Managing Liver Trauma

M. Rodiere1, F. Thony1, C. Letoublon2, P. Bouzat3 , C. Sengel1

1- Radiology Department2- Digestive Surgery Department

3- Anesthesia Department

University hospital of Grenoble

Mathieu Rodiere, M.D.

• No relevant financial relationship reported

Introduction

• Liver = largest intra-abdominal solid organ• Liver = Organ most frequently affected by trauma

• Prevalence = 1% to 8%• Mortality rate = 4.1% to 11.7%

• CT scan = reference technique for lesion diagnosisand aid in initial management

•

NOM

• NOM=Nonoperative management

• 86.3% of hepatic injuries are now managedwithout operative intervention

Tinkoff J Am Coll Surg. 2008

• Now the standard of care for hemodynamically stable patients with blunthepatic trauma

Guidelines

• Nonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline - J Trauma Acute Care Surg-2012

• Level 1– Patients who are hemodynamically unstable or who have diffuse

peritonitis after blunt abdominal trauma should be taken urgently for laparotomy

= Damage control surgeryLiver packingvascular exclusion

Guidelines

• Level 2– A routine laparotomy is not indicated in the

hemodynamically stable patient without peritonitis presenting with an isolated blunt hepatic injury.

– Angiography with embolization should be considered in a hemodynamically stable patient with evidence of active extravasation (a contrast blush) on abdominal CT scan.

Guidelines

• Level 3

– Interventional modalities including endoscopicretrograde cholangiopancreatography, angiography, laparoscopy, or percutaneousdrainage may be required to manage complications (bile leak, biloma, bile peritonitis, hepatic abscess, bilious ascites, and hemobilia) that arise as a result of nonoperative management of blunt hepatic injury

CT Scan

• A CT scan of the abdomen with intravenous contrastadministration is the optimal diagnostic modality for hemo- dynamically stable patients to aid in both the diagnosis and management of blunt hepatic trauma.

• Liver Lesions – Subcaps hematoma

– Intraparenchymal Hematoma

– Intraparenchymal laceration

– Active extravasation

– False aneurysm

Active extravasation

Intraparenchymal hematoma

Embolization principles

• Coeliac trunk must be analyse beforeembolization

• selective embolization = microcatheter

• Embolic material:

– Temporary or definitive

Results

• NOM– Success rates ranging from 82% to 100%. (US trauma centers) – Complications including bile leaks, hemobilia, bile peritonitis,

bilious ascites, hemoperitoneum, abdominal compartmentsyndrome, missed injuries, hepatic necrosis, hepatic abscess, and delayed hemorrhage.

– The complication rate increases with the grade of injury

• Embolization– success rate is 95% 1

– Hepatic necrosis is rare– First complication is gallbladder necrosis

1- Monnin- Place of arterial embolization in severe blunt hepatic trauma- 2008

For those patients who are hemodynamically unstable despite continuous re-suscitation, laparotomy followed by embolization if needed is likely a safer approach.

Take home message

• Nonoperative management = the gold standard

• CT Scan = Help NOM and embolization

• Liver Embolization

– Propose when active hemorrhage in CT scan

– Good success rate