Blunt Hepatic Trauma Research Articles

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

Nonoperative management of liver injuries (NOMLI) is highly successful and rarely leads to adverse events. Prospective observational study. High-volume academic level I trauma center. For 26 months, 78 consecutive unselected patients with liver injuries were followed up prospectively. In the absence of hemodynamic instability or signs of hollow visceral trauma, NOMLI was offered irrespective of the magnitude of the liver injury. Main Outcome Measure Failure of NOMLI, defined as a laparotomy after an initial decision to treat the patient nonoperatively. Of the 78 patients, 23 (29%) were operated on immediately, but only 12 (15%) for bleeding from the liver. All 12 patients required packing in addition to other maneuvers (hepatorrhaphy [n = 8], resection [n = 4], and liver isolation [n = 1]). Of the remaining 55 patients selected for NOMLI, the method failed in 8 for reasons unrelated to the liver injury: 2 underwent a splenectomy, 1 underwent a nephrectomy, 1 had a small-bowel repair, 1 underwent abdominal decompression for abdominal compartment syndrome, and 3 underwent a nontherapeutic laparotomy. The success rate of NOMLI was 85% (47 of 55 patients), but the liver-specific success rate was 100%. Compared with those in whom NOMLI was successful, patients in whom it failed had a higher Injury Severity Score and underwent more blood transfusions, but they had similar liver injury grades. In total, 66 (85%) of liver injuries did not bleed significantly. No adverse events were attributed to NOMLI. Nonoperative management of liver injuries is safe and effective regardless of the grade of liver injury. Failure of NOMLI is caused by associated abdominal injuries and not the liver. Fluid and blood requirements, the degree of injury severity, and the presence of other abdominal organ injuries may help predict failure.

Non-operative management of blunt hepatic trauma.

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. English language publications were reviewed. 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. 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.

Liver abscess after non-operative management of blunt liver injury.

The non-operative management of blunt liver trauma can be applied in almost 80% of patients with this type of injury, with the advantages of the need for fewer blood transfusions, less intra-abdominal sepsis, and a better survival rate, than with the operative approach. However, liver abscess, as a known complication of the non-operative management of blunt liver trauma, is discussed infrequently. Therefore, we herein review our experience and describe this complication in detail. From 1995 to 2001, 674 patients were admitted to our hospital due to blunt hepatic trauma. Among these patients, 279 underwent laparotomy and the remaining 395 patients were treated non-operatively. Twenty-two patients were identified as having liver abscess, with 16 of them belonging to the operative group, and six to the non-operative group. A retrospective review of these six patients and their characteristics, as well as pathogenesis, diagnosis, and the management of the liver abscesses, was conducted. These six patients were all male, with a median age of 19.5 years (range 3-24). The median injury severity score was 16.5 (range 9-25); three patients sustained grade-3 hepatic injury, and the other three were grade 4. The main diagnostic tool was abdominal computed tomography, and the abscesses took a median of 6 days (range 1-12) to form and be diagnosed. The abscesses were usually caused by infection from mixed organisms, and an abscess resulting from Clostridium infection developed within 1 day after injury. These abscesses were treated with antibiotics and drainage, and the median length of hospital stay was 26 days (range 8-44), without mortality or long-term morbidity. Liver abscess as a complication of the non-operative management of blunt hepatic trauma is a rare entity, with an incidence of 1.5% (6/395). It is usually seen in severe liver injury (grade 3 and above), but all our patients were all treated successfully, with no mortality. However, prolonged hospitalization may be required in this patient group.

Blunt liver injury: from non-operative management to liver transplantation

Therapeutic options for blunt hepatic trauma include both non-operative and operative management. We have reviewed our experience of the management of blunt hepatic trauma, from non-operative to liver transplantation. A total of 72 patients with blunt hepatic injury observed at the first surgical unit of Padua in a 3-year period (1998–2000) were analysed; we also included a patient who had a liver transplant in 1993 for severe liver trauma. Twenty-nine patients (39.7%) were treated conservatively, with a 93% success rate; 60.3% were treated surgically. Suture hepatorraphy was the most common procedure performed (52.3%). Advantages of non-operative management in our experience were the reduced need for transfusion (1.1 U versus 4.3 U) with 92% of patients not needing transfusion, and a reduced stay in the intensive care unit; there was no liver-related mortality. The overall morbidity in surgical patients was 30%, with 16% liver-related complications. Twelve surgical patients (27.2%) died, with a liver-related mortality of 18.2%. A large number of patients may present with an associated endo-abdominal injury, even in low-grade liver trauma, requiring rapid laparotomy. In high-grade hepatic trauma, the evolution toward liver failure is an indication for liver transplantation.

