non-operative management of isolated liver trauma

8/12/2019 Non-operative Management of Isolated Liver Trauma

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Conservative management for liver trauma

Hepatobiliary Pancreat Dis IntVol 00No 0 Month2014 www.hbpdint.com

Clinical Summary

AuthorAffiliations:Department of General Surgery, Jinling Hospital,Medicine School of Nanjing University, Nanjing 210002, China (Li M, YuWK, Wang XB, Ji W, Li JS and Li N)

CorrespondingAuthor: Ning Li, MD, Department of General Surgery,Jinling Hospital, Medicine School of Nanjing University, No. 305 EastZhongshan Road, Nanjing 210002, China (Tel: 86-25-80860037; Email:[email protected])

2014, Hepatobiliary Pancreat Dis Int. All rights reserved.doi: 10.1016/S1499-3872(14)60049-7Published online March 27, 2014.

ABSTRACT: Liver trauma is the most common abdominalemergency with high morbidity and mortality. Now, non-operative management (NOM) is a selective method for livertrauma. The aim of this study was to determine the successrate, mortality and morbidity of NOM for isolated liver trauma.

Medical records of 81 patients with isolated liver trauma in ourunit were analyzed retrospectively. The success rate, mortalityand morbidity of NOM were evaluated. In this series, 9 patients

with grade IV-V liver injuries underwent emergent operationdue to hemodynamic instability; 72 patients, 6 with gradeV, 18 grade IV, 29 grade III, 15 grade II and 4 grade I, withhemodynamic stability received NOM. The overall successrate of NOM was 97.2% (70/72). The success rates of NOMin the patients with grade I-III, IV and V liver trauma were100%, 94.4% and 83.3%. The complication rates were 10.0%and 45.5% in the patients who underwent NOM and surgicaltreatment, respectively. No patient with grade I-II liver traumahad complications. All patients who underwent NOM survived.NOM is the first option for the treatment of liver trauma if thepatient is hemodynamically stable. The grade of liver injuryand the volume of hemoperitoneum are not suitable criteriafor selecting NOM. Hepatic angioembolization associated withthe correction of hypothermia, coagulopathy and acidosis isimportant in the conservative treatment for liver trauma.

(Hepatobiliary Pancreat Dis Int 2014;00:000-000)

KEY WORDS:liver trauma; non-operative treatment;

non-operative management

Introduction

Liver parenchyma and its vasculature are fragileand very susceptible to blunt and penetratingtrauma which makes the liver the most frequently

injured abdominal organ.

[1]

Hemorrhagic shock due touncontrollable bleeding of vessels and parenchyma isthe major cause of death within the first 36 hours afterinjury.

[2] The management of liver trauma in the early

1900s was observation and expectant treatment andlater on, mainly operative intervention.[3] The currentpractice is either selective surgery or non-operativemanagement (NOM), depending on the grade of thetrauma. NOM of liver trauma was first reported in 1972,and has been one of the most significant changes in thetreatment of liver trauma over the past three decades.

[4, 5]

In recent years, the overall mortality in large series of

patients who sustained liver trauma has ranged from10% to 15%.[6, 7]Although the mortality of liver traumahas decreased in the past decades, the selection criteriafor NOM are constantly evolving, and conservativeapproaches are being increasingly adopted.

Several studies on patients with liver traumasuggested that early deaths are due to uncontrolledbleeding from associated intra- and extra-abdominalinjuries; whereas late deaths result from head injuryand sepsis with multi-organ failure.

[8-10] Patients with

liver trauma usually have complicated injuries, and

the results of NOM have been influenced by coexistingtrauma.[6, 7] The aim of this study was to determinethe success rate, mortality and morbidity of NOM inpatients with isolated liver trauma.

Methods

A retrospective analysis was performed on all thepatients treated for liver trauma in our unit betweenJanuary 2007 and April 2012. The medical recordsof patients with isolated liver trauma were extracted.

Isolated liver trauma was defined as liver injury with

Non-operative management of isolated liver

trauma

Min Li, Wen-Kui Yu, Xin-Bo Wang, Wu Ji, Jie-Shou Li and Ning Li

Nanjing, China


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Hepatobiliary & Pancreatic Diseases International


no other intra- or extra-abdominal involvement. Thesuccess rate, mortality and morbidity of patients whounderwent NOM or surgery were reviewed.

The grade of liver trauma was determined accordingto the scaling system of the American Association forthe Surgery of Trauma (AAST).

