Severe hepatic trauma: nonoperative management, definitive repair, or damage control surgery?

BACKGROUND: Management of severe liver injuries has evolved to include the options for nonoperative management and damage control surgery. The present study analyzes the criteria for choosing between nonoperative management and early surgery, and definitive repair versus damage control strategy during early surgery.

METHODS: In a retrospective analysis of 144 patients with severe (AAST grade III-V) liver injuries (94% blunt trauma), early laparotomy was performed in 50 patients. Initial management was nonoperative in 94 blunt trauma patients with 8 failures. Uni- and multivariate analyses were used to calculate predictor odds ratios (OR) with 95% confidence intervals (CI).

RESULTS: Factors associated with early laparotomy in blunt trauma included shock on admission, associated grade IV-V splenic injury, grade IV-V head injury, and grade V liver injury. Only shock was an independent predictor (OR, 26.1; 95% CI, 8.9-77.1; P < 0.001). The presence of a grade IV-V splenic injury predicted damage control strategy (OR infinite; P = 0.021). Failed nonoperative management was associated with grade IV-V splenic injury (OR, 14.00; 95% CI, 1.67-117.55), and shock (OR, 6.82; 95% CI, 1.49-31.29). The hospital mortality rate was 15%; 8 of 21 deaths were liver-related. Shock (OR, 9.3; 95% CI, 2.4-35.8; P = 0.001) and severe head injury (OR, 9.25; 95% CI, 3.0-28.9; P = 0.000) were independent predictors for mortality.

CONCLUSIONS: In patients with severe liver injury, associated severe splenic injury favors early laparotomy and damage control strategy. Patients who arrive in shock or have an associated severe splenic injury should not be managed nonoperatively. In addition to severe head injury, uncontrollable bleeding from the liver injury is still a major cause of early death.