title: A reaudit of specialist-managed liver trauma after establishment of regional referral and management guidelines.
abstract: BACKGROUND
  An earlier liver trauma audit (52 patients) noted that 50% were surgically managed at referring hospitals with a high morbidity and mortality, after which a regional referral and management algorithm was implemented in 2001. This study aims to reaudit specialist-managed liver trauma outcomes.
  
  
  METHODS
  Prospective analysis of 99 patients (68 male) treated for liver injury (LI) between 2001 and 2008. Patient characteristics, management, and outcome results of these were compared with the results of previous audit. LI severity was determined by computed tomography, operative findings, and classified according to liver Organ Injury Scale.
  
  
  RESULTS
  As implementation of guidelines, referrals increased from 5.2 patients/yr to 14.1 patients/yr, while LI profile was unchanged. Fewer patients were managed surgically with lower surgical intervention at referring hospitals (26 of 52 [50%] vs. 29 of 77 [38%]; p = 0.2). There has been a decrease in liver resection rates (14 of 26 [54%] vs. 3 of 37 [8%]; p = 0.0001]), overall mortality rate (12 of 52 [23%] vs. 11 of 99 [11%]; p = 0.059), and postoperative deaths.
  
  
  CONCLUSIONS
  This reaudit confirms the role of nonoperative management of liver trauma. Early use of computed tomography scan with specialist discussion, selective use of perihepatic packing, and transfer to a specialist unit should be standard practice in the management of complex liver trauma.
authors.affiliation: Liver Unit, Queen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom.
authors.forename: Krishnamoorthy
authors.initials: K
authors.lastname: Ramkumar
authors.forename: M Thamara P R
authors.initials: MT
authors.lastname: Perera
authors.forename: Ravi
authors.initials: R
authors.lastname: Marudanayagam
authors.forename: Chris
authors.initials: C
authors.lastname: Coldham
authors.forename: Simon P
authors.initials: SP
authors.lastname: Olliff
authors.forename: David A
authors.initials: DA
authors.lastname: Mayer
authors.forename: Simon R
authors.initials: SR
authors.lastname: Bramhall
authors.forename: John A C
authors.initials: JA
authors.lastname: Buckels
authors.forename: Darius F
authors.initials: DF
authors.lastname: Mirza
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000465:Algorithms; D005260:Female; D006498:Hepatectomy; D006767:Hospitals, District; D006769:Hospitals, General; D006801:Humans; D007902:Length of Stay; D008099:Liver / Q000293:injuries*; D008297:Male; D008485:Medical Audit; D008511:Medicine; D008875:Middle Aged; D009104:Multiple Trauma / Q000628:therapy; D010360:Patient Transfer; D012017:Referral and Consultation; D014057:Tomography, X-Ray Computed; D014949:Wounds, Nonpenetrating / Q000175:diagnosis / Q000601:surgery / Q000628:therapy; D055815:Young Adult