To acknowledge is to know gratitude

Dissertation

“AN OBSERVATIONAL STUDY ON MANAGEMENT AND OUTCOME OF LIVER TRAUMA, BASED ON WORLD SOCIETY OF

EMERGENCY SURGERY (WSES) GUIDELINES IN RGGGH”

Dissertation submitted to

THE TAMIL NADU Dr. M.G.R. MEDICAL UNIVERSITY CHENNAI

in partial fulfilment of the regulations for the Award of the degree of M.S. (General Surgery)

Branch – I

THE TAMIL NADU Dr. MGR MEDICAL UNIVERSITY CHENNAI

May 2020

CERTIFICATE

This is to certify that, the dissertation entitled “AN OBSERVATIONAL STUDY ON MANAGEMENT AND OUTCOME OF LIVER TRAUMA, BASED ON WORLD SOCIETY OF EMERGENCY SURGERY (WSES)

GUIDELINES IN RGGGH”

Is the bonafide work done by DR. T.SUGANTHAN , during his M.S. (General Surgery) course 2017-2020, done under my supervision and is submitted in partial fulfilment of the

requirement for theM.S.(BRANCH-I)- General Surgery of The Tamil nadu Dr.MGR Medical University, May 2020 examination.

Prof.R.KANNAN M.S Prof. R.KANNAN M.S.

Professor & Director Professor & Director

&

Institute of General Surgery Institute of General Surgery

Madras Medical College Madras Medical College

Chennai – 03. Chennai – 03.

Prof. DR. R. JAYANTHI M.D., FRCP [Glasg] , THE DEAN

DECLARATION

I, certainly declare that this dissertation titled “AN OBSERVATIONAL STUDY ON MANAGEMENT AND OUTCOME OF LIVER TRAUMA, BASED ON WORLD SOCIETY OF EMERGENCY SURGERY (WSES) GUIDELINES IN

RGGGH”represents a genuine work of mine. The contributions of any supervisors to the research are consistent with normal supervisory practice, and are acknowledged.

I also affirm that this bonafide work or part of this work was not submitted by me or any others for any award, degree or diploma to any other University board, either in India or abroad. This is submitted to The TamilNadu Dr. M.G.R Medical University, Chennai in partial fulfilment of the rules and regulations for the award of Master of Surgery Degree Branch I (General Surgery).

DATE:

PLACE: DR. T.SUGANTHAN

(POST GRADUATE)

ACKNOWLEDGEMENT

“

To acknowledge is to know gratitude

With proud privilege and deep respect, I express my gratitude and indebtedness to my revered Professors and Guide Prof.R.KANNAN M.S

Prof. S.BALAKRISHNAN, M.S, Prof. P. THANGAMANI M.S for their constant encouragement, patience, inspiration and support which they rendered in preparation of this dissertation and in my postgraduate studies.

I am deeply indebted to Prof.Dr. R.KANNAN M.S Director& Professor, Institute of General Surgery, Madras Medical College & Rajiv Gandhi Government General Hospital for his support and guidance.

I convey my special thanks and regards to my Assistant Professors

Dr. AASHIQ AHMED M.S, Dr.PRABHAKAR M.S, Dr.SAMPATH KUMAR M.S, Dr.ANANDAN M.S, their encouragement, valuable guidance and moral support throughout the course of this study.

I express my gratitude to the Dean, Dr. R. JAYANTHI M.D., FRCP Madras Medical College & Rajiv Gandhi Government General Hospital, Chennai-3 for permitting me to do this study.

I also thank my fellow postgraduates, friends and colleagues who have extended their co- operation in my work.

I thank my parents and family who have been my unflinching source of support and inspiration.

I would be failing in my duty if I do not show my deep sense of gratitude to all the patients who had helped me to become a surgeon and especially those who consented to be part of this study.

CERTIFICATE II

This is to certify that this dissertation work titled “AN OBSERVATIONAL STUDY ON MANAGEMENT AND OUTCOME OF LIVER TRAUMA, BASED ON WORLD SOCIETY OF EMERGENCY SURGERY (WSES) GUIDELINES IN RGGGH”

of the candidateDr. T.SUGANTHAN with registration Number221711019for the award ofM.S degree in the BRANCH -1 of General Surgery. I personally verified the urkund.com website for the

purpose of plagiarism Check. I found that the uploaded thesis file contains from introduction to conclusion pages and result shows 3% of plagiarism in the dissertation.

Guide & Supervisor sign with Seal.

CONTENTS

S.NO TITLE PAGE NO:

1. INTRODUCTION

10

2.

^{AIMS AND}

OBJECTIVES

3.

^{REVIEW OF}

LITERATURE

4. MATERIALS AND

METHODS

5. DATA ANALYSIS

AND RESULTS

6.

^DISCUSSION

7.

^CONCLUSION

8. BIBLIOGRAPHY

125

9.

^ANNEXURE

INTRODUCTION

INTRODUCTION

❖ Liver injuries are common in any high volume trauma centre .Our knowledge in its management has improved in the past three decades. Recent advances and minimally invasive techniques play a vital role in the conservative approach.

❖ It is very difficult for a trauma surgeon to control massive bleeding occurring in the liver following trauma.

❖ The bleeding structure is very tough to find out, and the crucial period of time to save the trauma victim before the onset of hypothermia, acidosis, and coagulopathy—the markers of an irreversible physiologic insult.

❖ Usual techniques of elective hepato-biliary surgery like segmental resection do not apply in hostile environment where the timing of intervention is a major factor in saving the life of the patient.

❖ It is very clear that the management of hepatic trauma has been a formidable challenge to all surgeons

❖ The evolvement of the management of hepatic trauma over the recent years is a reflection of the rapid understanding of the key parameters deciding the line of management in hepatic trauma.

❖ There were poor outcomes in patients where resection was done but future learning of the injured patient’s patho-physiology paved way for the concept of damage control that has been the key in modern trauma management.

❖ Meanwhile better learning of the outcome of various liver injuries in clinically stable patients has increased the conservative line of approach by using the modern imaging and minimally invasive procedures.

