Liver abscess after non-operative management of blunt liver injury

BACKGROUND: The non-operative management of blunt liver trauma can be applied in almost 80% of patients with this type of injury, with the advantages of the need for fewer blood transfusions, less intra-abdominal sepsis, and a better survival rate, than with the operative approach. However, liver abscess, as a known complication of the non-operative management of blunt liver trauma, is discussed infrequently. Therefore, we herein review our experience and describe this complication in detail. MATERIALS AND METHODS: From 1995 to 2001, 674 patients were admitted to our hospital due to blunt hepatic trauma. Among these patients, 279 underwent laparotomy and the remaining 395 patients were treated non-operatively. Twenty-two patients were identified as having liver abscess, with 16 of them belonging to the operative group, and six to the non-operative group. A retrospective review of these six patients and their characteristics, as well as pathogenesis, diagnosis, and the management of the liver abscesses, was conducted. RESULTS: These six patients were all male, with a median age of 19.5 years (range 3-24). The median injury severity score was 16.5 (range 9-25); three patients sustained grade-3 hepatic injury, and the other three were grade 4. The main diagnostic tool was abdominal computed tomography, and the abscesses took a median of 6 days (range 1-12) to form and be diagnosed. The abscesses were usually caused by infection from mixed organisms, and an abscess resulting from Clostridium infection developed within 1 day after injury. These abscesses were treated with antibiotics and drainage, and the median length of hospital stay was 26 days (range 8-44), without mortality or long-term morbidity. CONCLUSION: Liver abscess as a complication of the non-operative management of blunt hepatic trauma is a rare entity, with an incidence of 1.5% (6/395). It is usually seen in severe liver injury (grade 3 and above), but all our patients were all treated successfully, with no mortality. However, prolonged hospitalization may be required in this patient group.     

Hepatic haematoma following blunt injury: non-operative management

Four patients with multiple injuries including suspected closed hepatic injury are described, all of whom needed resuscitation in the Intensive Care Unit. All 4 had local signs suggesting hepatic injuries, but no evidence of generalized intraperitoneal bleeding.They were carefully monitored clinically, and the suspected diagnosis of hepatic haematoma was confirmed by ultrasound scanning and follow-up with repeated scans until complete resolution occurred. All made a satisfactory recovery and are well and asymptomatic, except for one patient who has residual orthopaedic disabilities.     

Comparison of hepatic abscess after operative and nonoperative management of isolated blunt liver trauma

Hepatic abscess has been well recognized as a complication after blunt hepatic injuries. The clinical presentation of hepatic abscess after the operative and nonoperative management of isolated blunt liver injury is compared in this study. From 1995 to 2000, 674 patients with blunt liver injury were admitted and were managed either operatively or nonoperatively. Hepatic abscess occurred in 21 of these patients. Six of the 21 patients had their liver injuries managed nonoperatively (group 1) and the remaining 15 had their liver injuries managed operatively (group 2). The severity of injury of both groups of patients was similar, but group 2 patients required more blood transfusion and had a higher incidence of abscess formation. The formation of abscess occurred within 12 days after admission in the group 1 patients but ranged from 5 days to 6 years in the group 2 patients. One of the group 1 and eight of the group 2 patients had recurrent abscesses and required repeated admission. The nonoperative management of blunt hepatic trauma had a better outcome than the operative approach in terms of a significant decrease in abdominal infections and tended to result in complete recovery without the need of repeated admission and drainage.     

Hepatic hematoma after blunt trauma--a case of nonoperative management to prevent liver abscess formation

In an eighteen-year-old boy with a high fever, an intra-hepatic infectious hematoma following blunt hepatic trauma was treated twice with intrahepatic arterial injection chemotherapy in an attempt to prevent conversion of the hematoma to an abscess. A decrease in body temperature occurred after the arterial injections, and the hematoma was gradually diminished in size. In selected patients with blunt hepatic trauma, intrahepatic arterial injection chemotherapy seems to be an effective treatment for prevention of liver abscess formation.     

