Selective non-operative management of penetrating liver injuries at a UK tertiary referral centre

Abstract

INTRODUCTION Selective non-operative management (SNOM) of penetrating abdominal injuries has increasingly been applied in North America in the last decade. However, there is less acceptance of SNOM among UK surgeons and there are limited data on UK practice. We aimed to review our management of penetrating liver injuries and, specifically, the application of SNOM. METHODS A retrospective review was performed of patients presenting with penetrating liver injuries between June 2005 and November 2013. RESULTS Thirty-one patients sustained liver injuries due to penetrating trauma. The vast majority (97%) were due to stab wounds. The median injury severity score was 14 and a quarter of patients had concomitant thoracic injuries. Twelve patients (39%) underwent immediate surgery owing to haemodynamic instability, evisceration, retained weapon or diffuse peritonism. Nineteen patients were stable to undergo computed tomography (CT), ten of whom were selected subsequently for SNOM. SNOM was successful in eight cases. Both patients who failed SNOM had arterial phase contrast extravasation evident on their initial CT. Angioembolisation was not employed in either case. All major complications and the only death occurred in the operatively managed group. No significant complications of SNOM were identified and there were no transfusions in the nonoperated group. Those undergoing operative management had longer lengths of stay than those undergoing SNOM (median stay 6.5 vs 3.0 days, p<0.05). CONCLUSIONS SNOM is a safe strategy for patients with penetrating liver injuries in a UK setting. Patient selection is critical and CT is a vital triage tool. Arterial phase contrast extravasation may predict failure of SNOM and adjunctive angioembolisation should be considered for this group.

Embolization in Trauma: Review of Basic Principles and Techniques

“…Many blunt and some penetrating injuries of the liver can be safely managed with NOM in hemodynamically stable patients. 21,22 Superselective embolization is always recommended in most cases unless massive diffuse bleeding is present requiring more proximal and nonselective embolization 23 (►Fig. 12).…”

Changes in Approach to Solid Organ Injury: What the Radiologist Needs to Know

“…49 The CT findings of free fluid and active contrast extravasation in the setting of penetrating trauma predict those patients who are at higher risk of failing NOM. 49 -52…”

Manejo No Operatorio Del Trauma Abdominal Penetrante; En Que Pacientes Realizarlo

“…Otro punto importante de mencionar en este grupo de pacientes es que sólo el 22.73% (5 casos) requirió una TAC contrastada de abdomen, 3 de ellos fueron producidos por proyectil de arma de fuego y 2 por arma corto-punzante, pudiendo deberse a lo mencionado en otros trabajos en cuanto a que la TAC en trauma penetrante tiene un papel limitado con su principal desventaja su baja sensibilidad para diagnosticar lesiones del mesenterio, diafragma y víscera hueca, mientras que ayuda en lesiones de armas de fuego para determinar trayectoria de proyectil y lesiones de órganos contiguos. 26,27,34 Para determinar el desenlace clínico de los pacientes manejados con el protocolo no operatorio, a los 30 días de ocurrido el trauma, se citó a control por consulta externa a cada uno de los pacientes, y en el caso de que no se presentaran, se realizó una llamada telefónica para saber si en realidad el paciente no requirió de ningún otro tipo de intervención; debido a que si bien casi todos los trabajos hablan del éxito de éste tipo de manejo, existe un gran número de pacientes de quienes no se sabe nada luego de su alta, habiendo la posibilidad de que el paciente se haya complicado y que decidiera acudir a otra casa de salud. Este estudio determinó 0% de mortalidad y complicaciones a 30 días de producido el trauma.…”