- Email: [email protected]
Non-operative management of blunt hepatic injury in multiply injured adult patients
Original Article
Non-operntive management ofblunt hepatic injury in multiply injured adult patients
A.S. AI-Mulhim H.A.H. Mohammad* Department of Surgery, KingFahad Hospital, Hofuf, P.O. Box 1164, Hofuf, AI-Hassa 31982 * Department of Surgery, Zagazig University, Egypt Correspondence to: A.S. AI-Mulhim, Department of Surgery, King Fahad Hospital, Hofuf, P.O. Box 1164, Hofuf, AI-Hassa 31982 Email: [email protected]
Background: Non-operative management of blunt liver trauma has now evolved into a common practice especially since abdominal CT has enabled a more precise evaluation of these patients. Clinical Material: Sixty-three patients, haemodynamically stable, were eligible for the study and enrolled into the protocol of non-operative management of blunt hepatic injury. Fifty-two (82.5%) patientswere successfully managed non-operatively (non-operative group). The remaining 11 (17.5%) patients failed the non-operative management and underwent exploratory laparotomy (laparotomy group). Results: Patients managed non-operatively tended to be younger than patients managed operatively (p < 0.05). The mean values of ISS were 16.2 ± 6.1 , 26.1 ± 8.5, P < 0.001 , in the nonoperative and laparotomy groups, respectively. Stay in the ICU wassignificantly decreased in the nonoperative patients (p < 0.001). Patients who had a laparotomy significantly increased requirement for bloodtransfusion (p < 0.001). Six (9.5%) patients managed non-operatively developed complications; perihepatic collections were observed in two patients, an urinoma in one patient and chest infection in three patients. Perihepatic collections and urinoma were successfully drained percutaneously by CTguidance and no furthertreatment was required. The mortality rate of the entire series of patients was 4.8% (three patients); one death couldbe related to hepatic injury itself andthe othertwo deaths were attributed to non-hepatic causes. No deaths occurred in the non-operative group. Conclusion: Non-operative management should be the initial approach to all patients with blunt liver injuries if haemodynamic stability can be ensured. When continued bleeding can be safely ruled out, a period of close monitoring in the ICU is warranted Keywords: Hepatic injury, non-operative S urg.l R Coil Surg Edinb Irel., I April 2003, 81-85
INTRODUCTION Until recently, operative management was the standard of care in treating liver injuries. Non -op erati ve management of blunt liver trauma, howe ver, has now evolved into a common practice , especially since abdominal computed tomography (CT) has enabled more preci se evaluation of these patie nts.F The strategy for this arose from the ob servations that many liver injuries had stopped bleeding at the time of laparotomy and needed little or no intervention. ' Guidelines for non-operati ve management of blunt liver injuries have been produced and published.v' > Improvement in resuscitation, careful monitoring in the intensive care unit © 2003 Surg J R Coli Surg Edinb Irelt: 2: 81-85
(ICU), coup led with advances in diagn ostic radiolo gy has helped to make non-operative polic y possible and acceptable amongst surgeons."? The aim of our stud y was to determ ine the place of non -operative management in haemod ynami cally stable patient s with blunt liver injuries , and appropriate CT information .
CLINICAL MATERIAL Of the 9 1 patients, 28 (30.8% ) were haemodynamically unstable and judged to be unsuitable for non-operative management, and underwent immediate exp loratory laparotomy. The remaini ng 63 pati ents were enrolled The Royal Colleges of Surgeons of Edinbu rgh and Ireland --~ ;11
w,
REFERENCES I.
2.
Meredith JW. Young J . Bowling J and RoboussinD. Non-operative management of blunt hepatic trauma: the exception or the rule. J Trauma 1994: 36: 529-35 . Pachter HL. Hofstetter SR. The current status of non-operative management of adult hepatic injuries. Am J Surg 1995: 169: 442-54.
3.
Fabian Te. Croce MA. Stanford GG. Payne LW. Mangiante sc, Voeller GR. Kudsk KA. Factors affecting morbidity following hepatic trauma: a prospective analysis of 482 injuries. Ann Surg
4.
Riad e. David e. Keith G and Gene AG. Evolution in the management of the complex liver injury at a level I trauma center. J
5.
Holland MJ. and Little JM. j onoperative management of blunt liver injuries. Br J Surg 1992: 78:
1991: 2 13: 540-44 .
Trauma 1998; 45: 1079-82.
968-74. 6.
Fang JF. Chen RJ. Lin Be. Hsu YB, Kao JL and Chen MF. Blunt hepatic injury: minimal intervention is the policy of treatment. J Trauma 2000; 49: 722-28 .
7.