Efficacy and safety of non-operative management of blunt liver trauma

Background  

The liver is the most frequently affected organ during blunt abdominal trauma. Blunt liver trauma management has changed in the last two decades with the introduction of the computed tomography (CT) scan and non-operative management of stable patients.     

Risk factors for mortality after endovascular repair for blunt thoracic aortic injury

ObjectiveDespite high use of endovascular repair, blunt thoracic aortic injury (BTAI) leads to significant mortality. We sought to identify risk factors and create a predictive model for mortality after thoracic endovascular aortic repair (TEVAR) based on available preoperative clinical data.MethodsWe queried the Vascular Quality Initiative TEVAR dataset from April 2011 to November 2017 to identify patients with BTAI as the indication for repair. Patient characteristics, injury grade, timing of repair, and technical aspects including left subclavian artery (LSCA) involvement and coverage were evaluated. Logistic regression was used to identify univariable predictors of the primary outcome of in-hospital mortality. A multivariable model was constructed to predict in-hospital mortality after TEVAR for traumatic aortic injury. The model was tested as a prediction tool, internally validated using 10-fold cross-validation approach, externally validated using early and late split samples, and finally simplified into a scoring system.ResultsWe identified 633 TEVAR cases performed for blunt trauma. The majority of patients were male (73.9%) with median age of 39 years (interquartile range, 27-56 years). Although 18.6% documented zone 2 or proximal involvement, 28.1% documented involvement or treatment of the LSCA. 8.9% of repairs were performed for a grade 1 injury, with an increase from 6.4% in 2014 to 16.7% in 2017 (P = .04). The overall in-hospital mortality rate was 7.3%. Independent predictors of mortality were age 60 year or greater (odds ratio [OR], 11.33; 95% confidence interval [CI], 5.30-24.23; P < .001), creatinine 1.2 or greater (OR, 5.28; 95% CI, 2.46-11.34; P < .001), male gender (OR, 4.26; 95% CI, 1.53-11.84; P = .005), Injury Severity Score of greater than 30 (OR, 3.86; 95% CI, 1.74-8.57; P = .001), and LSCA involvement (OR, 2.25; 95% CI, 1.11-4.53; P = .02). The model predicted in-hospital mortality with a C-statistic of 0.86 (95% CI, 0.80-0.92), and a simplified model based on a point system had a similar C-statistic of 0.86 (95% CI, 0.80-0.92; P = .44).ConclusionsTEVAR for BTAI is associated with a 7.3% in-hospital mortality in the Vascular Quality Initiative. Treatment of grade 1 injuries has increased significantly in recent years. Factors most strongly associated with mortality include age, male gender, renal impairment, LSCA involvement, and high ISS score. A simple point score model based on these variables robustly predicts in-hospital mortality and may assist in appropriate patient selection and risk stratification.     

Hepatic hematoma after blunt trauma —a case of nonoperative management to prevent liver abscess formation—

In an eighteen-year-old boy with a high fever, an intrahepatic infectious hematoma following blunt hepatic trauma was treated twice with intrahepatic arterial injection chemotherapy in an attempt to prevent conversion of the hematoma to an abscess. A decrease in body temperature occurred after the arterial injections, and the hematoma was gradually diminished in size. In selected patients with blunt hepatic trauma, intrahepatic arterial injection chemotherapy seems to be an effective treatment for prevention of liver abscess formation.     

Short-term and long-term changes in hepatic function in 60 patients with blunt liver injury

We treated 60 patients with blunt liver injury over 14 years. According to Makiya's scale of severity, 22 of these lesions (37%) were of Type I, 23 (38%) of Type II, and 15 (25%) of Type III. The overall mortality rate was 23% (14 patients). Changes in hepatic function were studied in these patients. Transaminase levels showed abnormal elevations immediately after the injury but rapidly decreased to normal levels within about 40 days in both the patients who survived the injury and those who died. The alkaline phosphatase activity showed moderate gradual elevations with time, exceeding 20 K.A. units 10 days after the injury in those who died. The total bilirubin level increased to only about 4 mg/dl in those who survived but exceeded 8 mg/dl 10 days after the injury in about 80% of those who died. The total cholesterol level decreased below 100 mg/dl in those who died. In chloric cobalt reaction, the R-value shifted to the left in those who survived but to the right in those who died. Total plasma protein, which decreased to about 6.0 gm/dl immediately after the injury, gradually recovered in those who survived but further declined in those who died. Percentage of gamma-globulin increased but remained below 20% in those who survived but exceeded 20% within 10 days of injury in many of those who died. Hepatic functions 5 years after the injury were generally within the normal range.     