AIMS AND OBJECTIVES

AIMS AND OBJECTIVES

1. To find the efficacy of WSES guidelines in classifying liver trauma and determining optimal treatment strategy.

2. To study the clinical course of non-operatively managed patients

3. To find out appropriate monitoring methods and frequency of monitoring of non-operatively managed patients.

4. To study the profile of various other associated injuries in liver trauma.

REVIEW OF LITERATURE

REVIEW OF LITERATURE

ANATOMY OF LIVER

The liver is the largest organ in the body. Its domed upper surface relates entirely to the diaphragm while its postero-inferior, or visceral, surface rests against the abdominal oesophagus, stomach, upper duodenum, hepatic flexure of the colon, right kidney and suprarenal gland, as well as carrying the gall bladder .

Its surface relations can be marked out by joining points on: the right costal margin in the mid-axillary line, (the 10th rib) the right 5th intercostal space ditto the left 5th intercostal space in the mid-clavicular line.

The liver can readily be marked out on the subject by its dullness to percussion.

The liver in the normal subject is not palpable on clinical examination; especially in a well developed male, the contracted anterior abdominal muscles mimic the liver edge, but careful percussion reveals that the so called liver edge is resonant.

Peritoneal attachments

Apart from a small posterior bare area, demarcated as the peritoneum from the diaphragm reflects onto it as the upper and lower layers of the coronary ligament, the liver is otherwise enclosed in peritoneum.

To the right, these layers fuse to form the short right triangular ligament. The falciform ligament runs to the liver from the umbilicus carrying the ligamentum teres (the obliterated fetal umbilical vein), in its free border.

The ligamentum teres passes into its fissure on the inferior surface of the liver, while the falciform ligament passes over the dome of the liver and then divides; its right limb joins the upper layer of the coronary ligament, while its left limb stretches out as the long narrow left triangular ligament, which joins the lesser omentum as this arises from the fissure for the ligamentum venosum.

The lesser omentum arises from the fissures of the portahepatis and the ligamentum venosum to attach along the lesser curvature of the stomach.

Anatomical subdivisions :

The superior aspect of the liver is divided by the falciform ligament into an anatomical right and smaller left lobe.

Posteroinferiorly it bears an H-shaped arrangement of fossae: Anteriorly and to the right e the fossa for the gall bladder. Posteriorly and to the right e the groove for the inferior vena cava.

Anteriorly and to the left the groove for the ligamentum teres (often partially bridged by liver tissue). Posteriorly and to the left e the fissure for the ligamentum venosum. This represents the obliterated fetal ductus venosus, which shunts oxygenated blood from the umbilical vein to the inferior vena cava, short-circuiting the liver. The cross-bar of the H is the porta hepatis.

Two additional lobes are marked out on the visceral aspect of the liver between the limbs of the H e the quadrate lobe anteriorly and the caudate lobe behind.

Lying in the porta hepatis, which measures about 5 cm in length, are a triad of important structures . These are: The right and left hepatic ducts, fusing into the common hepatic duct anteriorly and to the right.

The hepatic artery dividing into its left and right branches e rather more posteriorly and to the

Segmental anatomy :

The gross anatomical division of the liver into its right and left lobes is useful in gross description but is without morphological significance.

The areas of supply of the right and left hepatic arteries, with accompanying portal vein and bile duct branches, can be demarcated by a line passing through the inferior vena cava and the fossa of the gall bladder, i.e. into roughly equal functional right and left lobes.

These can be subdivided into a further eight segments, four to each functional lobe , each segment with its individual blood supply and biliary drainage.

This arrangement allows the surgeon to carry out segmental hepatic resections.

The hepatic veins :

The portal venous blood returns to the inferior vena cava via the hepatic veins.These are large and have a different distribution to the portal triad.

The three major veins are the right, left and central hepatic veins. These pass in a postero- superior direction through the liver substance to drain into the inferior vena cava at the postero-superior aspect of the liver.

The arrangement is variable, but usually the middle vein (the smallest of the three), opens into the left vein just before its termination.

In addition, there is always a variable number of accessory veins that run directly from the liver to open along the inferior vena cava distal to the openings of the main veins.

Compression of the portal triad at the foramen of Winslow (Pringle’s manoeuvre), will not control bleeding from divided hepatic veins in partial liver resections or in liver trauma.

The severity of liver injuries is universally classified according to the American Association for the Surgery of Trauma (AAST) grading scale . The majority of patients admitted for liver injuries have grade I, II or III and are successfully treated with nonoperative management (NOM).

In contrast, almost two-thirds of grade IV or V injuries require laparotomy (operative

management, OM) . However in many cases there is no correlation between AAST grade and patient physiologic status.

Moreover the management of liver trauma has markedly changed through the last three decades with a significant improvement in outcomes, especially in blunt trauma, due to improvements in diagnostic and therapeutic tools.

In determining the optimal treatment strategy, the AAST classification should be supplemented by hemodynamic status and associated injuries.

The anatomical description of liver lesions is fundamental in the management algorithm but not definitive.

In fact, in clinical practice the decision whether patients need to be managed operatively or undergo NOM is based mainly on the clinical conditions and the associated injuries, and less on the AAST liver injury grade.

Moreover, in some situations patients conditions lead to an emergent transfer to the

surgical exploration; thus confirming the primary importance of the patient’s overall clinical condition.

Ultimately, the management of trauma requires an assessment of the anatomical injury and its physiologic effects.

AAST GRADING OF LIVER INJURY

1. The AAST Liver Injury grading system simplifies the multitude of liver injuries in the following way Superficial parenchymal wounds that require easier techniques of controlling the bleeding Deep parenchymal injury or extensive

parenchymal disruption, need to be packed Deep injury involving major vascular

pedicles, require special procedures to control the bleeding and have worst prognosis

2. The management of a type of injury depends on the patient’s hemodynamic status and the net physiologic insult.

3. The segmental anatomy of the liver has no role here but helps in describing the location of injuries.

4. Presently it is better to evaluate the advantage of conservative management in blunt hepatic trauma in clinically stable patients irrespective of the grade of the injury.

MECHANISM OF LIVER INJURY :

❖ In blunt trauma, a variety of forces act over the abdomen causing injury to the liver In an accident involving rapid deceleration, such as a motor vehicle collision or a fall from height, the relatively massive liver continues to be in motion while movement of the torso has stopped.

❖ This causes a tension at the attachments of the liver. The liver parenchyma and the hepatic veins may be torn from the inferior vena cava.

❖ As a result there can be a pericaval hematoma to a torrential bleeding .

❖ Shearing forces at the interface between the liver and the attachments of the liver to the abdominal wall, such as the coronary or triangular ligaments, cause superficial or deep excavations of the liver parenchyma, which in turn may or may not bleed .

