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Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma...

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Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: Review three trauma mechanisms of injury that increase risk of liver injuries Discuss triage scenarios when a patient should go from the ED to OR, ED to imaging or ED to IR Interpret a CT scan for active liver injury
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Page 1: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Liver Injuries

Steven R. Granger, MD, FACS

Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare

Objectives: • Review three trauma mechanisms of injury that increase risk of

liver injuries • Discuss triage scenarios when a patient should go from the ED to OR,

ED to imaging or ED to IR • Interpret a CT scan for active liver injury

Page 2: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Hepatic Trauma

Steven R Granger, MDTrauma, Critical Care and General Surgery

Intermountain Medical Center

Page 3: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Liver Anatomy

• Largest solid abdominal organ• Relatively fixed position• Highly vascular• Second most commonly injured organ in abdominal trauma

• Most common cause of death after abdominal injury

Page 4: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Grading System

Page 5: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

“If trauma surgery is a contact sport, the badly injured liver is 

the Ninja master: a vicious, cunning and lethal adversary.  You 

have a window of about 20 minutes and 8‐10 units of blood to 

stop the bleeding. That’s all. Take much longer, lose more 

blood or make an error in judgement and the Ninja master 

wins again"

‐Top Knife (Asher Hirshberg)

Page 6: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Evolution in Management

Annals of Surgery 1908 Oct; 48(4): 541‐549

Page 7: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Historical Reference ‐ 1908

• Dr. Pringle• “During the last 11 years there have been 8 patients admitted to my service at the Glasgow Royal Infirmary, who sustained a rupture of the liver

• 3 died immediately• 5 survived initially with time to determine the best course of action

• All 4 taken to the OR died• 1 refused surgery and died after 3 days

• Describes the “Pringle Maneuver” of manually occluding the inflow from the portal vein and hepatic artery while exploring the liver ….. Led to less bleeding ……

Annals of Surgery 1908 Oct; 48(4): 541‐549

Page 8: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Historical Reference

“It is very probable that the slight ruptures will occasionally heal without surgical interference in consequence of this increased tension of the abdominal wall leading to the arrest of hemorrhage, but in the cases of severe injury to the liver this will not happen; many patients if left without surgical aid, will die from hemorrhage or shock in the first place, or if they get over these dangers will succumb later from intestinal obstruction and peritonitis, when the extravasated blood comes infected from the bowel, of which it has every chance if such a patient hold on long enough. So that if these severe cases are to be got through at all, I feel that operation must be an immediate one for the majority, and that some of these patients can be saved …………….

Annals of Surgery 1908 Oct; 48(4): 541‐549

Page 9: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Historical Reference

“It is a most unhappy calamity that a patient, whose life one is endeavoring to save, should die before an operation is completed, but it is a risk that has occasionally to be faced and in these cases of injury to the liver, one is most likely to avoid it, I believe, by the rapidity of operating, and this will be favored by the immediate arrest of the active hemorrhage that is going on, by seizing the portal vessels as soon as the abdominal cavity is opened; for by doing one can obtain a clear field and therefore time is gained for the treatment of the wound of the liver itself ………..

Annals of Surgery 1908 Oct; 48(4): 541‐549

Page 10: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Evolution into Modern Treatment Algorithms• University of Louisville Trauma program presented their 25 year experience in 2000

• U of L had 1,842 liver injuries over this 25 year period• Contrast to Dr. Pringle’s 8 patients over 11 years• Treatment choices presented as % of total cases in Table 1

• Dramatic change in Op vs Non op• By the last 2 years of this study

• 80% were managed nonoperatively

Annals of Surgery 2000 Sep; 232(3): 324‐330

Page 11: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Evolution into Modern Treatment Algorithms• University of Louisville 25 year experience

• Mortality rates changed dramatically• Death rate unrelated to liver injury showed little changed where as Liver only death rate changed from 10% to 3%

• The decline in death rates directly linked to death rate from hemorrhage

Annals of Surgery 2000 Sep; 232(3): 324‐330

Page 12: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Wester Trauma Association ‐ 2011Operative Management of Liver Trauma

J Trauma 2011; 71: 1‐5

Page 13: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Blunt Liver Trauma ManagementEAST Guidelines 2012

Eastern Association for the Surgery of TraumaJ Trauma. 73(5):S288‐S293, November 2012

Page 14: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

EAST Guidelines – 2012Questions tackled in the guidelines

• Is non‐operative management (NOM) appropriate for all hemodynamically stable adults regardless of severity of solid organ injury or presence of associated injuries (what about if they have a brain injury, etc)?

• What role does angiography have in NOM?• Is the risk of missing a hollow viscous injury a deterrent to NOM?• What is the best way to diagnose injury to the liver after blunt trauma?• What is the role of CT or US in NOM?• Should patients be on “bedrest” and for how long?• What period and evaluation is needed before releasing the patient back to full activity?

