A quarter century experience in liver trauma: a plea for early computed tomography and conservative management for all hemodynamically stable patients.

BACKGROUND

Advances in diagnostic imaging and the introduction of damage control strategy in trauma have influenced our approach to treating liver trauma patients. The objective of the present study was to investigate the impact of change in liver trauma management on outcome.

METHODS

A total of 468 consecutive patients with liver trauma treated between 1986 and 2010 at a single level 1 trauma center were reviewed. Mechanisms of injury, diagnostic imaging, hepatic and associated injuries, management (operative [OM] vs. nonoperative [NOM]), and outcome were evaluated. The main outcome analysis compared mortality for the early study period (1986-1996) versus the later study period (1997-2010).

RESULTS

395 patients (84%) presented with blunt liver trauma and 73 (16%) with penetrating liver trauma. Of these, 233 patients were treated with OM (50%) versus 235 with NOM (50%). The mortality rate was 33% for the early period and 20% for the later period (odds ratio 0.19; 95% CI 0.07-0.50, P = 0.001). A significantly increased use of computed tomography (CT) as the initial diagnostic modality was observed in the late period, which almost completely replaced peritoneal lavage and ultrasound. There was a significant shift to NOM in the later period (early 15%, late 63%) with a low conversion rate to OM of 4.2%. Age, degree of hepatic and head injury, injury severity, intubation at admission, and early period were independent predictors of mortality in the multivariate analysis.

CONCLUSIONS

Integration of CT in early trauma-room management and shift to NOM in hemodynamically stable patients resulted in improved survival and should be the gold standard management for liver trauma.