Management of blunt liver trauma in 134 severely injured patients

doi:10.1016/j.injury.2014.11.019

Injury

Volume 46, Issue 5, May 2015, Pages 837-842

https://doi.org/10.1016/j.injury.2014.11.019 Get rights and content

Abstract

Background

In haemodynamic stable patients without an acute abdomen, nonoperative management (NOM) of blunt liver injuries (BLI) has become the standard of care with a reported success rate of between 80 and 100%. Concern has been expressed about the potential overuse of NOM and the fact that failed NOM is associated with higher mortality rate. The aim of this study was to evaluate factors that might indicate the need for surgical intervention, and to assess the efficacy of NOM.

Methods

A single centre prospective study between 2008 and 2013 in a level-1 Trauma Centre. One hundred thirty four patients with BLI were diagnosed on CT-scan or at laparotomy. The median ISS was 25 (range 16–34).

Results

Thirty five (26%) patients underwent an early exploratory laparotomy. The indication for surgery was haemodynamic instability in 11 (31%) patients, an acute abdomen in 16 (46%), and 8 (23%) patients had CT findings of intraabdominal injuries, other than the hepatic injury, that required surgical repair. NOM was initiated in 99 (74%) patients, 36 patients had associated intraabdominal solid organ injuries. Seven patients developed liver related complications. Five (5%) patients required a delayed laparotomy (liver related (3), splenic injury (2)). NOM failure was not related to the presence of shock on admission (p = 1000), to the grade of liver injury (p = 0.790) or associated intraabdominal injuries (p = 0.866).

Conclusion

Physiologic behaviour or CT findings dictated the need for operative intervention. NOM of BLI has a high success rate (95%). Nonoperative management of BLI should be considered in patients who respond to resuscitation, irrespective of the grade of liver trauma. Associated intraabdominal solid organ injuries do not exclude NOM.

Introduction

In haemodynamic stable patients without an acute abdomen, nonoperative management (NOM) is the standard of care for patients with blunt liver injuries (BLI). Successful NOM results in lower transfusion requirements, abdominal infection rate, hospital length of stay, and has a positive impact on survival in high grade liver injuries in haemodynamically stable patients [1], [2], [3], [4], [5], [6], [7]. Patients that are haemodynamically stable or who respond to resuscitation, can be managed nonoperatively with high success rates [8], [9]. On the other hand, shock on admission has been reported to be associated with failure of NOM [10].

NOM is based on early computed tomography (CT) evaluation of the presence and severity of abdominal organ injuries. Signs of active bleeding and associated splenic injuries are reported to be predictive for early laparotomy and failure of NOM [11]. However hepatic extravasation seen on CT scan can be managed successfully without surgical or an angiographic intervention [12], [13].

Despite the initial enthusiasm and success of managing blunt liver injuries nonoperative, failed NOM has been associated with a higher mortality rate and a concern over the potential overuse of NOM has been expressed by other authors [14].

Patient selection for NOM is critical and may improve outcomes in patients with severe BLI. This study evaluated factors that indicate the need for surgical intervention, and assessed the efficacy and safety of NOM. Ethical approval was granted from the Human Research Ethics Committee of the Faculty of Health Sciences of the University of Cape Town.

Section snippets

Methods

One hundred thirty four patients with BLI were diagnosed on CT-scan or at laparotomy and included in a prospective study between 2008 and 2013. The study was conducted in a level-1 Trauma Centre and tertiary hepatobiliary referral hospital, serving a population of 2.5 million people. Patient demographics, mechanism of injury, data at presentation including shock (systolic blood pressure [SBP] < 90 mmHg), Glasgow coma score, vital parameters, haemoglobin level, serum lactate, base deficit, and

Results

One-hundred-and-thirty-four patients who had sustained blunt liver trauma were admitted during the study period covering 52 months. Seventy one (72%) were male with a mean age of 29 years (range 23–38), with a median ISS of 22 (range 14–34). The distribution of extra abdominal injuries is presented in Table 2. The mechanism of injury was a motor-vehicle accident in 57 patients, pedestrian vehicle accident in 49, blunt assault in 27 and a fall from a height in a single patient.

