Management of blunt hepatic injuries

Contribution by Dr Timothy C Fabian: liver trauma

The liver is the most commonly injured organ within the abdomen. Dr Fabian and his associates have made remarkable contributions to our understanding and management of these injuries. The current review summarizes the contributions.

Value of repeat CT for nonoperative management of patients with blunt liver and spleen injury: a systematic review

PURPOSE

To evaluate the effectiveness of routine repeat computed tomography (CT) for nonoperative management (NOM) of adults with blunt liver and/or spleen injury.

METHODS

We conducted a systematic review of randomized and non-randomized controlled trials (RCTs), quasi-experimental and observational studies of repeat CT in adult patients with blunt abdominal injury. We searched Medline, Embase, Web of Science, and Cochrane Central from their inception to October 2020 using Cochrane guidelines. Primary outcomes were change in clinical management (e.g., emergency surgery, embolization, blood transfusion, clinical surveillance), mortality, and complications. Secondary outcomes were hospital readmission and length of stay.

RESULTS

Search results yielded 1611 studies of which 28 studies including 2646 patients met our inclusion criteria. The majority reported on liver (n = 9) or spleen injury (n = 16) or both (n = 3). No RCTs were identified. Meta-analyses were not possible because no study performed direct comparisons of study outcomes across intervention groups. Only seven of the twenty-eight studies reported whether repeat CT was routine or prompted by clinical indication. In these 7 studies, among the 254 repeat CT performed, 188 (74%) were routine and 8 (4%) of these led to a change in clinical management. Of the 66 (26%) repeated CT prompted by clinical indication, 31 (47%) led to a change in management. We found no data allowing comparison of any other outcomes across intervention groups.

CONCLUSION

Routine repeat CT without clinical indication is not useful in the management of patients with liver and/or spleen injury. However, effect estimates were imprecise and included studies were of low methodological quality. Given the risks of unnecessary radiation and costs associated with repeat CT, future research should aim to estimate the frequency of such practices and assess practice variation.

LEVEL OF EVIDENCE

Systematic reviews and meta-analyses, Level II.

Evolution of non-operative management of liver trauma

The management of complex liver injury has changed during the last 30 years. Operative management has evolved into a non-operative management (NOM) approach, with surgery reserved for those who present in extremis or become hemodynamically unstable despite resuscitation. This NOM approach has been associated with improved survival rates in severe liver injury and has been the mainstay of treatment for the last 20 years. Patients that fail NOM and require emergency surgery are associated with increased morbidity and mortality. Better patient selection may have an impact not only on the rate of failure of NOM, but the mortality rate associated with it. The aim of this article is to review the evidence that helped shape the evolution of liver injury management during the last 30 years.

The rate of success of the conservative management of liver trauma in a developing country

BACKGROUND

The conservative treatment of liver trauma has made important progress over the last 10 years at the Trauma University Hospital in Tirana, Albania. The percentage of success was 58.7%. The aims of this study were to analyze the conservative treatment of liver trauma and to compare the results with those in the literature.

METHODS

This study was conducted prospectively from January 2009 to December 2012. We analyzed 173 patients admitted to our hospital with liver trauma. Liver injuries were evaluated according to the American Association for the Surgery of Trauma and the World Society of Emergency Surgery classification, while the anatomic gravity of the associated injuries was defined using the Injury Severity Score system. The potential mortality was estimated with the Revised Trauma Score.

RESULTS

Out of the 173 patients with liver trauma, 83.2% were male. The main cause of liver trauma was motor vehicle crashes (50.9%). Blunt trauma was the cause of liver injury in 129 cases (74.6%), and penetrating trauma occurred in 44 cases (25.4%). Initially, the decision was to manage 88 cases (50.9%) via the conservative approach. Of these, 73 cases (42.2%) were successfully treated with conservative treatment, while in 15 cases (17.2%), this approach failed. The success rate of conservative treatment by grade of injuries was as follows: grade I (38.4%), grade II (30.1%), grade III (28.8%), and grade IV (2.7%). The likelihood of the success of conservative treatment had a significant correlation with the grade of the liver injury (p < 0.00001), associated intra-abdominal injuries (p = 0.00051), and complications (z = 2.3169, p = 0.02051). The overall mortality rate of liver trauma was 13.2%.

CONCLUSIONS

The likelihood of success in using conservative treatment had a significant correlation with the grade of liver injury and associated intra-abdominal injuries. The limited hospital resources and low level of consensus on conservative treatment had a negative impact on the level of success.

Liver trauma

Management of blunt or penetrating injury to the liver remains a significant challenge to trauma surgeons. Liver injury remains common in both blunt and penetrating trauma of the abdomen. Unstable patients require immediate laparotomy. Selective patients can be managed without surgery and with careful monitoring. There has been a recent resurgence in the role of temporary packing in the management of liver trauma. Other commonly used techniques are resectional debribement and suture ligation of bleeding vessels. Complications include haemorrhage, bile leak and sepsis. Mortality is mainly due to damage to major hepatic blood vessels or other associated non-hepatic injuries. With improved understanding of the major causes of death from hepatic injury, improved resuscitation and intensive care, mortality has fallen below 10%.

Non-operative management versus operative management in high-grade blunt hepatic injury

BACKGROUND

Surgery used to be the treatment of choice in cases of blunt hepatic injury, but this approach gradually changed over the last two decades as increasing non-operative management (NOM) of splenic injury led to its use for hepatic injury. The improvement in critical care monitoring and computed tomographic scanning, as well as the more frequent use of interventional radiology techniques, has helped to bring about this change to non-operative management. Liver trauma ranges from a small capsular tear, without parenchymal laceration, to massive parenchymal injury with major hepatic vein/retrohepatic vena cava lesions. In 1994, the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma (AAST) revised the Hepatic Injury Scale to have a range from grade I to VI. Minor injuries (grade I or II) are the most frequent liver injuries (80% to 90% of all cases); severe injuries are grade III-V lesions; grade VI lesions are frequently incompatible with survival. In the medical literature, the majority of patients who have undergone NOM have low-grade liver injuries. The safety of NOM in high-grade liver lesions, AAST grade IV and V, remains a subject of debate as a high incidence of liver and collateral extra-abdominal complications are still described.

