Isolated blunt liver trauma: is nonoperative treatment justified?

Surgical intervention for paediatric liver injuries is almost history - a 12-year cohort from a major Scandinavian trauma centre

Background

Although nonoperative management (NOM) has become standard care, optimal treatment of liver injuries in children is still challenging since many of these patients have multiple injuries. Moreover, the role of angiography remains poorly defined, and a high index of suspicion of complications is warranted. This study reviews treatment and outcomes in children with liver injuries at a major Scandinavian trauma centre over a 12-year period.

Methods

Patients <17 years old with liver injury admitted to Oslo University Hospital Ullevaal during the period 2002-2013 were retrospectively reviewed. Data were compiled from the institutional trauma registry and medical records.

Results

A total of 66 children were included. The majority was severely injured as reflected by a median injury severity score of 20.5 (mean 22.2). NOM was attempted in 60 (90.9%) patients and was successful in 57, resulting in a NOM success rate of 95.0% [95% CI 89.3 to 100]. Only one of the three NOM failures was liver related, occurred in the early part of the study period, and consisted in operative placement of drains for bile leak. Two (3.0%) patients underwent angiographic embolization (AE). Complications occurred in 18 (27.3% [95 % CI 16.2 to 38.3]) patients. Only 2 (3.0%) patients had liver related complications, in both cases bile leak. Six (9.1%) patients underwent therapeutic laparotomy for non-liver related injuries. Two (3.0%) patients died secondary to traumatic brain injury.

Discussion

This single institution paediatric liver injury cohort confirms high attempted NOM and NOM success rates even in patients with high grade injuries and multiple accompanying injuries. AE can be a useful NOM adjunct in the treatment of paediatric liver injuries, but is seldom indicated. Moreover, bile leak is the most common liver-related complication and the need for liver-related surgery is very infrequent.

Conclusion

NOM is the treatment of choice in almost all liver injuries in children, with operative management and interventional radiology very infrequently indicated.

Outcomes and indications for intervention in non-operative management of paediatric liver trauma: a 5 year retrospective study

AIM

To determine the applicability of accurate computed tomography (CT) evaluation and embolization as non-operative management for liver trauma in a paediatric population.

MATERIAL AND METHODS

A retrospective observational study of 37 children (mean age 10.5 years) with hepatic trauma (28 blunt, 9 penetrating) admitted to a trauma referral centre over a 5 year period. All patients were evaluated with CT and scored with an Association for the Surgery of Trauma score. Inpatient information was reviewed for demographics, associated injuries, modes of management, efficacy and complications of management, and outcome.Statistical analysis was performed.

RESULTS

There were seven contusions, two grade I, two grade II, nine grade III, and 17 grade IV liver lacerations. Only two patients (grade IV, penetrating) underwent surgery for the management of bowel perforation. All children had non-surgical treatment of their liver trauma: three cases (grade IV) had primary angiography due to CT evidence of active bleeding and embolization was performed in two of these. Seven patients (two grade III, five grade IV)had angiography during the follow-up for evidence of a complicating pseudoaneurysm and embolization was performed in six of them. Embolization was successful in all the children; one minor complication occurred (cholecystitis). Endoscopic retrograde cholangiopancreatography (ERCP) plus stenting was performed in two cases for a bile leak. All 37 children had a positive outcome.

CONCLUSION

The present study demonstrates that non-operative management of hepatic trauma is applicable to children and may have a higher success rate than in adults.

Quality care in pediatric trauma

Infrastructure, processes of care and outcome measurements are the cornerstone of quality care for pediatric trauma. This review aims to evaluate current evidence on system organization and concentration of pediatric expertise in the delivery of pediatric trauma care. It discusses key quality indicators for all phases of care, from pre-hospital to post-discharge recovery. In particular, it highlights the importance of measuring quality of life and psychosocial recovery for the injured child.

Evaluating a conservative approach to managing liver injuries in Kashmir, India

AIM

There has been a steep rise in incidence of liver injury in the past few years because of increase in incidence of road traffic accidents. The aim of this study was to evaluate the role of non-operative management of liver injury due to blunt abdominal trauma.