Patients treated with urgent surgery

Thirty five (26%) patients required early surgical intervention, Table 3. The indication for surgery was haemodynamic instability in 11 (31%) patients, an acute abdomen in 16 (46%), and 8 (23%) patients had CT findings of intra-abdominal injuries, other than the hepatic injury, that required surgical repair. On the CT scan intravenous contrast extravasation in a grade V kidney injury with a combined grade V liver injury (n = 1) was found, enteric injuries (n = 5) and free fluid without solid organ

Patients managed with NOM

Conservative management was initiated for 99 (74%) patients, Table 4. One patient with a grade V liver injury underwent angioembolisation of a peripheral hepatic artery pseudoaneurysm as initial management. The indication for angioembolisation was a blush of contrast seen on the admission computed tomography angiography and a fall in haemoglobin serum level in haemodynamically stable patient. This patient was successful managed non-operatively. Five (5%) patients eventually required an

Deaths

The overall hospital mortality rate was 5% (Table 5a, Table 5b). The causes of death were associated head injuries in 3 patients (Gr I, Gr II & Gr III liver injuries) and multi-organ failure in 4 patients (Gr I (1), III (2), Gr IV (1) liver injuries). Two of the patients with multi-organ failure developed liver related complications (high output biliary fistula for which an ERCP and abdominal compartment syndrome). The liver related mortality for patients with blunt trauma was 2%. All patients

Discussion

Nonoperative management of severe blunt liver injury is on the increase with a similar increment in failure [14]. Currently more than 95% of blunt hepatic trauma is managed with NOM with a success rate of between 80% and 100% [1], [2], [3], [4], [5], [6], [7], [8], [9]. Many of the series include milder liver injuries, which are known to have a success rate close to 100%. In this study 76% of patients were managed nonoperatively with a success rate of 95%. Due to a selective use of CT abdomen

Conclusion

Haemodynamic instability, generalised peritonitis, worsening metabolic acidosis during resuscitation or CT-findings showing associated intra-abdominal injuries requiring surgical repair warrants early surgical exploration. NOM of blunt liver injuries in haemodynamic stable patients is feasible and safe. Liver related complications contribute to failure of NOM, but could not predict failure of NOM. Nonoperative management of BLI should be considered irrespective of the grade of liver trauma.

Conflict of interest

None.

Acknowledgements

Financial support, salary costs principal investigator, from the Prof. Michaël van Vloten Foundation, www.michaelfonds.nl, and the Scholten-Cordes Foundation, the Marti-Keuning Eckhardt Foundation, Netherlands.

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Cited by (53)

