title: Complications of nonoperative management of high-grade blunt hepatic injuries.
abstract: BACKGROUND
  Nonoperative management of blunt hepatic injuries is highly successful. Complications associated with high-grade injuries, however, have not been well characterized. The purpose of the present study was therefore to define hepatic-related complications and associated treatment modalities in patients undergoing nonoperative management of high-grade blunt hepatic injuries.
  
  
  METHODS
  Three hundred thirty-seven patients from two regional Level I trauma centers with grade 3 to 5 blunt hepatic injuries during a 40-month period were reviewed. Complications and treatment of hepatic-related complications in patients not requiring laparotomy in the first 24 hours were identified.
  
  
  RESULTS
  Of 337 patients with a grade 3 to 5 injury, 230 (68%) were managed nonoperatively. There were 37 hepatic-related complications in 25 patients (11%); 63% (5 of 8) of patients with grade 5 injuries developed complications, 21% (19 of 92) of patients with grade 4 injuries, but only 1% (1 of 130) of patients with grade 3 injuries. Complications included bleeding in 13 patients managed by angioembolization (n = 12) and laparotomy (n = 1), liver abscesses in 2 patients managed with computed tomography-guided drainage (n = 2) and subsequent laparotomy (n = 1). In one patient with bleeding, hepatic necrosis followed surgical ligation of the right hepatic artery and required delayed hepatic lobectomy. Sixteen biliary complications were managed with endoscopic retrograde cholangiopancreatography and stenting (n = 7), drainage (n = 5), and laparoscopy (n = 4). Three patients had suspected abdominal sepsis and underwent a negative laparotomy, whereas an additional three patients underwent laparotomy for abdominal compartment syndrome.
  
  
  CONCLUSIONS
  Nonoperative management of high-grade liver injuries can be safely accomplished. Mortality is low; however, complications in grade 4 and 5 injuries should be anticipated and may require a combination of operative and nonoperative management strategies.
authors.affiliation: Department of Surgery, University of Texas-Houston, Houston, TX 77030, USA. rosemary.a.kozar@uth.tmc.edu
authors.forename: Rosemary A
authors.initials: RA
authors.lastname: Kozar
authors.forename: John B
authors.initials: JB
authors.lastname: Moore
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Niles
authors.forename: John B
authors.initials: JB
authors.lastname: Holcomb
authors.forename: Ernest E
authors.initials: EE
authors.lastname: Moore
authors.forename: C Clay
authors.initials: CC
authors.lastname: Cothren
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Hartwell
authors.forename: Frederick A
authors.initials: FA
authors.lastname: Moore
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D002760:Cholangiopancreatography, Endoscopic Retrograde; D004621:Embolization, Therapeutic; D005260:Female; D006801:Humans; D022125:Lacerations / Q000628:therapy; D008099:Liver / Q000000981:diagnostic imaging / Q000293:injuries*; D008875:Middle Aged; D012189:Retrospective Studies; D015607:Stents; D014949:Wounds, Nonpenetrating / Q000150:complications* / Q000628:therapy