Long-term follow-up after liver transplantation for blunt hepatic trauma

Long-term follow-up after liver transplantation for blunt hepatic trauma

Mesenteric Ischemia: An Unusual Presentation of Traumatic Intrahepatic Arterioportal Fistula

Traumatic hepatic arterioportal fistulae (APF) are described infrequently as sequelae of hepatic trauma. These anomalies are usually associated with blunt hepatic trauma or iatrogenic injury. The majority of APF present within weeks to months of injury with gastrointestinal hemorrhage, hemobilia, abdominal pain, and diarrhea. When presenting remotely APFs are associated with portal hypertension, heart failure, gastrointestinal hemorrhage, ascites, and splenomegaly. We report an unusual case of mesenteric ischemia due to an APF that resulted from a penetrating liver injury 20 years before presentation. Successful treatment of the APF was achieved by intravascular catheter occlusion resulting in resolution of symptoms.

Intra-abdominal pressure monitoring as a guideline in the nonoperative management of blunt hepatic trauma.

Nonoperative management has been validated as a standard of care for patients with blunt hepatic trauma. We herein study the correlation of intra-abdominal pressure (IAP) and other clinical parameters to predict the failure of nonoperative management, and attempt to use IAP to determine further therapeutic options. During a 9-month period, 25 hemodynamically stable patients sustaining grades III to V blunt hepatic injuries were prospectively studied. They were admitted to the intensive care unit for clinical reevaluation, and hemodynamic and IAP monitoring. If the patient developed an IAP greater than 25 cm H(2)O, then an emergent laparotomy or laparoscopy was performed to achieve hemostasis and decompression of intra-abdominal hypertension (IAH). On the basis of an IAP of 25 cm H(2)O, the correlation between the IAP and an estimated amount of liver-related transfusion, the Pao(2)/Fio(2) ratio and peritoneal signs were analyzed. Of the 25 patients being studied, 20 (80%) had an IAP below 25 cm H(2)O, 1 of whom was found to have a pelvic abscess from an amputated segment of liver. On the other hand, five other patients with an IAP greater than 25 cm H(2)O received decompression and laparoscopic examinations, and one needed an open hepatorrhaphy. In general, though, 19 patients (76%) were successfully treated without operation. All recovered well after different therapeutic regimens; however, two developed liver abscesses, for a morbidity rate of 8% (2 of 25). This analysis revealed a strong association between the IAP value and the presence of peritoneal signs (Phi coefficient = 0.890, p < 0.001), but not in the estimated amount of liver-related transfusion and Pao(2)/Fio(2) ratio. This preliminary investigation suggests that IAH or abdominal compartment syndrome can develop while patients receive nonoperative management for grade III to V blunt hepatic injuries. There were no parameters that precisely reflected ongoing hepatic hemorrhage or predicted hemodynamic instability. Although the amount of hepatic hemorrhage was not accurately measured by the IAP, it could be reflected by an increased IAP. During nonoperative management, IAP monitoring may be a simple and objective guideline to suggest further intervention for patients with blunt hepatic trauma. Laparoscopic hepatic evaluation and abdominal decompression may be helpful in this situation.