Contemporary Management of Blunt Liver Trauma: An Analysis of the Trauma Quality Improvement Program Registry (2007–2019)
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To evaluate the effectiveness of management strategies for blunt liver injuries in adult patients.
Patients aged ≥18 years with blunt liver injuries registered via the Trauma Quality Improvement Program (2007–2019) were identified. Management strategies initiated within 24 hours of hospital presentation were classified as nonoperative management (NOM), embolization, surgery, or combination therapy. Patients were stratified by injury grade. Linear models estimated each strategy’s effect on hospital length of stay (LOS), intensive care unit (ICU) LOS, ventilator dependence, and mortality.
Of 78,127 included patients, 88.7%, 8.7%, 1.8%, and 0.8% underwent NOM, surgery, embolization, and combination therapy, respectively. Among patients with low-grade (n = 62,237) and high-grade (n = 15,890) injuries and compared with all other management strategies, NOM was associated with the shortest hospital LOS and ICU LOS. Among patients with low-grade injuries and compared with surgery, embolization was associated with a shorter hospital LOS (9.7 days; P < .001; Cohen d = 0.32) and ICU LOS (5.3 days; P < .001; Cohen d = 0.36). Among patients with high-grade injuries and compared with surgery, embolization was associated with a shorter ICU LOS (6.0 days; P < .01; Cohen d = 0.24). Among patients with low- and high-grade injuries and compared with embolization, surgery was associated with higher odds of mortality (P < .001).
Among patients presenting with blunt liver injuries and compared with surgery, embolization was associated with a shorter ICU LOS and lower risk of mortality.
Clinical outcomes of non-operative management and clinical observation in non-angioembolised hepatic trauma: A systematic review of the literature
2022, Chinese Journal of Traumatology - English Edition
Liver is the most frequently injured organ in abdominal trauma. Today non-operative management (NOM) is considered as the standard of care in hemodynamically stable patients, with or without the adjunct of angioembolisation (AE). This systematic review assesses the incidence of complications in patients who sustained liver injuries and were treated with simple clinical observation. Given the differences in indications of treatment and severity of liver trauma and acknowledging the limitations of this study, an analysis of the results has been done in reference to the complications in patients who were treated with AE.
A systematic literature review searched “liver trauma”, “hepatic trauma”, “conservative management”, “non operative management” on MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials databases, EMBASE, and Google Scholar, to identify studies published on the conservative management of traumatic liver injuries between January 1990 and June 2020. Patients with traumatic liver injuries (blunt and penetrating) treated by NOM, described at least one outcome of interests and provided morbidity outcomes from NOM were included in this study. Studies reported the outcome of NOM without separating liver from other solid organs; studies reported NOM complications together with those post-intervention; case reports; studies including less than 5 cases; studies not written in English; and studies including patients who had NOM with AE as primary management were excluded. Efficacy of NOM and overall morbidity and mortality were assessed, the specific causes of morbidity were investigated, and the American Association for the Surgery of Trauma classification was used in all the studies analysed. Statistical significance has been calculated using the Chi-square test.
A total of 19 studies qualified for inclusion criteria were in this review. The NOM success rate ranged from 85% to 99%. The most commonly reported complications were hepatic collection (3.1%), followed by bile leak (1.5%), with variability between the studies. Other complications included hepatic haematoma, bleeding, fistula, pseudoaneurysm, compartment syndrome, peritonitis, and gallbladder ischemia, all with an incidence below 1%.
NOM with simple clinical observation showed an overall low incidence of complications, but higher for bile leak and collections. In patients with grade III and above injuries, the incidence of bile leak, collections and compartment syndrome did not show a statistically significant difference with the AE group. However, the latter result is limited by the small number of studies available and it requires further investigations.
Non-operative management for abdominal solidorgan injuries: A literature review
2022, Chinese Journal of Traumatology - English Edition
Citation Excerpt :
Hepatobiliary iminodiacetic acid scan has a 100% sensitivity and specificity to detect bile leakage and bile duct injury.27 Additional diagnostic modalities such as CT scan, abdominal ultrasonography, magnetic resonance cholangiopancreatography (MRCP), percutaneous transcatheter cholangiography, and endoscopic retrograde cholangiopancreatography (ERCP) can be used to diagnose these complications.19,28 Currently there are still no consensus about the time to preform follow-up imaging after NOM in liver injury, but it is suggested to have follow-up imaging for a patient with non-specific abdominal complaint, developing jaundice, abruptly elevated liver enzymes, and high risks for biliary complications such as high-grade injury, central hepatic injury and post main hepatic artery embolization.
The philosophy of abdominal injury management is currently changing from mandatory exploration to selective non-operative management (NOM). The patient with hemodynamic stability and absence of peritonitis should be managed non-operatively. NOM has an overall success rate of 80%–90%. It also can reduce the rate of non-therapeutic abdominal exploration, preserve organ function, and has been defined as the safest choice in experienced centers. However, NOM carries a risk of missed injury such as hollow organ injury, diaphragm injury, and delayed hemorrhage. Adjunct therapies such as angiography with embolization, endoscopic retrograde cholangiopancreatography with stenting, and percutaneous drainage could increase the chances of successful NOM. This article aims to describe the evolution of NOM and define its place in specific abdominal solid organ injury for the practitioner who faces this problem.