OBJECTIVES

To assess the effects of non-operative management compared to operative management in high-grade (grade III-V) blunt hepatic injury.

SEARCH METHODS

The search for studies was run on 14 April 2014. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (Ovid), PubMed, ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), clinical trials registries, conference proceedings, and we screened reference lists.

SELECTION CRITERIA

All randomised trials that compare non-operative management versus operative management in high-grade blunt hepatic injury.

DATA COLLECTION AND ANALYSIS

Two authors independently applied the selection criteria to relevant study reports. We used standard methodological procedures as defined by the Cochrane Collaboration.

MAIN RESULTS

We were unable to find any randomised controlled trials of non-operative management versus operative management in high-grade blunt hepatic injury.

AUTHORS' CONCLUSIONS

In order to further explore the preliminary findings provided by animal models and observational clinical studies that suggests there may be a beneficial effect of non-operative management versus operative management in high-grade blunt hepatic injury, large, high quality randomised trials are needed.

Concomitant hollow viscus injuries in patients with blunt hepatic and splenic injuries: an analysis of a National Trauma Registry database

INTRODUCTION

Non-operative management has become the standard approach for treating stable patients sustaining blunt hepatic or splenic injuries in the absence of other indications for laparotomy. The liberal use of computed tomography (CT) has reduced the rate of unnecessary immediate laparotomies; however, due to its limited sensitivity in the diagnosis of hollow viscus injuries (HVI), this may be at the expense of a rise in the incidence of missed HVI. The aim of this study was to assess the incidence of concomitant HVI in blunt trauma patients diagnosed with hepatic and/or splenic injuries, and to evaluate whether a correlation exists between this incidence and the severity of hepatic or splenic injuries.

METHODS

A retrospective cohort study involving blunt trauma patients with splenic and/or liver injuries, between the years 1998 and 2012 registered in the Israel National Trauma Registry. The association between the presence and severity of splenic and/or liver injuries and the incidence of HVI was examined.

RESULTS

Of the 57,130 trauma victims identified as suffering from blunt torso injuries, 2335 (4%) sustained hepatic injuries without splenic injuries (H group), 3127 (5.4%) had splenic injuries without hepatic injuries (S group), and 564 (1%) suffered from both hepatic and splenic injuries (H+S group). Overall, 957 patients sustained 1063 HVI. The incidence of HVI among blunt torso trauma victims who sustained neither splenic nor hepatic injuries was 1.5% which is significantly lower than in the S (3.1%), H (3.1%), and H+S (6.7%) groups. In the S group, there was a clear correlation between the severity of the splenic injury and the incidence of HVI. This correlation was not found in the H group.

CONCLUSIONS

The presence of blunt splenic and/or hepatic injuries predicts a higher incidence of HVI, especially if combined. While in blunt splenic injury patients there is a clear correlation between the incidence of HVI and the severity of splenic injury, such a correlation does not exist in patients with blunt hepatic injury.

Value of repeat head computed tomography after traumatic brain injury: systematic review and meta-analysis

Diagnosis and management of traumatic brain injury (TBI) is crucial to improve patient outcomes. While initial head computed tomography (CT) scan is the optimum tool for quick and accurate detection of intracranial hemorrhage, the guidelines on use of repeat CT differ among institutions. Three systematic reviews have been conducted on a similar topic; none have performed a comprehensive meta-analysis of all studies. Search of Medline, the Cochrane Library database, and Clinicaltrials.gov , and a hand search of conference abstracts and references for all completed studies reporting data on change in management following repeat CT was conducted. Two authors reviewed all studies and extracted data using a standardized form. A proportional meta-analysis was conducted using the random-effects model for outcomes related to any change in management following repeat CT. Any change in management included intracranial intervention, change in intracranial pressure monitoring, and/or administration of drug therapy. Search results yielded 6982 references. In all, 41 studies enrolling 10,501 patients were included. Change in management following repeat CT was reported in 13 prospective and 28 retrospective studies and yielded a pooled proportion of 11.4% (95% confidence interval [CI] 5.9-18.4) and 9.6% (95% CI 6.5-13.2), respectively. In a subgroup analysis of mild TBI patients (Glasgow Coma Scale score 13 to 15), five prospective and nine retrospective studies reported on change in management following repeat CT with the pooled proportion across prospective studies at 2.3% (95% CI 0.3-6.3) and across retrospective studies at 3.9% (95% CI 2.3-5.7), respectively. The evidence suggests that repeat CT in patients with TBI results in a change in management for only a minority of patients. Better designed studies are needed to address the issue of the value of repeat CT in the management of TBI.

Solid Organ Injury Grading in Trauma: Accuracy of Grading by Surgical Residents

The American Association for the Surgery of Trauma developed an Organ Injury Scale for management of patients with splenic, kidney, or liver injuries. Despite widespread use of the guidelines, the person who determines the injury grade varies among institutions. Our purpose was to determine the accuracy and interobserver agreement between surgical residents and a radiologist in grading solid organ injuries. We retrospectively reviewed patients with solid organ injuries from January 2009 to May 2010 and compared the grade of solid organ injuries by a single resident with grades by a single blinded radiologist using a paired t test, analysis of variance, or Kruskal-Wallis. Computed tomography scans of 58 patients with splenic injuries, 43 with liver injuries, and 16 with kidney injuries were reviewed. Average grades for splenic injuries were 2.5 and 2.4 (radiologist/resident); liver injuries, 2.6 and 2.1; and kidney injuries, 2.7 and 2.8. There were no significant differences in grading by the radiologist and resident for splenic and kidney injuries; however, equal values were only achieved in 43 and 38 per cent, respectively. There was a significant difference (average rating difference 0.54, P = 0.0002) in grading between the radiologist and resident for liver injuries with only 35 per cent having equal values and the radiologist grading on average 0.5 points higher than the resident. No demographic, injury, or outcome variables were significantly associated with interobserver variability ( P > 0.05). Despite a significant difference for liver injury grading, interobserver agreement between residents and a single radiologist was low. Clinical implications and the impact on outcomes related to interobserver variations require further study.

