**6. Management**

**5. Hepatic injury grading**

306 Recent Advances in Liver Diseases and Surgery

with NOM (see Figure 3).

67% of hepatic injuries are Grade I, II, or III [26].

One of the most widely accepted injury grading scale to grade hepatic injuries is the American Association for the Surgery of Trauma (AAST) classification system. A study done using the National Trauma Data Bank (NTDB) in 2008 about the solid organ injuries showed that about

The nonoperative management (NOM) can give rise to higher successful outcome for lowgrade injuries (Grades I, II, and III) and less success in cases of high-grade injuries (Grades IV and V). The major benefit of AAST grading system is for predicting the likelihood of success

(a) (b)

(c)

**Figure 3.** CT scan images show (A) Grad II Subcapsular, nonexpanding, 10-50% surface area; intraparenchymal nonex‐ panding <10 cm diameter; (B) Grad III liver injury with >3 cm laceration in the left lobe; (C) CT showing Grade IV liver

Patients with Grade VI injuries are universally hemodynamically unstable and surgical

intervention is required. The grades of hepatic injury are described in Table 4 [27-29].

injury with parenchymal disruption involving more than 25% of the liver.

In the last 30 years, the management of liver injury has evolved significantly. The advancement of imaging studies has played an important role in the conservative approach for management. A shift from operative to nonoperative management for most hemodynamically stable patients with hepatic injury has been prompted by the speed and sensitivity of diagnostic imaging, particularly due to CT scanning and by advances in critical care monitoring [32, 33].

The operative versus NOM strategy depends upon presence of other injuries and medical comorbidities, hemodynamic status of the patient, and grade of liver injury (Table 5).

A positive FAST scan and DPL in hemodynamically unstable liver trauma patient promotes emergency abdominal exploration to establish the source of intraperitoneal hemorrhage. If the source is liver itself, an exploratory laparotomy is performed. The bleeding is control may be achieved through a damage-control approach or by using specific techniques for liver hemostasis. The approach depends upon the extent of the liver injury and presence and extent of associated injuries.


**Table 5.** Classification of patients as per their physiological conditions after abdominal trauma

Hemodynamically stable patients with blunt liver injury who do not have other indications for abdominal exploration can be kept under observation. Patients with right-sided penetrat‐ ing thoracoabdominal injuries, which can lacerate the liver, can remain hemodynamically stable. Such patients can also be kept under observation provided there are no associated intraabdominal injuries. Nonoperative management generally fails in patients with higher-grade injuries than those with lower-grade injuries. Still such patients should be treated with NOM as long as they are hemodynamically stable. Other patients who suffer extra-abdominal injuries but requiring intervention can also be kept under observation. Nonoperatively managed patients who continue to bleed, and even with ongoing blood transfusion have hemodynamic instability need surgical exploration. It is also indicated in those patients who manifest a persistent systemic inflammatory response syndrome (SIRS), like presence of ileus, fever, tachycardia, and oliguria. Grade III and higher injuries often requires a combined angiographic and surgical management [34].

#### **6.1. Nonoperative management**

Nonoperative management (NOM) is widely accepted as the treatment of choice for hemo‐ dynamically stable patients with hepatic injury and with no other associated injuries indicating urgent intervention. Nonoperative management (NOM) consists of repeated assessment, close monitoring, and supportive intensive

2e care management with utilization of indicated arteriography and hepatic embolization. Furthermore, NOM is now recommended for penetrating injury (stab wound) as well as lowvelocity gunshot wound to right upper quadrant in stable patients after exclusion of other injuries requiring urgent laparotomy. Most of the injuries that fall in this category are Grade I and II liver injuries [35].

In the positive response of trauma victim to initial fluid resuscitation with stable hemodynamic status, allows for further better imaging by CT scan of abdomen and pelvis. Angiogram and angioembolization are part of the management of all NOM algorithms if contrast extravasation is demonstrated to improve the success rate of NOM. Operative intervention is currently reserved to hemodynamically unstable patients, associated injuries requiring laparotomy, and failure of NOM [36].

The grade of liver injur4y alone and the volume of hemoperitoneum are not considered definitive criteria for selecting operative versus NOM [37].

Large retrospective reviews reported that more than 80% of patients with blunt hepatic injury could be treated by NOM with success rates more than 90% [38-40].

