Successful management of hepatic vein injury from blunt trauma in children

In children, the majority of deaths from blunt trauma to the liver are caused by large stellate fractures of the posterolateral aspect of the right lobe of the liver with extension into the hepatic veins. Four children with such injuries were successfully treated. Hypotension and abdominal tenderness are not early manifestations of this highly lethal injury in children. When an appropriate mechanism for liver injury exists, paracentesis or peritoneal lavage, followed by prompt laparotomy for hemoperitoneum, gives the best chance for early and successful treatment. Large cannulas in arm veins and cross matching for twice the patient's blood volume are used when there is a possibility of a liver injury.The important aspects of operative management are identification of the injury when the abdomen is first opened and prompt control of bleeding. The possibility of hepatic vein injury exists if the surgeon finds the coronary ligament disrupted by a large liver laceration on the posterolateral liver surface. Compressing the liver against the diaphragm will usually control the bleeding while blood replacement is accomplished. The hepatic vein entrance into the inferior vena cava is then exposed using a median sternotomy, if necessary. Partial occlusion of the inferior vena cava can usually be safely done with this direct approach if the blood volume has been restored. Frequently, valuable time and blood are lost if attempts are made to insert internal shunts.     

Management of blunt hepatic trauma

Management of blunt liver trauma has progressed over the last 20 years with the adoption of conservative non-operative management (CM) as the gold standard in 80-90% of patients. Clinical and hemodynamic changes, and CT imaging guide the conservative attitude or pose an indication for urgent surgical intervention in unstable patients. The adoption of CM for blunt liver trauma has resulted in an increased incidence of late complications. These consist principally of persistent hemorrhage, fistulas and bile leaks, the abdominal compartment syndrome, and hepatic necrosis or abscess. These late complications can be managed secondarily by planned interventions via laparotomy or laparoscopy, interventional radiology and/or endoscopic techniques in a non-emergency setting as indicated by circumstances and with the benefit of multidisciplinary consultation. These secondary interventions should not be considered a failure of conservative treatment, but rather as an anticipated eventuality in the management of these patients.     

Primary hepatic artery embolization in pediatric blunt hepatic trauma

Non-operative management of isolated blunt hepatic trauma is recommended except when hemodynamic instability requires immediate laparotomy. Hepatic artery angioembolization is increasingly used for hepatic injuries with ongoing bleeding as demonstrated by contrast extravasation on the CT scan. It is used primarily or after laparotomy to control ongoing hemorrhage. Hepatic angioembolization as part of multimodality management of hepatic trauma is reported mainly in adults, with few pediatric case reports. We describe our institution experience with primary pediatric hepatic angioembolization and review the literature with regard to indications and complications. Two cases (3 and 8 years old), with high-grade blunt hepatic injuries with contrast extravasation on the CT scan were successfully managed by emergency primary hepatic angioembolization with minimal morbidity and avoided laparotomy. To date, the only reports of pediatric hepatic angioembolization for trauma are 5 cases for acute bleeding and 15 delayed cases for pseudoaneurysm. The role of hepatic angioembolization in the presence of an arterial blush on CT in adults is accepted, but contested in a pediatric series, despite higher transfusion rate and mortality rate. We propose that hepatic angioembolization should be considered adjunct treatment, in lieu of, or in addition to emergency laparotomy for hemostasis in pediatric blunt hepatic injury.     

Nonoperative management of blunt hepatic trauma

Over the past 15 years, there have been dramatic changes in the management of blunt hepatic trauma, specifically in the imaging techniques, and in the non-operative management. Actually, in more than 80% of blunt hepatic trauma, non operative management is used. In the last 20% the surgical option has to be taken without delay, sometimes in extreme emergency, using the adapted surgical techniques. In this article the author describes the nonoperative management of blunt hepatic trauma: classification, presentation, initial decision, treatment, possible complications and results.     

选择性肝动脉栓塞治疗在闭合性肝损伤中的临床研究

目的:探讨选择性肝动脉栓塞治疗创伤性闭合性肝脏破裂出血的临床价值.方法:回顾性分析2009年8月-2012年2月收治的61例闭合性肝脏破裂出血患者的临床资料,其中单纯的药物治疗30例(药物组),药物加介入栓塞治疗31例(介入组),比较两组中转手术率、人均输红细胞量、平均住院时间、并发症发生率.结果:入院时,两组患者性别、年龄及肝脏损伤程度差异无统计学意义(均P＞0.05).与药物组比较,介入组中转手术率(12.9％ vs.30％),人均输红细胞量[(4.2±0.88) U vs.(6.6±1.47)U],平均住院时间[(7.2±5.2)d vs.(22.6±4.9)d]均明显减少(均P＜0.05),但两组并发症发生率(19.4％vs.23.3％)差异无统计学意义(P＞0.05).结论:选择性肝动脉栓塞治疗创伤性闭合性肝脏破裂具有临床疗效稳定,创伤小,恢复快等优势,是一种较安全,有效的治疗措施.     

Nonoperative management of adult blunt hepatic trauma in a municipal trauma center.