Efficacy and safety of non-operative management of blunt liver trauma

BACKGROUND

The liver is the most frequently affected organ during blunt abdominal trauma. Blunt liver trauma management has changed in the last two decades with the introduction of the computed tomography (CT) scan and non-operative management of stable patients.

OBJECTIVE

To determine the incidence, efficacy, and failure rate of blunt liver trauma non-operative management as well as the risk factors associated with such treatment in a level 1 trauma center in Colombia.

METHODS

We conducted an observational descriptive study on patients with blunt liver trauma who were admitted to a level 1 trauma center in Colombia. The evaluated outcomes were indications of immediate surgical treatment and the success of non-operative management.

RESULTS

A total of 73 patients were studied. The most common mechanism of trauma continues to be motor vehicle crashes. In 14 patients (19.2%), immediate surgical intervention was necessary and we observed a Revised Trauma Score (RTS) above 7.8 and intra-abdominal injuries as risk factors. Three patients died (21.4%). Fifty-nine patients (80.8%) received non-operative management, which failed in seven patients (11.2%). Age, severity of liver injury, and intra-abdominal injuries were not risk factors in the failure of non-operative management. Mortality in the non-operative management group was 1.7%.

CONCLUSION

Non-operative management is the treatment of choice for polytraumatized patients with blunt liver trauma who are hemodynamically stable. Non-operative management is an effective and safe treatment strategy. However, patients with an RTS score under 7.8 and other intra-abdominal non-liver injuries are at increased risk for an immediate surgical intervention.

Management of liver trauma

BACKGROUND

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.

METHODS

A literature review was undertaken to determine the current consensus on investigation and management strategies.

RESULTS

The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing.

CONCLUSIONS

Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

Management of liver trauma

BACKGROUND

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.

METHODS

A literature review was undertaken to determine the current consensus on investigation and management strategies.

RESULTS

The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing.

CONCLUSIONS

Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

[Surgical treatment of liver trauma: resection--when and how?]

Liver resection as an emergency procedure in patients with liver injury due to abdominal trauma has become a rare procedure. In most cases liver trauma can be managed conservatively. Currently surgery is only indicated in hemodynamically instable patients and in cases of progredient haematoma where the main aim is control of bleeding. Anatomical liver resection should be avoided and may only be performed in cases of total vascular avulsion. Debridement of devascularized tissue can also be carried out in terms of an atypical liver resection. This article elucidates the current indications for liver resection after traumatic liver injury.

[Hepatic trauma. Interventional and conservative therapy]

The non-operative management of hemodynamically stable patients with liver trauma has become the standard of care. Non-operative treatment has a success rate of >80%. In the majority of cases of hemodynamic instability or high grade liver injuries, however, a surgical approach is necessary. As for conservative treatment of liver trauma the surveillance of patients in the ICU is of utmost importance. Repeat CT scans are only necessary in patients with high grade injuries or in case of complications. Interventional procedures, such as the endoscopic retrograde cholangiopancreatography in cases of biliary complications or angiography for vascular complications, are increasingly being used in order to avoid surgery. The success rates of non-operative strategies have been improving continuously over the last decades.

Non-operative management of blunt liver trauma: feasible and safe also in centres with a low trauma incidence

BACKGROUND AND AIMS

Non-operative management (NOM) of blunt liver trauma is currently, if possible, the preferred treatment of choice. The present study evaluates the experience of blunt liver injury in adults in a Swedish university hospital.

MATERIAL AND METHODS

Forty-six patients with blunt liver trauma were treated from January 1994 through to December 2004. Patient charts were reviewed retrospectively to examine injury severity score (ISS), liver injury grade, diagnostics, treatment and outcome.

RESULTS

Thirty-five patients (76%) were initially treated non-operatively and 11 (24%) patients had immediate surgery. In four (11%) patients, NOM failed and the patients required surgery 8-72 h after admission. Patients failing non-operative care had a significantly lower systolic blood pressure on admission as compared with patients with successful NOM (P = 0.001). Patients immediately operated upon had higher ISS (P < 0.001) and were haemodynamically unstable to a greater extent (P < 0.001) as compared with patients initially considered for NOM. Operated patients had increased transfusion requirements (P < 0.001), longer total hospital stay (P = 0.011) and stay in the intensive care unit (ICU) unit (P < 0.001) as compared with NOM. One immediately operated and one failed NOM died (total mortality 4%). Seventeen patients in the NOM group were successfully treated without surgery despite the presence of at least one described risk factor.

CONCLUSIONS

Most patients with blunt liver trauma can be treated without surgery, and non-operative management may be performed even in the presence of established risk factors.

Nonoperative treatment of multiple intra-abdominal solid organ injury after blunt abdominal trauma

BACKGROUND

A number of large series' have attempted to examine the management of blunt solid organ injuries; however, only a few studies regarding multiple injuries exist. The aim of this study is to analyze whether multiple solid organ injury affects nonoperative management (NOM) and to look for predictive factors of NOM.

METHODS

All patients admitted with a diagnosis of blunt solid organ injury between January 1, 1999 and January 1, 2005 were included in this prospective observational study. Of the 468 patients who had solid organ injury, 46 patients met the inclusion criteria of multiple solid organ injuries. Presentation, mechanism of injury, injury grade, Abbreviated Injury Scale score, management, and outcomes were analyzed. Independent predictive factors of NOM failure were identified. Patients managed nonoperatively were compared with patients who had had emergent laparotomy and patients for whom NOM failed.

