Liver and Biliary Tract
INTRODUCTION
Liver injury occurs in approximately 5% of all trauma admissions.1 The liver’s size and anatomic location, directly under the right costal margin, make it the most susceptible organ for injury in blunt trauma and a frequently involved organ in penetrating trauma. The management of liver injury has evolved greatly over the last decade. There have been many technical advances in medicine, which now allow us to better diagnose and treat liver injuries both operatively and nonoperatively. However, the most severe liver parenchymal and venous injuries as well as those involving the portal triad continue to challenge even the most adept trauma or hepatobiliary surgeon and often lead to death. Therefore, despite our progress in liver injury management, many avenues for improvement remain to be explored.
HISTORY
Liver injury management has been described in many of the early surgical textbooks. We consider nonoperative management of hepatic injury a modern approach; however, a 1905 surgical text states, “If the evidences of a rupture of the liver, such as the signs of shock and hemorrhage…. the continuous increase in pain, due to progressive abdominal distention, and muscular rigidity, are absent, no operative intervention can be considered.”2 Mortality from liver injury was as high as 62.5% in these early years.3 Pringle wrote a landmark paper examining the management of severe liver injury in 1908.4 Although many authors previous to this paper had described suturing methods of liver parenchyma as well as gauze packing into the liver laceration, Pringle described a maneuver of occluding the porta hepatis with the surgeon’s fingers and thus decreasing the amount of hemorrhage from a severely injured liver. This procedure continues to be a useful tool in the management of liver trauma.
During World War II, new ideas in the management of severe liver injury surfaced. Madding et al. used the principles of early laparotomy, drainage procedures, advances in anesthetic and aseptic care, as well as transfusion technology to improve mortality to 27.7%.5 The techniques of hemorrhage control adopted at that time incorporated parenchymal reapproximation with large blunt liver needles, resection, and direct vessel ligation. These methods prevailed until approximately 10 years ago. Trends in management have now led to an emphasis on nonoperative treatment for those patients who remain hemodynamically stable and liver packing with damage control for those who are unstable.
ANATOMY
Comprehensive knowledge of hepatic anatomy is essential to the proper management of traumatic liver injuries. The understanding of the ligamentous attachments, parenchyma, and intraparenchymal and extraparenchymal vascularity of the liver is key to the effective application of methods for control and repair in liver injuries (Fig. 29-1).
FIGURE 29-1 Surgical anatomy of the liver: (1) inferior vena cava; (2) right hepatic vein; (3) middle hepatic vein; (4) left hepatic vein; (5) portal vein; (6) right branch portal vein; (7) left branch portal vein; (8) right triangular ligament; (9) coronary ligament; (10) left triangular ligament; (11) falciform ligament; (12) ligamentum teres.
Lobes
Cantlie first described the lobar anatomy in 1898. The liver is divided into two lobes by a 75° angle traversing from the gallbladder fossa posteriorly to the left side of the inferior vena cava. This is the so-called line of Cantlie. Therefore, the left lobe includes the hepatic tissue to the left of the falciform ligament along with the quadrate and caudate lobes. The right lobe consists of the remaining parenchyma.
Functional Anatomy
The functional anatomy of the liver separates the liver into segments pertinent to resection. In 1953, Couinaud provided the basis of modern resection planes by dividing the liver based on the distribution of the hepatic veins and glissonian pedicles.6 The right hepatic vein traverses between the right posterolateral (VI and VII) and right anteromedial (V and VIII) segments. On the left, the left hepatic vein delineates the anterior (III and IV) and posterior (II) segments. The caudate lobe (I) drains directly into the inferior vena cava (Fig. 29-2).
FIGURE 29-2 Functional division of the liver, according to Couinaud’s nomenclature. (Reproduced with permission from Blumgart LH, ed. Surgery of the Liver and Biliary Tract. New York: Churchill Livingstone; 1988. © Elsevier.)
