Blunt hepatic injury: A paradigm shift from operative to nonoperative management in the 1990s

Objective To analyze the outcome of hemodynamically stable patients with bl unt hepatic injury managed nonoperatively, and to examine the impact of thi s approach on the outcome of all patients with blunt hepatic injury. Summary Background Data Until recently, operative management has been the s tandard for liver injury. A prospective trial from the authors' institution had shown that nonoperative management could safely be applied to hemodyna mically stable patients with blunt hepatic injury. The present study review ed the authors' institutional experience with blunt hepatic trauma since th at trial and compared the results with prior institutional experience. Methods Six hundred sixty-one patients with blunt hepatic trauma during the 5-year period ending December 1998 were reviewed (NONOP2). The outcomes we re compared with two previous studies from this institution: operative 1985 to 1990 (OP) and nonoperative 1993 to 1994 (NONOP1). Results All 168 OP patients were managed operatively. Twenty-four (18%) of 136 NONOP1 patients and 101 (15%) of the 661 NONOP2 patients required immed iate exploration for hemodynamic instability. Forty-two (7%) patients faile d nonoperative management; 20 were liver-related. Liver-related failures of nonoperative management were associated with higher-grade injuries and wit h larger amounts of hemoperitoneum on computed tomography scanning. Twenty- four-hour transfusions, abdominal infections, and hospital length of stay w ere all significantly lower in the NONOP1 and NONOP2 groups versus the OP c ohort. The liver-related death rate was constant at 4% in the three cohorts over the three time periods. Conclusions Although urgent surgery continues to be the standard for hemody namically compromised patients with blunt hepatic trauma, there has been a paradigm shift in the management of hemodynamically stable patients. Approx imately 85% of all patients with blunt hepatic trauma are stable. In this g roup, nonoperative management significantly improves outcomes over operativ e management in terms of decreased abdominal infections, decreased transfus ions, and decreased lengths of hospital stay.