Hepatic artery pseudoaneurysm rupture: A case report.

Hepatic artery pseudoaneurysms are an uncommon complication of blunt hepatic trauma typically presenting in a delayed fashion. A 40-year-old male presented to a trauma centre after a 6-metre fall from a construction site with multiple injuries including a grade IV liver laceration centred around the porta hepatis. This liver injury was managed non-operatively. On day sixteen of admission, he had a sudden cardiac arrest from haemorrhagic shock with a subsequent CT demonstrating a ruptured extrahepatic proper hepatic artery pseudoaneurysm. Despite laparotomy and vessel repair, he died from pulmonary complications of aspiration pneumonia and acute lung injury associated with massive transfusion. The literature demonstrates conflicting views regarding the utility of repeat CT to detect a pseudoaneurysm in asymptomatic, non-operatively managed patients with blunt hepatic trauma. In particular, the literature does not distinguish the utility of repeat routine CT for intrahepatic and extrahepatic hepatic artery pseudoaneurysm, the latter if which is rarer. Current guidelines recommend against it, but there are observational studies suggesting utility, particularly in high grade (≥IV) liver injury. In patients with a high-grade injury extending to the porta hepatis, repeat imaging should be considered to detect possible pseudoaneurysm.

Persistent pseudoaneurysm after non-operative management of a Grade 4 liver injury.

A hepatic pseudoaneurysm (HPA) after blunt or penetrating liver injury is an unusual but potentially lethal complication that can develop from an injured hepatic artery branch [1-5]. Endovascular intervention with coil embolization to treat HPA is a safe and effective method and has become the standard first-line treatment, with a success rate achieving 70-100 % [13,14,15]. Infrequently the pseudoaneurysm is fed by collateral vessels and endovascular intervention may be unsuccessful. Other minimally invasive treatment options that can be considered include image guided percutaneous thrombin injection, endovascular placement of covered stents and injection of liquid agents such as fibrin glue [10,11]. We present a case of a young female who developed a post-traumatic persistent hepatic pseudoaneurysm requiring a total of nine interventions, including six endovascular interventions with angiography, three endoscopic procedures for bleeding, one percutaneous injection, and two re-admissions to the hospital. Although she avoided initial operative management, her three-month hospital course can be considered a failure of conservative management of blunt hepatic trauma due to the accrued health care costs and resources. The literature on the management of persistent pseudoaneurysm is limited. The decision to treat a persistent HPA that are found incidentally and stable in size needs further investigation.

Hepatectomy for massive hepatic necrosis after transcatheter arterial embolization hemostasis for hepatic hemorrhage following hepatic trauma: A case report.

Key Clinical Message: Although partial hepatic necrosis often occurs following endovascular treatment for bleeding associated with hepatic trauma, it is relatively rare that additional treatment is required. However, invasive procedures such as hepatic resection should sometimes be considered when infection occurs over massive hepatic necrosis. Abstract: Although partial hepatic necrosis following endovascular treatment for bleeding associated with hepatic trauma is occasionally experienced, it is relatively rare for the necrotic area of the liver to require additional treatment. However, invasive procedures such as hepatic resection should sometimes be considered when infection occurs over massive hepatic necrosis.

Non-operative Management of an Isolated Blunt Traumatic Retrohepatic Inferior Vena Cava Injury.

Traumatic inferior vena cava (IVC) injuries are often fatal. Blunt IVC injuries are encountered less often. Conservative management, albeit an option, is not often discussed in the literature. This report explores the non-operative management of a 52-year-old female unrestrained driver who presented with a blunt retrohepatic IVC injury identified on a computed tomography (CT) scan that revealed IVC disruption with extravasation of contrast. Here, we discuss the nonoperative management of the patient and review the literature concerning IVC anatomy, traumatic injuries, and management. We conclude that a hemodynamically stable patient with an isolated blunt traumatic IVC injury can be managed non-operatively.

