![]() ![]() This rate of usage is consistent with that in our unit. Cogbill et al 9 reported that SHAL was used in 10 of 210 severe liver injuries, and Asensio et al 10 noted its use in 1 of 22 cases of complex liver trauma in recent series. When arterial bleeding is controlled by a Pringle maneuver, SHAL should still be considered. SHAL was used in 13% of patients from 1975 to 1979, but that rate then diminished greatly. Flint and Polk 8 defined its use after several years’ experience, and the incidence of SHAL decreased dramatically since then. SHAL was developed at the University of Louisville and was used extensively in the early to mid-1970s 6,7 in retrospect, it was overused during this period. Treatment patterns changed dramatically during the study. 5 Because the percentage of serious injuries was unchanged, it would be difficult to assert that the improvement in the survival rate was due to a lower severity of injuries. The incidence of grades IV and V injuries was 15% to 20% through the years, similar to the 14% reported by Pachter et al. The grade of severe injuries has not changed. In the past 25 years, the annual number of injuries increased consistently, probably reflecting the continued increase in total trauma volume. Hemorrhage control was accomplished in 24 of the patients (85%). Thirty-six patients underwent angiography for hepatic injuries, with bleeding identified in 28 patients. The final difference in practice in the last 5 years was in the use of angiography and embolization to control bleeding. The major difference in the latter time period was that packing was performed earlier, with an average blood loss of 6.8 units received before packing, as opposed to 15 units in the earlier series. Analysis of the improved death rates showed that the severity of injuries did not change during the three time periods. From 1995 to 1999, the death rate decreased to 34.5% ( P ≤. In the succeeding 5-year period, the death rate actually increased to 68% as its use was expanded. 3,4 From 1983 to 1989, packing of liver injuries was associated with a 52% death rate. The death rate associated with packing significantly decreased in the past 5 years compared with reports from two earlier periods from our institution. With the advent of nonsurgical therapy, the use of angiography and embolization for hemorrhage control has increased from less than 1% to 9%. Patients with penetrating injuries were still treated surgically. From 1995 to 1999, two thirds of blunt injury patients were treated without surgery in the last 2 years, more than 80% did not undergo surgery. Nonsurgical therapy was not used to treat liver injuries with any regularity until the mid-1990s. In the latter two time periods, 8% of patients were treated by packing and planned reoperation as a part of a “damage control” strategy. ![]() In the late 1970s, there were virtually no patients treated by packing and planned reoperation. Individual vessel suture ligation, minor resectional débridement, tractotomy, hepatic mattress sutures, and other techniques have been used alone or in combination throughout the 25-year interval, but there were no consistent changes in treatment patterns. Omental flaps were rarely used before the mid-1980s but were used in approximately 10% of patients treated since then, often in combination with other treatments. Drainage as the only treatment used dramatically decreased. Major resection was used to control extensive laceration or large segments of devitalized liver tissue in each of the three periods examined, but the percentage declined from 6% to 3%.
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