Journal of Trauma and Injury

Case Report

A starry night: a case report of severe liver injury due to a close-range shotgun blast in Argentina: Rodrigo Antonio Gasque, José Gabriel Cervantes, Magalí Chahdi Beltrame, Marcelo Enrique Lenz-Virreira, Emilio Gastón Quiñonez; Received June 16, 2024 Accepted August 29, 2024 Published online October 21, 2024; DOI: https://doi.org/10.20408/jti.2024.0036 [Epub ahead of print]

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Abstract PDF: This report presents the case of a 20-year-old man who sustained a severe liver injury from a closerange shotgun blast. A prompt medical intervention, including damage control exploratory laparotomy and surgical debridement, was undertaken due to the extent of liver damage. Despite challenges such as a nondirected biliary fistula and extensive liver parenchymal injury, comprehensive surgical management led to successful treatment. Postoperative complications, including biloma and fungal infection, were managed appropriately, highlighting the importance of vigilant follow-up care. The case underscores the complexity of managing severe liver trauma and emphasizes the evolving role of trauma damage control strategies and minimally invasive procedures in achieving favorable outcomes.; Summary

Review Article

Endovascular embolization of persistent liver injuries not responding to conservative management: a narrative review: Simon Roh; J Trauma Inj. 2023;36(3):165-171. Published online September 15, 2023; DOI: https://doi.org/10.20408/jti.2023.0040

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Abstract PDF: Trauma remains a significant healthcare burden, causing over five million yearly fatalities. Notably, the liver is a frequently injured solid organ in abdominal trauma, especially in patients under 40 years. It becomes even more critical given that uncontrolled hemorrhage linked to liver trauma can have mortality rates ranging from 10% to 50%. Liver injuries, mainly resulting from blunt trauma such as motor vehicle accidents, are traditionally classified using the American Association for the Surgery of Trauma grading scale. However, recent developments have introduced the World Society of Emergency Surgery classification, which considers the patient's physiological status. The diagnostic approach often involves multiphase computed tomography (CT). Still, newer methods like split-bolus single-pass CT and contrast-enhanced ultrasound (CEUS) aim to reduce radiation exposure. Concerning management, nonoperative strategies have emerged as the gold standard, especially for hemodynamically stable patients. Incorporating angiography with embolization has also been beneficial, with success rates reported between 80% and 97%. However, it is essential to identify the specific source of bleeding for effective embolization. Given the severity of liver trauma and its potential complications, innovations in diagnostic and therapeutic approaches have been pivotal. While CT remains a primary diagnostic tool, methods like CEUS offer safer alternatives. Moreover, nonoperative management, especially when combined with angiography and embolization, has demonstrated notable success. Still, the healthcare community must remain vigilant to complications and continuously seek improvements in trauma care.; Summary

Case Reports

Incidental traumatic right diaphragmatic rupture: a missed case after trauma: Fatima Alharmoodi, Shadin Ghabra, Salem Alharthi; J Trauma Inj. 2023;36(1):56-59. Published online June 23, 2022; DOI: https://doi.org/10.20408/jti.2022.0008

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Abstract PDF: Traumatic diaphragmatic hernia is among the most uncommon conditions after severe trauma, and it is associated with high morbidity and mortality. The diagnosis is difficult and might be missed, but a multimodal investigation might help in terms of diagnostic yield. In this case report, we present a missed right diaphragmatic rupture 14 years after the trauma.; Summary

Penetrating liver injury caused by a metal fragment from a blast accident in a factory: a case report: Chan Hee Park, Jeong Woo Lee; J Trauma Inj. 2022;35(Suppl 1):S8-S14. Published online June 3, 2022; DOI: https://doi.org/10.20408/jti.2021.0085

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Abstract PDF Supplementary Material: Penetrating abdominal injuries are rare in countries that do not allow legal possession of firearms by the public. We report a case of a 27-year-old male patient with a penetrating liver injury caused by metal fragments released in a blast accident. On the day of the accident, there was a metal explosion, and multiple fragments of the metal lodged in the patient’s abdomen. The metal fragments were widely distributed over the abdomen and limited to the subcutaneous layer. A computed tomography scan showed that one metal fragment had penetrated near the right upper quadrant. First, we tried exploratory laparoscopy to accurately locate and remove the presumed metal fragment under the liver, on the side of the gallbladder, and near the duodenum. However, we could not find the metal fragment and converted the procedure to open laparotomy. The metal fragment was found to be completely lodged in segment 4, the quadrate lobe to the left of the gallbladder. To remove the fragment, a 2-cm incision was made on the liver surface where the metal fragment was found. The patient’s general postoperative condition was satisfactory, with no findings of bile leakage or bleeding. In conclusion, clinicians who do not have experience with these injuries can still provide adequate treatment by selecting a treatment method based on the patient’s condition as well as the velocity of trauma. The laparoscopic approach, as a less invasive procedure, may be worthwhile for treating penetrating trauma. Additionally, laparoscopic exploratory laparotomy may be considered in selected cases.; Summary

