Operative Management versus Conservative in Patients with Liver Trauma Injury

Operative Management versus Conservative in Patients with

Liver Trauma Injury

Wael mansy, MD; Morsi Mohamed, MD.

General Surgery Department, Zagazig University, Egypt.

Background: The liver is one of the most frequently damaged organs when abdominal trauma occurs. Currently, conservative management becomes the treatment of choice in hemodynamic stable patients.

Aim: To evaluate the results of an operative and conservative management of liver injury patients.

Patients and methods: From March 2011 to June 2015, 113 patients suffered from hepatic trauma were referred to Zagazig University hospital, trauma unit. The patients were classified according to the way of management: Group I, operative management; Group II, conservative management. Variables analyzed included demographic data, injury classification, associated lesions, surgical treatment, morbidity, mortality, and hospital stay.

Results: 113 patients had hepatic trauma. 39 (34.5%) patients were managed non- operatively. The commonest type of trauma was blunt and the main cause was motor vehicle in 59 (52.2%) patients. The second cause was stab injury with 33 (29.2%) patients. The least cause was gunshot injury in 21 (18.6%) patients. There was no significant difference in hospital stay between patients operated on and these managed non-operatively. There was no mortality in the patients managed conservatively.

Conclusions:  Conservative  management  is  a  safe  approach  for  hemo-dynamically stable patients with liver trauma. Conservative management patients should be admitted to intensive care unit for at least 48-72 hours for close monitoring of vital signs repeated clinical examinations and follow up investigations as indicated. Failure of conservative treatment did not show a higher incidence of complications or mortality. Good results obtained from conservative management resulted from a highly cooperated trauma team including surgery, anethesia, intensive care, cardiothoracic and neurosurgery doctors.

Key words: Conservative management, liver trauma and operative management.

Introduction:

The liver is the largest solid abdominal organ with a relatively fixed position, which makes it prone to injury.1  In Egypt in the last 3 years the incidence of liver trauma increased due to the increase in the frequency of abdominal firearm injury. Many studies during the last decade changed the therapeutic protocols in management of liver trauma.2

Conservative management took its role in liver injury hand by hand with operative management.  So  surgery  is  no  longer  the only option available.3 Surgery has to done for  extensive  lesions  with  hemodynamic instability or for the treatment of the complications. Surgical techniques include mass   sutures,   resection,   caval   shunting, SHAL (selective hepatic artery ligation), gauze pack or omental pack.4 Multiple studies showed  that  conservative  management  of liver injuries is effective. However, most of these studies were retrospective. In addition, the criteria for conservative management differed  among  centers  and  included different thresholds of age, hemodynamic compromise, abdominal tenderness, injury severity, associated extra-abdominal injuries, and grade of liver injury.5–7 The aim of this study was to analyze the effectiveness and the morbidity, the mortality of both conservative and surgical treatment in patients with hepatic injury attended in our trauma unit.

Patients and methods:

This was a review of our experience in the treatment of liver trauma from March 2011 ending in June 2015 including all the patients diagnosed with liver injury reported in our casualty unit. Injuries were graded according to the Organ Injury Scale as described by the American Association for the Surgery of Trauma.

To analyze the results the patients were divided into two groups:

Group I: operative treatment in 74 patients. Group  II:  conservative  treatment  in  39

patients.

Surgeon decided which way of treatment to apply.

Conservative treatment was depending on fulfilling the following criteria:

a) Hemodynamic stability.

b) Absence of signs of diffuse peritonitis physically.

c) No suspicion of associated injuries.

The initial radiological assessment was carried out with ultra- sonography and/or abdominal computerized tomography (CT) scan.

Conservative treatment for these patients included:

a)    Strict clinical control.

b)    Hemodynamic monitoring. c)  Daily pelvi-abdominal US.

d)   Serial determination of hemoglobin.

e)    Absolute bed rest for a period of 48–72 hours. 

