Liver Trauma Patients Research Articles

THE POSSIBILITY OF CONSERVATIVE MANAGEMENT OF BLUNT AND PENETRATING LIVER TRAUMA OF VARIOUS SEVERITY

Until now, surgery is a standard treatment strategy in liver trauma. However, continuous evolution and improvement of imaging and interventional techniques open a wide perspective for conservative management of liver trauma patients. In the recent years, this method is getting more and more widely used and becomes a component of the standard care protocols for patients with liver trauma in tertiary centers.

Outcome analysis of management of liver trauma: A 10-year experience at a trauma center.

To review the outcomes of liver trauma in patients with hepatic injuries only and in patients with associated injuries outside the liver. Data of liver trauma patients presented to our center from January 2003 to October 2013 were reviewed. The patients were divided into two groups. Group 1 consisted of patients who had hepatic injuries only. Group 2 consisted of patients who also had associated injuries outside the liver. Seven (30.4%) patients in group 1 and 10 (28.6%) patients in group 2 received non-operative management; the rest underwent operation. Blunt trauma occurred in 82.8% (48/58) of the patients and penetrative trauma in 17.2% (10/58). A higher injury severity score (ISS) was observed in group 2 (median 45 vs 25, P < 0.0001). More patients in group 1 were hemodynamically stable (65.2% vs 37.1%, P = 0.036). Other parameters were comparable between groups. Group 1 had better 30-d survival (91.3% vs 71.4%, P = 0.045). On multivariate analysis using the logistic regression model, ISS was found to be associated with mortality (P = 0.004, hazard ratio = 1.035, 95%CI: 1.011-1.060). Liver trauma patients with multiple injuries are relatively unstable on presentation. Despite a higher ISS in group 2, non-operative management was possible for selected patients. Associated injuries outside the liver usually account for morbidity and mortality.

Correlating MDCT Liver Injury Grade and Clinical Outcome in Patients Without Significant Extra-hepatic Injury

The aim of the study was to correlate multi-detector computed tomography (MDCT) grading with clinical severity and outcome in liver trauma patients without significant extrahepatic injury. Over a period of 2years (2011-2013), all patients showing evidence of liver injury on contrast-enhanced CT (CECT) abdomen and without significant extrahepatic trauma were prospectively included in the study. Correlation between the CT injury grade and outcome in terms of mortality, duration of ICU/hospital stay, fluid and blood requirements, need for intervention and complications were assessed. The significance of the difference in mortality, duration of ICU/hospital stay, fluid requirement and blood requirements among the patients with various injury grades was assessed by Kruskal-Wallis test. The significance of the difference in need for intervention and complications among the patients with various injury grades was assessed by Fisher's exact test. A total of 198 patients were found to have evidence of hepatic injury on CECT. Out of 198 patients, 117 had insignificant extrahepatic trauma. The overall mean age for these 117 patients was 25.74 ± 15.53 (age range 2-84years). Death rates according to AAST grades were 0% in grades II and III, 6.89% in grade IV and 9.09% in grade V (p = 0.053). The mean ICU and total hospital stay for grade II was 1.32 and 5.91days, for grade III was 1.76 and 8.48, for grade IV was 2.86 and 10.31days and for grade V was 6.54 and 12days, respectively (p = 0.0001 for ICU, p = 0.0003 for total stay). Mean input and fluid deficit according to various grades were 8634/2607ml for grade II, 9535/2555ml for grade III, 15,549/6242ml for grade IV and 19,958/8280ml for grade V (p value input-0.0016, output-input (fluid deficit)-0.0001). Average unit of RBC and sum of the blood products transfused were 1.73 and 2.26 for grade II, 2.18 and 2.72 for grade III, 3.03 and 6.27 for grade IV, 6.85 and 38.12 for grade V, respectively (p value RBC-0.10, total-0.037). The difference in the need of active surgical/endovascular intervention and complication rates was not significantly higher in higher injury grades. The grading of liver injury based on CECT findings can predict the clinical course in liver trauma patients with insignificant extrahepatic injuries.