Hepatic Artery
The common hepatic artery branches from the celiac artery. This provides about 25% of the hepatic blood flow and 50% of hepatic oxygenation. The artery then branches into the gastroduodenal, right gastric, and proper hepatic. The proper hepatic is found in the porta hepatis usually to the left of the common bile duct and anterior to the portal vein. At the hilum of the liver, the artery bifurcates into a right (the longer branch) and a left hepatic artery. There are a number of anatomic variances. The most frequent (11%) is the aberrant superior mesenteric origin of the right hepatic artery traversing behind the duodenum. Other variants include a left hepatic artery origin from the left gastric artery (8%) and the left and right hepatic arteries arising from a superior mesenteric artery origin (9%). With these multiple variants, great care must be taken when controlling the traumatic hemorrhage.
Hepatic Veins
The hepatic veins develop from within the hepatocytes’ central lobar veins. The superior, middle, and inferior vein branches originating from the right lobe form the right hepatic vein. The middle hepatic vein derives from the two veins arising from segments IV and V and frequently includes a branch from the posterior portion of segment VIII. In 90% of patients the middle hepatic vein joins the left hepatic vein just before draining into the inferior vena cava. The left hepatic vein is more variable in its segmental origin. Most important is the posterior positioning of the vein when dissecting the left coronary ligament; great caution must be used in this area to avoid inadvertent injury.
The retrohepatic vena cava is about 8–10 cm in length. It receives the blood of the hepatic veins and also multiple small direct hepatic vessels. Exposure to this area can be very difficult, especially when an injury and accompanying hemorrhage make visualization very difficult.
Portal Vein
The portal vein is formed from the confluence of the splenic and superior mesenteric veins directly behind the pancreatic head. It provides about 75% of hepatic blood flow and 50% of hepatic oxygen. The portal vein lies posteriorly to the hepatic artery and bile ducts as it ascends toward the liver. At the parenchyma, the portal vein divides into a short right and a longer left extrahepatic branch.
Ligaments
When operating on the liver, it is crucial to understand the ligamentous attachments. The coronary ligaments attach the diaphragm to the parietal surface of the liver. The triangular ligaments are at the lateral extensions of the right and left coronary ligaments. The falciform ligament with the underlying ligamentum teres attaches to the anterior peritoneal cavity. The medial portion of the coronary ligaments is where the hepatic veins traverse and therefore dissection in this area must be done with caution.
LIVER INJURY INCIDENCE AND CLASSIFICATION
Liver injury occurs in approximately 5% of all trauma admissions. Since the liver is the largest intra-abdominal organ, it is not surprising that the liver is the most commonly injured solid organ in blunt and penetrating injury. Data from the author’s institution over the past 5 years illustrate the frequency of liver injury compared to other abdominal solid organ injury (Table 29-1). Motor vehicle collision is by far the most common etiology for a blunt liver injury. This is followed by pedestrian/car collisions, falls, assaults, and motorcycle crashes. Liver injury in penetrating trauma is also frequent, ranging from 13% to 35% of penetrating admissions, and is dependent on the weapon utilized.
TABLE 29-1 Trauma Admissions, 2000 to May 2009 (N = 39,722)
Uniform classification of liver injury is essential to compare the efficacy of management techniques (Fig. 29-3). The American Association for the Surgery of Trauma established a detailed classification system that has been widely utilized7 (Table 29-2). This classification provides for uniform comparisons of both nonoperative and operatively managed hepatic injury.
TABLE 29-2 Liver Injury Scale (1994 Revision)
FIGURE 29-3 Hepatic injury grading is important to compare outcome.
