Management of liver trauma in Kuwait

Abstract

Objectives: The aim of this study was to introduce the concept of non-operative management (NOM) for blunt liver trauma by establishing a protocol and a prospective Liver Trauma Registry in Kuwait.

Subjects and methods: A prospective Liver Trauma Registry was started in 4 hospitals and it included 117 patients who had sustained blunt liver trauma (94 men and 23 women). Unstable patients were taken to surgery while stable patients were managed conservatively regardless of the grade of liver injury. High-grade (III-VI) liver injuries were managed in collaboration with the liver surgery specialist.

Results: The mean age of the 117 patients was 29.02 ± 11.18 years (range 7-63). NOM was successful in 94 (96%) patients and failed in 4 (4%) (these 4 then underwent successful surgery). Nineteen (16.2%) were unstable and underwent surgery immediately; 15 (79%) of them survived (they had had grade III-V injuries) and 4 died (2 with grade V injuries and 2 with grade VI injuries). Perihepatic packing was necessary in 8/19 (42%) patients. The overall mortality was 3.4% (4/117).

Conclusions: This study showed that NOM was successful in a majority of patients with blunt liver trauma. In addition, it confirmed that the magnitude of liver injury and haemoperitoneum did not preclude NOM as long as the patient was haemodynamically stable.

Fig. 1

AAST Liver Organ Injury Scale diagram. Lesions drawn on the left lobe show laceration depth and subcapsular haematoma. Lesions on the right lobe show intraparenchymal haematoma and parenchymal disruption.

Fig. 2

Outcome of management of the 117 patients admitted to the Liver Trauma Registry from 2003 to 2012.

Fig. 3

a A case of blush on CT scan: a 33-year-old man involved in a road-traffic accident. CT scan of the liver at 4:42 a.m. showed a grade IV injury in the right lobe with extravasation of contrast ‘blush’ (white arrow). He was haemodynamically stable. He was admitted to the ICU and received 1 unit of packed red blood cells. A repeat CT scan at 11:41 a.m. the next day, i.e. 31 h later, showed no blush and he remained stable with no further blood transfusion required up to discharge from hospital. b A case of abdominal compartment syndrome: an 8-year-old child after a road-traffic accident. November 1, 2005: CT scan of the liver showed a grade V injury involving segments VIII, VII and V; on arrival, his haemoglobin was 6 g/l. On November 11 (10th day in ICU), his abdomen became tense with a girth increase from 29 to 32 cm and signs of increased intra-abdominal pressure (desaturation, tachycardia 150/min with normal blood pressure and a decrease in urine output). The CT scan showed a large amount of intraperitonial fluid. Under ultrasound guidance, two large-bore percutaneous drains were inserted in the right and left sides of the abdominal cavity. A total of 1,450 ml of bilious-bloody fluid was drained and the pressure gradually decreased over 1 week. This was followed by a remarkable improvement in his general condition and a normalization of oxygen saturation and pulse rate. Follow-up CT scan on December 5 showed evidence of healing of the liver, no collection of intraperitoneal fluid and only two small residual intrahepatic haematomas.