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© 2020 EDIZIONI MINERVA MEDICA Minerva Chirurgica 2020 April;75(2):92-103

Online version at http://www.minervamedica.it DOI: 10.23736/S0026-4733.20.08193-6

ORIGINAL ARTICLE

Surgical treatment for severe liver injuries:

a single-center experience
Bianca MITRICOF 1, Vladislav BRASOVEANU 1, 2,
Doina HREHORET 2, Alexandru BARCU 2, Nausica PICU 2,
Elena FLUTUR 2, Dana TOMESCU 3, Gabriela DROC 3,
Ioana LUPESCU 4, Irinel POPESCU 1, 2, Florin BOTEA 1, 2 *

1Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania; 2Center of General Surgery and Liver
Transplantation, Fundeni Clinical Institute, Bucharest, Romania; 3Center of Anesthesia and Intensive Care, Fundeni
Clinical Institute, Bucharest, Romania; 4Center of Diagnostic and Interventional Radiology, Fundeni Clinical
Institute, Bucharest, Romania
*Corresponding author: Florin Botea, Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, soseaua Fun-
deni 258, Bucharest 022328, Romania. E-mail: florinbotea@gmail.com

A B S T RA C T
BACKGROUND: The liver is one of the most frequently injured organs in abdominal trauma. The advancements in di-
agnosis and interventional therapy shifted the management of liver trauma towards a non-operative management (NOM).
Nevertheless, in severe liver injuries (LI), surgical treatment often involving liver resection (LR) and rarely liver trans-
plantation (LT) remains the main option. The present paper analyses a single center experience in a referral HPB center
on a series of patients with high-grade liver trauma.
METHODS: Forty-five patients with severe LI, that benefitted from NOM (6 pts), LRs (38 pts), and LT (1 pt) performed
in our center between June 2000 and June 2019, were included in a combined prospective and retrospective study. The
median age of the patients was 29 years (median 33, range 10-76), and the male/female ratio of 33/12. Almost all cases
had blunt trauma, except 2 with stab wound (4.4%).
RESULTS: LIs classified according to the American Association for the Surgery of Trauma (AAST) system were 13.3%
(grade III), 44.2% (grade IV), and 42.2% (grade V); none were grade I, II or VI. The rate of major LR was 56.4% (22
LRs). The median operative time was 200 minutes (mean 236; range 150-420). The median blood loss was 750 ml (mean
940; range 500-6500). Overall and major complication rates were 100% (45 pts) and 33.3% (15 pts), respectively. Overall
mortality rate was 15.6% (7 pts).
CONCLUSIONS: Severe liver trauma, often involving complex liver resections, should be managed in a referral HPB
center, thus obtaining the best results in terms of morbidity and mortality.
(Cite this article as: Mitricof B, Brasoveanu V, Hrehoret D, Barcu A, Picu N, Flutur E, et al. Surgical treatment for severe liver
injuries: a single-center experience. Minerva Chir 2020;75:92-103. DOI: 10.23736/S0026-4733.20.08193-6)
Key words: Liver; Wounds and injuries; Hepatectomy.

D ue to its anterior location in the abdomen

and its fragility, the liver is one of the most
frequently injured organs in abdominal trauma.1
The advancements in diagnosis and intervention-
al therapy shifted the approach of liver injury (LI)
towards a non-operative management (NOM).
Indeed, many studies reported better outcome
after conservative management.2 Nevertheless,
in high-grade liver injuries, surgical treatment
remains the main option; in this regard, surgi-
cal approach is mandatory in hemodynamically
unstable patients, while debatable in stable ones:
some authors support the surgical approach,3 oth-
ers advocate the NOM.4 The present paper analy-
ses a single-center experience in a referral HPB
center on a series of patients with high-grade LI.

92 Minerva Chirurgica April 2020

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SURGICAL TREATMENT FOR SEVERE LIVER INJURIES MITRICOF

Materials and methods
Study group
The study was a combined prospective and ret-
rospective analysis of the patients treated for
LI in our center, between June 2000 and June
2019. Forty-five patients with severe LI, that
benefitted from NOM (6 pts), LRs (38 pts), and
LT (1 pt) were included in the analyses. The me-
dian age of the patients was 29 years (median
33, range 10-76), and the male/female ratio of
33/12.
Methods
We analyzed an HPB database with data collect-
ed prospectively (preoperative and intraoperative
data) and retrospectively (postoperative data)
from the medical records of patients undergoing
surgery for liver trauma in our center during the
last 19 years. Patient demographics, indications
for LR, intraoperative data (LI description, type
of surgical technique, type of liver resection,
employment of vascular exclusion, associated
procedures, blood loss, blood transfusion re-
quirements, duration of operation), pathologist
report, and postoperative data (complications
and mortality within 90 days from surgery) were
recorded and analyzed.
Study end-points
The primary outcome was the short-term surgi-
cal outcome, measured by postoperative com-
plications, major (at least class IIIB according
to the Dindo-Clavien classification) and overall
morbidity rates, and 90-day postoperative mor-
tality rates. The secondary end-point of the study
was the evaluation of the types of treatment used
in the present series.
Diagnostics
The evaluation of the trauma patient was based
on historical data (trauma to the right and middle
upper quadrant, right rib cage, or right flank),
mechanism of injury, prehospital vital signs,
fluctuations of vital signs, examination findings
(pain in the right upper abdomen, right chest
wall, or right shoulder due to diaphragmatic irri-
tation, associated with abdominal tenderness and
peritoneal signs), emergency lab tests (hemato-
crit, base deficit and lactate, and liver enzymes),
imaging (ultrasound ±CT scan), and underlying
medical conditions.5
Any pre-existing medical conditions should
be identified, particularly those requiring anti-
platelet or anticoagulant therapy.
CT scan (multidetector helical computed to-
mography) was used for detailed information re-
garding the trauma, guiding the management. It
was performed only in stabilized and cooperative
(otherwise sedated) patients, with particular care
to potential spinal cord injuries.
The American Association for the Surgery of
Trauma (AAST) classification system is the most
widely accepted injury grading scale based on
CT scan (Table I).6