Experimental study of the effects of absorbable gelatin sponge and non­absorbable polyvinyl alcohol particle material used in transcatheter arterial embolization on liver tissues.

Hepatic trauma is a leading cause of death in major abdominal trauma, and transcatheter arterial embolization has been widely used to treat it. However, there is limited research on whether absorbable gelatin sponge (AGS) and non-absorbable polyvinyl alcohol particles (PVA) have different effects on liver tissue, making it an important area of exploration. The present study investigated this issue using animal experiments by performing transhepatic arterial embolization with AGS and PVA. The effects on normal liver tissue in rabbits were examined by detecting liver function and inflammatory indexes, conducting histopathological examination, and using western blotting to detect apoptotic proteins. There were significant differences between the AGS and PVA groups after embolization. The AGS group exhibited a trend of improvement at ~1 week after embolization, and all indicators were statistically different until day 21 compared with the PVA group. The AGS group exhibited improved repair of hepatocytes and the biliary system based on H&E staining, while the PVA group exhibited more severe necrosis of the hepatocytes and biliary system around the embolization site. The western blotting results indicated that the Bcl-2/Bax ratio decreased on day 1 and day 3, and then rebounded in the AGS group on days 7 and 21, demonstrating gradual repair of hepatocytes compared with the PVA group.

Post-traumatic intrahepatic pseudoaneurysm: A case of successful conservative treatment.

Although post-traumatic intrahepatic pseudoaneurysms are rare in adults and even more uncommon in children, this serious complication can result in life-threatening bleeding. Most case studies have recommended surgical or endovascular interventions for preventing rupture or managing the bleeding from a ruptured intrahepatic pseudoaneurysm. Some studies also reported pseudoaneurysms could resolve without intervention and advised conservative therapy. In this case study, we describe a 19-month-old boy diagnosed with an intrahepatic pseudoaneurysm, upper gastrointestinal bleeding from the biliary tract, and hematoma infection. The patient received successful conservative treatment. After 36 days, the patient was discharged without signs of gastrointestinal bleeding and the steady shrinkage of the hematoma surrounding the pseudoaneurysm. The pseudoaneurysm and hematoma vanished at follow-up 18 months after the trauma. Conservative treatment may be considered a viable option, particularly for cases of post-traumatic intrahepatic pseudoaneurysms in children.

Predictors of need for endovascular intervention in hepatic trauma.

PURPOSE: Non-operative management of hepatic trauma with adjunctive hepatic arterial embolization (HAE) is widely accepted. Despite careful patient selection utilizing CTA, a substantial proportion of angiograms are negative for arterial injury and no HAE is performed. This study aims to determine which CT imaging findings and clinical factors are associated with the presence of active extravasation on subsequent angiography in patients with hepatic trauma. MATERIALS AND METHODS: The charts of 243 adults who presented with abdominal trauma and underwent abdominal CTA followed by conventional angiography were retrospectively reviewed. Of these patients, 49 had hepatic injuries on CTA. Hepatic injuries were graded using the American association for the surgery of trauma (AAST) CT classification, and CT images were assessed for active contrast extravasation, arterial pseudoaneurysm, sentinel clot, hemoperitoneum, laceration in-volving more than 2 segments, and laceration involving specific anatomic landmarks (porta hepatis, hepatic veins, and gallbladder fossa). Medical records were reviewed for pre- and post-angiography blood pressures, hemoglobin levels, and transfusion requirements. Angiographic images and reports were reviewed for hepatic arterial injury and performance of HAE. RESULTS: In multivariate analysis, AAST hepatic injury grade was significantly associated with increased odds of HAE (Odds ratio: 2.5, 95% CI 1.1, 7.1, p = 0.049). Univariate analyses demonstrated no significant association between CT liver injury grade, CT characteristics of liver injury, or pre-angiographic clinical data with need for HAE. CONCLUSION: In patients with hepatic trauma, prediction of need for HAE based on CT findings alone is challenging; such patients require consideration of both clinical factors and imaging findings.

