Non-Operative Management of High Grade Blunt Hepatic Injury: Clinical Complications and the Role of Collateral Damage (NOMLI)

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.

Study Overview

• Status: Completed
• Conditions: Liver Injury

Detailed Description

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

• Study Type: Observational
• Enrollment (Actual): 183

Contacts and Locations

Study Locations

• Switzerland
  • Bern, Switzerland, 3010
    • Dep. of Visceral and Transplant Surgery, Bern University Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years and older (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Patients with blunt liver injury treated at Bern University Hospital from 2000-2006

Description

Inclusion Criteria:

• Patients with blunt liver injury
• Treated from 2000-2006 at Bern University Hospital

Exclusion Criteria:

• < 16 years

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort
Observation; Patients with blunt liver injury

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Morbidity	During primary in-hospital stay

Secondary Outcome Measures

Outcome Measure	Time Frame
Liver-related morbidity	During in-hospital stay
Other morbidity	During in-hospital stay
Mortality	During in-hospital stay
Surgical interventions needed	During in-hospital stay

Collaborators and Investigators

• Sponsor: University of Bern
• Investigators: Study Director: Daniel Inderbitzin, MD, Dep. of Visceral and Transplant Surgery, Bern University Hospital Bern

Publications and helpful links

General Publications

• Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974 Mar;14(3):187-96. No abstract available.
• John TG, Greig JD, Johnstone AJ, Garden OJ. Liver trauma: a 10-year experience. Br J Surg. 1992 Dec;79(12):1352-6. doi: 10.1002/bjs.1800791238.
• Velmahos GC, Toutouzas K, Radin R, Chan L, Rhee P, Tillou A, Demetriades D. High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ. Arch Surg. 2003 May;138(5):475-80; discussion 480-1. doi: 10.1001/archsurg.138.5.475.
• Pachter HL, Knudson MM, Esrig B, Ross S, Hoyt D, Cogbill T, Sherman H, Scalea T, Harrison P, Shackford S, et al. Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. J Trauma. 1996 Jan;40(1):31-8. doi: 10.1097/00005373-199601000-00007.
• Kozar RA, Moore FA, Cothren CC, Moore EE, Sena M, Bulger EM, Miller CC, Eastridge B, Acheson E, Brundage SI, Tataria M, McCarthy M, Holcomb JB. Risk factors for hepatic morbidity following nonoperative management: multicenter study. Arch Surg. 2006 May;141(5):451-8; discussion 458-9. doi: 10.1001/archsurg.141.5.451.
• Kozar RA, Moore JB, Niles SE, Holcomb JB, Moore EE, Cothren CC, Hartwell E, Moore FA. Complications of nonoperative management of high-grade blunt hepatic injuries. J Trauma. 2005 Nov;59(5):1066-71. doi: 10.1097/01.ta.0000188937.75879.ab.
• Gao JM, Du DY, Zhao XJ, Liu GL, Yang J, Zhao SH, Lin X. Liver trauma: experience in 348 cases. World J Surg. 2003 Jun;27(6):703-8. doi: 10.1007/s00268-003-6573-z. Epub 2003 May 13.
• Hurtuk M, Reed RL 2nd, Esposito TJ, Davis KA, Luchette FA. Trauma surgeons practice what they preach: The NTDB story on solid organ injury management. J Trauma. 2006 Aug;61(2):243-54; discussion 254-5. doi: 10.1097/01.ta.0000231353.06095.8d.
• Resources for optimal care of the injured patient: an update. Task Force of the Committee on Trauma, American College of Surgeons. Bull Am Coll Surg. 1990 Sep;75(9):20-9. No abstract available.
• Cogbill TH, Moore EE, Jurkovich GJ, Feliciano DV, Morris JA, Mucha P. Severe hepatic trauma: a multi-center experience with 1,335 liver injuries. J Trauma. 1988 Oct;28(10):1433-8.

Study record dates

Study Major Dates

• Study Start: January 1, 2000
• Study Completion (Actual): December 1, 2006

Study Registration Dates

• First Submitted: June 6, 2008
• First Submitted That Met QC Criteria: June 9, 2008
• First Posted (Estimate): June 10, 2008

Study Record Updates

• Last Update Posted (Estimate): June 10, 2008
• Last Update Submitted That Met QC Criteria: June 9, 2008
• Last Verified: June 1, 2008

More Information

Terms related to this study

• Keywords: Morbidity; Mortality
• Additional Relevant MeSH Terms: Wounds and Injuries
• Other Study ID Numbers: KEK 29_04_2008