Conservative treatment considered failed and surgery indicated when:

a) The appearance of hemodynamic instability.

b)    Clinical signs of peritonism.

c) And/or a continued reduction in hematocrit values.

On confirmation of the hemo-dynamically stability and if the associated injuries doesn’t need surgical interference, the patients were transferred to inpatient wards. Abdominal CT and liver functions were routinely performed prior to hospital discharge. Follow up via US after 1, 3 and 6 weeks. CT repeated after 2 - 3 months to verify the resolution of the injuries Figure (1).

Regarding exploration, our policy was to achieve perfect haemostasis. Big exploratory incision was done for good exposure; either j shaped incision from the start or right subcostal extension if we consulted to deal with liver trauma after midline incision. Liver mobilization was the next step. Identification of the bleeder, and dealing with the cause were done accordingly (either suture ligation or haemostaic diathermy when the bleeding is minimal). We never took haemostatic through and through sutures, for bleeding control. After good haemostasis we searched for biliary leak which was death and deled with accordingly (when the patient was stable, we did intra-operative cholangiogram to search for the bile leak cause in difficult hidden leaks). We did damage control in unstable  patients,  packing  and  re-  explore the patient when became stable. In major lacerations we sometimes did non-anatomic resection. Lastly good drainage was applied Figure (2).

The variables analyzed for the two groups of patients included classification of hepatic injury, associated lesions, surgical technique, morbidity, mortality and hospital stay.

Results:

From March 2011 ending in June 2015,

113 patients with liver trauma were treated in our center. 72 male patients (63.7%), 29 female patients (25.7%) while only 12 child patients (10.6%). The most type of trauma was blunt 59 (52.2%) patients and the main cause   was   motor   vehicle   accident.  The second cause was stab injury with 33 (29.2%) patients. The least cause was gunshot injury with 21 (18.6%) patients.

Associated abdominal lesions were presented in 56 patients (49.5%). Common associated organ injuries were Spleen (8), Diaphragm (13), Kidney (5), Ureter (1), Stomach  (5),  Colon  (4),  Duodenum  (1), Chest  (12  haemo-thorax),  small  bowel  (6)

Figure (1): A&B: Right posterior liver injury at time of trauma. C: CT follow- up after one month. D: CT follow- up after 3 months.

Figure (2): A: Segment 6 injury. B: IVC Injury repair. C: Shuttered liver. D: Diathermy haemostasis after minor liver injury.

Table (1): Postoperative morbidity and mortality.

Table (2): Conservative cases in blunt and gunshot injuries.

and pancreas (1).

The classification of the severity of the liver injuries (in blunt trauma 59 patients) according to the HIS criteria was as follows: Grade I: 16 (27.1%); Grade II: 24 (40.7%); Grade III: 11(18.6%); Grade IV: 6 (10.2%); and Grade V: 2 (3.4%).

Surgical treatment: 74 patients (65.5%) underwent surgery on admission due to hemodynamic instability. Other causes for surgical treatment were: signs of peritoneal irritation on physical exploration, pneumo- peritoneum,   suspicion   of   diaphragmatic injury, renal injury. 

Management of the liver injury as stratified according to grade of injury at exploration:

Surgical options for management of liver injuries at exploration included application of absorbable gelatine sponge (gelfoam), suture of the liver injury, peri-hepatic packing and resection. Resection was non-anatomical.

Eighteen patients died (15.9%); 5 patients (27.8%) following blunt trauma, 4 patients (22.2%) for stab wounds and 9 patients (50.5%)  following  gunshot  injury.  Eleven patients  (61.1%)  were  presented  with shock on admission died compared to 7 patients (38.9%) were presented without shock. Among 19 patients with delay of >6 h, 14 patients (73.7%) died, compared to 5 patients (26.3%) of those whose delay was >6 h. Patients with grade V injuries had a significantly higher mortality rate compared to       patients   with   grades   I-IV   injuries. Significantly more patients with associated injuries died (15) compared to those with isolated injury (3) Table (1).