A recent Cochrane review also supported nonoperative management by concluding that currently there is no evidence to support the use of surgery over NOM for patients with abdominal trauma [41].

Some of the contraindications to nonoperative management of liver injury are listed in Table 6.

⋅ Other indication for abdominal surgery (e.g., peritonitis)

⋅ Gunshot injury (relative contraindication)

hemostasis. The approach depends upon the extent of the liver injury and presence and extent

Hemodynamically "unstable" Investigations need to be suspended as immediate surgical correction of the

Hemodynamically stable patients with blunt liver injury who do not have other indications for abdominal exploration can be kept under observation. Patients with right-sided penetrat‐ ing thoracoabdominal injuries, which can lacerate the liver, can remain hemodynamically stable. Such patients can also be kept under observation provided there are no associated intraabdominal injuries. Nonoperative management generally fails in patients with higher-grade injuries than those with lower-grade injuries. Still such patients should be treated with NOM as long as they are hemodynamically stable. Other patients who suffer extra-abdominal injuries but requiring intervention can also be kept under observation. Nonoperatively managed patients who continue to bleed, and even with ongoing blood transfusion have hemodynamic instability need surgical exploration. It is also indicated in those patients who manifest a persistent systemic inflammatory response syndrome (SIRS), like presence of ileus, fever, tachycardia, and oliguria. Grade III and higher injuries often requires a combined

Nonoperative management (NOM) is widely accepted as the treatment of choice for hemo‐ dynamically stable patients with hepatic injury and with no other associated injuries indicating urgent intervention. Nonoperative management (NOM) consists of repeated assessment, close

2e care management with utilization of indicated arteriography and hepatic embolization. Furthermore, NOM is now recommended for penetrating injury (stab wound) as well as lowvelocity gunshot wound to right upper quadrant in stable patients after exclusion of other injuries requiring urgent laparotomy. Most of the injuries that fall in this category are Grade

In the positive response of trauma victim to initial fluid resuscitation with stable hemodynamic status, allows for further better imaging by CT scan of abdomen and pelvis. Angiogram and angioembolization are part of the management of all NOM algorithms if contrast extravasation is demonstrated to improve the success rate of NOM. Operative intervention is currently reserved to hemodynamically unstable patients, associated injuries requiring laparotomy, and

Investigation is more limited. It is aimed at establishing whether the patient can be managed nonoperatively, whether angioembolization can be used or whether

Hemodynamically "normal" Investigation can be completed before treatment is planned.

surgery is required.

bleeding is required.

angiographic and surgical management [34].

**6.1. Nonoperative management**

monitoring, and supportive intensive

I and II liver injuries [35].

failure of NOM [36].

**Table 5.** Classification of patients as per their physiological conditions after abdominal trauma

of associated injuries.

308 Recent Advances in Liver Diseases and Surgery

Hemodynamically "stable"

**Table 6.** Contraindications to nonoperative management

Patients with isolated penetrating hepatic injuries due to abdominal stab wounds has been managed using nonoperative approach but management of patients with gunshot wounds remains controversial. Up to one third of patients of gunshot wound, who are treated using NOM approach, showed failure due to continuous bleeding and development of abdominal compartment syndrome. One of the most important concerns is missed injuries to the gastro‐ intestinal tract [42].

Patients that are managed by NOM needs to be admitted in hospital, placed on bed rest, and monitored continuously. If patients have a normal abdominal examination and stable hemo‐ globin for at least 24 hours, they can be discharged from hospitals. Large observational studies support this practice of discharging patients with liver injury regardless of the grade of injury. The clinical judgment of surgeon is important for deciding the length of observation [43]. Intensive care monitoring for at least 48-72 hours of hemodynamics and overall clinical condition is required for the rest of the cases. Other investigations and repeated clinical examinations and follow up investigations are done as indicated [44].

Thromboprophylaxis is indicated in patients with liver injury or other severe injuries who require hospitalization and are at a high risk for thromboembolism. At the same time, delay in the chemical thromboprophylaxis may be needed due to an increased risk of cerebral or bleeding from other sites. Success of pharmacologic prophylaxis is seen in patients in whom there are no other contraindications to pharmacologic prophylaxis and used when the hemoglobin gets stabilized with less than 1 g hemoglobin decrement over a 24-hour period of time [45].

