Conservative management for liver trauma

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Clinical Summary
Author Afliations: Department of General Surgery, Jinling Hospital,
Medicine School of Nanjing University, Nanjing 210002, China (Li M, Yu
WK, Wang XB, Ji W, Li JS and Li N)
Corresponding Author: Ning Li, MD, Department of General Surgery,
Jinling Hospital, Medicine School of Nanjing University, No. 305 East
Zhongshan Road, Nanjing 210002, China (Tel: 86-25-80860037; Email:
liningrigs@vip.sina.com)
2014, Hepatobiliary Pancreat Dis Int. All rights reserved.
doi: 10.1016/S1499-3872(14)60049-7
Published online March 27, 2014.
ABSTRACT: Liver trauma is the most common abdominal
emergency with high morbidity and mortality. Now, non-
operative management (NOM) is a selective method for liver
trauma. The aim of this study was to determine the success
rate, mortality and morbidity of NOM for isolated liver trauma.
Medical records of 81 patients with isolated liver trauma in our
unit were analyzed retrospectively. The success rate, mortality
and morbidity of NOM were evaluated. In this series, 9 patients
with grade IV-V liver injuries underwent emergent operation
due to hemodynamic instability; 72 patients, 6 with grade
V, 18 grade IV, 29 grade III, 15 grade II and 4 grade I, with
hemodynamic stability received NOM. The overall success
rate of NOM was 97.2% (70/72). The success rates of NOM
in the patients with grade I-III, IV and V liver trauma were
100%, 94.4% and 83.3%. The complication rates were 10.0%
and 45.5% in the patients who underwent NOM and surgical
treatment, respectively. No patient with grade I-II liver trauma
had complications. All patients who underwent NOM survived.
NOM is the rst option for the treatment of liver trauma if the
patient is hemodynamically stable. The grade of liver injury
and the volume of hemoperitoneum are not suitable criteria
for selecting NOM. Hepatic angioembolization associated with
the correction of hypothermia, coagulopathy and acidosis is
important in the conservative treatment for liver trauma.
(Hepatobiliary Pancreat Dis Int 2014;00:000-000)
KEY WORDS: liver trauma;
non-operative treatment;
non-operative management
Introduction
L
iver parenchyma and its vasculature are fragile
and very susceptible to blunt and penetrating
trauma which makes the liver the most frequently
injured abdominal organ.
[1]
Hemorrhagic shock due to
uncontrollable bleeding of vessels and parenchyma is
the major cause of death within the rst 36 hours after
injury.
[2]
The management of liver trauma in the early
1900s was observation and expectant treatment and
later on, mainly operative intervention.
[3]
The current
practice is either selective surgery or non-operative
management (NOM), depending on the grade of the
trauma. NOM of liver trauma was rst reported in 1972,
and has been one of the most signicant changes in the
treatment of liver trauma over the past three decades.
[4, 5]

In recent years, the overall mortality in large series of
patients who sustained liver trauma has ranged from
10% to 15%.
[6, 7]
Although the mortality of liver trauma
has decreased in the past decades, the selection criteria
for NOM are constantly evolving, and conservative
approaches are being increasingly adopted.
Several studies on patients with liver trauma
suggested that early deaths are due to uncontrolled
bleeding from associated intra- and extra-abdominal
injuries; whereas late deaths result from head injury
and sepsis with multi-organ failure.
[8-10]
Patients with
liver trauma usually have complicated injuries, and
the results of NOM have been inuenced by coexisting
trauma.
[6, 7]
The aim of this study was to determine
the success rate, mortality and morbidity of NOM in
patients with isolated liver trauma.
Methods
A retrospective analysis was performed on all the
patients treated for liver trauma in our unit between
January 2007 and April 2012. The medical records
of patients with isolated liver trauma were extracted.
Isolated liver trauma was dened as liver injury with
Non-operative management of isolated liver
trauma
Min Li, Wen-Kui Yu, Xin-Bo Wang, Wu Ji, Jie-Shou Li and Ning Li
Nanjing, China
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no other intra- or extra-abdominal involvement. The
success rate, mortality and morbidity of patients who
underwent NOM or surgery were reviewed.
The grade of liver trauma was determined according
to the scaling system of the American Association for
the Surgery of Trauma (AAST).
[11]
Failure of NOM was
dened as the need of surgical intervention to manage
bleeding at any time during hospitalization or in the
follow-up period. All patients were followed up by
phone calls for six months. Data analysis was performed
by SPSS 18.0 (SPSS Inc., Chicago, IL, USA). All results
were reported as meanstandard deviation.
