Non‐operative management of blunt liver injury: a new protocol for selected hemodynamically unstable patients under hypotensive resuscitation

Mitsusada, Makoto; Shirokawa, Masamitsu; Takeda, Toshiaki; Honda, Hideki

doi:10.1002/jhbp.19

Cited by 6 publications

(6 citation statements)

References 15 publications

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“…Recent studies have indicated that the selective nonoperative management of blunt hepatic and splenic injuries is a feasible strategy, even for hemodynamically unstable patients or those with a high grade of injuries. [ 19 , 20 ] Our present findings are consistent with these previous results, which implies that selectively performing CT scans would help physicians reduce unnecessary laparotomy in hemodynamically unstable patients.…”

Section: Discussionsupporting

confidence: 92%

Characteristics of computed tomography in hemodynamically unstable blunt trauma patients

Kim

Cho

et al. 2017

Medicine

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Emergent exploratory laparotomy is recommended for hemodynamically unstable blunt trauma patients suspected of having hemoperitoneum. However, given the unreliability of ultrasonography and rapid scan speed of computed tomography (CT), CT might help clinicians provide accurate information even in hemodynamically unstable trauma patients. This observational study aimed to describe the bleeding site and hospital course of severe blunt trauma patients with hemoperitoneum diagnosed by CT scan.We enrolled all consecutive adult blunt trauma patients (≥18 years old) who underwent whole-body CT before operation between February 2012 and October 2016. Patients with hemoperitoneum on CT images were included and categorized into hemodynamically stable and unstable (persistent hypotension despite fluid resuscitation) groups.Among 1723 severe blunt trauma patients, 136 patients with hemoperitoneum were included. Of these, 98 (72.1%) patients had documented intraperitoneal injury, and the liver (60.2%) was most frequently damaged site, followed by spleen (23.5%) and mesentery (23.5%). The rate of intraperitoneal organ injury did not differ between hemodynamically stable (n = 107) and unstable (n = 29) groups (69.2% vs 82.8%, P = .15), while the documented active internal bleeding was high in the unstable group (29.9% vs 69.0%, P < .001). In the unstable group, 14 (48.3%) patients underwent emergent operation, while 3 patients underwent embolization, and the others were treated in a conservative manner.Even in hemodynamically unstable hemoperitoneum patients, 17.2% had no documented intraperitoneal injury and over half of the patients were treated without emergent operation.

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Section: Discussionsupporting

confidence: 92%

Characteristics of computed tomography in hemodynamically unstable blunt trauma patients

Kim

Cho

et al. 2017

Medicine

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“…Most prior studies concluded that the main reason for the failure of NOM is the hemodynamic instability, whereas this observation was contradicted by Mitsusada et al [ 23 ]. Various predictors of NOM failure have been documented in the literatures [ 2 , 9 , 13 , 24 – 26 ].…”

Section: Discussionmentioning

confidence: 97%

“…According to the study of Miller et al [ 14 ], the failure rate of NOM attempted for high-grade BSI improved from 15% to 5% with the incorporation of a protocol. Mitsusada et al [ 23 ] reported that NOM of BHI applied for selected hemodynamically unstable patients (target SBP of 80 mmHg) under a revision protocol can decrease the overall laparotomy rates and transfusion requirements. Accordingly, a protocol based algorithm for the management of BHSI is proposed.…”

Section: Discussionmentioning

confidence: 99%

Non-operative management attempted for selective high grade blunt hepatosplenic trauma is a feasible strategy

et al. 2014

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BackgroundThere is growing evidence of clinical data recently for successful outcomes of non-operative management (NOM) for blunt hepatic and spleen injuries (BHSI). However, the effectiveness of NOM for high-grade BHSI remains undefined. The aim of the present study was to review our experience with NOM in high-grade BHSI and compare results with the existing related data worldwide.MethodsIn this retrospectively protocol-driven study, 150 patients with grade 3–5 BHSI were enrolled during a 3-year period. Patients were divided into immediate laparotomy (immediate OP) and initial non-operative (initial NOM) groups according to hemodynamic status judged by duty trauma surgeon. Patients who received initial NOM were divided into successful NOM (s-NOM) and failed NOM (f-NOM) subgroups according to conservative treatment failure. We analyzed the clinical characteristics and the outcomes of patients.ResultsTwenty-eight (18.7%) patients underwent immediate operations, and the remaining 122 (81.3%) were initially treated with NOM. Compared with the initial NOM group, the immediate OP group had significantly lower hemoglobin levels, a higher incidence of tube thoracostomy, contrast extravasation and large hemoperitoneum on computed tomography, a higher injury severity score, increased need for transfusions, and longer length of stay (LOS) in the intensive care unit (ICU) and hospitalization. Further analysis of the initial NOM group indicated that NOM had failed in 6 (4.9%) cases. Compared with the s-NOM subgroup, f-NOM patients had significantly lower hemoglobin levels, more hospitalized transfusions, and longer ICU LOS.ConclusionsNOM of high-grade BHSI in selected patients is a feasible strategy. Notwithstanding, patients with initial low hemoglobin level and a high number of blood transfusions in the ICU are associated with a high risk for NOM failure.

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“…A total of 18 of them were excluded because they did not focus on the primary subject, 5 of them were excluded because they were case reports and 2 of them were excluded because they were not written in the English language. Finally, a total of 10 studies were included in the review [9][10][11][12][13][14][15][16][17][18]. Almost all of them were retrospective studies and only one was an observational study.…”

Section: Resultsmentioning

confidence: 99%

Damage Control Interventional Radiology in Liver Trauma: A Comprehensive Review

Corvino,

Giurazza,

Marra

et al. 2024

JPM

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The liver is the second most common solid organ injured in blunt and penetrating abdominal trauma. Non-operative management (NOM) has become the standard of care for liver injuries in stable patients, where transarterial embolization (TAE) represents the main treatment, increasing success rates and avoiding invasive surgical procedures. In hemodynamically (HD) unstable patients, operative management (OM) is the standard of care. To date, there are no consensus guidelines about the endovascular treatment of patients with HD instability or in ones that responded to initial infusion therapy. A review of the literature was performed for published papers addressing the outcome of using TAE as the primary treatment for HD unstable/transient responder trauma liver patients with hemorrhagic vascular lesions, both as a single treatment and in combination with surgical treatment, focusing additionally on the different definitions used in the literature of unstable and transient responder patients. Our review demonstrated a good outcome in HD unstable/transient responder liver trauma patients treated with TAE but there still remains much debate about the definition of unstable and transient responder patients.

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Non‐operative management of blunt liver injury: a new protocol for selected hemodynamically unstable patients under hypotensive resuscitation

Abstract: All the selected unstable patients were successfully managed non-operatively after the protocol revision. The decrease in laparotomy rates and transfusion requirements confirmed the feasibility of our new protocol for these selected patients.

Cited by 6 publications

References 15 publications

Characteristics of computed tomography in hemodynamically unstable blunt trauma patients

Characteristics of computed tomography in hemodynamically unstable blunt trauma patients

Non-operative management attempted for selective high grade blunt hepatosplenic trauma is a feasible strategy

Damage Control Interventional Radiology in Liver Trauma: A Comprehensive Review

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