LIVER TRAUMA SELECTIVE NON-OPERATIVE MANAGEMENT Largest solid abdominal organ Dr. Ng Ka Kei Stephen Queen Elizabeth Hospital

Fixed between bony structures background Most frequently injured organ Thin capsule Fixed between bony structures Friable parenchyma Dual blood supply Most frequently injured organ in abdominal injury (incidence of 30-40%) Well-protected position Fragile parenchyma with thin Glisson’s capsule Wide-bore, thin walled vessels with high blood flow -> significant bleeding Sizable organ Feliciano DV, Surg Clin North Am 1989

mechanism Blunt Penetrating Road traffic accident Violence Stab injury Gunshot 66% Penetrating Different incidence around the world 66% Blunt Scollay JM et al. World J Surg 2005 Talving P et al. Scan J Surg 2003 Krige JE et al. S Afr J Surg 1997 Richardson JD et al. Ann Surg 2000

classification American Association for the Surgery of Trauma (AAST) Hepatic Injury Scale (1994 Revision) Size haematoma Length of laceration Parenchymal disruption Vascular injury Moore EE, et al. J Trauma 1995

classification Mild Moderate Severe American Association for the Surgery of Trauma (AAST) Hepatic Injury Scale (1994 Revision) Mild Moderate Severe Moore EE, et al. J Trauma 1995

evolution Always fatal in 1900s Significant improvement in survival Fatal at beginning of 20th century Richardson JD et al. Ann Surg 2000

Reasons of improvement Protocol Standardized protocol Resuscitation Haemostatic resuscitation Diagnosis CT / FAST Intensive Care Avoidance of lethal triad Radiological Intervention Angiogram and embolization Surgery Damage control Packing and reoperation Techniques for major injuries Fatal at beginning of 20th century Richardson JD et al. Ann Surg 2000

Before 1980 1990 Now Operative – liver resection Operative – Nonresectional techniques and packing Selective Nonoperative Nonoperative with Selective Operative - 86.3% nonoperative Shift of paradigm Nonoperative approach was at first applied to pediatric patients and has rapidly been extended to adults National trauma data base noted 86.3% are now managed without operative intervention Kozar RA et al, J Trauma 2009 Tinkoff G et al, J Am Coll Surg 2008

Advantages of NOM Lower hospital cost Earlier discharge Avoiding non-therapeutic laparotomy (and associated cost and morbidity) Fewer intra-abdominal complications Reduced number of transfusions Complications ranging 2.5-41% in patients w/ unnecessary laparotomy Stassen NA et al, J Trauma Acute Care Surg 2012

High success rate Success rate 82-100% Kozar RA et al, J Trauma 2009

Operative Non-operative

Prerequisite of NOM Only in centers capable of Precise diagnosis of severity of liver injury Intensive monitoring & management Rapid response to change in status Management of delayed complications Angiography and operating room availability Stassen NA et al, J Trauma Acute Care Surg 2012

Haemodynamically Unstable Haemodynamically stable Management Initial Assessment Abdominal exam Vital signs Response to resuscitation FAST Haemodynamically Unstable Peritonitis Haemodynamically stable ATLS definition of unstable: BP <90 + HR >120 + (skin vasoconstriction, altered GCS, or SOB) Laparotomy Stassen NA et al, J Trauma Acute Care Surg 2012

Haemodynamically Unstable Haemodynamically stable Management Initial Assessment Abdominal exam Vital signs Response to resuscitation FAST Haemodynamically Unstable Peritonitis Haemodynamically stable Laparotomy Blunt Blunt Penetrating Stassen NA et al, J Trauma Acute Care Surg 2012

Blunt liver trauma Predictors of NOM failure High CT-grade of injury Hepatic-related blood transfusion Multiple solid organ injuries Active contrast extravasation on CT Hypotension Velmhaos GC et al, Arch Surg 2003 Yanar H et al, J Trauma 2008

CT injury grade National Trauma Data Bank 35,897 liver injuries Grade I & II – 91% successful NOM Grade III – 79% Grade IV – 72.8% Grade V – 62.6% Even high-grade injuries have a high likelihood of successful nonoperative management Tinkoff G et al, J Am Coll Surg 2008

Transfusion No Consensus Pachter et al. 2 units transfusion suggests ongoing bleeding Carillo et al No more than 4 units of blood Hepatic related transfusion limit has not been verified Suggest ongoing bleeding and OM is necessary Kozar – transfusion requirement in first 24hrs postinjury shown to predict liver-related complications No Consensus Pachter HL et al, Am J Surg 1995 Carillo E et al, J Trauma 1999

Associated injury 150 patients Grade III to V blunt hepatosplenic trauma NOM if haemodynamically stable (n=122, 81.3%) Fail in 6 (4.9%) Hsieh TM, WJES 2014

Contrast Pooling Extra-parenchymal Intra- & extra-parenchymal Intraparenchymal Is indicative of active haemorrhage Intraperitoneal, intraparenchymal +/- haemoperitoneum Fang JF et al, Am J Surg 1998

Intra-peritoneal extravasation predict surgery Fang et al Intra-peritoneal extravasation predict surgery Misselbeck et al Angiography in patient with arterial blush 20 times more likely to require embolization Carrillo et al Efficacy of angioembolization 83% Mohr et al Early angioembolization decreases need for transfusions and liver- related operations Lose observation alone with planned angiographic embolization for signs of ongoing bleeding is also an option Fang JF et al, J Trauma 2006 Misselbeck TS et al, J Trauma 2009 Carrillo EH et al, J Trauma 1999 Mohr AM et al, J Trauma 2003