Table I.—The American Association for the Surgery of Trauma (AAST) classification system for liver injury (LI).
Grade Type of Injury Description of injury
I Hematoma subcapsular hematoma <10% of the liver surface area;
Laceration <1 cm in depth
II Hematoma subcapsular hematoma 10-50% of the liver surface area; intraparenchymal hematoma <10 cm in
diameter;
Laceration 1-3 cm in depth and ≤10 cm in length.
III Hematoma >50% surface area of ruptured subcapsular/parenchymal hematoma; intraparenchymal hematoma >10 cm
/ expanding
Laceration >3 cm in depth and >10 cm in length; liver vascular injury; active bleeding contained within the
parenchyma.
IV Laceration parenchymal disruption involving 25-75% of a hemiliver / 1-3 Couinaud segments; active liver bleeding
into the peritoneum.
V Laceration parenchymal disruption involving >75% of a hemiliver / >3 Couinaud segments.
Vascular juxtahepatic venous injury involving the retro hepatic vena cava/central major hepatic veins.
VI Vascular hepatic avulsion
*Advance one grade for multiple injuries up to grade III.

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MITRICOF SURGICAL TREATMENT FOR SEVERE LIVER INJURIES

Table II.—World Society of Emergency Surgery (WSES) classification and guidelines for blunt/penetrating (stab/
gun) liver injury.
Severity of LI WSES grade AAST grade Hemodynamic CT-scan Treatment
Minor I I-II Stable Yes/No NOM
Moderate II III Stable Yes + local exploration in penetrating LI NOM
Severe III IV-V Stable Yes + local exploration in penetrating LI NOM
IV I-VI Unstable No Surgery
LI: liver injury; NOM: nonoperative management; AAST: The American Association for the Surgery of Trauma.

Liver injury grading Liver trauma (blunt/penetrating)

LIs were classified according to the American
Association for the Surgery of Trauma (AAST)
system for liver injury6 (Table I). Hemodynamically Hemodynamically
To correlate between AAST grade and pa- stable unstable
tient’s physiologic status, the World Society of
Emergency Surgery (WSES) seems to be more
Contrast-enhanced
useful, reflecting both the hemodynamic status AAST I-VI
CT
Unoperative management

and the anatomic grade of the LI7 (Table II).

Operative management
Treatment AAST I-VI

The management strategy (operative or nonop-

erative) depended mainly on the hemodynamic Peritonitis
Yes
Surgery
status of the patient, but also of grade of LI,
and association with other injuries and medical No

comorbidities. The treatment of severe LIs in Active bleeding Yes

our center shifted over time from surgery only (contrast blush Embolization
at CT)
towards nonoperative management (NOM) in Effective Ineffective
selected cases according to the decisional algo- No
No
rithm depicted in Figure 1.
Serial clinical Hemodynamical
& lab assessment & clinical stability
NOM

NOM consisted in clinical observation, intensive Yes

supportive care and, in selected cases, arterial
embolization.
NOM was contraindicated in case of:8
•  hemodynamically unstable patient despite
initial resuscitation;
•  hemodynamically stable patients with:
•  other indication for abdominal surgery
(e.g., peritonitis);
•  gunshot injury – relative contraindication
due to high probability of NOM failure (up to
30% of cases)9 and undetected associated intra-
abdominal injuries;
•  concomitant severe head injuries;
•  absence of facilities and personnel for
appropriate intensive care monitoring and treat-
ment, for liver arterial embolization, and for
Figure 1.—Current nonoperative and operative management
of liver trauma.
urgent abdominal exploration in case of NOM
failure.
The criteria for failed NOM and therefore ne-
cessity for surgery, were:
•  continuous or recurrent bleeding demon-
strated by:
•  CT scan;10
•  necessity of ongoing aggressive fluid re-
suscitation or transfusion of more than 3 units of
blood transfusion related to the LI;11
•  hemodynamic instability following
NOM;
•  associated intra-abdominal injuries.

94 Minerva Chirurgica April 2020

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SURGICAL TREATMENT FOR SEVERE LIVER INJURIES MITRICOF

Surgery out 24-48 hours after initial surgery. When pack-

The surgical approach was always open. A large
incision that offered best access was always
considered, and was obtained by enlarging the
previous midline / right subcostal incision (the
midline incision was preferred by most surgeons
that performed the packing in other centers); in
case of LI involving the right posterior section
in patients with previous midline incision, a right
transversal incision was deployed transforming
the access in to a J-shaped incision. The type of
resection was classified according to the ana-
tomic nomenclature of Brisbane 2000 terminol-
ogy of liver anatomy and resections.12 Major LR
was defined as the removal of at least three seg-
ments. All established surgical techniques were
deployed: anatomic/non-anatomic, major/minor
resections; with/without prior liver mobilization
approaches.
Good exposure by quickly and completely
mobilizing the liver was usually useful. In ab-
sence of liver mobilization, the LI may not be
accessible for treatment, it could be treated in-
completely, or it may enlarge due to excessive
traction used to expose the lesion.
Superficial liver lacerations could respond to
conservative techniques such as manual com-
pression with or without associated Pringle ma-
neuver, electrosurgical techniques (mono- and
bipolar cautery, argon beam coagulation, energy-
device coagulation), topical hemostatic agents,
and even perihepatic packing in case of failure of
the other maneuvers (removed intraoperatively
or during a second operation). Deep lacerations
and voluminous parenchymal avulsions typically
required direct ligation of bleeding vessels, di-
rect liver suturing, liver resection (resectional
debridement or anatomic liver resection), selec-
tive hepatic artery ligation (right or left), with or
without perihepatic packing; absorbable mesh-
wrapping is also an option.13 When bleeding
originated from within a deep and narrow lacera-
tion of the liver (such as a penetrating wound),
a balloon tamponade could control the bleeding.
Whenever possible (in absence of sepsis or can-
cer), an autotransfusion procedure was recom-
mended.
Perihepatic pack removal was usually carried
ing was performed in other center, in order to be
safely transferred to our center, the patient had to
be hemodynamically stable. If not, checking for
any active bleeding source, repacking (if active
bleeding in liver was found despite initial pack-
ing), and/or more intensive care treatment were
recommended prior to transfer. Parenchymal
transection during LR was usually performed by
clamp crushing method (Kelly-clasia). In order
to reduce bleeding, vascular control consisting
in Pringle maneuver and total vascular exclusion
was used; when Pringle maneuver was deployed,
presence of left hepatic artery from left gastric
artery was always checked and clamped, if any.
Bleeding control of the liver cut surface was car-
ried out using the common methods (ligatures,
sutures, monopolar, bipolar and/or argon electro-
coagulation, fibrin sealant patch, and/or hemo-
static powder).
Juxtahepatic injuries of vena cava and/or main
hepatic veins (grade V) were very challenging to
control due to the severe bleeding and the diffi-
cult surgical access to these veins, and total vas-
cular exclusion was often used.
Liver transplantation was used when LI lead
to acute liver failure due to extensive parenchy-
mal necrosis.14
Coexistent injuries of other abdominal organs
were explored and treated during surgery.
Postoperative outcome
All postoperative complications during hospital
stay were recorded and classified according to
Dindo-Clavien et al.15 classification. Complica-
tions leading to life-threatening conditions (grade
IIIB and above) were classified as major. Com-
plications with no fatal potential were consid-
ered minor (grade IIIA and below). Liver-related
complications were defined as all complications
directly related with the liver resection, such as
bile leak, cut-surface hematoma or abscess, he-
moperitoneum, liver failure. The complication
rate was calculated based the most severe com-
plication for each LR. Operative mortality was
defined as death during surgical procedure or
within the 90 postoperative days; long-term fol-
low-up was considered not relevant for the study.