[11]Failure of NOM was

defined as the need of surgical intervention to managebleeding at any time during hospitalization or in thefollow-up period. All patients were followed up byphone calls for six months. Data analysis was performedby SPSS 18.0 (SPSS Inc., Chicago, IL, USA). All resultswere reported as meanstandard deviation.

The patients with hemodynamic instabilityunderwent emergent surgery. The selection criterionfor NOM was hemodynamic stability, which wasdefined as a systolic pressure >90 mmHg after adequateresuscitation (1 L of intravenous fluids within 1 hour).

The treatment algorithm of NOM involved monitoringpatients in an ICU with serial physical examinationsand hematocrits. Red blood cell (RBC) transfusionswere given when hemoglobin levels were less than 7g/L.

[12] Heart rate, blood pressure, respiratory rate,

central venous pressure and urinary output weremonitored. Acidosis was corrected promptly; rewarmingblankets and warm intravenous fluids were used toavoid hypothermia when core temperature was lowerthan 36 .

[13] Somatostatin was used in the patients

with biliary fistulas to decrease choleresis. Unlikeconventional approaches, we corrected coagulopathy

according to the result of thromboelastography (TEG)instead of prothrombin time (PT) and activated partialthromboplastin time (APTT). Blood products, includingfresh frozen plasma, platelet and cryoprecipitate, wereintravenously infused according to the results of TEG.The patients who had hemoperitoneum underwentultrasound guided percutaneous peritoneal drainage inorder to determine the volume of hemoperitoneum. Thecatheter was removed when hemoperitoneum resolvedas determined by ultrasonic monitoring or operationif needed. Hepatic artery angiography embolization

was used when computed tomography (CT) scanningdemonstrated contrast extravasation.

Results

Between January 2007 and April 2012, there were 268patients treated for liver trauma in our unit. Amongthem, 187 had multiple injuries and were excludedfrom this cohort. Of the remaining 81 patients, 9 withgrade IV-V liver injuries underwent emergent operationbecause of hypovolemic shock and 72 received NOM.

The average age of the 72 patients was 35.910.8

Table 1.Patient characteristics according to the management firstlyperformed

Characteristics NOM (n=72)Surgical management

(n=9)

Age (yr) 35.910.8 (17-69) 38.213.1 (19-62)

Male/Female 55/17 7/2

Causes of liver trauma

Traffic 30 5

Industrial 22 3

Falls 8 1

Assault 4 Sports 5

Penetrating injuries 3

Grade of liver trauma

I 4

II 15

III 29

IV 18 3

V 6 6

Hemoperitoneum (mL) 1537692 (430-3360) 1942308 (1400-3010)

years (range 17-69); these patients included 55 menand 17 women. Liver trauma consisted of traffic (n=30),industrial (n=22), falls (n=8), assault (n=4), sports(n=5) and penetrating injuries (n=3). Six patients hadliver trauma of grade V (8.3%), 18 grade IV (25.0%),29 grade III (40.3%), 15 grade II (20.8%), and 4 gradeI (5.6%). The average volume of hemoperitoneum was1537692 mL (range 430-3360) (Table 1). The patientswho received NOM underwent contrast-enhanced CTscanning of the abdomen (Fig. 1). The peak levels ofalanine aminotransferase, aspartate aminotransferase,and total bilirubin were 1520.0794.9 U/L (range237-3054), 1054.1531.6 U/L (range 172-2132), and23.4 10.5 mol/L (range 8.8-61.1), respectively. Theshortest reaction time was 16.77.8 minutes (range5.3-34.7, normal 5-10), the shortest kinetic time was 9.8 5.7 minutes (range 1.5-20.4, normal 1-3), and the level

Fig. 1.Contrast-enhanced CT scanning of grade IV blunt livertrauma.


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of maximum amplitude (MA) was 50.16.7 mm (range40.2-67.3, normal 50-70) (Fig. 2). There were 17 (23.6%)patients with hypothermia, and 41 patients (56.9%)with acidosis. Forty-eight patients received an average of7.46.2 U (range 3-18) RBC transfusions.

