Liver and Spleen Injury Management in Combat

Abstract

The management of liver and spleen injuries in the operational environment presents unique challenges to the military surgeon. The clock started long before the patient got to the military medical treatment facility. It is incumbent upon the deployed surgeon to be very familiar with the damage control philosophy in order to identify and treat the lethal triad of acidosis, hypothermia, and coagulopathy. Damage control resuscitation and damage control surgery are temporizing therapies to save lives. Solid organ injury in the abdomen after combat injury is predominantly a surgical disease. The key concepts for a successful operation are exposure and expedience. In addition, in the damage control scenario, it is crucial that the surgeon knows how much operating is too much operating. Splenectomy is the procedure of choice for battlefield splenic injuries with hemodynamic instability or significant transfusion requirement. Hepatic injuries are best managed at initial exploration by packing to restore the gross anatomic structure of the liver. Pringle maneuver, hepatic mobilization, and exclusion techniques may be necessary for a more severe injury.

Civilian Translation of the Military Experience and Lessons Learned

• Katherine M. McBride &
• and James R. Dunne 

Key Similarities

• Operative approaches and techniques to treat liver and spleen hemorrhage in the operating room are the same in military and civilian settings.

• The decision to operate rather than observe liver and spleen injuries in military settings may be similar to what the remote rural surgeon faces.

• High-velocity penetrating injuries of the liver and spleen may be better treated with operative therapy, regardless of setting.

Key Differences

• Access to diagnostic equipment such as computed tomography and interventional radiology techniques are frequently not available in the combat environment and lead to higher rates of exploration.

• The majority of liver and spleen injuries in civilian settings are managed without operation.

• The majority of liver and spleen injuries in civilian settings are from blunt trauma; the majority in military settings are from penetrating trauma.

• Resource allocation and remote location associated with the military setting pose additional challenges that may require a change in management plan (i.e., damage control surgery implementation or having a low threshold for abdominal exploration with even the seemingly innocuous penetrating abdominal wounds).

Dr. Eastridge’s chapter on liver and spleen management in combat outlines the surgical management of injuries to these organs. It raises some key points which are ubiquitous from the combat setting to the rural hospital and even to the level 1 trauma center in an urban setting . There are also similarities from the austere environment of the combat setting and the rural hospital that are quite different from the management at a level 1 trauma center.

One major difference between the “home front” and the combat setting is the ability to safely observe patients with serial exams and laboratory values. Due to the limited holding capacity on the battlefield, patients are often triaged, undergo damage control surgery, and are transferred to the next level of care and eventually out of theater in a relatively short time frame. On the “home front,” the algorithm for care often depends on the access to adequate resources and personnel. In rural hospitals with limited manpower and blood product availability, damage control surgery for critically injured patients followed by transfer to a higher level of care may be the patient’s best option for survival. However, at centers with interventional radiology, a fully functioning blood bank, 24/7 in-house support staff, and the ability to serially monitor patients, observation or minimally invasive techniques may be just as successful.

Currently, over 80% of blunt splenic and hepatic injuries in the United States can be managed nonoperatively. However, the rates of failure for nonoperative management of blunt splenic trauma are higher with each grade of splenic injury. In addition, level 2 trauma centers tend to have higher rates of failure of nonoperative management for blunt splenic and hepatic trauma than level 1 trauma centers. Therefore, consideration of hospital resources including manpower along with appropriate patient selection is key to successful management of these patients. For patients who require a laparotomy, intraoperative splenic salvage techniques, such as splenorrhaphy and partial splenectomy, are viable options in level 1 and level 2 trauma centers. Operative management for blunt hepatic injury is limited to hemodynamically unstable patients and those with the need for laparotomy for other injuries, since mortality after surgery still approaches 50%.