Lauren PA. Frederick BR and Steven RS. Selective nonoperativemanagementofliver and spleen injuries in neurologically impairedadult patients. Arch Surg
into the protocol of non-operative management and constituted the basic group of this study (Figure I). The decision to implement immediate surgical intervention was based on clinical findings. Exploratory laparotomy was performed on patients who had evidence of massive bleeding on presentation , persistent hypotension despite acti ve resuscitation, transfusion requirements of more than half their blood volume (40mllkg bodyweight) or associated hollow viscus injury." The criteria for non-operative management of blunt hepatic trauma , in our study, included the following: patients with liver injuries documented by CT who were haemodynamically stable , regardless of the extent of liver injury; hepatic-related transfusion limited to four units of blood; and absence of other abdominal injuries that would require exploratory laparotomy. 10 Haemodynamic stability was defined as serial blood pressure and heart rate measurements within the appropriate age range and with adequate end-organ perfusion, either initially or after limited fluid resuscitation. 1.2.1 I Initial resuscitation with Ringer 's lactate solution was carried out for all patients. Blood samples were taken and sent for routine haematology and biochemistry (including hepatic enzymes and serum amylase levels ), blood typing, etc. After resuscitation, all patients underwent CT scanning with 1em
TABLE1. MECHANISMS OF BLUNT HEPATIC INJURIES IN THE STUDIED POPULATION Mechanism of injury
Number
%
Motor vehicle accident Fall from height Pedestrian accident Sporting injuries Bicycle accidents Others
33 16 4 3 3 4
52.4 25.4
TOTAL
63
100.0
6.3 4.8 4.8 6.3
intervals from the lower chest to the pubic symphysis . Double contrast CT wa s performed with intra venous and orally administered contrast to improve visualisation of intraabdominal structures. Additional investigations were obtained based on suspicion of other injuries. According to the Organ Injury Scale (1994 revis ion) adopted by the American Association for the Surgery of Trauma, all hepat ic and associated other abdominal organ injuries were graded based on the appearance of the CT scan." The amount of haemoperitoneum was quantitated as follows: minimalperihepatic blood in the subphrenic or subhepatic space (approximately 500ml); moderate-perihepatic and blood along the paracolic gutter (less than lL); and large -perihepatic and blood along the paracolic gutter and accumulating in the pelvic cavity (more than 1L).13 Once the diagnosis of hepatic injury was established by CT, all patients were admitted to the intensive care unit (ICU) for close observation and monitoring for a variable length of stay. The patients were monitored in the ICU with serial haemoglobin assessments (every four hours) . When four serial assessments were stable, patients were transferred to a general surgical unit. On postadmission day three , patients were allowed to start quiet activ ity. On postadmission day seven, ifhaematology had not altered significantly, patients were discharged hom e after repeating the CT examination. Patients were instructed to undertake restricted acti vities at home for three weeks from the time of injury. A repeat of the abdominal CT was also considered in patients who had a decrease in haematocrit that may be related to liver injury to see if the injury had progressed. The patients were regularly evaluated on an outpatient's basis; weekly for four weeks and then monthly for two months . At three months post-injury, all the patients returned to the clinic for a final clinical assessment and CT examination. If they were clinicall y well at that time , they were allowed to return to full activity without restriction. © 2003Surg J R Coif Surg Edinb Irel1: 2: 81·85
TABLE 2. CLINICAL CHARACTERISTICS OF NON-OPERATIVE AND LAPAROTOMY GROUPS OF PATIENTS Parameters Age ICU stay
Non-operative group (n=52)
Laparotomy group
P value
32.8 ± 14.6
46.2 ± 15.9
< 0.05
2.5 ± 0.73
4.6 ± 1.4
< 0.001
GCS
14.2 ± 1.7
13.0 ± 2.9
> 0.05
ISS
16.2 ± 6.1
26.1 ± 8.5
< 0.001
247.3 ± 11 1.5
254 .1 ± 139.3
> 0.05
SGPT levels Blood transfusions (m/kgBWt)
19.1 ± 6.9
Failure of non-operative management was determined by clinical and laboratory evidence of ongoing haemorrhage or by the development of peritonitis. Continued haemorrhage was defined clinically by progressive abdominal distension and/or by the presence of tachycardia or hypotension refractory to fluid resuscitation. A fall in the haematocrit or persistent acidosis following resuscitation, were used as laboratory evidence of ongoing haemorrhage.' The injury severity score (ISS), the Glasgow coma scale (GCS), transfusion requirements, liver transaminase levels, associated injuries, length of stay in the ICU, complications both in hospital and within three months of discharge and total mortality were analysed.I'-" All the data were reported as the mean and standard deviation, and were compared using the student's t test.
RESULTS The present study included 63 patients with blunt hepatic injuries. Men constituted 65.1% of the population. Table 1 shows the mechanisms of injury: motor vehicle accident (49.2%) and fall from a height (25.4%) were the most common causes of blunt hepatic injuries in our study. Fifty-two (82.5%) of 63 patients, initially selected for nonoperative management, were managed successfully (non-operative group). The remaining 11 (17.5%) patients © 2003 Surg J R ColiSurg Edinb Ire/I: 2: 81-85
37.3 ±4.1
failed non-operative management and underwent exploratory laparotomy (laparotomy group). Table 2 compares the non-operative management and laparotomy groups. The mean values of age were 32.8 ± 14.6,46.2 ± 15.9, in the non-operative and laparotomy groups, respectively. Patients managed nonoperatively tended to be younger than those treated operatively (p < 0.05). A significant (p < 0.001) increase in the mean values of ISS, requirements for blood transfusion and ICU stay, was observed in the laparotomy compared with the non-operative patients. The initial liver transaminase (SGPT) value was elevated in 56 (87.5%) patients of the entire population. The mean values of SGPT were 274.3 ± 111.5, 254.1 ± 139.3, in the non-operative and laparotomy groups, respectively; were not significantly different between the two groups (Table 2). Despite evidence of hepatic injury on admission by CT scanning, the initial serum SGPT values were normal in seven (11.1%) patients. Eleven (17.5%) of our studied patients failed non-operative management, 1-7 days after admission. Seven of the 63 (11.1%) patients were explored for clinical evidence of ongoing haemorrhage with a falling haematocrit or a worsening appearance on CT scanning. The remaining four patients underwent exploratory laparotomy for the following indications, intestinal injury (two cases), pancreatic injury
< 0.001
8.