#### **6.2. Hepatic embolization**

Hepatic embolization can be very useful way for prevention of bleeding. Success rates for embolization depends on many factors. Factors that determine the success includes institution policy, technique of embolization, access to arteries, skill of operator, and type of embolization material used. A properly carried out hepatic embolization has replaced the need for initial operative intervention from many sites. The highest success of hepatic embolization appears to be when used preemptively in patients who demonstrate extravasation of contrast on the initial abdominal CT scan and when patient is hemodynamically stable. The technical success of this technique ranges from 68% to 87%. The incidence of recurrent hemorrhage is found to be low in retrospective reviews. Patients who have no success with observational management can be treated with hepatic embolization. It can also be used adjunctively to manage patients with ongoing bleeding or rebleeding from the liver after surgical treatment for liver injury [22].

#### **6.3. Benefits and risks of nonoperative management**

One of the main advantages of nonoperative management is that it reduces the risks inherent to surgery and anesthesia procedures. However, one of the main disadvantages associated with NOM includes an increased risk of missed intra-abdominal injury, particularly hollow viscus injury, risks associated with embolization, and transfusion-related illness.

Blood transfusion is a life-saving measure during excessive bleeding and related complica‐ tions. However, it is also associated with many complications. Commonly seen complications include intravascular volume overload (transfusion associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI), immunologic and allergic reactions, as well as immunomodulation (transfusion-related immune modulation, TRIM), hypothermia, and coagulopathy. Hepatic embolization is also associated with additional risks. These includes risk of bleeding, complications at the arterial access site, necrosis of liver, abscess in the liver or subdiaphragmatic space, inadvertent embolization of other organs (e.g., bowel, pancreas) or lower extremities, arterial intimal dissection, contrast-induced allergic reactions, and contrast-induced renal toxicity and nephropathy. When embolization is performed following contrast CT scan, particularly in patients who with volume depletion, the risk of contrastinduced nephropathy is even greater. Repeated clinical monitoring and surgical intervention is a must if conservative treatment fails. Studies have shown statistically significant difference in terms of requirements for blood transfusion and intra-abdominal complications when comparing patients receiving operative and nonoperative treatment of liver injuries. However, it shows no difference in the length of hospital stay [46].

The underlying important requirement for use of conservative or NOM is that this should be under guidance of highly trained surgeons. This is because unexpected and difficult to manage complications can occur during observation, and surgeon should be able to convert this management to difficult surgical strategies [47].

#### **6.4. Failure of nonoperative management**

Failure of NOM is defined as the need for urgent surgical intervention and is generally related to hemodynamic instability and bleeding that becomes apparent by the need for ongoing fluid resuscitation or transfusion. Patients who become hemodynamically unstable, by definition, have failed NOM. The option here is almost limited to the life-saving emergency exploration laparotomy. Arterial embolization is less favored after NOM failure, mainly due to the time needed to set up the interventional radiology suite, the complexity of the embolization procedure, and the possible failure that will delay a definitive surgical intervention [48].

**Figure 4.** Patient with Grade IV liver injury, as shown in Figure 3C, who was hemodynamically unstable and showed extravasation of contrast and was unfit for angioembolization underwent laparotomy and resection of the fragmented right posterior liver segment.

A number of complications should be anticipated in NOM. One of the most common compli‐ cations is biliary tree disruption with formation of biloma and/or persistent bile leak. Further‐ more, hepatic necrosis can be seen following angioembolization for hepatic injury. It may also be seen following other procedures like laparotomy and hepatorrhaphy. Factors that may contribute to or indicate failure of NOM include advanced age of patient, delayed bleeding, sudden and severe hypotension, and active extravasation of contrast not controlled by angioembolization [35, 49, 50].

#### **6.5. Surgical management**

The operative management of liver injuries that require surgical intervention can be a challenge even for experienced surgeons (Table 7).

material used. A properly carried out hepatic embolization has replaced the need for initial operative intervention from many sites. The highest success of hepatic embolization appears to be when used preemptively in patients who demonstrate extravasation of contrast on the initial abdominal CT scan and when patient is hemodynamically stable. The technical success of this technique ranges from 68% to 87%. The incidence of recurrent hemorrhage is found to be low in retrospective reviews. Patients who have no success with observational management can be treated with hepatic embolization. It can also be used adjunctively to manage patients with ongoing bleeding or rebleeding from the liver after surgical treatment for liver injury [22].