Glucocorticoid-induced S-Adenosylmethionine Enhances the Interferon Signaling Pathway by Restoring STAT1 Protein Methylation in Hepatitis B Virus-infected Cells

Patients with chronic hepatitis B usually exhibit a low response to treatment with interferon α (IFN-α). An alternative approach to increase the response rate of IFN-α might be to immunologically stimulate the host with glucocorticoids (GCs) before treatment with IFN-α, but the underlying mechanism remains unclear. We hypothesized that the GCs enhance IFN signaling by inducing S-adenosylmethionine (AdoMet) when hepatitis B virus (HBV) replication was effectively suppressed by IFN-α. Here, we investigated the effect of GCs and IFN-α on AdoMet production and methionine adenosyltransferase 1A (MAT1A) expression in vitro. Furthermore, we determined whether post-transcriptional regulation is involved in HBV-repressed MAT1A expression and AdoMet production induced by dexamethasone (Dex). We found that AdoMet homeostasis was disrupted by Dex and that Dex directly regulated MAT1A expression by enhancing the binding of the glucocorticoid receptor (GR) to the glucocorticoid-response element (GRE) of the MAT1A promoter. HBV reduced AdoMet production by increasing methylation at GRE sites within the MAT1A promoter. The X protein of hepatitis B virus led to hypermethylation in the MAT1A promoter by recruiting DNA methyltransferase 1, and it inhibited GR binding to the GRE in the MAT1A promoter. Dex could increase an antiviral effect by inducing AdoMet production via a positive feedback loop when HBV is effectively suppressed by IFN-α, and the mechanism that involves Dex-induced AdoMet could increase STAT1 methylation rather than STAT1 phosphorylation. These findings provide a possible mechanism by which GC-induced AdoMet enhances the antiviral activity of IFN-α by restoring STAT1 methylation in HBV-infected cells.

Screening and management of major bile leak after blunt liver trauma: a retrospective single center study.

BackgroundMajor bile leak after blunt liver trauma is rare but challenging. It usually requires endoscopic retrograde cholangiography (ERC) for management. However, there is still lack of specific indications. The aim of this study is to elucidate risk factors for major bile leak and indications for early ERC after blunt liver trauma.MethodsThe trauma registry of a level I trauma center in Taiwan was queried, and all blunt liver trauma patients from June, 2008 to June, 2011 were selected for retrospective review. Data collected included demographic data, laboratory data, Injury Severity Score (ISS), liver injury grade and location, management of liver trauma, length of ICU, hospital stay and treatment result. ERC was used to confirm major bile leak.Results288 blunt liver trauma patients were selected from 2,475 torso trauma patients. There were 214 (74.5%) male and 74 (25.7%) female patients. The mean ISS was 24.2. Most patients received conservative treatment. Transcatheter artery embolization (TAE) and operation were 15.6% and 10.8% respectively. Major bile leak occurred in 14 (4.9%) patients. Risk factors for bile leak include high-grade liver injury, centrally-located liver trauma and use of TAE. A bilirubin level greater than 43.6 μmol/L provides a sensitivity of 100% and specificity of 85.1% for predicting major bile leak.ConclusionsHigh injury grade; centrally-located liver trauma; and use of TAE are risk factors for major bile leak after blunt liver trauma. ERC should be arranged early if the patient has risk factors and their plasma bilirubin level is greater than 43.6μmol/L during admission.

