title: Improved outcomes in the non-operative management of liver injuries.
abstract: OBJECTIVE
  Non-operative management has become the treatment of choice in the majority of liver injuries. The aim of this study was to assess the changes in primary treatment and outcomes in a single Dutch Level 1 trauma centre with wide experience in angio-embolisation (AE).
  
  
  METHODS
  The prospective trauma registry was retrospectively analysed for 7-year periods before (Period 1) and after (Period 2) the introduction of AE. The primary outcome was the failure rate of primary treatment defined as liver injury-related death or re-bleeding requiring radiologic or operative (re)interventions. Secondary outcomes were liver injury-related intra-abdominal complications.
  
  
  RESULTS
  Despite an increase in high-grade liver injuries, the incidence of primary non-operative management more than doubled over the two periods, from 33% (20 of 61 cases) in Period 1 to 72% (84 of 116 cases) in Period 2 (P < 0.001). The failure rate of primary treatment in Period 1 was 18% (11/61), compared with 11% (13/116) in Period 2 (P= 0.21). Complication rates were 23% (14/61) and 16% (18/116) in Periods 1 and 2, respectively (P= 0.22). Liver-related mortality rates were 10% (6/61) and 3% (4/116) in Periods 1 and 2, respectively (P= 0.095). The increase in the frequency of non-operative management was even higher in high-grade injuries, in which outcomes were improved. In high-grade injuries in Periods 1 and 2, failure rates decreased from 45% (9/20) to 20% (11/55) (P= 0.041), liver-related mortality decreased from 30% (6/20) to 7% (4/55) (P= 0.019) and complication rates fell from 60% (12/20) to 27% (15/55) (P= 0.014). Liver infarction or necrosis and abscess formation seemed to occur more frequently with AE.
  
  
  CONCLUSIONS
  Overall, liver-related mortality, treatment failure and complication rates remained constant despite an increase in non-operative management. However, in high-grade injuries outcomes improved after the introduction of AE.
authors.affiliation: Trauma Unit, Department of Surgery, Academic Medical Centre, Amsterdam, the Netherlands. t.p.saltzherr@amc.uva.nl
authors.forename: Teun Peter
authors.initials: TP
authors.lastname: Saltzherr
authors.forename: Cees H
authors.initials: CH
authors.lastname: van der Vlies
authors.forename: Krijn P
authors.initials: KP
authors.lastname: van Lienden
authors.forename: Ludo F M
authors.initials: LF
authors.lastname: Beenen
authors.forename: Kees Jan
authors.initials: KJ
authors.lastname: Ponsen
authors.forename: Thomas M
authors.initials: TM
authors.lastname: van Gulik
authors.forename: J Carel
authors.initials: JC
authors.lastname: Goslings
mesh_terms: D000328:Adult; D016009:Chi-Square Distribution; D004621:Embolization, Therapeutic / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D008099:Liver / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery; D008297:Male; D009426:Netherlands; D010043:Outcome and Process Assessment, Health Care; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D036542:Tomography, Spiral Computed; D014193:Trauma Centers; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D055815:Young Adult