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Note: Tables and figures
of the article can be accessed and seen in the PDF file.
Introduction
The liver is the largest
solid abdominal organ with a relatively fixed position,
which makes it prone to injury (Zangana AM 2007). Damage
to the liver is the most common of death after abdominal
injury. The most common cause of liver injury is blunt
abdominal trauma, which is secondary to motor vehicle
crashes (MVC) (Nawaz Khan A et al. 2009). The
liver is frequently injured following abdominal trauma
and associated injuries contribute significantly to
mortality and morbidity, and may cause the liver injury
to be masked and diagnosis delayed (Beal SL 1990).
Management of hepatic injuries has evolved over the past
30 years. Prior to that time, a diagnostic peritoneal
lavage (DPL) positive for blood, was an indication for
exploratory celiotomy because of concern about ongoing
hemorrhage and/or missed intra-abdominal injuries
needing repair (EAST 2003).
The
recognition that between 50 and 80 per cent 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 (Pachter HL and Hofstetter
SR 1995).
Stimulated by the success of NOP management of spleen
and hepatic injuries in children who have stable
hemodynamic, there has been a trend towards NOP
management in hemodynamic stable adults with similar
injuries. A “paradigm shift” is said to
occur when the rules governing a process are
fundamentally changed, and such is the case with the
treatment of liver injuries. Modern treatment of liver
trauma is increasingly NOP (Konig T et al. 2007).
The
treatment of abdominal injuries has evolved and a NOP
approach has been adopted in an increasing number of
selected patients (Pachter HL and Hofstetter SR 1995).
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 (EAST
2003).
The
hemodynamic status of the patient is the most reliable
and critical factor for NOP management (Parks RW et
al. 1999, Coughlin P.A. et al. 2004, Sherlock
DJ and Bismuth H 1991, Oschner MG et al. 1993).
Neither
grade of injury nor amount of hemoperitoneum on CT
predicts the outcome of NOP management and mandates
laparotomy (EAST 2003, Fang JF 1998).
NOP
management of hepatic injuries is the treatment modality
of choice in hemodynamically stable patients,
irrespective of the grade of injury (Lyuboslavsky Y and
Pattillo M 2009, Gibson D et al. 2006). It
is associated with a low overall morbidity and mortality
and does not result in increases in length of stay, need
for blood transfusions, bleeding complications, or
visceral associated hollow viscus injuries as compared
with operative management (EAST 2003, Gibson D et al.
2006).
Purpose
This study attempted to
find the epidemiology, etiologies and managements of
liver trauma and to grade injuries according to the
Organ Injury Scale, in a population based study in Iran.
Material and Method
A Cross-Sectional study
consisting 16287 trauma patients referred to the main
hospitals of seven cities (Tehran, Shiraz, Ahwaz,
Tabriz, Qom, Mashhad and Kermanshah) from 1999 to 2000
was done. We excluded the entire patients admitted less
than 24 hours. Patients with hepatic injury treated at
hospitals included in this study.
The following data were
collected: demographics, mechanism of injury,
pre-hospital care, admission hemodynamic status, grade
of hepatic injury, associated injuries, failure of NOP
management, hospital stay in intensive care unit (ICU)
or in the ward and death.
Statistical analysis was
performed with SPSS version 18, 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.
Assessment of hemodynamic
stability was based on routine vital signs. Patients
with admission systolic blood pressure greater than 90
mmHg, either at admission or after low-volume
crystalloid infusion, were generally regarded as
hemodynamic stable. NOP management has been applied to
all hemodynamic stable patients with hepatic injury.
Patients who were hemodynamic stable and had no other
indication for immediate abdominal surgery underwent a
computed tomography (CT) scan or sonography, dependant
on availability in the centers. Unstable patients
underwent DPL to assess free blood in the abdominal
cavity.
Injury severity was
determined from CT and operative observations, and
classified by means of the Liver Injury Scale (LIS)
(Table 1) (Moore EE et al. 1995).
Hepatic injury was graded
according to the Hepatic Injury Scale established by the
American Association for the Surgery of Trauma (AAST).