MATERIALS AND METHODS

All patients with liver injury from blunt trauma abdomen were studied between January 2000 and January 2010. A total of 152 patients with liver injury were put on conservative management. Hundred and three (67.77%) patients were males and 49 (32.23%) were females with an age range of 15-60 years (32.8 years). Most of the injuries were because of road traffic accidents (81.57%). Liver injuries were graded according to Moore's classification using computed tomography. Patients with Grade V and VI were excluded from the study. Patients who were unstable hemodynamically on admission were also excluded from the study.

RESULTS

There was no mortality in our series. Eight patients needed exploration because they developed hemodynamic instability. Four of the patient developed post-operative liver abscess which was treated conservatively.

CONCLUSION

Non-operative management of liver injury due to blunt trauma abdomen is a safe, effective and treatment modality of choice in hemodynamically stable Moore's grade I to Grade IV injury.

Healing of Blunt Liver Injury After Non-Operative Management: Role of Ultrasonography Follow-Up

BACKGROUND

Non-operative management of patients with blunt liver trauma has become the standard of care. Usually after initial computed tomography (CT) evaluation and a short-term intra-hospital instrumental and clinical monitoring, no other imaging assessment is routinely requested. A restriction of physical activities for a few (unfixed number of) months is the most common recommendation. A few studies investigated the re-establishment of normal hepatic parenchymal architecture, but there is no evidence of the correct length of time for a certain resumption to normal life. To understand the progression of traumatic liver damage and the time course of healing, and to indicate the correct spontaneous recovery time, a long-term sonographic followup was done.

METHODS

Forty-four patients with blunt non-operatively managed hepatic injury were selected by a retrospective review of a prospectively collected database. At admission, in accordance with the American Association for the Surgery of Trauma (AAST), all lesions were evaluated by CT and graded by the Organ Injury Scale (OIS). The progression of liver repair was followed by ultrasonographic (US) controls on days 3, 5, 10, 15, 30, and 60, and monthly up to a complete clinical recovery and sonographic disappearance of lesions.

RESULTS

One OIS grade I, 20 grade II, 13 grade III, eight grade IV, and two grade V hepatic injuries were included in the study. Forty patients were monitored until liver normalization by 218 US examinations. The median time for liver repair in OIS grades II, III, IV, and V was 30, 63, 62, and 118 days, respectively, and 75% of the patients recovered in 60, 80, and 98 days in the II, III, and IV classes, respectively.

CONCLUSION

In our experience, a long time variability for spontaneous liver repair after blunt trauma and non-operative treatment was found, but a parenchymal US normalization was evidenced in a median time shorter than that usually reported in the literature.

Complications of nonoperative management of pediatric blunt hepatic injury: Diagnosis, management, and outcomes

BACKGROUND

Nonoperative management (NOM) of blunt hepatic injury is the standard of care in the hemodynamically stable pediatric patient, but it is not without pitfalls. The purpose of this study is to assess the incidence and types of complications associated with NOM in terms of diagnosis, management, and outcomes.

METHODS

A retrospective study of pediatric patients with blunt hepatic injuries admitted from 1991 through 1997 to a Level I pediatric trauma center was conducted. All stable patients were initially managed nonoperatively according to the Isolated Liver Laceration Critical Pathway. Surveillance was performed by physical examination and tracking of hematocrit and liver function test (LFT) results. Follow-up ultrasound (US) or computed tomography (CT) were performed as clinically indicated.

RESULTS

In all, 185 patients with nonoperatively managed blunt hepatic injuries were identified during a 7-year period. Over 90% (168/185) were successfully managed nonoperatively without adverse sequelae. Ten patients (5.4%) died: seven as a result of head injury; three as a result of multisystem organ failure; none directly attributable to their hepatic injuries. Complications occurred in seven patients (3.8%) with Grades III or IV right lobe liver lacerations and included biloma (5), hepatic artery pseudoaneurysm with hemobilia (1), and necrotic gallbladder (1). All seven patients (100%) had fever, persistent or worsening right upper quadrant pain, feeding intolerance, and persistently elevated LFTs. Complications were diagnosed by CT or US. Nonoperative treatment of complications was successful in four of the seven patients (57.1%) and consisted of percutaneous drain placement only (1), percutaneous drain placement and endoscopic retrograde cholangiopancreatography (ERCP)-guided stent placement (2) and angioembolization (1). Three patients (42.9%) required laparotomy, one for management of a concomitant pancreatic pseudocyst.

