M. E. Wooster2, M. Spalding1, A. Betz1, S. Sellers1, J. Balingcongan1, S. O’Mara1 1Grant Medical Center,Trauma Surgery And Critical Care,Columbus, OH, USA 2Doctors Hospital,General Surgery,Columbus, OH, USA
Introduction: The liver is the most commonly affected organ in blunt abdominal injury. Non-operative management of blunt hepatic trauma is the standard of care. The initiation of early deep vein thrombosis (DVT) prophylaxis, oral intake and ambulation was evaluated.
Methods: This is a retrospective review of 130 trauma patients over two years managed with a blunt hepatic injury guideline. Early serial hemoglobin, liver function tests, and angiography or hepatobiliary iminodiacetic acid (HIDA) scan were recommended for all injuries grade 3 or higher or if contrast blush noted on CT. Angiography and Endoscopic retrograde cholangiopancreatography (ERCP) was performed as warranted. Early DVT prophylaxis, oral intake, and ambulation were encouraged. Failure of non-operative intervention or peritonitis warranted exploratory laparotomy.
Results:
In grade 3 through 5, eleven leaks were identified, nine underwent non-operative management with success rates from 66% to 100%. Analysis of early liver function tests was not found to correlate with presence of biliary leak. Grade 4 and 5 injuries demonstrated a significantly increased leak rate over grade 3 injuries (38% vs 6%, p=0.012). There was no difference in duration of post trauma day identification of grade 3 versus grade 4 and 5 biliary leaks, respectively (2 vs 2.27, p>0.05).
After 24 hours, initiation of DVT prophylaxis, oral intake and ambulation was inversely related to grade. Eight patients underwent angiography and two underwent embolization. DVT prophylaxis was initiated later in Grade 5 injuries (p=0.03) with no increase in morbidity. Grade 5 patients had statistically significantly less oral intake after 24 hours (p=0.05) but no difference in ambulation.
One grade 4 patient suffered a missed injury with identification of biliary leak on post trauma day 8. One grade 5 patient failed non-operative management on post trauma day 2. There were no deaths.
Conclusion: The proposed blunt hepatic injury guideline enables safe non-operative manage of blunt liver injuries. These guidelines promote safe early initiation of DVT prophylaxis, oral intake and ambulation. Identification of high biliary leak rate in grade 3 and higher leak rates in grade 4 and 5 warrants evaluation of blunt hepatic injury with a HIDA scan for grade 3 or higher blunt hepatic injuries for effective non-operative management.