❖ In addition, direct compression force can also cause injury such as a steering wheel hitting against the liver.

❖ This type of force causes impringement of the ribs into the liver with rupture of the Glisson's capsule and the soft liver parenchyma

❖ The term bear claw defect is used when the imprint of the ribs can be seen as a pattern on the traumatised liver.

❖ Contusion of the dome of the right lobe of the liver may occur as a result of compression of the right hemidiaphragm against the liver.

❖ Extrahepatic biliary system injuries are of lesser incidence in comparison to liver injuries, because of the small surface area and the fibrous covering surrounding the portal triad structures.

❖ Penetrating injury to the liver or extrahepatic biliary system usually results from knives or bullets, but can also be iatrogenic caused by interventional radiologic procedures.

❖ A bullet creates a cavity whereas a knife creates a wound that is limited to its path

❖ The extent of damage done by a bullet depends on its pathway, velocity, yaw, and design.

❖ Most hepatic trauma bleeding is venous and not arterial. Such bleeding can be massive causing several litres to be lost in seconds.

❖ Since most liver bleeding is venous, low pressure tamponade is easily performed .

❖ The liver parenchyma is very easily disrupted

❖ Glisson's capsule has little elasticity so it is torn easily.

❖ It provides a stiff barrier for the containment of bleeding within the parenchyma, as with a subcapsular hematoma.

❖ CLINICAL PRESENTATIONS OF LIVER INJURY

➢ Blood Loss

➢ Peritonism

❖ Symptoms:

➢ Abdominal Pain

➢ Radiation to shoulder

➢ Altered Sensorium

❖ Signs:

➢ Hypotension

➢ RIF tenderness

➢ Guarding

➢ Generalised Peritonism

➢ Hemoperitoneum

➢ Biliary Peritonitis

❖ Delayed :

DIAGNOSIS:

❖ Clinical manifestations of hepatic injuries are related to the type of trauma, amount of blood loss, and peritoneal irritation.

❖ There would be a history of blunt or penetrating trauma with pain in the right upper abdominal quadrant which may be referred to the right shoulder due to irritation of the inferior surface of the diaphragm in addition to nausea and vomiting.

❖ Examination of the patient will show variable degrees of shock which may predominate the picture.

❖ Signs of peritoneal irritation such as tenderness, rebound tenderness, and guarding are usually found and these signs would be prominent in case of bile leak.

❖ The initial clinical assessment of patients with blunt abdominal trauma is often inaccurate as the associated injuries often cause tenderness and spasms in

❖ Studies showed that the accuracy rate of clinical evaluation alone does not exceed 65% for detecting intraperitoneal bleeding.

❖ Occasionally, patients with blunt abdominal trauma do well initially, but they subsequently develop a liver abscess, presumably due to unrecognised liver

damage and these patients present with signs and symptoms of deep-seated infection.

❖ The mechanism of injury is critically important in assessing patients with

abdominal injury and this information may be obtained from the patient, relatives, police, or emergency care personnel.

❖ Following initial assessment, a conscious patient, who is hemodynamically unstable following blunt trauma and has generalised peritonism, or those with sustained penetrating injury, should undergo immediate laparotomy without further investigation.

❖ Hemodynamically stable patients with suspected liver can be investigated at this stage to define the nature of the injury. Focused assessment with sonography for trauma (FAST)

Focused assessment with sonography for trauma (FAST) :

❖ It has gained increased acceptance, particularly in the emergency department, for the rapid evaluation of patients with blunt or penetrating abdominal trauma.

❖ It is cheap, portable, and noninvasive, compared to peritoneal lavage, and it does not use radiation or iodinated contrast media.

❖ The sensitivity of FAST for the presence of intra‑abdominal fluid in patients with trauma ranges from75% to 93.8% and the specificity from 97% to 100%.

❖ However, some pitfalls remain in abdominal ultrasonography such as missing injuries at the dome or lateral segments of the liver and difficulty in distinguishing hepatic lacerations or hematomas because they are isoechoic to the normal liver.

❖ Contrast-enhanced ultrasonography has been proved to be useful in penetrating liver trauma without prolongation of examination time and it increases the

sensitivity and the specificity of ultrasound in the evaluation of abdominal trauma not only in the detection of reeperitoneal fluid but also in the visualization of the parenchymal lacerations.

Contrast-enhanced computed tomography (CT) :

❖ It is the gold standard diagnostic tool as it has high sensitivity and specificity for detecting liver injuries which increase as the time between injury and scanning increases, evidently because hematomas and lacerations become better defined.

❖ CT without intravenous contrast enhancement is of limited value in hepatic trauma, but it can be useful in identifying or following up a hemoperitoneum.

❖ The advantages of CT scanning in hepatic injury include the following; accurate grading of liver injuries, crude quantitation of the degree of hemoperitoneum, mandatory for patients with blunt trauma whose liver injury is to be managed nonoperatively, and detection of missile tracts in penetrating trauma patients which

is imperative for surgeons who want to attempt nonoperative management of penetrating wounds.

❖ Although CT is very useful in the evaluation of stable patients with abdominal trauma, most authors agree that unstable patients, with either blunt or penetrating trauma, are unlikely to benefit from this investigation because of the valuable time that it requires.

❖ False-positive errors are recorded with CT scans where the adjacent ribs may mimic contusion or hematoma, especially in the presence of air contrast level within the stomach in a patient with a nasogastric tube.

❖ False‑negative findings may occur if contrast enhancement is used in patients with fatty liver where the enhanced fatty liver may become iso‑attenuating relative to the laceration or hematoma; in this situation, a non enhanced CT scan may provide useful information regarding hepatic injury.

❖ Branching hepatic lacerations can mimic unopacified portal or hepatic veins or dilated intrahepatic bile ducts, so careful evaluation of serial images has to be done

Liver laceration Intra parenchymal hematoma

Subcapsular hematoma Intraperitoneal hemorrhage in perihepatic space

Hemoperitoneum from liver injury Before and after contrast

Grade 1 subcapsular hematoma Grade 1 liver laceration

Grade 2 subcapsular hematoma Grade 3 liver laceration

Grade 3 intra parenchymal

hematoma Grade 4 liver injury

Grade 5 liver injury

Magnetic resonance imaging (MRI):

❖ It has a limited role in the evaluation of blunt abdominal trauma.