CONCLUSION

Complications of NOM of pediatric blunt hepatic injury are rare, but may include biloma, hepatic artery pseudoaneurysm, and necrotic gallbladder. Complications occur only with Grade III or greater injuries and are accompanied by fever, right upper quadrant pain, feeding intolerance, and persistently elevated LFTs. The clinician must maintain a high index of suspicion for the development of complications and have a low threshold for obtaining a CT or US for diagnosis. Interventional radiology techniques, angiography, and ERCP are useful adjuncts to nonoperative management, but some patients may still require laparotomy for management of complications.

Liver injuries in children: the role of selective non-operative management

INTRODUCTION

This review article on the management of blunt liver injury in children is based on the authors' experience of 311 patients over a 22-year period.

MATERIAL AND METHODS

All children presenting to our institution with confirmed blunt liver trauma were studied retrospectively. Hospital folders of 311 patients were analysed. Information was gathered about the clinical presentation, associated injuries, grade of injury, transfusion requirements and haemodynamic stability to examine factors influencing outcome.

RESULTS

The age of patients ranged between 3 weeks and 12 years (mean of 7 years). Injuries as a result of motor vehicle accidents (MVAs) were the most common (268; 232 pedestrian and 36 passenger), other causes were falls (26) assaults or child abuse(15), bicycle handle bar injury (2). One hundred and thirty-six patients sustained an isolated hepatic injury and 175 had multiple injuries. Associated injuries included 147 head injuries, 131 fractures, 66 thoracic and 143 intra-abdominal (74 spleen, 45 renal, 4 pancreatic and 4 hollow viscus). Two patients died soon after arrival, 21 underwent laparotomy, 13 of which were liver related, while 288 were treated non-operatively. One hundred and six patients required blood transfusion (mean of 21.3 ml/kg); 30% of the nonoperative group and 100% of the operative group. There were three fatalities from the operative group (1% total mortality), one secondary to a severe, head injury, one liver haemorrhage and one from multi-organ failure

DISCUSSION

The vast majority (93%) was successfully treated non-operatively with only 4% coming to liver related laparotomy, complications were lower, transfusions less and the in-hospital occupancy was shorter. Complication rate was 8% and mortality was 1%.

CONCLUSION

We confirm the success selective non-operative management of blunt liver trauma as adopted by this institution 20 years ago. It is now proven treatment in an appropriate centre. However, the challenge is to identify the severely injured child early and institute aggressive resuscitation and expedite laparotomy when indicated.

Blunt liver trauma in children

Diagnostic evaluation and treatment of blunt liver trauma in children have changed essentially over the last decades. In the period between January 1975 and December 2002, a total of 45 children, 18 girls and 27 boys, between the ages of 1 and 16 years (mean 8.19) were treated for liver rupture following blunt abdominal trauma. The most common causes of injury were traffic accidents (49%), followed by falls (22%), direct trauma due to impact (20%) and being run over by a vehicle (9%). A total of 26 patients had one or more concomitant injuries; the injury severity score was between 16 and 57 (mean 22.9), and 16 patients had additional injuries to other solid abdominal organs. Since we last used laparotomies to explore the abdomen and manage liver ruptures in 1984, we divided our patients into two groups with respect to the choice of diagnostic and treatment modalities: group I, consisting of children treated before 1984, and group II, consisting of children treated after 1985. In group I (n=12), a diagnosis was made in eight cases based on exploratory laparotomy, in two cases based on sonography and laparoscopy, in one case based on laparoscopy only, and in another case based on sonography only. In eight cases the rupture was treated operatively; there was one postsurgical sepsis and one ileus due to adhesions. One child hemorrhaged to death when the vena cava ruptured during surgery. In group II (n=33), sonography was sufficient for a diagnosis in 18 cases. In 12 cases an additional computed tomographic scan was performed following initial sonography, and in three cases a diagnostic laparotomy was done elsewhere. In five cases the rupture was treated operatively in other hospitals. Twenty-eight patients could be treated conservatively and without any complications. One child died 3 days after the accident as a result of a severe brain injury. Over the past 15 years we have seen a clear tendency toward conservative treatment of our patients, which is also in agreement with current literature. Initial sonography, supplemented by computed tomography when necessary, allows not only noninvasive initial diagnostic evaluation but is also helpful in the further course in hemodynamic stable patients. All patients who had been treated conservatively (n=30) had no complications related to the liver rupture.

