Non operative management of liver and spleen traumatic injuries: a giant with clay feet

After years of initial aggressive surgical intervention and a subsequent shift to damage control surgery (DCS), non operative management (NOM) has been shown to be safe and effective. In fact trauma surgeons realized that in liver trauma, it was safer to pack livers [1] than do finger fracture [2] or resection, and this represented a tangential issue to nonoperative approach. Damage control was not the paradigm shift for spleen and liver, but rather to address coagulopathy that was more commonly associated with penetrating major abdominal vascular injuries [3]. The shift to nonoperative care was largely motivated by intraoperative observations that many minor liver [4] and splenic injuries [5] were found no longer bleeding. Then CT arrived in the early 1980s and confirmed that many moderate liver and spleen injuries did not require OR intervention. Pediatric surgeons first lead the shift to nonoperative management for splenic trauma [6,7]. In the 90’s it became the gold standard for liver injuries in hemodynamically stable patients, regardless of injury grade and degree of hemoperitoneum [8], allowing better outcomes with fewer complications and lesser transfusions [9]. Nevertheless concerns have been raised regarding continuous monitoring required [10], safety in higher grades of injury [11] and general applicability of NOM to all haemodynamically stable patients [12]. Similarly, in the same period and following promising results obtained with splenic salvage [13] with several surgical techniques [14] such as splenorraphy, high intensity ultrasound, haemostatic wraps and staplers [15], NOM became the treatment of choice for blunt splenic injuries [5]. However it was immediately clear that NOM failure in adults was significantly higher than that observed in children (17% vs 2%). The incidence of immune system sequelae, coupled with Overwhelming Post Surgical Infection (OPSI) and their real clinical impact, is difficult to establish in the overall population including children [16]. Although recent reports [17] showed that despite a similar incidence and severity of solid organ injuries, Trauma centers with higher risk-adjusted mortality rates are more likely to undertake operative interventions for solid organ injuries. Data from The American College of Surgeons’ National Trauma Data Bank including 87,237 solid abdominal organ injuries showed that, despite a strongly significant increase in percentage of NOM for hepatic and splenic trauma, mortality has remained unchanged [18]. More recently several authors have highlighted an excessive use of NOM, which for some high grade liver injuries is pushed far beyond the reasonable limits, carrying increased morbidity at short and long term, such as bilomas, biliary fistulae, early or late haemorrhage, false aneurysm, arteriovenous fistulae, haemobilia, liver abscess, and liver necrosis [19]. Incidence of complications attributed to NOM increases in concert with the grade of injury. In a series of 337 patients with liver injury grades III-V treated non-operatively, those with grade III had a complication rate of 1%, grade IV 21%, and grade V 63% [20]. Patients with grades IV and V injuries are more likely to require operation, and to have complications of non-operative treatment. Therefore, although it is not essential to perform liver resection at the first laparotomy, if bleeding has been effectively controlled [21], increasing evidence suggests that liver resection should be considered as a surgical option in patients with complex liver injury, as an initial or delayed strategy, which can be accomplished with low mortality and liver related morbidity in experienced hands [22]. Liver resection in hepatic trauma should be considered when (1) massive bleeding related to a hepatic venous injury, (2) massive destruction and devitalized hepatic tissue is present, often partially resected by the injury itself, * Correspondence: [email protected] Maggiore Hospital Bologna Local Health District Trauma Surgery Unit (Head Dr. G. Tugnoli) Department of Emergency, Department of Surgery L. go Nigrisoli, ZIP 40123, Bologna, Italy Full list of author information is available at the end of the article Di Saverio et al. World Journal of Emergency Surgery 2012, 7:3 http://www.wjes.org/content/7/1/3 WORLD JOURNAL OF EMERGENCY SURGERY