Fifteen (13.3%) patients required a re- exploration for various reasons including damage control (3), removal of packs (7), biliary fistula (3) and burst abdomen (2). Postoperative complications arose in 27 patients (23.8%) and included biliary leak (6), pleural effusion (3), and chest infection (4) and wound problems (14).

Conservative treatment: 39 patients (34.5%) initially received conservative treatment that was effective in 33 (84.6%) cases.  The  morbidity  in  this  group  was 5 (12.8%) cases. Complications with the conservative treatment were a respiratory infection in 3 patients, one adult respiratory distress syndrome (ARDS) and one paralytic ileus Table (2).

Failure of conservative treatment: In 6 patients  (15.4%),  non  surgical  treatment failed with surgery being required. The reason for failure was hemodynamic instability in 4 cases and a maintained low hematocrit values in 2 cases. Four patients underwent surgery during the first 24 hours and the remaining two cases had surgery on the 3rd and 4th day, respectively.

Compared with the patients who underwent conservative management, patients who underwent a surgical treatment had a higher injury grade, more morbidity, mortality and more use of packed red blood cell (RBC), fresh frozen plasma (FFP), Platelet (PLT).

The risk factors for injury grade were: hemodynamic instability, vascular injury, surgical technique, hepatic mortality, hemo- peritoneum, lesion size, red blood cell (RBC), fresh frozen plasma (FFP), Platelet (PLT), hospital stay. 

There was no difference in morbidity between the three injury mechanisms. There was no difference in morbidity between patients with associated hollow visceral injury and those without associated hollow visceral injury but patients with hollow visceral injury had a higher mortality. Shock on admission and delay before surgery affected mortality.

Discussion:

In the last 15 years, the treatment of liver trauma had progressively evolved.8 At the beginning of 1990’s several papers discussed the possibility of non surgical treatment in patients with hemodynamic stability similar to pediatric surgeons in cases of hepatic and splenic injuries.4

The  aim  of  this  type  of  treatment  was not only to decrease the number of non therapeutic explorations9 but also to decrease morbidities and mortalities. Fortunately, a high percentage of injuries, around 85%, were not severe (<grade IV), these were previously managed with coagulation diathermy, hemostatic agents or superficial ligature. In these  injuries,  hemorrhage  stopped  at  the time of surgery in a considerable number of cases.10 Conservative treatment undoubtedly achieved the greatest percentage of success in this group of patients. However, in the remaining 10%-20% of the severe hepatic injuries the decision as to whether surgery was necessary  represented  a  difficult challenge for the surgeon.

In our center we routinely used abdominal ultra-sonography as the first diagnostic step in the study of abdominal trauma. This is a cheap, non-invasive investigation which is rapid and has a high sensitivity and specificity of 80%-95%,8 for the detection of intra- abdominal injuries, although it is operator- dependent with little specificity for detecting visceral  lesions.  Abdominal  CT  is  more rapid, sensitive and specific in the diagnosis of abdominal injuries.10 We believed that an abdominal CT should be carried out within the first 24 hours on suspicion of liver injury.

The applicability of conservative treatment in patients with liver injury has varied from 35% to 82% in publication.11 The two main were hemo- dynamic instability and the need for transfusion.12,13

The application of conservative treatment in cases of liver trauma forces surgeon to put the patient under continuous monitoring during the first 48 hours and to have rapid and efficient facilities to explore the patient once deteriorated.2 During the first years most series limited conservative management to non-severe injury (grade ≤III),14  restricting its use to values below 40% of the cases. Nowadays,  the  good  results  achieved  led to progressive widening of the inclusion criteria.10

Non-operative management of hepatic injuries is the treatment modality of choice in hemo-dynamically stable patients, irrespective of the grade of injury.15 Also Feliciano et al suggested conservative treatment for any lesion regardless of the injury force as long as the patient hemo-dynamically stable and with hemo-peritoneum of less than 500 ml estimated by CT scan.16  Currently

most authors consider that the decisive factor in deciding the conservative treatment should be hemodynamic stability independently of the injury grade and the quantity of hemo- peritoneum estimated by CT.9,12

