTS FIXED RETRACTOR
42 FALCIFORM LIGAMENT
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44 SIMPLE INJURIES (GRADES I-II, OIS) > 70% OF PATIENTS LACERATIONS, CAPSULAR TEARS TECHNIQUES ELECTROCAUTERY, ARGON BEAM HEMOSTATIC AGENTS + CLOSED SUCTION DRAINAGE
45 TOPICAL HEMOSTATIC AGENTS
46 COMPLEX INJURIES (GRADES III-VI, OIS) DIRECT APPROACH HEPATOTOMY / HEPATORRHAPHY RESECTIONAL DEBRIDEMENT RESECTION DAMAGE CONTROL TECHNIQUES
47 HEPATORRHAPHY
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49 RESECTIONAL DEBRIDEMENT Omental pedicle
50 PARENCHYMAL DIVISION EMERGENT ELECTIVE
51 SUBCAPSULAR HEMATOMA
52 SCORE, ACS Surg
53 STORM LONGMIRE CLAMP PARTIAL HEPATECTOMY
54 SELECTIVE HEPATIC ARTERY LIGATION
55 ABSORBABLE MESH HEPATORRHAPHY
56 HEPATIC VENOUS INJURIES HIGH MORTALITY INTRA- OR EXTRAHEPATIC THERAPEUTIC OPTIONS DIRECT REPAIR VASCULAR ISOLATION ATRIOCAVAL SHUNT DAMAGE CONTROL
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58 SCORE, ACS Surg
59 YELLIN, ARCH SURG 1971
60 SCORE, ACS Surg
61 RETROHEPATIC INFERIOR VENA CAVA
62 VENOUS INJURIES: MORTALITY (n = 1842) RICHARDSON, ANN SURG 2000
63 VENOUS INJURIES: THERAPY (n = 1842) RICHARDSON, ANN SURG 2000
64 DAMAGE CONTROL: RATIONALE MORTALITY RELATED TO: INTERVENTIONS TIME BLOOD LOSS (6u = failed intervention)
65 DAMAGE CONTROL: INDICATIONS Inability to achieve hemostasis (coagulopathy) Inaccessible major venous injury Time-consuming procedure in patient with suboptimal response to resuscitation Mgmt. of extra-abd. life-threatening injury Reassessment of intra-abdominal contents Inability to close fascia (visceral edema) SHAPIRO, J TRAUMA 2000
66 PERIHEPATIC PACKING DECIDE EARLY VICIOUS CYCLE HYPOTHERMIA ACIDOSIS COAGULOPATHY REOP: when cycle reversed RISK: INFECTION
67 LIVER PACKS
68 SCORE, ACS Surg
69 CT SCAN LIVER INJURY HEMOPERITONEUM OTHER ORGAN INJURIES GUIDES NONOP MGMT.
70 MULTIDISCIPLINARY TECHNIQUES INVASIVE RADIOLOGY ANGIOGRAPHY / EMBOLIZATION CT GUIDED DRAINAGE ERCP LAPAROSCOPY
71 MULTIDISCIPLINARY TECHNIQUES PRIMARY THERAPY ADJUNCTIVE TO OP / NONOP FOR COMPLICATIONS OF OP / NONOP
72 ABDOMINAL COMPLICATIONS VASCULAR BLEEDING INTRA-ABDOMINAL INTRAHEPATIC ANEURYSMS, FISTULAE BILIARY LEAKS, STRICTURES INFECTION / ABSCESS
73 ANGIOEMBOLIZATION INITIAL CT: CONTRAST BLUSH LATE BLEEDING / HEMOBILIA AFTER DAMAGE CONTROL
74 ANGIOEMBOLIZATION Pseudoaneurysm Post - occlusion
75 VENOUS STENTING Disruption of R hepatic vein at IVC Wallstent > DENTON, J TRAUMA 1997
76 HEMOBILIA TRIAD GI bleeding, RUQ pain, jaundice ETIOLOGY Liver injury (incl. iatrogenic) Abscess, aneurysm, tumor (rare) DX / RX: angiography / embolization
77 ERCP DIAGNOSIS OF HEMOBILIA
78 PORTAL TRIAD INJURIES n MORTALITY PORTAL VEIN 42 57% HEPATIC ARTERY 16 56% BILE DUCT 26 19% TOTAL 84 45% MULTIPLE 15 80% JURKOVICH, J TRAUMA 2003
79 PORTAL TRIAD INJURIES JURKOVICH, J TRAUMA 2003
80 EXTRAHEPATIC BILIARY TRACT
81 EXTRAHEPATIC BILE DUCT Carrel patch w/ cystic duct
82 VENOVENOUS BYPASS BIFFL, J TRAUMA 1998
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85 TRANSPLANTATION RINGE ESQUIVEL ANGSTADT n Veins injured Indic.: Bleeding Late necrosis Temporary PC shunt Retransplantation Survived BR J SURG 95 J TRAUMA 87 J TRAUMA 89
86 TRANSPLANTATION: CHALLENGES DECISION TIMING ORGAN AVAILABILITY ANHEPATIC MANAGEMENT ETHICAL ISSUES
87 ALGORITHM FOR BLEEDING MGMT. SCORE, ACS Surg
88 MAJOR ADVANCES TRAUMA CENTERS NONOPERATIVE MGMT. ADJUNCTIVE THERAPIES LIVER TRANSPLANTATION
89 SUMMARY COMMON INJURIES MOST MGMT. NOW NONOPERATIVE COMPLEX INJURIES: TECHNICAL CHALLENGES REMAIN FORMIDABLE MULTIDISCIPLINARY THERAPIES
90 Ali M. Cheaito, MD Bach. Sci., University of Michigan MD, Boston University General Surgery: Henry Ford Hospital Multiorgan Transplantation: UCLA Assistant Professor of Surgery, Division of General Surgery
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