While nonoperative management of blunt hepatic trauma has become the standard of care in children, its use in the adult population is not as well accepted. The purpose of this study was for the authors to review their experience with operative and nonoperative management of adults with blunt hepatic trauma at an urban trauma center. During the past 7 years, 56 adults were found on abdominopelvic computerized tomography or at exploratory laparotomy to have sustained blunt hepatic trauma. Nonoperative management was considered in patients who were hemodynamically stable; had no signs of peritoneal irritation; and had no other intra-abdominal injuries that might require surgical repair. Of the 56 patients, 20 were admitted to the surgical intensive care unit for careful observation. One patient required the administration of blood products and a second underwent laparotomy within 12 hours of presentation for progressive abdominal pain. This patient had a 4-cm liver laceration easily controlled with electrocautery. This review supports the judicious application of nonoperative management in the hemodynamically stable adult with blunt hepatic trauma who is without signs of significant peritoneal irritation or other intra-abdominal injuries that would require surgical repair.     

Nonoperative management of blunt hepatic trauma in adults

Although well accepted in pediatric patients, nonoperative management of blunt hepatic trauma in adults remains controversial. From January 1981 through May 1987, 66 adults were identified with blunt hepatic trauma that had been confirmed by abdominal exploration or abdominal computed tomography (CT): 46 underwent immediate operation, and 20 were initially managed nonoperatively. Patients were considered for nonoperative management only if they were hemodynamically stable and had no significant peritoneal irritation. CT criteria for nonoperative management included contained subcapsular or intrahepatic hematoma, unilobar fracture, absence of devitalized liver, minimal intraperitoneal blood, and absence of other significant intra-abdominal organ injuries. The predominant CT pattern in the 17 patients successfully managed nonoperatively included unilobar right-lobe fracture or intrahepatic hematoma. A small amount of blood in either gutter or in the pelvis did not portend failure of nonoperative management. No delayed complications were noted during an average follow-up of 27 months. Nonoperative management of blunt hepatic injury based on abdominal CT findings is a useful alternative in a select group of hemodynamically stable patients.     

Nonoperative management of pediatric blunt hepatic trauma

The purpose of this study was to examine the effect of operative versus nonoperative management of blunt hepatic trauma in children including transfusion practices. We reviewed the experience at our American College of Surgeons-verified Level I trauma center with pediatric commitment over a 5-year period. Children < or = 16 years of age suffering blunt liver injury as documented on admission CT scan were included in the study. Liver injuries identified on CT scan were classified according to the American Association for the Surgery of Trauma's Organ Injury Scaling system. All data are presented as mean +/- standard error. One case of pediatric liver trauma not identified on CT was excluded (prehospital cardiopulmonary resuscitation). Twenty-seven patients were included [age 9.3 +/- 1.0 years (range 3-16)]. Mechanisms of injury included motor vehicle crash (14), pedestrian struck by motor vehicle (7), bicycle crash (4), fall from height (1), and pedestrian struck by falling object (1). Trauma Score was 11.5 +/- 0.3. Distribution of Liver Injury Grade was as follows: grade I, 13; grade II, 9; grade III, 3; grade IV, 2; and grade V, 0. All five patients who underwent operative management had multiple organ injuries; three had concomitant splenic injury requiring operative repair; the remaining two had small bowel injury requiring repair. Hepatorrhaphy did not correlate with severity of liver injury: grade I, n = 1; II, n = 2; III, n = 1; and IV, n = 1. Three operated patients received blood transfusions. Twenty-two patients were managed with nonoperative treatment, of these only one required blood transfusion. No patients in the study died, three were transferred to subacute rehabilitation, one was transferred to another hospital, and 23 were discharged home. Our findings indicate that a majority of children with blunt hepatic injury as documented on CT scan can be managed with nonoperative treatment, and few require blood transfusions. Patients with multiple organ injury including simultaneous splenic injury are likely ideally managed through operative exploration and repair, whereas those with isolated liver injuries can be successfully managed nonoperatively.     

Major hepatic vein ligation necessitated by blunt abdominal trauma.

An unusual case involving avulsion of the middle and left hepatic veins secondary to blunt trauma is presented. Operative management of the injury resulted in ligation of both veins without resection of the parenchyma acutely deprived of venous outflow. The postoperative evaluation and review of the literature indicate that liver tissue will survive acute interruption of a major portion of its venous outflow. This case demonstrates that if after ligating major hepatic vein, the condition of the obstructed parenchyma stabilizes or improves under direct observation and if the condition of the patient does not deteriorate, resection may not be required.     

