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64
been evaluating patients for non-operative management of penetrating hepatic trauma.
These patients must be hemodynamically stable and carefully selected [ 6 – 8 ].
Patients who are managed with early operative management have higher Injury
Severity Scores (ISS), higher rates of hypotension upon presentation, and higher
mortality . Failure of NOM is also associated with higher overall mortality [ 4 ]. For
this reason, the attempt will be made to manage most patients with blunt liver injury
non-operatively. Angiography can be used as an adjunct to NOM or operative
management of liver injury [ 1 ]. The failure of non-operative management can be
due to the development of hemodynamic instability, failure to respond appropriately
to transfusion or drop in hematocrit, suspicion of injury to other organs requiring
operation, or clinical peritonitis [ 3 ]. Failures may be due to the liver injury itself or
due to injuries to other intra-abdominal organs. Not surprisingly, higher grade
injuries have a higher rate of failure. Grade IV and V injuries may have as high as
two-third failure rate [ 2 , 3 ]. Risk factors for failure are older age, lower admission
mean SBP, worse base defi cit, higher mean lactate, higher mean ISS, and hemoperitoneum extending into the pericolic gutter [ 3 ].
Operative management strategies can range from simple electrocautery and
topical hemostasis to liver transplantation at the other extreme end of the spectrum.
Most authors advocate a graded approach to the operative management of liver
trauma. This begins with topical hemostasis for lower grade injuries, to suture ligation
of bleeding vessels, to anatomic and non-anatomic liver resection s. In the 1990s the
concept of damage control laparotomy was reintroduced. Injuries to the liver are
usually to the veins, which are a low pressure system. These can often be controlled
simply with temporary gauze packing. This limits blood loss and allows for resuscitation of the patient. The patient can then return to the operating room in 24–72 h and
defi nitive control if needed can be achieved.
Search Strategy
A literature search from the PubMed Database of English language publications
from the last 10 years was used to identity published data on the operative management of liver trauma using the PICO outline (Table 6.1 ). Terms used in the search
were “operative liver trauma”, or “operative hepatic trauma ”. Articles were excluded
if the full text was not available through the institution. Case reports were excluded.
Table 6.1 PICO table for perioperative arrhythmia prophylaxis for lung resection
P (Patients) I (Intervention)
C (Comparator
group) O (Outcomes measured)
Patients with
traumatic liver
injury
Operative
management or
angioembolization
Non- operative
management
Failure of non-operative
management, morbidity and
mortality, liver related morbidity
and mortality
C. Evans and M.A. Croce
65
Twenty-six articles were selected to be used for the writing of this chapter. All studies used data from retrospective analysis, or data that was prospectively entered into
a trauma database. Other cited articles were review articles or book chapters. The
data was classifi ed using the GRADE system.
Results
Non-operative Management
Hemodynamically stable patients with blunt liver injury can be managed nonoperatively in up to 80 % of cases. All grades of liver injury except Grade VI can be
managed non-operatively [ 2 ]. Cumulative results of reported NOM in the last 10
years shows a success rate of 91.3 %. This is including studies looking only at high
grade liver injuries. Most common liver related reasons for the failure of NOM
include continued drop in hematocrit or continued bleeding, hemodynamic instability, and biloma or bile leak (table). Non-liver related causes of failure of NOM are
related to injury to other organs; mostly spleen, pancreas, or small bowel (Table 6.2 ).
Higher grades of liver injury according to AAST grading system are more likely
to be managed operatively and tend to have a higher failure rate of NOM. The
results of fi ve studies were tabulated showing failure rates in Grade I of 0 %, Grade
II of 0.8 %, Grade III of 3.0 %, Grade IV of 10.4 %, Grade V of 21.7 % [
9 – 13 ].