❖ It has no advantage over CT scanning, and there is no sufficient experience to establish its false‑positive and false‑negative findings.

❖ However, MRI may be useful in pregnant women in whom the radiation dose is a concern, in patients with renal failure, and in allergic patients to radiographic contrast medium.

❖ In addition, magnetic resonance cholangio-pancreatography (MRCP) can be used in the assessment of biliary injury including that of pancreatic duct trauma.

MINIMALLY INVASIVE TECHNIQUES :

Angiography:

➢ It can be used in stable patients where cross‑sectional imaging may provide sufficient detail to treat the patient conservatively.

➢ However, it has no role in unstable patients.

➢ A dynamic angiographic study may demonstrate the site of active bleeding.

➢ In addition, it can be combined with angiographic embolization, especially in high-grade liver injury.

Endoscopic retrograde cholangio-pancreatography (ERCP):

➢ It may help in the delineation of the biliary tree in patients with liver trauma, and stents may be used to treat biliary leaks.

➢ Patients with prolonged bile leaks require endoscopic retrograde

➢ When there is a high output from a percutaneously placed drain

indicating an injury to the segmental or lobar bile duct it is advisable to do ERCP to delineate the site of injury and decompress the biliary tree

Laparoscopy in patients with abdominal trauma :

➢ It can reduce negative and non therapeutic laparotomy rates, patient morbidity rates, hospital treatment costs, and can be used as therapeutic tool in selected patients.

➢ However, its use in this context requires further study.

➢ These patients often present with failure to thrive, persistent low grade fever and biliary peritonitis.

➢ A gasless system to prevent gas embolism is preferable.

➢ Supra-umblical, epigastric and a single subhepatic lateral ports are made.

➢ Laparoscopy helps in the evacuation of the fluid from all the

➢ An organised clot from around the liver is never removed but a perihepatic drain is placed to monitor the biliary output .

➢ The injured liver can be inspected as an added advantage and the collections may be sent for culture and sensitivity .

➢ There is documented evidence of improved respiratory parameters with complete resolution of systemic inflammatory response syndrome in patients having large collection of blood and bile.

Image guided drainage :

➢ Patients with perihepatic fluid collections/ intrahepatic abscess may benefit from percutaneous drainage.

➢ CT-guided percutaneous drainage plays a key role

➢ It reduces the need for laparotomy in a large number of cases.

➢ It will also help in spontaneous closure of the biliary fistula when the isolation of ductal system is not possible with ERCP

➢ However, the radiologic placement of small-caliber drains around the liver will not remove the litres of blood and bile distributed in all four abdominal quadrants and the pelvis .

WSES classification :

❖ The WSES position paper suggested dividing hepatic traumatic lesions into minor (grade I, II), moderate (grade III) and major/severe (grade IV, V, VI) .

❖ This classification has not previously been clearly defined by the literature.

Frequently low-grade AAST lesions (i.e. grade I-III) are considered as minor or moderate and treated with NOM .

❖ However some patients with high-grade lesions (i.e. grade IV-V laceration with parenchymal disruption involving more than 75 % of the hepatic lobe or more than 3 Couinaud segments within a single lobe) may be hemodynamically stable and successfully treated nonoperatively .

❖ On the other hand, “minor” lesions associated with hemodynamic instability often must be treated with OM.

❖ This demonstrates that the classification of liver injuries into minor and major must

❖ The Advanced Trauma Life Support (ATLS) definition considers as “unstable” the patient with: blood pressure <90 mmHg and heart rate >120 bpm, with evidence of skin vasoconstriction (cool, clammy, decreased capillary refill), altered level of consciousness and/or shortness of breath.

❖ The WSES Classification divides Hepatic Injuries into three classes:–Minor (WSES grade I).–Moderate (WSES grade II).–Severe (WSES grade III and IV).

❖ The classification considers either the AAST classification either the hemodynamic status and the associated lesions.

❖ Minor hepatic injuries:- WSES grade I includes AAST grade I-II hemodynamically stable either blunt or penetrating lesions.

❖ Moderate hepatic injuries:– WSES grade II includes AAST grade III hemodynamically stable either blunt or penetrating lesions.

❖ Severe hepatic injuries:– WSES grade III includes AAST grade IV-VI

❖ Severe hepatic injuries :- WSES grade IV includes AAST grade I-VI hemodynamically unstable either blunt or penetrating lesions.

Recommendations for non operative management (NOM) in blunt liver trauma (BLT) :

❖ Blunt trauma patients with hemodynamic stability and absence of other internal injuries requiring surgery, should undergo an initial attempt of NOM irrespective of injury grade (GoR 2 A).

❖ NOM is contraindicated in the setting of hemodynamic instability or peritonitis (GoR 2 A).

❖ NOM of moderate or severe liver injuries should be considered only in an

environment that provides capability for patient intensive monitoring, angiography, an immediately available OR and immediate access to blood and blood product (GoR 2 A).

❖ In patients being considered for NOM, CT-scan with intravenous contrast should be performed to define the anatomic liver injury and identify associated injuries (GoR 2 A).

❖ In hemodynamically stable blunt trauma patients without other associated injuries requiring OM, NOM is considered the standard of care.

❖ In case of hemodynamic instability or peritonitis NOM is contraindicated.

❖ The requirements to attempt NOM of moderate and severe injuries are the capability to make a diagnosis of the severity of liver injuries, and to provide intensive

management (continuous clinical monitoring, serial hemoglobin monitoring, and around-the-clock availability of CT-scan, angiography, OR, and blood and blood products).

❖ No evidence exists at present to define the optimal monitoring type and duration.

❖ In patients with ongoing resuscitative needs, the angioembolization is considered as an “extension” of resuscitation.

❖ However with the aim to reduce the need for transfusions and surgery, angio embolisation can be applied safely but generally only in selected centres.

❖ If required it can be safely repeated. Positive results associated with its early use have been published

❖ In blunt hepatic trauma, particularly after high-grade injury, complications occur in 12–14 % of patients.

❖ Diagnostic tools for complications after NOM include: clinical examination, blood tests, ultrasound and CT-scan.

❖ Although routine follow-up with CT-scan is not necessary,in the presence of abnormal inflammatory response, abdominal pain, fever, jaundice or drop of hemoglobin level, CT-scan is recommended.