Routine Repeat Imaging of Pediatric Blunt Solid Organ Injuries Is Not Necessary.

INTRODUCTION: Nonoperative management of hemodynamically stable patients with blunt splenic and/or hepatic injury has been widely accepted in the pediatric population. However, variability exists in the utilization and timing of repeat imaging to assess for delayed complications during index hospitalization. Recent level-IV evidence suggests that repeat imaging in children should be performed based on a patient's clinical status rather than on a routine basis. The aim of this study is to examine the rate of delayed complications and interventions in pediatric trauma patients with blunt splenic and/or hepatic injuries who undergo repeat imaging prompted either by a clinical change (CC) or non-clinical change (NCC). METHODS: A 9-year (2011-2019), retrospective, dual-institution study was performed of children (0-17 years) with blunt splenic and/or hepatic injuries. Patients were grouped based on reason for repeat imaging: CC or NCC. The rate of organ-specific delayed complications and interventions was examined by reason for scan. RESULTS: A total of 307 injuries were included in the study period (174 splenic, 113 hepatic, and 20 both). Of 194 splenic injuries, 30(15.5%) underwent repeat imaging (CC = 19; NCC = 11). Of 133 hepatic injuries, 27(20.3%) underwent repeat imaging (CC = 21; NCC = 6). There was no difference in the incidence of organ-specific delayed complications between the CC and NCC groups. Of the 4 patients with complications necessitating intervention, only one was identified based on NCC. CONCLUSIONS: Our data suggest routine repeat imaging is unnecessary in children with blunt splenic and/or hepatic injuries; therefore, practitioners may rely on a patient's clinical change.

Nonoperative Management of Blunt Hepatic Trauma: Comparison of Level I and II Trauma Centers.

INTRODUCTION: Most blunt liver injuries are treated with nonoperative management (NOM), and angiointervention (AI) has become a common adjunct. This study evaluated the use of AI, blood product utilization, pharmacological venous thromboembolic prophylaxis (VTEp), and outcomes in severe blunt liver trauma managed nonoperatively at level I versus II trauma centers. METHODS: American College of Surgeons Trauma Quality Improvement Program (TQIP) study (2013-2016), including adult patients with severe blunt liver injuries (AIS score>/= 3) treated with NOM, was conducted. Epidemiological and clinical characteristics, severity of liver injury (AIS), use of AI, blood product utilization, and VTEp were collected. Outcomes included survival, complications, failure of NOM, blood product utilization, and length of stay (LOS). RESULTS: Study included 2825 patients: 2230(78.9%) in level I and 595(21.1%) in level II centers. There was no difference in demographics, clinical presentation, or injury severity between centers. Angiointervention was used in 6.4% in level I and 7.2% in level II centers (P=.452). Level II centers were less likely to use LMWH for VTEp (.003). There was no difference in mortality or failure of NOM. In level II centers, there was a significantly higher 24-hour blood product utilization (PRBC P = .015 and platelets P = .002), longer ventilator days (P = .012), and longer ICU (P< .001) and hospital LOS (P = .024). The incidence of ventilator-associated pneumonia was significantly higher in level II centers (P = .003). CONCLUSION: Utilization of AI and NOM success rates is similar in level I and II centers. However, the early blood utilization, ventilator days, and VAP complications are significantly higher in level II centers.

Right Hepatic Artery Pseudoaneurysm Presenting As Upper Gastrointestinal Bleed: A Deadly Hit and Run Following Blunt Trauma.

Hepatic artery pseudoaneurysm (HAA) is a rare complication of blunt trauma, occurring in only 1% of patients. It is life-threatening with abysmal and atrocious outcomes if not recognized early and managed promptly. Other etiologies include transjugular-intrahepatic portosystemic shunt (TIPS), pancreatitis, cholecystectomy, and liver transplantation. We report a near-miss case in a 38-year-old woman following a motor vehicle accident. She sustained Grade III/IV liver laceration (>50% subcapsular hematoma), presenting with upper gastrointestinal bleeding (UGIB). Our patient was managed emergently intra-operatively, with hemostasis promptly achieved; however, she continued to bleed postoperatively, becoming hemodynamically unstable and unresponsive to both massive blood transfusions and high-dose proton pump inhibitors. Further imaging demonstrated HAA for which coil embolization was carried out by interventional radiology (IR).