Original Articles

Validity of the scoring system for traumatic liver injury: a generalized estimating equation analysis: Kangho Lee, Dongyeon Ryu, Hohyun Kim, Chang Ho Jeon, Jae Hun Kim, Chan Yong Park, Seok Ran Yeom; J Trauma Inj. 2022;35(1):25-33. Published online September 7, 2021; DOI: https://doi.org/10.20408/jti.2021.0009

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Abstract PDF Supplementary Material

Purpose
The scoring system for traumatic liver injury (SSTLI) was developed in 2015 to predict mortality in patients with polytraumatic liver injury. This study aimed to validate the SSTLI as a prognostic factor in patients with polytrauma and liver injury through a generalized estimating equation analysis. Methods: The medical records of 521 patients with traumatic liver injury from January 2015 to December 2019 were reviewed. The primary outcome variable was in-hospital mortality. All the risk factors were analyzed using multivariate logistic regression analysis. The SSTLI has five clinical measures (age, Injury Severity Score, serum total bilirubin level, prothrombin time, and creatinine level) chosen based on their predictive power. Each measure is scored as 0–1 (age and Injury Severity Score) or 0–3 (serum total bilirubin level, prothrombin time, and creatinine level). The SSTLI score corresponds to the total points for each item (0–11 points). Results: The areas under the curve of the SSTLI to predict mortality on post-traumatic days 0, 1, 3, and 5 were 0.736, 0.783, 0.830, and 0.824, respectively. A very good to excellent positive correlation was observed between the probability of mortality and the SSTLI score (γ=0.997, P<0.001). A value of 5 points was used as the threshold to distinguish low-risk (<5) from high-risk (≥5) patients. Multivariate analysis using the generalized estimating equation in the logistic regression model indicated that the SSTLI score was an independent predictor of mortality (odds ratio, 1.027; 95% confidence interval, 1.018–1.036; P<0.001). Conclusions: The SSTLI was verified to predict mortality in patients with polytrauma and liver injury. A score of ≥5 on the SSTLI indicated a high-risk of post-traumatic mortality.

Summary

Citations

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Liver Trauma: Management in the Emergency Setting and Medico-Legal Implications
Angela Saviano, Veronica Ojetti, Christian Zanza, Francesco Franceschi, Yaroslava Longhitano, Ermelinda Martuscelli, Aniello Maiese, Gianpietro Volonnino, Giuseppe Bertozzi, Michela Ferrara, Raffaele La Russa
Diagnostics.2022; 12(6): 1456. CrossRef

The Prognosis of Traumatic Small Bowel Injury Accompanied by Liver Injury: Yu Seong Noh, Sung Won Jung, Tae Gil Heo, Pyong Wha Choi, Jae Il Kim, Heung Man Jun, Yong Chan Shin, Sung Min Jung, Eun Hae Um; J Trauma Inj. 2021;34(1):44-49. Published online December 7, 2020; DOI: https://doi.org/10.20408/jti.2020.0052

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Abstract PDF: Purpose
The aim of this study was to elucidate the prognosis, and other clinical features, such as time to surgery and the amount of transfusion, of small bowel injury (SBI) accompanied by liver injury (LI).
Methods
We investigated 221 patients with SBI who visited an emergency center from October 2000 to March 2019. We excluded patients with injuries that directly led to mortality, and the remaining 149 patients were divided into the SBI alone (SBI-A) group and the SBI accompanied by LI (SBI-LI) group. Data were collected for preoperative and surgical outcome variables, and the treatment results were compared between groups.
Results
The SBI-LI group had a higher mortality rate than the SBI-A group (22.4% vs. 14.3%), but this difference was not statistically significant (p=0.061). There were no significant differences between the SBI-A and SBI-LI groups, except for the amount of red blood cell (RBC) transfusion (SBI-A: 3.53±0.1 vs. SBI-LI: 8.38±0.7 packs, p=0.035) and the length of intensive care unit (ICU) stay (SBI-A: 6.7±0.2 vs. SBI-LI: 11.1±0.5 days, p=0.047).
Conclusions
The SBI-LI group required more RBC transfusions and longer ICU stays than the SBI-A group. SBI accompanied by LI may show higher mortality than SBI alone; however, since the difference was not statistically significant in the present study, larger-scale follow-up research is needed.; Summary

