Major trauma centre and liver trauma

1. Management of liver trauma in
adults
Raimundas Lunevicius
Consultant Surgeon
Liverpool University Hospitals NHS FT, Aintree site
Mersey and Cheshire Major Trauma Centre
University of Liverpool
19th July 2018
1

2. Question 1
• What is the most important thing managing a
patient with liver trauma ?
2

3. Answer 1
recognition of the patient who should
proceed to immediate laparotomy
3

4. Question 2
What proportion of patients with liver injury
requires immediate laparotomy?
4

5. Answer 2
5%
5

6. Question 3
How often a subspecialist-liver surgeon would
be required during immediate laparotomy?
6

7. Answer 3
? %
Sporadic rare cases
7

8. Aim of this lecture:
summarize the basics of management of liver trauma in adults
Agenda:
Definition
Classifications
Its descriptors
Liver trauma radiology
Principles of management
8

9. Definition of traumatic injury to the liver
Traumatic injury to the liver is
any intentional / unintentional,
blunt / penetrating / impaled damage to the
liver and / or major perihepatic vessels
resulting from acute exposure to external,
mostly mechanical, energy.
9

10. 1. Liver trauma classification,
By Abbreviated Injury Scale / AIS 2005, Update 2008
NB! for epidemiologists / science, as AIS grades are taken into account calculating ISS (0 - 75)
6 AIS
grade
6 Descriptors Codes: Assigned to a 6-digit unique numerical identifier
(UNI) to the left of the decimal point (known as the predot code)
1 Minor
2 Moderate 541810.2 (for superficial hematoma)
541812.2 (for intraparenchymal hematoma ≤10 cm )
541820.2 (for laceration)
3 Serious 541814.3 (for hematoma)
541824.3 (for laceration)
4 Severe 541826.4 (for hematoma)
541840.4 (for laceration)
5 Critical 541828.5
6 Maximal:
untreatable
541830.6
The original AIS was defined in 1971, by AAM (Association for the Advancement of Automotive Medicine)
10

11. 2. Liver trauma classification,
The American Association for Surgery of Trauma (AAST)
FOR DAILY CLINICAL USE
AAST gr. Description / Definition
Grade I Parenchymal laceration (fracture, rupture) < 1 cm deep
Capsular avulsion with superficial hematoma ≤ 10 cm
Grade II Parenchymal laceration 1 – 3 cm deep
Intraparenchymal (subcapsular) hematoma ≤10 cm in diamether
Superficial hematoma >10-50%
Grade III Parenchymal laceration > 3 cm deep
Intraparenchymal (subcapsular) hematoma > 10 cm in diameter
Central penetrating wound
Grade IV Destruction of one hemiliver tissue (25-75% of the lobe or 1-3 S)
Massive central hematoma (‘burst’ injury)
Grade V Extensive disruption of both hemilivers tissue
Extensive disruption of > 3 S or >75% of a single lobe
Injury to major hepatic veins or retrohepatic IVC injury
Grade VI Hepatic avulsion (ie total separation of all vascular attachments)
11

12. However, it is universally accepted that the immediate management of liver
trauma is ultimately based on the the physiology of the patient, FIRSTLY
the radiological-anatomy of the injury (classifications), SECONDLY
I. PHYSIOLOGICAL STATUS is being classified as:
S - Stable
B - Borderline: management would depend on response to hemostatic resuscitation
U - Unstable: immediate surgery
E - In extremis: immediate surgery: thoraco-, laparo-, or nothing
II. CT-scan:
It is needed (when it is possible)
To date, only WSES liver trauma classification
covers these two practical points PARTIALLY:
The essence of this classification: the importance of injury grades is relative
as 90 - 95 % of adults are treated conservatively using follow-up imaging studies
12

13. 3. WSES Liver Trauma classification is beneficial
in practical surgery
WSES Grade Definition Utilization of AAST grade system
Grade 1 Minor: if stable AAST grade I – II
Grade 2 Moderate: if stable AAST grade III
Grade 3 Severe: if stable AAST grade IV – V
Grade 4 Severe: if unstable AAST grade I – VI
(1) It shows that importance of AIS or AAST grades in surgery is relative
(2) It delineates the patient who should proceed to immediate laparotomy:
Grade 4
However, it doesn’t stress the importance of borderline physiology
WSES liver trauma classification covers physiological status PARTIALLY
13

