Liver Injury and Damage Control

Liver Injury and Damage Control By Steven Stylianos New York, New York

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ECAUSE of the sustained success of nonoperative treatment of blunt abdominal trauma, 1 surgical experience with solid organ injury requiring immediate operation is declining. It is imperative that surgeons familiarize themselves with current treatment algorithms for the rare case of life-threatening abdominal trauma. The indications for immediate surgery after abdominal trauma in children include hemodynamic instability, evidence of persistent hemorrhage, suspicion of hollow viscus perforation, and major pancreatic ductal disruption. Maintenance of physiologic stability during the struggle for surgical control of severe bleeding is a challenge even for the most experienced surgeon, particularly when hypothermia, coagulopathy, and acidosis occur. This triad creates a vicious cycle in which each derangement augments and exacerbates the others, and the physiologic and metabolic consequences of the triad may preclude completion of the procedure. Increased emphasis on physiologic and metabolic stability in emergency abdominal operations has led to the development of staged, multidisciplinary treatment plans including abbreviated laparotomy, perihepatic packing, temporary abdominal closure, angiographic embolization, and endoscopic biliary stenting. 2,3 Asensio et aP reported on 22 patients with grade IV or V liver injuries treated between 1992 and 1997.3 Mean blood loss was estimated at 4.6 L, and mean packed red cell transfusion requirement was 15 U. Ten patients were packed at the first operation. Fifteen patients underwent postoperative angiographic embolization in attempt to control hemorrhage. Survival rate was 92% in 13 grade IV patients and 78% in 9 grade V patients. This report showed that abbreviated laparotomy with packing for hemostasis allowing resuscitation before planned reoperation is an alternative in unstable patients in whom further blood loss would be untenable. Once patients are rewarmed, coagulation factors replaced, and oxygen delivery optimized, they can be returned to the operating room for pack removal and definitive repair of injuries. Although abdominal packing (PACKS) with planned reoperation has been utilized with increasing frequency in adults during the past 2 decades,3-7 there is little experience reported in children. 8-13 A recent review reported 22 patients with refractory hemorrhage (ages 6 days to 20 years) treated with PACKS.8 The anatomic Seminars in Pediatric Surgery, Vol 10, No 1 (February), 2001: pp 23-25

site of hemorrhage was the liver or hepatic veins in 14, retroperitoneurn or pelvis in 7, and the pancreatic bed in 1. Fifteen patients (68%) had PACKS inserted during a primary operative procedure. Insertion of abdominal packing was accomplished in a mean of 2.5 hours (range, 1 to 5 hours) after the start of the primary procedure. Seven patients (32%) had PACKS inserted during a reexploration for persistent hemorrhage in a mean of 1 hour (range, 1 to 2 hours) after the start of the reexploration. Twenty of the 22 patients (91 %) were coagulopathic (mean prothrombin time > 16 seconds), hypothermic (mean temperature <35°C), and acidotic (mean pH <7.2) at the time of packing. The mean volume of intraoperative blood product transfusion before PACKS was 190 mL/kg (range, 50 to 600 mL/kg). Primary fascial closure was accomplished in 12 (55%) patients, whereas temporary skin closure or prosthetic material was used in the other 10. PACKS controlled hemorrhage in 21 of 22 (95%) patients. Removal of PACKS was possible within 72 hours in 18 (82%) patients. No patient rebelled after PACKS removal; however, 2 died with PACKS in place. Seven patients (32%) had an abdominal or pelvic abscess. All were drained successfully by laparotomy (6 patients) or percutaneous approach (1 patient). Six of these 7 patients with abdominal sepsis survived; overall, 18 patients (82%) survived. Two deaths were caused by multisystem organ failure; 1 was caused by cardiac failure associated with complex cardiac anomalies, and 1 was caused by exsanguination after blunt traumatic liver injury. There were no differences in volume of intraoperative blood product transfusion, time to initiate PACKS, physiologic status, or type of abdominal closure between survivors and nonsurvivors. From the Pediatric Trauma Service, Babies and Children's Hospital of New York and the Columbia University College of Physicians and Surgeons, New York, NY. Presented at the Fifth National Conference on Pediatric Trauma, Vail, Colorado, June 2000. Address reprint requests to Steven Stylianos, MD, Division of Pediatric Surgery, Babies and Children's Hospital of New York, 3959 Broadway, Room 207N, New York, NY 10032. Copyright © 2001 by w.B. Saunders Company 1055-8586/01/1001-0007$10.00/0 doi:10. 1053/spsu.2001. 19385 23

