Severe Blunt Liver Injury Often Best Treated Nonoperatively


TUCSON, ARIZ. — Nonoperative management of severe blunt liver injuries appears to be the best strategy of caring for hemodynamically stable patients, according to findings from a retrospective review of 561 patients.

Choosing between nonoperative and operative treatment schemes seems to make a difference, however, only in patients with the most severe liver injuries, A. Britton Christmas, M.D., reported at the annual meeting of the Central Surgical Association.

Prior to the 1990s, physicians diagnosed liver injuries primarily through peritoneal lavage, CT scanning, or surgical exploration. The care of suspected liver injuries included repair of vascular, parenchymal, or biliary structures and drainage of the perihepatic spaces to control biliary leaks and to avoid sepsis, said Dr. Christmas, a surgical resident at the University of Louisville (Ky.).

Improvements in imaging technologies for diagnosing solid-organ injuries and an increased interest in critical care monitoring have prompted a paradigm shift toward nonoperative management. In hemodynamically stable patients with blunt liver injury, nonoperative management has evolved into the standard of care at most U.S. trauma centers, Dr. Christmas said.

Although the reported success rate for nonoperative management of hepatic trauma ranges from 82% to 100%, justification for the preference of either operative or nonoperative management remains ambiguous, he said.

Dr. Christmas and his colleagues reviewed 561 cases of blunt liver injury in the trauma registry at the university during 1993–2003.

Operative management—defined as undergoing an operation within 24 hours after admission—in 183 patients led to higher overall mortality than did nonoperative management in 378 patients (18% vs. 5%); liver-related mortality similarly was higher in those who received operative management (11% vs. 0.4%). Hemodynamic instability occurred in 20% of the operatively managed patients but in none of those managed nonoperatively.

Operative mortality rose with the grade of hepatic injury, such that 7% of patients with grade 1 liver injury and 92% with grade 5 injury died. Patients with severe liver injury (grades 3–5) who were treated operatively had significantly higher mortality than did those treated nonoperatively.

The management strategy for grade 2 or 3 liver injury did not significantly impact mortality.

The percentage of patients able to be managed nonoperatively dropped as the grade of liver injury increased; 82% of patients with grade 1 injury and 32% with grade 5 injury received nonoperative care. One patient died as a result of nonoperative management when he bled after angiographic embolization and required an operation on the first post-injury day. He died on the third day after injury.

Intraabdominal injuries associated with blunt liver injury required an operation in 19% of nonoperatively managed patients. A total of 3% of patients who originally received nonoperative management ultimately required laparotomy after the first 24 hours.

Adjunctive surgical procedures, such as biliary drainage, endoscopic retrograde cholangiopancreatography, and angiographic embolization, were performed with a high degree of success in 42 patients managed nonoperatively, Dr. Christmas said.

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