Blunt liver trauma Predictors of NOM failure High CT-grade of injury Hepatic-related blood transfusion Associated injuries Active contrast extravasation on CT Hypotension No longer absolute Ci to NOM Velmhaos GC et al, Arch Surg 2003 Yanar H et al, J Trauma 2008

Guidelines (NOM) Western Trauma Association (WTA) Nonoperative management to haemodynamically stable patients and absence of other abdominal injuries that required exploration Eastern Association for the Surgery of Trauma (EAST) A routine laparotomy is not indicated in haemodynamically stable patient without peritonitis presenting with an isolated blunt hepatic injury World Society of Emergency Surgery (WSES) Patients should undergo an initial attempt of NOM in a scenario of blunt trauma, haemodynamic stability, isolated liver injury, irrespective of injury grade Kozar RA et al, J Trauma 2009 Stassen NA et al, J Trauma Acute Care Surg 2012 Coccolini F et al, WJES 2015

Guidelines (angiogram) Western Trauma Association (WTA) Haemodynamically stable patients with free intraperitoneal extravasation undergo immediate angiography Controversial in the group of stable patients with intraparenchymal contrast pooling Eastern Association for the Surgery of Trauma (EAST) Angiography with embolization should be considered in a haemodynamically stable patient with evidence of active extravasation on CT scan World Society of Emergency Surgery (WSES) Angiography with embolization may be considered the first-line intervention in patient with haemodynamic stability and arterial blush on CT Kozar RA et al, J Trauma 2009 Stassen NA et al, J Trauma Acute Care Surg 2012 Coccolini F et al, WJES 2015

Haemodynamically Unstable Haemodynamically stable Management Initial Assessment Abdominal exam Vital signs Response to resuscitation FAST Haemodynamically Unstable Peritonitis Haemodynamically stable Laparotomy Blunt Penetrating Stassen NA et al, J Trauma Acute Care Surg 2012

penetrating liver trauma Main reluctance Doubt to miss others abdominal lesions Esp hollow viscus perforation Demetriades D et al, Ann Surg 2006

Contraindications Haemodynamic instability Diffuse peritonitis Evisceration Impalement Biffl WL et al, J Trauma 2009 Como JJ et al, J Trauma 2010 Coccolini F et al, WJES 2015

YES -> Operative Management Key questions Any intraperitoneal organ injury? Any peritoneal penetration? YES -> Operative Management

Perform CT scan in all cases of penetrating liver injury suitable for NOM Retroperitoneal injury Missile trajectory Contrast pooling Look for: Pneumoperitoneum Free intra-peritoneal fluid in the absence of solid organ injury Localized bowel wall thickening Bullet tract close to hollow viscus with surrounding haematoma CT – only modality to assess retroperitoneum Operative Management Demetriades D et al, Ann Surg 2006 Benjamin E et al, Curr Trauma Rep 2015

Local Wound Exploration Peritoneal penetration Local Wound Exploration + ve - ve CT – only modality to assess retroperitoneum Operative Management Discharge Thompson JS et al, J Trauma 1980

CT – only modality to assess retroperitoneum Biffl WL et al, J Trauma 2009

Benjamin E et al, Curr Trauma Rep 2015

Western trauma association Biffl WL et al, J Trauma 2009

Year 2008-2010 5 centers, 222 patients Biffl WL et al, J Trauma 2011

Biffl WL et al, J Trauma 2011

Guidelines Eastern Association for the Surgery of Trauma (EAST) Patients with penetrating injury isolated to right upper quadrant of abdomen may be managed without laparotomy in the presence of stable vital signs, reliable examination, and minimal to no abdominal tenderness World Society of Emergency Surgery (WSES) NOM in penetrating liver trauma could be considered only in case of haemodynamic stability, absence of peritonitis and or evisceration and or impalement Serial clinical examination and local wound exploration must be always performed in case of stab wounds Como JJ et al, J Trauma 2010 Coccolini F et al, WJES 2015

Abdominal Compartment Syndrome complications Biliary Infections Abdominal Compartment Syndrome Bleeding Liver Necrosis Biliary – bile leak, haemobilia, bilioma, biliary peritonitis, biliary fistula Infections – abscesses and other infection Fabian TC et al, Trauma 2013 Stassen NA et al, J Trauma Acute Care Surg 2012

Monitoring Parameters SIRS Abdominal exam Jaundice Fever Hb level NOM: close observation and serial clinical examination Serial abd exam most important in penetrating injury, and ideally by same examiner Unstable/peritonitis -> Laparotomy Any suspicion -> Repeat CT scan Kozar RA et al, J Trauma 2009

Summary Yet the protocol is not perfect and hopefully these questions will be able to answer in the near future

IN THE FUTURE… Frequency of Hb measurement Frequency of abdominal exam Intensity and duration of monitoring Time to reinitiating oral intake Duration and intensity of restricted activity Optimum LOS for ICU/hospital Timing of DVT prophylaxis And more.. Yet the protocol is not perfect and hopefully these questions will be able to answer in the near future

Dr. Gerald W. Shaftan “the application of trained surgical judgment rather than dogma is the more rational and intelligent approach to the management of abdominal injury.” Shaftan GW et al, Am J Surg 1960

THANK YOU Largest solid abdominal organ