Automated quantitative assessment of pediatric blunt hepatic trauma by deep learning-based CT volumetry.

BACKGROUND: To develop an end-to-end deep learning method for automated quantitative assessment of pediatric blunt hepatic trauma based on contrast-enhanced computed tomography (CT). METHODS: This retrospective study included 170 children with blunt hepatic trauma between May 1, 2015, and August 30, 2021, who had undergone contrast-enhanced CT. Both liver parenchyma and liver trauma regions were manually segmented from CT images. Two deep convolutional neural networks (CNNs) were trained on 118 cases between May 1, 2015, and December 31, 2019, for liver segmentation and liver trauma segmentation. Liver volume and trauma volume were automatically calculated based on the segmentation results, and the liver parenchymal disruption index (LPDI) was computed as the ratio of liver trauma volume to liver volume. The segmentation performance was tested on 52 cases between January 1, 2020, and August 30, 2021. Correlation analysis among the LPDI, trauma volume, and the American Association for the Surgery of Trauma (AAST) liver injury grade was performed using the Spearman rank correlation. The performance of severity assessment of pediatric blunt hepatic trauma based on the LPDI and trauma volume was evaluated using receiver operating characteristic (ROC) analysis. RESULTS: The Dice, precision, and recall of the developed deep learning framework were 94.75, 94.11, and 95.46% in segmenting the liver and 72.91, 72.40, and 76.80% in segmenting the trauma regions. The LPDI and trauma volume were significantly correlated with AAST grade (rho = 0.823 and rho = 0.831, respectively; p < 0.001 for both). The area under the ROC curve (AUC) values for the LPDI and trauma volume to distinguish between high-grade and low-grade pediatric blunt hepatic trauma were 0.942 (95% CI, 0.882-1.000) and 0.952 (95% CI, 0.895-1.000), respectively. CONCLUSIONS: The developed end-to-end deep learning method is able to automatically and accurately segment the liver and trauma regions from contrast-enhanced CT images. The automated LDPI and liver trauma volume can act as objective and quantitative indexes to supplement the current AAST grading of pediatric blunt hepatic trauma.

Severe Blunt Liver Injury Complicated by Delayed Massive Hemobilia in a Toddler: A Case Report and Literature Review.

Introduction: Unintentional injuries remain a leading cause of disability among children. Although most of the pediatric patients suffering blunt liver injury can be successfully treated with non-operative therapy, the diagnosis and management of delayed life-threatening hemobilia following severe blunt liver injury, especially in the pediatric population, remain a challenge for clinicians. Case Presentation: A previously healthy 2-year-old girl suffered a severe blunt liver injury related to an electric bike, which was inadvertently activated by herself. She initially received non-operative therapy and was in a stable condition in the first 2 weeks. On the 16th and 22nd postinjury days, the patient presented with life-threatening massive hemobilia, which was confirmed via repeat emergent gastroscopy and hepatic arterial angiography. An emergency selective transarterial embolization of the involved branch of the left hepatic artery was successfully performed. The patient recovered uneventfully, and long-term follow-up was needed owing to a mild dilatation of the left intrahepatic bile duct. Discussion: Incidental injury in children should be considered as a major public health issue and preventive measures should be taken to reduce its occurrence. Delayed massive hemobilia after severe blunt liver trauma is rare, and its accurate and timely diagnosis via emergency hepatic arterial angiography and selective angioembolization may allow prompt and optimal management to achieve good outcomes in the pediatric population.

A novel inflatable device for perihepatic packing and hepatic hemorrhage control: A proof-of-concept study.

