Non-operative management of blunt liver trauma in a level II trauma hospital in Saudi Arabia.

BACKGROUND: To evaluate our experience with non-operative management of blunt liver trauma at a level II trauma hospital in the Kingdom of Saudi Arabia.
MATERIALS AND METHODS: We prospectively evaluated 56 patients treated for blunt liver trauma at our hospital over a 4-year period (April 2008 to April 2012). Patients who were hemodynamically stable [non-operative group I (NOP)] were treated conservatively in the intensive or intermediate care unit (ICU or IMCU). Patients who were hemodynamically unstable or needed laparotomy for other injuries were treated by urgent laparotomy [operative group II (OP)]. All NOP group patients had computed tomography (CT) of the abdomen with oral and intravenous contrast. Injuries grades were classified according to the American Association for the Surgery of Trauma (AAST). Follow-up CT of the abdomen was performed after 2 weeks in some cases.
RESULTS: A total of 56 patients were treated over a 4-year period. Twenty patients (35.7%) were treated by immediate surgery. NOP group of 36 patients (64.3%) were managed in the ICU by close monitoring. Surgically treated group had more patients with complex liver injury (90% versus 58.3%), required more units of blood (6.05 versus 1.5), but had a longer hospital stay (16.6 days versus 15.1 days). None of the patients from the non-operated group developed complications nor did they need operation. The only mortality (in two patients) was in the operated group.
CONCLUSION: The NOP treatment is a safe and effective method in the management of hemodynamically stable patients with blunt liver trauma. The NOP treatment should be the treatment of choice in such patients whenever CT and ICU facilities are available.

INTRODUCTION

The liver is the largest solid abdominal organ with a relatively fixed position, which makes it prone to injury. The most common cause of liver injury is blunt abdominal trauma, which is secondary to motor vehicle crashes (MVC), and associated injuries contribute significantly to mortality and morbidity and may masks the liver injury, leading to a delay in diagnosis.[123]

Management of hepatic injuries has evolved over the past 30 years. Prior to that time, a diagnostic peritoneal lavage positive for blood was an indication for exploratory laparotomy because of concern about ongoing hemorrhage and/or missed intra-abdominal injuries needing repair.[4] The recognition that between 50% and 80% of liver injuries stop bleeding spontaneously, coupled with better imaging of the injured liver by computed tomography (CT) has led progressively to the acceptance of non-operative (NOP) management with a resultant decrease in mortality rates.[5] Modern treatment of liver trauma is increasingly NOP. Advantages of NOP management include avoidance of non-therapeutic celiotomies and the associated cost and morbidity, fewer intra-abdominal complications compared to operative repair, and reduced transfusion risks. It is associated with a low overall morbidity and mortality and does not result in increases in length of the hospital stay, need for blood transfusions, bleeding complications, or associated hollow viscus injuries as compared with operative management. Improvement in resuscitation and careful monitoring in high dependency unit, coupled with advances in diagnostic tools has helped to make a NOP policy possible and acceptable.[678] Neither the grade of injury nor the amount of hemoperitoneum on CT predicts the outcome of NOP management and mandates laparotomy.[9]

Surgeons should have a clear understanding of the indications for operative intervention.[10] Patients with hepatic trauma associated with hemodynamic instability and other organ injuries require surgery, because they continue to have significantly higher mortality.[1112]

This study evaluated the outcome of NOP management of liver injury in a level II trauma hospital in Saudi Arabia.

MATERIALS AND METHODS

During a 48-month study period, starting April 2008, we prospectively included all patients who were admitted to our level II trauma hospital with blunt liver trauma diagnosed by abdominal ultrasonography (US) and CT in hemodynamically stable patients and operative findings in hemodynamically unstable patients. Ethical approval to conduct the study was obtained from our hospital ethics’ review committee before the commencement of the study.

Our protocol for treating patients with suspected blunt abdominal trauma was immediate resuscitation and Focused Abdominal Ultrasonography for Trauma (FAST) done (while resuscitation going on) in the emergency department (ER); once free intra-peritoneal fluid was detected in hemodynamically unstable patient, they were shifted immediately to the operative room (OR) for exploratory laparotomy and, if liver injury was found, they were included in the operative group (group II).

