Management of blunt liver trauma in 134 severely injured patients

Abstract

BackgroundIn 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. MethodsA 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). ResultsThirty 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). ConclusionPhysiologic 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.