Surgical management and outcome of blunt major liver injuries: experience of damage control laparotomy with perihepatic packing in one trauma centre.
BACKGROUND
This retrospective study aimed to assess the clinical experience and outcome of damage control laparotomy with perihepatic packing in the management of blunt major liver injuries.


METHODS
From January 1998 to December 2006, 58 patients of blunt major liver injury, American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) equal or greater than III, were operated with perihepatic packing at our institute. Demographic data, intra-operative findings, operative procedures, adjunctive managements and outcome were reviewed. To determine whether there was statistical difference between the survivor and non-survivor groups, data were compared by using Mann-Whitney U test for continuous variables, either Pearson's chi-square test or with Yates continuity correction for contingency tables, and results were considered statistically significant if p<0.05.


RESULTS
Of the 58 patients, 20 (35%) were classified as AAST-OIS grade III, 24 (41%) as grade IV, and 14 (24%) as grade V. At laparotomy, depending on the severity of injuries, all 58 patients underwent various liver-related procedures and perihepatic packing. The more frequent liver-related procedures included debridement hepatectomy (n=21), hepatorrhaphy (n=19), selective hepatic artery ligation (n=11) and 7 patients required post-laparotomy hepatic transarterial embolization. Of the 58 patients, 28 survived and 30 died with a 52% mortality rate. Of the 30 deaths, uncontrolled liver bleeding in 24-h caused 25 deaths and delayed sepsis caused residual 5 deaths. The mortality rate versus OIS was grade III: 30% (6/20), grade IV: 54% (13/24), and grade V: 79% (11/14), respectively. On univariate analysis, the significant predictors of mortality were OIS grade (p=0.019), prolonged initial prothrombin time (PT) (p=0.004), active partial thromboplastin time (APTT) (p<0.0001) and decreased platelet count (p=0.005).


CONCLUSIONS
The mortality rate of surgical blunt major liver injuries remains high even with perihepatic packing. Since prolonged initial PT, APTT and decreased platelet count were associated with high risk of mortality, we advocate combination of damage control resuscitation with damage control laparotomy in these major liver injuries.
Division of Trauma & Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan Hsien, Taiwan. Electronic address: linbc@cgmh.org.tw.
Being-Chuan
BC
Lin
Jen-Feng
JF
Fang
Ray-Jade
RJ
Chen
Yon-Cheong
YC
Wong
Yu-Pao
YP
Hsu
D000007:Abdominal Injuries / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D000063:Accidents, Traffic / Q000401:mortality; D000293:Adolescent; D000328:Adult; D000368:Aged; D001458:Bandages; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D004621:Embolization, Therapeutic; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D007813:Laparotomy; D008099:Liver / Q000293:injuries* / Q000473:pathology; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D011379:Prognosis; D012151:Resuscitation; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D013624:Taiwan / Q000453:epidemiology; D014193:Trauma Centers; D016896:Treatment Outcome; D014754:Violence / Q000706:statistics & numerical data; D014949:Wounds, Nonpenetrating / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*
Blunt major liver injuries; Damage control laparotomy; Damage control resuscitation; Injury severity score; Perihepatic packing; Transarterial embolization