INITIAL MANAGEMENT
Care for the patient with possible liver injury should proceed by the tenants of Advanced Trauma Life Support (ATLS). Of utmost importance is the initial evaluation, including attention to airway, breathing, and circulation (see Chapter 10). Other life-threatening injury may take precedence over possible internal injury in the primary survey. However, liver injury may indeed be a cause of hemorrhagic shock and cannot be overlooked. Resuscitation strategies are evolving in the care of trauma patients (see Chapter 12). The prospects of permissive hypotension, hypertonic saline resuscitation, and other strategies are the subject of many recent investigations.
Physical exam of the patient remains a critical component of the initial evaluation. However, physical exam of a trauma patient may indeed miss significant internal injury. A study by Olsen et al. found that trauma patients with a “benign” physical exam had a 43% incidence of significant intra-abdominal injury.8 Therefore, it is justified that patients with benign physical exams are further evaluated by either serial exams or radiologic methods. Plain radiographs and ultrasound obtained in the trauma bay may give clues to possible liver injury if lower right rib fractures, hemothorax, hemoperitoneum, or a ruptured diaphragm is diagnosed. Although nonoperative management has become routine, a patient exhibiting clear peritoneal signs and instability requires immediate celiotomy.
Important but often overlooked points include keeping the patient warm and collecting appropriate laboratory data. Hypothermia can have detrimental effects on coagulation and cardiac rhythm. Appropriate laboratory data should include type and cross, hematocrit, coagulation profile, amylase, and base deficit. Abnormalities can alert the clinician to possible internal injury and its severity.
DIAGNOSIS OF LIVER INJURY
Hemodynamically Unstable Patient
After primary survey and resuscitation have been initiated, the patient may still be hemodynamically unstable. In these cases it is necessary to immediately determine the possible causes of the continued shock state. This can be difficult in patients with multiple injuries involving many organ systems.
Intra-abdominal injury can be an obvious cause of instability if physical exam reveals peritoneal signs, penetrating injury, or increasing distention. More often, a rapid diagnostic modality must be employed. The two most pertinent modalities for these situations are diagnostic peritoneal lavage (DPL) and focused abdominal sonography for trauma (FAST).
Diagnostic Peritoneal Lavage
DPL is a very accurate method for determining the presence of intraperitoneal blood. Many reports have replicated the work of Root et al. that indicated up to a 98% accuracy of determining the presence of intra-abdominal blood.9 DPL is rapid and safe if performed with the semi-open or open technique. It remains a very useful tool in those patients who have altered sensorium and remain hemodynamically unstable. A positive DPL is defined as a gross aspiration of 10 mL of blood or greater than 100,000 RBC/mm3 in at least 300 mL of irrigant. A finding of gross blood in an unstable patient leads to immediate operative intervention. DPL does have limitations. It is not useful in determining the origin of the bloody aspirate and can actually be too sensitive since it is positive with minimal hemoperitoneum. Therefore, though it has its place in rapid determination of hemoperitoneum and subsequent immediate operative intervention, DPL has been replaced in most trauma centers by ultrasound and in more stable patients by computed tomography (CT) scanning.
Focused Abdominal Sonography for Trauma
The FAST exam has superseded DPL in many institutions for the determination of hemoperitoneum in the unstable bluntly injured patient (see Chapter 16). Surgeons have become very adept and familiar with this diagnostic modality. Richards et al. reported a 98% sensitivity of ultrasound for hemoperitoneum in grade III and higher liver injury.10 However, they were not able to identify the anatomic location of the hepatic parenchymal injury in 67% of these severely damaged livers. A multi-institutional study by Rozycki et al. concluded that the RUQ area is the most common site of hemoperitoneum accumulation in blunt abdominal trauma.11 This information was reiterated in another study that discovered that the “two most common patterns of fluid accumulation after hepatic injuries were the RUQ only and the RUQ and lower recesses.”12 If the initial exam of the RUQ is negative, it is recommended that the pericardial, LUQ, and pelvic areas also be examined. The FAST exam is about 97% sensitive when 1 L of peritoneal fluid is present, but the examiner can rarely see volumes less than 400 mL with current technology.13 A repeat FAST exam can be beneficial after the initial resuscitation. Further resuscitation may promote further bleeding that then leads to more intraperitoneal blood on FAST exam. FAST exam is very beneficial in those unstable patients in whom the diagnosis of hemoperitoneum requires emergent surgery.