Christmas et al. showed a similar trend of increasing operative management with
higher grade injuries [ 14 ]. Cohn et al. also reported a poor sensitivity for predicting
the need for operative management based on the AAST grading system for liver
Table 6.2 Failure of non-operative management and reasons for failure
Author (year) N op NOM
Fail
NOM
HD
unstable
Hct.
drop Peritonitis Other
Fang (2006) 278 64 214 30 0 24 0 6
Gaarder (2007) 114 41 73 11 ns ns ns ns
Ghnnam (2013) 56 20 36 0 ns ns ns ns
Kozar (2005) 337 107 230 12 0 1 0 11
Morales (2014) 117 19 98 7 0 2 2 3
Norrman (2009) 46 11 35 4 0 2 1 1
Parray (2011) 152 ns 152 8 8 0 0 0
Prichayudh (2013) 152 92 60 6 0 4 2 0
van der Wilden
(2012)
393 131 262 23 0 7 10 6
Zago (2012) 120 55 65 6 2 0 4 0
Combined 1765 540 1225 107 10 40 19 27
%Combined – – – 8.7 10.4 41.7 19.8 28.1
op operative management , NOM non-operative management , ns not studied
6 When Should You Operate on Major Hepatic Trauma?
66
trauma. They did, however, report that the fi ndings of lacerations involving more than
two segments, lacerations extending into the hilum, and active extravasation correlate
with a >90 % specifi city for either angiographic or operative intervention. Furthermore
they report a specifi city of 85 % for intervention for >500 cc hemoperitoneum [ 15 ].
Interestingly, Fang et al. reported an operative rate of 100 % in 14 patients who had
free extravasation of contrast into the peritoneal cavity [ 16 ] (Table 6.3 ).
Several factors are signifi cantly associated with failure of NOM. These include
hypotension on admission, worse base defi cit, higher lactate, higher ISS, vascular
blush on CT , and hemoperitoneum on CT scan extending into at least the paracolic
gutters [ 3 ]. Polanco retrospectively analyzed the National Trauma Data Bank for
isolated liver injuries. In over 3000 patients, increasing age, higher ISS, and hypotension on presentation were identifi ed as risk factors in patients more likely to fail
NOM [ 4 ]. In a smaller study, Norman et al. also found ISS and a lower presentation
blood pressure in patients failing NOM [ 17 ]. One study identifi ed only lower average
blood pressure as a predictor of failure [ 20 ], while other studies failed to identify
any variables as risk factors for failure of NOM [ 13 , 18 ].
Penetrating trauma to the abdomen is generally managed with laparotomy,
however case series do exist of the non-operative management of highly selective
patients. Inaba et al. reported a series of eight patients with isolated liver injury
and two patients with liver and kidney injury following gunshot wounds that were
managed non-operatively. One patient with a isolated liver injury underwent nontherapeutic laparotomy and was discharged home after an 79 day recovery in the
hospital [ 6 ]. MacGoey et al. presented a series of ten non-operatively managed
patients with penetrating injuries with two failures of NOM due to hemodynamic
instability [ 7 ]. Omoshoro-Jones et al. in a prospective study of 33 highly selected
patients with gunshot wounds to the liver, had only two non-liver related failures of NOM
[ 8 ]. These studies involved highly selected patients who were hemodynamically
Table 6.3 AAST grade of injury and failure of non-operative management based on grade
Non- operative management total Failure non-operative management
Author (year)
Grade I Grade
II
Grade
III
Grade
IV
Grade V Grade I Grade
II
Grade
III
Grade
IV
Grade
V
Ghnnam
(2013)
4 11 12 9 0 0 0 0 0 0
Kozar (2005) na na 130 92 8 na na 0 7 4
Norman
(2009)
24 11 3 1
Parray (2011) 30 63 26 33 0 0 0 2 6 0
Saltzherr
(2010)
20 43 30 10 1 0 1 4 2 0
van der
Wilden (2012)
na na na 234 28 na na na 19 4
Zago (2012) 51 14 5 1
Combined 58 74 209 378 51 0 1 6 34 9
C. Evans and M.A. Croce
67
stable with right upper quadrant gunshot wounds and no clinical signs of peritonitis
who had a reliable abdominal exam [ 6 – 8 ]. Based on the paucity of data, laparotomy
is recommended for patients with penetrating hepatic trauma .
