Liver trauma: management of devascularization injuries.

Injury to the liver is a commonly encountered problem in trauma and a frequent cause of morbidity and mortality. Mortality of grade IV and V injuries has been estimated to range between 35 and 80%. The diagnosis and treatment of liver injuries has undergone many changes in the past two decades because of the ready access to computed tomographic (CT) scanning and improvements in surgical approaches, anesthesia, and intensive care medicine. Death is usually a result of uncontrolled hemorrhage, or sepsis with or without multiorgan system failure. Currently, indications for surgical intervention are generally restricted to hemodynamic instability not amenable to nonsurgical intervention or standard resuscitation, complications such as sepsis not amenable to interventional treatment, and the suspicion or presence of other abdominal injuries mandating laparotomy. Surgical procedures range from packing, to anatomic liver resections, to total hepatectomy with liver transplant. Devascularization injuries to the liver occur when there is disruption of the vascular inflow to one or more hepatic segments. This injury pattern is important to recognize, as an initially stable patient may decompensate secondary to septic complications. This is in contrast to most patients with intraparenchymal bleeding who, once stabilized, generally experience improvement. The hepatopancreaticobiliary (HPB) service of the University of Alberta Hospital (UAH) has treated several casualties with devascularizing liver injury ultimately requiring definitive surgical resection. We propose a diagnostic process using serial augmented CT scanning to differentiate between intraparenchymal hemorrhage from devascularization injury. We conclude with a treatment algorithm for these injuries. PATIENTS AND METHODS Patients referred to the HPB service of the UAH with a diagnosis of devascularizing liver injury were reviewed over the period of January 2000 to December 2001. The UAH is a Level I (Canadian Trauma Association criteria) trauma center that supervises the reception, resuscitation, and definitive care of all trauma victims referred to it. Our Alberta Trauma Registry includes only patients with an Injury Severity Score of 12 or greater. Of these patients, there were 89 liver trauma patients over the same 2-year period including 43 with grade III, IV, or V injuries. The HPB service is consulted for the care of complicated liver injuries. Eligible patients were selected because they had been referred to the HPB service and found to have a devascularized liver. A retrospective chart review was carried out to obtain details of age, sex, cause of accident, length of hospital and intensive care unit (ICU) stay, diagnostic studies, details of liver injury, comorbidities, surgical procedures, other therapeutic interventions, complications, and outcome. All surgical procedures were performed by one surgeon (D.L.B.). Surgical methods used included four anatomic liver resections: three right lobectomies and one segment VII/VIII resection. All patients were prepared for major liver resection with the availability of venovenous bypass. The entire chest, abdomen, and groin were prepared and draped to gain access to the intrapericardial inferior vena cava and femoral veins if necessary. In the end, venovenous bypass was not used in any patient, and no patient required a sternotomy. Hepatectomy was performed with inflow occlusion in two patients and total vascular exclusion in two patients.