Nonoperative management and delayed hemorrhage after pediatric liver injury: new issues to consider

The authors report the case of a grade 4 liver laceration caused by blunt abdominal trauma. The liver injury was managed nonoperatively, both initially and after an episode of delayed hemorrhage. The patient suffered 2 additional as yet unreported complications of pediatric liver injury: a right pleural effusion causing respiratory embarrassment followed by duodenal obstruction; the latter was caused by hypertrophy of the left lobe of the liver. Although numerous reports suggest that delayed hemorrhage after pediatric liver injury should be managed operatively, the mortality of such intervention remains high, reaffirming the dictum that one must treat the patient and not the injury.

A minimally invasive approach to bile duct injury after blunt liver trauma in pediatric patients

A 12-year-old boy presented with a large liver laceration after blunt abdominal trauma. He was treated nonoperatively and subsequently had bile peritonitis from a bile leak. Endoscopic retrograde cholangiopancreatography (ERCP) visualized the bile duct injury and allowed decompression of the biliary tree with an endoscopically placed biliary stent. A drain also was placed over the laceration through a small subcostal incision. The patient recovered rapidly after this minimally invasive procedure and went home 9 days later.

Non-operative management of blunt hepatic trauma

BACKGROUND

Non-operative management is currently considered the treatment of choice in over 50 per cent of adult patients with blunt liver injury. This report reviews the criteria for non-operative management and its potential downside.

METHODS

English language publications were reviewed.

RESULTS

Most reports from major trauma centres in the USA support the non-operative treatment of patients with blunt liver injury if well established criteria are met. Using such criteria, non-operative treatment is successful in 50-80 per cent of cases. Adjunctive radiological techniques may be helpful in managing some complications of non-operative treatment.

CONCLUSION

Non-operative management is safe in haemodynamically stable patients with blunt liver injury. Computed tomography (CT) of the abdomen is extremely useful to document the extent of the damage and the presence of associated injuries, but it is not possible, based on CT alone, to predict failure; careful physiological monitoring in selected patients is indicated to avoid catastrophic complications.

Blunt abdominal trauma in children: risks of nonoperative treatment

This retrospective study includes 203 children who had intraabdominal injuries after blunt trauma, mainly bicycle accidents and falls. Of 145 patients with splenic injury, seven underwent surgery. There was a 100% splenic salvage rate. Twenty-nine children had hepatic injury and four underwent laparotomy. One patient who was initially treated conservatively had a complicated clinical course with rebleeding that led to two laparotomies. Three of 10 pancreatic injuries were operated on; one of them 4 weeks after the trauma because of a pseudocyst. Nineteen patients had gastrointestinal tract injuries. Of seven intramural hematomas, five were treated nonoperatively. Twelve patients had gastrointestinal perforations. Seven underwent laparotomy without delay. Three patients underwent surgery 24 hours after admission because of severe abdominal rigidity or pneumoperitoneum. There was one case of severe in-hospital delay in which splenic and hepatic injuries were thought to account for the physical findings. At laparotomy 36 hours after admission, a jejunal rupture and necrosis of the transverse colon were found. Nonoperative management of blunt abdominal trauma has been very successful regarding splenic ruptures. Conservative management of hepatic injuries is more hazardous, and treatment of pancreatic injuries is a matter of controversy. Gastrointestinal-tract perforations are difficult to diagnose and important to bear in mind while keeping a conservative attitude toward abdominal trauma.