Hemodynamically Stable Patient
Ultrasound and CT scanning are the mainstays of diagnosing hepatic injury in the hemodynamically stable but bluntly injured patient. Once the primary and secondary surveys have been completed, the patient at risk for intra-abdominal injury should undergo further radiologic evaluation for definitive diagnosis.
FAST
FAST examination, as mentioned above, has proven to be a very good diagnostic tool in the evaluation of the blunt trauma patient. Some centers are using ultrasound for definitive diagnosis of intra-abdominal injury. Most examiners, though, are unable to distinguish between different grades of hepatic injury by ultrasound.10 Also, the source of free fluid in the peritoneal cavity is difficult to discern by ultrasound alone, especially if multiple injuries are present. A FAST exam has been reported to have a sensitivity as high as 83.3% and specificity of 99.7%.14 With these relatively low false-negative rates, some institutions are observing patients with negative FAST and not proceeding with CT scanning. However, Chiu et al. in 1997 reported a 29% incidence of abdominal injury following negative initial FAST.15 They reported confounding clinical factors including contusion, pain, pelvic fracture, and lower rib fractures that were present in many of the false-negative patients. Also, 27% of these negative FAST patients underwent laparotomy for undetected splenic injury. A follow-up FAST exam was not performed on these patients prior to surgery and given the time for further hemoperitoneal fluid development these scans may now have been positive. Serial ultrasound exams are now used in many trauma centers if the initial scan is negative. Patients with pelvic ring-type fractures should undergo CT scan even if a negative FAST has been performed due to the more frequent occult injuries in these patients.16
Contrast-enhanced sonography shows some promise in the detection of liver injury. Contrast-enhanced ultrasound uses intravenously injected microbubbles containing gases other than air to produce the “contrasted” images. Valentino et al. reported a 100% sensitivity and specificity in seven liver injury patients with grade II–IV injuries.17 Similarly McGahan et al. reported 90% detection in liver injuries of the same grades.18 Another study described the ability of this modality to detect active extravasation from solid organs.19 With these advancements, patients may be subject to less risk from radiation or CT contrast. Also, this can be done at bedside instead of transporting a critical patient to a radiology suite. Overall, ultrasound is an excellent tool for the diagnosis of significant hepatic injury in the blunt trauma patient.
FAST also has an expanding role in penetrating abdominal trauma with an institutional series sensitivity of 46% and specificity of 94% in penetrating injury,20 therefore concluding that FAST can be used to triage patients more directly to surgery. However, the limitations of FAST in penetrating trauma are significant. In a patient with a possible tangential wound, the question is often if the peritoneum has been penetrated. A finding of fluid in Morison’s pouch confirms penetration and will result in immediate surgical intervention. A negative fluid accumulation, however, does not definitively rule out penetration. These results have been validated.21 Two interesting studies have demonstrated that fascial penetration can be verified by ultrasound examination.22,23 Again, the sensitivity of this modality is low but the specificity is high. Ultrasound may be a good screening tool for finding fascial penetration and a positive result could alleviate the patient of a painful bedside wound exploration and also contribute to operative decision making. Future study in this area may develop greater uses for ultrasound in select penetrating injuries.
CT Scanning
The advent of CT scanning and advances in that technology have resulted in tremendous changes in the management of liver injury. Since the first use of CT to diagnose intra-abdominal injury in the early 1980s, CT has become a routine part of the management of trauma patients.24 One recent study revealed that the specificity of the clinical examination with bedside radiologic investigations of plain x-ray and sonography in addition to laboratory values is not sufficient to preclude the blunt trauma patient from obtaining a CT scan for definitive diagnosis of injury.25 The advent of the helical CT scan has improved resolution as well as increased the speed of a head to pelvis scan to less than 10 minutes. Trauma surgeons now use CT scans for diagnosis and for management decisions in liver injuries. Being able to grade the extent of injury and to follow an existing injury can determine if nonoperative management is possible and successful (Fig. 29-4).
