Blunt Hepatic Injury: A Paradigm Shift From Operative to Nonoperative Management in the 1990s

Abstract

ObjectiveTo 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. Summary Background DataUntil 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. MethodsSix 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). ResultsAll 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 highergrade 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. ConclusionsAlthough 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.

Retrospective Evaluation of Magnitude, Severity and Outcome of Traumatic Hepatobiliary Injury at a Level-I Trauma Center in India

“…The most common mechanism of liver injury in our study was blunt trauma (94 %) due to road traffic injuries among all age groups, which is much higher than reported in published literature [3,4]. Petrowsky et al [4] had reported 84 % incidence of blunt liver injury while Malhotra et al [3] had shown 82 % incidence of blunt liver trauma due to road traffic injuries.…”

“…The incidence of liver injury in our study is higher as compared to reported incidence of liver injury in literature. Croce et al [2] reported 5 % incidence of liver injury while Malhotra et al [3] had reported 4.6 % incidence of liver injury.…”

“…Petrowsky et al [4] had reported 84 % incidence of blunt liver injury while Malhotra et al [3] had shown 82 % incidence of blunt liver trauma due to road traffic injuries.…”

Focus on Blunt Solid Organ Injuries

“…In most cases, treatment of injuries has shifted from early surgical treatment to NOM. NOM of blunt abdominal injuries is well established and strategies based on hemodynamic stability and CT scan findings are now widely used in the treatment of solid organ injuries [3][4][5].…”

“…Over the past three decades multiple studies have shown that NOM of solid organ injuries is effective, with a reported success rate of more than 90% [3][4][5].…”