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STEVEN STYLIANOS

The consequences of prolonged operations with massive blood product replacement include hypothermia, coagulopathy, and acidosis. Although the surgical team may keep pace with blood loss, life-threatening physiologic and metabolic consequences are inevitable and many of these critically ill patients are unlikely to survive once their physiologic reserves have been exceeded. A multiinstitutional review identified exsanguination as the cause of death in 82% of 537 intraoperative deaths at 8 academic trauma centers. 14 The mean pH was 7.18 and mean core temperature was 32°C before death. Lethal abdominal hemorrhage in infants and children can result from a variety of causes. Moulton et al l5 reported survival in only 5 of 12 (40%) consecutive operative cases of retrohepatic vascular or severe parenchymal liver injury in children. VanderKolk et aP2 reported severe liver hemorrhage in 8 of 68 (12%) infants during laparotomy for necrotizing enterocolitis (NEC), with 1 of these 8 infants surviving. The concept of planned reoperation for severe abdominal hemorrhage as a strategy against probable exsanguination in critically injured patients with the triad of hypothermia, coagulopathy, and acidosis was reintroduced by Feliciano et al. 4 The goal of abbreviated laparotomy is to interrupt the life-threatening triad and allow for rewarming, replacement of clotting factors, and restoration of maximal oxygen delivery before planned reoperation. Significant improvement in survival rate has been reported by Rotondo (77% v 11 %) when comparing abbreviated "damage control" laparotomy to ill-advised, prolonged attempts at definitive repair in retrospective analysis of unstable trauma patients. 5 Review of nearly 700 patients with abdominal packing from several institutions shows hemostasis in 80%, survival rate of 32% to 73%, and abdominal abscess rates of 10% to 40%.6,7 It is essential to emphasize that the success of the abbreviated laparotomy and planned reoperation depends on an early decision to use this strategy before irrevers-

ible shock. A staged operative strategy for unstable patients represents advanced surgical care and requires sound surgical judgment and expertise. Abdominal packing, when used as a desperate, last-ditch resort after prolonged attempts at hemostasis have failed, has been uniformly unsuccessful. Physiologic and anatomic criteria have been identified as indications for abdominal packing. Most of these have focused on intraoperative parameters including pH (7,2), core temperature «35°C), and coagulation values (prothrombin time> 16 seconds) in patients with diffuse hemorrhage requiring large volumes of blood product transfusion. Twenty of the 22 patients in our review met these criteria. The optimal time for reexploration is controversial because neither the physiologic end points of resuscitation nor the increased risk of infection with prolonged packing are well defined. Removal of PACKS was accomplished within 72 hours in 82% of patients in this series. The obvious benefits of hemostasis provided by packing should be balanced against the potential detrimental effects of increased intraabdominal pressure on ventilation, cardiac output, renal function, mesenteric circulation, and intracranial pressure. Timely alleviation of the secondary "abdominal compartment syndrome" may be a critical salvage maneuver for patients. Temporary abdominal wall closure at the time of packing can prevent the abdominal compartment syndrome. Ten of 22 (45 %) patients in this review had temporary closure while packs were in place. We recommend temporary abdominal wall expansion in all patients requiring packing until the hemostasis is obtained and visceral edema subsides. Abdominal packing for control of exsanguinating hemorrhage is a life-saving maneuver in highly selected patients in whom coagulopathy, hypothermia, and acidosis render further surgical procedures unduly hazardous. Early identification of patients likely to benefit from abbreviated laparotomy techniques is crucial for success.

REFERENCES 1. Denton JR, Moore EE, Codwell DM: Multimodality treatment for Grade V hepatic injuries: Perihepatic packing, arterial embolization, and venous stenting. J Trauma 42:964-968, 1997 2. Stylianos S and the APSA Trauma Committee: Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. J Pediatr Surg 35: 164-169, 2000 3. Asensio JA, Demetriades D, Chahwan S, et al: Approach to the management of complex hepatic injuries. J Trauma 48:66-69, 2000 4. Feliciano DV, Mattox KL, Jordan GL: Intraabdominal packing for control of hepatic hemorrhage: Areappraisal. JTrauma 21:285-290,1981 5. Rotondo MF, Schwab CW, McGonigal MD, et al: Damage control: An approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 35:375-383, 1993

6. Cogbill TH, Moore EE, Jurkovich GJ: Severe hepatic trauma: A multicenter experience with 1,335 liver injuries. J Trauma 28: 14331438, 1988 7. Hirshberg A, Mattox KL: Planned reoperation for severe trauma. Ann Surg 222:3-8, 1995 8. Stylianos S: Abdominal packing for severe hemorrhage. J Pediatr Surg 33 :339-342, 1998 9. Stylianos S, Jacir NN, Hoffman MA, et al: Pediatric blunt liver injury and coagulopathy managed with packs and silo. J Trauma 30:1409-1410, 1990 10. Evans S, Jackson RJ, Smith SD: Successful repair of major retrohepatic vascular injuries without the use of shunt or sternotomy. J Pediatr Surg 28:317-320, 1993

LIVER INJURY AND DAMAGE CONTROL

11. Horwitz JR, Black T, Lally KP, et al: Venovenous bypass as an adjunct for the management of a retrohepatic venous injury in a child. J Trauma 39:584-585, 1995 12. VanderKolk WE, Kurz P, Daniels J, et al: Liver hemorrhage during laparotomy in patients with necrotizing enterocolitis. J Pediatr Surg 31:1063-1067, 1996 13. Davies MRQ: Iatrogenic hepatic rupture in the newborn and

25 its management by pack tamponade. J Pediatr Surg 32:1414-1419, 1997 14. Hoyt DB, Bulger EM, Knudson MM, et al: Death in the operating room: An analysis of a multi-<:enter experience. J Trauma 37:426432, 1994 15. Moulton SL, Lynch FP, Canty TO, et al: Hepatic vein and retrohepatic vena caval injuries in children: Sternotomy first ? Arch Surg 126:1262-1266, 1991