Severe blunt hepatic trauma in children

Background: Severe blunt hepatic injury in children is associated with a high mortality rate. Although nonoperative management has become the treatment of choice for mild to moderate liver trauma, there is no consensus as to the optimal treatment for the most severe hepatic injuries in children. Methods: A statewide trauma registry was reviewed to identify children (age 18 years or less) treated for a severe blunt liver injury for the period 1993 to 1998. Only children with an American Association for the Surgery of Trauma grade V (AIS code 541828.5) liver injury were included. Database records were reviewed for demographic information, associated injuries, survival rate, length of stay (LOS), intensive care days (ICUD), and treatment rendered after resuscitation in the emergency department. Results: Thirty children with a grade V liver injury were identified. The mean age was 11.2 years (range, 1 to 18), and the overall survival rate was 56%. Data for 5 patients were excluded (4 patients died in the emergency department, and 1 patient was transferred to another institution after arrival). Survivors had a trend toward a lower injury severity score (ISS) (36.1 v 44.6; P <.1) and a significantly higher Glasgow Coma Scale (GCS), 12.5 v 6.6; P <.007). Patients with a decreased GCS had a lower overall survival rate (GCS < 8, 30% v GCS > 8, 76%). In the subset of 14 patients taken directly to the operating room, there was no difference between survivors (n = 6, 43%) and nonsurvivors (n = 8, 57%) in ISS (43 v 43; P value, not significant) or GCS (8.6 v 8.0; P value, not significant). Of the 11 patients treated nonoperatively, 10 (91%) survived with an average ISS of 33 and GCS of 13.8. Nonsurvivors more often had identified associated injuries to other abdominal and retroperitoneal organs. Conclusions: Severe hepatic injury is associated with a very high overall mortality rate in children. A low GCS is associated with a significant decrease in survival rate and may be the most important factor in outcome. Patients taken directly to the operating room have a slightly greater injury severity and a decreased survival rate compared with those treated nonoperatively. Thresholds and indications for laparotomy in these patients are not clear, and the need for operative management should be guided by the child's physiologic response to resuscitation. For those patients whose physiologic response to resuscitation permitted nonoperative management, a good outcome was achieved. J Pediatr Surg 36:974-979. Copyright © 2001 by W.B. Saunders Company.

Nonoperative Management of Pediatric Blunt Hepatic Trauma

The purpose of this study was to examine the effect of operative versus nonoperative management of blunt hepatic trauma in children including transfusion practices. We reviewed the experience at our American College of Surgeons-verified Level I trauma center with pediatric commitment over a 5-year period. Children < or = 16 years of age suffering blunt liver injury as documented on admission CT scan were included in the study. Liver injuries identified on CT scan were classified according to the American Association for the Surgery of Trauma's Organ Injury Scaling system. All data are presented as mean +/- standard error. One case of pediatric liver trauma not identified on CT was excluded (prehospital cardiopulmonary resuscitation). Twenty-seven patients were included [age 9.3 +/- 1.0 years (range 3-16)]. Mechanisms of injury included motor vehicle crash (14), pedestrian struck by motor vehicle (7), bicycle crash (4), fall from height (1), and pedestrian struck by falling object (1). Trauma Score was 11.5 +/- 0.3. Distribution of Liver Injury Grade was as follows: grade I, 13; grade II, 9; grade III, 3; grade IV, 2; and grade V, 0. All five patients who underwent operative management had multiple organ injuries; three had concomitant splenic injury requiring operative repair; the remaining two had small bowel injury requiring repair. Hepatorrhaphy did not correlate with severity of liver injury: grade I, n = 1; II, n = 2; III, n = 1; and IV, n = 1. Three operated patients received blood transfusions. Twenty-two patients were managed with nonoperative treatment, of these only one required blood transfusion. No patients in the study died, three were transferred to subacute rehabilitation, one was transferred to another hospital, and 23 were discharged home. Our findings indicate that a majority of children with blunt hepatic injury as documented on CT scan can be managed with nonoperative treatment, and few require blood transfusions. Patients with multiple organ injury including simultaneous splenic injury are likely ideally managed through operative exploration and repair, whereas those with isolated liver injuries can be successfully managed nonoperatively.

Classification and treatment of pooling of contrast material on computed tomographic scan of blunt hepatic trauma.