FIGURE 29-4 Algorithm for nonoperative management of blunt liver injury.
CT scanning is also being used in penetrating injury. Triple-contrast CT in back and flank wounds has been shown to have good sensitivity; however, the sensitivity for diaphragmatic and small bowel injury is poor.26 Therefore, a minor hepatic laceration can be evaluated and nonoperatively managed with CT guidance but continued frequent abdominal exam must also accompany this algorithm.
Laparoscopy
Laparoscopy has been successfully used to diagnose peritoneal penetration of penetrating trauma, thus saving the patient from a nontherapeutic exploratory laparotomy.27 Repair of hepatic injury found at laparoscopy has also been reported.28,29 In carefully selected patients, laparoscopy can be advantageous in the diagnosis and repair of hepatic injury.
MANAGEMENT OF LIVER TRAUMA
Anatomic relationships are key to understanding the management of liver trauma. Blunt hepatic injury traverses almost exclusively along the segments of the liver. This most likely occurs due to the strength of the fibrous covering around the portal triad preventing injury from transecting these structures. However, the hepatic veins do not have a similar fibrous structure and therefore, having less resistance, are the primary structures injured in blunt trauma. Penetrating trauma, on the other hand, involves both venous and arterial injury with direct transection of any structure in the trajectory. These anatomic principles are key to understanding the rationale for making decisions in the management of liver trauma.
Hemodynamically Stable Patient with Blunt Injury
Nonoperative treatment of the hemodynamically stable patient with blunt injury has become the standard of care in most trauma centers (see Fig. 29-4). In 1995, Croce et al. published a prospective trial of nonoperative management of liver injury.1 In this study patients with all grades and volumes of hemoperitoneum were evaluated against operative controls. They found that they were able to successfully manage 89% of hemodynamically stable patients without celiotomy. Most blunt liver injuries produce hepatic venous injuries that are low pressure (3–5 cm H2O). Hence, hemorrhage usually stops once a clot forms on the area of disruption. Successful nonoperative therapy resulted in lower transfusion requirements, abdominal infections, and hospital lengths of stay. Hurtuk et al. have reported that indeed trauma surgeons “practice what they preach” in a recently published evaluation of the National Trauma Data Bank. They found that in the past 10 years there has been no effect on mortality in solid organ injury with prevalence of nonoperative management.30 Coimbra et al. reiterated these data by examining their experience in nonoperative treatment of grade III and IV hepatic injury.31 They reported no mortality in their nonoperatively managed patients and “discouraged” operative management of these injuries.
Approximately 85% of patients with blunt liver trauma are stable. Once stability has been established, the patient must be carefully analyzed for the appropriateness of nonoperative care. The patient cannot exhibit signs of peritonitis and must continue to be hemodynamically stable without a significant transfusion requirement. The authors are generally comfortable in nonoperatively managing a stable patient with 3–5 U of blood in his or her abdomen. A contrast-enhanced helical CT scan should be obtained to evaluate injury grade, amount of hemoperitoneum, evidence for enteric injury, active extravasation of contrast, and presence of pseudoaneurysm (Fig. 29-5).
FIGURE 29-5 CT scan demonstrating a “contrast blush,” indicative of active arterial bleeding in a patient with a grade IV blunt hepatic injury.
