Liver trauma: WSES position paper
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WORLD JOURNAL OF EMERGENCY SURGERY
REVIEW
Open Access
Liver trauma: WSES position paper Federico Coccolini1*, Giulia Montori1, Fausto Catena2, Salomone Di Saverio3, Walter Biffl4, Ernest E. Moore4, Andrew B. Peitzman5, Sandro Rizoli6, Gregorio Tugnoli3, Massimo Sartelli7, Roberto Manfredi7 and Luca Ansaloni1
Abstract The liver is the most injured organ in abdominal trauma. Road traffic crashes and antisocial, violent behavior account for the majority of liver injuries. The present position paper represents the position of the World Society of Emergency Surgery (WSES) about the management of liver injuries. Keywords: Liver trauma, Surgery, Hemorrage, Operative management, Non-operative management
Background The liver is the most injured organ in abdominal trauma [1–3]. Road traffic crashes and antisocial, violent behavior account for the majority of liver injuries [2]. As demonstrated by several studies the management of liver trauma has deeply changed through the last three decades with a significant improvement in outcomes, especially in blunt trauma [1, 2, 4]. Most liver injuries are grade I, II or III and are successfully treated by observation only (NonOperative Management, NOM). In contrast two-thirds of grade IV or V injuries necessitate laparotomy (Operative Management, OM) [3]. These operations are generally challenging and difficult. Richardson et al. proposed as the main reasons for improvement in survival: 1) improved results with packing and reoperation, 2) use of arteriography and embolization, 3) advances in operative techniques for major hepatic injuries, and 4) decrease in hepatic venous injuries undergoing operation [1, 3]. The severity of traumatic liver injuries is universally classified according to the AAST classification system (Table 1) [5]. The present paper represents the position of the World Society of Emergency Surgery (WSES) about the treatment of liver trauma. This paper results from the Second World Congress of WSES that has been held in Bergamo (Italy) on July 2013. Levels of evidence have been evaluated in agreement with the Oxford guidelines [6]. As the WSES includes surgeons from the whole world, this position paper aims to give the state of the art of the management of liver trauma, maintaining into account the * Correspondence: [email protected] 1 General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy Full list of author information is available at the end of the article
secondary different possibilities in its management. In actuality, not all trauma surgeons work in the same conditions and have the same facilities and technologies. Classification
Hepatic traumatic lesions can be classified as minor (grade I, II), moderate (grade III) or major/severe (grade IV, V) injuries (Fig. 1a, b) [3, 7–9]. This classification is not well defined in the literature, but aims to define the type of management that can be adopted and the related outcome [8]. Frequently low-grade American Association for the Surgery of Trauma (AA
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