Pooling of contrast material on computed tomographic (CT) scan represents free extravasation of blood as a result of active bleeding. For patients with blunt hepatic injury, aggressive management such as angiography or celiotomy is usually indicated if this sign is detected. The purposes of this study were to further categorize this CT scan finding and to correlate its characteristics with clinical outcomes. This CT scan classification might be helpful for the selection of appropriate management. During a 42-month period, 276 patients with blunt hepatic injury were treated. Two hundred twelve of them were hemodynamically stable after initial resuscitation and underwent abdominal CT scan examination. Pooling of contrast material was detected on the CT scans of 15 patients. The CT scans and medical records were reviewed. Special attention was paid to the presence, location, and character of the extravasated contrast material. The finding of pooling of contrast material on CT scan was categorized into three types according to its location and character. Type I showed extravasation and pooling of contrast material in the peritoneal cavity (six patients). All patients with type I CT scan findings became hemodynamically unstable soon after CT scan examination and required emergent laparotomy. Type II findings showed simultaneous presence of hemoperitoneum and intraparenchymal contrast material pooling (six patients). Four patients with type II CT scan findings required laparotomy for hemostasis. Type III findings showed intraparenchymal contrast material pooling without hemoperitoneum (three patients). All patients with type III CT scan signs remained hemodynamically stable. With the use of a high-speed spiral CT scanner, it is possible to predict the necessity of operative management or angiography for patients with blunt hepatic injury before deterioration of hemodynamic status. The presence of pooling of contrast material within the peritoneal cavity indicates active and massive bleeding. Patients with this CT scan finding show rapid deterioration of hemodynamic status. Most of these patients might require emergent surgery. Pooling of contrast material in a ruptured hepatic parenchyma indicates active bleeding. Close monitoring and emergent angiography should be performed. Deterioration of hemodynamic status in these patients usually requires prompt surgical intervention. Intraparenchymal pooling of contrast material with unruptured liver capsule often indicates a self-limited hemorrhage. Patients with this CT scan finding have a high possibility of successful nonoperative treatment.

Factors determining operative mortality of grade V blunt hepatic trauma.

Despite recent advances in the management of severe hepatic injuries, the operative mortality rate of grade V hepatic injuries still ranges from 67% to 80%. Grade V hepatic injuries involving the retrohepatic cava or main hepatic veins are almost always lethal, especially those from blunt trauma. The purpose of this study is to understand the risk factors determining operative mortality in grade V blunt hepatic trauma, and to try to improve the surgical management of these injuries. A retrospective study was conducted at a medical center that offers services including primary, secondary, and tertiary care. Forty-four patients with grade V blunt hepatic injuries were treated during a 6-year period from January 1, 1991, to December 31, 1996. The operative mortality was compared by a multivariate analysis. Forty-four patients with grade V blunt hepatic injuries were identified. Seven patients had only parenchymal injuries, and the others had vascular and associated parenchymal injuries. Venorrhaphy was used in 37 patients; 29 were treated using a nonshunting approach, and 8 with an atriocaval shunt. The overall mortality rate was 68% (30 of 44), and liver-related mortality was 50% (22 of 44). Univariate analysis revealed that the significant variables affecting operative mortality were initial systolic blood pressure, initial base deficit, the Glasgow Coma Scale, injury type, number of resected segments, and total intraoperative blood loss. Based on forward stepping logistic regression analysis, patients with an initial base deficit of -6 mmol/L or less (relative risk = 17.3), and a total intraoperative blood loss of 5,000 mL or more (relative risk = 23.5) would, significantly, encounter a worsening prognosis. Initial base deficit and total intraoperative blood loss were the significant factors that determined operative mortality after grade V blunt hepatic trauma. We suggest that prompt resuscitation and expeditious and appropriate surgical management, to control operative blood loss, is the only way to reduce operative mortality in patients with grade V blunt hepatic trauma.

Laparoscopic decompression of abdominal compartment syndrome after blunt hepatic trauma.

Abdominal compartment syndrome (ACS) can occur in a variety of surgical conditions, particularly those with major life-threatening hemorrhage, massive volume resuscitation, prolonged operation times, and coagulopathy. In severely traumatized patients, the incidence of ACS is reported to be as high as 14% to 15% after damage control laparotomies. Although favorable results have been achieved with nonsurgical management of adult blunt hepatic trauma, the failure rates still range from 0% to 19%. Exploratory laparotomy is considered the intervention of choice in patients with blunt hepatic trauma who fail nonsurgical treatment. Expedient abdominal decompression currently is the treatment of choice after ACS. Oliguria, tachypnea, and tachycardia developed in two blunt hepatic trauma patients with grade IV and V injuries while they were receiving nonsurgical treatment. The intra-abdominal pressures measured more than 35 and 25 cm H 2O, respectively. Two patients with grade II and III ACS received laparoscopic examination instead of laparotomy. Their ACS was decompressed effectively via laparoscopy without any adverse effects. Therefore, we suggest that laparoscopy can be used as a safe alternative for the decompression of ACS.

