Successful nonoperative management of the most severe blunt liver injuries: a multicenter study of the research consortium of new England centers for trauma.
OBJECTIVE
Grade 4 and grade 5 blunt liver injuries can be safely treated by nonoperative management (NOM).


METHODS
Retrospective case series.


METHODS
Eleven level I and level II trauma centers in New England.


METHODS
Three hundred ninety-three adult patients with grade 4 or grade 5 blunt liver injury who were admitted between January 1, 2000, and January 31, 2010.


METHODS
Failure of NOM (f-NOM), defined as the need for a delayed operation.


RESULTS
One hundred thirty-one patients (33.3%) were operated on immediately, typically because of hemodynamic instability. Among 262 patients (66.7%) who were offered a trial of NOM, treatment failed in 23 patients (8.8%) (attributed to the liver in 17, with recurrent liver bleeding in 7 patients and biliary peritonitis in 10 patients). Multivariate analysis identified the following 2 independent predictors of f-NOM: systolic blood pressure on admission of 100 mm Hg or less and the presence of other abdominal organ injury. Failure of NOM was observed in 23% of patients with both independent predictors and in 4% of those with neither of the 2 independent predictors. No patients in the f-NOM group experienced life-threatening events because of f-NOM, and mortality was similar between patients with successful NOM (5.4%) and patients with f-NOM (8.7%) (P = .52). Among patients with successful NOM, liver-specific complications developed in 10.0% and were managed definitively without major sequelae.


CONCLUSIONS
Nonoperative management was offered safely in two-thirds of grade 4 and grade 5 blunt liver injuries, with a 91.3% success rate. Only 6.5% of patients with NOM required a delayed operation because of liver-specific issues, and none experienced life-threatening complications because of the delay.
Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
Gwendolyn M
GM
van der Wilden
George C
GC
Velmahos
Timothy
T
Emhoff
Samielle
S
Brancato
Charles
C
Adams
Georgios
G
Georgakis
Lenworth
L
Jacobs
Ronald
R
Gross
Suresh
S
Agarwal
Peter
P
Burke
Adrian A
AA
Maung
Dirk C
DC
Johnson
Robert
R
Winchell
Jonathan
J
Gates
Walter
W
Cholewczynski
Michael
M
Rosenblatt
Yuchiao
Y
Chang
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D008099:Liver / Q000293:injuries*; D008297:Male; D008875:Middle Aged; D009511:New England; D012189:Retrospective Studies; D014193:Trauma Centers; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000628:therapy*; D055815:Young Adult