RESULTS

Fifteen patients (33%) underwent emergency laparotomy because of hypovolemic shock that was unresponsive to aggressive resuscitation, and 31 (66%) were selected for NOM. Among the 31 patients, NOM was successful in 23 (75%). No specific organ injury combination was found to affect NOM failure. Admission lactate level [odds ratio(OR), 1.44; 95% confidence interval (CI), 1.05-1.98; p = 0.025], a drop in the hematocrit greater than 20% in the first hour after admission (OR, 1.13; 95% confidence interval CI, 1.04-1.24; p = 0.007), and solid viscus score (OR, 1.67; 95% CI, 1.03-2.80; p = 0.04) were significant independent risk factors in those patients for whom NOM failed. In logistic regression analysis, hypotension at admission (OR, 0.96; 95% CI, 0.92-0.99; p = 0.014) and transfusion in the first 6 hours after admission (OR, 1.03; 95% CI, 1.00-1.05; p = 0.015) were found to significantly affect the success rate of nonoperative management.

CONCLUSION

Lactate levels at admission, solid viscus score, necessity of transfusion, crystalloid resuscitation, and a drop in the hematocrit in the first hour after admission are useful parameters for judging the failure of NOM. Although there is a higher failure rate of NOM in multiple solid organ injury, NOM can still be considered in these cases with extra caution.

A clinically relevant liver injury grading system by CT, preliminary report

Current computed tomography (CT) grading scales are anatomic and do not reliably identify those liver injuries requiring intervention (surgery or angioembolization). We propose a clinically relevant CT grading system that could predict need for intervention. CT scans of 11 patients with hepatic injury were reviewed to establish criteria that correspond with intervention. Five features were identified that were associated with intervention: laceration in greater than or equal to three segments, laceration extending into the hilum, hemoperitoneum, active extravasation, and sentinel clot. Radiologists then evaluated the predictability of these criteria by analyzing 24 CT scans. Inter-observer agreement of the American Association for the Surgery of Trauma (AAST) grading system was compared to this new system. In the analysis of 24 CT scans, active extravasation and sentinel clot demonstrated the highest specificity for intervention. This new grading system had superior inter-observer agreement (k=0.56) as compared to the AAST grading system (k=0.47). Active extravasation and the presence of sentinel clot should form the foundation of a new liver grading system.

Ultrasonography for Interval Assessment in the Nonoperative Management of Hepatic Trauma

Abdominal ultrasonography (US) is gaining widespread acceptance as a valuable diagnostic tool in the initial evaluation of trauma victims. We investigated the utility of US as a follow-up radiologic study in nonoperative hepatic trauma. Patients with liver injury designated for non-operative management were prospectively studied over a 2-year period at our primary adult resource center for trauma. Computed tomography (CT) and radiologist-performed US were obtained at admission and at 1 week. The ability of US to detect lesions, fluid, and complications was evaluated by comparing with the corresponding CT. Twenty-five hepatic trauma patients in the study were successfully managed nonoperatively and had both initial and follow-up US and CT scans: 1 (4%) grade I, 5 (20%) grade II, 7 (28%) grade III, 7 (28%) grade IV, and 5 (20%) grade V. Four complications developed [biloma (3) and biliary fistula (1)] in 3 patients with grade IV injury and 1 with a grade II injury. Interval US appropriately detected a complication or confirmed the absence of complication in all (13/13, 100%) patients with low-grade (I–III) injury and only missed a small biloma in one patient with a grade IV injury. Interval US and CT agreement was 92 per cent for change in hemoperitoneum or parenchymal lesion. Ultrasonography is a convenient imaging modality in the evaluation of hepatic trauma. US is sufficient to detect or exclude complications in low-grade injuries. In high-grade injuries, US may be an adjunct to CT for definitive interval assessment.

Selective non-operative management of liver gunshot injuries

BACKGROUND

In contrast to non-surgical treatment of blunt liver trauma, non-operative management (NOM) of liver gunshot injuries (LGSIs) is not widely accepted. This prospective study evaluated an experience of NOM of gunshot wounds to the liver.

METHODS

All patients presenting with LGSIs who were haemodynamically stable with no evidence of peritonism underwent a protocol of NOM.

RESULTS

Thirty-three patients (mean age 25 (range 13-50) years) were enrolled over a 36-month period. Fourteen had grade III injuries according to the American Association for the Surgery of Trauma (AAST) classification, whereas 11 and eight patients sustained major (AAST IV/V) and minor (AAST I/II) injuries respectively. NOM was successful in 31 of 33 patients. Two patients required delayed laparotomy for indications unrelated to the hepatic trauma. One patient died from necrotizing fasciitis, which appeared unrelated to the liver injury.

CONCLUSION

This study demonstrated that, regardless of the grade of liver trauma, NOM is safe and effective in appropriately selected patients with LGSI treated in centres with suitable facilities.

Non-operative management of blunt hepatic injury in multiply injured adult patients

BACKGROUND

Non-operative management of blunt liver trauma has now evolved into a common practice especially since abdominal CT has enabled a more precise evaluation of these patients.

CLINICAL MATERIAL

Sixty-three patients, haemodynamically stable, were eligible for the study and enrolled into the protocol of non-operative management of blunt hepatic injury. Fifty-two (82.5%) patients were successfully managed non-operatively (non-operative group). The remaining 11 (17.5%) patients failed the non-operative management and underwent exploratory laparotomy (laparotomy group).

RESULTS

Patients managed non-operatively tended to be younger than patients managed operatively (p < 0.05). The mean values of ISS were 16.2 +/- 6.1, 26.1 +/- 8.5, p < 0.001, in the non-operative and laparotomy groups, respectively. Stay in the ICU was significantly decreased in the non-operative patients (p < 0.001). Patients who had a laparotomy significantly increased requirement for blood transfusion (p < 0.001). Six (9.5%) patients managed non-operatively developed complications; perihepatic collections were observed in two patients, an urinoma in one patient and chest infection in three patients. Perihepatic collections and urinoma were successfully drained percutaneously by CT guidance and no further treatment was required. The mortality rate of the entire series of patients was 4.8% (three patients); one death could be related to hepatic injury itself and the other two deaths were attributed to non-hepatic causes. No deaths occurred in the non-operative group.

CONCLUSION

Non-operative management should be the initial approach to all patients with blunt liver injuries if haemodynamic stability can be ensured. When continued bleeding can be safely ruled out, a period of close monitoring in the ICU is warranted.

