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Nonoperative Management of Major Liver Trauma—When Failure May Be a Success: Comment on “Successful Nonoperative Management of the Most Severe Blunt Liver Injuries”

Nonoperative Management of Major Liver Trauma—When Failure May Be a Success: Comment on... In the 1980s, nonoperative management (NOM) of liver injuries began to come of age. Stable liver injuries could be managed with a period of observation. I vividly recall a discussion in a publication where prominent trauma surgeons lamented deaths they had contributed to by operating on minimally bleeding hepatic lacerations in stable patients. All concluded that you should not poke a skunk. Major liver trauma continues to be a lethal injury. In this issue of the Archives, the Research Consortium of New England Centers for Trauma group reviews the success of operative management and NOM in 393 patients with grade 4 or grade 5 blunt liver injury during a 10-year period.1 Important and practical lessons can be gleaned from this study. Major liver injuries are unusual. If distributed equally, each trauma center would see 3 or 4 high-grade liver injuries yearly, making preparation and planning critical. van der Wilden et al1 did not describe the plan of care, but this is a circumstance in which 2 trained trauma surgeons are needed in the operating room (OR) to maximize survival. The 52.7% mortality associated with immediate operation (IO) in the study1 is daunting. We do not know how or of what these patients died but can assume that many died of uncontrolled hemorrhage. We sometimes assume that NOM implies no intervention. It does not. About one-third of the patients in the study by van der Wilden et al underwent angiography, with many having embolization. Nonoperative management does not imply that these patients are not continuing to bleed. Many have ongoing hemorrhage at a lower but not insignificant rate. You can quibble with the authors' definition of successful NOM (“if a patient did not receive an abdominal operation during the index hospital stay and did not succumb to the liver injury”).1 Given the extraordinarily high mortality associated with IO, I would consider delayed operation a success because it did not increase mortality. We would all trade IO with damage control for a biloma managed percutaneously. Failed NOM may in fact be a success. When these patients fail NOM because of hemorrhage, they do not bleed to death. One can assume that, when they are taken to the OR in a controlled fashion with their coagulopathies and temperatures corrected, laparotomy becomes a less hair-raising adventure for surgeon and patient alike. Approximately 2% of patients in the study by van der Wilden et al failed NOM because of intestinal or gallbladder necrosis. Missed injuries are a constant reminder that isolated injuries are not always isolated. Many questions remain unanswered. How many of the patients in the study's IO group did not need IO? Most agree that the severely hypotensive resuscitation nonresponder needs to go to the OR. How do we manage the metastable patient with intermittent hypotension: OR or IR? Will damage control resuscitation paradigms with early fresh frozen plasma and blood transfusion decrease the number of patients needing IO? Failed NOM would seem to beat IO almost every time. Maybe failure is not so bad after all. Back to top Article Information Correspondence: Dr Kispert, Dartmouth Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756 (Paul.H.Kispert@Hitchcock.org). Financial Disclosure: None reported. References 1. van der Wilden GM, Velmahos GC, Emhoff T, et al. Successful nonoperative management of the most severe blunt liver injuries: a multicenter study of the Research Consortium of New England Centers for Trauma. Arch Surg. 2012;147(5):sne120005423-428Google ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Nonoperative Management of Major Liver Trauma—When Failure May Be a Success: Comment on “Successful Nonoperative Management of the Most Severe Blunt Liver Injuries”

Kispert, Paul H.
Archives of Surgery , Volume 147 (5) – May 1, 2012
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References (2)

Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.2012.341
Publisher site
See Article on Publisher Site

Abstract

In the 1980s, nonoperative management (NOM) of liver injuries began to come of age. Stable liver injuries could be managed with a period of observation. I vividly recall a discussion in a publication where prominent trauma surgeons lamented deaths they had contributed to by operating on minimally bleeding hepatic lacerations in stable patients. All concluded that you should not poke a skunk. Major liver trauma continues to be a lethal injury. In this issue of the Archives, the Research Consortium of New England Centers for Trauma group reviews the success of operative management and NOM in 393 patients with grade 4 or grade 5 blunt liver injury during a 10-year period.1 Important and practical lessons can be gleaned from this study. Major liver injuries are unusual. If distributed equally, each trauma center would see 3 or 4 high-grade liver injuries yearly, making preparation and planning critical. van der Wilden et al1 did not describe the plan of care, but this is a circumstance in which 2 trained trauma surgeons are needed in the operating room (OR) to maximize survival. The 52.7% mortality associated with immediate operation (IO) in the study1 is daunting. We do not know how or of what these patients died but can assume that many died of uncontrolled hemorrhage. We sometimes assume that NOM implies no intervention. It does not. About one-third of the patients in the study by van der Wilden et al underwent angiography, with many having embolization. Nonoperative management does not imply that these patients are not continuing to bleed. Many have ongoing hemorrhage at a lower but not insignificant rate. You can quibble with the authors' definition of successful NOM (“if a patient did not receive an abdominal operation during the index hospital stay and did not succumb to the liver injury”).1 Given the extraordinarily high mortality associated with IO, I would consider delayed operation a success because it did not increase mortality. We would all trade IO with damage control for a biloma managed percutaneously. Failed NOM may in fact be a success. When these patients fail NOM because of hemorrhage, they do not bleed to death. One can assume that, when they are taken to the OR in a controlled fashion with their coagulopathies and temperatures corrected, laparotomy becomes a less hair-raising adventure for surgeon and patient alike. Approximately 2% of patients in the study by van der Wilden et al failed NOM because of intestinal or gallbladder necrosis. Missed injuries are a constant reminder that isolated injuries are not always isolated. Many questions remain unanswered. How many of the patients in the study's IO group did not need IO? Most agree that the severely hypotensive resuscitation nonresponder needs to go to the OR. How do we manage the metastable patient with intermittent hypotension: OR or IR? Will damage control resuscitation paradigms with early fresh frozen plasma and blood transfusion decrease the number of patients needing IO? Failed NOM would seem to beat IO almost every time. Maybe failure is not so bad after all. Back to top Article Information Correspondence: Dr Kispert, Dartmouth Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03756 (Paul.H.Kispert@Hitchcock.org). Financial Disclosure: None reported. References 1. van der Wilden GM, Velmahos GC, Emhoff T, et al. Successful nonoperative management of the most severe blunt liver injuries: a multicenter study of the Research Consortium of New England Centers for Trauma. Arch Surg. 2012;147(5):sne120005423-428Google ScholarCrossref

Journal

Archives of Surgery – American Medical Association

Published: May 1, 2012

Keywords: liver injuries

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