The patients with hemodynamic instability
underwent emergent surgery. The selection criterion
for NOM was hemodynamic stability, which was
dened as a systolic pressure >90 mmHg after adequate
resuscitation (1 L of intravenous uids within 1 hour).
The treatment algorithm of NOM involved monitoring
patients in an ICU with serial physical examinations
and hematocrits. Red blood cell (RBC) transfusions
were given when hemoglobin levels were less than 7
g/L.
[12]
Heart rate, blood pressure, respiratory rate,
central venous pressure and urinary output were
monitored. Acidosis was corrected promptly; rewarming
blankets and warm intravenous uids were used to
avoid hypothermia when core temperature was lower
than 36 .
[13]
Somatostatin was used in the patients
with biliary stulas to decrease choleresis. Unlike
conventional approaches, we corrected coagulopathy
according to the result of thromboelastography (TEG)
instead of prothrombin time (PT) and activated partial
thromboplastin time (APTT). Blood products, including
fresh frozen plasma, platelet and cryoprecipitate, were
intravenously infused according to the results of TEG.
The patients who had hemoperitoneum underwent
ultrasound guided percutaneous peritoneal drainage in
order to determine the volume of hemoperitoneum. The
catheter was removed when hemoperitoneum resolved
as determined by ultrasonic monitoring or operation
if needed. Hepatic artery angiography embolization
was used when computed tomography (CT) scanning
demonstrated contrast extravasation.
Results
Between January 2007 and April 2012, there were 268
patients treated for liver trauma in our unit. Among
them, 187 had multiple injuries and were excluded
from this cohort. Of the remaining 81 patients, 9 with
grade IV-V liver injuries underwent emergent operation
because of hypovolemic shock and 72 received NOM.
The average age of the 72 patients was 35.910.8
Table 1. Patient characteristics according to the management rstly
performed
Characteristics NOM (n=72)
Surgical management
(n=9)
Age (yr) 35.910.8 (17-69) 38.213.1 (19-62)
Male/Female 55/17 7/2
Causes of liver trauma
Trafc 30 5
Industrial 22 3
Falls 8 1
Assault 4
Sports 5
Penetrating injuries 3
Grade of liver trauma
I 4
II 15
III 29
IV 18 3
V 6 6
Hemoperitoneum (mL) 1537692 (430-3360) 1942308 (1400-3010)
years (range 17-69); these patients included 55 men
and 17 women. Liver trauma consisted of trafc (n=30),
industrial (n=22), falls (n=8), assault (n=4), sports
(n=5) and penetrating injuries (n=3). Six patients had
liver trauma of grade V (8.3%), 18 grade IV (25.0%),
29 grade III (40.3%), 15 grade II (20.8%), and 4 grade
I (5.6%). The average volume of hemoperitoneum was
1537692 mL (range 430-3360) (Table 1). The patients
who received NOM underwent contrast-enhanced CT
scanning of the abdomen (Fig. 1). The peak levels of
alanine aminotransferase, aspartate aminotransferase,
and total bilirubin were 1520.0794.9 U/L (range
237-3054), 1054.1531.6 U/L (range 172-2132), and
23.4 10.5 mol/L (range 8.8-61.1), respectively. The
shortest reaction time was 16.77.8 minutes (range
5.3-34.7, normal 5-10), the shortest kinetic time was 9.8
5.7 minutes (range 1.5-20.4, normal 1-3), and the level
Fig. 1. Contrast-enhanced CT scanning of grade IV blunt liver
trauma.
Conservative management for liver trauma
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of maximum amplitude (MA) was 50.16.7 mm (range
40.2-67.3, normal 50-70) (Fig. 2). There were 17 (23.6%)
patients with hypothermia, and 41 patients (56.9%)
with acidosis. Forty-eight patients received an average of
7.46.2 U (range 3-18) RBC transfusions.
All patients who underwent NOM survived. Seventy
out of 72 patients were managed successfully without
operation, including 5 patients with grade V, 17 with
grade IV and 48 with grade I-III liver trauma. The
overall success rate of NOM was 97.2%. The success
rates of NOM in the patients with grade I-III, IV and V
liver trauma were 100%, 94.4% and 83.3%, respectively.
Thirty-ve patients underwent hepatic angiography
because of extravasation of contrast material on CT
scanning. Of these patients, 24 (68.6%) required
embolization (Fig. 3, Table 2). In the 24 patients,
bleeding was stopped in 22 patients, and 2 patients
(1 grade IV and 1 grade V) needed operation because
of hemorrhagic shock. The success rate of hepatic
angioembolization (HAE) was 91.7%. Among the
70 patients who were managed successfully without
operation, 7 had complications. The overall morbidity
of NOM for liver trauma was 10.0%. No patient
with grade I-II liver trauma had complications. One
patient with grade III liver trauma had a biloma. Three
patients with grade IV liver trauma had complications
including 2 bilomas and 1 biliary stula. Three of 6
Fig. 2. TEG data of a patient with severe liver trauma showing coagulo-
pathy.