❖ Bleeding, abdominal compartment syndrome, infections (abscesses and other infections), biliary complications (bile leak, hemobilia, bilioma, biliary peritonitis, biliary fistula) and liver necrosis are the most frequent complications associated with NOM.

❖ Ultrasound is useful in the assessment of bile leak/biloma in grade IV-V injuries, especially with a central laceration. Re-bleeding or secondary hemorrhage are frequent (as in the rupture of a subcapsular hematoma or a pseudoaneurysm).

❖ In the majority of cases (69 %), “late” bleeding can be treated non-operatively.

❖ Biliary complications can occur in 30 % of cases. Endoscopic retrograde cholangio- pancreatography (ERCP) and eventual stenting, percutaneous drainage and surgical intervention (open or laparoscopic) are all effective ways to manage biliary complications.

❖ In presence of intrahepatic bilio-venous fistula (frequent associated with bilemia) ERCP represents an effective tool.

❖ CT-scan or ultrasound-guided drainage are both effective in managing peri- hepatic abscesses (incidence 0–7%).

❖ In presence of necrosis and devascularization of hepatic segments surgical management would be indicated.

❖ Hemobilia is uncommon and frequently associated with pseudo-aneurysm.

❖ In hemodynamically stable and non-septic patients embolization is safe and could be considered as the first approach; otherwise surgical management is mandatory.

❖ Lastly, the liver compartment syndrome is rare and has been described in some case

❖ Decompression by percutaneous drainage or by laparoscopy has been described.

❖ No standard follow-up and monitoring protocol exist to evaluate patients with NOM liver injuries.

❖ Serial clinical evaluation and hemoglobin measurement are considered the pillars in evaluating patients undergone to NOM.

❖ Abdominal ultrasound could help in managing non-operatively managed liver trauma patients.

Recommendations for NOM in penetrating liver trauma (PLT):

❖ NOM in penetrating liver trauma could be considered only in case of hemodynamic

stability and absence of: peritonitis, significant free air, localized thickened bowel wall, evisceration, impalement (GoR 2 A).

❖ NOM in penetrating liver trauma should be considered only in an environment that provides capability for patient intensive monitoring, angiography, an immediately available OR and immediate access to blood and blood product (GoR 2 A).

❖ CT-scan with intravenous contrast should be always performed to identify penetrating liver injuries suitable for NOM (GoR 2 A).

❖ Serial clinical evaluations (physical exams and laboratory testing) must be performed to detect a change in clinical status during NOM (GoR 2 A).

❖ Angioembolisation is to be considered in case of arterial bleeding in a hemodynamic stable patient without other indication for OM (GoR 2 A).

❖ Severe head and spinal cord injuries should be considered as relative indications for OM, given the inability to reliably evaluate the clinical status (GoR 2A).

❖ The most recent published trials demonstrate a high success rate for NOM in 50 % of stab wounds (SW) in the anterior abdomen and in about 85 % in the posterior

abdomen.

❖ The same concept has also been applied to gunshot wounds (GSWs).

❖ However, a distinction should be made between low and high-energy penetrating trauma in deciding either for OM or NOM.

❖ In case of low energy, both SW and GSW, NOM can be safely applied. High energy GSW and other ballistic injuries are less amenable to NOM because of the high- energy transfer, and in 90 % of cases an OM is required.

❖ Of note, a 25 % non-therapeutic laparotomy rate is reported in abdominal GSWs.

❖ This confirms that in selective cases NOM could be pursued either in GSWs. Clinical trials report a high success rate of NOM in penetrating liver injuries (69 to 100 %).

❖ Absolute requirements for NOM are: hemodynamic stability, absence of peritonitis, and an evaluable abdomen .

❖ Current guidelines suggest that hemodynamically stable patients presenting with evisceration and/or impalement and/or diffuse peritonitis should be considered candidates to be directly taken to the OR without CT-scan.

❖ These findings are particularly important in cases of gunshot injuries.

❖ Other suggested predictive criteria of NOM failure in abdominal GSWs are:

associated head and spinal cord injuries (that preclude regular clinical

examination) and significant reduction in hemoglobin requiring more than 2–4 units of blood transfusion in 24 h.

❖ In SWs the role of CT scan has been questioned.

❖ Local wound exploration (LWE) is considered accurate in determining the depth of penetration; sometimes in little wounds it would be necessary to enlarge a little the incision.

❖ However, wound exploration near the inferior costal margin should be avoided if not strictly necessary because of the high risk to damage the intercostal vessels.

❖ Emergency laparotomy has been reported to be necessary even in some cases with negative CT-scan.

❖ CT-scan may be necessary in obese patients and when the wound tract is long, tangential and difficult to determine the trajectory.

❖ In NOM of GSWs the CT-scan can help in determining the trajectory. However not all authors consider it mandatory.

❖ CT-scan has a specificity of 96 % and a sensitivity of 90.5 % for GSWs requiring laparotomy.

❖ The gold standard to decide for OM or NOM remains the serial clinical examination.

❖ NOM is contraindicated in case of CT-scan detection of free intra-or retro-peritoneal air, free intra-peritoneal fluid in the absence of solid organ injury, localised bowel wall thickening, bullet tract close to hollow viscus with surrounding hematoma and in high energy penetrating trauma.

❖ In NOM strict clinical and hemoglobin evaluation should be done (every 4–6 h for at least 48 h); once stabilized the patient could be transferred to the ward.

❖ There is considerable variation in local CT-scan imaging practices, and no uniform

❖ Variations are dependent on imaging hardware, radiation exposure, contrast dose, and image sequences, among other factors.

❖ For example, image acquisition may occur in a triphasic fashion (non-contrast, arterial, and portal venous phases), or as a single phase following a split bolus contrast injection, providing a mixed arterial and portal venous phase.

❖ These variables have not been standardised across centers, or in the literature, and require expert radiologist consideration and manipulation for optimal diagnostic yield, and are dependent on the study indication.

❖ Even in penetrating liver trauma, the angioembolization is considered as an

“extension” of resuscitation in those patients presenting with ongoing resuscitative needs.

❖ However angioembolization can be applied safely only in selected centers. If required it can be safely repeated.

❖ The main reluctance of surgeons to employ NOM in penetrating trauma is related to the fear of missing other abdominal lesions, especially hollow viscus perforation.

❖ In patients without peritonitis on admission, no increase in mortality rates with

❖ On the other hand, non-therapeutic laparotomy has been demonstrated to increase the complication rate.