In hemodynamically stable patients found to have intra peritoneal fluid by abdominal US, abdominal CT with intravenous contrast was done immediately or within 24 hours in all cases and liver injury graded by CT were included in group I (NOP group) [Figures 1–3]; all patients were admitted in the intensive or intermediate care unit (ICU or IMCU) and kept under close observation. All the patients were monitored for serial complete blood count (CBC) assessment every 8-12 hours. All patients were advised to restrict their activity quietly in the bed for 48-72 hours. When three serial CBC assessments were stable and the follow-up abdominal US findings had not worsened, the patients were shifted to the ward and allowed quiet activity. On the 7th day, if there was no significant alteration in the hematology and US findings and the patient continued to be stable, the patient was discharged home with instructions to restrict activity at home for 2-4 weeks from the time of injury. Moreover, these patients were regularly followed-up bi-weekly at a outpatient clinic.

Figure 1

Axial post-contrast CT shows small hepatic contusion

Figure 3

Axial post-contrast CT shows capsular tear, large stellate hepatic laceration involving segments 7 and 8, active hemorrhage, and subcapsular hematoma, grade IV

Axial post-contrast CT shows capsular tear, stellate hepatic laceration with injury close to the hilum, no hematoma, grade III

Data on demographic characteristics, injury type and severity, associated injuries, blood transfusions, interventions, failure of NOP management, hospital stay, and death were presented. Patients were grouped into those who underwent an immediate operation (OP) and those who were managed without operation (NOP).

Assessment of hemodynamic stability was based on routine vital signs. Patients with systolic blood pressure >90 mmHg, either at admission or after 2 l crystalloid infusion, were generally regarded as hemodynamic stable. NOP management was applied to all hemodynamic stable patients with hepatic injury, regardless of the grade of liver injury.

Injury severity was determined from CT and operative observations and classified by means of the Liver Injury Scale (LIS) [Table 1].[13] Patients who underwent laparotomy for hemodynamic instability or any other indication, either with or without a CT scan, were classified as being treated operatively. Other patients admitted to the ICU or surgical ward for observation were classified as being treated non-operatively.

Table 1

The liver injury scale classification[13]

Any patient who was initially observed in the ICU and subsequently required surgery was considered a failure of NOP management. NOP management was discontinued in patients with hemodynamic instability, who were unresponsive to moderate amounts of crystalloid infusion, who had a significant fall in hematocrit and hemoglobin concentration, or if any intra-abdominal hollow viscus injury was suspected. There were no other specifically defined criteria for abandonment of NOP management.

Statistical analysis was performed with SPSS version 19 using the Chi-square test for discrete variables and the unpaired t test for continuous variables. Level of significance was set at P < 0.05.

RESULTS

A total number of 4382 trauma patients were referred to our hospital and 846 (19.3%) patients had abdominal trauma; 56 patients (6.6%) had hepatic injury, 52 (92.9%) were male, and 4 (7.1%) were female. The mean age was 36.7 ± 15.3 years (range 17-81 years) [Table 2]. Most hepatic trauma were due to motor vehicle crashes (MVCs) including car drivers and pedestrians, 50 cases (89.2%) while non-traffic causes including falls were the etiology in 5 patients (8.9%) of blunt hepatic trauma [Table 3]. Associated traumas (85.7%) included both intra and extra-abdominal injuries. Spleen trauma was the most common associated intra-abdominal injured organ seen in 4 (7.1%) patients. Other associated injuries were thorax (26.8%), intracranial injury (25%), and lower extremity (12.5%). Isolated hepatic injuries were in 8 (14.3%) cases [Table 3]. Duration of hospital stay was 0-36 days with a mean of 15.6 ± 7.6 days and a median of 14.5 days. There was insignificant difference in hospital stay between the patients operated and those managed non-operatively [Table 2]. Patients with operative management had significantly worse admission hemodynamic parameters, higher ISS, and higher grade of liver trauma. ISS mean and median were 26.3 ± 12.8 and 25 years, respectively. One patient was explored because of renal injury [Figure 4]. Grading of injury showed significant difference with the management (P < 0.001). A significantly higher death rate was in the patients with higher ISS (P < 0.0001). Dead patients had higher grade of injury. In group II patients, bleeding was controlled via techniques of suturing, packing, resection, and debridement [Table 4 and Figure 5]. Two patients with grade V and VI of injury needed immediate surgery and died due to severity of injury and hemorrhage.