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MITRICOF SURGICAL TREATMENT FOR SEVERE LIVER INJURIES

Results tively (Figure 2; Table IV). Interventional arte-

Diagnostics
The topography of the LIs is depicted in the Ta-
ble III. LIs classified according to the American
Association for the Surgery of Trauma (AAST)
system were 13.3% (grade III), 44.2% (grade
IV), and 42.2% (grade V); none were grade I, II
or VI (Table IV). Almost all cases had blunt trau-
ma (95.6%), except 2 with stab wound (4.4%).
The LI was associated with other traumas in
15 pts (38.5%): trauma of other abdominal and
pelvic structures in 14 pts (35.9%), of the thorax
in 14 pts (35.9%), of the head in 4 pts (10.3%),
and limbs/ vertebral column in 3 pts (7.7%).
Treatment
Out of the 45 pts with LI, 6 pts (13.3%) benefit-
ted from non-operative management, and 39 pts
from surgery. Overall and major complication
rates were 100% (45 pts) and 33.3% (15 pts), re-
spectively. The overall mortality rate was 15.6%
(7 pts).
Nonoperative management
NOM was used in 6 pts with grade III and grade
IV LIs in 4 pts (8.9%) and 2 pts (4.4.%), respec-
Table III.—The topography of the liver injuries (LIs).
Topography of LIs N.
Right hemiliver 27
Left hemiliver 10
Bilobar 7 15.6
Segment 1 alone 1 2.2
Total 45
rial embolization was performed in one patient
with active bleeding from a liver laceration, but
hemodynamically stable, with good results. Ma-
jor morbidity rate was 16.6% (1 pt). One patient
died by septic shock due to bilateral pneumonia
(Klebsiella pneumoniae and Pseudomonas aeru-
ginosa). Mortality rate after NOM was 16.6% (1
out of 6 pts).
Surgery
Thirty-nine patients were operated: 38 pts
(84.4%) had 39 LRs (one patient had 2 consecu-
tive LRs), and 1 pt (2.2%) had LT (after 2 con-
secutive LRs). The patients either had prior liver
packing (30 pts; 66.7%) or were hemodynami-
cally unstable (9 pts; 20%).
The rate of major LR was 56.4% (22 LRs).
The LR were anatomic in 28 cases (62.2%). The
types of LR are resumed in Table V; Figure 3,
Figure 4 are examples of the resection types
used. Among anatomic LR, the right hemihepa-
tectomy was the most frequently used technique
(16 pts; 41%). Among patients who had prior
surgery, 12 (41.4%) had significant biliary fistula
that necessitated anatomic liver resection of the
corresponding territory (7 cases) or biliary re-
construction with cholangio/hepatico-jejunosto-
my with a Roux-en-Y loop (5 cases) (Figure 5).
%
60.0 Subcapsular Hemoperitoneum
hematoma
22.2
of the liver
100

Table IV.—The liver injuries (LIs) classified according

to the American Association for the Surgery of Trau-
ma (AAST) system and therapeutic management.
Nonoperative
AAST Total Surgery
management
grade
N. % N. % N. %
I 0 0.0 0 0.0 0 0.0
II 0 0.0 0 0.0 0 0.0
III 6 13.3 4 8.9 2 4.4
IV 20 44.4 2 4.4 18 40.0 Figure 2.—Hemodynamically stable patient with AAST II
V 19 42.2 0 0.0 19 42.2 grade liver injury — at CT-scan subcapsular hematoma of
VI 0 0.0 0 0.0 0 0.0 about 20% of the liver surface, with minimum hemoperito-
neum with no active bleeding; benefitted from nonoperative
Total 45 100.0 6 13.3 39 86.7
management (without embolization).

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SURGICAL TREATMENT FOR SEVERE LIVER INJURIES MITRICOF

Table V.—Type of liver resection (LR) involved in the

management of the liver injuries (LIs).
Type of liver resection N. %
Major resections 22 56.4
Minor resections 17 43.6
Anatomic resections 28 62.2
Trisectionectomy 0 0.0 A B
Right hemihepatectomy 16 41.0 Figure 5.—Hemodynamically unstable patient with AAST
Left hemihepatectomy 2 5.1 grade V liver injury. A 34-year old obese male, victim of
Central LR (anatomic) 0 0.0 a tractor accident, with hemorrhagic shock, massive he-
Left lateral sectionectomy 8 20.5 moperitoneum with large laceration of the right hemili-
Posterior right sectionectomy 2 5.1 ver, with juxtahepatic injury of the hilum (vascular injury
of the right portal vein and rupture of the common bile
Non-anatomic resections 11 28.2 duct), right hemothorax, multiple rib fractures, fractures
Extended right hemihepatectomy 4 10.3 of the right upper and lower limbs; emergency operation
Extended left hemihepatectomy 1 2.6 in other hospital for liver and juxtahepatic injuries (right
Extended left lateral sectionectomy 1 2.6 portal ligation and perihepatic packing); at admittance in
Central LR (non-anatomic) 1 2.6 our center: stable, high transaminases, complete biliary fis-
tula; relaparotomy after 36 hours: right hemihepatectomy
Limited non-anatomic resection 4 10.3 with biliary reconstruction (hepaticojejunostomy); reinter-
vention for large biliary fistula with redo hepaticojejunos-
tomy, with favorable postoperative course. Intraoperative
aspects after right hemihepatectomy: the metallic canula
is inserted into the stump of the common hepatic duct (A);
aspect after hepaticojejunostomy protected with external
biliary stent (B).

