Gunshot injuries to the liver: The role of selective nonoperative management

Background: Selective nonoperative management of blunt liver injuries has b ecome standard practice in most trauma centers. We evaluated the role of se lective nonoperative management of gunshot wounds to the liver. Study Design: This was a retrospective review of gunshot wounds to the live r treated in a level I trauma center. Patients with peritoneal signs or hem odynamic instability were operated on without delay. Patients with a soft, nontender abdomen and no signs of heavy bleeding were selected for nonopera tive management. Liver injury was diagnosed by CT scan. If peritonitis or s igns of substantial internal bleeding developed, an operation was performed ; otherwise the patient was discharged within a few days of admission. Anal ysis was restricted to the group of patients with isolated liver injuries. Results: During a 42-month period, 928 patients were admitted with abdomina l gunshot injuries, 152 of whom (16%) had a liver injury. In 52 patients (3 4% of all liver injuries), the liver was the only injured intraabdominal or gan (4 patients had associated kidney or splenic injuries that did not requ ire surgical repair). Thirty-six of the patients (69%) with isolated liver injuries had an emergent operation because of signs of peritonitis or hemod ynamic instability. The remaining IG patients (31%) were selected for nonop erative management (3 patients had associated right kidney injury). Five pa tients in the observed group required delayed operation because of developm ent of signs of peritonitis (4 patients) or abdominal compartment syndrome (1 patient). The remaining 11 patients (7% of all liver injuries or 21% of isolated liver injuries) were managed successfully without operation. One p atient with delayed operation developed multiple complications from abdomin al compartment syndrome, and 1 patient in the nonoperative group had a bilo ma, which was treated with percutaneous drainage. Conclusions: Selected patients with isolated grades I and II gunshot wounds to the liver can be managed nonoperatively. (J Am Coll Surg 1999;188:343-3 48, (C) 1999 by the American College of Surgeons).