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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Liver trauma

, M.D., M.P.H. and , M.D., Ph.D.

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The management of liver trauma has undergone significant change over the last 30 years. Large series from the 1960s and 70s managed both blunt and penetrating injuries operatively (Crosthwait 1962, Defore 1976). One of the major reasons mandating operative management was the use of peritoneal tap or diagnostic peritoneal lavage for diagnosis. In the setting of liver injury, this test will almost always be positive, indicating the need for operation.

Case reports of successful nonoperative management appeared in the late 1970s. These cases were diagnosed by liver-spleen scan when patients developed increasing abdominal tenderness after blunt abdominal trauma. More widespread use of nonoperative management began with the use of CT scan for diagnosing blunt abdominal trauma (Meyer, 1985). Nonoperative management has become the standard for managing injured children without hemodynamic compromise. The majority of adults with blunt hepatic injury can also be managed nonoperatively (Pachter, 1995). Evidence-based guidelines for the nonoperative management of blunt hepatic trauma in children and adults have recently been published by the Eastern Association for the Surgery of Trauma (EAST). Criteria for nonoperative management include a hemodynamically normal patient, ability to monitor the patient in an intensive care unit if necessary, blood bank capability, and 24 hour availability of an operating room. Follow-up CT scans to follow the injury and document healing do not alter management decisions.

Arteriography has been used adjunctively in the management of hepatic trauma, initially when operative maneuvers failed to gain control of exsanguinating hemorrhage. More recently, arteriography with embolization has been used to extend the indications for nonoperative management prior to exploration, often obviating the need for operation (Carrillo, 1999).

The horizons of nonoperative management are currently being extended further, into management of penetrating injuries. This approach has been used for several years, but only in isolated centers and primarily for stab wounds (Demetriades, 1985). Current controversy centers on which patients and which injuries are suitable for nonoperative management.

There are several questions and controversies regarding the management of liver trauma, many of which have been answered by the EAST's practice guidelines. This chapter will focus on one old question and two current controversies.

Settled controversy: management choice for blunt hepatic injury

1. What are the data supporting nonoperative management as the method of choice for patients with blunt hepatic injury?

Data support a grade III recommendation favoring nonoperative management.

There are no randomized, prospective data comparing nonoperative to operative management. The data initially evolved from isolated case reports establishing the safety of this approach to large series documenting the change from primarily operative to primarily nonoperative management of hemodynamically normal patients with blunt liver injury. All of these data are level V. Level IV data stratified by year confirmed equivalent safety with decreased lengths of stay and fewer transfusions for injuries of similar AAST grade managed nonoperatively in later years versus operatively in earlier years. There are 4 level III series establishing that prospective application of a nonoperative algorithm for blunt trauma patients increases the number of patients managed nonoperatively, and a single nonrandomized series (Croce, 1995) showing that nonoperative management was associated with fewer transfusions and fewer abdominal complications than operative management. These conclusions may be colored by the confounding factors of associated injuries and hemodynamic compromise in the operative group.

Simplistically, the decision in a hemodynamically normal patient may be boiled down to the concern about a missed injury versus the morbidity of an unnecessary laparotomy done to exclude this potential injury, and the potential morbidity of delayed hemorrhage or other nonoperative complication. The risk of a missed injury is small; 0.5% in the multi-institutional series (Pachter, 1995). The risk of delayed hemorrhage is also small; the overall abdominal complication rate in this series was 5%. The majority of complications such as biloma, intraabdominal abscess, and hemobilia, are seen in patients managed either operatively or nonoperatively. The morbidity of a negative or nontherapeutic celiotomy can approach 25% (Weigelt, 1988). Because of the concern about potential missed injuries and the ability to reliably follow serial abdominal exams, patients with neurologic injury were initially excluded from many series of nonoperative management. However, level V data from several series have shown that these patients can be successfully managed nonoperatively.