One of the 7 cases with significant biliary fistula

Figure 3.—Case presentation of an AAST IV grade liver
injury (LI). 34-year old male with polytrauma by car acci-
dent, hemodynamically unstable; at CT-scan — rupture of
segments 4, 5, and 8 — parenchymal disruption involving
3 Couinaud’s segments; previous surgery in other hospital
(hepatorrhaphy and perihepatic packing); at admittance in
our center: stable, ileus, fever, tachycardia, oliguria, high
transaminase levels (ALT 244 UI/l; AST 111 UI/l), leuco-
cytosis (22.000 el/mm3); relaparotomy after 36 hours (ul-
trasound guided nonanatomic liver resection of segments 4,
5 and 8), with no major complications (minor biliary fistula
treated conservatively).
Figure 4.—Case presentation of an AAST IV grade liver in-
jury (LI). 21-year old male, hemodynamically unstable, with
LI by car accident; at CT-scan: rupture and ischemia of seg-
ments 2-3 — parenchymal disruption involving over 25% of
liver volume; prior surgery in other hospital (hepatorrhaphy
and perihepatic packing); at admittance in our center: stable
patient, very elevated transaminase levels (ALT 1136; AST
984); relaparotomy after 48 hours: left lateral sectionecto-
my; favorable postoperative course.
necessitated two consequent LR, of segment 1
and right hemihepatectomy, respectively.
Vascular reconstruction was performed for
proper hepatic artery, portal vein, and hepatic
veins in 1, 1, and 2 cases, respectively; the recon-
struction technique consisted in either removal of
the previous stenotic suture and re-suture or end-
to-end anastomosis with/without graft interposi-
tion.
The median operative time was 200 minutes
(mean 236; range 150-420). The median blood
loss was 750 ml (mean 940; range 500-6500).
Overall and major postoperative complication
rates were 100% (38 pts) and 36.8% (14 pts),
respectively. Postoperative mortality rate was
15.3% (6 pts).
Liver transplantation was needed in one pa-
tient, a 22-year old female, who had acute liver
failure due to extensive bilobar laceration of the
liver (segments 4, 5, 8, 6, and 7). The patient
sustained a polytrauma in a car crash (bilateral
pulmonary contusion, right pneumothorax, mul-
tiple rib fractures, cerebral concussion, and frac-
ture of the right upper limb), and was operated in
other hospital for grade V laceration with hemo-
dynamical instability and hemoperitoneum. The

