STATUS OF NONOPERATIVE MANAGEMENT OF BLUNT HEPATIC INJURIES IN 1995 -A MULTICENTER EXPERIENCE WITH 404 PATIENTS

Introduction: Nonoperative management is presently considered the trea tment modality of choice in over 50% of adult patients sustaining blun t hepatic trauma who meet inclusion criteria. A multicenter study was retrospectively undertaken to assess whether the combined experiences at level I trauma centers could validate the currently reported high s uccess rate, low morbidity, and virtually nonexistent mortality associ ated with this approach. Thirteen level I trauma centers accrued 404 a dult patients sustaining blunt hepatic injuries managed nonoperatively over the last 5 years. Seventy-two percent of the injuries resulted f rom motor vehicle crashes. The mean injury severity score for the enti re group was 20.2 (range, 4-75), and the American Association for the Surgery of Trauma-computerized axial tomography scan grading was as fo llows: grade I, 19% (n = 76); grade II, 31% (n = 124); grade III, 36% (n = 146); grade IV, 10% (n = 42); and grade V, 4% (n = 16). There wer e 27 deaths (7%) in the series, with 59% directly related to head trau ma. Only two deaths (0.4%) could be attributed to hepatic injury. Twen ty-one (5%) complications were documented, with the most common being hemorrhage, occurring in 14 (3.5%). Only 3 (0.7%) of these 14 patients required surgical intervention, 6 were treated by transfusions alone (0.5 to 5 U), 4 underwent angio-embolization, and 1 was further observ ed. Other complications included 2 bilomas and 3 perihepatic abscesses (all drained percutaneously). Two small bowel injuries were initially missed (0.5 %), and diagnosed 2 and 3 days after admission. Overall, 6 patients required operative intervention: 3 for hemorrhage, 2 for mi ssed enteric injuries, and 1 for persistent sepsis after unsuccessful percutaneous drainage. Average length of stay was 13 days. Nonoperativ e management of blunt hepatic injuries is clearly the treatment modali ty of choice in hemodynamically stable patients, irrespective of grade of injury or degree of hemoperitoneum. Current data would suggest tha t 50 to 80% (47% in this series) of all adult patients with blunt hepa tic injuries are candidates for this form of therapy. Exactly 98.5% of patients analyzed in this study successfully avoided operative interv ention. Bleeding complications are infrequently encountered (3.5%) and can often be managed nonoperatively. Although grades TV and V injurie s composed 14% of the series, they represented 66.6% of the patients r equiring operative intervention and thus merit constant re-evaluation and close observation in critical care units. The optimal time for fol low-up computerized axial tomography scanning seems to be within 7 to 10 days after injury.