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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 3  |  Page : 84-88

Management of blunt liver trauma: Observational hospital-based study


Department of Surgery, GMC, Aurangabad, Maharashtra, India

Date of Submission04-Nov-2019
Date of Acceptance28-Apr-2020
Date of Web Publication23-Sep-2020

Correspondence Address:
Dr. Anant N Beedkar
Department of Surgery, GMC Aurangabad-431 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_35_19

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  Abstract 


Background: Conservative management of blunt liver trauma is being recommended based on evidence from research studies. The present study describes the observations concerning the management of blunt liver trauma from a tertiary care centre in Marathwada region of Maharashtra.
Patients and Methods: This observational hospital-based study included hemodynamically stable patients with confirmed blunt liver trauma, admitted at our tertiary care hospital. Patients who were not hemodynamically stable on admission; but later became hemodynamically stable after resuscitation were also included in the study. Hemodynamic stability was assessed based on systolic BP >90 mmHg; Pulse rate <100, and transfusion requirements <2 units. Diagnostic tools used were routine laboratory tests, Ultrasound imaging and CECT abdomen and pelvis. The AAST classification was used for grading the liver injury in patients in whom CT scan was done. Patients were assessed for clinical and hemodynamic status. Resuscitation, was done by using crystalloid solution and blood. The patients were then transferred to the intensive care unit for monitoring of vitals like pulse rate, systolic BP and abdominal distension. Regular observations and documentation of vital signs abdominal distension and haemoglobin were done, and once there is a change in the hemodynamic status patient was scheduled for surgical intervention. Patients were followed at 1, 2, 3, and 6 months interval.
Results: Total 31 (29 males, 2 females) blunt liver trauma patients were included. In total 26 patients (83.9%) were managed conservatively. Five patients (16.1%) were operated based on hemodynamic parameters. Most of the patients with grade II, III and IV liver trauma were managed conservatively with satisfactory results.
Conclusion: Study findings favour nonoperative management of blunt liver trauma in hemodynamically stable patients and also in patients who are responsive to resuscitation.

Keywords: CECT Abdomen, blunt liver injury, hemodynamic stability, blunt abdominal injury


How to cite this article:
Kasekar AJ, Beedkar AN, Jadhav SP, Tongse PS. Management of blunt liver trauma: Observational hospital-based study. Arch Int Surg 2019;9:84-8

How to cite this URL:
Kasekar AJ, Beedkar AN, Jadhav SP, Tongse PS. Management of blunt liver trauma: Observational hospital-based study. Arch Int Surg [serial online] 2019 [cited 2020 Oct 25];9:84-8. Available from: https://www.archintsurg.org/text.asp?2019/9/3/84/295922




  Introduction Top


The liver is a vital organ having the largest size among solid organs. Although it is located in the abdomen hidden behind the ribs, it is prone to injuries and frequently affected in abdominal trauma. The management of liver trauma involves conservative as well as surgical treatment options depending on the overall clinical condition of the patient.[1],[2] Previously, operative management was the standard of care for the blunt liver trauma patients; with the rationale of haemostasis and bile drainage. However, it was later found that non-drainage of bile did not affect the outcome adversely. In the last few decades, there has been a shift in management strategy with non-operative management considered as superior in the management of blunt trauma except in patients who were hemodynamically unstable.[3],[4] With the increasing availability and use of imaging techniques, it has become easier to decide the mode of management and the proportion of patients managed conservatively has increased. There is recent data from India as well as other countries reflecting conservative management as useful in most of the blunt liver trauma patients.[5],[6],[7],[8],[9] Fodor et al. reviewed the literature and there is a lack of conclusive evidence in support of the strategy of conservative treatment of blunt liver and spleen trauma.[10] The present study describes the observations regarding the management of blunt liver trauma at a tertiary care centre in India.


  Patients and Methods Top


This prospective observational hospital-based study was conducted from Nov 2015 to Nov 2017. The research was done at a public tertiary care centre in Marathwada region of Maharashtra state in India. The Institutional Ethics Committee approved the study protocol. Informed consent was taken from each participant before inclusion in the study. Hemodynamically stable patients with confirmed blunt liver trauma admitted at our tertiary care hospital were included in the study. The patients hemodynamically unstable on admission; but became hemodynamically stable after resuscitation, were also included in the study. The hemodynamically unstable patients; even after initial resuscitation, were excluded from the study. Patients with evidence of penetrating liver trauma were also excluded from the study. Hemodynamic stability was assessed based on systolic blood pressure more than 90mmHg; Pulse rate <100, and transfusion requirement less than two units. Patients after assessment and resuscitation were admitted in Trauma Intensive care unit and were further assessed on the same parameters. Diagnostic tools used were routine laboratory tests, Ultrasound imaging and Contrast Enhanced Computed Tomography (CECT) of the abdomen and pelvis.