❖ Nevertheless OM in penetrating liver injuries has a higher liver-related complication rate (50–52 %) than in blunt ones.

Follow-up after successful NOM :

❖ Clear and definitive direction for post-injury follow-up and normal activity resumption in those patients who experienced NOM haven’t been published yet.

❖ General recommendations are to resume usual activity after 3–4 months in patients with an uncomplicated hospital course.

❖ This derives from the observation that the majority of liver lesions heal in almost 4 months.

❖ If the CT-scan follow-up (in grade III-V lesions) has shown significant healing normal activity can be resumed even after 1 month.

❖ Patients should be counselled not to remain alone for long periods and to return to the hospital immediately if they experience increasing abdominal pain,

lightheadedness, nausea or vomiting.

Recommendations for operative management (OM) in liver trauma (blunt and penetrating) :

❖ Patients should undergo OM in liver trauma (blunt and penetrating) in case of hemodynamic instability, concomitant internal organs injury requiring surgery, evisceration, impalement (GoR 2 A).

❖ Primary surgical intention should be to control the hemorrhage, to control bile leak and to institute an intensive resuscitation as soon as possible (GoR 2 B).

❖ Major hepatic resections should be avoided at first, and considered subsequently (delayed fashion) only in case of large devitalized liver portions and in centers with the necessary expertise (GoR 3 B).

❖ Angioembolisation is a useful tool in case of persistent arterial bleeding (GoR 2 A).

❖ In those cases where no major bleeding are present at the laparotomy, the bleeding may be controlled by compression alone or with electrocautery, bipolar devices, argon beam coagulation, topical hemostatic agents, or omental packing.

❖ In presence of major haemorrhage more aggressive procedures can be necessary.

❖ These include first of all hepatic manual compression and hepatic packing, ligation of vessels in the wound, hepatic debridement, balloon tamponade, shunting procedures, or hepatic vascular isolation.

❖ It is important to provide concomitant intra operative intensive resuscitation aiming to reverse the lethal triad .

❖ Temporary abdominal closure can be safely considered in all those patients when the risk of developing abdominal compartment syndrome is high and when a second look after patient’s hemodynamic stabilization is needed.

❖ Anatomic hepatic resection can be considered as a surgical option.

❖ In unstable patients and during damage control surgery a non-anatomic resection is safer and easier.

❖ For staged liver resection, either anatomic either non-anatomic ones can be safely made with stapling device in experienced hands.

❖ If despite the fundamental initial maneuvers (hepatic packing, Pringle maneuver) the bleeding persists and evident lesion to a hepatic artery is found, an attempt to control it should be made.

❖ If repair is not possible a selective hepatic artery ligation can be considered as a viable option. In case of right or common hepatic artery ligation, cholecystectomy should be performed to avoid gallbladder necrosis.

❖ Post-operative angioembolization is a viable option, when possible, allowing hemorrhage control while reducing the complications.

❖ After artery ligation, in fact, the risk of hepatic necrosis, biloma and abscesses

❖ Portal vein injuries should be repaired primarily. The portal vein ligation should be avoided because liver necrosis or massive bowel edema may occur.

❖ Liver Packing and a second look or liver resection are preferable to portal ligation.

❖ In those cases where Pringle maneuver or arterial control fails, and the bleeding persists from behind the liver, a retro-hepatic caval or hepatic vein injury could be present.

❖ Three therapeutic options exist:

1) Tamponade with hepatic packing

2) Direct repair (with or without vascular isolation) 3) Lobar resection.

❖ Liver packing is the most successful method of managing severe venous injuries.

❖ Direct venous repair is problematic in non-experienced hands, with a high mortality

❖ When hepatic vascular exclusion is necessary, different types of shunting procedures have been described, most of them anecdotally.

❖ The veno-veno bypass (femoral vein to axillary or jugular vein by pass) or the use of fenestrated stent grafts are the most frequent type of shunt used by surgeons familiar with their use.

❖ The atrio-caval shunt bypasses the retro-hepatic cava blood through the right atrium using a chest tube put into the inferior cava vein. Mortality rates in such a

complicated situations are high.

❖ Liver exclusion is generally poorly tolerated in the unstable patient with major blood loss .

❖ In the emergency, in cases of liver avulsion or total crush injury, when a total hepatic resection must be done, hepatic transplantation has been described .

❖ The exact role of post-operative angio-embolization is still not well defined.

❖ Two principal indications have been proposed:

1) After primary operative hemostasis in stable or stabilized patients, with an evidence at contrast enhanced CT-scan of active bleeding.

2) As adjunctive hemostatic control in patients with uncontrolled suspected arterial bleeding despite emergency laparotomy.

ROLE OF IMMEDIATE RELAPAROTOMY:

❖ The following are dangerous situations requiring urgent exploration

➢ continued bleeding

➢ abdominal compartment syndrome

➢ a missed injury

❖ Unpacking is done slowly and the injury site is visualised for the source of continuous bleeding.

❖ Laparotomy of the entire abdomen is done again cautiously to find other missed sources of bleeding.

❖ The following could be the reasons for bleeding :

1.Inadequate hemostasis of the original injury 2. Another source of bleeding in the vicinity 3. Iatrogenic trauma

4. Diffuse coagulopathy

❖ Rebleeding worsens the prognosis of the patient and increases mortality rate.

❖ It is a big challenge in achieving hemostasis after rebleeding as the liver will be grossly swollen and fragile for any further intervention .

ROLE OF RELAPAROTOMY FOR PACK REMOVAL:

❖ There is a technical challenge of the timing and technique of removing the packs

❖ TIMING OF RELAPAROTOMY :

1. The ideal time for unpacking the liver will be after 36 to 48 hours from the initial surgery.

2. There have been reports of increasing sepsis, respiratory and wound related complications if unpacking is done after 3 day

3. This ideal period of time activates the coagulation system in an effective manner and arrests the bleeding from the damaged liver.

4. It is also effective in identifying the missed solid organ or hollow viscus injuries with chances of effective intervention.

5. There is and added advantage of easier closure of the abdomen and lesser wound related complications

STEPS TO BE DONE :

1. The first step will be adequate irrigation over the packing with normal saline and never an attempt of removal to be made without irrigation.

2. Packs have to be removed slowly layer by layer if abdominal pads are used and one by one if surgipads are used.

3. If there is continuous trickling of blood from the injured area it is ideal to give manual compression and wait for a few minutes.

