Status of Nonoperative Management of Blunt Hepatic Injuries in 1995

Abstract

Nonoperative management is presently considered the treatment modality of choice in over 50% of adult patients sustaining blunt hepatic trauma who meet inclusion criteria. A multicenter study was retrospectively undertaken to assess whether the combined experiences at level I trauma centers could validate the currently reported high success rate, low morbidity, and virtually nonexistent mortality associated with this approach. Thirteen level I trauma centers accrued 404 adult patients sustaining blunt hepatic injuries managed nonoperatively over the last 5 years. Seventy-two percent of the injuries resulted from motor vehicle crashes. The mean injury severity score for the entire group was 20.2 (range, 4-75), and the American Association for the Surgery of Trauma-computerized axial tomography scan grading was as follows: grade I, 19% (n = 76); grade II, 31% (n = 124); grade III, 36% (n = 146); grade IV, 10% (n = 42); and grade V, 4% (n = 16). There were 27 deaths (7%) in the series, with 59% directly related to head trauma. Only two deaths (0.4%) could be attributed to hepatic injury. Twenty-one (5%) complications were documented, with the most common being hemorrhage, occurring in 14 (3.5%). Only 3 (0.7%) of these 14 patients required surgical intervention, 6 were treated by transfusions alone (0.5 to 5 U), 4 underwent angio-embolization, and 1 was further observed. Other complications included 2 bilomas and 3 perihepatic abscesses (all drained percutaneously). Two small bowel injuries were initially missed (0.5%), and diagnosed 2 and 3 days after admission. Overall, 6 patients required operative intervention: 3 for hemorrhage, 2 for missed enteric injuries, and 1 for persistent sepsis after unsuccessful percutaneous drainage. Average length of stay was 13 days. Nonoperative management of blunt hepatic injuries is clearly the treatment modality of choice in hemodynamically stable patients, irrespective of grade of injury or degree of hemoperitoneum. Current data would suggest that 50 to 80% (47% in this series) of all adult patients with blunt hepatic injuries are candidates for this form of therapy. Exactly 98.5% of patients analyzed in this study successfully avoided operative intervention. Bleeding complications are infrequently encountered (3.5%) and can often be managed nonoperatively. Although grades IV and V injuries composed 14% of the series, they represented 66.6% of the patients requiring operative intervention and thus merit constant re-evaluation and close observation in critical care units. The optimal time for follow-up computerized axial tomography scanning seems to be within 7 to 10 days after injury.

Trauma hepático: uma experiência de 21 anos

“…This is in concordance with other published studies, and with the paradigm that men are often more exposed to traumatic injuries 2,10,11 . The young population is most affected, with an average age of 29.4 years, following the worldwide averages of 35, 32, 31 and 30 respectively in Germany, South Africa, Scotland and the USA [12][13][14][15] . Blunt and penetrating injuries vary according to the studied geographic region.…”

“…Most hepatic injuries are minor, requiring minimal or no surgical intervention. However, major hepatic injuries are associated with a high rate of morbidity and mortality 2,[15][16][17][18] . A very important concept that has emerged in the management of major hepatic trauma is that direct suture of severed blood vessels and bile duct is the most effective treatment.…”

“…The mean ISS for BHT varied between 17 and 22 in several studies 4,15,[20][21][22] . Non-operative treatment, performed on 74 of the 288 patients with BHT, has become the treatment of choice for patients with BHT admitted with hemodynamic stability.…”

“…Non-operative treatment, performed on 74 of the 288 patients with BHT, has become the treatment of choice for patients with BHT admitted with hemodynamic stability. Important points to highlight in non-operative treatment are fewer complications, less need for blood transfusions and lower mortality, even for higher grade injuries of the liver 15,[22][23][24][25][26][27] . The support of interventional radiology can be necessary, with advantages in patient prognosis 27 .…”

Blunt Trauma Liver-Conservative or Surgical Management: A Retrospective Study

“…Right lobe is more often involved, owing to its larger size and proximity to the ribs [5,6]. Compression against the fixed ribs, spine or posterior abdominal wall results in predominant damage to segments 6, 7 and 8 of the liver (>85%).…”