ročník 12,2004 č.4
Trauma jater

Liver trauma - State of the art lecture

Jaeck D, Rosso, E.

Centre de Chirurgie Viscérale et de Transplantation
CHU Hautepierre, 67200 Strasbourg, France

Introduction

Abdominal blunt trauma represents the main cause of death in people of age less than 40 years (1). The liver is the most frequently injured intra-abdominal organ in this kind of event, with an incidence varying from 3 to 10 %. Isolated hepatic lesions are rare and in 77 to 90 % of cases, lesions of other organs and viscera are involved. Road traffic accident account for the majority of liver injuries. Liver injuries secondary to blunt trauma are typical in Europe (80 to 90 % of all liver injuries) (2, 3), while penetrating injuries account for 66 % of liver trauma in South Africa (4) and up to 88 % in North America (5, 6).

Mechanism, type and classification of liver injuries

Two main mechanisms of blunt trauma have been described: deceleration injuries and compression injuries. Violent deceleration as in road traffic accidents or fall from a height, produce laceration of liver parenchyma at the sites of attachment to the diaphragm, usually between the posterior and the anterior sector of the right lobe. On the other hand compression injuries, as direct blow to the abdomen, cause disruption of the hepatic parenchyma preserving the Glissonian capsula. The typical findings in these cases are subcapsular and intraparenchymal haematomas. Penetrating injuries are constantly associated to liver parenchyma damage. In 1987 the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma produced a Hepatic Injury Scale. It was revised in 1994 with the fundamental objective to provide a clear description of hepatic injuries in order to facilitate comparison between different treatments, rather than to assign prognostic value to each hepatic injury (7) (Table I). Virtually every major trauma center has routinely adopted its use for classification of liver trauma.

Grade Injury Description
Grade I Haematoma Subcapsular, < 10 % surface area
Laceration Capsular tear, < 1 cm parenchymal depth
Grade II Haematoma Subcapsular, 10 - 50 % surface area ;
intraparenchymal, < 10 cm in diameter
Laceration 1 - 3 cm parenchymal depth, < 10 cm in length
Grade III Haematoma Subcapsular, > 50 % surface area or expanding;
ruptured subcapsular or parenchymal haematoma.
Intraparencymal haematoma > 10 cm or expanding
Laceration >3 cm parenchymal depth
Grade IV Laceration Parenchymal disruption involving 25 - 75 % of hepatic lobe or 1 - 3 Couinaud's segments within a single lobe
Grade V Laceration Parenchymal disruption involving >75 % of hepatic lobe
or > 3 Couinaud's segments within a single lobe
Vascular Juxtahepatic venous injuries ; i.e.,
retrohepatic vena cava/central major hepatic veins
Grade VI Vascular Hepatic avulsion

Tab. 1 - Moore classification

Management of liver trauma

a) - Non-operative management
Initial diagnosis, assessment and management of the patient with severe liver trauma should proceed according to a standardized algorithm by a specialist team, which includes an experienced liver surgeon, an anesthetist, and an interventional radiologist. In haemodynamically stable patients with blunt liver trauma spontaneous hemostasis occurs in 50 to 80 %. Since the initial report on conservative management of blunt liver injuries in four pediatric patients in 1972 (8), various criteria have been used in selection of patients for conservative treatment, however haemodynamic stability and absence of peritonitis seem to be the most reliable criteria. In these cases abdominal CT - scan should be considered the gold standard as initial investigation. In fact, it can delineate the anatomic extent of the injury, it can quantitate the importance of blood in the peritoneal cavity and identify active bleeding, and finally it can reliably detect the presence of both intraperitoneal and retroperitoneal associated injuries. Nonoperative management consists in the admission of the patient in the Intensive Care Unit (ICU) for active observation and resuscitation, and in the selective use of angiography for embolization of bleeding vessels. In stable patients angiography should be attempted when CT - scan, after the administration of intravenous contrast, shows a blush or pooling of contrast material within the hepatic parenchyma or in patient in ICU with fall in hemoglobin and/or hematocrit while haemodynamically stable. The success rate for nonoperative management of liver trauma is high and is usually reported to exceed 80 % (9).
b) - Cause of failure of non operative management
Delayed abdominal explorations (3 to 15 %) (9, 10) for failed non-operative treatment frequently reveal bile leaks or bile collections, liver abscesses, missed enteric injuries, and only rarely late hemorrhage.
c) - Indication for urgent laparotomy
Patients haemodynamically unstable with clinical and ultrasound evidence of massive haemoperitoneum need an emergency laparotomy; most of these patients have severe liver injuries grade III - V. In such cases the principal aim of the laparotomy is hemorrhage control, avoiding the installation of the "mortal triad": hypothermia, coagulopathy, and acidosis. Initial control of bleeding can be achieved by bimanual compression, portal triad compression, perihepatic packing or manual compression of the abdominal aorta above the celiac axis. Further evaluation of the extent of liver injury should be delayed until an adequate intraoperative resuscitation is achieved. Several surgical strategies have been proposed to managed severe liver injuries: hepatorrhaphy, hepatotomy with direct suture ligation of bleeding vessels, resectional debridement, anatomical resection, selective hepatic artery ligation, mesh wrapping, omental packing, and perihepatic packing followed by angiography for embolization. However there is no evidence that one strategy is better than the others; indeed the hepatobiliary surgeon should be able to manage most of these techniques and to choose the most appropriate one in each patient.
d) - Damage control and wall closure in severe liver trauma
In some cases the surgeon is faced to a catastrophic haemorrhage, in such a situation only damage control laparotomy (laparotomy, packing, temporary abdominal closure) should be performed. As general principle the abdomen should be left open to avoid the abdominal compartment syndrome and damage to the fascia. Several techniques have been suggested to provide intestinal protection and temporary abdominal closure including running suture of the skin, Bogota bag, prosthetic mesh, and finally the Vacuum - Assisted Fascial Closure (VACF). Recently Miller et al has reported a prospective study using VACF for treatment of open abdomen (11). According to the author this techniques allows high fascial closure rates obviating the need for subsequent ventral hernia repair.
e) - Penetrating liver injuries
The majority of penetrating civilian injuries to the liver result in a lesser degree of parenchymal damage than do those injuries incurred by blunt trauma. The current standard of care for penetrating injuries still remains operative interventions, however several authors claim for non-operative management in selected cases. Once again patients presenting haemodynamic instability or abdominal tenderness require immediate operative intervention without further diagnostic tests. However, CT - scan, diagnostic peritoneal lavage and diagnostic laparoscopy have a fundamental role in evaluating stable patients with minimal physical finding. Among this group of patients some cases can be selected for non-operative management.
f) - Associated injuries
Complications following liver trauma have been reported in up to 64 % of the patients. Severity of the liver trauma and associated injuries seem to be most significant factors associated to postoperative problems. Among the associated injuries diaphragmatic rupture remains a diagnostic challenge for both radiologists and surgeons. In most cases, the diagnosis may be obvious at the chest radiography and CT scan. However, some specific signs require MRI or operative intervention by laparoscopy / thoracoscopy or laparotomy. Surgical management of diaphragmatic rupture depends on clinical presentation, and the time of diagnosis (early or late). However, all injuries of the diaphragm should be repaired.
g) - Mortality and specific morbidity of liver trauma.
Patients sustaining liver trauma and surviving the first 24 hours are exposed to severe complications. Most of these complications are liver - related including delayed haemorrhage, haemobilia, biliary fistula, arterial - portal venous fistula, but some others are general complication such as prolonged hyperthermia, sepsis, and intra - abdominal abscesses. The mortality of hepatic trauma is directly related to either early exsanguination or late postoperative sepsis. The reported mortality (10 to 15 % ) for hepatic injuries remains unchanged over the past decade. The main explanation for the constancy of the mortality rate is that even if the mortality for minor grade (I-II) hepatic trauma is low the number of major liver trauma arriving alive to the hospital is increasing.