9.
10.
I I.
12.
13.
14.
1996; 131 : 309-14. David AP, Denis DB. Ernest EE and FrederickMK. on-operative Management of Solid Organ Injuries in Children Results in Decreased Blood Utilization. J Pedia tr 1999;34: 1695-99. Carrillo EH. Spain DA, Wohltmann CD. Schmieg RE. Boaz PW. Miller FB. Richardson JD. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma 1999;46: 619-24. Carrillo EH, Platz A, Miller FB, Richardson JD and Polk He. on-operative management of blunt hepatic trauma. Br J Surg 1998;85: 461-68. Durham RM, Buckley J, Keegan M, Fravell S, Shapiro MJ. Mazuski J. Management of blunt hepatic injuries. Am J Surg 1992: 164: 477-51. Moore EE.CogbillTH. Malangeni MA, Jurkovi GJ, Shackford SR, Champion HR, McAninch J\V. Organ injury scaling. SlIIg Clin North Am 1995; 75: 293-97. Yih-Gang e. Mu-Shun Hand Jer-Ming L Non-operative management for extensive hepatic and splenic injuries with significant hemoperitoneum in adults. J Trauma 1998: 45: 36065. Baker SP and ei1 B. The injury
The Royal Colleges of Surgeons of Edinburgh and Ireland _ _:11 ~
15.
16.
17.
18.
19.
20.
21.
22.
23.
severity score . J Trauma 1972; 16: 882-85 . Champion HR. Sacco W1. Cope WS. Gann DS. Gennarclli TA and Flanagan ME. a revision of the trauma score . J Trauma 1989; 29: 623-26 . Boone DC. Federle M, Billiar TR ct al. Evolution of management of major hepatic trauma: identification of patterns of injury. J Trauma 1995; 39 : 344-50. Croce MA. Fabian TC and Menke PG. on-operative management of blunt hepatic trauma is the treatment of choice for haemodynamicallystable patients. Results of a prospective trial. AIIII Surg 1998; 22 1: 744-55 . Moon KL and Federle MP. Computed tomography in hepatic trauma. Am J Radiol 1983; 141: 309-17. Meyer AA. Crass RA. Lim RC. Jeffrey RB. Federle MP and Trunkey DD. Selective nonoperative management of blunt liver injury using Computed Tomography. Arch Surg 1985; 120: 550-54 . Knudson MM, Lim RC. Oakes DD and Jetfrery RB. onoperative management of blunt liver injuries in adults : the need for continued surveillance. J Trauma 1990; 30: 1494-500. Harold S, Beth AS, Larry MJ, Roger RB. Barbara AL, Jorge RV, Clyde EM, Robert TJ and Andrew HM. Non-operative management of blunt hepatic injuries: safe at any grade. J Trauma 1994; 37 : 616-21.
(one case) and splenic infarction (one case). Associated and multiple injuries were observed in 58 (92 .1%) patients. Associated intraabdominal injuries most commonly invol ved : spleen (14 .3%); intestine (4.8 %); kidney (7.9% ) and pancreas (1.6 %) (Table 3). Extra-abdominal trauma most frequently resulted in thoracic Injury (36.5% ), head injury (26 .98%) , orthopaedic injuries (26 .98%), soft tissue damage ( 19.05%), maxillofacial (7.9%) and spinal injury (4.76%). In the current study, there were six complications in the non-operative group. Two patients developed perihepatic collections. The collection was infected in one patient. Percutaneous CT-guided drainage successfully dealt with these two collections, at seven and nine days after injury. No further treatment was required. A urinoma developed in one patient with renal injury and was successfully drained percutaneously. The remaining three patients developed chest infections and responded to antibiotic therapy. The mortality rate of the entire series of patients was 4.76% (three patients). There was no mortality in patients who underwent successful non-operative management. All of the three deaths occurred in the laparotomy group: two deaths were attributed to non-hepatic causes (severe head and thoracic injury). Only one death could be related to hepatic injury itself. Analysis of this case revealed that the patient had cirrhosis and became hypotensive 30 hours after the injury. Despite active effort to stop the bleeding, this could not be controlled.
Smith JB. Wengrovitz MA. and Delong BS. Prospective validation of criteria, including age, for safe, non-surgical management of the ruptured spleen. J Trauma 1992; 33: 385-89. Charles DG, Ralph LW. Robert LS and Charle s JM. on-operative management of blunt splenic injury in adults: age over 55 years as a powerful indicator for failure. Am LSurg 1996; 183: 133-39.
