Journal of Emergencies, Trauma, and Shock
Home About us Editors Ahead of Print Current Issue Archives Search Instructions Subscribe Advertise Login 
Users online:1362   Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size   


 
 Table of Contents    
LETTER TO EDITOR  
Year : 2015  |  Volume : 8  |  Issue : 4  |  Page : 239-240
"The best is nothing": Non-operative management of hemodynamically stable grade V liver trauma


1 Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna, Italy
2 Department of Radiology, Interventional Radiology Unit, Maggiore Hospital, Bologna, Italy
3 Department of Emergency, Trauma ICU, Trauma Center, Maggiore Hospital, Bologna, Italy

Click here for correspondence address and email

Date of Web Publication7-Oct-2015
 

How to cite this article:
Tugnoli G, Cinquantini F, Coniglio C, Biscardi A, Piccinini A, Gordini G, Di Saverio S. "The best is nothing": Non-operative management of hemodynamically stable grade V liver trauma. J Emerg Trauma Shock 2015;8:239-40

How to cite this URL:
Tugnoli G, Cinquantini F, Coniglio C, Biscardi A, Piccinini A, Gordini G, Di Saverio S. "The best is nothing": Non-operative management of hemodynamically stable grade V liver trauma. J Emerg Trauma Shock [serial online] 2015 [cited 2020 Jul 15];8:239-40. Available from: http://www.onlinejets.org/text.asp?2015/8/4/239/166756


Dear Editor,

A 50-year-old male was the restrained passenger involved in high-energy car crash on the highway. He was hypotensive in the emergency room (blood pressure [BP] 80/60 mmHg). Fluid resuscitation was initiated with reasonable improvement of Blood Pressure and Heart Rate and maintenance of hemodynamic stability thereafter. Contrast-enhanced computed tomography (CT scan with intravenous contrast) showed a large liver hematoma occupying a greater portion of the right lobe, with minimal amount of peritoneal free fluid, an active arterial blush and a large hematoma extending vertically, all around the Inferior Vena Cava in its retrohepatic tract, consistent with a contained venous bleeding from hepatic veins injury (American Association for the Surgery of Trauma grade V) [Figure 1]. The patient was kept under permissive hypotension and cautious fluid resuscitation, showing a transient response throughout the next hour. Urgent angioembolization was performed achieving the closure of the arterial bleeding with coils [Figure 1]. Hemodynamics improved after resuscitation and the patients remained stable in the next days. Repeated CT scan 6 days later showed a significant improvement of the liver hematoma and reabsorption of the juxtacaval hematoma and resolution of the caval compression [Figure 2].
Figure 1: Initial computed tomography scan at admission showing the juxtacaval hematoma and a significant caval compression and the possible of venous wall injury (discontinuity); Angiographic embolization with coils (right panel)

Click here to view
Figure 2: Repeated computed tomography after 6 days showing the resolution of juxtahepatic hematoma and decrease of caval compression (left panel) and the normal evolution of the liver hematoma and residual coil from angioembolization (right panel)

Click here to view


Grade V liver trauma is fortunately quite rare with a high operative mortality (67-80%). [1] In unstable patients, damage control surgery with selective use of angioembolization, can be able to achieve an overall mortality rate of 51.3% [2] grade V liver trauma account for roughly 15% of the hemodynamically stable patients, and showed a failure rate of 12% and admission systolic blood pressureBP seems to be lower in the patients failing non-operative management (NOM) however no reliable predictor of failure other than the ultimate development of hemodynamic instability can be identified. [3] While in the management of such injuries, one might initially think that performing the best surgical procedure is the repair of the venous injury and fixing the problem, therefore the patient might end up in Operating Room for life-threatening and technically demanding surgical operations, must be kept in mind that sometimes wait and see, with NOM and angioembolization, is the most prudent strategy to achieve the best outcomes.

 
   References Top

1.
Chen RJ, Fang JF, Lin BC, Hsu YP, Kao JL, Chen MF. Factors determining operative mortality of grade V blunt hepatic trauma. J Trauma 2000;49:886-91.  Back to cited text no. 1
    
2.
Di Saverio S, Catena F, Filicori F, Ansaloni L, Coccolini F, Keutgen XM, et al. Predictive factors of morbidity and mortality in grade IV and V liver trauma undergoing perihepatic packing: Single institution 14 years experience at European trauma centre. Injury 2012;43:1347-54.  Back to cited text no. 2
    
3.
Croce MA, Fabian TC, Menke PG, Waddle-Smith L, Minard G, Kudsk KA, et al. Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. Results of a prospective trial. Ann Surg 1995;221:744-53.  Back to cited text no. 3
    

Top
Correspondence Address:
Salomone Di Saverio
Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna
Italy
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.166756

Rights and Permissions


    Figures

  [Figure 1], [Figure 2]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed1589    
    Printed37    
    Emailed0    
    PDF Downloaded14    
    Comments [Add]    

Recommend this journal