Table 2

Characteristics of patients groups

Table 3

Grades, causes of liver injury, and associated injuries

Figure 4

Coronal post-contrast CT shows combined liver and right kidney injury and the patient was explored, liver tear sutured, and kidney repaired

Table 4

Operative methods for controlling bleeding in patients (n=20) with liver trauma

Figure 5

Intraoperative liver tear stopped bleeding spontaneously

DISCUSSION

The size of the liver and its solid (non-compressible) consistency when combined, renders it vulnerable to blunt forces, applied either to the upper abdominal or lower thoracic regions, especially on the right. It is the most frequently damaged abdominal organ and is second only to the brain in overall visceral susceptibility to this modality of violence.[14] Because the liver is predominantly perfused with low-pressure venous blood, hepatic parenchymal injuries can often be treated non-operatively in stable patients. In the absence of definable active arterial extravasation, even extensive lacerations may be treated conservatively.[15] Non-surgical treatment has become the standard of care in hemodynamically stable patients with blunt liver trauma. The use of helical CT in the diagnosis and management of blunt liver trauma is mainly responsible for the notable shift during the past decade from routine surgical to non-surgical management of blunt liver injuries.[12]

In the literature, the most common cause of liver injury is blunt abdominal trauma, which is secondary to MVC; in most instances, blunt liver trauma is associated with spleen injury in 45% of patients. Rib fractures are associated with injury to the right superior aspect of the liver in 33% of patients. Isolated liver injury occurs in <50% of patients. Both blunt and penetrating liver injuries are more common in males, which are similar to our results mentioned above.[161718] Konig et al., reviewed their liver trauma to assess their experience with these injuries, and the success of NOP management protocols and concluded liver trauma managed in a trauma centre has low morbidity and mortality. Mortality is governed mainly by poly trauma and, in the case of the liver, by the severity of grade of injury.[3] In our study, success rate of NOP was 100%, none of the case needed laparotomy; this coincide with the reported success rate in literatures. Initially, NOP management was applied to only lower-grade hepatic injuries and to patients with only mild to moderate amounts of hemoperitoneum.[11] As experience accumulated, more patients with blunt hepatic injury were managed non-operatively. In the current study, hemodynamically stable patients with no other injuries requiring operative intervention formed 64% of the total cases, and all these patients were successfully managed none surgically. In the initial reports of NOP management, there was concern that it would lead to higher transfusion requirements and to prolonged ICU and hospital lengths of stay. Although there have been reports about excessive blood being transfused in the hope that bleeding will stop, in recent studies, NOP management did not carry with it a greater need for transfusion than did operative management. Most reports agree with our study, that transfusion requirements are less with NOP management.[151920]

Complication such as “biloma” and abscess formation has been reported. Their incidence varies from 2.8% for biloma and 0.7% for abscess.[21] We had no case of such complications.

Our patients who were non-operatively managed, showed no significant difference in the hospital lengths of stay. The death rate of all patients with liver injury was 3.6%, very similar to the rate in other reports.[415] Patients with significant liver injury leading to death usually have early indications for surgery. All patients managed non-operatively were alive with no death reported [Table 5].

Table 5

Literature review of outcome of NOP management of liver injury

Limitation of study

In this study, all hemodynamically stable patients, irrespective of the grade of hepatic injury, underwent NOP management. We could not try to shorten the hospital stay for NOP group and will be considered in the future study.[23]

CONCLUSION

We concluded that hemodynamically stable patients with liver injuries can be managed safely non-operatively, while urgent surgery continues to be the standard for hemodynamically compromised patients. NOP management does not lead to longer hospital stay or increased blood transfusion rates and it had excellent outcome.