Application of damage control surgery in the treatment of severe liver trauma patients

Objective To investigate the clinical application and nursing effect of damage control surgery （ DCS ） in treating patients with severe liver trauma .Methods A retrospective study was used to investigate 83 patients with severe liver trauma （ grade Ⅳ, and Ⅴ） from January 2008 to December 2012 associated with the lethal triad of coagulopathy , hypothermia , and acidosis treated by DCS .Nursing intervention included fluid resuscitation , care of lethal triad and postoperative complications .And the control group was 31 patients with liver trauma of grade Ⅳand Ⅴwho had be treated without DCS .Results The mortality rate was 25.3%and 51.6% in the DCS group and the control group , and the difference was statistically significant （χ2 =7.13, P<0.01）.The main cause of death was coagulopathy .The incidence of abdominal compartment syndrome was respectively 6.0% and 19.4% in the DCS group and the control group , the incidence of subdiaphragmatic abscess was 7.2%and 22.6%, and the differences were statistically significant （χ2 =4.60, 5.27, respectively;P<0.05）.Conclusions DCS for patients with severe liver trauma can obviously increase their survival rate .The point of nursing intervention was limited fluid resuscitation before the surgery , correction of coagulopathy , hypothermia and acidosis during ICU as well as prevention and management of postoperative complications after the surgery . Key words: Damage control; Liver trauma; Coagulopathy; Nursing intervention

Incidence of liver trauma and relative risk factors for mortality: A population-based study

BackgroundLiver trauma is the main cause of death arising from blunt abdominal injury. Nonoperative management (NOM) has been advocated to be a safe option for stable patients who have suffered liver trauma. This study used a population-based dataset to illustrate the incidence of liver trauma, its various causes and treatment, and outcomes. MethodsInformation about all patients with any ICD-9-CM coded as liver injury was retrieved as part of a claims dataset for the years 2007 and 2008 from the database maintained in the Bureau of National Health Insurance in Taiwan. Thereafter, statistical analyses were conducted to discover the incidence, mortality rate, percentage of patients receiving NOM, and the association between variables such as age, gender, injury mechanisms, associated injuries, and outcome. ResultsA total of 3196 liver trauma patients were admitted in 2007 and 2008, resulting in 264 deaths. The incidence rate is 13.9/100,000 population. The highest incidence rate was in the age 15–24 years group, 25.9/100,000 population; the highest mortality rate was in the age 75–84 years group, 2.1/100,000 population. Additionally, rural residents possessed a higher incidence and mortality rate than urban residents (15.9/100,000 population vs. 12.2/100,000 population and 1.4/100,000 population vs. 1.0/100,000 population). By using logistic regression, the mortality rate was significantly higher in the groups with patients aged >64 years, renal failure or liver cirrhosis, with head or chest, or other abdominal injury. If a patient received a hepatic or abdominal operation, this was retrospectively found to be associated with increased mortality risk (4.731 times, p < 0.001 and 4.311 times, p < 0.001, respectively); however, the characteristics of the treating hospitals did not influence the mortality rate. Patients whose monthly income was >US$660 were found to have a higher mortality risk (2.209 times, p < 0.001). ConclusionThe overall incidence rate of liver trauma was higher in the younger age group and in rural residents. A higher risk of mortality was found in the age > 64 years group, pedestrians hit in motor-vehicle accidents, renal failure or liver cirrhosis, with head or chest, or other abdominal injury.

Non operative management of abdominal trauma - a 10years review.

