Elsevier

Surgery

Volume 138, Issue 4, October 2005, Pages 606-611
Surgery

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

https://doi.org/10.1016/j.surg.2005.07.018Get rights and content

Background

The justification and preference for operative versus nonoperative management of hepatic injuries caused by blunt trauma remains ambiguous. This review assesses the outcome of operative and nonoperative management of liver injury after blunt trauma.

Methods

We retrospectively reviewed the demographics, severity of injury, severity of liver injury, associated concomitant injuries, management scheme, and outcome of patients with documented hepatic injury from 1993 to 2003.

Results

The overall mortality rate was 9.4%, with 3.7% caused by the liver injury itself. Fifty-nine percent (330 of 561) of liver injuries were of low severity (grades I and II), with an overall mortality rate of 6.6% caused by concomitant injuries and liver-related mortality of 0%. Forty-one percent (231 of 561) of liver injuries were high-severity injuries (grades III, IV, and V). Mortality for nonoperative management of high-severity liver injuries was 2.2%. If operative intervention was required because of hemodynamic instability or concomitant injuries then the mortality rate was significantly higher at 30%. Forty-two of the 378 (11%) liver injuries treated nonoperatively required an adjunctive procedure for successful management.

Conclusions

Selective management of liver injuries presented a low liver-related mortality rate. Low-grade injuries can be managed nonoperatively with excellent results. High-grade injuries can be managed nonoperatively, if operative intervention is not required for hemodynamic instability or associated injuries, with a low mortality. In these patients, adjunctive procedures will be required selectively for successful nonoperative management of high-grade liver injuries. High-grade injuries requiring operative management because of hemodynamic instability or concomitant injuries continue to have significantly higher mortality.

Section snippets

Patients and methods

After approval by the institutional review board, all trauma patients who sustained a blunt hepatic injury from 1993 to 2003 were identified by the trauma registry at the University of Louisville Hospital. Records then were reviewed for demographics, severity of injury, severity of liver injury, associated concomitant injuries, management scheme, adjunctive procedures, and outcome data. The grade of liver injury was determined from initial CT determination or intraoperative findings based on

Results

A total of 561 patients who incurred a hepatic injury from blunt trauma were identified from 1993 to 2003. Fifty-nine percent (330 of 561) were low-grade injuries of which 169 were grade I injuries and 161 were grade II injuries. Forty-one percent were high-grade injuries comprised of 136 grade III, 76 grade IV, and 19 grade V injuries. Table I shows the demographic data for all liver injuries by grade of injury. Of interest, patients in all groups were of similar age. As the severity of the

Discussion

The liver remains the most commonly injured abdominal organ in blunt trauma patients.10 More than a decade has elapsed since Feliciano16 proposed nonoperative management for all hepatic injuries, regardless of grade or extent, in the presence of hemodynamic stability. Subsequently, this concept has been expanded to include those who regain hemodynamic stability after arrival to the trauma center.8 Historically, nonoperative management of grades I, II, and III hepatic injuries has been widely

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Presented at the 62nd Annual Meeting of the Central Surgical Association, Tucson, Arizona, March 10-15, 2005.

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