INTRODUCTION: Uncontrolled bleeding is the primary cause of death in complex liver trauma and perihepatic packing is regularly utilized for hemorrhage control. The purpose of this study was to investigate the effectiveness of a novel inflatable device (the airbag) for perihepatic packing using a validated liver injury damage control model in swine. MATERIAL AND METHODS: The image of the human liver was digitally isolated within an abdominal computerized tomography scan to produce a silicone model of the liver to mold the airbag. Two medical grade polyurethane sheets were thermal bonded to the configuration of the liver avoiding compression of the hepatic pedicle, hepatic veins, and the suprahepatic vena cava after inflation. Yorkshire pigs (n = 22) underwent controlled hemorrhagic shock (35% of the total blood volume), hypothermia, and fluid resuscitation to reproduce the indications for damage control surgery (coagulopathy, hypothermia, and acidosis) prior to a liver injury. A 3 × 10 cm rectangular segment of the left middle lobe of the liver was removed to create the injury. Subsequently, the animals were randomized into 4 groups for liver damage control (240 min), Sponge Pack (n = 6), Pressurized Airbag (n = 6), Vacuum Airbag (n = 6), and Uncontrolled (n = 4). Animals were monitored throughout the experiment and blood samples obtained. RESULTS: Perihepatic packing with the pressurized airbag led to significantly higher mean arterial pressure during the liver damage control phase compared to sponge pack and vacuum airbag 52 mmHg (SD 2.3), 44.9 mmHg (SD 2.1), and 32 mmHg (SD 2.3), respectively (p < 0.0001), ejection fraction was also higher in that group. Hepatic hemorrhage was significantly lower in the pressurized airbag group compared to sponge pack, vacuum airbag, and uncontrolled groups; respectively 225 ml (SD 160), 611 ml (SD 123), 991 ml (SD 385), 1162 ml (SD 137) (p < 0001). Rebleeding after perihepatic packing removal was also significantly lower in the pressurized airbag group; respectively 32 ml (SD 47), 630 ml (SD 185), 513 ml (SD 303), (p = 0.0004). Intra-abdominal pressure remained similar to baseline, 1.9 mmHg (SD 1), (p = 0.297). Histopathology showed less necrosis at the border of the liver injury site with the pressurized airbag. CONCLUSION: The pressurized airbag was significantly more effective at controlling hepatic hemorrhage and improving hemodynamics than the traditional sponge pack technique. Rebleeding after perihepatic packing removal was negligible with the pressurized airbag and it did not provoke hepatic injury.

Hepatic trauma.

Management of trauma-related liver injury has undergone a paradigm shift over the past four decades. In hemodynamically stable patients, the standard of care in the majority of level-one trauma centers has shifted to nonoperative management with high success rates, especially with low-grade liver injuries (i.e., grade I and II liver injuries). Advances in critical care medicine, cross-sectional imaging, and transarterial embolization techniques have led to the improvement of patient outcomes and decreased mortality rates in patients with arterial injuries. Currently, no consensus guidelines on appropriate patient selection criteria have been published by the Society of Interventional Radiology (SIR) or the American Association for the surgery of Trauma (AAST). Based off the current literature, nonoperative management with hepatic angiography and transarterial embolization (TAE) should be the treatment of choice in hemodynamically stable patients with clinical suspicion of arterial injury. TAE has been shown to improve success rates of nonoperative management and is well tolerated by most patients with low complication rates. Hepatic necrosis is the most common and concerning reported complication but can be reduced with selective approach and choice of embolic agent. The majority of literature supporting the use of TAE for trauma-related liver injury consists of retrospective case series and additional larger scale studies are needed to determine the efficacy of TAE in this setting. However, it is clear from the current literature that hepatic TAE is an effective and safer option to operative management in treating arterial hemorrhage in the setting of traumatic hepatic injury.

Repeat Imaging in Blunt Hepatic Injuries Can Wait for Clinical Change.

