Approach to the management of complex hepatic injuries

Background: Complex hepatic injuries American Association for the Surgery o f Trauma Organ Injury Scale grades IV and V incur high mortality rate rangi ng from 40 to 80%, respectively. The objective of this study is to assess t he clinical experience with an aggressive approach to the management of the se, the most complex of hepatic injuries, Methods: This is a retrospective 6-year study (1992-1997) at an American Co llege of Surgeons urban Level I trauma center of patients sustaining comple x hepatic injuries whose interventions included surgery, angiographic embol ization, endoscopic retrograde cholangiopancreatography plus biliary stenti ng and percutaneous computed tomographic-guided drainage. The main outcome measure was survival. Results: A total of 22 patients sustaining complex hepatic injuries; mean a ge 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 mt; mean number of units of bl ood transfused was 15. The patients underwent the following interventions: surgery (n = 22), re-operated (n = 13), mean number of operations 1.6 (rang e, 1-4), extensive hepatotomy and hepatorrhaphy (n = 17), nonanatomic resec tion (n = 7), formal hepatectomy (n = 4), packing (n = 10), direct approach to hepatic veins (n = 3); angiographic embolization (n = 15); endoscopic r etrograde cholangiopancreatography and stenting (n = 5); computed tomograph ic 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 ra tes can be achieved with an aggressive approach to the management of comple x hepatic injuries, including surgery, early packing, angiographic emboliza tion, endoscopic retrograde cholangiopancreatography and stenting of biliar y leaks, and drainage of hepatic abscesses.