The history of trauma surgery is one of consistent forward movement, with new techniques and technologies continuously improving the outcomes for injured patients.
But when facing an injury that has seen patient survival plateau for decades, it may be time to reexamine the surgical approach, according to Andrew B. Peitzman, MD, FACS, who will deliver today’s Scudder Oration in Trauma, “Major Hepatic Injury: We Can Do Better,” at 12:45 pm in Rooms 205–208/213–216 Level 2 South.
Approximately 85% of blunt liver injuries can be managed nonoperatively with the aid of computed tomography (CT) imaging and techniques such as angioembolization.
However, operative mortality for major liver injuries (grade IV and V), which often requires advanced surgical techniques for hemorrhage control, remains high.
“Grade IV and V injuries are relatively uncommon, and even many of those we can manage nonoperatively,” said Dr. Peitzman, who is the Mark M. Ravitch Chair in Surgery at the University of Pittsburgh Medical Center in Pennsylvania.
“But there are still certain patients who require laparotomy for bleeding control. Unfortunately, mortality for laparotomy for bleeding control in a major liver injury remains high and hasn’t changed in the decades since the introduction of CT imaging and nonoperative management,” he added.
In his lecture, Dr. Peitzman will go through major inflection points over the past decades that explain how trauma surgeons have arrived at this juncture, and then discuss why mortality hasn’t improved when an operative course is indicated.
The lecture will focus on the two main eras of treating hepatic injury.
In the 1970s, trauma surgeons performed many liver resections for hepatic trauma in what Dr. Peitzman calls the era of liver resections. By the end of that decade, however, when outcomes were studied, the mortality for liver resection was more than 50%. Consequently, liver resection for trauma was abandoned.
Improving diagnostic and interventional technology led to less frequent operations for hepatic injury, with an emphasis on nonresectional therapy.
The 1980s began an era of nonoperative management and nonresectional operations. Although basic maneuvers, such as hepatorrhaphy and packing, will acutely tamponade the bleeding in most cases, higher-grade injuries such as hepatic venous injuries may require advanced operative techniques.
“Because we operate on these major liver injuries so much less often, the ability to perform the necessary procedures is diminished,” Dr. Peitzman said. “The major liver injuries are uncommon to begin with, and they're difficult to control, and we've lost many our skills over the years with the evolution of nonoperative management. We need to restore our skillset for when the situation demands it, and options for how to restore our skillsets will be described.”
A portion of the lecture will be dedicated to describing the two phases of operative management that are generally performed in treating major hepatic injury. The initial operation is for lifesaving bleeding control, generally accomplished with basic techniques. However, severe cases will require advanced techniques, which will be discussed. The second operation is the return to the OR where surgeons perform definitive management of the liver injury, which may include liver resection.
“There are two operations with different appropriate options and different goals, and I want to detail unique concepts in this approach,” he said.
The Scudder Oration on Trauma, sponsored by the ACS Committee on Trauma, will be made available for on-demand viewing shortly after the live presentation.