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MITRICOF SURGICAL TREATMENT FOR SEVERE LIVER INJURIES
patient underwent 3 consecutive operations (liv-
er packing followed by 2 consecutive resectional
debridement of segments 4, 5, 6, and 6, 7, 8,
respectively) and subsequently developed acute
liver failure (total bilirubin of 25 mg/dL, INR
2.8). She was therefore transplanted in our center
with a whole liver graft (brain dead donor), being
alive with no complications and fully socially re-
inserted at 4 years after transplantation.
Discussion
The first treatment of LI was reported in the early
17th century, when a small piece of liver (pro-
truding from abdomen after knife wound) was
excised. In 1846, J. McPherson excised a small
piece of liver from a spear wound, and in 1870
V. von Bruns successfully excised a “nut-sized”
section of liver from a fellow surgeon suffering
from gunshot wounds. In 1880, L. Tait reported
the first laparotomy for liver trauma, while in
1885, P. Postemski recommended suturing the
liver to control bleeding.16
Traumatic injuries represent the third cause
of death world-wide, with more than 5 million
deaths each year.17 The liver and spleen are the
most commonly injured solid organs.18, 19 LI is
more common in young individuals; indeed, this
happened also in our experience, the median
age being 29 years (median 33). Moreover, LI is
more common in men than women (3:1 ratio),17
and similar result was registered in our study,
with a male/female ratio of 33/12 (2.8:1). Blunt
LI is most frequent in northern Europe (>90%),20
while penetrating LI is most common in Ameri-
cas.21 Indeed, most of our patients had blunt
traumas (95.6%), while only 2 cases (4.4%) had
penetrating LI, both by stab wounds. Blunt LI is
usually caused by motor vehicle collision,22 the
right posterior section (segments 6 and 7) being
the most common site of trauma lesion.23 Indeed,
in our study LIs were located more frequently in
the right hemiliver (60%), almost always involv-
ing the right posterior section.
As in any trauma, for optimal results, the
emergency centers, emergency medical services
transport and the tertiary centers must effectively
cooperate in order to maximize the diagnostic
and therapeutic efficiency.
98 Minerva Chirurgica April 2020
Diagnostic
A negative history and exam do not reliably
exclude LI. High values of liver transaminase
increase the likelihood of LI and may be an in-
dicator of severity of the injury. A base deficit
less than -6 was associated with intra-abdominal
hemorrhage and the need for laparotomy and
blood transfusion.24
CT scan is the primary method for identifying
intra-abdominal injury, with high sensitivity and
specificity (97-98% and 97-99%, respectively);23
in case of a negative CT scan, the rate of missed
injury is extremely low (<0.06%).23 Magnetic
resonance imaging may be useful in a subset of
hemodynamically stable patients who cannot un-
dergo CT scan (allergy to radiological contrast)
or necessitates MRI cholangiography for extra-
hepatic biliary injury.
Liver injury grading
Most LIs are of low-grade according to AAST
classification, as 67% of LIs are AAST low grade
I-III LI,22 when the success of NOM is most
likely to occur. Higher grade LI (IV-V) may be
managed by NOM or surgery, depending on
the dynamics of the clinical status. Grade VI LI
are always severely hemodynamically unstable
(hemorrhagic shock) and therefore surgery is
mandatory in this situation; however, due to the
cataclysmic event, the patient often does not ar-
rive in time for surgery.
However, there is no correlation between
AAST grade and patient physiologic status, so
AAST classification should be supplemented
by hemodynamic status and associated injuries.
Therefore, the LI grading system proposed by the
World Society of Emergency Surgery (WSES)
seems to be more useful, reflecting both the he-
modynamic status and the anatomic grade of the
LI.7 In our experience, World Society of Emer-
gency Surgery (WSES) classification had more
upfront relevancy, the hemodynamical instability
being the main criteria for choosing surgery over
NOM, LIs grade being of secondary importance.
Improved availability, rapidity and sensitiv-
ity of diagnostic imaging, most notably CT scan,
alongside with the development of critical care
monitoring, determined a shift from surgery to
 ©
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cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically
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SURGICAL TREATMENT FOR SEVERE LIVER INJURIES MITRICOF
NOM for most hemodynamically stable patients
with LI, leading to a significant decrease of both
morbidity and mortality.25
Treatment
Liver trauma had always represented a difficult
challenge. The significant developments in the
last two decades in diagnosis, patient monitoring
and interventional therapies, and the optimal re-
sults of non-operative approach in spleen trauma
favor the non-operative management of liver trau-
ma. Independently of the grade of LI, the manage-
ment is determined by the hemodynamical status:
surgery is mandatory in emergency in unstable
patients, while non-operative approach, although
still controversial in high-grade LI, may be used
in stable cases. Even though surgery in high-grade
injuries may result in high mortality as well, there
are no randomized study to compare surgery ver-
sus NOM in stable patients.26 Hemodynamic in-
stability, not the grading of the injury, represents
the main indication for operative approach.
In patients with LI, the following scenarios are
to be considered:
•  regular vital signs and lab tests (low risk) —
clinical observation of less than 12 hours is usu-
ally enough to rule out occult intra-abdominal
injury;27
•  regular vital signs but modified lab tests (he-
matocrit <30 percent, AST/ALT >130 units/L,
microscopic hematuria >25 red blood cells per
high power field) and/or high-risk examination
findings (e.g. peritoneal irritation signs, abdomi-
nal distension, seat belt sign). CT scan is recom-
mended with the following scenario:
•  no LI at CT — clinical observation of less
than 12 hours is recommended;
•  LI at CT, without active bleeding — NOM
is recommended;
•  LI at CT with active bleeding — either
NOM or immediate surgery is recommended,
depending on hemodynamically stability:
•  NOM is recommended in blunt or stab (but
not gunshot) penetrating LI in hemodynamically
stable patients, in I-V AAST grade injuries, in
absence of other intra-abdominal injuries. Even
though extra-abdominal lesions requiring sur-
gery could be present (except severe head trau-
ma), NOM of LI is still recommended;
Vol. 75 - No. 2 Minerva Chirurgica 99
•  emergent abdominal surgery must be of-
fered to:
•  hemodynamically unstable patient with a
positive FAST ultrasound exam, independently
of the AAST grade injury (I-VI);
•  hemodynamically stable patients but with
associated intra-abdominal injuries leading to
peritonitis (e.g. signs of peritoneal irritation, evi-
dence of pneumoperitoneum) and/or diaphrag-
matic rupture, persistent and severe digestive
bleeding;
•  failure of NOM, with patient becoming
unstable despite aggressive conservative treat-
ment including blood transfusion±liver arterial
embolization;
•  persistent systemic inflammatory re-
sponse (SIRS - ileus, fever, tachycardia, oliguria);
•  unexplained signs of bleeding in an un-
stable patient with strongly suspected intra-ab-
dominal trauma.
When available, resuscitative endovascular
balloon occlusion of the aorta may provide he-
modynamic support until definitive treatment
with angioembolization or laparotomy.
Nonoperative management
NOM is deployed in over 80% of blunt LI with a
success rate of over 90%.25 NOM seems to be as-
sociated with improved overall survival in com-
parison with surgical treatment, while reducing
the overall costs.28 The improvements in inten-