High-grade injury, large hemoperitoneum, contrast extravasation, and pseudoaneurysm are not contraindications for nonoperative management; however, these patients are at higher risk for nonoperative failure and may need a multimodality approach to stabilize their nonoperative injury. Stable patients with high-grade injury may be observed. However, Malhotra et al. noted that 14% of grade IV and 22.6% of grade V injuries fail nonoperative management, which was substantially higher than the 3–7.5% failure rate of more minor injuries.32 That same article reports large hemoperitoneum (blood around liver, pericolic gutter, and in the pelvis by CT) as a significant factor in failure of nonoperative management but that it could not predict which patients would ultimately fail nonoperative management. Richardson et al. speculated that many experienced trauma surgeons have taken stable but high-grade injury patients to the operating room only to find that “manipulation of venous injuries resulted in massive hemorrhage that resulted in the patient’s death.”33 They concluded that nonsurgical treatment has a “positive impact on survival.”
A CT finding of contrast blush or extravasation has previously meant that patients were not candidates for nonoperative therapy. However, with the assistance of interventional radiology, some patients may be candidates for embolization and nonoperative treatment. Successful embolization of hepatic arterial injury in patients who are hemodynamically stable but with CT scans demonstrating intrahepatic contrast pooling was reported in 1996.34 Choosing the appropriate patient for embolization can be a challenge. One interesting study looked at 11 patients with hepatic injury and CT evidence of contrast extravasation who were stable “only with continuous resuscitation.”35 These patients were evaluated by hepatic angiography and seven patients were successfully treated with hepatic embolization. The other four patients had no active extravasation seen by angiography and became hemodynamically stable not requiring surgery. Misselbeck et al. reviewed their 8-year experience with hepatic angioembolization and found that hemodynamically stable patients with contrast extravasation on CT scan were 20 times more likely to require embolization than those without extravasation.36 Arterial extravasation with blunt liver injury is much less common than venous injury. However, many centers are anecdotally noting excellent results with a multimodality approach.
Complications of Nonoperative Blunt Hepatic Injury Management
Most patients with blunt nonoperative liver injuries heal without complication. Follow-up CT scans generally show resolution of severe injuries within 4 months and about 15% show complete resolution at hospital discharge.1 However, complications can arise and management requires the surgeon to be prepared to deal with the possible adverse outcomes.37 A retrospective multi-institutional study included 553 patients with grade III–V injury.38 Of these patients, 12.6% developed hepatic complications that included bleeding, biliary problem, abdominal compartment syndrome, and infection. Significant coagulopathy and grade V injury were found to be predictors of complication. Therefore, with current nonoperative management strategies, complications must be dealt with appropriately.
Bile Leaks
One of the more frequent complications is bile leakage. Bilomas or bile leak can occur in 3–20% of nonoperatively managed patients.1 Hepatobiliary hydroxy iminodiacetic acid (HIDA) scan and MRCP have been used to localized bile leaks.39 Evidence of bile leak by HIDA scan does not mandate intervention. In fact, of the 14 patients found to have HIDA evidence of bile leak in a 1995 study, only 1 patient became symptomatic and required percutaneous drainage.1 Abnormal liver function tests, abdominal distention, and intolerance to feeding may all indicate a bile leak. CT scan evaluation with percutaneous drainage usually remedies the problem completely. However, large bile leaks can develop. Many authors have described management of bile peritonitis or large leaks not responsive to percutaneous drainage using percutaneous drainage techniques along with endoscopic retrograde cholangiography (ERC) and biliary stent placement.40 It has also been demonstrated that sphincterotomy can decrease the biliary pressure and allow healing of the bile leak.41 In some instances, actual stenting of a large ductal injury can be accomplished.42 Griffen et al. have reported success with a combined laparoscopic and ERC approach. They described patients with biliary ascitis taken to operating room for laparoscopic bile drainage and placement of drain near injury site with postoperative ERC and bile duct stenting. They report no septic complications and healing of the substantial biliary leaks.43 The authors have rarely experienced a persistent bile leak in the nonoperatively managed patient. Bile leaks or bilomas are drained percutaneously, sometimes for up to 4–6 weeks, and they nearly always resolved without ERC or other decompressive maneuvers.