Radio-Frequency Tissue Ablation in Liver Trauma: An Experimental Study

The liver is the most frequently injured intra-abdominal organ. Radio-frequency tissue ablation (RFA) with cooled tip electrodes is here experimentally used for the treatment of liver trauma. A grade III and a grade III to IV trauma each were produced in the livers of 10 domestic pigs. RFA was applied around the sites of injury until hemostasis was achieved. The animals were sacrificed at 0, 3, 7, 14, and 21 days and examined. The livers were subjected to histologic and radiologic examination. Two similar traumas were created in the livers of two more animals and were left surgically untreated as a control group. The two untreated animals died immediately postoperatively, proving the severity of the injuries. Hemostasis was achieved in all treated animals. Mortality and morbidity were zero. No blood, pus, bile, or other fluid was found in the abdomen at sacrifice. A three-zone pattern of lesion was recognized around the electrode placement at histology. RFA is an efficient and safe hemostatic method for grade HI and grade III to IV hepatic trauma. Further studies are required for its use in humans.

Management of blunt liver trauma in a tertiary referral centre

BACKGROUND

In recent years, several reports from North America have highlighted the success of conservative treatment in patients with blunt liver trauma. The aim of this study was to identify trends in the management of blunt liver trauma in a UK tertiary referral centre dealing with both adults and children over a 10-year period.

METHODS

A retrospective case note review was performed on 71 consecutive patients (58 male patients) of median age 25 years admitted to the hepatobiliary unit over the 10-year period from 1992 to 2001 with blunt liver trauma. Data relating to referring source, severity of liver injury, initial and subsequent management and outcome were collected using a standard pro forma.

RESULTS

Sixty-two of the 71 patients were referred from other surgical units. Of these, 14 had undergone laparotomy at the referring hospital, with ten having perihepatic packing; the other 48 were managed conservatively. Of the 62 patients transferred to the authors' unit, 12 required surgical intervention for the liver injury. The mean number of patients with blunt liver trauma increased between the first second 5-year periods, from 3.2 to 11.0 patients per year. There was a significant reduction in the proportion of patients requiring surgery for the liver injury in both the authors' unit (from seven of 16 patients in 1992-1996 to seven of 55 in 1997-2001; P = 0.017, chi(2) test) and referring hospitals (from six of 12 to eight of 50; P = 0.014, chi(2) test). The reduction in the mortality rate, from two (12.5 per cent) of 16 in the first period to four (7.3 per cent) of 55 in the second, was not significant (P = 0.880, chi(2) test).

CONCLUSION

This study demonstrated a marked increase in the number of patients with blunt liver trauma referred to a regional hepatobiliary centre in recent years. It has confirmed that the majority of such patients can be treated successfully without surgery.

Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management

BACKGROUND

During the past decade, nonoperative management (NOM) of hemodynamically stable blunt trauma patients with liver (L) or spleen (S) injury has become the standard of care. This trend has led to concerns over missed associated intra-abdominal injuries with concomitant morbidity. To better understand the incidence and risk of missed injury, patterns of associated intra-abdominal injury were examined in all patients with blunt liver and spleen injuries, and missed injuries were reviewed in patients undergoing NOM.

METHODS

Patients were identified from the registry of a Level I trauma center over a 3-year period. Records were reviewed for demographics, injury characteristics, and associated injuries. Indications for primary operation were hemodynamic instability or significant associated intra-abdominal injury. Missed injury was defined as unsuspected intra-abdominal injury requiring laparotomy in patients otherwise undergoing NOM for liver or spleen injury.

RESULTS

Eight hundred three patients (338 in the L group, 345 in the S group, and 120 in the L + S group) were treated between December 1995 and December 1998. Rates of planned NOM were 89% (L group), 78% (S group), and 75% (L + S group). On examination of all patients with blunt liver or spleen injuries, the incidence of associated intra-abdominal injury was higher in the L group at 5% as compared with 1.7% in the S group (p = 0.02). The associated intra-abdominal injury rate in the L + S group was similar to the L group at 4.2%. Although in the L and S groups, rates of diaphragm (0.5% vs. 1%, p = 0.45) and intra-abdominal bladder injury (0.3% vs. 0.3%, p = 0.99) were similar, bowel injury was more common in the L group (11% vs. 0%, p = 0.0004), as was pancreatic injury (7% vs. 0%, p = 0.007). In NOM patients, missed injury occurred in seven (2.3%) L patients versus zero S patients (p = 0.012). No L + S patient had unexpected injuries. Missed injuries included two small bowel, three diaphragm, one pancreas, and one mesenteric tear.

CONCLUSION

Damage to the pancreas and bowel is significantly associated with liver as opposed to spleen injuries. Actual missed intra-abdominal injury with NOM mirrors this pattern, occurring more often with liver than with spleen injuries. However, the overall incidence of missed injury is quite low, and should not influence decisions concerning eligibility for NOM. We speculate that the greater amount and/or different vector of energy transfer needed to injure the liver versus the spleen accounts for the greater rate of associated injuries to the pancreas/small bowel.

Management of liver trauma with implications for the rural surgeon

BACKGROUND

The majority of patients with liver trauma can be managed conservatively. However, the unstable patient requires emergency laparotomy to control bleeding. Controversy exists regarding the primary surgical management of these injuries. This is of particular relevance for the isolated rural general surgeon.

METHODS

The literature was reviewed by searching MEDLINE databases from 1966 to the present time. The majority of the evidence presented is level 3, with interpretations and recommendations based on the experience of the senior authors.

RESULTS

In the majority of patients, conservative management remains the mainstay of treatment. However, haemodynamic -instability requires urgent laparotomy. Perihepatic packing should be used to arrest bleeding. Primary anatomical resection is rarely indicated, especially in non-specialist centres.

CONCLUSION

In the remote rural setting, severe liver trauma remains a daunting condition for the general surgeon to manage. Primary surgical treatment should be perihepatic packing, stabilization and urgent transfer; there is no place for primary anatomical resection outside specialist units.