4. If the bleeding subsides local hemostatic agents can be kept over it to prevent any further bleeding.

5. If the hemostasis is not satisfactory there must be no hesitation in repacking the liver

6. Absorbable meshes can be kept over the injured parenchyma before packing which serves not only in preventing bleeding while unpacking but also as an effective tamponade and keeps the injured areas of the parenchyma together.

7. It is ideal to inspect the other areas of the abdomen thoroughly as missed injuries can be identified and the required surgical intervention carried out.

8. There have been reports of reduced anastomotic leaks if bowel anastomosis is carried out during the time of relaparotomy .

9. Skillful and ideal timing of relaparotomy improves the outcome of higher grade liver injuries

MATERIALS AND METHODS

MATERIALS AND METHODS

Title

“ AN OBSERVATIONAL STUDY ON

MANAGEMENT AND OUTCOME OF LIVER TRAUMA, BASED ON WORLD SOCIETY OF

EMERGENCY SURGERY (WSES) GUIDELINES IN RGGGH ”

Aims and Objectives

1. To find the efficacy of WSES guidelines in classifying liver trauma and determining optimal treatment strategy.

2. To study the clinical course of non-operatively managed patients 3. To find out appropriate monitoring methods and frequency of monitoring of non-operatively managed patients.

4. To study the profile of various other associated injuries in liver trauma.

Study Centre Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai

Duration of Study February 2018 to September 2019

Study Design Observational study (Prospective)

Sample Size 50 cases

Inclusion Criteria All trauma victims sustaining blunt and penetrating trauma to the liver with or without associated injuries

Exclusion Criteria Abdominal trauma with isolated injury to the extra hepatic biliary tree or other visceral structures without liver trauma

Ethics Clearance Approved

Methodology

All Patients who fit the inclusion criteria will be observed and following data collected

1.Routine blood investigations -Hemoglobin

- Hematocrit

-Liver Function Test All these will be done serially 2. USG Abdomen

3. CECT Abdomen (i.v. contrast) for all cases

4. AAST grading system will be used to assess anatomy of liver injury 5.WSES classification will be the standard methodology used to assess the severity of liver injury

6. Management of liver injury will be based on WSES guidelines 7. Patients managed conservatively will be followed up prospectively and till discharge or death

8. Serial Abdominal examination 9. Time of reinitiating oral intake

10. Duration and intensity of restricted activity

11. Conclusions will be drawn based on the above parameters and all efforts to decide effectiveness of WSES guidelines in management of liver trauma and appropriate monitoring of NOM patients.

Sponsorship (Yes/

No) If Yes details No

Conflict of Interest No

DATA ANALYSIS

AND RESULTS

In our study, of a total population of 50 patients, 45 were male (90%) and 5

were female (10%) patients.

Out of 50 patients in the study, 48 were alive (96%) and 2 patients expired (4%)

Out of 50 patients in the study, 37 were due to road traffic accidents, 9 were due

to fall from height, 2 were due to assault and 2 were due to train traffic accident.

Out of 50 patients in the study, 44 were managed conservatively and 6 were

operated.

In the study, 48 patients had abdominal pain, 18 had vomiting, 46 had

tenderness and 39 patients had guarding at the time of presentation.

Out of 50 patients in the study, 6 patients had hemodynamic instability

(hypotension and tachycardia).

Out of 50 patients in the study, 22 were grade -1, 12 were grade -2, 10 were

grade -3 , 5 were grade – 4, 1 was grade 5 and no grade 6 injuries observed

(AAST grades).

Out of 50 patients in the study, 34 were grade 1, 7 were grade 2,

3 were grade 3 and 6 were grade 4 (WSES grades ).

Out of 44 patients managed conservatively, all 22 grade 1 were alive, all

12 grade 2 were alive, all 7 grade 3 were alive, 2 grade 4 were alive and 1 grade

4 expired. Grade 5 was not managed conservatively.

out of 50 patients in the study, all 34 WSES grade 1 managed

conservatively, all 7 grade 2 managed conservatively, all 3 grade 3 managed

conservatively and all WSES grade 4 were operated.

Out of 44 managed conservatively, all 34 WSES grade 1 were alive, all 7 grade

2 were alive, 2 grade 3 were alive and 1 grade 3 expired. WSES grade 4 was not

managed conservatively .

Out of 50 patients in the study, all 34 WSES grade 1 were alive, all 7 WSES

grade 2 were alive, 2 WSES grade 3 were alive and 1 expired,

5 WSES grade 4 were alive and 1 expired.

Out of 50 patients in the study, all 22 AAST grade 1 were alive, All 12 AAST

grade 2 were alive, all 10 grade 3 alive , 4 grade 4 alive and 1 expired,

1 grade 5 expired

Out of 50 patients in the study, 22 AAST grade 1 managed conservatively, 12

grade 2 managed conservatively, 7 grade 3 managed conservatively and 3

grade 3 operated, 3 grade 4 managed conservatively and 2 grade 4 operated,

1 grade 5 operated.

Chart displaying day wise observation of haemoglobin and hematocrit

values of 50 patients ( mean value of the day charted ). Improvement of

hemoglobin value in patients who were alive observed

The decline of liver enzymes from abnormality to normalcy in patients who

were alive

The decline of other parameters of LFT from abnormality to normalcy in

patients who were alive.

The variation of WBC values towards normalcy in patients who

were alive.

Follow up USG abdomen on day 4 showed decrease in size in 73% of patients and same size in 27% of patients who were alive.

Follow up USG abdomen near discharge showed decrease in size in all patients

who were alive .

The predominant lobe to be involved is right lobe contributing to 74% of liver

injuries

In this study, Lung is more commonly associated with liver injury contributing

to 38%, followed by spleen 33%, kidney 2% and bowel 2% subsequently.

A. Extravasation of contrast in CECT

RESOLUTION OF LIVER INJURY IN THE SAME

PATIENT IN CT TAKEN AFTER ONE YEAR

LIVER LACERATION AT THE TIME OF

PRESENTATION

DISCUSSION

❖ This study involving 50 patients was conducted in RAJIV GANDHI GOVERNMENT GENERAL HOSPITAL CHENNAI over a time span of 18 months approximately ( February 2018 - September 2019 ) recording all the patients admitted in trauma ward who were fitting the inclusion criteria.