IntroductionDue to high rate of operative mortality and morbidity non-operative management of blunt liver and spleen trauma was widely accepted in stable pediatric patients, but the general surgeons were skeptical to adopt it for adults. The current study is analysis of so far largest sample (1071) of hemodynamically stable blunt liver, spleen, kidney and pancreatic trauma patients managed non operatively irrespective of severity of a single /multiple solid organ injury or other associated injuries with high rate of success.MethodsExperience of 1071 blunt abdominal trauma patients treated by NOM at a tertiary care National Trauma Centre in Oman (from Jan 2001 to Dec 2011) was reviewed, analyzed to determine the indications, methods and results of NOM. Hemodynamic stability along with ultra sound, CT scan and repeated clinical examination were the sheet anchors of NOM. The patients were grouped as (1) managed by NOM successfully, (2) failure of NOM and (3) directly subjected to surgery.ResultsDuring the 10 year period, 5400 polytrauma patients were evaluated for abdominal trauma of which 1285 had abdominal injuries, the largest sample study till date. Based on initial findings 1071 patients were admitted for NOM. Out of 1071 patients initially selected 963 (89.91%) were managed non operatively, the remaining 108 (10.08%) were subjected to laparotomy due to failure of NOM. Laparotomy was performed on 214(19.98%) patients as they were unstable on admission or had evidence of hollow viscous injury.ConclusionNOM for blunt abdominal injuries was found to be highly successful in 89.98% of the patients in our study. Management depended on clinical and hemodynamic stability of the patient. A patient under NOM should be admitted to intensive care / high dependency for at least 48-72 hours for close monitoring of vital signs, repeated clinical examinations and follow up investigations as indicated.

Conservative approach in the management of isolated penetrating liver trauma

BackgroundDamage to the liver is the most common cause of death after abdominal injury. The most common cause of liver injury is blunt abdominal trauma. In the case of penetrating injury, non-intervention management has not been adequately addressed. Selective non-operative management of stab wounds especially to the liver has been reported. MethodsThis study was carried out from May 2006 to April 2011 at the Main Alexandria University Hospital, Faculty of Medicine, Alexandria, Egypt. This study consisted of 62 liver trauma patients and the following data were collected: demographics, mechanism of injury, pre-hospital care, hemodynamic status, grade of hepatic injury, associated injuries, failure of non-operative (NOP) management, hospital stay in intensive care unit (ICU) or in the ward and death. Patients were eligible for the study if they sustained isolated penetrating right hypochondrial injury. Assessment of hemodynamic stability was based on routine vital signs. Injury severity was determined from CT and classified by means of the Liver Injury Scale. ResultsThis study was carried out for 62 consecutive patients with hepatic trauma in a five year period. Mean age was 33.6years with a range of 16–54years. The isolated penetrating liver injuries included knives, guns (gunshot & shotgun injuries) and other sharp objects. All patients were treated successfully via NOP management except five patients (8%) who failed NOP management. These five patients were hemodynamically unstable and were unresponsive to crystalloid and blood transfusion. The five patients underwent surgery (suturing, packing, and resectional debridement). Two patients (3.2%) died because of high grade liver injury. The overall actuarial one-year survival in NOP management was 96.8%. ConclusionsLow grade penetrating hepatic injuries (G I-III) can be managed non-operatively with excellent results; even G IV penetrating liver injuries with hemodynamically stable patients can be managed safely non-operatively.

Lessons from liver transplantation

Lessons from liver transplantation

A Quarter Century Experience in Liver Trauma: A Plea for Early Computed Tomography and Conservative Management for all Hemodynamically Stable Patients

Advances in diagnostic imaging and the introduction of damage control strategy in trauma have influenced our approach to treating liver trauma patients. The objective of the present study was to investigate the impact of change in liver trauma management on outcome. A total of 468 consecutive patients with liver trauma treated between 1986 and 2010 at a single level 1 trauma center were reviewed. Mechanisms of injury, diagnostic imaging, hepatic and associated injuries, management (operative [OM] vs. nonoperative [NOM]), and outcome were evaluated. The main outcome analysis compared mortality for the early study period (1986-1996) versus the later study period (1997-2010). 395 patients (84%) presented with blunt liver trauma and 73 (16%) with penetrating liver trauma. Of these, 233 patients were treated with OM (50%) versus 235 with NOM (50%). The mortality rate was 33% for the early period and 20% for the later period (odds ratio 0.19; 95% CI 0.07-0.50, P = 0.001). A significantly increased use of computed tomography (CT) as the initial diagnostic modality was observed in the late period, which almost completely replaced peritoneal lavage and ultrasound. There was a significant shift to NOM in the later period (early 15%, late 63%) with a low conversion rate to OM of 4.2%. Age, degree of hepatic and head injury, injury severity, intubation at admission, and early period were independent predictors of mortality in the multivariate analysis. Integration of CT in early trauma-room management and shift to NOM in hemodynamically stable patients resulted in improved survival and should be the gold standard management for liver trauma.