The American Association for the Surgery of Trauma (AAST) - Liver Trauma Classification (Moore EEet al.).[11] was used for grading the liver injury in patients in whom CT scan was done.

Patients were assessed clinically and hemodynamically on presentation. Resuscitation, if needed, was done by using crystalloid solution and blood. The patients were then shifted to the intensive care unit for monitoring of vitals like pulse rate, systolic blood pressure and abdominal distension. Regular observations and documentation of vital signs abdominal distension and haemoglobin were done, and once there is a change in the hemodynamic status patient was scheduled for surgical intervention. Patients were followed at 1, 2, 3, and 6 months interval.

The description of data was done using Microsoft Excel 2013.


  Results Top


During the study period, a total of 31 blunt liver trauma patients were included as per defined criteria. [Table 1] shows the age distribution of the 31 patients, along with the mode of management. Out of these 31 patients, 26 patients (83.9%) were managed conservatively. In total 5 patients (16.1%) were operated upon based on hemodynamic parameters described. Among the study subjects, there were 29 males and 2 females signifying the male preponderance. The mode of injury in most of the patients (29 out of 31 patients) was a Road Traffic accident, whereas there were 2 cases of fall. There was no case of assault. All patients presented with right hypochondriac pain (100%) and 15 patients (48.4%) presented with right lower chest pain. [Table 2] shows the associated injuries in the studied patients. On presentation, 25 (80.65%) patients had a pulse rate >100 beats/min, whereas 12 (38.7%) patients had systolic blood pressure <90 mm of Hg, following resuscitation with fluids and an average of two pints of blood. The pulse rate and systolic blood pressure stabilized in all conservatively managed patients.
Table 1: Age distribution of blunt liver trauma patients according to conservative (nonoperative) management and surgical (operative) management

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Table 2: Associated injuries in blunt liver trauma patients

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Out of 31 patients studied, 29 patients were subjected to CECT abdomen and pelvis after Ultrasonography (USG) was suggestive of hemoperitoneum with a liver laceration. [Figure 1], [Figure 2], [Figure 3], [Figure 4] shows few of the CT images of the studied subjects, whilst Intra operative image of grade III liver injury is shown in [Figure 5]. Only 2 patients were managed using USG as the diagnostic tool. In these two patients, the CECT was not done given the patient is hemodynamically stable on presentation, and as haemoglobin was maintained static without any fall. The AAST grading of liver injury in the study patients is shown in [Table 3]. The duration of hospitalization required in conservative and operatively managed study patients is shown in [Table 4]. A total of 4 patients had complications in our study group, of which one patient had Common Bile Duct (CBD) stricture and was managed operatively. In total 2 patients had a liver abscess of smaller size, which was managed conservatively. Only 1 patient had a hematoma, which was managed conservatively. [Figure 1], [Figure 2], [Figure 3], [Figure 4] highlight examples of grades of liver injury as seen on CT and [Figure 5] was taken intraoperatively.
Figure 1: CECT Image with grade I Liver Injury

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Figure 2: CECT Image with grade II Liver Injury

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Figure 3: CECT Image with grade III Liver Injury

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Figure 4: CECT Image with grade IV Liver Injury

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Figure 5: Intraoperative Image for grade III Liver Injury

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Table 3: American association of surgery for trauma, CECT grading of liver injury in study group

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Table 4: Duration of hospital stay of liver injury patients in study group

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  Discussion Top


In our study, most of the patients were managed conservatively with satisfactory results. Operation theatre availability was guaranteed in the same tertiary care hospital if there was any need for urgent intervention. CT scan was needed in most patients and was quite helpful in management decisions. Of late, the non- operative management of blunt liver trauma has become the choice mode of treatment, especially with the help of imaging techniques like CT scan and Ultrasonography.[2] Cachecho et al. have advocated the conservative management of blunt liver trauma as it required less use of blood products and had better survival rates.[12] Petrowsky et al. studied the outcomes of conservative management of blunt liver trauma over 25 years. They have concluded that; the integration of computed tomography investigation in the early trauma management and the increasing preference for conservative management strategy in the hemodynamically stable patients has improved survival rates. They recommended the non-operative treatment as the gold standard for the management of blunt liver trauma patients.[8] Recently, Jyothiprakasan et al. studied 54 patients managed conservatively even in patients with higher grades of liver injury. They recommended the non-operative treatment as the primary mode of therapy in hemodynamically stable patients even for higher degrees of liver injury. The Morbidity and mortality were reported by them to be less in patients managed conservatively.[6] Hommes et al. also said that the non-operative management of blunt trauma of the liver has become the standard of care and has high Success rates of 100%. In their study, the success rates were 95%. It was suggested that the hemodynamic status and CT findings should be taken into consideration for the decision regarding management option. Non-operative management should be the option of choice in patients who respond to resuscitation even if there is a higher grade of liver trauma and if the associated organ injuries to abdominal organs do not rule out conservative management.[13] Zago et al. have also studied the blunt liver trauma management outcomes over 21 years from 1990 to 2010 and found that non-operative management of blunt trauma of the liver was safe and effective.[14]

