Approach to the management of complex hepatic injuries

Background: Complex hepatic injuries American Association for the Surgery of Trauma Organ Injury Scale grades IV and V incur high mortality rate ranging from 40 to 80%, respectively. The objective of this study is to assess the clinical experience with an aggressive approach to the management of these, the most complex of hepatic injuries. Methods: This is a retrospective 6-year study (1992-1997) at an American College of Surgeons urban Level I trauma center of patients sustaining complex hepatic injuries whose interventions included surgery, angiographic embolization, endoscopic retrograde cholangiopancreatography plus biliary stenting and percutaneous computed tomographic-guided drainage. The main outcome measure was survival. Results: A total of 22 patients sustaining complex hepatic injuries; mean age of 26 years (range, 10-52 years), mean Revised Trauma Scale score of 9.9, mean Injury Severity Score of 32 (range, 16-75), American Association for the Surgery of Trauma - Organ Injury Scale grade IV (13 cases); grade V (9 cases). Mean estimated blood loss was 4,600 mL; mean number of units of blood transfused was 15. The patients underwent the following interventions: surgery (n = 22), re-operated (n = 13) mean number of operations 1.6 (range, 1-4), extensive hepatotomy and hepatorrhaphy (n = 17), nonanatomic resection (n = 7), formal hepatectomy (n = 4), packing (n = 10), direct approach to hepatic veins (n = 3); angiographic embolization (n = 15); endoscopic retrograde cholangiopancreatography and stenting (n = 5); computed tomographic guided drainage (n = 6). Mean length of stay in the intensive care unit was 21 days (range, 2-134 days), mean hospital length of stay was 40 days (range, 2-147 days). Overall mortality rate was 14% (3 of 22 cases), hepatic mortality rate was 9% (2 of 22 cases), mortality rate by injury grade was 8% grade IV (1 of 13 cases) and 22% grade V (2 of 9 cases). Conclusion: In this select patient population, improvements in mortality rates can be achieved with an aggressive approach to the management of complex hepatic injuries, including surgery, early packing, angiographic embolization, endoscopic retrograde cholangiopancreatography and stenting of biliary leaks, and drainage of hepatic abscesses.