sive care management and use of interventional
radiology appears to significantly contribute to
the high successful rate of NOM.29
Disadvantages of NOM are:30
•  increased risk for biliary complications,
such as biloma and/or persistent bile leak which
occur in up to 21% of cases, manifested as ab-
dominal pain and/or a persistent systemic inflam-
matory response syndrome (fever, tachycardia,
and leucocytosis);31
•  increased risk of missed intra-abdominal in-
jury, particularly hollow viscus injury;
•  transfusion-related conditions, such as trans-
fusion-associated circulatory overload (TACO),
transfusion-related acute lung injury (TRALI),
hypothermia, coagulopathy, immunologic and
allergic reactions, and transfusion-related im-
mune modulation (TRIM);
 ©
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cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically
to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,
MITRICOF SURGICAL TREATMENT FOR SEVERE LIVER INJURIES
•  risks associated with embolization tech-
niques, mainly ischemic complications (liver ne-
crosis and abscess, biloma and bile leaks); other
complications may be arterial access site com-
plications (hematoma or bleeding), inadvertent
embolization of other organs (e.g., bowel, pan-
creas), contrast-induced nephropathy.
In our experience, NOM represented only
13.3% of our cases (6 pts), due to the high-grade
LIs and the fact that in most cases, the patients
were referred to us after emergency surgery in
other hospitals (76.9%). The mortality rate re-
corded after NOM was 16.6% (1 out of 6 pts);
the patient had associated trauma (extensive
bilateral pulmonary contusion with respiratory
failure, treated left hemothorax, spleen rupture
treated with splenectomy in other hospital, pel-
vic fracture, retroperitoneal hematoma, and left
upper and lower limb fractures), died due to sep-
ticemia following pulmonary sepsis.
Interventional treatment
Angioembolization has become the gold standard
for the treatment of bleeding in liver injuries in
hemodynamically stable patients. Furthermore,
interventional radiology has a paramount role in
the management of posttraumatic complications,
such as pseudoaneurysm, intrahepatic arterio-
venous fistula, haemobilia (angioembolization),
symptomatic biloma and abscesses (percutane-
ous guided drainage).32 Of note, there was one
patient with grade V LI that underwent arterial
embolization and was referred to our center for
LT for acute liver failure; unfortunately. The pa-
tient developed septicemia (and died), and there-
fore could not benefit from LT. This patient was
excluded from the study group because he was
not managed by neither NOM or surgery.
The success rate of angioembolization in LI
may be up to 93%,30 depending on the expertise
and facilities. It appears to be most effective in
hemodynamically stable patients with active
bleeding at CT. When the source of bleeding is
not seen at angiography, empiric embolization
guided by the previous CT may be performed to
reduce the risk of bleeding. Therefore, up to 5%
of NOM patients may require embolization.33
Liver arterial embolization can also be used
adjunctively in case of ongoing liver bleeding or
100 Minerva Chirurgica April 2020
rebleeding after surgery in 12-28% of operated
patients.33
In our experience, only one case (2.2%) ben-
efitted from interventional arterial embolization.
The low rate of embolization was mainly due to
unavailability during night and weekend.
Surgery
Approximately 15% of patients with LI require
surgical treatment.22 In our study, this rate was
much higher (84.4%) because we addressed only
high-grade LIs, IV and V grades LIs representing
82.2%, and most of our patients were transferred
after prior surgery (66.7%).
Surgical management of LIs is challenging
even for experienced surgeons due to liver size,
quality of parenchyma (such as steatosis, hepati-
tis), dual blood supply (portal, hepatic arterial),
complex biliary drainage system, intricate and
difficult-to-access venous drainage, and fre-
quent anatomic variants of all these structures.
The operation is even more difficult due to im-
paired visibility due to presence of bulky clots
and large quantity of blood into the peritoneum.
Moreover, because the operation is carried out on
a hemodynamically unstable patient, the surgical
maneuvers must be swift in order to obtain rapid
hemostasis, consisting in temporary bleeding
control, to allow effective intensive resuscitation
of the patient. This is followed by definitive he-
mostasis using a variety of techniques, that can
be deployed immediately in hemodynamically
stable patients, or in a delayed manner (after
packing), following intensive care resuscitation,
in case of unstable patients.
The use of perihepatic packing as maneuver
for temporary bleeding control reduces the ex-
tent of subsequent surgical procedures. The more
complex the LI, the better the chance for cure if
the definitive treatment (LR) is performed during
a second operation preferably by an expert team
in a tertiary center, after stabilizing the patient.
The timing of relaparotomy for removal of
the perihepatic packs is controversial.34 Re-
moval after less than 24 hours has high risk of
rebleeding, while after 48 hours has a higher
risk of sepsis. Therefore, the interval of 24 to
48 hours is generally excepted. If bleeding oc-
curs after removing the packs, repacking should
 ©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2020 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically
to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,
SURGICAL TREATMENT FOR SEVERE LIVER INJURIES MITRICOF
be considered, followed by relaparotomy after
another 24-48 hours.
The operative approach has also developed
over the last two decades. Direct suture/ligation
of the intra-parenchymal bleeding vessel, perihe-
patic packing, repair of venous injury under total
vascular isolation, in association with preopera-
tive and/or postoperative angioembolization are
the methods initially preferred, while LR remain
the main option in case of inefficiency of the
above-mentioned methods.35
Nowadays, LR is considered to have minimal
role in the management of hepatic injury because
of the high morbidity and mortality in many re-
ports. Nevertheless, it is known that high-vol-
ume centers and high-volume surgeons correlate
with improved outcomes after LR.36 Indeed, in
specialized liver surgery/transplant centers, the
morbidity and the mortality after LR for severe
liver injuries are as low as 17-30%, and 2-9%,
respectively.37, 38 Liver resection is reserved for
severe injuries, the main policy being preserva-
tion of as much as possible of liver parenchyma.
In our study, all patients that underwent surgery
benefitted either of LR or LT. Our resection poli-
cy shifted over time from major resection to con-
servative more limited LR whenever possible.
The preferred method for liver transection was
Kelly-clasia, which we consider most suitable
in emergency situations because it is rapid and
does not rely on devices that are time consum-
ing. Bleeding control on the cut liver surface was
very carefully performed, preferably using liga-
tions and sutures; hemostatic materials (prefer-
ably fibrin sealant patch) were used only for mi-
nor bleeding or even just to protect non-bleeding
sensitive surfaces (e.g. large vessels exposed on
the cut surface) against recurrent bleeding due to
coagulation impairment.
In case of liver necrosis (following LI, embo-
lization or hepatorrhaphy) the treatment consists
in surgical debridement for limited necrosis,
upfront liver resection (rather than repeated de-
bridement) in case of large necrosis,30 and even
LT in case of acute liver failure due to extensive
necrosis.
Liver transplant is, in rare situations, the sal-
vage option for a severe LI,14 including hepatic
avulsion (grade V injury), resulting in acute liver