Despite the fact that the quality of the data favoring nonoperative management over operative management is only average (the majority level V, few level IV and fewer level III series) the overwhelming amount of data lend additional support to this recommendation. Many of the level V series have substantial numbers of patients, some are multi-institutional, and encompass different levels of trauma centers.

Current controversies: role of angiography and management of penetrating injuries

2. What role does arteriography play in the management of hepatic trauma?

Data support a grade III recommendation for the use of arteriography post-celiotomy or as an adjunct to nonoperative management.

Arteriography with embolization was first used after initial operative management failed to control active bleeding (level V). It also had early use in extending the ability to nonoperatively manage patients with liver injury diagnosed by liver-spleen scan (level V). More recently, level III data have evaluated its use in the management of patients that required ongoing resuscitation to maintain normal hemodynamics. Although not always successful in avoiding the operating room, this technique appears to allow nonoperative management in a larger group of patients. It is important to realize that patients with previous embolization can bleed again (Hagiwara, 1993) and can suffer similar complications to those patients managed operatively (Carrillo, 1999). Further data are needed to make a stronger recommendation about whether initial operative management or initial angioembolization offers the best management alternative.

3. Should nonoperative management be used in the treatment of patients with penetrating liver injury?

Data support a grade III recommendation using selective nonoperative management for penetrating liver injuries.

Penetrating injuries have a higher incidence of associated injuries than blunt injuries, approaching 70%. Several series document the safety of nonoperative treatment for select patients with penetrating injury. These patients are hemodynamically normal without peritonitis. Level III and level V data show that approximately 30% of patients may be candidates for this approach, but the failure rate may be as high as 30% (Demetriades, 1999). Nonoperative management initially involved serial abdominal exams without radiologic studies, but recently has included CT evaluation of the missile tract. Management of penetrating injuries nonoperatively requires all of the capabilities necessary to manage blunt-injured patients; a hemodynamically normal patient without peritoneal signs, 24 hour surgeon and operating room availability, blood bank resources, and intensive care unit monitoring. The weight of the evidence is not as great as it is for blunt injury, but there are enough level III data to make a grade III recommendation for the safety of this approach. There are no data available regarding outcome of operative versus nonoperative management of penetrating injuries.

References

1.
Carrillo E H. et al. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma. (1999);46:619–622. [PubMed: 10217224]
2.
Croce M A. et al. Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients: results of a prospective trial. Ann Surg. (1995);221:744–55. [PMC free article: PMC1234706] [PubMed: 7794078]
3.
Crosthwait R W. et al. The surgical management of 640 liver injuries in civilian practice. Surg Gynecol Obstet. (1962);114:650–654. [PubMed: 13882400]
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Defore W W, Mattox K L, Jordan G L, Beall A C. Management of 1590 consecutive cases of liver trauma. Arch Surg. (1976);111:493–497. [PubMed: 1259588]
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Demetriades D. et al. Gunshot injuries to the liver: the role of selective nonoperative management. J Am Coll Surg. (1999);188:343–348. [PubMed: 10195716]
6.
Eastern Association for the Surgery of Trauma (EAST) (1999) Guidelines for the management of liver trauma .
7.
Hagiwara A. et al. Delayed hemorrhage following transcatheter arterial embolization for blunt hepatic injury. Cardiovasc & Interv Radiol. (1993);16:380–383. [PubMed: 8131171]
8.
Meyer A A. et al. Selective nonoperative management of blunt liver injury using computed tomography. Arch Surg. (1985);120:550–554. [PubMed: 3985796]
9.
Pachter H L, Hofstetter S R. The current status of nonoperative management of adult blunt hepatic injuries. Am J Surg. (1995);169:442–445. [PubMed: 7694987]
10.
Weigelt J A, Kingman R G. Complications of negative laparotomy for trauma. Am J Surg. (1988);156:544–547. [PubMed: 3202270]
Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6996

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