Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: trauma surgeons still need to operate, but angioembolization helps.
BACKGROUND
American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) grades IV and V complex hepatic injuries are highly lethal. Our objectives were to review experience and identify predictors of outcome and to evaluate the role of angioembolization in decreasing mortality.


METHODS
This was a retrospective 8-year study of all patients sustaining AAST-OIS grades IV and V hepatic injuries managed operatively. Statistical analysis was performed using univariate and multivariate logistic regression. The main outcome measure was survival.


RESULTS
The study included 103 patients, with a mean Revised Trauma Score of 5.61 +/- 2.55 and a mean Injury Severity Score of 33 +/- 9.5. Mechanism of injury was penetrating in 80 (79%) and blunt in 23 (21%). Emergency department thoracotomy was performed in 21 (25%). AAST grade IV injuries occurred in 51 (47%) and grade V injuries occurred in 52 (53%). Mean estimated blood loss was 9,414 mL. Overall survival was 43%. Adjusted overall survival rate after emergency department thoracotomy patients were excluded was 58%. Results stratified to AAST-OIS injury grade were as follows: grade IV, 32 of 51 (63%); grade V, 12 of 52 (23%); grade IV versus grade V (p < 0.001) odds ratio, 2.06; 95% confidence interval, 2.72 (1.40-3.04). Logistic regression analysis identified as independent predictors of outcome Revised Trauma Score (adjusted p < 0.0002), angioembolization (adjusted p < 0.0177), direct approach to hepatic veins (adjusted p < 0.0096), and packing (adjusted p < 0.0013).


CONCLUSIONS
Improvements in mortality can be achieved with an appropriate operative approach. Angioembolization as an adjunct procedure decreases mortality in AAST-OIS grades IV and V hepatic injuries.
Asensio
Juan A
JA
Department of Surgery, University of Southern California Medical Center, Los Angeles 90033-4525, USA. asensio@usc.edu
Roldán
Gustavo
G
Petrone
Patrizio
P
Rojo
Esther
E
Tillou
Areti
A
Kuncir
Eric
E
Demetriades
Demetrios
D
Velmahos
George
G
Murray
James
J
Shoemaker
William C
WC
Berne
Thomas V
TV
Chan
Linda
L
D004621:Embolization, Therapeutic; D005260:Female; D006801:Humans; D008099:Liver / Q000293:injuries*; D016015:Logistic Models; D008297:Male; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D015599:Trauma Severity Indices; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000401:mortality / Q000601:surgery* / Q000628:therapy