Table 2. A summary of patients successfully treated with NOM
Grade of
liver
trauma
No
invasive
procedure
Drainage
Drainage and
angiography
Drainage,
angiography
and
embolization
Total
I 4 0 0 0 4
II 8 5 1 1 15
III 1 16 7 5 29
IV 0 3 2 12 17
V 0 0 1 4 5
Total 13 24 11 22 70
Table 3. Complications of the patients according to the management
nally performed
Grade of liver
trauma
NOM (n=70) Surgical management (n=11)
I 0
II 0
III 1 (3.4%)
Biloma
IV 3 (17.6%) 1 (25%)
2 Bilomas Biliary stula and hemorrhage
1 Biliary stula
V 3 (60%) 4 (57.1%)
1 Biloma
2 Biliary stulas
1 Intra-abdominal abscess and
hemorrhage
1 Biliary stula and hemorrhage
2 Biliary stulas
Total 7 (10.0%) 5 (45.5%)
Fig. 3. Angiography of grade IV blunt liver trauma.
patients with grade V liver trauma had complications
including 1 biloma and 2 biliary stulas (Table 3).
Three biliary stulas were due to the injury of the
right hepatic duct identied by endoscopic retrograde
cholangiopancreatograhpy (ERCP), and were resolved by
subsequent surgery in which cholangiojejunostomy was
performed. Because the diameter was <3 cm, and there
were no clinical symptoms, 4 patients with bilomas were
treated conservatively.
Eleven patients underwent operation due to
hemodynamic instability, including 9 direct surgery and
2 failed NOM. The 9 patients had an average volume of
hemoperitoneum of 1942308 mL (range 1400-3010).
In these patients, concomitant right hepatic vein
injury occurred in 4, left hepatic vein in 1, portal vein
in 1, ruptured gallbladder in 3 and common bile duct
laceration in 1. After angiography, ruptured gallbladders
were excised and the continuity of the common bile
ducts was restored with interrupted suture. All patients
received hepatic packing which was removed by re-
operation 3 days later. Two patients (18.2%) died after
operation due to multi-organ dysfunction syndrome.
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Eight postoperative complications occurred in 5 patients,
hemorrhage in 3, intra-abdominal abscess in 1, and
biliary stulas in 4 (Table 3). Postoperative hemorrhage
happened in 3 patients on day 2 after gauze removal, of
which 2 patients were treated by HAE, and 1 required
another hepatic packing.
Discussion
The paradigm for management of liver trauma
has shifted over the past decades, from mandatory
operation to selective NOM. This paradigm shift has
been attributed to several factors: (1) the recognition
that 50%-80% of liver injuries stop bleeding
spontaneously, (2) the successful NOM in children,
and (3) the signicant development of CT scanning,
interventional radiology and critical care.
[5, 14]
A recent
review of the National Trauma Data Base in America
showed that 86.3% of all liver injuries were managed
conservatively.
[15]
In the current series, 72 patients with
liver trauma whose hemodynamics were stable were
selected for NOM. This included 53 patients with grade
III-V and 19 patients with grade I-II liver trauma. The
volume of hemoperitoneum in the patients who had
abdominal free uid was 1537692 mL (range 430-3360)
compared with those underwent surgery (1942308
mL, range 1400-3010). The NOM success rate in the
patients with grade I-III liver trauma (n=48) was 100%;
in those with grade IV and V was 94.4% and 83.3%,
respectively. The overall success rate of NOM was 97.2%
which is higher than that reported in other studies.
[16-18]

We conclude that the liver trauma patients with stable
hemodynamics can be treated without operation with
a high success rate. The grade of liver trauma and
the volume of hemoperitoneum are not signicant
parameters for selecting NOM. These conclusions are
consistent with those reported elsewhere.
[4, 19]

CT scanning is currently the standard evaluation
modality for stable patients with abdominal injury.
[20, 21]

Hoff et al
[22]
reported a sensitivity of 92%-97% and
a specicity of 98.7% in liver trauma. The nding
of extravasation of contrast material within the liver
parenchyma on CT scanning is indicative of active
hemorrhage. Fang et al
[23]
reported that 75% of
patients with contrast extravasation and hemodynamic
instability required operation. Embolization of hepatic
arterial bleeding could control bleeding from 68%
to 87%.
[23]
In the current study, patients with stable
hemodynamics were diagnosed by contrast-enhanced
CT. Thirty-ve patients underwent hepatic arterial
angiography because of extravasation of contrast
material on CT scanning, and 24 required embolization.
