Blunt hepatic trauma: comparison between surgical and nonoperative treatment

Long-Term Follow-Up After Non-operative Management of Blunt Splenic and Liver Injuries: A Questionnaire-Based Survey

BACKGROUND

Non-operative management (NOM) of blunt splenic or liver injuries (solid organ injury, SOI) has become the standard of care in hemodynamically stable patients. However, the incidence of long-term symptoms in these patients is currently not known. The aim of this study was to assess long-term symptoms in patients undergoing successful NOM (sNOM) for SOI.

METHODS

Long-term posttraumatic outcomes including chronic abdominal pain, irregular bowel movements, and recurrent infections were assessed using a specifically designed questionnaire and analyzed by univariable analysis.

RESULTS

Eighty out of 138 (58%) patients with SOI undergoing sNOM) responded to the questionnaire. Median (IQR) follow-up time was 48.8 (28) months. Twenty-seven (34%) patients complained of at least one of the following symptoms: 17 (53%) chronic abdominal pain, 13 (41%) irregular bowel movements, and 8 (25%) recurrent infections. One female patient reported secondary infertility. No significant association between the above-mentioned symptoms and the Injury Severity Score, amount of hemoperitoneum, or high-grade SOI was found. Patients with chronic pain were significantly younger than asymptomatic patients (32.1 ± 14.5 vs. 48.3 ± 19.4 years, p = 0.002). Irregular bowel movements were significantly more frequent in patients with severe pelvic fractures (15.4 vs. 0.0%, p = 0.025). A trend toward a higher frequency of recurrent infections was found in patients with splenic injuries (15.9 vs. 2.8%, p = 0.067).

CONCLUSION

A third of patients with blunt SOI undergoing sNOM reported long-term abdominal symptoms. Younger age was associated with chronic abdominal symptoms. More studies are warranted to investigate long-term outcomes immunologic sequelae in patients after sNOM for SOI.

Nonoperative management of blunt liver injury in hemodynamically stable versus unstable patients: a retrospective study

PURPOSE

The success rate of nonoperative management (NOM) of traumatic liver injury is approximately 90%. Although NOM has become the standard treatment when patients' vital signs are stable, open surgical hemostasis is often selected when these signs are unstable. At our hospital, we extensively use NOM along with transcatheter arterial embolization (TAE) to treat patients with severe abdominal trauma, as per our original protocol. We also apply NOM for severe liver injury with unstable hemodynamics. This retrospective study aimed to investigate the efficacy of NOM for blunt liver injury in hemodynamically stable and unstable patients.

METHODS

We retrospectively examined 23 patients with severe liver injuries who underwent NOM after visiting our emergency outpatient department between 2007 and 2017. Patients were assigned to either the stable group with stable hemodynamics or the unstable group with unstable hemodynamics.

RESULTS

The stable group comprised 13 patients, and the unstable group comprised 10 patients. All patients underwent TAE. While all patients in the stable group were discharged alive, one patient in the unstable group died during the hospital stay. The response rate to NOM was 90%, and no patient switched from NOM to open surgery. A higher rate of complications with a significantly longer average stay in the intensive care unit was observed in the unstable group.

CONCLUSIONS

Even in the unstable group, NOM with TAE performed under careful general management facilitated avoidance of open surgery and provided high survival rates.

Epidemiological evaluation of hepatic trauma victims undergoing surgery

OBJECTIVE

to evaluate the epidemiological variables and diagnostic and therapeutic modalities related to hepatic trauma patients undergoing laparotomy in a public referral hospital in the metropolitan region of Vitória-ES.

METHODS

we conducted a retrospective study, reviewing charts of trauma patients with liver injuries, whether isolated or in association with other organs, who underwent exploratory laparotomy, from January 2011 to December 2013.

