Objective: Modern approach to complex abdominal trauma favours conservative treatment including endovascular intervention for solid organ lesions. The aim of this study was to review the safety of non-operative management of high-grade (III-IV) liver injuries (NOMLI) beyond established criteria as defined by algorithms of Advanced Trauma Live Supportâ (ATLSâ).
Methods: All patients with liver injuries (LI) admitted our hospital between 2000-2006 were included. LI were identified by contrast enhanced abdominal computed tomography scan or laparotomy and graded according to Moore et al. NOMLI was attempted in all hemodynamically stable patients.
Results: A total of 186 (125 male, 61 female) patients with LI were identified. There were 180 blunt and 6 penetrating abdominal traumas. Mean injury severity score (ISS) of the operatively and non-operatively treated patients was 29.8 ± 12.1, and 26.6 ± 12.5 respectively (p=0.1438, students t-test). 42 patients required immediate surgical or endovascular abdominal interventions. Of these, 19 (45.2%) procedures were purely liver related. All of these liver lesions were grade III, IV and V. Endovascular coiling was carried out in 3 out of 19 patients. One patient needed surgical evacuation of a hematoma on day 3 after selective coiling of a right segmental hepatic artery. In total, 169 out of 186 (90.9%) patients profited from a NOMLI. Alternative indications for a primarily surgical approach were splenic injuries grade IV-V in hemodynamically unstable patients (n=10), penetrating abdominal injury (n=6), major intra-abominal vascular lesion (n=4), and visceral perforation (n=3). The overall cohort mortality was 16.7% but only 6 patients died due to the LI (3.2%). A total of 59 (73.8%) out of 80 patients with LI grade III-V were primarily managed by NOMLI. Of these patients, 8 (13.6%) suffered from liver related complications (5 biliary leakages, 1 abscess formation and 2 delayed bleedings) and 14 (23.7%) from extra-abdominal complications.
Conclusions: Even in high grade LI (grade III-IV) NOMLI represents a safe treatment option with a low probability of liver related (13.6%) but a relatively high rate of extra-abdominal complications (23.7%). The successful management of LI implements in the majority of cases the treatment of collateral injuries and general complications. The option of endovascular coiling seems to lower the risk of emergency laparotomies and the rate of NOMLI failure. The benefit and safety of endovascular interventions and the timely and correct implementation into the trauma algorithms requires further investigation.