What are the management strategies for complications of liver and splenic lacerations?

Management of Complications from Liver and Splenic Lacerations

Complications from liver and splenic lacerations should be managed with minimally invasive techniques as first-line therapy: percutaneous drainage for abscesses and bilomas, angioembolization for delayed hemorrhage and pseudoaneurysms, and endoscopic interventions for biliary fistulas, reserving surgery only for failures of these approaches. 1

Hemorrhagic Complications

Delayed Hemorrhage

• Delayed hemorrhage without severe hemodynamic compromise should be managed first with angiography and angioembolization (AG/AE), not immediate surgery. 1
• Therapeutic angioembolization can significantly reduce the failure rate of non-operative management in both splenic and hepatic injuries with documented active bleeding. 1
• In hemodynamically unstable patients with ongoing bleeding after initial damage control procedures, angioembolization remains a useful adjunctive tool. 1

Pseudoaneurysms

• Hepatic artery pseudoaneurysms must be managed with AG/AE to prevent rupture, regardless of symptoms. 1
• This represents a strong recommendation because untreated pseudoaneurysms carry high risk of catastrophic rupture. 1

Persistent Arterial Bleeding Post-Surgery

• Angioembolization is the preferred tool for persistent arterial bleeding after non-hemostatic or damage control surgical procedures. 1
• REBOA (resuscitative endovascular balloon occlusion of the aorta) may be used as a bridge to definitive hemorrhage control in hemodynamically unstable patients. 1

Infectious Complications

Intrahepatic Abscesses

• Intrahepatic abscesses should be treated with percutaneous drainage as first-line therapy. 1
• This approach successfully manages most cases without need for surgical intervention. 1
• Surgery should be reserved only for failures of percutaneous drainage or when abscesses are not amenable to percutaneous access. 1

Post-Embolization Syndrome (Splenic Injuries)

• Post-embolization syndrome occurs in up to 90% of pediatric patients, consisting of abdominal pain, nausea, ileus, and fever. 2
• This is self-limited and resolves spontaneously in 6-9 days without specific intervention. 2
• Major complications from splenic embolization occur in only 3.7-28.5% of cases, significantly lower than the 32% infectious complication rate with splenectomy. 2

Biliary Complications

Bilomas

• Symptomatic or infected bilomas should be managed with percutaneous drainage. 1
• Asymptomatic bilomas can be observed without intervention. 1

Biliary Fistulas

• Delayed post-traumatic biliary fistulas should be managed with percutaneous drainage/lavage combined with endoscopic stenting as the first approach when no other indication for laparotomy exists. 1
• Combination of percutaneous drainage and endoscopic techniques (ERCP with stenting) should be considered for post-traumatic biliary complications not suitable for percutaneous management alone. 1
• This step-up approach minimizes morbidity compared to immediate surgical intervention. 1

Surgical Management of Complications

Indications for Delayed Surgery

• Laparoscopy should be considered as the initial approach for delayed surgery to minimize invasiveness and tailor the procedure to the specific lesion. 1
• Interval laparoscopic exploration may be considered in selected cases where intra-abdominal injury is suspected days after initial trauma, as an extension of non-operative management. 1

Hepatic Debridement

• Major hepatic resections should be avoided initially and only considered in subsequent operations for resectional debridement of large areas of devitalized liver tissue, performed by experienced surgeons. 1
• Primary surgical intention should focus on controlling hemorrhage and bile leak with damage control principles. 1

Thromboprophylaxis During Recovery

Mechanical Prophylaxis

• Mechanical thromboprophylaxis is safe and should be used in all patients without absolute contraindications. 1

Pharmacologic Prophylaxis

• LMWH-based prophylaxis should be started as soon as possible following trauma and is safe in selected patients with liver or splenic injury treated non-operatively. 1
• For patients on anticoagulants, individualize the risk-benefit balance of anticoagulant reversal. 1

Supportive Care Measures

Mobilization and Nutrition

• Early mobilization should be achieved in stable patients to prevent complications. 1
• Enteral feeding should be started as soon as possible in the absence of contraindications. 1

Critical Pitfalls to Avoid

• Do not rush to surgery for complications that can be managed with interventional radiology or endoscopy - the morbidity of laparotomy in young trauma patients includes wound infections and long-term complications like eventration and bowel obstruction in 10-40% of cases. 1
• Do not assume all contrast blush on CT requires immediate intervention in hemodynamically stable patients, particularly in children. 1
• Do not delay angioembolization for hepatic artery pseudoaneurysms even if asymptomatic, as rupture risk is high. 1
• Ensure facilities have 24/7 capability for emergency intervention before committing to non-operative management of complications. 1