Case Reports

Priority Setting in Damage Control Surgery for Multiple Abdominal Trauma Following Resuscitative Endovascular Balloon Occlusion of the Aorta: Yoonjung Heo, Seok Won Lee, Dong Hun Kim; J Trauma Inj. 2020;33(3):181-185. Published online September 30, 2020; DOI: https://doi.org/10.20408/jti.2020.0040

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Abstract PDF Supplementary Material: Damage control surgery (DCS) is an abbreviated laparotomy procedure that focuses on controlling bleeding to limit the surgical insult. It has become the primary treatment modality for patients with exsanguinating truncal trauma. Herein, we present the case of a 47-year-old woman with liver, kidney, and superior mesenteric vein (SMV) injuries caused by a motor vehicle collision. The patient underwent DCS following resuscitative endovascular balloon occlusion of the aorta (REBOA). In this case report, we discuss the importance of priority setting in DCS for the treatment of multisystem damage of several abdominal organs, particularly when the patient has incurred a combination of major vascular injuries. We also discuss the implications of damage control of the SMV, perihepatic packing, and right-sided medial visceral rotation. Further understanding of DCS, along with REBOA as a novel resuscitation strategy, can facilitate the conversion of uniformly lethal abdominal injuries into rescuable injuries.; Summary

Hepatic Hemangioma Rupture Caused by Blunt Trauma: Gil Hwan Kim, Jae Hun Kim, Sang Bong Lee; J Trauma Inj. 2017;30(4):235-237. Published online December 30, 2017; DOI: https://doi.org/10.20408/jti.2017.30.4.235

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Abstract PDF

Hepatic hemangioma is the most frequently occurring benign tumor of the liver. Hepatic hemangioma rupture is a rare phenomenon, which can lead to life-threatening conditions. Here, we report a case of hepatic hemangioma rupture caused by blunt trauma. Explorative laparotomy was performed due to unstable vital signs and abdominal massive hemoperitoneum revealed on computed tomography. We detected arterial bleeding from a hepatic hemangioma and performed primary suture of the liver and postoperative angiographic embolization.

Summary

Citations

Citations to this article as recorded by

Post‐traumatic rupture of hepatic haemangioma
Tessa Gaynor, Vanshika Sinh, Jonathan Reddipogu
ANZ Journal of Surgery.2023; 93(11): 2754. CrossRef

Original Article

Analysis of Abdominal Trauma Patients Using National Emergency Department Information System: In Gyu Song, Jin Suk Lee, Sung Won Jung, Jong Min Park, Han Deok Yoon, Jung Tak Rhee, Sun Worl Kim, Borami Lim, So Ra Kim, Il Young Jung; J Trauma Inj. 2016;29(4):116-123. Published online December 31, 2016; DOI: https://doi.org/10.20408/jti.2016.29.4.116

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Abstract PDF

PURPOSE
To develop an inclusive and sustainable trauma system as the assessment of burden of injuries is very much important. The purpose of this study was to evaluate the estimates and characteristics of abdominal traumatic injuries.
METHODS
The data were extracted from the National Emergency Department Information System. Based on Korean Standard Classification for Disease 6th version, which is the Korean version of International Classification of Disease 10th revision, abdominal injuries were identified and abdominal surgeries were evaluated with electronic data interchange codes. Demographic factors, numbers of surgeries and clinical outcomes were also investigated.
RESULTS
From 2011 to 2014, about 24,696 patients with abdominal trauma were admitted to the hospitals annually in South Korea. The number of patients who were admitted to regional and local emergency medical centers was 8,622 (34.91%) and 15,564(63.02%), respectively. Based on National Emergency Department Information System, liver was identified as the most commonly injured abdominal solid organ (39.50%, 9,754/24,696, followed by spleen (17.57%, 4,338/24,696) and kidney (12.94%, 3,195/24,696).
CONCLUSION
This study shows that the demand for abdominal trauma care is considerable in South Korea and most of the patients with abdominal trauma were admitted to regional or local emergency centers. The results of this study can be used as good source of information for staffs to ensure proper delivery of abdominal trauma care in trauma centers nationally.

