Guidelines for Operative and Nonoperative Management of Liver Trauma (WSES, 2020)

World Society of Emergency Surgery (WSES)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

May 29, 2020

The guidelines on management of liver trauma were published on March 30, 2020, by the World Society of Emergency Surgery (WSES).[1]

Nonoperative Management

In the absence of other internal injuries requiring surgery, nonoperative management should be the treatment of choice for all hemodynamically stable minor (WSES I; American Association for the Study of Trauma [AAST] I-II), moderate (WSES II; AAST III), and severe (WSES III; AAST IV-V) injuries.

In transient responders with moderate and severe injuries, nonoperative management should be considered only in selected settings where there is immediate availability of trained surgeons, operating rooms (ORs), continuous monitoring (ideally in an intensive care unit [ICU] or emergency department [ED]), and access to angiography (AG), angioembolization (AE), blood and blood products; and in locations where a system exists to quickly transfer such patients to higher-level-of-care facilities.

Computed tomography (CT) with intravenous (IV) contrast should always be performed when nonoperative management is being considered.

AG/AE may be considered as a first-line intervention in hemodynamically stable patients with arterial blush on CT. In hemodynamically stable children, the presence of contrast blush on CT is not an absolute indication for AG/AE.

Serial clinical evaluations (physical examinations and laboratory testing) must be performed to detect a change in clinical status during nonoperative management.

Nonoperative management should be attempted in the setting of concomitant head trauma and/or spinal cord injury with reliable clinical examination, unless the patient could not achieve specific hemodynamic goals for the neurotrauma and the instability might be due to intra-abdominal bleeding.

ICU admission in isolated liver injury may be required only for moderate and severe lesions.

In selected cases where an intra-abdominal injury is suspected in the days after the initial trauma, interval laparoscopic exploration may be considered as an extension of nonoperative management and a means to plan patient management in a step-up treatment strategy.

In low-resource settings, nonoperative management could be considered in hemodynamically stable patients who have no evidence of associated injuries and negative findings on serial physical examinations, imaging, and blood tests.

Operative Management

Hemodynamically unstable and nonresponder patients (WSES IV) should undergo operative management.

The primary surgical intention should be to control hemorrhage and bile leakage and initiate damage-control resuscitation as soon as possible.

Major hepatic resections should be avoided at first and considered only in subsequent operations, in a resectional debridement fashion, in cases of large areas of devitalized liver tissue, done by experienced surgeons.

AE is a useful tool in case of persistent arterial bleeding after nonhemostatic or damage-control procedures.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be used in hemodynamically unstable patients as a bridge to other, more definitive procedures for hemorrhage control.

Short- and Long-Term Follow-up

Intrahepatic abscesses may be successfully treated with percutaneous drainage.

Delayed hemorrhage without severe hemodynamic compromise may be managed at first with AG/AE.

Hepatic artery pseudoaneurysm should be managed with AG/AE to prevent rupture.

Symptomatic or infected bilomas should be managed with percutaneous drainage.

A combination of percutaneous drainage and endoscopic techniques may be considered in managing posttraumatic biliary complications not amenable to percutaneous management alone.

Lavage/drainage and endoscopic stenting may be considered as the first approach in delayed posttraumatic biliary fistula without any other indication for laparotomy.

Laparoscopy as the initial approach should be considered in cases of delayed surgery so as to minimize the invasiveness of surgical intervention and allow tailoring of the procedure to the lesion.

For more information, please go to Blunt Abdominal Trauma, Penetrating Abdominal Trauma, and Pediatric Abdominal Trauma.

For more Clinical Practice Guidelines, please go to Guidelines.


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