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 publis hed concerning nonoperative management of minor liver injuries, with c umulative success rates greater than 95%. However, no prospective anal ysis that involves a large number of higher grade injuries has been re ported. The current study was conducted to evaluate the safety of nono perative 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. Uns table patients underwent laparotomies, and stable patients had abdomin al computed tomography (CT) scans. Those with nonhepatic operative ind ications underwent exploration, and the remainder were managed nonoper atively in the trauma intensive care unit. This group was compared wit h a hemodynamically matched operated cohort of blunt hepatic trauma pa tients (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%) tailed observation and underwent celiotomy-5 were liver-relat ed failures (5%) and 7 were nonliver related (6%). Liver related failu re rates for CT grades I through V were 20%, 3%, 3%, 0%, and 12%, resp ectively, and rates according to hemoperitoneum were 2% for minimal, 6 % for moderate, and 7% for large. The remaining 100 patients were succ essfully 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). Co mparing the nonoperative group to the control group, there were no dif ferences in admission hemodynamics or hospital length of stay, but non operative 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 hemodynamica lly stable patients with blunt hepatic injury, regardless of injury se verity. There are fewer abdominal complications and less transfusions when compared with a matched cohort of operated patients. Based on adm ission characteristics or CT scan, it is not possible to predict failu res; therefore, intensive care unit monitoring is necessary.