In our study all the patients with grade V injury underwent surgery. In our limited experience  severe  grade  V  injuries  were required            surgical            treatment.                 Nonetheless, in  a  series  of  500  patients  who  received conservative  treatment,                 Malhota   et        al., described a failure rate of only 23% in the group  of  patients  (n  =  30)  with  grade  V lesions.17   Other  series  show  that  a  non- operative                   management         of     high-grade liver injury have been successful 10 but is associated  with  significant  morbidity  and correlates with the grade of liver injury.18 We have failure rate (15.4) in 6 patients from 39 patients.

High-grade injuries can be managed conservatively,  if  operative  intervention  is not required for hemodynamic instability or associated injuries, with a low mortality.19–21

In this subgroup with high risk of conservative treatment failure, the use of angiography with may be useful.22-24

The mortality from juxta-hepatic venous injuries is generally reported from 50% to 80% and the direct approach is the correct and rapid interference in these lesions.25 In our study the morbidity and mortality were not greater in the patients with conservative treatment failure compared to similar injuries in the surgical group.

The fact that 50-80% of liver injuries stop bleeding spontaneously, coupled with better imaging of the injured liver by CT, has led to the acceptance of conservative management with resultant decrease in mortality rates.26

This is especially more applicable to blunt liver injuries.27 Also, selective non-operative management of liver injuries is now becoming acceptable for firearm injuries as well.

Conclusion:

Conservative treatment in liver injury is applicable in hemodynamic stability patients. It is associated with a low overall morbidity and does not result in increases in length of stay. Also it is safe and effective regardless of the grade of liver injury. But, in our opinion, patients with grade V lesions should undergo surgical treatment after diagnosis.

Failure  of  conservative  treatment  does not necessarily lead to an increase in the incidence of complications or mortality in well equipped hospitals which permits the immediate possibility of performing surgery. Usually failure of conservative management was caused by associated abdominal injuries and not the liver. The degrees of injury severity, blood requirements, and the presence of other abdominal organ injuries have its role in conservative management failure.

Reference:

1-    Zangana A: Penetrating liver war injury: A report on 676 cases, after Baghdad invasion and iraqi civilian war April 2003. J of Advances in Medical and Dental Sciences 2007; 1(1): 10–14.

2-   Norrman   G,   Tingstedt   B,   Ekelund   M, Andersson R: Non- operative management of blunt liver trauma: Feasible and safe also in centers with a low trauma incidence. HPB 2009; 11(1): 50–56.

3-   Zago T, Pereira B, Calderan T, Hirano E, Rizoli S, Fraga G: Blunt hepatic trauma: Comparison between surgical and non- operative treatment. Rev Col Bras Cir 2012; 39(4): 307–313.

4-   Zago T, Tavares Pereira B, Araujo Calderan T,  Godinho  M,  Nascimento  B,  Fraga  G: Non-operative  management  for  patients with grade IV blunt hepatic trauma. World J Emerg Surg 2012; 7(1): 8.

5-   Pereira    B:    Non-operative    management of hepatic trauma and the interventional radiology: An update review. Indian J Surg

2013; 75(5): 339–345.

6-   Giannopoulos G, Katsoulis E, Tzanakis N, Panayotis A, Digalakis M: Non-operative management  of  blunt  abdominal  trauma. Is it safe and feasible in a district general hospital? Scand J Trauma Resuscitation & Emerg Med 2009; 17: 22–28.

7-   Gwendolyn  M,  Van  der  Wilden,  George C, Timothy E, Samielle B: Successful non- operative management of the most severe blunt liver injuries: A multicenter study of the research consortium of New England centers for trauma. Arch Surg 2012; 147(5): 423–428.

8-   Richardson J: Changes in the management of injuries to the liver and spleen. J Am Coll Surg 2005; 200(5): 648–669.