The hemorrhage was stopped in 22 patients. The success
rate of HAE was 91.7%.
Hemorrhage can result in hypothermia,
coagulopathy and acidosis, so called lethal triad. Each
exacerbates the others. The vicious cycle rapidly
deteriorates the patients and causes death. Mortality
increases signicantly in trauma patients with a core
temperature less than 34 and approached 100%
when less than 32 .
[24]
In this series, warm blankets
and intravenous uids were used to avoid hypothermia
when core temperatures were lower than 36 .
Various coagulation problems can appear when liver
injury occurs. This may be due to the hemorrhage, or
to liver dysfunction, which causes both qualitative and
quantitative alterations in pro- and anticoagulants, and
platelets. Reduced degradation of activated components,
hyperbrinolysis and decient metabolism of citrate
in the blood components may also play a role. We
monitored blood coagulation of the patients through the
results of TEG. In contrast to conventional coagulation
tests which assay only clot formation time in a plasma
environment, TEG assesses overall hemostasis, the
cumulative effects of procoagulant, anticoagulant
proteins, brinogen and platelets. Component
measurements of the TEG reect specic phases of clot
formation.
[25]
In many studies, TEG shows superior
properties compared to conventional coagulation
parameters.
[26]
Prolonged reactive time suggests clotting
factor deciency or heparin effect. The kinetic time
reects the time from initial brin formation required
to reach specic clot rmness and is proportional
to brinogen concentrations and platelet count. The
maximum amplitude reects maximal clot strength
and is proportional to the amount and function of
platelet. Blood products were infused to liver trauma
patients to correct coagulopathy according to the results
of TEG which could have resulted in a shorter time to
correct coagulopathy. The appropriate correction of
coagulopathy promotes the formation of blood clotting
for hemostasis.
During operation, measures to rapidly control
bleeding are essential. Methods to control damage with
liver packing and staged re-operation have become
standard treatment in patients requiring emergent
laparotomy for severe liver trauma.
[27]
Perihepatic
packing controls profuse hemorrhage in up to 80% of
patients undergoing laparotomy.
[28, 29]
In this study, all
11 patients who underwent operation received hepatic
packing, and bleeding was controlled in 8 (72.7%) of
them.
Some studies
[4, 30]
reported that the complication
rates of liver trauma were low in most series of blunt
Conservative management for liver trauma
Hepatobiliary Pancreat Dis IntVol 00No 0 Month2014 www.hbpdint.com
liver injury, ranging from 0 to 7%. However, as the
majority of patients in those studies had lower grade
liver traumas, the ndings cannot be extrapolated
to patients with high grade lesions. In the current
series, 80.6% (50/62) of grade III-V and all patients
with grade I-II liver trauma underwent NOM without
complications. The complication rates were 10.0% and
45.5% in the patients who underwent NOM and surgical
treatment, respectively. Li Petri et al
[31]
reported a series
of 53 patients with complex liver trauma, in which 29
patients underwent operation and 24 patients were
treated conservatively. No patients who underwent NOM
had complications, whereas 7 subjects (29.2%) who
were surgically treated had liver related complications,
including 4 bile leaks and 3 intra-abdominal abscesses.
The complication rate of surgical treatment was higher
than that of NOM. The patients who received operation
had a higher probability of hemodynamic instability
and a higher grade of liver injury than those who
received NOM. Perioperative contamination might lead
to abscess.
In the current study, aside from 9 patients with
hemodynamic instability who underwent emergent
operation, 72 patients (88.9%) received NOM with a
success rate of 97.2%. The results of NOM for isolated
liver trauma were excellent. We consider that: (1)
NOM could and should be used in not only mild, but
also moderate to severe liver trauma patients with
hemodynamic stability; (2) The grade of liver injury and
the volume of hemoperitoneum are not suitable criteria
for selecting NOM; (3) Bleeding in cases of severe liver
trauma is frequently accompanied by life-threatening
complications. HAE combined with correction of
hypothermia, coagulopathy and acidosis are important
aspects of the conservative treatment for liver trauma.
Acknowledgements: The authors thank Mr. Zhen-Guo Zhao for
his assistance with data collection.
Contributors: LJS and LN proposed the study. LM performed
research and wrote the rst draft. YWK, WXB and JW collected
and analyzed the data. All authors contributed to the design
and interpretation of the study and to further drafts. LN is the
guarantor.
Funding: None.
Ethical approval: This retrospective study was approved by Medical
Ethics Committee of Jinling Hospital.
Competing interest: No benets in any form have been received
or will be received from a commercial party related directly or
indirectly to the subject of this article.
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Received February 28, 2013
Accepted after revision November 25, 2013