Objective: This prospective study was designed to evaluate the outcome of conservative non-operative (NOM) and surgical management as regards morbidity and mortality in patients with blunt liver trauma.
Patients & Methods: The study included 176 patients admitted to Emergency Department (ED) with blunt abdominal trauma through a period of 4 years. After preliminary resuscitation, hepatic injury was graded in all patients using focused abdominal sonography for trauma (FAST) and in hemodynamically stable patient or patients with negative FAST; CT was performed. NOM was confined to hemodynamically stable patients, but was discontinued in patients with hemodynamic instability, unresponsiveness to moderate amounts of crystalloid infusion or a significant fall in hematocrit, or if any intraabdominal injury requiring repair was suspected. Operative treatment included temporary compression with packs (TP), deep mattress sutures (DMS) or individual ligation (L) of the bleeding vessels, devitalized tissue debridement (D) and omental packing (OP) of the laceration (LDOP management) was applied. Damage control (DC) laparotomy was used for major liver injuries using perihepatic pack to be removed after 24-72 hours.
Results: At ED, one patient arrived shocked and resuscitative measures failed to compensate and died and was excluded off the study; 108 patients (61.3%) were hemodynamically stable, 45 patients (25.6%) became stable on resuscitative measures, while 22 patients (12.5%) required emergency laparotomy. CT examination detected associated hollow viscus injury in 17 patients (9.7%), all underwent laparoscopy and repair was conducted in 12 patients but laparotomy was required in 5 patients. NOM was applied to 136 hemodynamically stable patients (77.3%); one patient (0.7%) died because of adult respiratory distress syndrome; 13 patients (16.2%) showed deterioration of general condition during NOM and required surgical interference, the other 122 patients responded to NOM, remained stable and no surgical interference was required and were discharged on the 5th day with a success rate of NOM of 89.7%. Surgical interference was conducted in 52 patients; 22 at time of presentation, 17 patients after CT examination and 13 patients after failure of NOM with a surgical management rate of 29.5%. Damage control laparotomy was required to control bleeding in 9 hemodynamically unstable patients with extensive bleeding. The total trauma-related mortality rate, irrespective of line of management was 4.6%, with NOM-associated mortality rate of 0.7% and surgery-associated total mortality rate was 13.6%; mortality rate in patients underwent DMS was 30% while was 22.2% in patients underwent DC maneuver.
Conclusion: It could be concluded that for hemodynamically stable patients with liver injury; conservative non-operative management reduces the frequency of non-therapeutic laparotomy and hospital stay with a mortality rate of 0.7%, while for hemodynamically unstable patients damage control laparotomy is the appropriate management modality and reduces operative time, other surgical maneuvers could be adjusted according to situation after laparotomy with a total postoperative mortality of 13.6%.
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