BACKGROUND: There is variability regarding the utilization and timing of repeat imaging in adult patients with blunt hepatic injury who are managed nonoperatively. This study examines the rate of delayed complications and interventions in patients with blunt hepatic injuries who undergo repeat imaging prompted either by clinical change (CC) or non-clinical change (NCC). METHODS: A nine-year, retrospective, dual-institution study was performed of adult patients with blunt hepatic injuries. Patients were identified based on whether repeat imaging was performed and reason for reimaging: CC or NCC. The incidence of delayed complications and interventions was examined for each type of scan. RESULTS: Of 365 patients, 122 (33.4%) underwent repeat imaging [CC, n = 72 (59%); NCC, n=50 (41%)]. Mean time to repeat imaging was shorter in the NCC group [CC = 7.6 ± 8 days; NCC = 4.7 ± 6.3 days, P = 0.034]. Delayed complications were found in 30 (25%) patients reimaged, [CC, n = 20; NCC, n = 10, P = 0.395]. Interventions were performed in 12 (40%) patients [CC, n = 10; NCC, n = 2, P = 0.120]. CONCLUSIONS: Repeat imaging due to NCC occurred earlier than imaging performed by CC. One quarter of patients reimaged demonstrated a delayed complication, with nearly half undergoing intervention. There was no difference in incidence of delayed complications or interventions between groups, suggesting repeat imaging can be prompted by clinical change in blunt hepatic injuries.

Transcatheter arterial embolization for severe blunt liver injury in hemodynamically unstable patients: a 15-year retrospective study.

BACKGROUND: Transcatheter arterial embolization (TAE) is the first-line nonsurgical treatment for severe blunt liver injury in patients, whereas operative management (OM) is recommended for hemodynamically unstable patients. This study investigated the comparative efficacy of TAE in hemodynamically unstable patients who responded to initial infusion therapy. METHODS: This retrospective study enrolled patients with severe blunt liver injuries, which were of grades III-V according to the American Association for the Surgery of Trauma Organ Injury Scale (OIS). Patients who responded to initial infusion therapy underwent computed tomography to determine the treatment plan. A shock index > 1, despite undergoing initial infusion therapy, was defined as hemodynamic instability. We compared the clinical outcomes and mortality rates between patients who received OM and those who underwent TAE. RESULTS: Sixty-two patients were included (eight and 54 who underwent OM and TAE, respectively; mean injury severity score, 26.6). The overall in-hospital mortality rate was 6% (13% OM vs. 6% TAE, p = 0.50), and the hemodynamic instability was 35% (88% OM vs. 28% TAE, p < 0.01). Hemodynamically unstable patients who underwent TAE had 7% in-hospital mortality and 7% clinical failure. Logistic regression analysis showed that the treatment choice was not a predictor of outcome, whereas hemodynamic instability was an independent predictor of intensive care unit stay ≥7 days (odds ratio [OR], 3.80; p = 0.05) and massive blood transfusion (OR, 7.25; p = 0.01); OIS grades IV-V were predictors of complications (OR, 6.61; p < 0.01). CONCLUSIONS: TAE in hemodynamically unstable patients who responded to initial infusion therapy to some extent has acceptable in-hospital mortality and clinical failure rates. Hemodynamic instability and OIS, but not treatment choice, affected the clinical outcomes.

Accident-related hepatic trauma in a medical clinical center in eastern China: a cross-sectional study.