14. Liverpool, Aintree:
S+B+U+E classification + physiology and physiological response
Type Physiology Initial management Utilisation of AAST grade
S Stable CT: Conservative (SNOM) Any but Grade VI
B Borderline MHP + CT: all options to consider Any but Grade VI
U Unstable MHP + CT, if responsive:
ALL OPTIONS to consider
Any but Grade VI
E In extremis Surgery immediately Any (Grade I – VI)
MHP =
Immediate Hemostatic Resuscitation using Belmont Rapid Infuser
0(-) warmed blood 750 (3 units) ml a minute =
5 L in 5 minutes in AE Resus
at Aintree: 3L Reservoir and Heat Exchange Set for 4 packs
14

15. Belmont® Rapid Infuser
3L Reservoir and Heat Exchange Set for 4 packs: at Aintree
• 5L in 5 minutes
• Full prevention of air embolism
• This technology saved thousands of life globally by infusing warm blood and
helped to avoid unnecessary so called ‘damage control’ surgery in thousands
15

16. Interim conclusions
Know classifications & descriptors well
But DO NOT over-estimate liver injury grades
Bear in mind:
1. Status of physiology
2. Monitor response to hemostatic resuscitation (Belmont)
3. Assess CT-SCAN BASED INJURY ANATOMY
4. Understand impact of concomitant injuries
5. Listen what radiologist is telling you
6. Listen what other doctors and nurses are telling to you
Finally, BE PRECISE CONSULTING and REPORTING
16

17. CASES
• Most if the cases and images are original
• Some images downloaded from www
– For teaching, education purposes
– With editions:
• R. Lunevicius (using text boxes and arrows) clarified
liver, vascular, gallbladder, and injury anatomy
17

18. Grade I injury to the liver: stabbing
superficial subcapsular (< 10%) & small (1cm) intraparenchymal hematoma
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19. Grade I injury to the liver
Q 1: What is the likelihood of pseudoaneurysm?
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20. Grade I injury to the liver
Q 1: What is the likelihood of pseudoaneurysm?
A 1: low: < 5% or very low: < 1%
20

21. Grade I injury to the liver
Q 2: Should we re-CT-scan every patient
with grade I or II in post-trauma day 4?
21

22. Grade I injury to the liver
Q 2: Should we re-CT-scan every patient
with grade I or II in post-trauma day 4?
A 2A: Not
A 2B: Yes, if a patient has risk factors
(chronic liver disease, coagulopathy, etc. )
22

23. Grade I injury to the liver: stabbing
Celiac angiogram: pseudoaneurysm in S8: for angioembolisation
23

24. Grade I injury to the liver: stabbing
Postembolisation selective angiogram
A6
24
A8

25. Grade II injury to the liver: blunt
Large subcapsular hematoma (>10 – 50%)
25

26. Grade II injury: blunt
large subcapsular hematoma and S6 intraparenchymal hematoma (≤ 10 cm)
S6
26

27. Grade II injury: blunt trauma
Celiac angiogram: multiple pseudoaneurysms of the branches from the
right posterior sectional artery
S7
S6
S8
S5
Gb
LHA
MHA
RHA
27

28. Grade III injury: penetrating (ex. No. 1)
Parenchymal laceration > 3 cm deep
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29. Grade III injury: blunt trauma (ex. No. 2)
Large subcapsular hematoma, laceration > 3 cm deep (not in this tomogram) and
intraparenchymal hematoma > 10 cm in diameter in S6-S7 (S7 in this image)
MHV
IVC
RHV
Posterior
section
29

30. Grade III injury: blunt (ex. No. 3)
subcapsular and intraparenchymal hematoma (clots) > 10 cm
30

31. Grade IV injury: blunt trauma
superlarge subcapsular hematoma > 10 cm (unclotted and clotted blood) +
signs of right lobar (right lobe) destruction
IVC Right hemiliver
Left hemiliver
S4
31

32. Case report: Grade III liver injury
(original case report)
• Male, 40
• Fall on a solid object
• Interval 10 hours
• Stable, in terms ABCDE
• Hg 135 g/L, 105 g/L
after 12 hours
• CT-scan: S6-S7
S7
Posterior portal vein
32

33. Laceration, truncation of P6,
perihepatic blood, fracture of the rib:
Conservative management
33

34. Post-trauma Day 4
Radiology: No active bleeding or pseudo-aneurysms demonstrated.
CONSERVATIVE management
S5
S7
S6
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35. Case report: Impaled Grade III injury to the liver,
as central hepatic injury (original case report)
• 20 year-old male
• Injury mechanism: cross
bow shot
• Primary trauma survey:
– ABCD stable
– E: right anterior
thoracoabdominal region is
impaled with bow
• IV contrast enhanced CT-
scan within 30 minutes
35