Angiography and Embolization
The EAST guidelines for management of liver trauma give a level 2 recommendation
to the use of angiography and embolization as an adjunct to operative management
of liver trauma or as a primary treatment modality for NOM in transient responders
to resuscitation. They also give a level 2 recommendation to the use of angiography
in patients who have an active blush on CT scan [ 1 ]. Sivrikoz et al. performed
a retrospective analysis of over 6000 patients with isolated grade IV and V blunt
hepatic injuries from the National Trauma Data Bank to investigate the role of
angioembolization . Eleven percent of these patients underwent angiographic embolization. Angiographic embolization was shown to be an independent predictor of
survival in both patients undergoing operation and patients managed non- operatively
[ 19 ]. Saltzherr et al. showed a reduced mortality in high grade liver injuries and
higher percentage of liver injuries successfully managed non- operatively after the
introduction of angiographic embolization at their facility [ 11 ]. Christmas et al.
showed embolization prevented failure of non-operative management in patients
with persistent liver bleeding in 11 of 12 patients [ 14 ]. Van der Wilden et al. report
successful non-operative management of grade IV and V while heavily relying on
angiography and embolization. Embolization had a 93 % success rate for preventing
FOM for persistent bleeding in 59 patients [ 20 ]. Dabbs et al. performed a retrospec-
tive analysis of 538 patients admitted with high grade liver injuries. One hundred
sixteen of these underwent angiography and 71 had embolization. Forty- three
of these patients had hepatic related complications including 100 % of patients
with grade 5 injuries and thee were eight liver related deaths. The most common
complication they observed was major hepatic necrosis which made up 42 % of the
complications [ 21 ].
Outcomes
Published studies over the last 10 years were combined to determine the morbidity
and mortality , liver related (LR) morbidity and mortality of operative, NOM and
failure of NOM for blunt hepatic trauma . Not all studies consistently differentiated
LR morbidity and mortality from all cause morbidity and mortality. Some only
report LR morbidity and mortality or combined morbidity and mortality. Some
studies focus only on high grade liver injuries. Not surprisingly, patients who were
managed with an operation, either on presentation or after failure of NOM trended
towards having higher morbidity and mortality. Morbidity of NOM was 18 % with
6 When Should You Operate on Major Hepatic Trauma?
68
mortality of 3.6 %. LR NOM morbidity was 2.2 % with no mortalities. Failure of
NOM had a morbidity and mortality of 55 % and 14.4 %, respectively. LR failure
NOM had morbidity of 44.8 % and mortality of 14.1 %. Operative morbidity and
mortality were 79.9 % and 43.6 %. LR operative morbidity and mortality were
34.9 % and 21.3 % [ 9 , 10 , 13 , 16 – 18 , 20 , 22 – 24 ] (Table 6.4 ). Christmas et al.
showed a signifi cantly higher mortality in grade III–V injuries managed operatively
vs. non- operatively [ 14 ].
Surgical Strategies
Operative management of the liver fi rst involves proper mobilization to allow for
suffi cient exposure to deal with the injury. This begins by dividing the ligamentum
teres and mobilizing the falciform ligament off the abdominal wall. The right and
left triangular and coronary ligaments should also be divided so that both lobes of
the liver are freely mobile. The caveat is that the presence of a confi ned, nonexpanding retrohepatic hematoma should be a contraindication to mobilization of the liver
in patients with blunt trauma. This often signifi es an injury to the retrohepatic veins
or inferior vena cava. Mobilizing the liver can lead to uncontrolled hemorrhage
from these injuries [ 2 ].
Bleeding from minor lacerations to the liver can usually be controlled with
manual compression, electrocautery, or topical hemostatic agents. The argon beam
coagulator or Aquamantis may also be used to control hemorrhage, but should not
be used for deep lacerations [ 25 ]. In damage control situations, packing the liver
with gauze laparotomy pads and compression are the fi rst line strategies to control
bleeding [ 23 , 25 ]. These will be removed at a planned second look laparotomy after
the patient has been properly resuscitated, usually between 24 and 72 h after the
initial operation. Often, the liver is packed in conjunction with other hemostatic
procedures [ 3 ].
