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Risk Factors for Hepatic Morbidity Following Nonoperative Management
Multicenter Study
Rosemary A. Kozar, MD, PhD;
Frederick A. Moore, MD;
C. Clay Cothren, MD;
Ernest E. Moore, MD;
Matthew Sena, MD;
Eileen M. Bulger, MD;
Charles C. Miller, PhD;
Brian Eastridge, MD;
Eric Acheson, MD;
Susan I. Brundage, MD;
Monika Tataria, MD;
Mary McCarthy, MD;
John B. Holcomb, MD
Arch Surg. 2006;141:451-459.
Hypothesis Early risk factors for hepatic-related morbidity in patients undergoing initial nonoperative management of complex blunt hepatic injuries can be accurately identified.
Design Multicenter historical cohort.
Setting Seven urban level I trauma centers.
Patients Patients from January 2000 through May 2003 with complex (grades 3-5) blunt hepatic injuries not requiring laparotomy in the first 24 hours.
Intervention Nonoperative treatment of complex blunt hepatic injuries.
Main Outcome Measures Complications and treatment strategies.
Results Of 699 patients with complex blunt hepatic injuries, 453 (65%) were treated nonoperatively. Overall, 61 patients (13%) developed 87 hepatic complications including bleeding (38), biliary (bile peritonitis, 7; bile leak, 9; biloma, 11; biliary-venous fistula, 1; and bile duct injury, 1), abdominal compartment syndrome (5), and infections (abscess, 7; necrosis, 2; and suspected abdominal sepsis, 6), which required 86 multimodality treatments (angioembolization, 32; endoscopic retrograde cholangiopancreatography and stenting, 9; interventional radiology drainage, 16; paracentesis, 1; laparotomy, 24; and laparoscopy, 4). Hepatic complications developed in 5% (13 of 264) of patients with grade 3 injuries, 22% (36 of 166) of patients with grade 4 injuries, and 52% (12 of 23) of patients with grade 5 injuries. Univariate analysis revealed 24-hour crystalloid, total and first 24-hour packed red blood cells, fresh frozen plasma, platelet, and cryoprecipitate requirements and liver injury grade to be significant but only liver injury grade (grade 4 odds ratio, 4.439; grade 5 odds ratio, 12.001) and 24-hour transfusion requirement (odds ratio, 6.446) predicted complications by multivariable analysis.
Conclusions Nonoperative management of high-grade liver injuries is associated with significant morbidity and correlates with grade of liver injury. Screening patients with transfusion requirements and high-grade injuries may result in earlier diagnosis and treatment of hepatic-related complications.
Author Affiliations: University of Texas, Houston (Drs Kozar, F. A. Moore, and Miller); Denver Health Medical Center, Denver, Colo (Drs Cothren and E. E. Moore); University of Washington School of Medicine, Seattle (Drs Sena and Bulger); University of Texas Southwestern, Dallas (Dr Eastridge); US Army Institute of Surgical Research, Fort Sam Houston, Tex (Drs Acheson and Holcomb); Stanford University Medical Center, Stanford, Calif (Drs Brundage and Tataria); Wright State University School of Medicine, Dayton, Ohio (Dr McCarthy).
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