Non transplant surgical considerations: Hepatic surgery and liver trauma

Abstract

Surgery represents one of the main options for the management of liver related conditions, including benign or malignant tumors, biliary abnormalities, and trauma. Liver resections are major operations and carried a significant mortality risk until recently. Within the last 30 years the results have significantly improved, with a post-operative mortality below 3% in specialized centers around the world. At the same time, surgery for liver trauma has become quite rare and the majority of patients are managed non-operatively. When an operation is necessary, most are treated with peri-hepatic packing and a staged operation. While there are significant differences between these two groups with liver disease, the complexity of their treatment results in their admission to the intensive care unit (ICU). Caring for postoperative liver patients or those with liver trauma requires a thorough understanding of each disease process, and almost every intensivist will encounter several of these patients throughout a career. Before a postoperative patient arrives in the ICU, they have undergone an extensive evaluation to ensure that surgery is the best treatment option. Patient operability, tumor resectability, and adequacy of the future liver remnant are taken into consideration before any procedure is performed. Nonetheless, morbidity is still as high as 30-45%, and major complications occur in around 20%. Patients with hepatic trauma suffer similarly high morbidity and, in severe liver injury, mortality exceeds 40%. However, non-operative management and changes in surgical technique have improved survival. Complications in surgical and trauma patients overlap significantly and include typical surgical complications such as post-operative infections, as well as, organ system failure, electrolyte abnormalities, cardiopulmonary events, and venous thromboembolism. Providers must also be familiar with liver-specific complications such as hemorrhage, bile leak/bilomas, liver abscesses, hepatic necrosis, and post-operative hepatic insufficiency when caring for this high-risk patient population. The intensive care management of the patient with liver-related surgical disease or hepatic trauma may challenge even the most experienced medical practitioner; and, because of the complex nature of these patients, care should be provided in conjunction with a multidisciplinary team capable of providing the diagnostic, endoscopic, medical, and surgical treatments necessary for the best patient outcomes.