If persistent bleeding or bile leak is present despite packing, the injury will need
further exploration. The Pringle maneuver is useful to control infl ow while the
wound is explored. In general, this should not be left in place for more than
30–45 min [ 2 ]. Intermittent clamping in a 15 min on 15 min off fashion is preferred
[ 25 ]. If bleeding persists despite the Pringle maneuver, bleeding is most likely from
a retrohepatic venous source. Visible bleeding vessels or bile duct s in the liver
parenchyma should be suture ligated. Injuries to large veins can be repaired with
5–0 polypropylene suture. Often bleeding and bile leak is hidden deep within a
laceration. To gain exposure, the fi nger fracture technique can be used to further
open up the liver parenchyma, ligating and dividing vessels as they are exposed.
However, this can be quite time consuming. Alternatively a laparoscopic stapler
with vascular loads can be used to divide the liver more quickly [ 2 , 25 ].
Every effort should be made to control bleeding from a retrohepatic venous
injury by packing alone [
23 ]. If forced to repair this type of injury, total vascular
insolation needs to be achieved. This is accomplished by controlling the suprarenal
C. Evans and M.A. Croce
69
Table 6.4 Morbidity and mortality and liver related morbidity and mortality from liver trauma
Author (year) N op NOM Fail
NOM
MB
LR
NOM
MB
NOM
ML
NOM
LR
ML
Fail
MB
LR
fail
MB
Fail
ML
Fail
LR
ML
op
MB
LR
op
MB
op
ML
Op
LR
ML
Fang (2006) 278 64 214 30 3 3 ns ns 7 3 8 8 ns ns ns ns
Gaarder (2007) 114 41 73 11 ns ns ns 0 ns ns ns 0 ns ns ns 0
Ghnnam (2013) 56 20 36 0 ns ns 0 0 na na na na ns ns 2 2
Kozar (2005) 337 107 230 12 ns 2 ns ns ns 4 1 1 ns ns ns ns
Morales (2014) 117 19 98 7 10 5 2 0 ns ns 0 0 11 8 11 8
Norrman (2009) 46 11 35 4 9 ns 0 0 3 ns 1 1 7 ns 1 0
Parray (2011) 152 ns 152 8 ns ns 0 0 4 4 0 0 ns ns ns ns
Pricha-yudh
(2013)
152 92 60 6 13 6 1 0 ns ns ns ns 59 28 37 29
van der Wilden
(2012)
393 131 262 23 91 ns 13 ns 23 ns 2 ns 112 ns 69 ns
Zago (2012) 120 55 65 6 7 0 0 0 2 2 1 1 57 22 23 ns
Combined 1765 540 1225 107 133 16 16 0 39 13 13 11 246 58 143 39
op operative management , NOM non-operative management , fail failure of NOM, MB morbidity , ML mortality , LR liver related
6 When Should You Operate on Major Hepatic Trauma?
70
IVC, and suprahepatic IVC and the porta hepatis. The suprahepatic IVC is readily
controlled within the pericardium either via a median sternotomy or by incising the
tendinous portion of the diaphragm. The suprarenal IVC can be approached by performing a Kocher maneuver or by mobilizing the left lobe of the liver and entering
the lesser sac along the lesser curvature of the stomach. Historically the Schrock
atriocaval shunt has been advocated for addressing these injuries. However, survival
is uniformly poor and this technique has all but been abandoned [ 2 , 23 ].
Morales Uribe et al. discussed their operative management techniques for blunt
liver trauma. Of 19 patients, three with grade I liver injuries required no intervention
to the liver, one with a grade II injury was treated by suturing. Of the remaining high
grade injuries, seven were treated with packing alone, two with packing plus suturing,
two with packing plus non-anatomic resection , one with packing plus hepatic artery
ligation. They had eight liver related mortalities including both patients undergoing
resection and the patient undergoing hepatic artery ligation [ 18 ]. Polanco et al.
reported a much lower mortality rate for operative management . In 144 patients with
liver trauma, resection was performed in 56 patients, packing in 30 patients, hepatorrhaphy in 15, and no liver intervention in the remaining 16. They had an overall
series mortality of 9 % including non-operatively managed patients and those who
succumbed in the trauma bay. Patients managed by resection had an overall morbidity of 62.5 % and mortality of 17.8 %, but liver related morbidity and mortality were
30 % and 9 % respectively. Mortality for hepatic venous injury was only 25 %. The
authors advocate resection for continued venous bleeding, devitalized tissue for
which the injury has done a large portion of the resection, and major bile leak s [ 26 ] .