9-   Peitzman  A,  Ferrada  P,  Puyana  J:  Non- operative management of blunt abdominal trauma: Have we gone too far? Surg Infect (Larchmt) 2009; 10(5): 427–433.

10- Silvio E, Madrazo G, Ramos R: Current treatment of hepatic trauma. Cir Esp 2008;83(5): 227–234.

11- Swift    C,    Garner    J:    Non-operative management of liver trauma. J R Army Med Corps 2012; 158(2): 85–95.

12-  Gonzalez C, Suberviola C, Holanda P, Ots E,  Dominguez  A,  Ballesteros  M,  et  al: Liver trauma. Description of a cohort and evaluation of therapeutic options. Cir Esp 2007; 81(2): 78–81.

13-  Velmahos G, Toutouzas K, Radin R, Chan L, Demetriades D: Non-operative treatment of blunt injury to solid abdominal organs: A prospective study. Arch Surg 2003; 138(8):844–851.

14-  Lyuboslavsky Y, Pattillo M: Stable patients with blunt liver injury: Observe, do not operate! J of Critical Care Medicine 2009; 32(1): 14–18.

15-  Velmahos G, Toutouzas K, Radin R, Chan L, Rhee P, Tillou A, et al: High success with non-operative management of blunt hepatic trauma: The liver is a sturdy organ. Arch Surg 2003; 138(5): 475–480.

16-  Van der Vlies C, Olthof D, Gaakeer M, Ponsen K, Van Delden O, Goslings J: Changing patterns in diagnostic strategies and the treatment of blunt injury to solid abdominal organs. Int J Emerg Med 2011; 4: 47.

17-  Kozar  R,  Moore  F,  Cothren  C,  Moore  E, Sena M, Bulger E, et al: Risk factors for hepatic morbidity following non-operative management: Multicenter study. Arch Surg 2006; 141(5): 451–459.

18-  Christmas A, Wilson A, Manning B, Franklin G, Miller F, Richardson J, et al: Selective management  of   blunt   hepatic   injuries including non-operative management is a safe  and  effective  strategy.  Surgery  2005; 138(4): 606–610.

19-  Marmorale C, Guercioni G, Siquini W: Non- operative management of blunt abdominal injuries. Chir Ital 2007; 59(1): 1–15.

20- Gourgiotis  S,  Vougas  V,  Germanos  S, Dimopoulos N, Bolanis I, Drakopoulos S, et al: Operative and non-operative management of blunt hepatic trauma in adults: A single- center report. J Hepatobiliary Pancreat Surg 2007; 14(4): 387–391.

21- Kozar  R,  Moore  J,  Niles  S,  Holcomb  J, Moore E, Cothren C, et al: Complications of non-operative management of high-grade blunt hepatic injuries. J Trauma 2005; 59 (5): 1066–1071.

22- Heyn J, Ladurner R, Ozimek A: Diagnosis and preoperative management of multiple injured patients with explorative laparotomy because of blunt abdominal trauma. Eur J Med Res 2008; 13: 517–524.

23- Cohn S, Arango J, Myers J: Computed tomography grading systems poorly predict the need for intervention after spleen and liver injuries. Am Surg 2009; 75: 133–139.

24- Polanco P, Leon S, Pineda J, Puyana J, Ochoa J, Alarcon L, et al: Hepatic resection in the management of complex injury to the liver. J Trauma 2008; 65(6): 1264–1270.

25- Sartorelli, Kennith H, Frumiento, Carmine R, Frederick B, Osler, et al: Non-operative management of hepatic, splenic, and renal injuries in adults with multiple injuries. Journal               of   Trauma-Injury   Infection   & Critical Care 2000; 49(1): 56–62.

26- Degiannis E, Psaras G, Smith M: Abdominal gunshot wounds. Current status of selective non-operative  management.  S  Afr  J  Surg

27-  Omoshoro-Jones   J,  Nicol  A,  Navsaria   P: gunshot injuries. Br J Surg 2005; 92: 890-895.