Liver Injury Clinical Trial
Official title:
Retrospective Single Centre Study Which Investigates the Safety of the Non-Operative Management of Patients With High Grade Blunt Liver Injuries (NOMLI) and the Impact of to the LI Collateral Intra- and Extra-Abdominal Damage on Interventions and Outcome
Little is known about the role of collateral damage in patients with high grade liver injuries (LI). This retrospective single centre study investigates the safety of the non-operative management of patients with high grade blunt liver injuries (NOMLI) and the impact of to the LI collateral intra- and extra-abdominal damage on interventions and outcome. We first hypothesized that NOMLI can be safely achieved also in high-grade liver injured patients, the management of trauma patients with LI mainly consist of the treatment of collateral damages and their complications, and causes of death are in the majority of cases not liver related. A retrospective study involving 183 patients with blunt hepatic injuries was therefore carried out to investigate these hypotheses.
Background:
Modern approach to liver injured patients favours non-operative management of liver injury
(NOMLI) including endovascular artery occlusion. Numerous studies over the past two decades
have confirmed the feasibility of NOMLI in up to 95% of hemodynamically stable patients with
blunt trauma mechanisms. To further improve the outcome of patients with hepatic injuries,
investigations should focus on the overall morbidity and mortality of NOMLI. Purely
hepatic-related complication rates in most series are low, ranging from 0-7% and parallel
the grade of liver lesion. But the majority of patients included in those studies suffered
low-grade liver injuries (LI). Regarding the safety of NOMLI in high grade lesions, the
results may be biased. Complications in patients with high-grade LI are more frequent and
their management is considerably more complex. Regarding the sparsely available literature
focussing on the morbidity of NOMLI in high grade LI, hepatic-related complication rates of
11 and 13% have been described. Only the LI grade and the amount of packed red blood cell
(PRBC) transfusion at 24 hours postinjury predicted hepatic-related complications. No data
is available concerning the impact of collateral intra- and extra-abdominal damage on
complications of NOMLI in those patients. Of note, up to 75% of patients with LI suffer from
collateral intra- and extra-abdominal lesions. These injuries vary in their surgical
importance but severe complications and to the LI independent laparotomies must be expected
in a significant number of patients. Rates of such nonspecific laparotomies have been
described in up to 20% of patients with hepatic trauma. Over the past decade, overall
mortality of liver injured patients remained relatively constant, averaging between 10-15%.
This mortality rate represents deaths of all causes in the clinical course of these complex
trauma patients. There are studies which already suggested, that early deaths in patients
with LI also were caused by uncontrolled bleedings from associated intra- and
extra-abdominal injuries, and that most late deaths result from collateral head injuries and
sepsis with multi-organ-failure (MOF). But no detailed data about the occurrence of
extra-abdominal complications after NOMLI has been published so far.
Objective:
We first hypothesized that NOMLI can be safely achieved also in high-grade liver injured
patients, the management of trauma patients with LI mainly consist of the treatment of
collateral damages and their complications, and causes of death are in the majority of cases
not liver related. A retrospective study involving 183 patients with blunt hepatic injuries
was therefore carried out to investigate these hypotheses.
Methods:
The study was conducted at the Bern University Hospital, Switzerland between January 2000
and December 2006. An average of 286 (range, 204-344) multiple injured patients were treated
in our level I trauma centre each year. Only blunt liver injured patients were included. All
charts (including surgery and autopsy reports) were reviewed retrospectively. Demographic
data collected included age, gender, mechanism of injury. Injury patterns were defined by
the Abbreviated Injury Score (AIS) and Injury Severity Score (ISS). The grade of hepatic
injury was determined by an experienced radiologist and by two experienced hepatobiliary
surgeons in parallel based on contrast enhanced computed tomography (CT) scan findings
(Siemens® Somatom Sensation 16) or by laparotomy according to the American Association for
the Surgery of Trauma Organ Injury Scale for hepatic injuries. For the current study,
high-grade injuries were considered grades 3 to 5. Other data collected included the number
and types of surgical procedures, hepatic-related and overall complications, and causes of
deaths. All patients were managed and resuscitated using the protocols outlined in the
Advanced Trauma Life Support (ATLS) manual of the American College of Surgeons Committee on
Trauma. NOMLI was
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Observational Model: Cohort, Time Perspective: Retrospective
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