Abscess
Perihepatic abscesses have also been uncommonly encountered with nonoperative management. The patient may exhibit signs of sepsis, abnormal liver function tests, abdominal pain, or food intolerance. Abscesses, like biliary collections, can often be managed by CT-guided drainage catheters. However, if the patient fails to improve with drainage and antibiotics, wide surgical drainage should be performed. This may involve merely incision and adequate drainage of the cavity or it may involve extensive debridement of the hepatic parenchyma.
Hemorrhage
Delayed hemorrhage after nonoperative management is a feared complication. Gates presented a review of the subject in 1994 and suggested an overall incidence of delayed hematoma rupture of 0–14%.44 The 14% figure is well above current reports. He discussed 13 publications and determined that 69% of these delayed hemorrhage cases could have been successfully treated nonsurgically. Using the same criteria that were originally utilized to manage these patients nonoperatively, namely, hemodynamic stability without ongoing blood loss, patients with delayed hemorrhage can undergo hepatic angiographic embolization and observation with success. Therefore, it seems that delayed hemorrhage is actually a rare and manageable complication.
Devascularization
Disruption of vascular inflow to a hepatic segment following trauma or post-angioembolization can lead to necrosis of that segment of liver. The consequences of necrosis may include elevation of liver transaminases, coagulopathy, bile leaks, abdominal pain, feeding intolerance, respiratory compromise, renal failure, and sepsis.45 Many studies suggest that patients with significant necrosis should undergo hepatic resection before complications arise.46,47 Devascularization can be identified by CT scan. It can be differentiated from intraparenchymal hemorrhage when follow-up CT scans reveal segments of liver that remain devascularized or have air within the devascularized area.45
Hemobilia
Hemobilia can occur after blunt hepatic injury. In 1871, Quincke described the triad of right upper quadrant pain, jaundice, and upper GI bleeding that indicated hemobilia. This triad may not be evident in the trauma patients with hemobilia.48 In a 1994 study, three patients developed hemobilia with massive upper gastrointestinal hemorrhage following blunt hepatic injury.49 The authors concluded that hepatic artery pseudoaneurysm with hemobilia is predisposed by bile leak and that angiographic embolization was appropriate for patients without sepsis and with small cavities. However, formal hepatic resection or drainage, after angiographic vascular control, may be necessary for septic patients or those with large cavities. Hemobilia is much less common with the prevalence of nonoperative management. With operative interventions of the past including large parenchymal suturing and vessel ligation, communications between vessels and bile ducts often occurred iatrogenically. Now that nonoperative care is practiced, we rarely see hemobilia.
Systemic Inflammatory Response
Nonoperatively treated patients with inadequately drained bile or blood collections may be susceptible to the development of a systemic inflammatory responses syndrome that may include respiratory distress. Recent articles from Franklin et al. and from Letoublon et al. advocate laparoscopic evacuation of undrained bile or hemoperitoneum at postinjury days 3–5.50,51 They report a marked decrease in the inflammatory response in many of these patients.