Eastern Association for the Surgery of TraumaJ Trauma. 73(5):S288‐S293, November 2012

Page 15: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

CLASS OF EVIDENCE LEVEL OF RECOMMENDATION

I Prospective randomized Class I data or strong Class II

II Prospective non‐compRetrospective w/ controls

Class II data or preponderance of Class III evidence

III Retrospective analysesLacking scientific evidence, generally supported by Class III data.  Useful for education and guiding clinical research

(0)

(12)

(82)

Page 16: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

EAST Guidelines – 2012Recommendations

• Level 1 Recommendation (only one)• Patients who are hemodynamically unstable or who have diffuse peritonitis after blunt abdominal trauma should be taken EMERGENTLY to the operating room

• Level 2 Recommendation• Abdominal trauma, stable patient, CT scan should be performed• Routine laparotomy is NOT indicated in hemodynamically stable patients without peritonitis presenting with an isolated blunt hepatic injury

• Non operative management of hepatic injuries should be done in an environment that is capably for the various interventions which may be necessary

• Grade of injury, Age, Head Injury, Degree of hemoperitoneum, Blush on CT, ISS …….. Are not indications for surgery

• Hollow viscous injury or development of peritonitis warrants surgical intervention• Angiography with embolization should be considered in a hemodynamically stable patient with evidence of active extravasation

Eastern Association for the Surgery of TraumaJ Trauma. 73(5):S288‐S293, November 2012

Page 17: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Wester Trauma AssociationNon‐operative Management of Blunt Hepatic Trauma

J Trauma Acute Care Surg 2012  73(5), Supp 4

Page 18: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

EAST Guidelines – 2012Recommendations

• Level 3 Recommendations• Repeat CT if clinical changes including persistent systemic inflammatory response, increasing persistent abdominal pain, jaundice, unexplained drop in hematocrit

• Interventional modalities including ‐ ERCP, angiography, laparoscopy, percutaneous drains may be required to manage complications

• Bile leak, biloma, bile peritonitis, hepatic abscess, bilious ascites, hemobilia• Likelihood increases with Grade of injury – Complication rates

• Grade III ‐ 1%• Grade IV ‐ 21%• Grade V ‐ 63%

• Pharmacologic prophylaxis to prevent VTE can be used • optimal timing of safe initiation has not been determined

Eastern Association for the Surgery of TraumaJ Trauma. 73(5):S288‐S293, November 2012

Page 19: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

EAST Guidelines – 2012Recommendation

• Could not be determined with currently available literature• Frequency of hemoglobin measurements

• Currently protocol driven in context of clinical scenario• Frequency of abdominal exams• Intensity or duration of monitoring

• art line, tele , how long in ICU / hospital• Time to starting PO• Duration of activity restrictions in and out of the hospital• When to start DVT prophylaxis

• Standardize approaches / Protocol development

Eastern Association for the Surgery of TraumaJ Trauma. 73(5):S288‐S293, November 2012

Page 20: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

• Strict bedrest following BHI is not justified• Early mobilization prevents later 

complications and is not associated with poor outcomes or delayed hemorrhage in Hepatic, Splenic or Renal Injury

Arch Surg 2008 Oct;143(10):972‐6

Page 21: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

• Unstable / Peritonitis = OR ‐ Level 1• Unreliable exam = Local wound exploration / laparoscopy / laparotomy ‐ Level 1

• Brain, spinal cord injuries, intoxicated, need anesthesia) • Stable without peritonitis Stab Wound = OR versus selective nonoperativemanagement (SNOM) ‐ Level 2

• If SNOM = serial exams (level 2), consider CT (level 2), consider laparoscopy (level 2), watch for 24 hours (level 3)

• Isolated Liver with stable hemodynamics and without peritonitis may be managed nonoperatively – Level 3

J Trauma 68 (3), March 2010

Page 22: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Penetrating Abdominal Trauma

https://bedahunmuh.files.wordpress.com/2010/06/algorithm‐for‐penetrating‐abdominal‐injury.jpg

Page 23: Liver Injuries Steven R. Granger, MD, FACS · Liver Injuries Steven R. Granger, MD, FACS Trauma Surgeon, Intermountain Medical Center, Intermountain Healthcare Objectives: • Review

Summary

• Management of liver trauma has evolved and current treatment trends are associated with mortality improvements

• Non‐operative management of blunt hepatic trauma is the standard of care in the hemodynamically stable patient without peritonitis

• Complications for high grade injuries are common enough to warrant a high index of suspicion and potential interventions

• Prepare patients at admission for the potential of a prolonged course and multiple interventions = Manage expectations

• Isolated penetrating liver trauma may also warrant selective non‐operative management

• Development of protocols standardizes care of these patients


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