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

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. 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. 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). 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. 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.

Multi‐systemic Trauma in a Ferret

SummaryA 5‐year old, neutered, male, domestic sable ferret presented 24 hours after escaping outside and sustaining unknown trauma. Physical examination findings included tachycardia, tachypnea, and hind limb paresis in a laterally recumbent patient. Radiographs, laboratory evaluation, and abdominocentesis revealed the presence of hemoperitoneum, blunt hepatic trauma, pneumothorax, and a small abdominal hernia. The ferret was treated with resuscitative fluids, thoracocentesis, abdominal counterpressure, and blood transfusion. This is the first case report of multi‐systemic trauma in a ferret. The ferret made a complete recovery and was discharged to the referring veterinarian three days after presentation. (Vet. Emerg. Crit. Care, 10:13–18, 2000)

Ultrasound detection of blunt hepatic trauma: Hemoperitoneum and parenchymal patterns of injury

Ultrasound detection of blunt hepatic trauma: Hemoperitoneum and parenchymal patterns of injury

Advances in abdominal interventional radiology

Advances in abdominal interventional radiology

Le traitement actuel des traumatismes fermés du foie: son intérêt et ses pièges. Á propos d'une série de 130 cas

Study aim The management of blunt hepatic trauma has been modified by the development of conservative methods. Risks and pitfalls of this new approach must be determined. Patients and methods From January 1985 to September 1998, 130 patients with blunt hepatic trauma were treated by the same team. Among them, 38 patients were referred from another centre (21 already having undergone operations). Eighty patients (61%) had an initial non operative management and 50 patients (39%) underwent emergency laparotomy. Perihepatic packing was performed in 24 patients, hepatic sutures in 22, limited hepatic resection in six, and major hepatectomy in two patients only. Results There were three deaths in the non operative management group (mortality rate: 3.5%) and 11 patients required a secondary laparotomy: four for haemorrhage, one for enteric injury, two for acute pancreatitis, one for bile leakage, one for subphrenic abscess, one for acute cholecystis. There were 14 deaths in the emergency laparotomy group (mortality rate: 28%), including four intraoperative deaths due to haemorrhage and two due to abdominal compartment syndrome. Conclusions In the nonoperative management group a close clinical survey of the patient is necessary and a secondary laparotomy often indicated. In the operative management group, early packing requires reintervention if the patient is unstable. Alternative means of temporary closure may allow coverage without tension in order to avoid the abdominal compartment syndrome.

Delayed hemorrhage after nonoperative management of blunt hepatic trauma in children: A rare but significant event

Purpose: Nonoperative management of blunt hepatic injury (BHI) has become widely accepted in hemodynamically stable children without ongoing transfusion requirements. However, late hemorrhage, especially after discharge from the hospital can be devastating. The authors report the occurrence of serious late hemorrhage and the sentinel signs and symptoms in children at risk for this complication. Methods: Nonoperative management of hemodynamically stable children included computed tomography (CT) evaluation on admission and hospitalization with bed rest for 7 days, regardless of injury grade. Activity was restricted for 3 months after discharge. Hepatic injuries were classified according to grade, amount of hemoperitoneum, and periportal hypoattenuation. Results: Over 5 years, nonoperative management was successful in 74 of 75 children. One child returned to the hospital 3 days after discharge with recurrent hemorrhage necessitating surgical control. Review of the CT findings demonstrated that he was the only child with severe liver injury in all four classifications. A second child, initially treated at an outside hospital, presented 10 days after injury with ongoing bleeding and died despite surgical intervention. Only the two children with delayed bleeding had persistent right abdominal and shoulder discomfort in the week after BHI. Conclusions: Our findings support nonoperative management of BHI. However, late hemorrhage heralded by persistence of right abdominal and shoulder pain may occur in children with severe hepatic trauma and high injury severity scores in multiple classifications.