One of the main advantages of nonoperative management is that it reduces the risks inherent to surgery and anesthesia procedures. However, one of the main disadvantages associated with NOM includes an increased risk of missed intra-abdominal injury, particularly hollow

Blood transfusion is a life-saving measure during excessive bleeding and related complica‐ tions. However, it is also associated with many complications. Commonly seen complications include intravascular volume overload (transfusion associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI), immunologic and allergic reactions, as well as immunomodulation (transfusion-related immune modulation, TRIM), hypothermia, and coagulopathy. Hepatic embolization is also associated with additional risks. These includes risk of bleeding, complications at the arterial access site, necrosis of liver, abscess in the liver or subdiaphragmatic space, inadvertent embolization of other organs (e.g., bowel, pancreas) or lower extremities, arterial intimal dissection, contrast-induced allergic reactions, and contrast-induced renal toxicity and nephropathy. When embolization is performed following contrast CT scan, particularly in patients who with volume depletion, the risk of contrastinduced nephropathy is even greater. Repeated clinical monitoring and surgical intervention is a must if conservative treatment fails. Studies have shown statistically significant difference in terms of requirements for blood transfusion and intra-abdominal complications when comparing patients receiving operative and nonoperative treatment of liver injuries. However,

The underlying important requirement for use of conservative or NOM is that this should be under guidance of highly trained surgeons. This is because unexpected and difficult to manage complications can occur during observation, and surgeon should be able to convert this

Failure of NOM is defined as the need for urgent surgical intervention and is generally related to hemodynamic instability and bleeding that becomes apparent by the need for ongoing fluid resuscitation or transfusion. Patients who become hemodynamically unstable, by definition, have failed NOM. The option here is almost limited to the life-saving emergency exploration laparotomy. Arterial embolization is less favored after NOM failure, mainly due to the time

viscus injury, risks associated with embolization, and transfusion-related illness.

**6.3. Benefits and risks of nonoperative management**

310 Recent Advances in Liver Diseases and Surgery

it shows no difference in the length of hospital stay [46].

management to difficult surgical strategies [47].

**6.4. Failure of nonoperative management**

⋅ Rich and difficult-to-access venous drainage

#### **Table 7.** Operative challenges in the management of liver injury

<sup>⋅</sup> Complex anatomical structure of the liver

<sup>⋅</sup> Large size

<sup>⋅</sup> High blood supply (vascularity), which is dual in nature

Operative intervention is most commonly preferred for penetrating abdominal or thoracic injuries with hemodynamically unstable patients. If the injury is a result of a high-velocity gunshot wound and if there is associated hollow viscus injury, it is always the preferred approach [51]. Hemodynamic status rather than grade of injury is more important indication for operative management in patients with blunt abdominal and chest injuries. As a general rule, a higher-grade injury usually has higher potential for failure of nonoperative manage‐ ment. Emergency laparotomy is also indicated in NOM if there is rebleeding, constant decline of hemoglobin, and increased transfusion requirement, as well as the failure of angioemboli‐ zation of actively bleeding vessels [52].

Various surgical methods that are described include direct suture ligation of the parenchymal bleeding vessel, repair of venous injury under total vascular isolation and damage control surgery with utilization of preoperative, and/or postoperative angioembolization and perihe‐ patic packing. Less preferred methods include anatomical resection of the liver, vascular ligation and use of the atriocaval shunt [53].

#### **6.6. Damage control surgery**

Damage control or damage limitation surgery is the concept originated from naval strategy, whereby a ship which has been damaged can be managed with minimal repairs to prevent it from sinking and definitive repairs can wait until it reaches port. One of the approaches includes perihepatic packing and closure of the abdominal incision using either a Bogata bag or a partial closure of proximal abdominal incision. With the similar approach, a minimum surgery is needed to stabilize the patient's condition, and in the meantime, the physiological derangement can be corrected. Damage control surgery is done with main objectives, including stopping any active surgical bleeding and controlling any contamination. The timing of reexploration depends upon many factors, including the correction of acidosis, coagulopathy, and hypothermia (i.e. trauma's lethal triad). The window considered safe during damage control surgery is 12-48 hours for reexploration and formal completion of the surgery [54, 55].

The algorithm for blunt liver trauma management is depicted in Figure 5.