Non-operative management of blunt hepatic trauma has become an accepted treatment in recent years." The primary requirement of this policy is haemodynamic stability." :" Any physiological instability after initial resuscitation mandates laparotomy and current guidelines recommend surgery if the patient requires replacement of more than half of his/her blood volume. ]-2.5.6.9
DISCUSSION
• • • The Royal Colleges of Surgeons of Edinburgh and Ireland
Until continued bleeding can be ruled out , a period of intensive monitoring is neces sary and an experienced surgical team must follow the patient closel y. In our series, non-operati ve management of blunt liver injuri es was successful in 82.5% of patients . This result is comparable to finding s reported by Croce et al (1993).17 The latter reported a success rate of up to 90% in their patients. Other studies have documented successful non-operative management in 85% to 100% of their patients. ]. 18-20 The hepatic injury grading scale proposed by the American Association for the Surgery of Trauma can serve as a yardstick so that data from different centres can be standardised and compared." However, its use as a decision-making tool has been called into question by many authors.v --" Moon and Federle (1983) found that the need for surgery for patients with blunt hepatic injury was more closel y correlated with the amount of haemoperitoneum than the size of the hepatic laceration. IS In our study, neither the grade of hepatic injury nor the amount of haemoperitoneum could predict the need for laparotomy. Thi s result was in accordance with the pre vious results of Hiatt et al (1990) .24 They suggested that the decision for laparotomy should be determined by the patient's overall clinical picture , not by the "exact nature of liver injury". In our series there were limited numbers of high-grade liver injuries. Patients with grade V and VI liver injurie s were lacking in our study. However, a grad e VI inj ury has a very high mortality rate and patients with this type of injury are unlikely to be in a haemodynam ic stable condition. The initial serum SGPT values were elevated in 56 (87 .5%) patient s studied. The mean values of SGPT were 274.3 ± 111.5, 254 ± 139.3, P > 0.05, in the non-operati ve and laparotomy groups , respectively. Despite evidence of hepatic injury on the admis sion CT, the initial serum SGPT values were normal in seven ( I I %) patients. The initia l serum SGPT value neither excluded the presence of hepatic injury nor predicted © 2003SurgJ R ColiSurg Edinb Ire/l : 2: 81-85
/
~
• •
CT
ICU
k"' ......... Stable patient
Unstable patient
- - - - -- ---.... Surgical intervention
• Moved if haematocritlhaemoglobin levels stable General ward
• •
CTat 7th day
Discharge
the need for laparotomy, in our patients. The severity of injury, in our study, was measured by the ISS.I.J15 A highly significant (p < 0.00 I) increase in the mean value of ISS was observed in the laparotomy group, when compared with the non-operative group. Despite this result, ISS was of limited clinical value when considering any individual case. Judgement to operate or not, in our patients, was dependent mainly on the clinical parameters rather than numerical values of the ISS. Critics of non-operative management cite the potential risk for missing other serious intraabdominal injuries and increasing utilisation of blood transfusion, with all its attendant risks." In the current study, there were no missed injuries. The mean values for blood transfusion requirements were 37.3 ± 4.1, 19.1 ± 6.9, p < 0.001, in the laparotomy and non-operative groups, respectively. The significant increase in requirement for blood transfusion in the laparotomy patients could not be attributed to the severity of the hepatic injury per se, as there was no significant difference in the mean values of grading of hepatic injuries between the two study groups. The significant (p < 0.001) increase in the mean value ofISS, in the laparotomy group of patients, may explain the increased requirements for blood transfusion in this © 2003 Surg J R CallSurg Edinb Ire/t. 2; 8t-85
Figure 1: Protocol used for the enrolement of patients into the study
group. Patients are more likely to receive more blood transfusions if more than one organ is affected. Advancing age has been implicated to influence the success rate of nonoperative management of blunt abdominal trauma.v-"-" Our data show that patients managed non-operatively tended to be younger than patients who underwent surgery (p < 0.05). The majority of our patients who were managed nonoperatively were less than 30 years, while 45.5% of the laparotomy group of patients were more than 50 years of age. Five of eight patients who were older than 50 years, failed non-operative management; two of them were responsible for 66.6% of the total mortality in this series. Intolerance to severe haemodynamic instability may explain the increased incidence of failure in these patients. The non-operative management of blunt hepatic injury, when accompanied by head injury, remains problematic and controversial. Head injury may complicate the management of these patients in two ways; firstly, because of an altered level of consciousness, physical examination may become unreliable, secondly, the potential release of tissue thromboplastin from head trauma (although experimentally unproven) may lower the success rate with non-operative management by impairing the coagulation profile. c5on Head injuries
were observed in 17 (26.9%) patients of our studied population. Analysis of this subgroup revealed that five patients (29.4%) failed non-operative management and their mean GCS value was 10.6 ± 2.96. As the mean value of GCS in nonoperative patients insignificantly differed from that of the laparotomy group of patients (p > 0.05), the failure of nonoperative management may be related to factors other than head injury. Patients who failed non-operative management were older with significantly high ISS (p < 0.001). The existence of these two factors may explain the incidence of failure in these patients. In conclusion, this series has reaffirmed the validity of a selective policy of nonoperative management of blunt liver injury. The most important decision facing the surgeon is to distinguish between patients who need an operation and those in whom an operation may be avoided. Haemodynamically unstable patients need an operation whilst those patients who are stable on arrival or those who respond quickly to fluid resuscitation can be managed non-operatively with a high success rate (82.5%), thereby, reducing the number of unnecessary laparatomies.
Copyright: 12March 2003 24.
25.
26.
27.
Hiatt JR. Harrier I-ID. Keonig BV et al. on-operative management of major blunt hepatic injury with hemoperitoneum . Arch Surg 1990; 125: 101-07. Sande JJ, Veltkamp JJ. Musser! RJ. Vielvoye GJ. Hemostasis and Computerized tomography in head inj ury. J Neurosurg 1981; 55 : 718-26. Gan do S. Tedo I and Kubo ta M. Post-trauma coagulation and fibrinolys is. Crit Care Med 1992; 20: 594-603. Pietropaoli JA. Rogers FB. Shackford SR. Wald WL. Schmoker J D and Zh uang J. The de leterious elTects of intraoperative hypotension: an outcome in patients with severe head injuries. J trauma 1992; 33 : 403-07.