Pediatric hepatic trauma: Does clinical course support intensive care unit stay?

Purpose: The objective of this study is to determine if grade of liver injury predicts outcome after blunt hepatic trauma in children and to initiate analysis of current management practices to optimize resource utilization without compromising patient care. Methods: A retrospective review of 36 children who had blunt hepatic trauma treated at a pediatric trauma center from 1989 to present was performed. Hepatric injuries graded (AAST Organ Injury Scaling) ranged from grade I to IV. Injury Severity Score (ISS), Glasgow Coma Score (GCS), transfusion requirements, liver transaminase levels, associated injuries, intensive care unit (ICU) length of stay, and survival were analyzed. Results: Mean (±SEM) age was 6.6 ± 0.8 years, mean grade of hepatic injury was 2.4 ± 0.2, mean ISS was 17 ± 2.6, mean GCS was 13 ± 1, and mean transfusion was 15.4 mL/kg of packed red blood cells (PRBC). There were three deaths with a mean ISS of 59 ± 9 and a mean GCS of 3 ± 0. Death was not associated with a high-grade liver injury, survivors versus nonsurvivors, 2.3 ± 0.2 versus 2.7 ± 0.3, but was associated with ISS, 13 ± 1.4 versus 59 ± 9 ( P = .005) and GCS, 14 ± 1 versus 3 ± 0 ( P = .005). Only one patient (grade III, ISS = 43) underwent surgery. There were no differences in mean ISS or GCS between grades I to IV patients. The hepatic injury grades of patients requiring transfusion versus no transfusion were significantly different, 3.4 ± 0.2 versus 2.2 ± 0.2 ( P = 0.04). Abused patients had high-grade hepatic injuries and significant laboratory and clinical findings. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were significantly higher in grade III and IV injuries than in grades I and II, 1,157 ± 320 versus 333 ± 61 ( P = .02) and 1,176 ± 299 versus 516 ± 86 ( P = .04), respectively. No children with grade I or II injury had a transfusion requirement or surgical intervention. There were no liver-related complications. Conclusions: Mortality and morbidity rates in pediatric liver injuries, grades I to IV, correlate with associated injuries not the degree of hepatic damage. ALT, AST, and transfusion requirements are significantly related to degree of liver injury. Low-grade and isolated high-grade liver injuries seldom require transfusion. Blunt liver trauma rarely requires surgical intervention. In retrospect, the need for expensive ICU observation for low-grade and isolated high-grade hepatic injuries is questionably warranted.

Nonoperative management for extensive hepatic and splenic injuries with significant hemoperitoneum in adults.

Although several retrospective studies have been published concerning nonoperative management of minor liver and spleen injuries, few studies have prospectively analyzed the results of nonoperative management for higher-grade liver and spleen injuries. Is it possible to manage extensive hepatic or splenic injuries with hemoperitoneum nonoperatively? The current study was conducted to evaluate the safety of nonoperative management of blunt hepatic and splenic trauma with significant hemoperitoneum in hemodynamically stable patients regardless of injury severity. We used the nonoperative methods prospectively to treat consecutive patients with blunt spleen or liver injury during a 35-month period. Patients with unstable conditions underwent emergency laparotomies, and those who were stable underwent abdominal computed tomography for further evaluation. We analyzed the clinical characteristics and the success rate of this method thoroughly. Twenty-four patients with severe hepatic or splenic injuries treated nonoperatively were included in this study. Among these 24 patients, 18 (75%) with hepatic or splenic injuries had grades of III or greater on the Organ Injury Scale. Twenty patients (83.3%) had moderate to large amounts of hemoperitoneum. Four patients (16.7%) failed at observation and underwent emergency celiotomy, two for liver-related and two for spleen-related causes. There were no differences between the nonoperative and operative management groups in terms of mean age, initial systolic blood pressure, initial heart rate, emergency room fluid requirement except emergency blood transfusion, abdominal complications, and hospital length of stay. We suggest that nonoperative management may be undertaken successfully in appropriately designed areas with close observation for the hemodynamic stable patient.