Grade-related Liver injury management and its outcome

INTRODUCTION

Liver is more prone to injury due to large size, fixed position and thin capsule. It takes second place among all the injuries and achieve between 15-20%.^1,2

Liver trauma varies between countries due to social, regulatory and environmental conditions. Blunt injuries are more popular in Europe while penetrating injuries have higher rates in USA. ³

Until 1990, explorative laparotomy was used in liver trauma. The application of conservative management started with the introduction of CT for diagnosing abdominal trauma.⁴ Hemodynamic stability is the main determinant of the way of treatment of liver injury, although a higher grade injury is associated with higher incidence of laparotomy.⁵

Mortality due to liver injury is often determined by factors as grade and nature of injuries, associated injury, experiences of the treating institution and the medical history of the patients’ themselves.³  

The aim is to manage the patients with liver trauma according to grade of trauma and assess the outcome.

PATIENT AND MATERIALS

From January 2013 to January 2014, liver trauma patients presented to emergency departments of Shebin Elkom Teaching hospital and National Liver Institute were enrolled. After initial evaluation and resuscitation with anti-shock measures and blood sampling for cross matching, a complete history was taken from every patient then a general examination was done to exclude associated injuries and an abdominal examination was done for presence of bruises, the site and depth of penetrating injuries and to detect acute abdomen.

Emergency laboratory investigations were drawn. Ultrasonography was done in all patients to detect hemoperitonium while the hemodynamic stable patients had CT scan to determine site and depth of injury, grading of liver trauma according to AAST Liver Injury Scale (Figure 1).

Two groups were then elicited; Stable and Unstable Groups. In the former group, conservative management was taken out. The inclusion criteria of the patients were stable hemodynamic status, good response to resuscitation, low blood transfusion requirements and absence of signs of peritonitis.⁶

The Conservative measures were ICU admission, absolute bed rest, pulse, blood pressure, respiratory rate and temperature charting and hemodynamic monitoring (serial hemoglobin, hematocrit value and prothrombin concentration).⁶ Continuous monitoring via serial examinations, serial follow up FAST and Abdominal CT were taken out to detect any changes. The criteria for discontinuing conservative management were the tachycardia and/or hypotension in the first 48 hours of observation, increased transfusion requirement, increased abdominal pain and tenderness, expansion of a hematoma on CT or a development of a symptomatic perihepatic fluid collection, hematoma or biloma.⁷

Operative intervention occurred in the other group. The criteria for immediate operation were hemodynamically instability on admission, recurrence of instability after stabilization, signs of peritonitis on physical examination and penetrating injuries in unstable patients.⁷

Intraoperatively, compression and perihepatic packing was done then injury was assessed. If there was superficial capsular tear or laceration, gel foam was used. If the injury was superficial, suture hepatorraphy was done (Figure 2). Deep or avulsed injuries were resected. In massive uncontrollable bleeding and/or hemodynamic instability, perihepatic packing was done with reexploration after proper resuscitation. Hemostasis was done either by omental pack, Gelfoam or cauterization. Drains were inserted in the hepatorenal pouch and the pelvis and the wound was closed.

Postoperatively, closed monitoring occurred in ICU then they either stay or transferred to surgical ward. Postoperative follow-up include close monitoring of pulse, blood pressure, respiratory rate, temperature and drains and full laboratory investigations every other day. If there was more than 100 cc/hr blood collection, the abdomen was reexplored. In all patients, morbidity, mortality and length of hospital stay were recorded. Follow-up data were recorded.

Data were collected and tabulated for statistical analysis by Statistical Package for Social Science (SPSS) program version 26, Chicago, Illinois, USA. Descriptive statistics was expressed as mean, SD, range and Chi-square test in quantitative data and as percentage, frequency and Student t-test in qualitative analysis. Kaplan-Meier survival analysis and multiple logistic regression analysis were used for multivariate analysis. P value was considered significant if it was less than 0.05.

RESULTS

Thirty patients were assigned into 2 groups according to their hemodynamic status after resuscitation; stable group including 18 patients and unstable group including 12 patients. Demographically, no statistical significance difference was found. Among the stable group, one patient was diabetic while the other was hypertensive. In the unstable group, only one patient (3.33%) was diabetic. Blunt trauma occurred in 24 patients mainly road traffic accident. Stab abdomen was found to be the main cause of penetrating trauma. No significance was found between both groups in regards the interval that passed from trauma to admission (Table 1).

The mean value of hematocrit was higher in stable group (p 0.003). The total leucocytic count, ALT and AST were higher in the unstable group (p 0.014, 0.007, 0.008 respectively). No significance was found in regards to the amount of free fluid detected by ultrasonography. Eleven patients in the stable group were found to have no co-injuries while one patient only in the unstable group was found to have no co-injury (p 0.004) (Table 2).

In the stable group, 2 patients developed hemodynamic instability and/or peritonitis during the first 48 hours and they were transferred to OR (p 0.001). In the unstable group, 6 patients required suture hepatorraphy while 2 patients had damage control therapy. In the stable group, 14 patients did not need any further management while 2 patients had medical treatment for brain oedema, one patient had chest tube insertion for hemopneumothorax and another one had skin traction for fracture femur. In the unstable group, one patient did not need any further management while 4 patients had splenectomy, 3 patients had chest tube insertion, 2 patients had intraoperative reduction of eviscerated viscus. One patient had a repair of enterotomy (Table 3).

After the management, Grade II was the most in the stable group while it was grade III and IV in the other group (p 0.0023). There were high requirements of blood transfusion in the unstable group (p 0.003). 3 patients stayed in ICU for further observation in stable group because of severity of trauma or severe co-injuries while 7 patients in the other group required postoperative ICU (p 0.018) (Table 4).

In stable group, fifteen patients had no morbidity. Two patients had hemorrhage with failure of conservative treatment and reexploration occurred after 48 hours. No mortality was encountered in the stable group. In the other group, massive hemorrhage was observed through the drains in 3 patients; one of them responded to correction of coagulopathy while the other 2 cases died postoperatively from severe irreversible shock and DIC. 3 patients suffered from biliary leakage; one case responded to medical treatment, one case underwent ultrasound guided aspiration and one case underwent ERCP and stenting. One patient had seroma in which antibiotics and repeated dressing were successful (Table 5).

The most important risk factors that can affect the management were the grade of injury (p 0.002, OR 2.92). The survival probability after 16 hours from admission was 93.3% in all patients, 83.3% in the unstable and 100% in the stable group (Figure 3).

On follow-up, 15 patients in stable group showed satisfactory progress while one patient had subphrenic abscess that resolved by antibiotics, one patient had subhepatic collection that resolved by sonar guided aspiration. One patient with hepatitis required hepatology consultation. In the unstable group, six patients were free while 2 patients had subphrenic abscess and 2 patients had secondary sutures for gapped wound (Figure 4).

Figure 1: CT shows intraparenchymal hematoma (Grade III hepatic injury) in a female patient, 2 years old with history of RTA who responded to conservative management.

Figure 2 Exploration reveals an extensive tear (Grade III) in segment IV to the left of the gall bladder (A, B). Suture hepatorraphy was done together with gel foam (C).

Figure 3 Results of Kaplan-Meier survival analysis test.

Figure 4 Follow-up among the conservative group.

Table 1 The demographic data among patients included in the study.

Table 2 The clinical findings among patients included in the study.

Table 3: The Management of the patients included in the study.

Table 4: The outcome findings among the patients included in the study.

Table 5: Morbidity and mortality among the patients included in the study.