BACKGROUND: The treatment of hepatic injury can be complex. Medical clinical centers are often the first line hospitals for the diagnosis and treatment of hepatic trauma in China. The aim of the study is to summarize the experience in the diagnosis and treatment of hepatic trauma in one medical clinical center in China. METHODS: This retrospective study included patients with hepatic trauma admitted between January 2002 and December 2019 at the Xishan People's Hospital of Wuxi. The outcomes were cure rate and death within 14 days post-discharge. RESULTS: Among the 318 patients with hepatic trauma, 146 patients underwent surgical treatment, and 172 received conservative treatment; three patients were transferred to other hospitals for further treatment; 283 patients were cured, and 35 died. Severe hepatic trauma occurred in 74 patients, with a mortality rate of 31.1% and accounting for 65.7% of total mortality. American Association for the Surgery of Trauma (AAST) grading ≥ III (OR = 3.51, 95%CI: 1.32-9.37, P = 0.012) and multiple organ injury (OR = 7.51, 95%CI: 2.51-22.46, P < 0.001) were independently associated with death. Among patients with AAST grading ≥ III, surgery was an independent protective factor for death (OR = 0.08, 95%CI: 0.01-0.45, P = 0.004). Among patients with ASST ≥ III and who underwent surgery, age (OR = 5.29, 95%CI: 1.37-20.33, P = 0.015) and peri-hepatic packing (PHP) (OR = 5.54, 95%CI: 1.43-21.487, P = 0.013) were independently associated with death. CONCLUSIONS: AAST grading ≥ III and multiple organ injury were independently associated with death. Among patients with AAST grading ≥ III, surgery was an independent protective factor for death. Among patients with ASST ≥ III and who underwent surgery, age and PHP were independently associated with death.

Blunt and Penetrating Liver Trauma have Similar Outcomes in the Modern Era.

BACKGROUND: The trend in liver trauma management has progressively become increasingly conservative. However, a vast majority of literature focuses heavily on the management of blunt trauma. This study reviews the management of hepatic trauma at a major trauma center in a developing world setting, in order to compare blunt and penetrating liver trauma and to define current management algorithms and protocols. METHODS: All patients who sustained liver trauma between 2012 to 2018 were identified in the Hybrid Electronic Medical Registry and extracted for further analysis. RESULTS: A total of 808 patients with hepatic trauma were managed by our trauma center. There were 658 males and 150 females. The mean age was 30 years (standard deviation 13.3). A total of 68 patients died (8.2%) and a total of 290 (35%) patients required intensive care unit admission. The mean presenting shock index was 0.806 (standard deviation 0.67-1.0), the median Injury Severity Score was 18 (interquartile range 10-25) and the mean Revised Trauma Score was 12 (standard deviation 11-12). There were 367 penetrating and 441 blunt liver injuries. The age distribution was similar in both groups. There were significantly less females in the penetrating group. The shock index and the Injury Severity Score on presentation were significantly worse in the blunt group, respectively: 0.891 (standard deviation 0.31) versus 0.845 (standard deviation 0.69) (p < 0.001) and score 21 (interquartile range 13-27) versus 16 (interquartile range 9-20) (p < 0.01). The opposite applied to the Revised Trauma Score of 11.75 (standard deviation 0.74) versus 11.19 (standard deviation 1.3) (p < 0.001). There were significantly more associated intra-abdominal injuries in the penetrating group than the blunt group, in particular that of hollow organs, and 84% of patients with a penetrating injury underwent a laparotomy while only 33% of the blunt injuries underwent a laparotomy. The mortality rate was comparable between both groups. CONCLUSION: Hepatic trauma is still associated with a high morbidity rate, although there have been dramatic improvements in mortality rates over the last three decades. The mortality rates for blunt and penetrating liver trauma are now similar. Non-operative management is feasible for over two-thirds of blunt injuries and for just under 20% of penetrating injuries.

The Role of Angioembolization in Hepatic Trauma.

The liver is one of the most commonly injured solid organs in blunt abdominal trauma. Non-operative management is considered to be the gold standard for the care of most blunt liver injuries. Angioembolization has emerged as an important adjunct that is vital to the success of the non-operative management strategy for blunt hepatic injuries. This procedure, however, is fraught with some possible serious complications. The success, as well as rate of complications of this procedure, is determined by degree and type of injury, hepatic anatomy and physiology, and embolization strategy among other factors. In this review, we discuss these important considerations to help shed further light on the contribution and impact of angioembolization with regards to complex hepatic injuries.