The Royal Colleges of Surgeons of Edinburgh and Ireland
_.-:lllol
Non-operntive management ofblunt hepatic injury in multiply injured adult patients
A.S. AI-Mulhim H.A.H. Mohammad* Department of Surgery, KingFahad Hospital, Hofuf, P.O. Box 1164, Hofuf, AI-Hassa 31982 * Department of Surgery, Zagazig University, Egypt Correspondence to: A.S. AI-Mulhim, Department of Surgery, King Fahad Hospital, Hofuf, P.O. Box 1164, Hofuf, AI-Hassa 31982 Email: [email protected]
Background: Non-operative management of blunt liver trauma has now evolved into a common practice especially since abdominal CT has enabled a more precise evaluation of these patients. Clinical Material: Sixty-three patients, haemodynamically stable, were eligible for the study and enrolled into the protocol of non-operative management of blunt hepatic injury. Fifty-two (82.5%) patientswere successfully managed non-operatively (non-operative group). The remaining 11 (17.5%) patients failed the non-operative management and underwent exploratory laparotomy (laparotomy group). Results: Patients managed non-operatively tended to be younger than patients managed operatively (p < 0.05). The mean values of ISS were 16.2 ± 6.1 , 26.1 ± 8.5, P < 0.001 , in the nonoperative and laparotomy groups, respectively. Stay in the ICU wassignificantly decreased in the nonoperative patients (p < 0.001). Patients who had a laparotomy significantly increased requirement for bloodtransfusion (p < 0.001). Six (9.5%) patients managed non-operatively developed complications; perihepatic collections were observed in two patients, an urinoma in one patient and chest infection in three patients. Perihepatic collections and urinoma were successfully drained percutaneously by CTguidance and no furthertreatment was required. The mortality rate of the entire series of patients was 4.8% (three patients); one death couldbe related to hepatic injury itself andthe othertwo deaths were attributed to non-hepatic causes. No deaths occurred in the non-operative group. Conclusion: Non-operative management should be the initial approach to all patients with blunt liver injuries if haemodynamic stability can be ensured. When continued bleeding can be safely ruled out, a period of close monitoring in the ICU is warranted Keywords: Hepatic injury, non-operative S urg.l R Coil Surg Edinb Irel., I April 2003, 81-85
INTRODUCTION Until recently, operative management was the standard of care in treating liver injuries. Non -op erati ve management of blunt liver trauma, howe ver, has now evolved into a common practice , especially since abdominal computed tomography (CT) has enabled more preci se evaluation of these patie nts.F The strategy for this arose from the ob servations that many liver injuries had stopped bleeding at the time of laparotomy and needed little or no intervention. ' Guidelines for non-operati ve management of blunt liver injuries have been produced and published.v' > Improvement in resuscitation, careful monitoring in the intensive care unit © 2003 Surg J R Coli Surg Edinb Irelt: 2: 81-85
(ICU), coup led with advances in diagn ostic radiolo gy has helped to make non-operative polic y possible and acceptable amongst surgeons."? The aim of our stud y was to determ ine the place of non -operative management in haemod ynami cally stable patient s with blunt liver injuries , and appropriate CT information .
CLINICAL MATERIAL Of the 9 1 patients, 28 (30.8% ) were haemodynamically unstable and judged to be unsuitable for non-operative management, and underwent immediate exp loratory laparotomy. The remaini ng 63 pati ents were enrolled The Royal Colleges of Surgeons of Edinbu rgh and Ireland --~ ;11
w,
REFERENCES I.
2.
Meredith JW. Young J . Bowling J and RoboussinD. Non-operative management of blunt hepatic trauma: the exception or the rule. J Trauma 1994: 36: 529-35 . Pachter HL. Hofstetter SR. The current status of non-operative management of adult hepatic injuries. Am J Surg 1995: 169: 442-54.
3.
Fabian Te. Croce MA. Stanford GG. Payne LW. Mangiante sc, Voeller GR. Kudsk KA. Factors affecting morbidity following hepatic trauma: a prospective analysis of 482 injuries. Ann Surg
4.
Riad e. David e. Keith G and Gene AG. Evolution in the management of the complex liver injury at a level I trauma center. J
5.
Holland MJ. and Little JM. j onoperative management of blunt liver injuries. Br J Surg 1992: 78:
1991: 2 13: 540-44 .
Trauma 1998; 45: 1079-82.
968-74. 6.
Fang JF. Chen RJ. Lin Be. Hsu YB, Kao JL and Chen MF. Blunt hepatic injury: minimal intervention is the policy of treatment. J Trauma 2000; 49: 722-28 .
7.