Clinical application of contrast-enhanced ultrasound in diagnosis of liver and spleen trauma

Objective To discuss clinical application value of contrast-enhanced ultrasound(CEUS) technology in the diagnosis of liver and spleen trauma. Methods Retrospective analysis 25 cases of liver and spleen trauma patients, the conventional ultrasonic CEUS complete material, analysis of the liver and spleen damage CEUS performance,and with surgery and computed tomography(CT) strengthen comparative analysis of the sensitivity of the conventional ultrasonic, CEUS, specific degree and the classification accuracy. Results Among the surgery or CT confirmed 23 cases for liver and spleen rupture,the pure 8 cases liver, injury 13 cases of pure spleen rupture ,liver and spleen composite injury in 2 cases. And surgery or CT comparison, the sensitivity of the CEUS and specific degrees were 90.5％ and 66.7％ ,significantly higher than conventional ultrasound 59. 1％ and 33.3％ (P ＜0.05) ;CEUS classification was 91.3％ (21/23), significantly higher than the rules of ultrasound was 65.2％ ( 15/23 ), both differences were statistically significant( P ＜ 0.05). Conclusion CEUS diagnosis liver and spleen, due to the sensitivity of the damage degree high, and the classification accuracy was higher, the diagnosis to accurately evaluate the extent of the damage to the liver and spleen in liver and spleen, the loss of the diagnosis and treatment of clinical guidelines choice had important value of clinical application. Key words: Contrast-enhanced ultrasound; Liver; Spleen ; Trauma

The X Protein of Hepatitis B Virus Inhibits Apoptosis in Hepatoma Cells through Enhancing the Methionine Adenosyltransferase 2A Gene Expression and Reducing S-Adenosylmethionine Production

The X protein (HBx) of hepatitis B virus (HBV) is involved in the development of hepatocellular carcinoma (HCC), and methionine adenosyltransferase 2A (MAT2A) promotes the growth of liver cancer cells through altering S-adenosylmethionine homeostasis. Thus, we speculated that a link between HBx and MAT2A may contribute to HCC development. In this study, the effects of HBx on MAT2A expression and cell apoptosis were investigated, and the molecular mechanism by which HBx and MAT2A regulate tumorigenesis was evaluated. Results from immunohistochemistry analyses of 37 pairs of HBV-associated liver cancer tissues/corresponding peritumor tissues showed that HBx and MAT2A are highly expressed in most liver tumor tissues. Our in vitro results revealed that HBx activates MAT2A expression in a dose-dependent manner in hepatoma cells, and such regulation requires the cis-regulatory elements NF-κB and CREB on the MAT2A gene promoter. Electrophoretic mobility shift assay (EMSA) and chromatin immunoprecipitation (ChIP) further demonstrated that HBx facilitates the binding of NF-κB and CREB to MAT2A gene promoter. In addition, overexpression of HBx or MAT2A inhibits cell apoptosis, whereas knockdown of MAT2A expression stimulates apoptosis in hepatoma cells. Furthermore, we demonstrated that HBx reduces MAT1A expression and AdoMet production but enhances MAT2β expression. Thus, we proposed that HBx activates MAT2A expression through NF-κB and CREB signaling pathways to reduce AdoMet production, inhibit hepatoma cell apoptosis, and perhaps enhance HCC development. These findings should provide new insights into our understanding how the molecular mechanisms underline the effects of HBV infection on the production of MAT2A and the development of HCC.