A multidisciplinary approach in the management of hepatic injuries

We reviewed 87 patients with hepatic injuries who were admitted to King Chulalongkorn Memorial Hospital, Bangkok, Thailand, from January 1995 to December 1999; 76% of them had sustained blunt trauma and 24% penetrating trauma. Their injury severity scores (ISS) ranged from 4 to 57 (mean 20.94+/-12.8); 50% of them were in shock on arrival; 8.1, 28.7, 25.3, 19.5, and 18.4% suffered from hepatic injuries graded I, II, III, IV, and V, respectively. Seventeen patients (19.5%) were successfully managed non-operatively; three of them underwent hepatic angiography, which in two revealed leakage of contrast medium from the right hepatic artery; both were successfully treated by embolization. One patient had bile leakage and collection, which was successfully treated by ultrasound-guided percutaneous drainage. Seventy patients (80.5%) underwent exploratory laparotomy; nine of them died in the operating room. Of the remaining 61 who left the operating room alive, 21 had perihepatic packing, which was frequently used in those with injuries to segments V, VI, VII, and VIII (Couinaud's nomenclature). Eight patients who had packing and one who had not died in the postoperative period. Two patients who had packing underwent subsequent hepatic angiography with embolization before successful pack removal. The overall mortality was 20.7%. The mortality in complex hepatic injuries (grades IV and V) was 13 out of 33 (39.4%). We believe that non-operative management should be considered in haemodynamically stable patients. Angiography with embolization is invaluable in improving outcome in both non-operative and operative patients. Perihepatic packing is life-saving in complex hepatic injuries that cannot be effectively treated by simple surgical procedures. Finally, ultrasound- or CT-guided percutaneous drainage of bile leakage or collections spared a number of patients from open and complicated surgery.

Evolution in the treatment of complex blunt liver injuries

Over the last decade, major changes in the treatment of patients with blunt liver injuries have occurred, specifically with the nonoperative treatment of more complex injuries. These major changes can be summarized as follows: 1. Patients with blunt liver injuries are screened expeditiously by surgeon-performed ultrasonography. Depending on the initial findings and response to resuscitation, further decisions are made regarding the further evaluation. 2. Computed tomographic scanning is the mainstay of diagnosis for hepatic injuries after blunt trauma; the initial CT findings will help the trauma surgeon to determine the nonoperative treatment. 3. Liver injuries of grades I through III can be observed safely in a monitored unit and not necessarily in an ICU setting. Patients with injuries of grades IV and V are best initially observed in an ICU. 4. More than two thirds of patients with injuries of grades IV and V can be treated nonoperatively. However, 50% of these patients will require some type of interventional treatment, but not necessarily a laparotomy. 5. Initial findings on the CT scan can help to identify those patients who will need some type of interventional treatment and to identify associated injuries. 6. Elderly patients or patients with associated medical comorbidities can also be treated nonoperatively if strict guidelines are followed. 7. Complications in patients with complex blunt liver injuries are not uncommon. However, most of the complications can be safely treated by less invasive procedures.

Y. A Successful Multitnodality Strategy for Management of Liver Injuries

The treatment of liver injuries involves many strategies ranging from observation to operative intervention and includes numerous options such as angiography, packing, and damage-control procedures. In July 1994 we instituted a protocol for the management of traumatic liver injuries. The main objective of this study was to evaluate the management of liver injuries occurring since the institution of the protocol. Two hundred three consecutive adult patients with liver injuries were evaluated at our Level I trauma center between July 1994 and May 1999. Eighty-eight per cent of the injuries were blunt with a mean Injury Severity Score (ISS) of 24.3 ± 0.8 and a survival probability (Ps) of 90.0 ± 1.5 per cent. The overall mortality was 6.4 per cent. A comparison between patients with minor liver injuries and patients with more severe injuries [Abbreviated Injury Score (AIS) <3 vs >3] demonstrated no difference in mortality between the two groups despite a Ps of 93.8 ± 1.3 per cent in patients with an AIS <3 versus 84.1 ± 3.3 per cent in patients with an AIS >3. The most common complication in our patient population was posthemorrhagic anemia, which was seen in 10.8 per cent of cases. Severity of injury did not result in a significant difference in the complication rate. Patients who underwent laparotomy had a statistically higher ISS, a lower Ps, and a mortality rate of 11.5 per cent compared with 3.7 per cent ( P = 0.03) in patients managed nonoperatively. However, a comparison of patients undergoing laparotomy with those who did not and who had equivalent ISS demonstrated no difference in mortality. Our results demonstrated that a preplanned management strategy was a successful way in which to treat patients with traumatic liver injuries. Although nonoperative management of liver injuries has been common practice a management plan that involves a multimodal surgical strategy is essential.

Nonsurgical Management of Solid Abdominal Organ Injury in Patients over 55 Years of Age

Age greater than 55 is often stated to be a contraindication to nonoperative management of intraperitoneal solid organ injury, based upon failures in early experiences of nonoperative therapy. Refinements in the criteria for nonoperative management of hepatic and splenic injuries have yielded improved success rates compared with those in initial reports, raising questions as to the validity of an age-related contraindication. A retrospective chart review of patients more than 55 years of age sustaining blunt hepatic and/or splenic injury at two urban Level I trauma centers was performed. Patients were stratified into three groups in which selection criteria could not consistently be determined: those managed nonoperatively, those managed operatively, and those who died within 24 hours. The purpose of this review is to identify whether age is a determinant for nonoperative management of abdominal solid organ injury. Eighty-eight patients were identified (mean age, 68.7 ± 9.8), 17 of whom died in the emergency department or after operative intervention. Of the remaining 71 patients, 37 were originally managed nonoperatively (mean age 69.9 ± 9.1, mean Injury Severity Score 19.9), 24 sustained hepatic injuries (grades I–IV), 12 sustained splenic injuries (grades I–III), and one patient sustained both organ injuries. Three patients with multisystem trauma died from complications unrelated to their solid organ injury (one brain death, one septic death, and one respiratory arrest). A single patient, with a grade I liver injury, required delayed exploration (for a persistent, unexplained metabolic acidosis) and underwent a nontherapeutic celiotomy. All but one of the 37 patients were successfully treated nonoperatively, for a 97 per cent success rate. We conclude that hemodynamically stable patients more than 55 years of age sustaining intra-abdominal injury can be observed safely. Age alone should no longer be considered an exclusion criterion for nonoperative management of intraabdominal solid organ injury.

