Delayed Presentation of Severe Blunt Liver Trauma Following a 12-Foot Fall: A Case Report of a Grade 4 Hepatic Injury With a Concurrent Grade 1 Renal Injury.

The delayed presentation of a 15-year-old female with a complex Grade 4 liver injury and a concurrent Grade 1 renal injury sustained from a fall exemplifies the heightened vulnerability of adolescents to blunt hepatic trauma. Unlike typical presentations where symptoms like abdominal pain and internal bleeding appear immediately, this case emphasises the potential for delayed manifestation, posing unique challenges for diagnosis and management. This case, managed at a leading trauma centre, underscores the distinct challenges compared to adult cases due to adolescents' larger space available for the organ and immature livers. While presenting more management complexity than typical splenic injuries, prompt intervention with emergency laparotomy and hepatic packing proved crucial for the patient's successful outcome. This case emphasises the critical role of early identification, vigilant monitoring, and strict activity restrictions post-operatively for optimal adolescent liver trauma management and serves as a reminder of the spectrum of potential injuries, including bile duct and vascular damage alongside contusions and haematomas.

Right Diaphragmatic Rupture: A Case Report of a Rare Surgical Trauma Emergency.

Diaphragmatic injuries, particularly on the right side, are a rare yet challenging clinical scenario, especially when associated with other injuries. We present the case of a 38-year-old male patient who sustained a fall from a significant height, resulting in blunt abdominal trauma, chest injuries, right-side diaphragmatic injury, a grade 4 liver injury, and fractures of the right ribs, right femur, and pelvis. The patient also suffered a lung laceration with hemopneumothorax. The clinical team managed these injuries through a video-assisted thoracoscopy, laparotomy, and primary repair of the diaphragmatic rupture. The postoperative course was complicated by a low-output bile leak and infection of the orthopedic surgical wound, but these were effectively managed, and the patient showed a steady recovery. This case underscores the complexity of managing traumatic injuries that span multiple body regions and systems, requiring a coordinated, multidisciplinary approach. It also highlights the critical role of timely intervention and appropriate surgical strategies in the successful recovery of patients from complex traumas.

Grade V Liver Injury Presented With Peritonitis Treated With Stapler-Assisted Hepatic Segmentectomy: A Case Report.

The liver is one of the most commonly injured solid organs in blunt abdominal trauma. In patients who are hemodynamically normal, most cases of blunt liver injuries are managed conservatively. At present, nonoperative management (NOM) is the standard of care for both minor and severe liver injuries. Usually, patients with severe liver injuries, i.e., grades IV and V, are treated with surgical intervention versus angioembolization depending if patients are hemodynamically stable or not. We present a hemodynamically stable 53-year-old male patient with a grade V blunt liver injury with complete avulsion of the left lobe of the liver after a motor vehicle collision (MVC). Very few cases of complete hepatic avulsions have been published in the literature. We discuss surgical management with stapler-assisted hepatectomy in emergency trauma laparotomy for bleeding control.

Spontaneous Thrombosis of a Hepatic Pseudoaneurysm Following Blunt Liver Injury.

Hepatic pseudoaneurysm (HPA) is a rare complication of liver injury in children. Prophylactic embolization is preferable to prevent life-threatening hemorrhage due to pseudoaneurysm rupture. We present the case of a four-year-old boy who sustained a grade III liver injury from blunt abdominal trauma. He was conservatively managed since he was hemodynamically stable. Follow-up contrast-enhanced computed tomography (CECT) performed 10 days following the injury revealed an HPA measuring 4 mm × 4 mm × 3 mm. Herein, we chose conservative treatment for HPA as the patient was asymptomatic and hemodynamically stable. Conservative treatment was successful, and HPA spontaneously resolved 23 days following the injury without radiologic or surgical intervention. Although there are studies reporting asymptomatic HPAs that have spontaneously resolved, the natural history of HPAs remains unknown. Conservative treatment may be an option for asymptomatic HPA; however, to identify factors contributing to spontaneous thrombosis, further evaluation is needed.

Predictive factors of non-operative management failure in 494 blunt liver injuries: a multicenter retrospective study.