Anticoagulation Is Associated with Increased Mortality in Splenic Injuries
2021, Journal of Surgical Research
Anticoagulation (AC) is associated with worse outcomes after trauma in some but not all studies. To further investigate the effect of AC on outcomes in patients with splenic injury, we analyzed the Trauma Quality Programs Participant Use File (PUF)
The 2017 PUF was used to identify adult (18+ y) with all mechanisms and grades of splenic injury. Demographics, comorbidities, hospital course and outcomes were compared between AC and non-AC patients.
A total of 18,749 patients were included, 622 were on AC. The AC patients were older but had comparable gender composition to non-AC patients. Injury Severity Score (18.2 versus 22.5) and rates of serious (AIS ≥ 3) injury were all lower in the AC group (P = 0.001).
AC patients received fewer units of RBC (5.7 versus 8.0 units, P < 0.001) and FFP (3.9 versus 5.4 units, P < 0.001) in the first 24 h but underwent angiography at similar rates (23.6 versus 24.5%, P = 0.8). Among those who underwent angiography, patients were more likely to undergo embolization if they were on AC (89.7 versus 73.9%, P = 0.04). Rates of splenic surgery were comparable (19.3 versus 21.5%, P = 0.2) between AC versus non-AC patients. Median LOS was longer in AC patients (6.3 versus 5.6 d, P = 0.002). AC patients had a higher mortality (13.3 versus 7.0%, P = 0.001). In a multivariable binary logistic regression, AC was an independent risk factor for mortality with OR 1.4 (95% CI: 1.1-1.9)
Anticoagulation is associated with increased mortality in patients with splenic injury.
Embolization versus Surgery for Stabilized Patients with Solid Organ Injury
2021, Journal of Vascular and Interventional Radiology
Citation Excerpt :
CT assessment may reveal and localize arterial extravasation, which is a general indication for embolization (2,3). The application of embolization to unstable patients with isolated solid organ injuries is based on the physiology of the patient and initial CT assessment to determine the most appropriate treatment approach (ie, nonoperative management, embolization, and/or laparotomy), as previously reported (4,13). PSM was used to compare laparotomy with embolization, while adjusting for clinically significant differences (eg, physiology, trauma severity of the injured organ, and time courses).
To compare embolization with laparotomy for the management of hemodynamically unstable patients with solid organ injury who responded to initial resuscitation.
Data from a Japanese nationwide trauma registry were analyzed. Included were hemodynamically unstable patients (systolic blood pressure <90 mm Hg and blood transfusion within the first 24 hours) whose initial computed tomography assessment confirmed the presence of solid organ injuries (liver and/or spleen). A total of 224 patients were included (median age: 53 years, interquartile range: 32–69; 73.3% male; liver injury = 131 [58%] and spleen injury = 98 [44%]; median organ injury scale: 3, interquartile range: 3–4; median injury severity score: 19, interquartile range: 16–25). Patients who underwent embolization were compared with those who underwent laparotomy. The primary outcome was in-hospital survival. The data were evaluated using a propensity score matching analysis.
Laparotomy and embolization were performed in 133 (59.1%) and 91 (40.4%) patients, respectively. Of those, 111 (84%) and 84 (92%) patients achieved in-hospital survival after laparotomy and embolization, respectively. No significant difference in in-hospital survival (P = .053) was noted. The propensity score matching model did not reveal a significant difference in in-hospital survival (P = .276).
No significant difference was observed between embolization and laparotomy in terms of in-hospital survival among unstable patients who responded to initial resuscitation with solid organ injury.
Early hospital discharge following non-operative management of blunt liver and splenic trauma: A pilot randomized controlled trial
2021, Injury
Despite the acceptance of non-operative management (NOM), there is no consensus on the optimal length of hospital stay in patients with blunt liver and splenic injury (BLSI). Recent studies on pediatric patients have demonstrated the safety of early discharge following NOM for BLSI. We aimed at evaluating the feasibility and safety of early discharge in adult patients with BLSI following NOM in a randomized controlled trial.
After initial assessment and management, patients aged 18–60 years with BLSI planned for NOM were randomized into 2 groups: Group A (test group; discharge day 3), and Group B (control group; discharge day 5). Standard NOM protocol was followed. These patients were discharged on the proposed day if they met the pre-defined discharge criteria. All patients were followed at days 7, 15, and 30 of discharge.
Sixty patients were recruited, 30 randomized to each arm. Most patients were males and aged less than 30 years. Road traffic injury was the most common mode of injury. Both groups were comparable in demography and injury-related parameters. 27 patients (90%) from group A and 28 patients (93%) from group B were discharged on the proposed day. Three patients had unplanned hospital visits for reasons unrelated to BLSI. All patients were asymptomatic and had a normal examination during their scheduled follow-up visits.
Adult patients undergoing NOM for BLSI can be safely discharged after 48 h of in-hospital observation, provided other injuries precluding discharge do not exist.

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Management of blunt liver trauma in 134 severely injured patients

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Patients treated with urgent surgery

Patients managed with NOM

Deaths

Discussion

Conclusion

Conflict of interest

Acknowledgements

HPB (Oxford)

Injury

Non-operative management of blunt liver injuries

Br J Surg

Nonoperative management of blunt hepatic trauma: the exception or the rule?

J Trauma

Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. Results of a prospective trial

Ann Surg

Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients

J Trauma

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

Ann Surg

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

J Trauma

High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ

Arch Surg

Selective management of blunt hepatic injuries including nonoperative management is a safe and effective strategy

Surgery