Interventional radiology has also become a key tool in the armamentarium of the trauma surgeon at larger centers. Patients with solid organ injuries can often be successfully managed with interventional techniques, without the need for a laparotomy. The main advantage of these procedures includes their noninvasive nature and their ability to be repeated if necessary. Angiographic embolization for the treatment of solid organ hemorrhage has become the mainstay of treatment for solid organ injuries in the stable trauma patient at centers where this resource is available. Angiography for blunt splenic trauma can be successful in up to 95% of patients when applied selectively in stable patients with a blush or pseudoaneurysm on CT or nonselectively for any grade 3, 4, or 5 splenic injury in the stable patient.

Damage control resuscitation has been a major advancement in the management of hepatic and splenic trauma. In the combat setting, this often is associated with damage control surgery. Massive transfusion in these cases is frequently fresh whole blood donated within an hour after injury. Fresh whole blood is not currently available in most civilian hospitals; however, some hospitals have access to modified whole blood that has been stored and is leuko-reduced resulting in nonfunctioning platelets. This modified whole blood has been shown to have similar outcomes and transfusion volumes to the balanced component therapy of most massive transfusion protocols (1:1:1). Most rural hospitals, however, typically only have two units of packed red bloods cells if at all, let alone the ability to institute a massive transfusion in a 1:1:1 fashion. As the trauma centers grow in size, their ability to perform more of a controlled resuscitation improves. For example, level 1 trauma centers have the capability to perform both massive transfusions and damage control surgery followed by continued resuscitation in the intensive care unit under the guide of a trained intensivist. This is followed by the ability to quickly return to the operating room once the patient stabilizes or if their condition continues to deteriorate.

An additional difference between the combat and civilian setting is the mechanism of injury. Penetrating trauma rates average around 11% for civilian centers but approach 70% in combat settings and often involve an increased percentage of high-velocity wounding mechanisms compared to civilian penetrating injuries. Due to these differences, operative management in the combat setting is often required in order to identify and treat multisystem injuries.

There are many similarities and differences in the management of solid organ injuries when comparing treatment in a combat setting compared to that in a civilian setting. There are more noninvasive options available in the civilian setting, especially in levels 1 and 2 trauma centers. However, the combat setting and the rural hospital are similar in that they often result in more operative interventions due to lack of resources when compared to larger trauma centers. Over the years, there have been many advances in the treatment of these patients thanks to the military. Patient selection and a thorough understanding of available resources will be key in the proper application of these advances moving forward both in the combat setting and back here at home.

Suggested Reading

Berg RJ, Inaba K, Okoye O, Pasley J, Pasley J, Teixeira PG, Esparza M, et al. The contemporary management of penetrating splenic injury. Injury Int J Care. 2014;45:1394–400.

Bjerke S, Pohlman T, Saywell RM, Przybylski MP, Rodman Jr GH. Evolution, not revolution: splenic salvage for blunt trauma in a statewide voluntary trauma system—a 10-year experience. Am J Surg. 2005;191:413–7.

Cotton BA, Podbielski J, Camp E, Welch T, del Junco D, Bai Y, et al. A randomized controlled pilot trial of modified whole blood versus component therapy in severely injured patients requiring large volume transfusions. Ann Surg. 2013;258(4):527–33.

Hafiz S, Desale S, Sava J. The impact of solid organ injury management on the US health care system. J Trauma Acute Care Surg. 2014;77(2):310–4.

Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg. 2008;248(3):447–58.

Jeremitsky E, Smith RS, Ong AW. Starting the clock: defining nonoperative management of blunt splenic injury by time. Am J Surg. 2013;205:298–301.

Melloul E, Denys A, Demartines N. Management of severe blunt hepatic injury in the era of computed tomography and transarterial embolization: a systematic review and critical appraisal of the literature. J Trauma Acute Care Surg. 2015;79:468–74.

Miller PR, Chang MC, Hoth JJ, Mowery NT, Hildreth AN, Martin RS, et al. Prospective trial of angiography and embolization for all grade III to V lunt splenic injuries: nonoperative management success rate is significantly improved. J Am Coll Surg. 2014;218(4):644–8.