Blunt hepatic injury: a paradigm shift from operative to nonoperative management in the 1990s

OBJECTIVE

To analyze the outcome of hemodynamically stable patients with blunt hepatic injury managed nonoperatively, and to examine the impact of this approach on the outcome of all patients with blunt hepatic injury.

SUMMARY BACKGROUND DATA

Until recently, operative management has been the standard for liver injury. A prospective trial from the authors' institution had shown that nonoperative management could safely be applied to hemodynamically stable patients with blunt hepatic injury. The present study reviewed the authors' institutional experience with blunt hepatic trauma since that trial and compared the results with prior institutional experience.

METHODS

Six hundred sixty-one patients with blunt hepatic trauma during the 5-year period ending December 1998 were reviewed (NONOP2). The outcomes were compared with two previous studies from this institution: operative 1985 to 1990 (OP) and nonoperative 1993 to 1994 (NONOP1).

RESULTS

All 168 OP patients were managed operatively. Twenty-four (18%) of 136 NONOP1 patients and 101 (15%) of the 661 NONOP2 patients required immediate exploration for hemodynamic instability. Forty-two (7%) patients failed nonoperative management; 20 were liver-related. Liver-related failures of nonoperative management were associated with higher-grade injuries and with larger amounts of hemoperitoneum on computed tomography scanning. Twenty-four-hour transfusions, abdominal infections, and hospital length of stay were all significantly lower in the NONOP1 and NONOP2 groups versus the OP cohort. The liver-related death rate was constant at 4% in the three cohorts over the three time periods.

CONCLUSIONS

Although urgent surgery continues to be the standard for hemodynamically compromised patients with blunt hepatic trauma, there has been a paradigm shift in the management of hemodynamically stable patients. Approximately 85% of all patients with blunt hepatic trauma are stable. In this group, nonoperative management significantly improves outcomes over operative management in terms of decreased abdominal infections, decreased transfusions, and decreased lengths of hospital stay.

Management of liver trauma

BACKGROUND AND METHODS

Management of blunt or penetrating injuries to the liver remains a significant challenge. This review discusses the mechanisms of liver injury, grading system for severity, available diagnostic modalities and current management options. It is based on a Medline literature search and the authors' clinical experience.

RESULTS

Unstable patients require immediate laparotomy, but selected patients who are haemo- dynamically stable may be managed without operation. The preferred operative techniques include resectional debridement, hepatotomy with direct suture ligation and perihepatic packing; anatomical resection, hepatic artery ligation and various bypass techniques have a limited, more defined role for selected injuries. Major complications include haemorrhage, sepsis and bile leak.

CONCLUSION

Enhanced resuscitation, anaesthesia and intensive care have contributed to a significant reduction in mortality rates from liver trauma. Optimum results are obtained with a specialist team that includes an experienced liver surgeon, anaesthetist, endoscopist and interventional hepatobiliary radiologist with expertise in managing postoperative complications.

Selective hepatic arterial embolization of grade IV and V blunt hepatic injuries: an extension of resuscitation in the nonoperative management of traumatic hepatic injuries

BACKGROUND

Recognizing the significant mortality and complications inherent in the operative management of blunt hepatic injuries, hepatic arterial embolization was evaluated as a bridge between operative and nonoperative interventions in patients defined as hemodynamically stable only with continuous resuscitation.

METHODS

Seven of 11 patients with grade IV or V hepatic injuries identified by computed tomography underwent hepatic arterial embolization. A prospective evaluation of hepatic embolization based on subsequent hemodynamic parameters was assessed by matched-pair analysis. A summary of this study population's demographic data and outcomes is presented, including age, Glasgow Coma Scale score, Injury Severity Score, Revised Trauma Score, computed tomography grade, intensive care unit and hospital length of stay, transfusion requirements, complications, and mortality.

RESULTS

No statistical difference was demonstrated between pre-embolization and postembolization hemodynamics and volume requirements. After embolization, however, continuous resuscitation was successfully reduced to maintenance fluids. Hepatic embolization was the definitive therapy for all seven patients who underwent embolization.

CONCLUSION

Results of this preliminary investigation suggest that hepatic arterial embolization is a viable alternative bridging the therapeutic options of operative and nonoperative intervention for a subpopulation of patients with hepatic injury.

Evolution in the management of the complex liver injury at a Level I trauma center

BACKGROUND

Management of the severe liver injury evolved from mandatory surgical repair to a more selective approach. This paper reviews the changes in management of the severe liver injury at a Level I trauma center.

METHODS

We reviewed the records of patients with severe liver injury admitted to a Level I trauma center between January 1984 and December 1995. The patients were divided into two groups, G1 and G2, based on their date of admission before or after January 1991. The two groups were compared for blood products use, management of the liver injury, and outcome.

RESULTS

One hundred six patients were compared for age, sex, Acute Physiology and Chronic Health Evaluation II score, Injury Severity Score, abdominal Abbreviated Injury Scale score, and the presence of concomitant injuries. There was no difference in management or outcome of the victims of penetrating injury between G1 and G2 (n = 48). The blunt injury patients in G1 (n = 22) had more liver surgery (p = 0.006), blood transfusion (p = 0.040), intra-abdominal sepsis (6 vs. 0), and higher mortality (p = 0.041) than those in G2 (n = 36).

CONCLUSION

Isolated severe blunt liver injury may be managed nonoperatively with better survival and less blood products use.

Non-operative management of blunt hepatic trauma

BACKGROUND

Non-operative management is currently considered the treatment of choice in over 50 per cent of adult patients with blunt liver injury. This report reviews the criteria for non-operative management and its potential downside.

METHODS

English language publications were reviewed.