RESULTS

We studied 392 patients, 107 of these with liver injury. The male: female ratio was 6.6 : 1 and the mean age was 30.12 years. Penetrating liver trauma occurred in 78.5% of patients, mostly with firearms. Associated injuries occurred in 86% of cases and intra-abdominal injuries were more common in penetrating trauma (p <0.01). The most commonly used operative technique was hepatorrhaphy and damage control surgery was applied in 6.5% of patients. The average amounts of blood products used were 6.07 units of packed red blood cells and 3.01 units of fresh frozen plasma. The incidence of postoperative complications was 29.9%, the most frequent being infectious, including pneumonia, peritonitis and intra-abdominal abscess. The survival rate of patients suffering from blunt trauma was 60%, and penetrating trauma, 87.5% (p <0.05).

CONCLUSION

despite technological advances in diagnosis and treatment, mortality rates in liver trauma remain high, especially in patients suffering from blunt trauma in relation to penetrating one.

Comparison between operative versus non-operative management of traumatic liver injury

Backgrounds/Aims

The aim of this study was to compare operative versus non-operative management of patients with liver injury and to ascertain the differences of the clinical features.

Methods

From April 2000 to July 2012, 191 patients were admitted to Seoul St. Mary's Hospital and St. Vincent's Hospital for liver injuries. Of these, 148 patients were included in this study. All patients were diagnosed using computed tomography (CT). The liver injury was graded in accordance with the American Association for the Surgery of Trauma liver injury scoring scale. Patients were divided into two groups: those who underwent surgery and those treated with non-operative management (NOM). There was a comparison between these two groups concerning the clinical characteristics, grade of liver injury, hemodynamic stability, laboratory findings, and mortality.

Results

According to the 148 patient records evaluated, 108 (72.9%) patients were treated with NOM, and 40 (27.1%) underwent surgery. Patients treated with NOM had significantly fewer severe injuries as rated using the Revised Traumatic Injury Scale, Injury Severity Score, and Glasgow Coma Scale. Grade of liver injury and number of patients with extravasation of contrast dye on CT and hemoperitoneum were higher in the operative group than in the NOM group. There were significant differences between the two groups for: heart rate, respiratory rate, systolic blood pressure, and mean hemoglobin levels at admission and after 4 hours. The operative group experienced a significantly higher mortality than the NOM group.

Conclusions

The results of our study suggest that hemodynamic stability and the following should be considered for deciding the treatment for liver injuries: grade of liver injury, amount of blood loss, and injury scales scores.

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.

Is it possible to use transaminases for deciding on surgical or non-operative treatment for blunt liver trauma?

BACKGROUND

We aimed to research the relation of transaminase levels in blunt liver trauma (BLT) with the intensity of the trauma and the use of transaminase levels for deciding on surgical or non-operative treatment.

METHODS

In all, 44 patients with BLT diagnosed by computerized tomography (CT) were involved in this retrospective study. By testing the correlation of the transaminase levels and the grade of liver injury with receiver operator characteristics (ROC), area under the curve (AUC) was calculated; besides, the sensitivity, specificity, and cut-off values of transaminases were calculated separately for the grades. Moreover, same method was repeated for the surgically and non-operatively treated patients. Cut-off value was assessed for surgical and non-operative treatments. The efficiency of transaminases in deciding non-operative treatment was compared with that of other methods using ROC test applied on focused abdominal sonography in trauma (FAST), hemodynamic instability, blood replacement rate, aspartate aminotransferase (AST), and alanine aminotransferase (ALT).

RESULTS

It was observed that the AUC, sensitivity, and specificity increased correspondingly with the grade rise of transaminase levels in BLT. In the selection of non-operative treatment/surgery, following values have been confirmed: AUC for AST: 0.851 (sensitivity: 86%, specificity: 73%, cut-off value: 498 U/L), AUC for ALT: 0.880 (sensitivity: 86%, specificity: 81%, cut-off value: 498 U/L), AUC for replacement: 0.948 (sensitivity: 86%, specificity: 94%), AUC for hemodynamic instability: 0.902 (sensitivity: 86%, specificity: 94%), and AUC for FAST: 0.642 (sensitivity: 57%, specificity: 75%).

CONCLUSIONS

It was found that in BLT, transaminases can predict the injury rating with higher accuracy as the grade rises, and they outrival FAST in terms of determining the need for laparotomy.