title: Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: trauma surgeons still need to operate, but angioembolization helps.
abstract: 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.
authors.affiliation: Department of Surgery, University of Southern California Medical Center, Los Angeles 90033-4525, USA. asensio@usc.edu
authors.forename: Juan A
authors.initials: JA
authors.lastname: Asensio
authors.forename: Gustavo
authors.initials: G
authors.lastname: Roldán
authors.forename: Patrizio
authors.initials: P
authors.lastname: Petrone
authors.forename: Esther
authors.initials: E
authors.lastname: Rojo
authors.forename: Areti
authors.initials: A
authors.lastname: Tillou
authors.forename: Eric
authors.initials: E
authors.lastname: Kuncir
authors.forename: Demetrios
authors.initials: D
authors.lastname: Demetriades
authors.forename: George
authors.initials: G
authors.lastname: Velmahos
authors.forename: James
authors.initials: J
authors.lastname: Murray
authors.forename: William C
authors.initials: WC
authors.lastname: Shoemaker
authors.forename: Thomas V
authors.initials: TV
authors.lastname: Berne
authors.forename: Linda
authors.initials: L
authors.lastname: Chan
mesh_terms: 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