Risk factors for blunt thoracic aortic injury in children

Background/Purpose

Because blunt thoracic aortic injury is rare in children, a high index of suspicion is needed to identify this injury. The purpose of this study was to use a large national trauma database to define the risk factors for blunt thoracic aortic injury in children.

Methods

Using the National Trauma Database, the authors compared patient demographics, mechanism of injury, and associated injuries between children sustaining blunt trauma with and without a thoracic aortic injury. Factors independently associated with this injury were identified using multivariate methods.

Results

Among 26,940 children with a blunt mechanism of injury, 34 (0.1%) children sustained a thoracic aortic injury, 14 (41%) of whom died. Thoracic aortic injuries were independently associated with age, injury sustained as an occupant in a motor vehicle crash, and severe injuries (Abbreviated Injury Scale value of ≥3) involving the head, thorax (other than aorta), abdomen, and lower extremities.

Conclusions

Older children involved in a motor vehicle crash with severe head, torso, and lower extremity injuries are a group at high risk for injury to the thoracic aorta. These easily identifiable risk factors may facilitate more rapid identification of this rare and potentially fatal injury.     

Diagnosis and management of bile leaks after blunt liver injury

BACKGROUND: Nonoperative management (NOM) of blunt liver injuries (BLIs) is common, but little data exist on the management of complications related to NOM. Furthermore, bile leaks are emerging as frequent complications of NOM. The goal of this study was to determine which BLI patients are at greatest risk for bile leaks and how to manage this complication. METHODS: Patients treated with NOM, including angiographic embolization (AE) and observation, were compared with those undergoing operation (OR). Mortality, hospital length of stay, liver-related complications, and severity of liver injury were compared among the groups. RESULTS: Two hundred eighty-one patients sustained a BLI from 1997 through 2004. The Injury Severity Score and age of the groups were similar. The mortality rate of the OR patients was higher (P = .02). All bile leaks occurred in patients with a liver Abbreviated Injury Score (AIS) of > or = 4. For survivors of more than 4 days, 71% of OR, 50% of AE, and 17% of observed patients developed bile leaks. For the OR and AE groups, HIDA scanning detected all leaks, leading to earlier drainage procedures. Detection of a bile leak in NOM patients before 5 days of hospitalization led to shorter HLOS, P = .02. No patient with a negative HIDA scan developed a subsequent bile leak. CONCLUSIONS: NOM of BLIs is associated with lower mortality, but significant complications. Bile leaks are more common in patients with higher liver AIS, and in this study presented in only those with liver AIS > or = 4. HIDA scanning successfully diagnosed all patients with bile leaks and led to less invasive drainage procedures over time and shorter HLOS.     

成人钝性肝损伤非手术治疗评价

目的评价成人钝性肝损伤非手术治疗的结果。方法对1982年10月至2002年10月收治的132例成人钝性肝损伤进行分析,其中非手术治疗34例,占全部病例25·8%,诊断除病史外1995年以前辅以腹腔穿刺或B超检查,部分患者行CT检查。1995年以后全部辅以CT检查。手术治疗98例。结果以1995年前后为界,非手术治疗率分别为16·7%(14/84)和41·7%(20/48)(χ2=9·98,P<0·01),非手术治疗成功率94·1%。手术治疗组中手术时肝损伤创面已无活动出血仅单纯引流病例分别为21·4%(15/70)和10·7%(3/28)(χ2=1·53,P>0·05)。结论应用CT扫描以及血液动力学监测,在严格选择适应证的情况下,某些成人钝性肝损伤病例是可以采用非手术治疗的。     

