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

2. 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

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. 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 % in patients w/ unnecessary laparotomy
Stassen NA et al, J Trauma Acute Care Surg 2012

10. High success rate
Success rate %
Kozar RA et al, J Trauma 2009

11. Operative
Non-operative

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

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

20. 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

21. 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

22. 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

23. 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

24. 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

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

26. 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

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

28. 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

29. 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

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

31. Benjamin E et al, Curr Trauma Rep 2015

32. Western trauma association
Biffl WL et al, J Trauma 2009

33. Year
5 centers, 222 patients
Biffl WL et al, J Trauma 2011

34. Biffl WL et al, J Trauma 2011

35. 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

36. 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

37. 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

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

40. 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

41. 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

42. THANK YOU
Largest solid abdominal organ