Lauren PA. Frederick BR and Steven RS. Selective nonoperativemanagementofliver and spleen injuries in neurologically impairedadult patients. Arch Surg
into the protocol of non-operative management and constituted the basic group of this study (Figure I). The decision to implement immediate surgical intervention was based on clinical findings. Exploratory laparotomy was performed on patients who had evidence of massive bleeding on presentation , persistent hypotension despite acti ve resuscitation, transfusion requirements of more than half their blood volume (40mllkg bodyweight) or associated hollow viscus injury." The criteria for non-operative management of blunt hepatic trauma , in our study, included the following: patients with liver injuries documented by CT who were haemodynamically stable , regardless of the extent of liver injury; hepatic-related transfusion limited to four units of blood; and absence of other abdominal injuries that would require exploratory laparotomy. 10 Haemodynamic stability was defined as serial blood pressure and heart rate measurements within the appropriate age range and with adequate end-organ perfusion, either initially or after limited fluid resuscitation. 1.2.1 I Initial resuscitation with Ringer 's lactate solution was carried out for all patients. Blood samples were taken and sent for routine haematology and biochemistry (including hepatic enzymes and serum amylase levels ), blood typing, etc. After resuscitation, all patients underwent CT scanning with 1em
TABLE1. MECHANISMS OF BLUNT HEPATIC INJURIES IN THE STUDIED POPULATION Mechanism of injury
Number
%
Motor vehicle accident Fall from height Pedestrian accident Sporting injuries Bicycle accidents Others
33 16 4 3 3 4
52.4 25.4
TOTAL
63
100.0
6.3 4.8 4.8 6.3
intervals from the lower chest to the pubic symphysis . Double contrast CT wa s performed with intra venous and orally administered contrast to improve visualisation of intraabdominal structures. Additional investigations were obtained based on suspicion of other injuries. According to the Organ Injury Scale (1994 revis ion) adopted by the American Association for the Surgery of Trauma, all hepat ic and associated other abdominal organ injuries were graded based on the appearance of the CT scan." The amount of haemoperitoneum was quantitated as follows: minimalperihepatic blood in the subphrenic or subhepatic space (approximately 500ml); moderate-perihepatic and blood along the paracolic gutter (less than lL); and large -perihepatic and blood along the paracolic gutter and accumulating in the pelvic cavity (more than 1L).13 Once the diagnosis of hepatic injury was established by CT, all patients were admitted to the intensive care unit (ICU) for close observation and monitoring for a variable length of stay. The patients were monitored in the ICU with serial haemoglobin assessments (every four hours) . When four serial assessments were stable, patients were transferred to a general surgical unit. On postadmission day three , patients were allowed to start quiet activ ity. On postadmission day seven, ifhaematology had not altered significantly, patients were discharged hom e after repeating the CT examination. Patients were instructed to undertake restricted acti vities at home for three weeks from the time of injury. A repeat of the abdominal CT was also considered in patients who had a decrease in haematocrit that may be related to liver injury to see if the injury had progressed. The patients were regularly evaluated on an outpatient's basis; weekly for four weeks and then monthly for two months . At three months post-injury, all the patients returned to the clinic for a final clinical assessment and CT examination. If they were clinicall y well at that time , they were allowed to return to full activity without restriction. © 2003Surg J R Coif Surg Edinb Irel1: 2: 81·85
TABLE 2. CLINICAL CHARACTERISTICS OF NON-OPERATIVE AND LAPAROTOMY GROUPS OF PATIENTS Parameters Age ICU stay
Non-operative group (n=52)
Laparotomy group
P value
32.8 ± 14.6
46.2 ± 15.9
< 0.05
2.5 ± 0.73
4.6 ± 1.4
< 0.001
GCS
14.2 ± 1.7
13.0 ± 2.9
> 0.05
ISS
16.2 ± 6.1
26.1 ± 8.5
< 0.001
247.3 ± 11 1.5
254 .1 ± 139.3
> 0.05
SGPT levels Blood transfusions (m/kgBWt)
19.1 ± 6.9
Failure of non-operative management was determined by clinical and laboratory evidence of ongoing haemorrhage or by the development of peritonitis. Continued haemorrhage was defined clinically by progressive abdominal distension and/or by the presence of tachycardia or hypotension refractory to fluid resuscitation. A fall in the haematocrit or persistent acidosis following resuscitation, were used as laboratory evidence of ongoing haemorrhage.' The injury severity score (ISS), the Glasgow coma scale (GCS), transfusion requirements, liver transaminase levels, associated injuries, length of stay in the ICU, complications both in hospital and within three months of discharge and total mortality were analysed.I'-" All the data were reported as the mean and standard deviation, and were compared using the student's t test.
RESULTS The present study included 63 patients with blunt hepatic injuries. Men constituted 65.1% of the population. Table 1 shows the mechanisms of injury: motor vehicle accident (49.2%) and fall from a height (25.4%) were the most common causes of blunt hepatic injuries in our study. Fifty-two (82.5%) of 63 patients, initially selected for nonoperative management, were managed successfully (non-operative group). The remaining 11 (17.5%) patients © 2003 Surg J R ColiSurg Edinb Ire/I: 2: 81-85
37.3 ±4.1
failed non-operative management and underwent exploratory laparotomy (laparotomy group). Table 2 compares the non-operative management and laparotomy groups. The mean values of age were 32.8 ± 14.6,46.2 ± 15.9, in the non-operative and laparotomy groups, respectively. Patients managed nonoperatively tended to be younger than those treated operatively (p < 0.05). A significant (p < 0.001) increase in the mean values of ISS, requirements for blood transfusion and ICU stay, was observed in the laparotomy compared with the non-operative patients. The initial liver transaminase (SGPT) value was elevated in 56 (87.5%) patients of the entire population. The mean values of SGPT were 274.3 ± 111.5, 254.1 ± 139.3, in the non-operative and laparotomy groups, respectively; were not significantly different between the two groups (Table 2). Despite evidence of hepatic injury on admission by CT scanning, the initial serum SGPT values were normal in seven (11.1%) patients. Eleven (17.5%) of our studied patients failed non-operative management, 1-7 days after admission. Seven of the 63 (11.1%) patients were explored for clinical evidence of ongoing haemorrhage with a falling haematocrit or a worsening appearance on CT scanning. The remaining four patients underwent exploratory laparotomy for the following indications, intestinal injury (two cases), pancreatic injury
< 0.001
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9.
