1. Politrauma surgery division
A&E
Umberto I University Hospital - La Sapienza University of Rome
Treatment's Evolution of Hepatic Trauma: state of the art and experience of Umberto I
Hospital
(Marco Nardini)
Introduction: trauma is the main cause of death in ages between 0-40 years. Abdominal trauma,
and hepatic trauma with it, represent an important part of the problem. Despite the attention of
scientific society on this problem started so long ago in history of medicine, a multitude of
unanswered questions remain in literature for nonoperative magement of blunt hepatic injuries.
However there is growing consensus that a routine laparotomy is not indicated in the
hemodynamically stable patient without peritonitis.
Aims: We assume that patients with high-grade liver injuries could be managed successfully with a
carefully designed protocol. In this protocol we need to asses the importance of the non-operative
managment and there is still a lack in literature on how to use the modern interventional procedures
including endoscopic retrograde pancreatography, angiography, laparoscopy or percutaneus
drainage to manage complications that arise as a result of nonoperative management of hepatic
injury (bile leak, biloma, bile peritonitis, hepatic abscess, bilious ascites and hemobilia). The main
purpose of this review is to start a systematic collection of data for the register of trauma and start to
build the guideline for the management of hepatic trauma.
Methods: retrospective study of the managment of patients with hepatic trauma, different grades
according to the AAST-Organ Injury Scale, admitted consecutively from 2009 to 2011.
We collected the cases of 62 patients admitted in A&E with diagnosis of hepatic injuries. We
divided the patient on the basis of the grades of the injuries, the associated lesions and the treatment
they underwent.
Summary: 75.8% (47/62) were male. The mean age was 33 (range 8-86) the median age was 36. In
most of cases (67%, 42/62) the causes of the injuries was atributable to road accident, 6 patients,
9.7%, had a domestic accident, 5 patients, 8.1%, were victims of violence, 4 patients, 6.6%,
reported hepatic injury after sport activities, 3 patients, 4.8%, reported iatrogenic lesions and 2
patient, 3.2%, were admitted after accident during work. The triage codes was red in 24 patients and
yellow in 34. Most frequent associated lesions was skeletal fracture, following there were thoracic
trauma and brain injury, then other abdominal organs were involved. Only 4 patients could not
receive CT scan because of their haemodinamic instability and they underwent emergency
laparotomy and the injury was graded directly by the surgeon as IV in three cases, and III in one
patients. All the patients received abdominal ultrasound in resus room. 18 patients received surgical
treatment with different procedures adopted to arrest the hemorrage or repair the liver, vascular
structures or bilial structures. No patient that underwent nonoperative management died.
Conclusion: Our experience confirm plenty the good results of nonoperative treatment and damage
control surgery approach as described by international litterature.
The nonoperative treatment must always be adopted and the main feature in the patient's
managment decision algorithm is the haemodinamic stability. In this review the suprahepatic veins
lesions brought always to death and in these cases haemorragic shock was already very high grade
at admission in A&E. If the mortality is lower the morbility is higher in the nonoperative
management and here there is the need to assess the importance of interventional procedure.