Recommendations
Liver injuries should be operated on when a patient is hemodynamically unstable,
develops peritonitis, continues to bleed, or has other abdominal injuries requiring an
operation. Although some studies have shown successful NOM of penetrating liver
injuries, this has been done in specialized centers with the resources to do so. Due
to the high possibility of missing associated abdominal injuries, NOM of penetrating
liver injuries is not recommended. NOM of blunt injuries should only be attempted
in centers with units capable of continuous monitoring of patients with serial
physical exams and laboratory studies. Angiographic embolization can be used as a
modality to aid NOM or as an adjunct to operative management , but should not be
used as a replacement for operative intervention in unstable patients. All hemodynamically stable patients with blunt liver injuries should undergo a CT scan.
Although higher grade injuries are associated with higher failure of NOM, CT grading
alone is not predictive of failure. Operative management of liver injuries should
include a graded response to the injury using the simplest technique possible
to manage the problem. Peri-hepatic packing should be used as a damage control
strategy to allow time for appropriate resuscitation. Liver resection can be used for
defi nitive management when required.
C. Evans and M.A. Croce
71
A Personal View of the Data
More recent studies confi rm earlier data which resulted in a paradigm shift from
operative to selective NOM of blunt liver injury. Characteristics of the liver injury
which result in failure of NOM are not based on the radiographic severity of the
injury, and the decision to operate should be based on the patients clinical status.
While there is clearly a lower morbidity and mortality rate for patients in whom
successful NOM can be achieved, one should not hesitate to operate when the
situation calls for it.
Recommendations
• Trial of NOM for all patients who are hemodynamically stable with blunt liver
injuries
• Operative management for penetrating liver injuries
• Operative management of blunt liver injuries who are or become hemodynamically
stable, patients who develop peritonitis, patients with ongoing bleeding, or
patients with associated injuries requiring an operation
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C. Evans and M.A. Croce
73© Springer International Publishing Switzerland 2016
J.M. Millis, J.B. Matthews (eds.), Diffi cult Decisions in Hepatobiliary
and Pancreatic Surgery, Diffi cult Decisions in Surgery: An Evidence-Based
Approach, DOI 10.1007/978-3-319-27365-5_7
Chapter 7
Surgical Treatment of Hepatocellular
Carcinoma: Resection Versus Transplantation
Thomas Pham , Tsuyoshi Todo , Robert Gish , and Waldo Concepcion
Abstract Hepatocellular carcinoma is the second most common cause of cancer
mortality worldwide and its incidence is rising in North America, with an estimated
35,000 cases in the U.S. in 2014. The best chance for cure is surgical resection in
the form of either segmental removal or whole organ transplantation although recent
survival data on radiofrequency ablation approximates surgical resection and could
be placed under the new moniker of “thermal resection”. The debate between surgical resection and transplantation focuses on patients with “within Milan criteria”
tumors, single tumors, and well compensated cirrhosis who can safely undergo
either procedure. Although transplantation historically has had better survival outcomes, early diagnosis, reversal of liver disease, and innovations in patient selection
and neo-adjuvant therapies have led to similar 5-year survival. Transplantation
clearly has less risk of tumor recurrence but exposes recipients to long term immunosuppression and its side effects. Liver transplantation is also limited by the severe
global limit on the supply of organ donors whereas resection is readily available.
The current data does not favor one treatment over the other for patients with
minimal or no portal hypertension and normal synthetic function. Instead, the
decision to resect or transplant for HCC relies on multiple factors including tumor
characteristics, biology, geography, co-morbidities, location, organ availability,
social support and practice preference.
T. Pham
Department of Surgery , Stanford University , Stanford , CA , USA
T. Todo
Department of Medicine , Stanford University , Stanford , CA , USA
R. Gish
Stanford University Medical Center , 750 Welch Rd, Ste. 319 MC 5731 ,
Palo Alto , CA 94304 , USA
W. Concepcion (
*)
Department of Surgery , Stanford University , Stanford , CA , USA
Stanford University Medical Center , 750 Welch Rd, Ste. 319 MC 5731 ,
Palo Alto , CA 94304 , USA
e-mail:
waldo1@stanford.edu