Management of blunt pancreatic trauma in children

Purpose  Blunt abdominal trauma is the major cause of abdominal injury in children. Because of the retroperitoneal location, insidious signs and symptoms and the lack of sensitivity with common imaging modalities often lead to difficulties in making an accurate diagnosis. The most common complication is the formation of a pancreatic fistula, pancreatitis and a pancreatic pseudocyst, which usually manifests within 3 or 4 weeks after injury. Methods  The case records of seven children (4 male, 3 female) treated for blunt pancreatic injury in the department of pediatric surgery, University Hospital, Split were reviewed. Results  The treatment modalities were selected according to the grade of the pancreatic injury, hemodynamic status and associated injuries. Because all of the patients were classified as grade I or II according to the American Association for the Surgery of Trauma (AAST) classification, a conservative treatment was selected for all seven patients. In four patients the conservative treatment resulted in the total regression of the clinical, biochemical and radiological signs within four weeks (AAST grade I). In the other three patients, pancreatic pseudocysts arose within 3 or 4 weeks after the injury (AAST grade II). Conclusions  The status of the main pancreatic duct and the location of the pancreatic injury constitute the basis of the AAST scoring system. This scale should be used as a guide to selecting a surgical or conservative strategy. Based on these data, two factors appear to be the most important determinants of the treatment strategy for children with pancreatic injury: the grade of the pancreatic injury, which is determined according to the status of the main pancreatic duct and the clinical status of the patient.     

Utility of radiographic hepatic injury grade in predicting outcome for children after blunt abdominal trauma

Background/Purpose: The American Association for the Surgery of Trauma (AAST) liver injury grading system has been adopted in the management of pediatric hepatic injuries. However, the usefulness of this grading system in children remains undefined. The authors, therefore, examined the validity of AAST grading in the management of pediatric blunt liver injury. Methods: The authors identified 152 patients, ages 0 to 18 years, with blunt hepatic injury treated at our pediatric trauma center between 1995 and 2000. Radiographic AAST grade was assigned retrospectively by 2 radiologists. Variables analyzed included age, gender, Glasgow Coma Score (GCS), Injury Severity Score (ISS), and associated injuries. Outcome measures were mortality rate and length of stay (LOS). Statistical analysis was performed using analysis of variance or linear regression. Results: Computed tomography (CT) scans were available for 95 patients. Radiographic injury grade did not correlate with mortality rate, hospital LOS or intensive care unit (ICU) LOS. ISS and associated injury, but not age, gender, or GCS, were predictive of LOS. Grade did not correlate with mortality rate, ICU LOS, or hospital LOS. Conclusions: Radiographic liver grading does not predict outcome reliably in children and should not be the main parameter utilized to guide clinical decision making. A role for scoring systems that utilize factors such as associated injuries and ISS is indicated.     

Isolated blunt trauma injury to the hepatic duct

Isolated bile duct injuries are quite rare. The diagnosis may be difficult. The presence of continued abdominal pain, nausea, vomiting, distention and jaundice in addition to abnormal liver function tests and often a leukocytosis mandate that a biliary tract injury be ruled out. The most important diagnostic study for confirming a biliary tract injury is paracentesis. The ERCP is then done to delineate the anatomy of the injury. Transhepatic cholangiography is an alternative to the ERCP. Treatment for a biliary duct injury must be selected on an individual basis.     

Severe hepatic trauma：surgical strategies

Objective:To probe into effective surgical procedures and improve the outcome of treatment for patients with severe hepatic injury.Methods:A retrospective study involving 113 patients with severe hepatic trauma(AAST grade IV and V) during the past 12 years was carried out.Ninety-eight patients underwent surgical treatment.Surgical interventions including hepatectomy or direct control of bleeding vessels by finger fracture technique with Pringle maneuver, selective ligation of hepatic artery,retrohepatic caval repair with total hepatic vascular occlusion,and perihepatic packing were mainly used.Results:In the 98 patients treated operatively,the survival rate was 69.4%(68/98).Among 40 patients with juxtahepatic venous injury(JHVI),15 were cured with the maximum blood transfusion of 12 000 ml.Eight cases of Grade IV injury treated nonoperatively were cured.The percentage of failure of nonoperative management was 42.9%(6/14).The overall mortality rate was 32.7%(37/113),and 57% of the deaths were due to exsanguinations.Conclusions:Reasonable surgical procedures based on classification of hepatic injuries can increase the survival rate of severe liver trauma.Accurate perlihepatic packing is effective in dealing with JHVI.     

Gastrointestinal tract perforation in children due to blunt abdominal trauma.

Over a 14-year period 587 children under 13 years of age were admitted with blunt injury to the abdomen. Twenty-nine (4.9 per cent) of these were found to have bowel rupture. Evidence of peritonitis was present at initial evaluation in 11 children (38 per cent). Radiological evidence of perforation (pneumoperitoneum) was present in only five of 27 (19 per cent) with a further six of 27 (22 per cent) showing dilated loops of bowel or fluid levels. Thus 59 per cent of radiographs were not diagnostic. The mean time from admission to laparotomy was 17 h. Proximal bowel perforation was common and perforation at multiple sites occurred in five patients; 59 per cent had a concomitant injury which resulted in two deaths (from head injury). Initial clinical and radiological evidence of bowel perforation can be misleading and reliance on such indicators may result in significant diagnostic delay. Frequently repeated clinical examination is advocated; progression of abdominal signs should alert the clinician to proceed to laparotomy.