Blunt liver injury: from non-operative management to liver transplantation

Therapeutic options for blunt hepatic trauma include both non-operative and operative management. We have reviewed our experience of the management of blunt hepatic trauma, from non-operative to liver transplantation. A total of 72 patients with blunt hepatic injury observed at the first surgical unit of Padua in a 3-year period (1998-2000) were analysed; we also included a patient who had a liver transplant in 1993 for severe liver trauma. Twenty-nine patients (39.7%) were treated conservatively, with a 93% success rate; 60.3% were treated surgically. Suture hepatorraphy was the most common procedure performed (52.3%). Advantages of non-operative management in our experience were the reduced need for transfusion (1.1U versus 4.3U) with 92% of patients not needing transfusion, and a reduced stay in the intensive care unit; there was no liver-related mortality. The overall morbidity in surgical patients was 30%, with 16% liver-related complications. Twelve surgical patients (27.2%) died, with a liver-related mortality of 18.2%. A large number of patients may present with an associated endo-abdominal injury, even in low-grade liver trauma, requiring rapid laparotomy. In high-grade hepatic trauma, the evolution toward liver failure is an indication for liver transplantation.     

Risk factors for renal stone formation in patients with spinal cord injury

To determine factors that may influence kidney stone formation in spinal cord injury patients, the medical records of 893 patients who had been followed up by the Milwaukee Veterans Administration Medical Center from 1970 to 1984 were extensively reviewed. Urography showed that 12 patients had kidney stones. Twenty-four non-kidney stone patients with a similar age range, sex and duration of time since injury were selected as controls. Variables, such as level of spinal lesion, completeness of neurological dysfunction, presence of ureteric reflux etc, were compared and analysed statistically. The results showed that there was no difference between patients with and those without renal stone as far as the level of spinal injury and completeness of spinal cord lesion were concerned. There was no relationship between kidney stone formation and methods of urinary drainage or the presence of ureteric reflux. However, patients with good bladder control had no renal calculi. Serum creatinine, phosphorus, uric acid and calcium levels were similar in both groups of patients. There was a relationship between sepsis, positive urine culture and kidney stone formation. The absence of physical activity was not a risk factor for renal calculi and patients on a high fibre diet had the same incidence of stones as those on a regular diet.     

肝移植术后急性肺损伤的危险因素分析

目的 总结62例肝移植患者的临床资料，回顾性分析术后急性肺损伤（acute lung injury，ALI）发生的危险因素。方法 按ALI的诊断标准，将62例患者分为急性肺损伤组（ALI组）和非急性肺损伤组（NO—ALI组），比较两组的年龄、性别、原发病因、手术方式及预后。单因素、Logistic回归分析肝移植术后ALI发生的危险因素。结果 两组患者年龄、性别、原发病因及手术方式无明显差别。12例ALI发生在术后1d至4周，3例死亡。单因素分析发现，术后肺部感染、术中及术后的门肺高压、术中输血量、术中补液量、术后再次开腹、术后急性肾功能衰竭、术后激素冲击治疗对ALI的发生有显著影响。回归分析提示，术后肺部感染、术中及术后的门肺高压是ALI发生的危险因素。结论 术后肺部感染、术中及术后的门肺高压是肝移植术后ALI发生的危险因素，重视上述因素对预防与减少ALI的发生具有较重要的临床意义。     

Haemobilia after penetrating and blunt liver injury: treatment with selective hepatic artery embolisation