Summary

Citations

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Abdominal stab wound in A Pregnant woman resulting in Evisceration, Uterine Perforation and Fetal Chest Injury: A Case Report and Literature Review
Oumarou O, Landry TW, Joe NC, Wirwah FT, Ulrich BS, Jean-Paul EN
Journal of Surgery and Surgical Research.2019; : 010. CrossRef

Case Report

Right Diaphragmatic Injury Accompanied by Herniation of the Liver: A Case Report: Min A Lee, Kang Kook Choi, Gil Jae Lee, Byung Chul Yu, Dae Sung Ma, Yang Bin Jeon, Jung Nam Lee, Min Chung; J Trauma Inj. 2016;29(2):43-46. Published online June 30, 2016; DOI: https://doi.org/10.20408/jti.2016.29.2.43

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Abstract PDF: Traumatic diaphragmatic injury (TDI) occurs in 1% of patients of blunt abdominal trauma. Most TDIs involve the left diaphragm, however the authors experienced TDI accompanied by a liver laceration of the right diaphragm. When detected early, TDI can be easily treated, however serious complications can occur if not. When diaphragmatic injury is suspected due to clinical manifestation, comprehensive analysis of the patient data including radiologic findings is important.; Summary

Original Articles

Clinical Analysis on Patients with Traumatic Liver Injury: Hong Man Yoon, Yoo Seok Yoon, Sang Hyun Shin, Jai Young Cho, Do Joong Park, Hyung Ho Kim, Ho Seong Han; J Korean Soc Traumatol. 2007;20(2):125-129.

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Abstract PDF: PURPOSE
The liver is one of the most commonly injured organs in abdominal trauma. Surgery has played a major role in treating traumatic liver injury. Recently, it was reported that conservative treatment could be the first-line management for hemodynamically stable patients without combined intraabdominal surgical problems. The aim of this study was to examine the prognostic factors in traumatic liver injury.
METHODS
The medical records of 41 patients who were treated for traumatic liver injury at Seoul National University Bundang Hospital from March 2003 to October 2007 were retrospectively reviewed.
RESULTS
Among the 41 patients, 34 cases (82.9%) were managed nonsurgically, and 7 cases (17.1%) were managed surgically. Out of the 5 (12.2%) mortalities, 2 were encountered in those who underwent surgery, and 3 were encountered in those who were treated nonsurgically. Univariate analysis showed that the initial systolic blood pressure, the initial hemoglobin level, and the grade of liver injury were significant prognostic factors for survival. Multivariate analysis indicated that initial low systolic blood pressure was the only independent risk factor.
CONCLUSION
Patients with unstable vital signs initially have a poor prognosis. Aggressive management might be helpful for improving the survival rate in these patients.; Summary

Surgical Management of Traumatic Liver Injury: Sun Wook Han, Hwa Soo Lee, Sang Ho Bae, Gil Ho Kang, Sung Yong Kim, Moo Jun Baek, Moon Soo Lee, Hyung Chul Kim, Moo Sik Cho, Chang Ho Kim; J Korean Soc Traumatol. 2006;19(1):21-27.

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Abstract PDF: PURPOSE
The liver is one of the most commonly injured organs by blunt or penetrating abdominal trauma. Patients with liver injury can be treated by using nonoperative or operative management. The aim of this study was to study patients with traumatic liver injury who were treated by using operative management.
METHODS
Ninety-eight patients with traumatic liver injury underwent surgical treatment from January 1995 to December 2004 at Soonchunhyang University Cheonan hospital. Medical records were reviewed retrospectively, and demographic, clinical, operative, and postoperative datas were collected and analyzed.
RESULTS
Among the patients with operative management, the peak incidence was in the third and the fourth decades. The male-to-female ratio was 1.9:1. The most frequent injury mechanism was blunt trauma (85.7%). Abdominal computed tomography was the diagnostic modality used most frequently. Severe liver injury above Grade III was seen in 80.6% of all patients, and long bone fracture was the most common combined injury. Patients were managed by using various techniques, including simple closure, liver resection, and perihepatic packing. Pulmonary complications were the most common postoperative complications (35.7%). the overall mortality rate was 17.3%. Between the survival group and the expired group, the amount of transfusion for the expired group was statistically more than that for the survival group.
CONCLUSION
Operative management is an effective treatment modality for hemodynamically unstable patients with severe traumatic liver injury. The amount of transfusion is a significant prognostic factor for survival.; Summary

The Utility of Liver Transaminase as a Predictor of Liver Injury in Blunt Abdominal Trauma: Jong Seok Lee, Sung Chan Oh, Hye Jin Kim, Suk Jin Cho, Sang Lae Lee, Seok Yong Ryu; J Korean Soc Traumatol. 2010;23(2):151-156.