❖ Patients admitted with liver injury having hemodynamic instability inspite of resuscitation , suspected peritonitis, suspected bowel injury and penetrating injury were taken for laparotomy.

❖ 6 patients were operated . The following were the indications:

➢ NUMBER OF PATIENTS HEMODYNAMIC INSTABILITY : 6 ( including 2 bowel injuries )

➢ SUSPECTED BOWEL INJURY: 2

➢ SUSPECTED PERITONITIS : 0

➢ PENETRATING INJURY: 0

❖ Out of the 6 patients operated, all were having WSES grade 4.

❖ Out of the 6 patients operated , 3 were having AAST grade 3 liver injury , 2 were having AAST grade 4 injury and 1 patient had AAST grade 5 injury

OPERATIVE METHODS AND FINDINGS

OPERATIVE METHOD NUMBER OF PATIENTS

Peri hepatic packing 2

Hepatorrhaphy 3

Non anatomical debridement 1

OPERATIVE PROTOCOL :

❖ Patients blood grouping and typing was done along with on table availability of cross matched packed red blood cells and fresh frozen plasma.

❖ Abdomen opened by midline laparotomy in all cases and horizontal extension to right side was made in one case for good exposure.

❖ Hemoperitoneum was drained. Rapid evisceration of small bowel followed by identification of foramen of Winslow and PRINGLES maneuver was done using a umbilical tape brought out via the gastro hepatic ligament.

❖ In cases where bleeding was minimal and patient was hemodynamically stable after these initial steps, careful identification of the bleeders over the laceration was made and diathermy coagulated following which Hepatorraphy was done using 2-0 chromic catgut and to prevent cut through gel foam was kept before taking the bite.

❖ This was possible in 3 cases but in 2 cases where the hemodynamic status did not return to normalcy inspite of Pringles maneuver

Perihepatic packing was done using abdominal pads in multiple layers to provide an adequate tamponade.

❖ After the packing hemodynamic status returned to normalcy and there were no soakage of the pads after a waiting period of fifteen minutes during which through laparotomy was done to identify other injuries.

❖ There was no difference in outcome of closing either the skin alone or the rectus intermittently and no patients developed abdominal

compartment syndrome .

❖ Planned relaparotomy was done after 48 hours for cases in which packing was done .

❖ The removal of the pads was done slowly after adequate irrigation with saline.

❖ Out of the two cases none had further bleeding and gel foam was kept over the laceration and abdomen was closed with 1 prolene and skin with 1-0 ethilon.

❖ 2 Cases where hepatorraphy was done had associated jejunal perforation and ascending colon perforation respectively.

❖ Jejunal resection and anastomosis was done as the hemodynamic status of the patient normalised after hepatorraphy and there was very minimal soiling intraperitoneally.

❖ Another case had ascending colon perforation but the soiling was too much for an anastomosis and hence limited resection with proximal ileostomy and transverse colostomy was done.

❖ Both patients were alive.

❖ One patient with AAST grade 5 and WSES grade 4 liver injury with associated splenic injury in whom non anatomical debridement of liver for necrosis of liver and splenectomy done, expired in 24 hours because of the initial insult due to hypovolemic shock and sepsis.

❖ Parenchymal dissection was carried out with crush clamp technique and the tip of the segment 7 necrosed area was resected.

❖ All operated patients were shifted to intensive surgical care unit and

CONSERVATIVE MANAGEMENT PROTOCOL :

❖ All patients with hemodynamic stability were subjected to all investigations in trauma ward and shifted to intensive surgical care unit.

❖ These patients were monitored periodically with :

➢ Abdomen girth chart

➢ Serial clinical examination periodically like new onset of liver tenderness or enlargement of liver marked

➢ Intake - output chart

➢ CBC 6^th hourly for first 48 hours and then every day.

➢ LFT, RFT and coagulation profile were done daily

➢ Transfusion if there were low Haemoglobin levels

➢ Injection vitamin k and albumin.

➢ Strict bed rest

➢ ICD care

➢ Chest physiotherapy and incentive spirometry

➢ Higher antibiotics, analgesics and bronchodilators

➢ Check ultrasound on 4^th day and near discharge after the patient starts mobilising.

❖ Only one patient with AAST grade 4 and WSES grade 3 on conservative management had sudden fall in haemoglobin level and developed hemodynamic instability during the course of treatment on day 2 and planned for emergency laparotomy but expired before proceeding to surgery.

CONSERVATIVE VS OPERATIVE

RESPIRATORY COMPLICATIONS

OPERATIVE GROUP

PACKING - 2 HEPATORRHAPHY - 3 RESECTION - 1 Lung injury - 0 Lung injury - 0 Lung injury - o No lung injury - 2 No lung injury - 3 No lung injury - 1

❖ No patient in operative group had lung injury and all patients who underwent hepatorrhaphy and packing were extubated successfully .

❖ Only one patient with AAST grade 5 and WSES grade 4 could not be extubated due to severe hypoxia caused by associated splenic injury

.

CONSERVATIVE GROUP

NO LUNG INJURY - 31 LUNG INJURY - 13

Associated splenic injury- 1 Associated splenic injury - 3 Associated kidney injury - 1 Associated kidney injury - 1

Other injuries- nil Other injuries- nil

❖ Only one patient patient who developed hemodynamic instability during the course of conservative management was intubated due to hypoxia caused by sudden fall in hemoglobin.

❖ No other patients required ventilatory care.

❖ ICD removal done in lung injury associated patients after serial chest x ray and lung expansion

❖ No respiratory infection encountered in conservative group

❖ Grade of liver injury had no association with respiratory complications.

HENCE REGARDLESS OF THE GRADE OF INJURY CONSERVATIVE GROUP HAD LESSER RESPIRATORY

COMPLICATIONS COMPARED TO THE OPERATIVE GROUP

BLOOD TRANSFUSION :

➢ OPERATIVE GROUP:

❖ The on table requirement of transfusions and fresh frozen plasma were higher.

❖ On an average the operative group required 5 packed cell transfusions and 8 fresh frozen plasma transfusions per patient .

❖ The higher the grade , the higher the requirement of transfusions.

➢ CONSERVATIVE GROUP

❖ This group required on an average less than 2 packed red blood cells and less than 4 fresh frozen plasma per patient .

❖ The lower grades almost required no transfusions .

HENCE CONSERVATIVE GROUP HAS LESSER RISK OF

TRANSFUSION AND TRANSFUSION RELATED COMPLICATIONS