All patients who underwent NOM survived. Seventyout of 72 patients were managed successfully withoutoperation, including 5 patients with grade V, 17 withgrade IV and 48 with grade I-III liver trauma. Theoverall success rate of NOM was 97.2%. The successrates of NOM in the patients with grade I-III, IV and Vliver trauma were 100%, 94.4% and 83.3%, respectively.Thirty-five patients underwent hepatic angiographybecause of extravasation of contrast material on CTscanning. Of these patients, 24 (68.6%) requiredembolization (Fig. 3, Table 2). In the 24 patients,bleeding was stopped in 22 patients, and 2 patients

(1 grade IV and 1 grade V) needed operation becauseof hemorrhagic shock. The success rate of hepaticangioembolization (HAE) was 91.7%. Among the70 patients who were managed successfully withoutoperation, 7 had complications. The overall morbidityof NOM for liver trauma was 10.0%. No patientwith grade I-II liver trauma had complications. Onepatient with grade III liver trauma had a biloma. Threepatients with grade IV liver trauma had complicationsincluding 2 bilomas and 1 biliary fistula. Three of 6

Fig. 2.TEG data of a patient with severe liver trauma showing coagulo-pathy.

Table 2.A summary of patients successfully treated with NOM

Grade of

liver

trauma

No

invasive

procedure

DrainageDrainage and

angiography

Drainage,

angiography

and

embolization

Total

I 4 0 0 0 4

II 8 5 1 1 15

III 1 16 7 5 29

IV 0 3 2 12 17

V 0 0 1 4 5

Total 13 24 11 22 70

Table 3.Complications of the patients according to the managementfinally performed

Grade of liver

traumaNOM (n=70) Surgical management (n=11)

I 0 II 0

III 1 (3.4%)

Biloma

IV 3 (17.6%) 1 (25%)

2 Bilomas Biliary fistula and hemorrhage

1 Biliary fistula

V 3 (60%) 4 (57.1%)

1 Biloma

2 Biliary fistulas

1 Intra-abdominal abscess and

hemorrhage

1 Biliary fistula and hemorrhage

2 Biliary fistulas

Total 7 (10.0%) 5 (45.5%)Fig. 3.Angiography of grade IV blunt liver trauma.

patients with grade V liver trauma had complicationsincluding 1 biloma and 2 biliary fistulas (Table 3).Three biliary fistulas were due to the injury of theright hepatic duct identified by endoscopic retrogradecholangiopancreatograhpy (ERCP), and were resolved bysubsequent surgery in which cholangiojejunostomy wasperformed. Because the diameter was


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Eight postoperative complications occurred in 5 patients,hemorrhage in 3, intra-abdominal abscess in 1, andbiliary fistulas in 4 (Table 3). Postoperative hemorrhagehappened in 3 patients on day 2 after gauze removal, ofwhich 2 patients were treated by HAE, and 1 requiredanother hepatic packing.

Discussion

The paradigm for management of liver traumahas shifted over the past decades, from mandatoryoperation to selective NOM. This paradigm shift hasbeen attributed to several factors: (1) the recognitionthat 50%-80% of liver injuries stop bleedingspontaneously, (2) the successful NOM in children,and (3) the significant development of CT scanning,interventional radiology and critical care.[5, 14] A recent

review of the National Trauma Data Base in Americashowed that 86.3% of all liver injuries were managedconservatively.

[15] In the current series, 72 patients with

liver trauma whose hemodynamics were stable wereselected for NOM. This included 53 patients with gradeIII-V and 19 patients with grade I-II liver trauma. Thevolume of hemoperitoneum in the patients who hadabdominal free fluid was 1537692 mL (range 430-3360)compared with those underwent surgery (1942308mL, range 1400-3010). The NOM success rate in thepatients with grade I-III liver trauma (n=48) was 100%;

in those with grade IV and V was 94.4% and 83.3%,respectively. The overall success rate of NOM was 97.2%which is higher than that reported in other studies.

[16-18]

We conclude that the liver trauma patients with stablehemodynamics can be treated without operation witha high success rate. The grade of liver trauma andthe volume of hemoperitoneum are not significantparameters for selecting NOM. These conclusions areconsistent with those reported elsewhere.

[4, 19]

CT scanning is currently the standard evaluationmodality for stable patients with abdominal injury.[20, 21]Hoff et al[22] reported a sensitivity of 92%-97% and

a specificity of 98.7% in liver trauma. The findingof extravasation of contrast material within the liverparenchyma on CT scanning is indicative of activehemorrhage. Fang et al[23] reported that 75% ofpatients with contrast extravasation and hemodynamicinstability required operation. Embolization of hepaticarterial bleeding could control bleeding from 68%to 87%.

[23] In the current study, patients with stable

hemodynamics were diagnosed by contrast-enhancedCT. Thirty-five patients underwent hepatic arterialangiography because of extravasation of contrast

material on CT scanning, and 24 required embolization.

The hemorrhage was stopped in 22 patients. The successrate of HAE was 91.7%.