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Abstract PDF: PURPOSE
The liver is the second most common organ injured by blunt abdominal trauma. The purpose of this study was to determine the utility of liver transaminase in screening blunt abdominal trauma patients for traumatic liver injury.
METHODS
We retrospectively reviewed the medical records of 231 patients who sustained blunt trauma and were at risk for traumatic liver injury between June 2009 and August 2010. All of them underwent a focused assessment with sonography for trauma (FAST) and abdominal computed tomography (CT). Based on the diagnosis of abdominal CT, patients were divided into two groups: group I with liver injury and group II without liver injury. We compared the two groups and calculated the sensitivity, the specificity and the predictive values of serum aspartate aminotransferase (AST) and serum alanine aminotransferase (ALT) by using multiple cutoff values.
RESULTS
Of 231 patients with no abdominal free fluid in the FAST, 33 had traumatic liver injury on abdominal CT. The mean AST and ALT levels in group I (311.6 IU/L and 228.1 IU/L, respectively) were significantly higher than the values in group II (48.4 IU/L and 35.6 IU/L, respectively). The cutoff to distinguish liver injury is 60 IU/L for AST and 58 IU/L for ALT, with 93.8% sensitivity and 79.8% specificity for AST, and 90.6% sensitivity and 87.4% specificity for ALT.
CONCLUSION
We recommend that all patient with suspected blunt abdominal trauma be evaluated using serum liver transaminase as a screening test for liver injury even though no abdominal free fluid is shown on the FAST. If AST > 60 IU/L and/or ALT > 58 IU/L, abdominal CT was useful to confirm liver injury in this study; Summary

Case Report

Hemothorax Without Injury of the Pleural Cavity due to Diaphragmatic and Liver Laceration Caused by a Right Upper Anterior Chest Stab Wound: Kyu Seok Cho, Hyo Chul Youn, Jung Heon Kim, Sang Mok Lee; J Korean Soc Traumatol. 2010;23(1):49-52.

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Abstract PDF: A hemothorax usually occur, due to injuries to the intercostal and great vessels, pulmonary damage, and sometimes fractured ribs. We report a case in which the hemothorax that occurred, neither intrathoracic injury nor injury to internal thoracic vessels and organs, via lacerated diaphragmatic and liver laceration due to a right upper part of anterior chest stab injury caused by a sharp object. The patient's general conditions gradually worsened, so chest and abdominal computed tomogram were taken. The abdominal computed tomogram revealed diaphragmatic injuries and bleeding from the lacerated liver. We performed an exploratory laparotomy to control the bleeding from the lacerated liver with simple primary sutures. In addition exploration was performed in the right pleural space through the lacerated diaphragm with a thoracoscopic instrument. There were no bleeding foci in the right pleural space, the vessels, or the lung on the thoracoscopic video. Closure of the lacerated diaphragm was achieved with simple, primary sutures. The postoperative course of the patient was uneventful, and the patient was discharged.; Summary

Original Article

Traumatic Liver Injury in Pediatric Patients: Byung Han Koo, Joon Beom Park, Keum Seok Bae, Sung Joon Kang; J Korean Soc Traumatol. 2009;22(2):242-247.

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Abstract PDF: PURPOSE
Trauma is an important cause of death in children. In particular, the liver is the second most commonly organ injured by blunt abdominal trauma. Treatment of patients with liver injury is has changed, and non-operative treatment is the major treatment method at present. In this study, we reviewed traumatic liver injury in pediatric patients.
METHODS
Seventy-seven patients younger than 16 years of age with traumatic liver injury were assessed for 10 years from July 1999 to June 2009 at Wonju Christian hospital. Records of the patients were reviewed retrospectively. Demographic and clinical data were analyzed.
RESULTS
The median age was 6 years, and the male-to-female ratio was 1.2 : 1. The most common injury grade was grade I. The majority of injuries were caused by was traffic accidents, and the second most common cause of injuries was falls. Twenty-four patients had liver injuries alone, and the most common accopaning injury was a lung injury. The average hospital stay was 20.7 days, and the average ICU stay was 4.8 days. Four patients died (5.2%). There were 6 patients with under 10 points on the Glasgow coma scale (GCS). Among these patients, three died. All mortality cases had over 16 points on the Injury Severity Score (ISS). Two patients were treated surgically, one of whom died. Of the 75 patients with non-operative management, three died due to associated injuries.
CONCLUSION
Most pediatric patients with liver injury have good results with non-operative management. Associated injuries and hemodynamic instability are predictive of patient outcome, and those with isolated liver injuries can be successfully managed non-operatively.; Summary

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