36. 36
S8
G
S5
S5
G
S5
G
S6

37. Report of a radiologist
A cross bow passes through the liver and the superior
pole of the right kidney.
There does not appear to have been any major vascular
or hollow viscus injury
37

38. What did we discuss?
What would you do?
(audience)
Mini-MDT conference:
EGS & Trauma Consultant and HB Consultant
Questions
38

39. We discussed 4 management options:
1. The conservative management plan
consisting of removing the impaled object in theatre under GA,
observing, monitoring & managing complications in theatre (if
they would occur)
2. Removal of the impaled object and,
afterwards, laparoscopy for inspection
3. Laparoscopy & removal of the impaled object
4. Laparotomy and removal of the foreign body
Q: What was the outcome of discussion?
39

40. Disagreement in views, but the outcome:
Laparotomy (right subcostal) and removal of the foreign body
Straightforward removal of a foreign body
No bleeding (Surgicel applied)
Washout
One drain
Uneventful recovery
Discharge
with estimated chance of incisional hernia 20 %
40

41. Grade IV: RTA
S6-7 laceration, large parenchymal hematoma, active bleeding, destruction of
posterior section, haemoperitoneum: SURGERY, as grossly unstable
Haemoperitoneum
Haemoperitoneum
41
S7

42. Grade IV: RTA
SEGMENTAL RESECTION carried out
Post op CT-scan: AND… WHAT is this?
42

43. Grade IV: RTA
SEGMENTAL RESECTION carried out
Post op CT-scan: well demarkated infarction of left hemiliver
LESSON: DO NOT DO TOO MUCH / control damage just
43

44. Case report: Grade III (or IV)
(original case report)
• A male, 17
• With a thoracoabdominal
impalement injury
following an alleged
assault and stabbing
• The long handle of the
knife protruded from
right lateral
thoracoabdominal region
entering the 7th
intercostal space in the
anterior axillary line
• ABCD: stable (tachicardia)
Lunevicius R, O’Sullivan A. Unusual management of thoracoabdominal impalement injury to the right hemiliver
and diaphragm. Chin J Trauma 2014;17:1-3
44

45. Contrast enhanced CT-scan
PV
Haemoperitoneum
S8
45

46. Q: Management plan?
46

47. SNOM
• Manual removal of impaled knife under GA in theatre
• Insertion of chest drain: haemothorax,
• Observation 2 hours in operating theatre under GA
• Admission to HDU 24 hours
• PTBD of S8 biloma, as biliopleural fistula via chest drain
• ERCP / 10F biliary stent
• Chest drain removed as no signs of fistula
• Discharge on post trauma day 28
47

48. Management of biloma:
PTBD and ERCP / stent
S8
RHV
LHV
MHV
S8
48

49. Grade III (and >) injury to the liver
Q 1: What is the likelihood of pseudoaneurysm?
49

50. Grade III (and >) injury to the liver
A 1: moderate > 5%
50

51. Grade III (and >) injury to the liver
Q 2: Should we re-CT-scan every patient in post-
trauma day 4?
51

52. Grade III (and >) injury to the liver
A 2: YES
52

53. Case report: Grade V blunt injury
fall from height (3 m) (original case report)
• A, B - patent
C - hypotension, tender abdomen
D - fluctuating GCS 13 to 15
• CT-SCAN:
– R branch of the PV is not visualised
– Contrast blushes within several
areas of the right lobe in keeping
with active haemorrhage
– Hypoperfusion of R hemiliver
– Moderate vol haemoperitoneum
• Immediate trauma laparotomy
– EGS/Trauma and HB Consultants
– PERIHEPATIC PACKING
53

54. +10 hours from the presentation: CT-scan:
Surgical packing material in the RUQ
No CT evidence of active haemorrhage
Patient proceeded to angiography: the aim would be..?
54

55. ‘At the time of the procedure I did not feel there was any vascular abnormality requiring
treatment’: no embolisation
Coeliac axis and Hepatic artery angiogram
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56. Post-trauma day 1: removal of packs + drainage
Question:
Why In Day 1 as injury was classified as Gr. 5?
56

