Damage control surgery for grade IV blunt hepatic injury with multiple organ damage in a child: a case report

Background Intra-abdominal hemorrhage caused by blunt hepatic injury is a major cause of morbidity and mortality in patients with abdominal trauma. Some of these patients require laparotomy, and rapid decision-making and life-saving surgery are essential. Damage control (DC) surgery is useful for treating children in critical situations. We performed this technique to treat an 8-year-old boy with grade IV blunt hepatic injury and multiple organ damage. This is the first report of the use of the ABTHERA Open Abdomen Negative Pressure Therapy System (KCI, now part of 3 M Company, San Antonio, TX, USA) for DC surgery to rescue a patient without neurological sequelae. Case presentation An 8-year-old boy was brought to the emergency department of our hospital after being run over by a motor vehicle. He had grade IV blunt hepatic injury, thyroid injury, and bilateral hemopneumothorax. Although he was hemodynamically stable, the patient’s altered level of consciousness, the presence of a sign of peritoneal irritation, and suspicion of intestinal injury led us to perform exploratory laparotomy. As part of a DC strategy, we performed gauze packing to control hemorrhage from the liver and covered the abdomen with an ABTHERA Open Abdomen Negative Pressure Therapy System to improve the patient’s general condition. Eighteen days after admission, the patient was diagnosed with a biliary fistula, which improved with percutaneous and external drainage. He had no neurological sequelae and was discharged 102 days after injury. Conclusion The DC strategy was effective in children with severe blunt hepatic injury. We opted to perform DC surgery because children have less hemodynamic reserve than adults, and we believe that using this strategy before the appearance of trauma triad of death could save lives and improve outcomes. During conservative management, it is important to adopt a multistage, flexible approach to achieve a good outcome.

Grade IV blunt hepatic injury treated conservatively and successfully in a non-trauma centre: a case report

Management of blunt hepatic injury changed over the past three decades as a non-operative treatment is nowadays advocated by most in haemodynamically stable patients. We present the case of a young female patient with a high-grade blunt liver injury successfully treated in a non-trauma centre. She developed several complications secondary to the injury like a delayed bleeding, two different bilomas and a reactive pleural effusion requiring surgical expertise, interventional radiology, upper gastro-intestinal endoscopy and intensive care facilities. In the literature, the mortality and the morbidity rates for grade IV liver injuries respectively reach 16% and 39%. Because of potential delayed symptoms or signs and high complication rate, we think it should be appropriate to manage such a complex patient in a centre where at least above-mentioned specialities are available. Otherwise, a referral to a trauma centre should be a better option.

Studying the clinical profile of blunt hepatic trauma

Background: The liver is the largest intra-abdominal organ and is considered to be the second commonest organ to be injured in blunt abdominal trauma. Blunt hepatic injuries due to road traffic accidents are the sixth leading cause for death in India. Approximately 15-20% of abdominal injury presents as hepatic trauma and is liable for 50% of death resulting from abdominal trauma. The mortality rate is higher with blunt hepatic trauma than penetrating injuries. The advent of improved and expeditious imaging technologies amid advances in critical-care monitoring, prompted a significant shift towards conservative management of solid-organ abdominal injuries.Methods: The study was conducted over 96 patients in General Surgery Department, PGIMS, Rohtak with a history of blunt hepatic injury. The study duration was from 16th May 2018 till 1st June 2020. The aim of the study was to evaluate the pattern of blunt hepatic trauma and the patterns with which they presented in the emergency department.Results: In this study, 98.96% of the patients were managed conservatively whereas only 1.04% of patients needed surgical intervention. Conservative approach was possible because of strict patient monitoring, availability of experienced surgeons and radiologists, good intensive care unit care.Conclusions: The study concluded that conservative management of the patient is better than operative management and can be done in the patients who are hemodynamically stable. Most of the patients settle after 48 hours if managed conservatively.

Non-Operative Management of Isolated Blunt Hepatic Trauma - An Observational Study

BACKGROUND Blunt trauma is one of the most serious and most common causes of death in youth. Specifically, liver is one of the most frequently injured organs during abdominal trauma. During the last two decades, management of blunt trauma to the liver has changed from mainly operative intervention, to the current practice of selective operative and non-operative management (NOM). Avoidance of a laparotomy with its short- and long-term risks is of great benefit to the patient. Majority of patients admitted for liver injury have grade I, II and III injuries and are successfully treated with non-operative management. METHODS We conducted a prospective observational study over a period of 24 months between August 2017 and August 2019 among a total of 48 patients, in the Department of General Surgery, Government Medical College, Srinagar, and associated hospitals who were haemodynamically stable with isolated blunt hepatic trauma. RESULTS As liver trauma occurs more frequently in men, we found that male to female ratio was 3 : 1. In our study, 97 % of patients with isolated blunt hepatic trauma were haemodynamically stable, rest 3 % patients stabilized after initial resuscitation. Most of the complications 14.58 % occurred in higher grade injuries (grade IV and V). The complication rate in our study group was 18.75 %. CONCLUSIONS About 90 % of haemodynamically stable patients with isolated blunt hepatic injury can be managed successfully by non-operative management and nonoperative management is the treatment of choice irrespective of the grade of injury, mode of blunt trauma, age, and gender. KEYWORDS Non Operative Management, Hepatic Trauma

Aspirin Does Not Increase the Need for Hemostatic Interventions in Blunt Liver and Spleen Injuries.

Background: The prohemorrhagic effect of aspirin may cause concern about worse prognoses when treating blunt hepatic or splenic injuries. This study investigated whether preinjury aspirin yields an increasing need for hemostatic interventions.Methods: Admission and outpatient records were extracted from the Taiwan National Health Insurance Research Database (NHIRD) from 2003 to 2015. Patients with splenic or hepatic injuries were identified. Patients with preinjury nonaspirin APAC or with penetrating injuries were excluded. The primary outcome measurement was the necessity of invasive procedures to stop bleeding, including transarterial embolization (TAE) and surgeries. One-to-two propensity score matching (PSM) was used to minimize selection bias. Multilogistic regression (MLR) analysis was used to identify factors associated with hemostatic interventions.Results: 20,470 (60.6%) had blunt hepatic injuries, and 15,235 (45.1%) had blunt splenic injuries, of whom 691 (3.4%) and 667 (4.4%) used preinjury aspirin, respectively. In the blunt hepatic injury cohort, there was no significant difference in the need for hemostatic procedures (TAE (6.1% vs 6.1%, p=1.000), exploratory laparotomy (6.1% vs 6.1%, p=1.000), hepatectomy (3.0% vs 2.7%, p=0.694) or hepatorrhaphy (14.3% vs 15.0%, p=0.681)). MLR analysis showed that preinjury aspirin did not increase the need for hemostatic interventions (OR 0.92, 95% CI 0.73-1.16, p=0.473). Regarding the blunt splenic injury cohort, there was no significant difference in the need for hemostatic procedures (TAE (11.5% vs 10.6%, p=0.547), splenectomy (43.5% vs 41.4%, p=0.407) or splenorrhaphy (3.0% vs 3.3%, p=0.698)). An MLR analysis showed that preinjury aspirin did not increase the need for hemostatic interventions (OR 1.12, 95% CI 0.91-1.38, p=0.290).Conclusions: Preinjury aspirin use is not associated with increased hemostatic procedures in blunt hepatic or splenic injuries.