Patients who underwent celiotomy 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. Any patient initially observed
in the ICU and subsequently requiring surgery was
considered a failure of NOP management. NOP management
was discontinued in patients with hemodynamic
instability unresponsive to moderate amounts of
crystalloid infusion or a significant fall in hematocrit,
or if any intra-abdominal hollow viscus injury was
suspected. There were no other specifically defined
criteria for abandonment of NOP management.
Results
A total number of 16287
trauma patients referred and 2266 (13.91%) patients had
abdominal trauma (including both outpatients and
inpatients). Out of 84 patients with hepatic injury,
68(81%) patients were male and 16(19%) were female. The
average age was 23.8 ± 14.4 years
(range 3-67), and the male-to-female ratio was 3.9:1.
Some
patients received pre-hospital care which is displayed
in Table 2.
Most hepatic trauma patients had blunt injury 63(75%).
Blunt liver trauma was 77.8% in males and 22.2% in
females. Fifty-three (63.1%) were due to MVCs including
car drivers, pedestrians and motorcycles. Non-traffic
causes including falls and bicycles were the etiology in
10 patients (11.9%) of blunt hepatic trauma. Penetrating
injuries 21(25%) included: knives, guns (gunshot &
shotgun injuries) and others. Demographic data showed in
Table 3.
Associated traumas 66(78.6%) included both intra and
extra-abdominal injuries. Spleen trauma was the most
common associated injured organ seen in 46 (54.8%)
patients. Other associated injuries were thorax 21(25%),
pelvic organ 9(10.7%), intracranial injury 8(9.5%) and
lower extremity 8(9.5%). Blunt hepatic injury was
associated with other organ injuries in 79.4%, spleen
trauma in 55.6%, thoracic injuries in 20.6% and head
injury in12.7% of cases. Isolated hepatic injuries were
in 18 (21.4%) cases. Generally, duration of hospital
stay was 0 to 67 days with mean 8.32 and median 5 days
and in those with isolated liver injury was 9.1 and 5
days, respectively. Duration of transient disability was
5 to 100 days with mean 28.4 and median 21days. There
was no significant difference in hospital stay and
transient disability between the patients operated and
managed non-operatively.
Patients treated via NOP or operative management. Seven
patients (8.3%) with NOP management failed and operated.
Figure 1 shows managements of 84 patients in this study.
Patients with failure of NOP management had
significantly worse admission hemodynamic parameters,
higher ISS and higher grade of liver trauma.
ISS mean and median were 16.4 and 11, respectively.
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 (Table 4).
Grading
of the hepatic injuries in the study community,
according to LIS is presented in Figure 2.
Patients operated via techniques of; suturing, packing,
resection and debridement, and cholecystectomy.
Operations of the studied patients are revealed in Table
5.
Figure
3 represents type of management and operational option.
Thirteen (15.5%) patients died. Two patients with grade
IV of injury needed immediate surgery and died due to
severity of injury and hemorrhage. The other dead
patients had associated injuries including: head
(subarachnoid hemorrhage) and spleen injury in 1, head
(subarachnoid hemorrhage) and thoracic injury in 1,
pelvic fracture in 1, thoracic injuries resulting in
acute respiratory distress syndrome for 5 and spleen
injuries in 3. All patients with grade 5 and 6 died,
they had high grade of hepatic trauma in addition to the
associated injuries.
Limitation of study
Unfortunately we had no
documented data regarding transfusion requirements of
all patients. In this study all patients with low grade
hepatic injury in this study underwent NOP management;
we cannot assess safety of this approach for high grade
injuries. Patients with liver trauma should have
follow-up imaging study and liver function test. In this
study, post discharge we had no follow- up assessment.
Discussion
Operative therapy has been the
standard of care for liver injuries from the beginning
of the century until the beginning of the 1990s. This
has been based on the dual rationale of hemostasis and
bile drainage. Since the early 1980s, sporadic reports
of adult patients with blunt hepatic trauma treated
non-operatively have appeared in the literature (Farnell
MB et al. 1988, Brasel KJ et al. 1997).