Management of Hepatic Trauma: a 9-Year Experience in ’s-Hertogenbosch

Background: In patients who sustain abdominal trauma the liver is the most frequently injured organ. Although treatment for haemodynamically unstable patients remains urgent surgery, there has been a shift of management in haemodynamacally stable patients towards non-operative management. We performed an outcome assessment of traumatic hepatic injury.Methods: A retrospective study was performed to assess incidence, mechanisms, management and outcome of traumatic liver injury in the region of ’s-Hertogenbosch, the Netherlands, in the period 1999–2007.Results: A total of 47 patients were identified. Thirty-six patients had blunt hepatic trauma, eleven sustained penetrating hepatic injury. In 67% (n = 24) of the blunt hepatic trauma patients the initial intention was to treat non-operatively. Yet, two patients underwent explorative laparotomy after one and two days. In the penetrating liver trauma patients, 91% (n = 10) underwent urgent surgery. In total, 31 of 47 patients were treated conservatively.Conclusion: Blunt hepatic trauma is the most common cause of hepatic trauma. Most patients sustaining hepatic trauma can be managed conservatively at a dedicated ICU and/or surgical trauma ward.

Management of bleeding emergencies: when to use recombinant activated Factor VII

Recombinant activated Factor VII (rVIIa) was originally released as a clotting factor, with use limited to a select group of patients who had few other treatment options. Due to the apparent ability of rVIIa to stop bleeding, no matter what the underlying cause, there is great interest in use of rVIIa in a wide range of bleeding patients. This article discusses rVIIa and its uses in a variety of patients, especially liver disease and trauma patients, and makes suggestions for appropriate use. Although most of the reports on rVIIa are anecdotes and case series, there is increasing data for clinical trials to help guide usage.

Liver trauma

Background: The choice of indications favoring an operative or a conservative approach in liver trauma is difficult, and can be a matter of life and death for the patient. Methods: Evaluation of the abdomen in trauma cases is discussed with regard to assessment of the clinical picture and the value of individual imaging modalities and invasive diagnostic procedures such as arteriography and peritoneal lavage. The various surgical techniques are appraised with respect to the kind and extent of liver trauma involved. Results: Management of liver trauma has tended to become more conservative when the course allows. On average, 30% to 50% of all liver-trauma patients can be treated conservatively. Conservative observation does, however, require continuous monitoring, regular re-evaluation with CT or sonography, hemodynamic stability (no more than 2 units of packed erythrocytes) and absence of concomitant intraabdominal injuries. Shock and peritonism require an immediate laparotomy. Conclusions: Today, hematoperitoneum is no longer an indication for immediate laparotomy. With severe liver ruptures (grades IV and V) requiring surgery, debridement rather than resection is favored as it reduces risk and spares parenchyma. With shock and/or manifest coagulopathies, a perihepatic tamponade can serve as a bridging measure until the liver trauma can be treated definitively.

Measurement of plasma annexin V by ELISA in the early detection of acute myocardial infarction

Annexin V is a calcium binding protein which is widely present in various cells and tissues. Using annexin V which we isolated and purified from human cardiac muscle, we prepared an anti-human cardiac annexin V monoclonal antibody. Identification of annexin V was made by means of partial amino acid sequences. An enzyme-linked immunosorbent assay (ELISA) was developed using this monoclonal antibody and anti-canine cardiac annexin V polyclonal antibody. With this ELISA, plasma annexin V concentration was measured in 196 normal healthy individuals, 23 acute myocardial infarction (AMI) patients who were hospitalized within 6 h after the onset of chest pain, and 130 patients with other diseases, including lung, liver and kidney disease. The plasma annexin V concentration in normal healthy individuals was 1.7 ± 0.6 ng/ml (mean ± S.D.), while that in AMI patients was elevated to 13.2 ± 6.8 ng/ml ( P < 0.0001) at the time of initial blood drawing, 3.2 ± 1.5 h after onset of pain, and these values were higher than normal in 21 out of 23 cases (91.3%) of AMI. In all cases excepting 3, annexin V concentration immediately decreased after the onset of pain. The annexin V concentration in patients with old myocardial infarction, chest pain syndrome, valvular heart disease, lung disease and kidney disease was 1.8 ± 0.8, 2.0 ± 0.7, 1.7 ± 1.1, 2.3 ± 1.4 and 2.1 ± 1.2 ng/ml, respectively, being within normal limits. The values in liver disease patients and trauma patients were 3.7 ± 2.7 ( P < 0.05) and 3.3 ± 2.4 ( P < 0.05) ng/ml, respectively, being slightly higher than that in normal healthy individuals.