Hemorrhage can result in hypothermia,coagulopathy and acidosis, so called lethal triad. Eachexacerbates the others. The vicious cycle rapidly

deteriorates the patients and causes death. Mortalityincreases significantly in trauma patients with a coretemperature less than 34 and approached 100%when less than 32 .

[24] In this series, warm blanketsand intravenous fluids were used to avoid hypothermiawhen core temperatures were lower than 36 .

Various coagulation problems can appear when liverinjury occurs. This may be due to the hemorrhage, orto liver dysfunction, which causes both qualitative andquantitative alterations in pro- and anticoagulants, andplatelets. Reduced degradation of activated components,hyperfibrinolysis and deficient metabolism of citrate

in the blood components may also play a role. Wemonitored blood coagulation of the patients through theresults of TEG. In contrast to conventional coagulationtests which assay only clot formation time in a plasmaenvironment, TEG assesses overall hemostasis, thecumulative effects of procoagulant, anticoagulantproteins, fibrinogen and platelets. Componentmeasurements of the TEG reflect specific phases of clotformation.

[25] In many studies, TEG shows superior

properties compared to conventional coagulationparameters.

[26]Prolonged reactive time suggests clotting

factor deficiency or heparin effect. The kinetic timereflects the time from initial fibrin formation requiredto reach specific clot firmness and is proportionalto fibrinogen concentrations and platelet count. Themaximum amplitude reflects maximal clot strengthand is proportional to the amount and function ofplatelet. Blood products were infused to liver traumapatients to correct coagulopathy according to the resultsof TEG which could have resulted in a shorter time tocorrect coagulopathy. The appropriate correction ofcoagulopathy promotes the formation of blood clottingfor hemostasis.

During operation, measures to rapidly controlbleeding are essential. Methods to control damage withliver packing and staged re-operation have becomestandard treatment in patients requiring emergentlaparotomy for severe liver trauma.

[27] Perihepatic

packing controls profuse hemorrhage in up to 80% ofpatients undergoing laparotomy.

[28, 29] In this study, all

11 patients who underwent operation received hepaticpacking, and bleeding was controlled in 8 (72.7%) ofthem.

Some studies[4, 30]

reported that the complication

rates of liver trauma were low in most series of blunt


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liver injury, ranging from 0 to 7%. However, as themajority of patients in those studies had lower gradeliver traumas, the findings cannot be extrapolatedto patients with high grade lesions. In the currentseries, 80.6% (50/62) of grade III-V and all patients

with grade I-II liver trauma underwent NOM withoutcomplications. The complication rates were 10.0% and45.5% in the patients who underwent NOM and surgicaltreatment, respectively. Li Petri et al[31]reported a seriesof 53 patients with complex liver trauma, in which 29patients underwent operation and 24 patients weretreated conservatively. No patients who underwent NOMhad complications, whereas 7 subjects (29.2%) whowere surgically treated had liver related complications,including 4 bile leaks and 3 intra-abdominal abscesses.The complication rate of surgical treatment was higherthan that of NOM. The patients who received operation

had a higher probability of hemodynamic instabilityand a higher grade of liver injury than those whoreceived NOM. Perioperative contamination might leadto abscess.

In the current study, aside from 9 patients withhemodynamic instability who underwent emergentoperation, 72 patients (88.9%) received NOM with asuccess rate of 97.2%. The results of NOM for isolatedliver trauma were excellent. We consider that: (1)NOM could and should be used in not only mild, butalso moderate to severe liver trauma patients with

hemodynamic stability; (2) The grade of liver injury andthe volume of hemoperitoneum are not suitable criteriafor selecting NOM; (3) Bleeding in cases of severe livertrauma is frequently accompanied by life-threateningcomplications. HAE combined with correction ofhypothermia, coagulopathy and acidosis are importantaspects of the conservative treatment for liver trauma.

Acknowledgements: The authors thank Mr. Zhen-Guo Zhao forhis assistance with data collection.Contributors: LJS and LN proposed the study. LM performedresearch and wrote the first draft. YWK, WXB and JW collected

and analyzed the data. All authors contributed to the designand interpretation of the study and to further drafts. LN is theguarantor.Funding:None.Ethical approval:This retrospective study was approved by MedicalEthics Committee of Jinling Hospital.Competing interest: No benefits in any form have been receivedor will be received from a commercial party related directly orindirectly to the subject of this article.

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Received February 28, 2013Accepted after revision November 25, 2013

non-operative management of isolated liver trauma

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