However, surgical literature confirms that as many as
86% of liver injuries have stopped bleeding by the time
surgical exploration is performed, and 67% of operations
performed for blunt abdominal trauma are
non-therapeutic. Imaging techniques, particularly CT
scanning, have made a great impact on the treatment of
patients with liver trauma, and use of these techniques
has resulted in marked reduction in the number of
patients requiring surgery and non-therapeutic
operations (Nawaz Khan A et al. 2009).
Nonsurgical treatment has become the standard of care in
hemodynamically stable patients with blunt
liver trauma. The use of helical computed
tomography (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 nonsurgical management of
blunt liver injuries. CT is the diagnostic modality
of choice for the evaluation of blunt liver trauma
in hemodynamically stable patients and can
accurately help identify hepatic parenchymal
injuries, help quantify the degree of hemoperitoneum,
and reveal associated injuries in other
abdominal organs, retroperitoneal structures,
and the gastrointestinal tract (Yoon W et al;
2005).
Almost
80% of adults and 97% of children are treated
nonsurgically by using careful follow-up imaging
studies. The most common cause of liver injury is blunt
abdominal trauma, which is secondary to MVC in most
instances (Nawaz Khan A et al. 2009).
In our study blunt traumas and MVCs were 75% and
63.1%, respectively.
In the
literature, 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 less
than 50% of patients. Both blunt and penetrating liver
injuries are more common in males. Most liver trauma
occurs in adults who drive motor vehicles or engage in
fighting (Nawaz Khan A. et al. 2009), which are
similar to our results mentioned above.
Konig
T. 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 severity of grade of injury (Konig
T et al. 2007).
NOP
management can safely be applied to hemodynamically
stable patients with blunt hepatic injury. Although
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 (Brasel KJ et al. 1997).
While
small lacerations of the liver substance may be, and no
doubt are, recovered from without “operative
interference: if the laceration be extensive and vessels
of any magnitude are torn, hemorrhage will, owing to the
structural arrangement of the liver, go on
continuously”( Pringle J.H. 1908).
The
patients in whom NOP management failed had significantly
worse admission hemodynamic parameters, a higher ISS,
more hemoperitoneum, and a higher incidence of vascular
blush in the liver on CT. DPL was used only for the
unstable, multiply injured patient to diagnose
intra-abdominal hemorrhage, or for the diagnosis of
hollow viscus injury. In conjunction with the
development of CT as the primary diagnostic modality
came the additional observation that 60% to 80% of the
liver injuries had spontaneously stopped bleeding by the
time of laparotomy and also that lack of biliary
drainage did not adversely affect outcome (Malhotra AK
et al. 2000, Fabian TC et al. 1991).
Initially, NOP management was applied to only
lower-grade hepatic injuries (Durham RM et al.
1992, Bynoe RP et al. 1992) and to patients with
only mild to moderate amounts of hemoperitoneum (Meyer
AA et al. 1985, Farnell MB et al. 1988).
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
39% of the total, and 31% of these patients were
successfully managed nonsurgically.
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
the recent studies, NOP management does not carry with
it a greater need for transfusion than operative
management. Most reports suggest that transfusion
requirements are less with NOP management (Pachter HL
et al. 1996, Sherman HF et al. 1995, Croce MA
et al. 1995). Our patients non-operatively
managed, showed no significant difference in the
hospital lengths of stay.
The
death rate of all patients with liver injury was 15.5%,
very similar to the rate in other reports (Malhotra AK
et al. 2000, Croce MA et al. 1995). The
patients with significant liver injury leading to death
usually have early indications for surgery. All the
patients managed non-operatively were alive with no
death report.
Conclusion
In this study hepatic trauma was
in 0.5% of all trauma patients. We concluded hemodynamic
stable patients can be managed safely non-operatively,
while urgent surgery continues to be the standard for
hemodynamic compromised patients with hepatic trauma.
NOP management does not lead to longer hospital stay.
Low grade injuries can be managed non-operatively with
excellent results.
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