R. J. Miskimins1, A. Greenbaum1, P. Kilen2, S. D. West1, S. W. Lu1 1University Of New Mexico HSC,Department Of Surgery,Albuquerque, NM, USA 2University Of New Mexico HSC,School Of Medicine,Albuquerque, NM, USA
Introduction: The initial treatment of high grade liver injuries is primarily determined by the patient’s hemodynamic status. Non-Operative management has become the standard in hemodynamically stable patients with high grade blunt liver injuries. We sought to evaluate the differences in high grade blunt liver injuries managed non-operatively vs. those requiring laparotomy.
Methods: The records of patients with blunt high grade liver injuries defined as AAST grade 4 and 5 from Jan 2008 to July 2015 at an ACS verified Level I trauma center were retrospectively reviewed. Charts were reviewed to identify liver-directed interventions and liver-related complications. The trauma database was used to obtain demographics, initial vitals, ISS, length of stay, and mortality. Statistical analysis was performed with the Mann Whitney U and Fisher exact tests.
Results: Eighty-six patients met inclusion criteria, with blunt high grade liver injuries, 20 grade 5 and 66 grade 4. Fifty-one (59%) patients were initally managed non-operatively and 35 (41%) initally required laparotomy. Of those initally managed non-operatively, 7 (14%) failed and required laparotomy (5 abdominal compartment syndrome (ACS), 2 peritonitis). Those who failed non-operative management were more likely to have undergone angioembolization (57% vs 16%, p=0.03). In the operative group, 12 patients (35%) died, 7 (20%) in the first 24 hours from hemorrhagic shock and 3 (9%) from multi-organ system failure. No patients initially managed non-operatively and subsequently requiring laparotomy died. When comparing the two groups, the operative groups had higher ISS (38 vs 27, p <0.01), lower initial SBP (87 vs 113 mmHG, p <0.01), higher transfusion of PRBC (11 vs 1 units, p<0.01) and FFP (9 vs 1 units, p <0.01), and longer ICU stays 12 vs 4 days (p <0.01). Bile leak was more prevalent in the operative group (33% vs 9%, p<0.01), as was ischemic gallbladder injury 24% vs 2% (p<0.01). When comparing patients that underwent embolization in both groups to patients not receiving embolization, the embolization group experienced higher rates of liver abscess (35% vs 3%, p=<0.01) and bile leak (50 % vs 12%).
Conclusions: Blunt AAST Grade IV-V liver trauma patients requiring laparotomy had significantly higher mortality, transfusion requirements and ICU length of stay when compared to patients managed non-operatively in our institution. Non-Operative management augmented with hepatic embolization has higher rates of failure compared to those not receiving hepatic embolization; however, these failures resulted from ACS and peritonitis as opposed to hemorhage.