Non-operative management (NOM) has become the major treatment of blunt liver trauma (BLT) with a NOM failure rate of 3-15% due to liver-related complications. The aim of the study was to determine the predictive factors and a risk-stratified score of NOM failure. From 2013 to 2021, all patients with BLT in three trauma centers were included; clinical, biological, radiological and outcome data were retrospectively analyzed. Predictive factors and a risk-stratified score associated with NOM failure were identified. Four hundred and ninety-four patients with BLT were included. Among them, 80 (16.2%) had isolated BLT. Fifty-nine patients (11.9%) underwent emergent operative management (OM) on the day of admission and 435 (88.1%) had a NOM. NOM failure rate was 11.5%. Patients with a NOM failure more frequently had a hemoperitoneum (p < 0.001), liver bleeding (p < 0.001), blood transfusion (p < 0.001) and angioembolization (p < 0.001) compared to patient with a successful NOM. In multivariate analysis, the presence of hemoperitoneum (OR = 5.71; 95 CI [1.29-25.45]), angioembolization (OR = 8.73; 95 CI [2.04-38.44] and severe liver injury (AAST IV or V) (OR = 8.97; 95 CI [3.36-23.99]) were independent predictive factors of NOM failure. When these three factors were associated, NOM failure rate was 83.3%. The AAST grade, the presence of hemoperitoneum and the realization of liver angioembolization on the day of admission are three independent predictive factors of NOM failure. Our risk-score based on these three factors stratify the risk of NOM failure in BLT and could be used for a more appropriate level of medical survey adapted to each patient. Level of evidence: prospective observational cohort study, Level III.

Effectiveness of Tranexamic Acid in Reducing Hemorrhage in Isolated Blunt Solid Organ Injury.

INTRODUCTION: There is considerable interest in the use of tranexamic acid (TXA) for the control of hemorrhages in trauma patients. Multiple recent studies found that TXA used in the setting of a suspected significant hemorrhage in trauma patients significantly reduced mortality. To date, there are no cited studies that specifically address hemorrhage due to solid organ injury (i.e., kidneys, liver, and spleen) and TXA use in humans. Our current research addresses whether TXA is effective in reducing complications and mortality from traumatic hemorrhage in the setting of a specific solid organ injury. METHODS: We conducted a retrospective observational cohort study utilizing propensity score matching at Arrowhead Regional Medical Center (ARMC) from February 1, 2009 to February 1, 2019. This study period marks five years prior to and five years after February 1, 2004, which is the date when TXA first started to be used at ARMC in the management of traumatic hemorrhage. We compared for statistical difference between corresponding injury types in the TXA and non-TXA groups. RESULTS: Before the propensity matching, there were 123 patients who received TXA and 118 patients who did not. After propensity match for age and injury severity score (ISS), 35 patients were included in each group. We found no statistically significant difference between TXA and non-TXA treatment groups in terms of mortality at 24 hours (p-value=0.4945), mortality at 48 hours (p-value=0.4945), and mortality at 28 days (p-value=0.7426). We found no statistically significant difference between the need for interventional radiology intervention at 72 hours (p-value=0.3932), surgical intervention at 72 hours (p-value=0.2123) and possible TXA related complications (p-value=1). CONCLUSION: Although prior studies showed that TXA use in the setting of trauma may be beneficial, the specific candidate-selection criteria remain unclear. The results of our study suggest that the benefit from TXA in the setting of the isolated splenic, liver, and or renal injury may be negligible. We believe that this first-of-its-kind study adds to the growing body of knowledge about the utility of TXA and helps guide patient-selection criteria.

Blunt liver trauma: effectiveness and evolution of non-operative management (NOM) in 145 consecutive cases.

In recent decades, haemodynamically stable patients with traumatic liver injuries have been managed conservatively. The primary aim of this study is to retrospectively analyse the outcomes of the authors' approach to blunt hepatic trauma according to the degree of injury. The secondary aim is to analyse the changes in the decision-making process for blunt liver trauma management over the last 10 years. A total of 145 patients with blunt liver trauma managed by one trauma team were included in the study. Causes, sites and grades of injury, clinical conditions, ultrasonography and CT results, associated injuries, laboratory data, types of treatment (surgical or non-operative management/NOM), blood transfusions, complications, and lengths of hospitalization were recorded and analysed. A total of 85.5% of patients had extrahepatic injuries. The most frequently involved liver segments were VII (50.3%), VI (48.3%) and V (40.7%). The most common injury was grade III OIS (40.6%). Fifty-nine patients (40.7%) were treated surgically, with complications in 23.7% of patients, whereas 86 patients (59.3%) underwent NOM, with a complication rate of only 10.5%. The evolution over the last 10 years showed an overall increase in the NOM rate. This clinical experience confirmed that NOM was the most appropriate therapeutic choice for blunt liver trauma even in high-grade injuries and resulted in a 100% effectiveness rate with a 0% rate of conversion to surgical treatment. The relevant increase in the use of NOM did not influence the effectiveness or safety levels over the last 10 years; this was certainly related to the increasing experience of the team and the meticulous selection and monitoring of patients.

Post-Blunt Traumatic Hemobilia From Pseudoaneurysm Successfully Treated With Embolization.