Our experience

Between 1992 and 2002, 42 patients with isolated abdominal blunt injury were referred to our department and were retrospectively reviewed. The initial treatment was decided according to four criteria: blood pressure (< 95 mm Hg), haemodynamic stability after fluid administration, hemoglobin level (< 8 g/l), and acidosis after initial resuscitation (pH < 7.35). According to these criteria, 33 patients required an immediate operation while the other 9 were initially managed non - operatively. Among these 9 patients, 4 (44.4 %) required a laparotomy because of non - operative treatment failure. Mortality and morbidity were 13.5 % and 51.3 % respectively after immediate operation and 6 patients required 8 relaparotomies. Some representative and complex clinical cases are presented, during the lecture.

Conclusion

According to most recent reports and to our experience we suggest that any blunt hepatic injury, regardless of its magnitude, should be managed without operation if the patient is haemodynamically stable and in absence of peritoneal signs. Non - operative management constitutes the gold standard of liver trauma treatment. However, associated extrahepatic injuries should not be overlooked. The perihepatic packing is still an effective and easy way to control catastrophic hemorrhage. Optimal surgical results are obtained by experienced specialist team including a liver surgeon.

References

  1. Romano L, Giovine S, Guidi G, Tortora G, Cinque T, Romano S. Hepatic trauma: CT findings and considerations based on our experience in emergency diagnostic imaging. Eur J Radiol 2004, 50: 59 - 66
  2. Parks RW, Chrysos E, Diamond T. Management of liver trauma. Br J Surg 1999, 86: 1121 - 1135
  3. Schweizer W, Tanner S, Baer HU, Lerut J, Huber A, Gertsch P, Blumgart LH. Management of traumatic liver injuries. Br J Surg 1993, 80 : 86 - 88
  4. Krige JE, Bornman PC, Terblanche J. Liver trauma in 446 patients. S Afr J Surg 1997, 35: 10 - 15
  5. Cogbill TH, Moore EE, Jurkovich GJ, Feliciano DV, Morris JA, Mucha P. Severe hepatic trauma: a multi-center experience with 1,335 liver injuries. J Trauma 1988, 28: 1433 - 1438
  6. Wilson RH, Moorehead RJ. Hepatic trauma and its management. Injury 1991, 22: 439 - 445
  7. Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J Trauma 1995, 38: 323 - 324
  8. Richie JP, Fonkalsrud EW. Subcapsular hematoma of the liver. Nonoperative management. Arch Surg 1972, 104: 781 - 784
  9. Velmahos GC, Toutouzas K, Radin R, Chan L, Rhee P, Tillou A, Demetriades D. High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ. Arch Surg 2003, 138: 475 - 480; discussion 480 - 481
  10. Goldman R, Zilkoski M, Mullins R, Mayberry J, Deveney C, Trunkey D. Delayed celiotomy for the treatment of bile leak, compartment syndrome, and other hazards of nonoperative management of blunt liver injury. Am J Surg 2003, 185: 492 - 497
  11. Miller PR, Meredith JW, Johnson JC, Chang MC. Prospective evaluation of vacuum-assisted fascial closure after open abdomen: planned ventral hernia rate is substantially reduced. Ann Surg 2004, 239: 608 - 614, discussion 614 - 616.

Address for correspondence:

Daniel Jaeck MD, PhD, FRCS
Professor of surgery
Centre de Chirurgie Viscérale et de Transplantation
CHU Hautepierre
67200 Strasbourg
France