Surgical management of juxtahepatic venous injuries in blunt hepatic trauma.

The purpose of this analysis was to understand better the problems faced in the management of blunt juxtahepatic venous injuries and to try and simplify the controversies regarding the optimal surgical approach to these injuries. Charts of 92 blunt liver trauma patients treated between July 1, 1991 to June 30, 1993 were reviewed. Nineteen patients with blunt juxtahepatic venous injuries were identified. The isolated left hepatic vein injury group (five patients) were all treated using a nonshunting approach with no mortalities. Half of the isolated right hepatic vein injury group (ten patients) received an atriocaval shunt, and the other half did not. These two different approaches each produced one survivor, with a combined mortality rate of 80% (eight of ten patients). One of the combined injuries group (four patients) received a total hepatectomy followed by liver transplantation. Another received a shunt. The other two were treated without shunting, but all of them expired. The overall mortality rate was 63.2% (12 of 19 patients), with nine patients dying intraoperatively or immediately postoperatively from exsanguination. The other three died 10, 25, and 30 days postoperatively because of sepsis. Juxtahepatic venous injury should be suspected after failure of the Pringle maneuver to stop bleeding and the different venous injuries differentiated by palpation of the adjacent hepatic parenchymal injuries. If an isolated left hepatic vein injury is found and the liver parenchymal injury is limited to segments II, III, or IV, then a nonshunting approach will achieve the optimal outcome.

Blunt Liver Trauma at SunnybrookMedical Centre: A 13 Year Experience

Between June 1, 1976 and June 30, 1989 The Regional Trauma Unit at Sunnybrook Medical Centre in Toronto, Ontario, Canada received 3730 patients. Of these 335 (9%) sustained a liver injury, 95% being due to blunt trauma. Open peritoneal lavage was performed on 80% of liver trauma patients (267/335), 99% being true positive. A laparotomy was performed on 97% of patients (324/335). Major surgical treatment was required in 132 patients (41%) and minor treatment in 192 patients (59%). The remaining 11 patients were treated conservatively (n = 3) or died during resuscitation (n = 8). Morbidity directly related to the liver injury was seen in 29 of 249 surviving patients (11%) although overall morbidity was 27% (67/249). Reoperation was required in 6% (14/249) with abscess or hematoma accounting for 11 of 14 operations. The overall mortality rate was 26% (86/335). Eighty two percent of patients (n = 276) had a grade I, II or III liver trauma according to Moore’s classification with a mortality of 12% (n = 32). The remaining 18% of patients (n = 59) had a grade IV or V liver trauma with a mortality of 44% (n = 26). Of the 86 deaths, head injury accounted for 48 (56% of deaths); liver hemorrhage for 17 (20%), liver sepsis for (1%) and other causes for 20 deaths (23%). Thus death due to the liver injury itself (hemorrhage and sepsis) occurred in 18 out of 335 patients (5% overall). Head injury accounted for the death of 48 out of 335 patients (14% overall). Over the past 13 years a trend has occurred at our institution whereby we are seeing less liver trauma in our population of multiply injured patients from 12% (1976–1983) down to 7% (1985–1989); with a gradual decline in overall mortality from 32% (1976–1983) to 19% (1985–1989), whereas the precentage of deaths due to head injuries and liver injury have increased.