Unusual Complications
Large subcapsular hematomas have been described to elevate intraparenchymal pressures high enough to cause segmental portal hypertension and hepatofugal flow.52 This “compartment syndrome of the liver” was described in a patient managed non-operatively whose decreasing hematocrit and increasing liver function tests promoted angiographic examination revealing the hepatofugal flow in the right portal vein. After operative drainage of the tense hematoma, the patient did well with reversal of flow and viability of the right lobe liver tissue. This type of compressive complication has also been described causing a Budd–Chiari syndrome when hematoma results in intrahepatic vena cava compression or hepatic venous obstruction.53
Follow-Up CT Scanning of Blunt Hepatic Injury
Definitive data on the value of follow-up CT scanning of blunt hepatic injury are not available. Recent published reports suggest postobservation CT scans on those with more severe (grade III–V) injuries. Cuff et al. reported that of the 31 patients who received follow-up CT scans 3–8 days postinjury, only 3 patients’ scans affected future management.54 Additionally, the three scans that affected management were obtained due to a change in clinical picture and not merely routine. A 1996 report similarly concluded that follow-up CT did not change decision making in those with grade I–III injury.55 The authors’ institution concluded from their follow-up of 530 patients, including 89 grade IV or V, that follow-up CT scans are not indicated as part of the nonoperative management of blunt liver injuries.56 Follow-up CT scans are indicated only for those patients who develop signs or symptoms suggestive of hepatic abnormality. By scanning only those with clinical suspicion, there is a small inherent risk of missing unsuspected, possibly deleterious pseudoaneurysms that may result in delayed hemorrhage and require embolization. If a patient has had a follow-up CT that reveals significant healing, a postdischarge scan is not necessary. However, if significant healing has not occurred or if the patient had a grade IV or V injury, our practice is to obtain a postdischarge scan at 4–6 weeks after the injury.
Resumption of Activity
No steadfast rules apply to activity resumption in patients with uncomplicated hospital courses following blunt hepatic injury. The practice of keeping a patient from activity for 4 months has been commonly employed. This practice most likely resulted from the observation that most hepatic injury seems to have resolved by CT in 4 months. A contrary approach to this practice can be based on some interesting animal studies. Dulchavsky et al. found in animal studies that hepatic wound burst strength at 3 weeks was as great or greater than uninjured hepatic parenchyma.57 This is most likely a result of fibrosis throughout the injured parenchyma and Glisson’s capsule. Therefore, activity can be resumed about 1 month after injury if a follow-up CT (in grade III–V) has shown significant healing.
Hemodynamically Stable Patient with Penetrating Injury
Nonoperative Management of Penetrating Injury
Peritoneal penetration has mandated operative exploration for many years. However, many trauma centers have adopted selective nonoperative management of knife stab wounds to the right upper quadrant. The work of Nance and Cohn in 1969 supported this nonoperative care in patients with stab wounds who were hemodynamically stable and had no evidence of peritoneal irritation.58 Since then, reports of successful nonoperative management of gunshot wounds (GSW) have been published. Renz and Feliciano prospectively treated 13 patients with right thoracoabdominal GSW nonoperatively.59 The rationale behind this management is that these wounds of small caliber weapons may have injury to diaphragm and liver only, sparing any intestinal injury. The authors stressed the importance of serial abdominal exams and contrast CT scanning in their successful nonoperative management of penetrating injury. Other center experience has concurred with this selective nonoperative management.60,61 Demetriades et al. even reported successful nonoperative management of penetrating grade III and IV liver injuries that required angioembolization.62 The criteria for non-operative management include those patients who are hemodynamically stable, have no peritoneal signs, and are not mentally impaired. These patients then undergo contrast-enhanced CT scan to rule out other abdominal visceral injury. Serial abdominal exams as well as close hemodynamic monitoring are also implemented. Triple-contrast CT of 86 abdominal GSW, as reported by Shanmuganathan et al., had a sensitivity and specificity of 97% and 98%, respectively.63 Velmahos et al. do not use triple-contrast CT at their center. They report a sensitivity and specificity of 90.5% and 96%, respectively, in diagnosing intra-abdominal organ injuries requiring surgical intervention.64
All trauma surgeons do not accept nonoperative management of GSW. Missed or deliberate nonrepair of small diaphragmatic lesions may lead to long-term adverse sequelae, not only of diaphragmatic herniation but also of possible biliopleural fistula.65 Late intervention for other missed injury (e.g., duodenal injury) may also lead to substantial morbidity. Nonoperative management of RUQ penetrating trauma must be performed under the care of a center that has not only the capability of close continuous monitoring but also CT radiology accessibility and immediate operating room availability.
Operative Management of Patients with Minor Liver Injury
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