Although traumatic haemobilia is uncommon and occurs in less than 3% of liver injuries, the magnitude of the bleeding may result in life-threatening complications. This study evaluated the efficacy of selective hepatic artery embolisation (HAE) in the control of bleeding in patients with traumatic haemobilia. The demographic, clinical and angiographic data on all patients with traumatic haemobilia were obtained from a prospectively documented database of patients undergoing visceral angiography for liver haemorrhage between 1967 and 2002. During the 36-year period under review, 30 patients were found to have haemobilia on selective hepatic angiography. Ten of these 30 patients had haemobilia due to accidental non-iatrogenic trauma and form the basis of this study. In 8 of the 10 patients haemobilia resulted from penetrating liver injuries and two patients had blunt trauma. The mean delay between the initial injury and the diagnosis of haemobilia was 23.5 (range 1-120) days. The mean blood loss before angiography was 8 (range 3-19) units. Six patients were treated successfully with selective hepatic arterial embolisation, three required surgery and one resolved without any intervention. There were no deaths and no complications resulting in long term sequelae. Traumatic haemobilia is an uncommon but life-threatening complication of liver injury. Selective arterial embolisation is the initial treatment of choice with a substantial rate of success and a low incidence of serious complications.     

成人钝性肝损伤的非手术治疗

目的：评价成人钝性肝损伤非手术治疗的效果。
方法：回顾性分析近6年间非手术治疗96例成人钝性肝损伤患者的临床资料。其中肝外伤I级者51例（53.1%）,Ⅱ级30例（31.3%）,Ⅲ级12例（12.5%）,Ⅳ级3例（3.1%）。诊断包括病史、超声检查,腹腔穿刺及CT检查。入院后监测生命体征,并给予对症支持治疗。
结果：非手术治疗成功87例,成功率90.6%,中转手术治疗9例。共发生并发症15例,包括右侧胸腔积液12例,肝周脓肿3例,经对症处理后均痊愈。
结论：对钝性肝损伤施行非手术治疗是可行的;严格选择适应证、注意监测血流动力学、超声及CT等辅助检查,是提高成功率的关键。

     

Nonoperative management for patients with grade IV blunt hepatic trauma

Introduction

The treatment of complex liver injuries remains a challenge. Nonoperative treatment for such injuries is increasingly being adopted as the initial management strategy. We reviewed our experience, at a University teaching hospital, in the nonoperative management of grade IV liver injuries with the intent to evaluate failure rates; need for angioembolization and blood transfusions; and in-hospital mortality and complications.

Methods

This is a retrospective analysis conducted at a single large trauma centre in Brazil. All consecutive, hemodynamically stable, blunt trauma patients with grade IV hepatic injury, between 1996 and 2011, were analyzed. Demographics and baseline characteristics were recorded. Failure of nonoperative management was defined by the need for surgical intervention. Need for angioembolization and transfusions, in-hospital death, and complications were also assessed

Results

Eighteen patients with grade IV hepatic injury treated nonoperatively during the study period were included. The nonoperative treatment failed in only one patient (5.5%) who had refractory abdominal pain. However, no missed injuries and/or worsening of bleeding were observed during the operation. None of the patients died nor need angioembolization. No complications directly related to the liver were observed. Unrelated complications to the liver occurred in three patients (16.7%); one patient developed a tracheal stenosis (secondary to tracheal intubation); one had pleural effusion; and one developed an abscess in the pleural cavity. The hospital length of stay was on average 11.56 days.

Conclusions

In our experience, nonoperative management of grade IV liver injury for stable blunt trauma patients is associated with high success rates without significant complications.

     

Nonoperative management of major blunt liver injury with hemoperitoneum

We evaluated the role of nonoperative therapy in 16 patients with blunt multisystem trauma, hemodynamic stability following resuscitation, and major lobar liver injury; the patients were treated with a protocol of intensive care unit observation and computed tomographic scanning to identify and follow up the hepatic lesion. Computed tomographic scans showed right-lobe or bilobar liver lacerations and/or subcapsular hematomas in all patients and associated hemoperitoneum in 8 patients. Exploration was required in 2 patients; both were found to have a hemoperitoneum and a nonbleeding liver laceration. There were no deaths. Patients with hemoperitoneum requiring transfusion had significantly greater injury severity scores and longer intensive care unit and hospital stays. The major advantage of a nonoperative approach is the opportunity to stabilize major extra-abdominal (particularly head) injuries as the first priority. Unstable hemodynamics, abdominal distension, and falling hematocrit are indications for prompt exploration. Nonoperative care of these injuries requires a strict treatment protocol.