Hemobilia is an uncommon but serious complication of traumatic liver injury. Diagnosis can be difficult because the presentation of gastrointestinal (GI) bleeding may be minimal or massive, and its delay is quite variable, ranging from a few days to several months. Radiologic evaluation, including ultrasound, CT, endoscopic retrograde cholangiopancreatography, and angiography, can be used for the diagnosis. Once the clinical presentation and diagnosis are considered, diagnostic and therapeutic arteriography must be performed as soon as possible. Here, we present a case of hemobilia two weeks postoperative for blunt traumatic liver injury in a 13-year-old boy who was treated successfully by N-butyl 2-cyanoacrylate (NBCA) embolization of the pseudoaneurysm.

Risk factors and management of different types of biliary injuries in blunt abdominal trauma: Single-center retrospective cohort study.

BACKGROUND: Biliary injuries after blunt abdominal traumas are uncommon and difficult to be predicted for early management. The aim of this study is to analyze the risk factors and management of biliary injuries with blunt abdominal trauma. METHOD: Patients with blunt liver trauma in the period between 2009 to May 2019 were included in the study. Patients were divided into 2 groups for comparison; a group of liver parenchymal injury and group with traumatic biliary injuries (TBI). RESULTS: One hundred and eight patients had blunt liver trauma (46 patients with liver parenchymal injury and 62 patients with TBI). TBI were; 55 patients with bile leak, 3 patients with haemobilia, and 4 patients with late obstructive jaundice. Eight patients with major bile leak and 12 patients with minor bile leak had been resolved with a surgical drain or percutaneous pigtail drainage. Nineteen patients (34.5%) with major and minor bile leak underwent successful endoscopic retrograde cholangiopancreatography (ERCP). Sixteen patients (29.1%) underwent surgical repair for bile leak. In Multivariate analysis, the possible risk factors for prediction of biliary injuries were central liver injuries (P = 0.032), high grades liver trauma (P = 0.046), elevated serum level of bilirubin at time of admission (P = 0.019), and elevated gamma glutamyl transferase (GGT) at time of admission (P = 0.017). CONCLUSION: High-grade liver trauma, central parenchymal laceration and elevated serum level of bilirubin and GGT are possible risk factors for the prediction of TBI. Bile leak after blunt trauma can be treated conservatively, while ERCP is indicated after failure of external drainage.

Laparoscopic anatomical liver resection after complex blunt liver trauma: a case report.

BACKGROUND: Various minimally invasive therapies are important adjuncts to management of hepatic injuries. However, there is a certain subset of patients who will benefit from liver resection, but there are no reports in the literature on laparoscopic anatomical liver resection for the management of complications after blunt liver trauma. CASE PRESENTATION: A 20-year-old male was admitted to the Emergency Unit of a tertiary referral center following a car accident. The patient was hemodynamically stable, and a radiologic workup demonstrated an isolated grade 3 injury of the left hemiliver. Initially, a nonoperative management was indicated, but during days following the injury, a high-volume biliary fistula complicated the clinical course. Despite percutaneous drainage, the development of devastating consequences of biliary peritonitis was imminent. A pure laparoscopic anatomical liver resection was performed. Left lateral sectionectomy eliminated the source of bile leak, and the surgery was completed with abdominal cavity lavage. Postoperative outcome was uneventful, and the patient was discharged on day 9 after injury and day 4 after surgery returning to his normal activity. CONCLUSIONS: In highly selected, hemodynamically stable patients with no other life-threatening concomitant injuries, laparoscopic liver resection in elective setting is feasible and safe for the management of complications after complex blunt trauma of the left liver. Extensive experience with hepatic surgery is needed, and surgeons should understand the increased risk they assume by taking on more complex surgical techniques.

Major hepatectomy for complex liver trauma.

The liver is the most frequently injured intraperitoneal organ, despite its relatively protected location. The liver consisting of a relatively fragile parenchyma contained within the Glisson capsule, which is thin and does not provide it with great protection. The management of hepatic trauma has undergone a paradigm shift over the past several decades with significant improvement in outcomes. Shifting from mandatory operation to selective nonoperative treatment, and, presently, to nonoperative treatment with selective operation. Operative management emphasizes packing, damage control, and utilization of interventional radiology, such as angiography and embolization. Because of the high morbidity and mortality, liver resection seems to have a minimal role in the management of hepatic injury in many reports, but in a specialized referral center, like our institute, surgical treatment becomes, in many cases, the only life-saving treatment. Innovations in liver transplant surgery, living liver donation, and the growth of specialized liver surgery teams have changed the way that surgeons and hepatic resection are done.

Is it possible to use transaminases for deciding on surgical or non-operative treatment for blunt liver trauma?