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12.
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1996; 131 : 309-14. David AP, Denis DB. Ernest EE and FrederickMK. on-operative Management of Solid Organ Injuries in Children Results in Decreased Blood Utilization. J Pedia tr 1999;34: 1695-99. Carrillo EH. Spain DA, Wohltmann CD. Schmieg RE. Boaz PW. Miller FB. Richardson JD. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma 1999;46: 619-24. Carrillo EH, Platz A, Miller FB, Richardson JD and Polk He. on-operative management of blunt hepatic trauma. Br J Surg 1998;85: 461-68. Durham RM, Buckley J, Keegan M, Fravell S, Shapiro MJ. Mazuski J. Management of blunt hepatic injuries. Am J Surg 1992: 164: 477-51. Moore EE.CogbillTH. Malangeni MA, Jurkovi GJ, Shackford SR, Champion HR, McAninch J\V. Organ injury scaling. SlIIg Clin North Am 1995; 75: 293-97. Yih-Gang e. Mu-Shun Hand Jer-Ming L Non-operative management for extensive hepatic and splenic injuries with significant hemoperitoneum in adults. J Trauma 1998: 45: 36065. Baker SP and ei1 B. The injury
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severity score . J Trauma 1972; 16: 882-85 . Champion HR. Sacco W1. Cope WS. Gann DS. Gennarclli TA and Flanagan ME. a revision of the trauma score . J Trauma 1989; 29: 623-26 . Boone DC. Federle M, Billiar TR ct al. Evolution of management of major hepatic trauma: identification of patterns of injury. J Trauma 1995; 39 : 344-50. Croce MA. Fabian TC and Menke PG. on-operative management of blunt hepatic trauma is the treatment of choice for haemodynamicallystable patients. Results of a prospective trial. AIIII Surg 1998; 22 1: 744-55 . Moon KL and Federle MP. Computed tomography in hepatic trauma. Am J Radiol 1983; 141: 309-17. Meyer AA. Crass RA. Lim RC. Jeffrey RB. Federle MP and Trunkey DD. Selective nonoperative management of blunt liver injury using Computed Tomography. Arch Surg 1985; 120: 550-54 . Knudson MM, Lim RC. Oakes DD and Jetfrery RB. onoperative management of blunt liver injuries in adults : the need for continued surveillance. J Trauma 1990; 30: 1494-500. Harold S, Beth AS, Larry MJ, Roger RB. Barbara AL, Jorge RV, Clyde EM, Robert TJ and Andrew HM. Non-operative management of blunt hepatic injuries: safe at any grade. J Trauma 1994; 37 : 616-21.
(one case) and splenic infarction (one case). Associated and multiple injuries were observed in 58 (92 .1%) patients. Associated intraabdominal injuries most commonly invol ved : spleen (14 .3%); intestine (4.8 %); kidney (7.9% ) and pancreas (1.6 %) (Table 3). Extra-abdominal trauma most frequently resulted in thoracic Injury (36.5% ), head injury (26 .98%) , orthopaedic injuries (26 .98%), soft tissue damage ( 19.05%), maxillofacial (7.9%) and spinal injury (4.76%). In the current study, there were six complications in the non-operative group. Two patients developed perihepatic collections. The collection was infected in one patient. Percutaneous CT-guided drainage successfully dealt with these two collections, at seven and nine days after injury. No further treatment was required. A urinoma developed in one patient with renal injury and was successfully drained percutaneously. The remaining three patients developed chest infections and responded to antibiotic therapy. The mortality rate of the entire series of patients was 4.76% (three patients). There was no mortality in patients who underwent successful non-operative management. All of the three deaths occurred in the laparotomy group: two deaths were attributed to non-hepatic causes (severe head and thoracic injury). Only one death could be related to hepatic injury itself. Analysis of this case revealed that the patient had cirrhosis and became hypotensive 30 hours after the injury. Despite active effort to stop the bleeding, this could not be controlled.
Smith JB. Wengrovitz MA. and Delong BS. Prospective validation of criteria, including age, for safe, non-surgical management of the ruptured spleen. J Trauma 1992; 33: 385-89. Charles DG, Ralph LW. Robert LS and Charle s JM. on-operative management of blunt splenic injury in adults: age over 55 years as a powerful indicator for failure. Am LSurg 1996; 183: 133-39.
