title: Surgical management of AAST grades III-V hepatic trauma by Damage control surgery with perihepatic packing and Definitive hepatic repair-single centre experience.
abstract: BACKGROUND
  Severe liver injury in trauma patients still accounts for significant morbidity and mortality. Operative techniques in liver trauma are some of the most challenging. They include the broad and complex area, from damage control to liver resection.
  
  
  METHODS
  This is a retrospective study of 121 trauma patients with hepatic trauma American Association for Surgery of Trauma (AAST) grade III-V who have undergone surgery. Indications for surgery include refractory hypotension not responding to resuscitation due to uncontrolled hemorrhage from liver trauma; massive hemoperitonem on Focused assessment by ultrasound for trauma (FAST) and/or Diagnostic peritoneal lavage (DPL) as well as Multislice Computed Tomography (MSCT) findings of the severe liver injury and major vascular injuries with active bleeding.
  
  
  RESULTS
  Non-survivors have significantly higher AAST grade of liver injury and higher Injury Severity Score (ISS) (p = 0.000; p = 0.0001). Non-survivors have significant hypotension on arrival and lower Glasgow Coma Scale (GCS) on admission (p = 0.000; p = 0.0001). Definitive hepatic repair was performed in 62(51.2 %) patient. Damage Control, liver packing and planned re-laparotomy after 48 h were used in 59(48.8 %). There was no statistically significant difference in terms of the surgical approach. There was significant difference in the amount of red blood cells (RBC) transfusion in the first 24 h between survivors and non-survivors (p = 0.001). Overall mortality rate was 33.1 %. Regarding complications non-survivors had significantly prolonged bleeding and higher rate of Acute respiratory distress syndrome (ARDS) (p = 0.0001; p = 0.0001), while survivors had significantly higher rate of pleural effusion (p = 0.0001).
  
  
  CONCLUSIONS
  All efforts in the treatment of severe liver injuries should be directed to the rapid and effective control of bleeding, because uncontrollable hemorrhage is the cause of early death and it requires massive blood transfusion, all of which contributes to the late fatal complication.
authors.affiliation: Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Emergency Surgery, University of Belgrade, Serbia, Pasteur Str.2, Belgrade, 11000 Serbia.
authors.forename: Krstina
authors.initials: K
authors.lastname: Doklestić
authors.affiliation: Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Emergency Surgery, University of Belgrade, Serbia, Pasteur Str.2, Belgrade, 11000 Serbia.
authors.forename: Branislav
authors.initials: B
authors.lastname: Stefanović
authors.affiliation: Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Emergency Surgery, University of Belgrade, Serbia, Pasteur Str.2, Belgrade, 11000 Serbia.
authors.forename: Pavle
authors.initials: P
authors.lastname: Gregorić
authors.affiliation: Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Emergency Surgery, University of Belgrade, Serbia, Pasteur Str.2, Belgrade, 11000 Serbia.
authors.forename: Nenad
authors.initials: N
authors.lastname: Ivančević
authors.affiliation: Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Emergency Surgery, University of Belgrade, Serbia, Pasteur Str.2, Belgrade, 11000 Serbia.
authors.forename: Zlatibor
authors.initials: Z
authors.lastname: Lončar
authors.affiliation: Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Department for Anesthesiology, University of Belgrade, Serbia, Belgrade, Serbia.
authors.forename: Bojan
authors.initials: B
authors.lastname: Jovanović
authors.affiliation: Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Department for Anesthesiology, University of Belgrade, Serbia, Belgrade, Serbia.
authors.forename: Vesna
authors.initials: V
authors.lastname: Bumbaširević
authors.affiliation: Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Emergency Surgery, University of Belgrade, Serbia, Pasteur Str.2, Belgrade, 11000 Serbia.
authors.forename: Vasilije
authors.initials: V
authors.lastname: Jeremić
authors.affiliation: Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Physical and Rehabilitation Medicine, Clinical Center of Serbia, Belgrade, Serbia.
authors.forename: Sanja Tomanović
authors.initials: ST
authors.lastname: Vujadinović
authors.affiliation: Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Department for Anesthesiology, University of Belgrade, Serbia, Belgrade, Serbia.
authors.forename: Branislava
authors.initials: B
authors.lastname: Stefanović
authors.affiliation: Faculty of Medicine and Institute for Medical Statistics and Informatics, University of Belgrade, Belgrade, Serbia.
authors.forename: Nataša
authors.initials: N
authors.lastname: Milić
authors.affiliation: Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Emergency Surgery, University of Belgrade, Serbia, Pasteur Str.2, Belgrade, 11000 Serbia.
authors.forename: Aleksandar
authors.initials: A
authors.lastname: Karamarković
keywords: Damage control surgery (DCS); Exsanguinating trauma patients; Hemorrhage; Liver trauma; Mortality