RESULTS

Most reports from major trauma centres in the USA support the non-operative treatment of patients with blunt liver injury if well established criteria are met. Using such criteria, non-operative treatment is successful in 50-80 per cent of cases. Adjunctive radiological techniques may be helpful in managing some complications of non-operative treatment.

CONCLUSION

Non-operative management is safe in haemodynamically stable patients with blunt liver injury. Computed tomography (CT) of the abdomen is extremely useful to document the extent of the damage and the presence of associated injuries, but it is not possible, based on CT alone, to predict failure; careful physiological monitoring in selected patients is indicated to avoid catastrophic complications.

CT scan evaluation of blunt hepatic trauma

Information provided by CT scan allows for determination of the extent of liver injury and identification of other nonhepatic abdominal injuries. This information, coupled with clinical assessment, can be used to optimize management. Contrast-enhanced CT scan can monitor progression or resolution of hepatic injuries, detect complications, and guide percutaneous treatment of some complications. This article discusses CT scanning technique; classification, sites, and mechanisms of liver injury; CT scan appearance of liver injury; and complications of hepatic trauma.

Trends in the management of hepatic injury

BACKGROUND

Options for management of blunt hepatic injury have broadened to include both operative management (OM) and nonoperative management (NOM). We identify trends in evaluation and management of blunt hepatic injury at a level 1 trauma center.

METHODS

Charts of 106 patients with blunt hepatic injuries from July 1, 1991 to June 30, 1995 were reviewed for method of abdominal evaluation (computed tomography versus DPL), injury severity score, liver injury grade, method of management, length of stay (LOS), transfusion requirements, complications, and outcome.

RESULTS

Nonoperative management steadily increased to 86%. Successful NOM occurred in 96% (48 of 50) and was not related to injury grade. Transfusion requirements were significantly greater in the group with OM versus those with NOM (11.3 versus 2.7). Patients with NOM also had significantly shorter intensive care unit stay and total LOS.

CONCLUSIONS

The majority of patients with blunt liver injury can be successfully managed nonoperatively regardless of injury grade. Nonoperative management may allow decreased resource utilization because of shorter hospital stays and decreased transfusion requirements.

Nonoperative Management of Solid Abdominal Visceral Injury: Part II. Liver and Kidney

Only in recent years has it been recognized that the injured liver is not only capable of spontaneous hemostasis, but also that it can heal itself remarkably well without surgical intervention. Currently, the approach to stable patients with blunt liver trauma should be nonoperative, regardless of the age of the patient, the degree of liver injury, or the amount of blood in the peritoneal cavity. However, success with this method of management is highly dependent on selection of patients whose liver has ceased bleeding and who do not have an associated intra-abdominal injury in need of operative repair. Similarly, a nonoperative approach is appropriate in patients with blunt renal trauma if the injury is properly staged and if major urinary extravasation and vascular injuries are not present.

Clinical analysis of the utility of repeat computed tomographic scan before discharge in blunt hepatic injury

OBJECTIVES

Nonoperative management of hemodynamically stable blunt hepatic injury has emerged as an acceptable and safe treatment. Surveillance of this population's injuries is costly. As a prelude to establishing practice guidelines, the utility of repeat computed tomographic (CT) scans was investigated.

METHODS

A retrospective study was conducted on 243 hepatic injuries. The CT scans of 95 patients managed nonoperatively who did not have ongoing transfusion requirements were reviewed and graded according to the American Association for the Surgery of Trauma (AAST) hepatic injury scale. Patients were grouped according to injury grade, assigned to two subgroups (patients with one CT scan versus more than one CT scan) and compared with respect to several physiologic and clinical variables.

RESULTS

Statistical analysis revealed no significant difference between subgroups with the same grade of injury. No significant difference was demonstrated between subgroups' length of stay.

CONCLUSIONS

No patients failed nonoperative treatment or succumbed to their injuries. Findings on repeat CT scan have not altered the decision to discharge the clinically stable patient having suffered a grade III or lower liver injury.

Complex hepatic injuries

The most significant contribution to the management of hepatic injuries over the past 5 years has been the nonoperative management of blunt injuries in the adult patient. Recent data suggest that as many as 80% of all blunt hepatic injuries may be treated in this fashion, with a success rate exceeding 95%. The fear of missing hollow viscus injuries, as well as the risk of sudden hemorrhage in the observational period, leading to an increase in hepatic-related deaths, seems exaggerated. The intraoperative management of complex hepatic injuries revolves around strict adherence to resuscitation prior to addressing the lesion itself. At times, "damage control" with termination of surgery and "packing" the patient with planned re-exploration are critical, as these maneuvers are often lifesaving. The Pringle maneuver and intrahepatic hemostasis for grades III to IV injuries have resulted in a mortality rate under 10%. Juxtahepatic venous injuries continue to carry an inordinately high mortality rate. Intracaval shunts, when used, should be inserted early in the course of the operation before excess transfusions are given and acidosis and hypothermia develop.

A multivariate analysis of the prognostic factors in severe liver trauma

To examine the significance of physiologic and biochemical variables in liver trauma quantitatively, and to establish the early predictors of mortality according to the causes of death, 36 consecutive patients who underwent surgery for liver trauma between 1984 and 1993 were retrospectively studied. A univariate analysis revealed that shock, preoperative systolic blood pressure (SBP), preoperative alanine aminotransferase (ALT), the number of associated organ injuries, the Glasgow Coma Score (GCS), blood replacement requirements, and postoperative blood urea nitrogen (BUN) were significant prognostic factors of survival after liver trauma. However, a multivariate analysis indicated that GCS, postoperative BUN, the number of associated organ injuries, preoperative ALT, and SBP were independent prognostic factors. Because the causes of death after liver trauma can be divided into early hemorrhage and late sepsis, a multiple regression analysis of preoperative and postoperative variables was performed for each cause. The prognostic factors for hemorrhagic death were preoperative ALT, base excess, and the platelet count, whereas those for death due to sepsis were preoperative SBP and the presence of gastrointestinal injuries. These results suggest the value of measuring the preoperative serum level of ALT as a new independent prognostic factor for predicting overall and hemorrhagic death following severe liver trauma.