Non-operative management of blunt hepatic trauma has become an accepted treatment in recent years." The primary requirement of this policy is haemodynamic stability." :" Any physiological instability after initial resuscitation mandates laparotomy and current guidelines recommend surgery if the patient requires replacement of more than half of his/her blood volume. ]-2.5.6.9
DISCUSSION
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Until continued bleeding can be ruled out , a period of intensive monitoring is neces sary and an experienced surgical team must follow the patient closel y. In our series, non-operati ve management of blunt liver injuri es was successful in 82.5% of patients . This result is comparable to finding s reported by Croce et al (1993).17 The latter reported a success rate of up to 90% in their patients. Other studies have documented successful non-operative management in 85% to 100% of their patients. ]. 18-20 The hepatic injury grading scale proposed by the American Association for the Surgery of Trauma can serve as a yardstick so that data from different centres can be standardised and compared." However, its use as a decision-making tool has been called into question by many authors.v --" Moon and Federle (1983) found that the need for surgery for patients with blunt hepatic injury was more closel y correlated with the amount of haemoperitoneum than the size of the hepatic laceration. IS In our study, neither the grade of hepatic injury nor the amount of haemoperitoneum could predict the need for laparotomy. Thi s result was in accordance with the pre vious results of Hiatt et al (1990) .24 They suggested that the decision for laparotomy should be determined by the patient's overall clinical picture , not by the "exact nature of liver injury". In our series there were limited numbers of high-grade liver injuries. Patients with grade V and VI liver injurie s were lacking in our study. However, a grad e VI inj ury has a very high mortality rate and patients with this type of injury are unlikely to be in a haemodynam ic stable condition. The initial serum SGPT values were elevated in 56 (87 .5%) patient s studied. The mean values of SGPT were 274.3 ± 111.5, 254 ± 139.3, P > 0.05, in the non-operati ve and laparotomy groups , respectively. Despite evidence of hepatic injury on the admis sion CT, the initial serum SGPT values were normal in seven ( I I %) patients. The initia l serum SGPT value neither excluded the presence of hepatic injury nor predicted © 2003SurgJ R ColiSurg Edinb Ire/l : 2: 81-85
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k"' ......... Stable patient
Unstable patient
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• Moved if haematocritlhaemoglobin levels stable General ward
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the need for laparotomy, in our patients. The severity of injury, in our study, was measured by the ISS.I.J15 A highly significant (p < 0.00 I) increase in the mean value of ISS was observed in the laparotomy group, when compared with the non-operative group. Despite this result, ISS was of limited clinical value when considering any individual case. Judgement to operate or not, in our patients, was dependent mainly on the clinical parameters rather than numerical values of the ISS. Critics of non-operative management cite the potential risk for missing other serious intraabdominal injuries and increasing utilisation of blood transfusion, with all its attendant risks." In the current study, there were no missed injuries. The mean values for blood transfusion requirements were 37.3 ± 4.1, 19.1 ± 6.9, p < 0.001, in the laparotomy and non-operative groups, respectively. The significant increase in requirement for blood transfusion in the laparotomy patients could not be attributed to the severity of the hepatic injury per se, as there was no significant difference in the mean values of grading of hepatic injuries between the two study groups. The significant (p < 0.001) increase in the mean value ofISS, in the laparotomy group of patients, may explain the increased requirements for blood transfusion in this © 2003 Surg J R CallSurg Edinb Ire/t. 2; 8t-85
Figure 1: Protocol used for the enrolement of patients into the study
group. Patients are more likely to receive more blood transfusions if more than one organ is affected. Advancing age has been implicated to influence the success rate of nonoperative management of blunt abdominal trauma.v-"-" Our data show that patients managed non-operatively tended to be younger than patients who underwent surgery (p < 0.05). The majority of our patients who were managed nonoperatively were less than 30 years, while 45.5% of the laparotomy group of patients were more than 50 years of age. Five of eight patients who were older than 50 years, failed non-operative management; two of them were responsible for 66.6% of the total mortality in this series. Intolerance to severe haemodynamic instability may explain the increased incidence of failure in these patients. The non-operative management of blunt hepatic injury, when accompanied by head injury, remains problematic and controversial. Head injury may complicate the management of these patients in two ways; firstly, because of an altered level of consciousness, physical examination may become unreliable, secondly, the potential release of tissue thromboplastin from head trauma (although experimentally unproven) may lower the success rate with non-operative management by impairing the coagulation profile. c5on Head injuries
were observed in 17 (26.9%) patients of our studied population. Analysis of this subgroup revealed that five patients (29.4%) failed non-operative management and their mean GCS value was 10.6 ± 2.96. As the mean value of GCS in nonoperative patients insignificantly differed from that of the laparotomy group of patients (p > 0.05), the failure of nonoperative management may be related to factors other than head injury. Patients who failed non-operative management were older with significantly high ISS (p < 0.001). The existence of these two factors may explain the incidence of failure in these patients. In conclusion, this series has reaffirmed the validity of a selective policy of nonoperative management of blunt liver injury. The most important decision facing the surgeon is to distinguish between patients who need an operation and those in whom an operation may be avoided. Haemodynamically unstable patients need an operation whilst those patients who are stable on arrival or those who respond quickly to fluid resuscitation can be managed non-operatively with a high success rate (82.5%), thereby, reducing the number of unnecessary laparatomies.
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Hiatt JR. Harrier I-ID. Keonig BV et al. on-operative management of major blunt hepatic injury with hemoperitoneum . Arch Surg 1990; 125: 101-07. Sande JJ, Veltkamp JJ. Musser! RJ. Vielvoye GJ. Hemostasis and Computerized tomography in head inj ury. J Neurosurg 1981; 55 : 718-26. Gan do S. Tedo I and Kubo ta M. Post-trauma coagulation and fibrinolys is. Crit Care Med 1992; 20: 594-603. Pietropaoli JA. Rogers FB. Shackford SR. Wald WL. Schmoker J D and Zh uang J. The de leterious elTects of intraoperative hypotension: an outcome in patients with severe head injuries. J trauma 1992; 33 : 403-07.
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