The treatment of hepatic injury can be complicated. Unfortunately, the expertise level in specialized hepatic surgery in clinical medical hospitals is generally low. This study aimed to summarize the experience in the diagnosis and treatment of hepatic trauma in one clinical hospital in China. The results suggest that despite improvements in technologies for liver surgery, the level of hepatic trauma repair in clinical medical hospital is low partly because of the limitations in experience and hospital conditions, while most important is because of emergency incident to hepatic trauma itself. AAST grading ≥ III and multiple organ injury were independently associated with death. Among patients with AAST grading ≥ III, surgery was an independent protective factor for death. Among patients with ASST ≥ III and who underwent surgery, age and PHP were independently associated with death.
Over the past 20 years, with the continuous accumulation of experience in the treatment of severe hepatic trauma, the establishment of novel concepts for trauma treatment and the improvement in treatment methods, the mortality of grade III and IV hepatic trauma has dropped to less than 10% in large hospitals [10]. On the other hand, the data from clinical medical centers are not optimistic: in the past 15 years, the mortality of severe hepatic trauma in the hospital reached 25.4%, and none of the patients below grade III died of hepatic trauma directly[11]. Therefore, for clinical medical hospitals, it is particularly necessary to attach great importance to the treatment of severe hepatic trauma above grade III and strive to improve the success rate.
First, for patients with severe hepatic injury, time means life. During the rescue, attention should be paid to every detail and factors that may delay diagnosis and treatment. As far as possible, emergency trauma rescue teams should be set up in clinical medical hospitals. Once severe trauma occurs, ambulance first-aid personnel can inform the emergency department of hospitals to open the fast-track channel and arrange the rescue team members and various bedside examination machines. The blood transfusion department can inform the central blood bank to prepare a large amount of blood. For patients with suspected severe hepatic injury, venous access is preferred to the upper limb vein, internal jugular vein, or subclavian vein. The superficial veins collapse and are difficult to puncture, and repeated puncture should be avoided to save time. The internal jugular vein or subclavian vein should be catheterized by an experienced anesthesiologist. For patients with suspected severe hepatic injury and unstable vital signs, liquid resuscitation should be carried out as soon as possible according to the principle of crystalloid fluid first and then colloid fluid (crystal: colloid ratio of 2–3:1) before the blood supply arrives, so as to maintain blood pressure, improve shock, prevent cardiac arrest, and gain valuable time for further surgery to stop bleeding. Four patients with severe hepatic injury in this study were delayed for a long time due to various causes at the scene of the accident. Although they were rescued with the best efforts after being sent to the hospital, they still died of hemorrhagic shock and multiple organ failure before laparotomy due to excessive intraperitoneal bleeding, which exceeded the patients’ physiological compensation limit. Therefore, the length of time after injury is an extremely important factor for whether or not patients with a severe hepatic injury can be successfully rescued.
The time from injury is very important for wounded patients with suspected abdominal bleeding, especially with short injury time. Bedside ultrasound and intensive monitoring should be performed first to determine the amount of abdominal bleeding and observe the stability of the vital signs. The temporary “stability” of the initial vital signs will lead to increased bleeding, shock, and even death during the examinations. Simultaneously, negative ultrasound results cannot completely exclude liver damage. Nowadays, abdominal CT is considered to be the preferred method for the diagnosis of abdominal injury in patients with stable hemodynamics [18]. After the diagnosis of hepatic injury, injury assessment is necessary to select a reasonable treatment strategy according to the grade of hepatic injury, according to AAST [12, 19, 20]. Although CT and ultrasound are important methods for the diagnosis of hepatic trauma, they cannot accurately reflect the AAST grade. The velocity and amount of abdominal hemorrhage and the stability of circulation are the most direct indicators of the severity of hepatic injury [10, 18, 21].
The indications for non-surgical and surgical treatments should also be understood, especially in the presence of grade III or above injury [17]. Emphasizing the importance of non-surgical treatment is a major change in the concept of treating hepatic trauma over the last 20 years [22], and nowadays, non-surgical treatment for severe hepatic trauma has become a tendency [23, 24]. Namely, the determinants of non-surgical treatment for hepatic trauma lie in whether the hemodynamics of patients are stable, and whether there are other combined injuries requiring surgical treatment, rather than relying unilaterally on the grading of hepatic trauma and intraperitoneal blood accumulations. In this study, although 14 patients presented large intraperitoneal blood accumulations, it was found that the bleeding at the hepatic laceration stopped spontaneously during laparotomy. It should be noted that the conservative treatment for hepatic trauma combined with splenic or renal contusion and laceration should be very careful. For such patients, close attention should be paid to the changes in vital signs and abdominal signs under intensive monitoring. Ultrasonography or CT should be reviewed timely, and delayed splenic or renal rupture should be monitored, which is the most common cause of the failure in conservative treatment for hepatic trauma. Based on many years of clinical experience, the authors’ opinion is that although non-surgical treatment has gradually turned into the main treatment for hepatic trauma, conservative treatment for severe hepatic trauma above grade III still needs to be carefully selected. Especially in clinical medical hospitals, good monitoring conditions and experienced team of liver surgery are missing. Once conservative treatment fails, the rapid and effective surgical transfer cannot be ensured, and surgical indications should be expanded.
