Non-operative management of liver trauma
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Non-operative Management of Liver Trauma Review Article A. Marinis, S. Rizos Received 27/05/2012 Accepted 08/09/2012
Abstract Aim-Background: Non-operative management (NOM) of liver trauma is well-established and accepted in current clinical practice. Initially considered as appropriate for lower grades of injury, NOM is now widely preferred for moderate and severe liver injuries too. Methods: This review is based on a search of the English literature in Pubmed, using terms such as “liver trauma” and “non-operative”. Reconsideration of currently used indications and selection criteria for the non-operative management of liver trauma, as well as therapeutic strategies, complications and patient outcome, are discussed. Results: Appropriate selection of patients according to the following criteria is essential for the successful outcome of NOM: haemodynamic stability (on arrival or after initial resuscitation), the absence of associated injuries to intra- or retro-peritoneal organs necessitating operative intervention, and the availability of a multidisciplinary team including an experienced radiologist, an experienced liver (preferably) surgeon and intensive care facilities. The volume of haemoperitoneum and the grade of injury are not considered factors that preclude NOM. Of paramount importance is the monitoring of signs of peritonitis, related to a possible unrecognised hollow viscus injury, which is appropriately managed operatively. Computed tomography is also important for early diagnosis of ongoing bleeding, in order to intervene either angiographically (embolization) or operatively (haemostasis). Mortality during NOM varies between 0.4% (liver-related) up to 13% (associated injuries). Conclusions: In conclusion, the main selection criterion of patients with liver trauma for NOM is haemodynamic stability, independent of the grade of injury and the volume of haemoperitoneum. Accurate
A. Marinis (Corresponding author), S. Rizos - First Department of Surgery, Tzaneion General Hospital, 1 Afentouli & Zanni, 18536, Piraeus, Greece e-mail: [email protected]
interpretation of liver CT scanning is of paramount importance, in order to exclude or diagnose any associated injuries requiring operative intervention or active bleeding that can be treated with angiography and selective embolization. The prospect of haemodynamic instability not improving with resuscitation, the increased need for liver-related blood transfusions (> 4 pRBCs), and failure of conservative treatment to deal with complications, necessitate prompt operative intervention to avoid the consequences of delayed management.
Key words:
Liver trauma, Non-operative
Introduction In 1908, J H. Pringle provided the first description of operative management of liver trauma [1]. Unfortunately, all eight patients died postoperatively; thereafter, Pringle recommended the non-operative management (NOM) of these injuries. However, his recommendation was not deemed acceptable for more than half a century, and it was only in 1972 that a new paper for this subje
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