R. G. Ramos1, D. Newhouse1, K. Lemon1, J. Alvikas1, L. Alarcon1, B. Zuckerbraun1, A. Peitzman1, A. Humar1, M. Neal1, A. Tevar1 1University Of Pittsburg,Surgery,Pittsburgh, PA, USA
Introduction: The liver is the most commonly injured abdominal organ, with American Association for the Surgery of Trauma (AAST) grade IV or V injuries comprising only 15% of these injuries. Although the majority of these safely undergo non-operative management (NOM), AAST grade IV and V liver injuries continue to be associated with high NOM failure rates and a 20% mortality rate. Patients who fail NOM have increased morbidity and mortality when compared to patients who receive up-front operative management (OM). In order to define the best management strategies for high grade liver injuries, we conducted an analysis of grade IV and grade V injuries managed at our institution from January 2010 to July 2018.
Methods: This is a retrospective review of patients admitted to our institution with an AAST grade IV or V liver injury from January 2010 to July 2018. Demographic data, mechanism of injury, length of stay (LOS), intensive care unit (ICU) LOS, morbidity, and mortality were obtained from electronic medical records. Patients undergoing laparotomy in the first 6 hours were considered to have received OM. Attempted NOM was defined as no surgery in the first 6 hours. Failure of NOM was defined as surgical intervention after the first 6 hours. The type of OM, operative time, complications of OM, IR interventions, need for endoscopic retrograde cholangiopancreatography (ERCP), failed NOM, angioembolization, morbidity, and mortality were described.
Results: During the study period, our institution admitted 123 patients with high grade liver trauma. Mechanism of injury was blunt in 102 patients (83%) and penetrating in 21 patients (17%). Median age was 30 years (IQR 22-43). Median LOS was 12 days (IQR 6-21). AAST grade of their liver injuries was grade IV in 85 patients (69%) and grade V in 38 patients (31%). Seventy three patients (59%) underwent OM, 50 (41%) underwent NOM, and 7 (6%) failed NOM. The overall mortality was 13 (11%). Mortality in the OM group was 13 (18%), 8 (62%) of these patients died within 24 hours of admission. The indication for surgery was hemodynamic instability (systolic blood pressure < 100 mm Hg and/or heart rate > 120 bpm) in all 13 patients. There were no fatalities in the failed NOM group or the NOM group.
Conclusion: Despite advances in ICU care and NOM strategies, high grade liver injuries continue to be associated with significant morbidity and mortality. This study describes the most severely injured liver trauma cohort in the literature with 85 (69%) grade IV injuries, and 38 (31%) grade V injuries. Our overall mortality (11%) and our OM group mortality (18%) are lower than the mortality reported in the most recent National Trauma Data Bank analysis of severe blunt liver injury (20%). This suggests that operative management continues to be a viable option in selected patients with high grade liver injuries.