Vol. 75 - No. 2 Minerva Chirurgica 101
failure. Good outcome in selected cases have
been reported.39 Compared with non-trauma re-
cipients, post-trauma recipients experience a sig-
nificantly higher retransplantation rate, but with
similar long-term survival.40 In our study, only
one patient, a 22-year old female, had LT for
acute liver failure due to extensive bilobar lac-
eration of the liver, who is currently alive with
no complications at 4 year after transplantation,
fully socially reinserted, with a 2-years old child.
Consequently, we consider that complex liver
resections, vascular and biliary reconstructions
are to be carried out in highly specialized tertiary
centers, minimizing the morbidity and mortal-
ity rates and having the liver transplantation as a
salvage treatment. With an experience of around
3500 liver resections and 1000 LTs (since 2000),
our center is an established national reference
center for liver surgery.41
Other treatments
Persistent bile leak is recommended to be treat-
ed, as first line therapy, by endoscopic retrograde
cholangio-pancreatography with stent placemen,
or percutaneous transhepatic biliary drainage as
an alternative. Failure of these interventional
methods usually necessitates surgery with re-
moval of the liver parenchyma feeding the bile
leak or with biliary reconstruction.
In case significant choleperitoneum and failed
interventional drainage, laparoscopy with ab-
dominal irrigation and drainage is recommend-
ed. Similarly, in case of persistent large hemo-
peritoneum even in absence of active bleeding,
the same approach is recommended.
Abscesses are usually successfully managed
with antibiotics and percutaneous drainage tech-
niques, but surgery may be needed if interven-
tional techniques fail to provide adequate drain-
age.
Morbidity and mortality
The morbidity is dependent on the AAST grade
of L,42 very low for grade I and II, 5% for grade
III, and more than 50% for grade V.43
Mortality increases in AAST high-grade LIs,
and have decreased over time due to NOM and
emergent perihepatic packing,44 especially in
 ©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2020 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically
to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,
MITRICOF SURGICAL TREATMENT FOR SEVERE LIVER INJURIES
grade IV and V LIs.28, 43 Many of the high-grade
LIs can be successfully managed by NOM with
overall low mortality rates ranging from 0-8%.
In our experience, the mortality after NOM was
higher (16.6%), but the 1 case that died during
NOM was not due to LI. Mortality rate is much
higher (30-68%) for high-grade LI requiring sur-
gery, regardless if it is deployed immediately or
after failed NOM;33 moreover mortality increas-
es significantly to up to 77% in case of injury of
vena cava and liver hilum.45 In our experience
treating high-grade LIs, the mortality rate was
15.8%. Most probably, the lower rate in com-
parison with the literature is due to some extent
to the possible existence of cases with similar LIs
that initiated treatment in other centers but were
never referred to our center due to a dismal out-
come.
Conclusions
The management of liver injury must be based on
both anatomy of injury and its physiopathologi-
cal effects. The main approach is nonoperative,
including angioembolization in selected cases,
while surgery is reserved mainly for unstable
patients. Continuous proactive monitoring off all
trauma injuries is mandatory in order to be able
to detect and treat immediately any complication
related to the liver or other concomitant injured
organs. For optimal results, the emergency cen-
ters, emergency medical services transport and
the tertiary centers must effectively cooperate.
References
1.  Clancy TV, Gary Maxwell J, Covington DL, Brinker
CC, Blackman D. A statewide analysis of level I and II
trauma centers for patients with major injuries. J Trauma
2001;51:346–51.
2.  Pachter HL, Hofstetter SR. The current status of nonopera-
tive management of adult blunt hepatic injuries. Am J Surg
1995;169:442–54.
3.  Asensio JA, Demetriades D, Chahwan S, Gomez H, Han-
peter D, Velmahos G, et al. Approach to the management of
complex hepatic injuries. J Trauma 2000;48:66–9.
4.  Carrillo EH, Platz A, Miller FB, Richardson JD, Polk HC
Jr. Non-operative management of blunt hepatic trauma. Br J
Surg 1998;85:461–8.
5.  Brasel KJ, Nirula R. What mechanism justifies ab-
dominal evaluation in motor vehicle crashes? J Trauma
2005;59:1057–61.
102 Minerva Chirurgica April 2020
6.  Gaarder C, Gaski IA, Næss PA. Spleen and liver injuries:
when to operate? Curr Opin Crit Care 2017;23:520–6.
7.  Coccolini F, Catena F, Moore EE, Ivatury R, Biffl W,
Peitzman A, et al. WSES classification and guidelines for
liver trauma. World J Emerg Surg 2016;11:50.
8.  Badger SA, Barclay R, Campbell P, Mole DJ, Diamond T.
Management of liver trauma. World J Surg 2009;33:2522–37.
9.  Richardson JD, Escluso A. Changes in the manage-
ment of injuries to the liver and spleen. J Am Coll Surg
2005;200:648–69.
10.  Malhotra AK, Fabian TC, Croce MA, Gavin TJ, Kudsk
KA, Minard G, et al. Blunt hepatic injury: a paradigm shift
from operative to nonoperative management in the 1990s.
Ann Surg 2000;231:804–13.
11.  Huang YC, Wu SC, Fu CY, Chen YF, Chen RJ, Hsieh CH,
et al. Tomographic findings are not always predictive of failed
nonoperative management in blunt hepatic injury. Am J Surg
2012;203:448–53.
12.  Terminology Committee of the IHPBA. Escluso A.
Terminology of liver anatomy and resections. HPB Surg
2000;2:333–9.
13.  Søndenaa K, Tasdemir I, Andersen E, Skadberg JE, Søre-
ide JA. Treatment of blunt injury of the spleen: is there a place
for mesh wrapping? Eur J Surg 1994;160:669–73.
14.  Popescu I, Ionescu M, Braşoveanu V, Hrehoreţ D, Copca
N, Lupaşcu C, et al. The Romanian National Program for
Liver Transplantation - 852 Procedures in 815 Patients over
17 Years (2000-2017): A Continuous Evolution to Success.
Chirurgia (Bucur) 2017;112:229–43.
15.  Dindo D, Demartines N, Clavien PA. Classification of
surgical complications: a new proposal with evaluation in
a cohort of 6336 patients and results of a survey. Ann Surg
2004;240:205–13.
16.  McClusky DA 3rd, Skandalakis JE. Surgical Anatomy.
The Embryologic and Anatomic Basis of Modern Surgery:
Anatomic and Surgical History of the Liver. Athens: Paschali-
dis Medical Publications; 2004. p: 1007-8.
17.  Murray CJ, Lopez AD. Alternative projections of mor-
tality and disability by cause 1990-2020: Global Burden of
Disease Study. Lancet 1997;349:1498–504.
18.  Isenhour JL, Marx J. Advances in abdominal trauma.
Emerg Med Clin North Am 2007;25:713–33, ix.
19.  Davis JJ, Cohn I Jr, Nance FC. Diagnosis and manage-
ment of blunt abdominal trauma. Ann Surg 1976;183:672–8.
20.  Talving P, Beckman M, Häggmark T, Iselius L. Epidemi-
ology of liver injuries. Scand J Surg 2003;92:192–4.
21.  Magana-Sánchez IJ, García-Núnez LM, Loera-Torres
MA. Trauma hepático [chapter 18]. In: Manual del Curso de
Entrenamiento en Cirugía Avanzada en Trauma. Mexico City:
Colegio Mexicano de Cirujanos Militares A.C.; 2013. p. 76-9.
22.  Tinkoff G, Esposito TJ, Reed J, Kilgo P, Fildes J,
Pasquale M, et al. American Association for the Surgery of
Trauma Organ Injury Scale I: spleen, liver, and kidney, valida-
tion based on the National Trauma Data Bank. J Am Coll Surg
2008;207:646–55.
23.  Holmes JF, McGahan JP, Wisner DH. Rate of intra-ab-
dominal injury after a normal abdominal computed tomo-
graphic scan in adults with blunt trauma. Am J Emerg Med
2012;30:574–9.
24.  Mofidi M, Hasani A, Kianmehr N. Determining the ac-
curacy of base deficit in diagnosis of intra-abdominal injury
in patients with blunt abdominal trauma. Am J Emerg Med
2010;28:933–6.
25.  Petrowsky H, Raeder S, Zuercher L, Platz A, Simmen HP,
 ©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2020 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically

to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,

SURGICAL TREATMENT FOR SEVERE LIVER INJURIES MITRICOF

Puhan MA, et al. A quarter century experience in liver trau-
ma: a plea for early computed tomography and conservative
management for all hemodynamically stable patients. World J
Surg 2012;36:247–54.
26.  Cirocchi R, Trastulli S, Pressi E, Farinella E, Avenia S,
Morales Uribe CH, et al. Non-operative management versus
operative management in high-grade blunt hepatic injury. Co-
chrane Database Syst Rev 2015;(8):CD010989.
27.  Jones EL, Stovall RT, Jones TS, Bensard DD, Burlew
CC, Johnson JL, et al. Intra-abdominal injury following blunt
trauma becomes clinically apparent within 9 hours. J Trauma
Acute Care Surg 2014;76:1020–3.
28.  Pachter HL, Feliciano DV. Complex hepatic injuries.
Surg Clin North Am 1996;76:763–82.
29.  Shrestha B, Holcomb JB, Camp EA, Del Junco DJ, Cot-
ton BA, Albarado R, et al. Damage-control resuscitation in-
creases successful nonoperative management rates and sur-
vival after severe blunt liver injury. J Trauma Acute Care Surg
2015;78:336–41.
30.  Green CS, Bulger EM, Kwan SW. Outcomes and com-
plications of angioembolization for hepatic trauma: A sys-
tematic review of the literature. J Trauma Acute Care Surg
2016;80:529–37.
31.  Hommes M, Nicol AJ, Navsaria PH, Reinders Folmer
E, Edu S, Krige JE. Management of biliary complications in
412 patients with liver injuries. J Trauma Acute Care Surg
2014;77:448–51.
32.  Goffette PP, Laterre PF. Traumatic injuries: imaging and
intervention in post-traumatic complications (delayed inter-
vention). Eur Radiol 2002;12:994–1021.
33.  Melloul E, Denys A, Demartines N. Management of
severe blunt hepatic injury in the era of computed tomogra-
phy and transarterial embolization: A systematic review and
critical appraisal of the literature. J Trauma Acute Care Surg
2015;79:468–74.
34.  Nicol AJ, Hommes M, Primrose R, Navsaria PH, Krige
JE. Packing for control of hemorrhage in major liver trauma.
World J Surg 2007;31:569–74.
35.  Duane TM, Como JJ, Bochicchio GV, Scalea TM. Re-
evaluating the management and outcomes of severe blunt
liver injury. J Trauma 2004;57:494–500.
36.  Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lu-
cas FL, Batista I, et al. Hospital volume and surgical mortality
in the United States. N Engl J Med 2002;346:1128–37.
37.  Polanco P, Leon S, Pineda J, Puyana JC, Ochoa JB, Alar-
con L, et al. Hepatic resection in the management of com-
plex injury to the liver. J Trauma 2008;65:1264–9, discussion
1269–70.
38.  Li Petri S, Gruttadauria S, Pagano D, Echeverri GJ, Di
Francesco F, Cintorino D, et al. Surgical management of com-
plex liver trauma: a single liver transplant center experience.
Am Surg 2012;78:20–5.
39.  Heuer M, Kaiser GM, Lendemans S, Vernadakis S,
Treckmann JW, Paul A. Transplantation after blunt trauma to
the liver: a valuable option or just a “waste of organs”? Eur J
Med Res 2010;15:169–73.
40.  Kaltenborn A, Reichert B, Bourg CM, Becker T, Lehner
F, Klempnauer J, et al. Long-term outcome analysis of liver
transplantation for severe hepatic trauma. J Trauma Acute
Care Surg 2013;75:864–9.
41.  Botea F, Ionescu M, Braşoveanu V, Hrehoreţ D, Alex-
andrescu S, Grigorie M, et al. Liver Resections in a High-
Volume Center: Form Standard Procedures to Extreme Sur-
gery and Ultrasound-guided Resections. Chirurgia (Bucur)
2017;112:259–77.
42.  Kozar RA, Moore JB, Niles SE, Holcomb JB, Moore
EE, Cothren CC, et al. Complications of nonoperative
management of high-grade blunt hepatic injuries. J Trauma
2005;59:1066–71.
43.  Kozar RA, Moore FA, Cothren CC, Moore EE, Sena M,
Bulger EM, et al. Risk factors for hepatic morbidity follow-
ing nonoperative management: multicenter study. Arch Surg
2006;141:451–8, discussion 458–9.
44.  Peitzman AB, Richardson JD. Surgical treatment of inju-
ries to the solid abdominal organs: a 50-year perspective from
the Journal of Trauma. J Trauma 2010;69:1011–21.
45.  Piper GL, Peitzman AB. Current management of hepatic
trauma. Surg Clin North Am 2010;90:775–85.

Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material
discussed in the manuscript.
Authors’ contributions.—Conceived and designed the analysis: Florin Botea, Irinel Popescu, Bianca Mitricof; data collection: Alex-
andru Barcu, Naudica Picu, Elena Flutur; contributed data: Vladislav Brasoveanu, Doina Hrehoret, Dana Tomescu, Gabriela Droc,
Ioana Lupescu; performed the analysis: Bianca Mitricof, Florin Botea, Irinel Popescu; wrote the paper: Bianca Mitricof, Florin Botea,
Irinel Popescu.
History.—Article first published online: January 29, 2020. - Manuscript accepted: January 9, 2020. - Manuscript revised: November
28, 2019. - Manuscript received: September 30, 2019.

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