Clinical analysis of the utility of repeat computed tomographic scan before discharge in blunt hepatic injury

OBJECTIVES

Nonoperative management of hemodynamically stable blunt hepatic injury has emerged as an acceptable and safe treatment. Surveillance of this population's injuries is costly. As a prelude to establishing practice guidelines, the utility of repeat computed tomographic (CT) scans was investigated.

METHODS

A retrospective study was conducted on 243 hepatic injuries. The CT scans of 95 patients managed nonoperatively who did not have ongoing transfusion requirements were reviewed and graded according to the American Association for the Surgery of Trauma (AAST) hepatic injury scale. Patients were grouped according to injury grade, assigned to two subgroups (patients with one CT scan versus more than one CT scan) and compared with respect to several physiologic and clinical variables.

RESULTS

Statistical analysis revealed no significant difference between subgroups with the same grade of injury. No significant difference was demonstrated between subgroups' length of stay.

CONCLUSIONS

No patients failed nonoperative treatment or succumbed to their injuries. Findings on repeat CT scan have not altered the decision to discharge the clinically stable patient having suffered a grade III or lower liver injury.

Nonoperative management of biliary tract fistulas after blunt abdominal trauma in a child

Nonoperative treatment was carried out in a 12-year-old girl who presented with biliary fistulas after blunt abdominal trauma with hepatic injury. A computed tomography-guided percutaneous puncture showed biliary peritonitis and permitted the positioning of an efficient intraperitoneal drainage. Endoscopic retrograde cholangiography was very helpful for visualization and accurate localization of biliary injuries. This permitted positioning a nasobiliary drain to reduce intrabiliary pressure and to bypass a lesion of the common hepatic duct. This nonoperative management allowed healing of fistulas within 20 days, without bile duct stricture (noted on the follow-up intravenous cholangiogram 18 months later).

Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. Results of a prospective trial

BACKGROUND

A number of retrospective studies recently have been published concerning nonoperative management of minor liver injuries, with cumulative success rates greater than 95%. However, no prospective analysis that involves a large number of higher grade injuries has been reported. The current study was conducted to evaluate the safety of nonoperative management of blunt hepatic trauma in hemodynamically stable patients regardless of injury severity.

METHODS

Over a 22-month period, patients with blunt hepatic injury were evaluated prospectively. Unstable patients underwent laparotomies, and stable patients had abdominal computed tomography (CT) scans. Those with nonhepatic operative indications underwent exploration, and the remainder were managed nonoperatively in the trauma intensive care unit. This group was compared with a hemodynamically matched operated cohort of blunt hepatic trauma patients (control subjects) who had been prospectively analyzed.

RESULTS

One hundred thirty-six patients had blunt hepatic trauma. Twenty-four (18%) underwent emergent exploration. Of the remaining 112 patients, 12 (11%) failed observation and underwent celiotomy--5 were liver-related failures (5%) and 7 were nonliver related (6%). Liver related failure rates for CT grades I through V were 20%, 3%, 3%, 0%, and 12%, respectively, and rates according to hemoperitoneum were 2% for minimal, 6% for moderate, and 7% for large. The remaining 100 patients were successfully treated without operation--30% had minor injuries (grades I-II) and 70% had major (grades III-V) injuries. There were no differences in admission characteristics between nonoperative success or failures, except admission systolic blood pressure (127 vs. 104; p < 0.04). Comparing the nonoperative group to the control group, there were no differences in admission hemodynamics or hospital length of stay, but nonoperative patients had significantly fewer blood transfusions (1.9 vs. 4.0 units; p < 0.02) and fewer abdominal complications (3% vs. 11%; p < 0.04).

CONCLUSIONS

Nonoperative management is safe for hemodynamically stable patients with blunt hepatic injury, regardless of injury severity. There are fewer abdominal complications and less transfusions when compared with a matched cohort of operated patients. Based on admission characteristics or CT scan, it is not possible to predict failures; therefore, intensive care unit monitoring is necessary.