BACKGROUND: We aimed to research the relation of transaminase levels in blunt liver trauma (BLT) with the intensity of the trauma and the use of transaminase levels for deciding on surgical or non-operative treatment. METHODS: In all, 44 patients with BLT diagnosed by computerized tomography (CT) were involved in this retrospective study. By testing the correlation of the transaminase levels and the grade of liver injury with receiver operator characteristics (ROC), area under the curve (AUC) was calculated; besides, the sensitivity, specificity, and cut-off values of transaminases were calculated separately for the grades. Moreover, same method was repeated for the surgically and non-operatively treated patients. Cut-off value was assessed for surgical and non-operative treatments. The efficiency of transaminases in deciding non-operative treatment was compared with that of other methods using ROC test applied on focused abdominal sonography in trauma (FAST), hemodynamic instability, blood replacement rate, aspartate aminotransferase (AST), and alanine aminotransferase (ALT). RESULTS: It was observed that the AUC, sensitivity, and specificity increased correspondingly with the grade rise of transaminase levels in BLT. In the selection of non-operative treatment/surgery, following values have been confirmed: AUC for AST: 0.851 (sensitivity: 86%, specificity: 73%, cut-off value: 498 U/L), AUC for ALT: 0.880 (sensitivity: 86%, specificity: 81%, cut-off value: 498 U/L), AUC for replacement: 0.948 (sensitivity: 86%, specificity: 94%), AUC for hemodynamic instability: 0.902 (sensitivity: 86%, specificity: 94%), and AUC for FAST: 0.642 (sensitivity: 57%, specificity: 75%). CONCLUSIONS: It was found that in BLT, transaminases can predict the injury rating with higher accuracy as the grade rises, and they outrival FAST in terms of determining the need for laparotomy.

Management of blunt liver trauma in 134 severely injured patients.

BACKGROUND: In haemodynamic stable patients without an acute abdomen, nonoperative management (NOM) of blunt liver injuries (BLI) has become the standard of care with a reported success rate of between 80 and 100%. Concern has been expressed about the potential overuse of NOM and the fact that failed NOM is associated with higher mortality rate. The aim of this study was to evaluate factors that might indicate the need for surgical intervention, and to assess the efficacy of NOM. METHODS: A single centre prospective study between 2008 and 2013 in a level-1 Trauma Centre. One hundred thirty four patients with BLI were diagnosed on CT-scan or at laparotomy. The median ISS was 25 (range 16-34). RESULTS: Thirty five (26%) patients underwent an early exploratory laparotomy. The indication for surgery was haemodynamic instability in 11 (31%) patients, an acute abdomen in 16 (46%), and 8 (23%) patients had CT findings of intraabdominal injuries, other than the hepatic injury, that required surgical repair. NOM was initiated in 99 (74%) patients, 36 patients had associated intraabdominal solid organ injuries. Seven patients developed liver related complications. Five (5%) patients required a delayed laparotomy (liver related (3), splenic injury (2)). NOM failure was not related to the presence of shock on admission (p=1000), to the grade of liver injury (p=0.790) or associated intraabdominal injuries (p=0.866). CONCLUSION: Physiologic behaviour or CT findings dictated the need for operative intervention. NOM of BLI has a high success rate (95%). Nonoperative management of BLI should be considered in patients who respond to resuscitation, irrespective of the grade of liver trauma. Associated intraabdominal solid organ injuries do not exclude NOM.

Non-operative management of blunt liver trauma: feasible and safe also in centres with a low trauma incidence.

BACKGROUND AND AIMS: Non-operative management (NOM) of blunt liver trauma is currently, if possible, the preferred treatment of choice. The present study evaluates the experience of blunt liver injury in adults in a Swedish university hospital. MATERIAL AND METHODS: Forty-six patients with blunt liver trauma were treated from January 1994 through to December 2004. Patient charts were reviewed retrospectively to examine injury severity score (ISS), liver injury grade, diagnostics, treatment and outcome. RESULTS: Thirty-five patients (76%) were initially treated non-operatively and 11 (24%) patients had immediate surgery. In four (11%) patients, NOM failed and the patients required surgery 8-72 h after admission. Patients failing non-operative care had a significantly lower systolic blood pressure on admission as compared with patients with successful NOM (P = 0.001). Patients immediately operated upon had higher ISS (P < 0.001) and were haemodynamically unstable to a greater extent (P < 0.001) as compared with patients initially considered for NOM. Operated patients had increased transfusion requirements (P < 0.001), longer total hospital stay (P = 0.011) and stay in the intensive care unit (ICU) unit (P < 0.001) as compared with NOM. One immediately operated and one failed NOM died (total mortality 4%). Seventeen patients in the NOM group were successfully treated without surgery despite the presence of at least one described risk factor. CONCLUSIONS: Most patients with blunt liver trauma can be treated without surgery, and non-operative management may be performed even in the presence of established risk factors.