When doing an operation, PHP is a very important and practical technique in damage control surgery (DCS) [25]. Inferior vena cava and hepatic vein are low-pressure systems. The effect of PHP on such venous hemorrhage is efficacious [16, 26, 27]. Sometimes, it is difficult to find the exact bleeding site during surgery, and the Pringle maneuver can be used to block hepatic blood flow from the first porta hepatis. During the operation, when there is still a large amount of dark red blood gushing from the hepatic fissure, it should be considered that the bleeding originates from the hepatic vein, short hepatic vein, and/or retro-hepatic inferior vena cava laceration. Such injuries are particularly difficult for general surgeons to treat in clinical medical hospitals. In addition, catastrophic hemorrhage is often caused by dissecting, exposing, and suturing the bleeding site. Extensive and uncontrollable bleeding during the surgical incision, abdominal cavity, and hepatic wound indicates that the body has severe coagulation dysfunction, and the patient is on the verge of death and may be unable to tolerate further surgery. At this moment, surgery should be completed after effective PHP using dry gauze pad (gelatin sponge or omentum can be used between the gauze pad and the liver surface to prevent secondary bleeding when removing the gauze). Actually, accurate and skillful application of this technology is related to the success of saving patients’ lives and can gain time for emergency transfer to superior hospitals with better technical conditions for further rescue. In addition, the significance of PHP is also that, when hepatic rupture is intraoperatively found to be combined with splenic rupture, mesenteric laceration and simultaneous massive hemorrhage of multiple organs in the abdominal cavity, temporary PHP can be used to control bleeding at the site of hepatic injury, and then other bleeding foci such as splenic rupture and mesenteric rupture can be treated calmly. According to our experience, the surgeons determine patients’ injury and physiological state in advance and try to perform PHP actively and decisively before patients’ general condition deteriorates, instead of being forced to perform PHP in a hurry when patients show physical exhaustion and severe coagulation dysfunction. Second, excessive gauze packing can compress the inferior vena cava and renal vein, which might lead to abdominal compartment syndrome and might aggravate hepatic laceration and hemorrhage. The packing can be removed 72 h to one week after surgery, depending on the condition of patients. Early removal may lead to re-bleeding, and late removal may cause an increased risk of abdominal infection [28]. In order to reduce the incidence of abdominal infection after surgery for severe hepatic rupture, effective drainage was placed around the liver (subphrenic, subhepatic and hepatic section) and pelvic cavity during PHP in the first surgery and packing removal in the second surgery, and timely dressing change could be made to prevent retrograde infection.
In addition, for patients with severe hepatic trauma on the verge of death, intraoperative intensive monitoring and life support are particularly important, which requires the cooperation of experienced anesthesiologists and surgeons. Whether anesthesiologists’ monitoring and resuscitation for patients with severe hepatic trauma during the surgery are proper sometimes directly affects the occurrence of a series of severe complications such as brain swelling, large-area cerebral infarction, renal failure, disseminated intravascular coagulation, and abdominal compartment syndrome after surgery, and thereby influencing the success rate of rescue. Therefore, rescuing patients with severe hepatic trauma is not a battle for the surgeons alone.
For a long time, general surgeons in clinical medical hospitals have not paid attention to the objective fact that abdominal compartment syndrome may occur after surgery for severe hepatic trauma. Abdominal compartment syndrome refers to that intra-abdominal pressure rises sharply due to various reasons, resulting in circulatory, respiratory and renal dysfunction, manifested as an obvious abdominal bulge, tension, hypoxia, increased airway resistance, and oliguria or anuria [29]. This syndrome is common in severe abdominal trauma, such as hepatic trauma. The causes include massive intra-abdominal hemorrhage, excessive crystal fluid infusion during shock resuscitation, visceral ischemia-reperfusion injury, and inappropriate PHP [9, 16, 17]. It should be emphasized that long-term hepatic portal occlusion can aggravate liver ischemia and hypoxia, which is already in shock, leading to severe liver swelling, gastrointestinal congestion, and even affecting field exposure and further surgical operations, which is also one of the causes of the abdominal compartment syndrome. Some scholars have proposed that bicyclol has a significant protective effect on hepatic ischemia-reperfusion injury and can improve the regeneration ability of residual liver [10, 30].
This study has limitations. It was a single-center study with retrospectively analysis. There was no comparator group from higher-level hospitals.