The present study has limitations of being a single-centre hospital-based study. The study design and sample size restrict the external validity and generalizability of the study findings. However, the literature available is in line with study results, and non-operative management of blunt trauma of the liver can be suggested as a useful mode of treatment. To conclude, our study findings favour the non-operative management of blunt trauma of liver, especially in hemodynamically stable patients and patients responsive to resuscitation.

Financial support and sponsorship

Resources and Infrastructure: Department of Surgery, Government Medical College, Aurangabad.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Feliciano DV. Surgery for liver trauma. Surg Clin North Am 1989;69:273-84.  Back to cited text no. 1
    
2.
She WH, Cheung TT, Dai WC, Tsang SH, Chan AC, Tong DK, Leung GK, Lo CM. Outcome analysis of management of liver trauma: A 10-year experience at a trauma center. World J Hepatol 2016;8:644-8.  Back to cited text no. 2
    
3.
Fabian TC, Croce MA, Stanford GG, Payne LW, Mangiante EC, Voeller GR, et al. Factors affecting morbidity following hepatic trauma. A prospective analysis of 482 patients. Ann Surg 1991;213:540-8.  Back to cited text no. 3
    
4.
Malhotra AK, Fabian TC, Croce MA, Gavin TJ, Kudsk KA, Minard G, et al. Blunt hepatic injury: A paradigm shift from operative to nonoperative management in the 1990s. Ann Surg 2000;231:804-13.  Back to cited text no. 4
    
5.
David Richardson J, Franklin GA, Lukan JK, Carrillo EH, Spain DA, Miller FB, et al. Evolution in the management of hepatic trauma: A 25-year perspective. Ann Surg 2000;232:324-30.  Back to cited text no. 5
    
6.
Vinod Kumar J, Madhusudhan C, Reddy CS. Study of blunt trauma abdomen involving liver injuries based on grade of injury, management: A single center study. Int Surg J 2019;6:793-7.  Back to cited text no. 6
    
7.
Brillantino A, Iacobellis F, Festa P, Mottola A, Acampora C, Corvino F, et al. Non-operative management of blunt liver trauma: Safety, efficacy and complications of a standardized treatment protocol. Bull Emerg Trauma 2019;7:49-54.  Back to cited text no. 7
    
8.
Petrowsky H, Raeder S, Zuercher L, Platz A, Simmen HP, Puhan MA, et al. A quarter century experience in liver trauma: A plea for early computed tomography and conservative management for all hemodynamically stable patients. World J Surg 2012;36:247-54.  Back to cited text no. 8
    
9.
Saleh AF, Al Sageer E, Elheny A. Management of liver trauma in Minia University Hospital, Egypt. Indian J Surg 2016;78:442-7.  Back to cited text no. 9
    
10.
Fodor M, Primavesi F, Morell-Hofert D, Haselbacher M, Braunwarth E, Cardini B, et al. Non-operative management of blunt hepatic and splenic injuries-practical aspects and value of radiological scoring systems. Eur Surg 2018;50:285-98.  Back to cited text no. 10
    
11.
Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: Spleen and liver (1994 revision). J Trauma 1995;38:323-4.  Back to cited text no. 11
    
12.
Cachecho R, Clas D, Gersin K, Grindlinger GA. Evolution in the management of the complex liver injury at a Level I trauma center. J Trauma 1998;45:79-82.  Back to cited text no. 12
    
13.
Hommes M, Navsaria PH, Schipper IB, Krige JE, Kahn D, Nicol AJ. Management of blunt liver trauma in 134 severely injured patients. Injury 2015;46:837-42.  Back to cited text no. 13
    
14.
Zago TM, Pereira BM, Calderan TR, Hirano ES, Rizoli S, Fraga GP. Blunt hepatic trauma: Comparison between surgical and nonoperative treatment. Rev Col Bras Cirur 2012;39:307-13.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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