57. Post Trauma Day 9 (10:00 am): multiple pseudoaneurysms
Segments VI and VII are infarcted and replaced with fluid containing some gas locules. There are a few pseudoaneurysms noted arising from right
hepatic artery branches. The largest measures 8mm and arises near the origin of the segment VI branch, with a tiny 3mm pseudoaneurysm seen
slightly more distal to this. There is a further 6mm pseudoaneurysm seen more superiorly, probably arising from the segment VIII branch. INFERIOR
RIGHT PORTAL VEIN branch appears truncated (POSTERIOR SECTIONAL PORTAL VEIN)
Conclusion: MULTIPLE pseudoaneurysms arising from the segment VI and segment VIII branches of the right hepatic artery.
WHY DAY 9 (not 4-5) 57

58. Q: What would you do?
58

59. Q: What would you do?
A: Angioembolisation vs No angioembolisation
59

60. Angioembolisation – not done
• 10 hours later (D9):
hypovolemic shock,
fresh blood though the drain,
distended abdomen
• 3rd emergency laparotomy
Other opinions?
Surgery plan?
• What has been done?
60

61. • Ligation of right hepatic
artery & drain
• Day 7 post 3rd
laparotomy: fever
• Bile via drain: > 300 mL
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62. Day 10 post 3rd laparotomy
ERCP, ST: diffuse leak in the central parenchyma of right hemi-
liver
Therapeutic ERCP actions:
Insertion of plastic stent into CBD (length – 5 cm; diameter – 10 Fr)
Insertion of pancreatic pigtail stent (length – 5 cm, diameter – 4 Fr)
62

63. 16 March 2018
(2 months): US Abdomen :
Fluid noted within the
posterior segments of the
liver.
63

64. Summary
D0: CT + Emergency packing
D1: Removal of packs and drain
D4: CT-requested
D7: Done on this day: large false aneurysms
reported; but not reacted immediately
D7: Severe re-bleeding & Theatre: RHA ligation
(bleeding from right lateral section (6 / 7 ) stopped,
drain.
D10: External bile leak: ERCP, ST, Stent
64

65. 0
500
1000
1500
2000
2500
3000
3500
0 10 20 30
Units / Liter
Post-trauma day
ALT
Upper normal limit
0
50
100
150
200
250
0 10 20 30
Units / Liter
Post-trauma day
ALP
Lower normal limit
Upper normal limit
0
10
20
30
40
50
60
0 10 20 30
Micromol / Liter
Post-trauma day
Bilirubin
Upper normal limit
0
50
100
150
200
250
0 10 20 30
mg / L
Post-trauma day
CRP
Upper normal limit
Linear (CRP)
65

66. Management
Primum non nocere (‘first, do not harm’)
Recognition of the patient who should proceed to
immediate laparotomy is of utmost importance
NOM (95%)
Stable/bordeline/response to hemostatic resuscit
includes IR and endoscopic techniques
OM (5%)
66

67. Who is running this race?
The EGS Surgeon and HB when needed
67

68. Non-operative management
• Admit all pts with gr. 2-4 injuries to monitored bed (Ht < 32% to ICU)
• When Ht is stable
– Transfer to regular flow + advance diet
– Ht and Hg daily, Liver enzymes and bilirubin on day 2
– Mobilize when stable
• Grade I and II: discharge on day 1 – 2
• Grade III and IV or V: re-CT-scan on Day 4 (3-5)
• After discharge
– No school / work for a week
– No physical education for six weeks
– No major contact sports
• Grade I and II – for six weeks
• Grade III–V – for three months
– Instruct to return immediately to the ED if
• Worsening RUQ pain, fever, jaundice,...
• If so, consider biloma, UGI bleeding, secondary hemorrhage; avoid laparotomy.....
68

69. Operative management
Operative management when
– ‘grossly unstable (gr. 3 shock = 30% blood loss):
NO CT-scan is required – OPERATING THEATRE
– Hemodynamically bordeline patient
When NOT RESPONSIVE to
haemostatic resuscitation via Belmont® Rapid Infuser
69

70. Operative management
Immediately to Theatre: 2 ASSISTANTS / 2 scrub nurses
Prepare from chin to mid-thigh / two large suction devices
Midline incision + suction + quick gentle inspection
- Split lig. teres hepatis (not Falciform ligament !)
Firstly, assess hepatoduodenal ligament (for portal bleeding),
Secondly, assess liver AND classify bleeding into 2 classes:
(1) If it is bleeding from Portal Vein:
compress vein anatomically with fingers of L hand (50% JOB DONE);
use a pack/compression (as the alternative) / tourniquet
(2) NOT from PV: pack peri-hepatically / compress / wait
TEMPORAL CONTROL achieved: relax a moment and think
70

71. Thank you
71