Citation Information :
Gupta AK, Chandel VS, Chandel LR, Chauhan A, Malhotra P. Nonoperative Management in Blunt Liver Trauma: A Study done in a Tertiary Care Hospital of a Hilly State in India. Panam J Trauma Crit Care Emerg Surg 2018; 7 (1):33-37.
Aim: To evaluate the efficacy of nonoperative treatment in blunt trauma liver.
Materials and methods: A 1-year prospective study was conducted in the Department of Surgery, Indira Gandhi Medical College (IGMC), Shimla, Himachal Pradesh, India, on 31 patients with blunt trauma with liver injuries proved on ultrasonography (USG) focused assessment with sonography for trauma (FAST) and contrast-enhanced computed tomography (CECT) abdomen. Once admitted, patients with grades I or II liver injury with no other comorbidities and other associated injuries were managed conservatively. Patients with grades III, IV, or V liver injury or lower grade liver injury with other associated injuries were observed and monitored strictly. Patients were considered a failure if the patient developed signs of peritonitis.
Results: Out of 83 patients with blunt abdominal trauma, 31 patients fulfilled the inclusion criteria for nonoperative management (NOM). The incidence of blunt liver trauma (BLT) was 37.34% Out of these, one patient required operative management (OM). Average age was 27 years. Out of 31 patients, 25 (80.6%) patients were males and 6 (19.4%) were females. Totally, 24 (77.4%) patients acquired injury due to road side accidents. Totally, 25 (80.6%) patients reported to the hospital within 6 hours of injury and 5 (16.1%) within 7 to 12 hours. On grading of liver injuries depending on CECT findings, 6 (19.4%) patients presented with grade I injury, 7 (22.6%) patients with grade II injury, 11 (35.5%) with grade III injury, and 6 (19.4%) with grade IV injury. Grade V injury was noted in 1 (3.2%) patient. Sixteen patients required blood transfusion. The NOM was successful in 96.8% of the patients. Liver-specific success rate of NOM was 100%. Mean hospital stay was 10.8 days for NOM.
Conclusion: Patients of blunt liver injury who are hemodynamically stable should be considered for NOM.
Clinical significance: The NOM is a highly feasible and safe method for being cost-effective, requiring shorter hospital stay, and avoiding high morbidity.
Cusheri A, Giles GR, Moosa AR, editors. Essential surgical practice: 3rd ed. Oxford: Butterworth International; 1998. p. 263-304.
Zangana AM. Penetrating liver War injury: a report on 676 cases, after Baghdad invasion and Iraqi Civilian War April 2003. J Adv Med Dent Sci 2007 Sep;1(1):10-14.
Feliciano DV, Rozycki GS. Hepatic trauma. Scand J Surg 2002;91(1):72-79.
Silvio-Estaba L, Madrazo-González Z, Ramos-Rubio E. Actualización del tratamiento de los traumatismos hepáticos. Cirugía Española 2008 May;83(5):227-234.
Pachter HL, Knudson MM, Esrig B, Ross S, Hoyt D, Cogbill T, Sherman H, Scalea T, Harrison P, Shackford S, et al. Status of non-operative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. J Trauma 1996 Jan;40(1):31-38.
Croce MA, Fabian TC, Menke PG, Waddle-Smith L, Minard G, Kudsk KA, Patton JH Jr, Schurr MJ, Pritchard FE. Nonoperative management of blunt hepatic trauma is the treatment of choice for haemodynamically stable patients. Ann Surg 1995 Jun;221(6):744-755.
Knudson MM, Lim RC Jr, Oakes DD, Jeffery RB Jr. Non-operative management of blunt liver injuries in adults: the need for continued surveillance. J Trauma 1990 Dec;30(12): 1494-1500.
Meredith JW, Young JS, Bowling J, Roboussin D. Non-operative management of blunt hepatic trauma: the exception or the rule? J Trauma 1994 Apr;36(4):529-535.
Pachter H, Liang H, Hofstetter S. Liver and biliary tract trauma In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 1996. p. 633-680, 681-682.
Leppaniemi AK, Mentula PJ, Streng MH, Koivikko MP, Handolin LE. Severe hepatic trauma: non operative management, definitive repair or damage control surgery. World J Surg 2011 Dec;35(12):2643-2649.
Helling TS, Ward MR, Balon J. Is the grading of liver injuries a useful clinical tool in the initial management of blunt trauma patient? Eur J Trauma Emerg Surg 2009 Apr;35(2):95-101.
Federico JA, Horner WR, Clark DE, Isler RJ. Blunt hepatic trauma. Nonoperative management in adults. Arch Surg 1990 Jul;125(7):905-909.
Yanar H, Ertekin C, Taviloglu K, Kabay B, Bakkaloglu H, Guloglu R. Nonoperative treatment of multiple intra-abdominal solid organ injury after blunt abdominal trauma. J Trauma 2008 Apr;64(4):943-948.
Velmahos GC, Toutouzas K, Radin R, Chan L, Rhee P, Tillou A, Demetriades D. High success with nonoperative management of Blunt Hepatic Trauma: the liver is a sturdy organ. Arch Surg 2003 May;138(5):475-481.
Gad MA, Saber A, Farrag S, Shams ME, Ellaban GM. Incidence, patterns, and factors predicting mortality of abdominal injuries in trauma patients. N Am J Med Sci 2012 Mar;4(3):129-134.
Magray M, Shahdhar M, Wani M, Shafi M, Sheikh J, Wani H. Studying the role of computed tomography in selective management of blunt abdominal trauma patients in a single tertiary care centre In Northern India. Internet J Surg 2013;30(2):1-5.
Emery KH, McAneney CM, Racadio JM, Johnson ND, Evora DK, Garcia VF. Absent peritoneal fluid on screening trauma ultrasonography in children: a prospective comparison with computed tomography. J Pediatr Surg 2001 Apr;36(4):565-569.
Ekiz F, Yucel T, Emergen I, Gurdal SO, Gonullu D, Yankol Y. The comparison of the results of the conservative treatment between isolated solid organ injuries and those injuries associated with extra-abdominal injuries after blunt abdominal trauma. Ulus Travma Acil Cerrahi Derg 2003 Jan;9(1):23-29.
Rutledge R, Hunt JP, Lentz CW, Fakhry SM, Meyer AA, Baker CC, Sheldon GF. A statewide, population based timeseries analysis of the increasing frequency of non-operative management of abdominal solid organ injury. Ann Surg 1995 Sep;222(3):311-326.
Sartorelli KH, Frumiento C, Rogers FB, Osler TM. Nonoperative management of hepatic, splenic and renal injures in adults with multiple injuries. J Trauma 2000 Jul;49(1):56-62.
Duane TM, Como JJ, Bochicchio GV, Scalea TM. Re-evaluating the management and outcomes of severe blunt liver injury. J Trauma 2004 Sep;57(3):494-500.
Fischer RP, Miller-Crotchet P, Reed RL 2nd. The hazards of non-operative management of adults with blunt abdominal injury. J Trauma 1988 Oct;28(10):1445-1449.
Kemmeter PR, Hoedema RE, Foote JA, Scholten DJ. Concomitant blunt enteric injuries with injuries of the liver and spleen: a dilemma for trauma surgeons. Am Surg 2001 Mar;67(3):221-226.