Risk factors for hepatic morbidity following nonoperative management: multicenter study.

HYPOTHESIS Early risk factors for hepatic-related morbidity in patients undergoing initial nonoperative management of complex blunt hepatic injuries can be accurately identified. DESIGN Multicenter historical cohort. SETTING Seven urban level I trauma centers. PATIENTS Patients from January 2000 through May 2003 with complex (grades 3-5) blunt hepatic injuries not requiring laparotomy in the first 24 hours. INTERVENTION Nonoperative treatment of complex blunt hepatic injuries. MAIN OUTCOME MEASURES Complications and treatment strategies. RESULTS Of 699 patients with complex blunt hepatic injuries, 453 (65%) were treated nonoperatively. Overall, 61 patients (13%) developed 87 hepatic complications including bleeding (38), biliary (bile peritonitis, 7; bile leak, 9; biloma, 11; biliary-venous fistula, 1; and bile duct injury, 1), abdominal compartment syndrome (5), and infections (abscess, 7; necrosis, 2; and suspected abdominal sepsis, 6), which required 86 multimodality treatments (angioembolization, 32; endoscopic retrograde cholangiopancreatography and stenting, 9; interventional radiology drainage, 16; paracentesis, 1; laparotomy, 24; and laparoscopy, 4). Hepatic complications developed in 5% (13 of 264) of patients with grade 3 injuries, 22% (36 of 166) of patients with grade 4 injuries, and 52% (12 of 23) of patients with grade 5 injuries. Univariate analysis revealed 24-hour crystalloid, total and first 24-hour packed red blood cells, fresh frozen plasma, platelet, and cryoprecipitate requirements and liver injury grade to be significant but only liver injury grade (grade 4 odds ratio, 4.439; grade 5 odds ratio, 12.001) and 24-hour transfusion requirement (odds ratio, 6.446) predicted complications by multivariable analysis. CONCLUSIONS Nonoperative management of high-grade liver injuries is associated with significant morbidity and correlates with grade of liver injury. Screening patients with transfusion requirements and high-grade injuries may result in earlier diagnosis and treatment of hepatic-related complications.

[1]  J. Richardson,et al.  Changes in the management of injuries to the liver and spleen. , 2005, Journal of the American College of Surgeons.

[2]  D. Trunkey.  Hepatic trauma: contemporary management. , 2004, The Surgical clinics of North America.

[3]  L. Magnotti,et al.  Angiographic embolization for liver injuries: low mortality, high morbidity. , 2003, The Journal of trauma.

[4]  Charles C. Miller,et al.  Both primary and secondary abdominal compartment syndrome can be predicted early and are harbingers of multiple organ failure. , 2003, The Journal of trauma.

[5]  P. Rhee,et al.  High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ. , 2003, Archives of surgery.

[6]  W. Shoemaker,et al.  Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: trauma surgeons still need to operate, but angioembolization helps. , 2003, The Journal of trauma.

[7]  C. Létoublon,et al.  Nonoperative management of blunt hepatic trauma. , 2002, Minerva anestesiologica.

[8]  T. Fabian,et al.  Blunt hepatic injury: a paradigm shift from operative to nonoperative management in the 1990s. , 2000, Annals of surgery.

[9]  P. Lambert,et al.  Nonoperative Management of Blunt Liver Trauma: The Value of Follow-Up Abdominal Computed Tomography Scans , 2000, The American surgeon.

[10]  B. Boulanger,et al.  A Minimally Invasive Approach to Bile Peritonitis after Blunt Liver Injury , 2000, The American surgeon.

[11]  D. Spain,et al.  Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. , 1999, The Journal of trauma.

[12]  J. Marks,et al.  Biliary stenting is more effective than sphincterotomy in the resolution of biliary leaks , 1998, Surgical Endoscopy.

[13]  J. Hiatt,et al.  Limited value of routine followup CT scans in nonoperative management of blunt liver and splenic injuries. , 1996, The American surgeon.

[14]  T. Fabian,et al.  Nonoperative Management of Blunt Hepatic Trauma Is the Treatment of Choice for Hemodynamically Stable Patients Results of a Prospective Trial , 1995, Annals of surgery.

[15]  H. Champion,et al.  Organ injury scaling: spleen and liver (1994 revision). , 1995, The Journal of trauma.

[16]  Y. Asari,et al.  Endoscopic retrograde cholangiography in the nonsurgical management of blunt liver injury. , 1993, The Journal of trauma.

[17]  Jeffrey S. Young,et al.  Nonoperative management of blunt hepatic trauma: the exception or the rule? , 1993, The Journal of trauma.

[18]  H. Champion,et al.  Organ injury scaling: spleen, liver, and kidney. , 1989, The Journal of trauma.

[19]  J. Morris,et al.  Severe hepatic trauma: a multi-center experience with 1,335 liver injuries. , 1988, The Journal of trauma.

[20]  E. Moore,et al.  Complications of nonoperative management of high-grade blunt hepatic injuries. , 2005, The Journal of trauma.

[21]  James W. Jones,et al.  Anatomic resection for severe liver trauma. , 2002, World Journal of Surgery.

[22]  W. Shoemaker,et al.  Approach to the management of complex hepatic injuries. , 2000, The Journal of trauma.

[23]  Paul J. Harrison,et al.  Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. , 1996, The Journal of trauma.

[24]  J. Morris,et al.  Hepatic enzyme response and hyperpyrexia after severe liver injury. , 1992, The American surgeon.