A successful multimodality strategy for management of liver injuries

The treatment of liver injuries involves many strategies ranging from observation to operative intervention and includes numerous options such as angiography, packing, and damage-control procedures. In July 1994 we instituted a protocol for the management of traumatic liver injuries. The main objective of this study was to evaluate the management of liver injuries occurring since the institution of the protocol. Two hundred three consecutive adult patients with liver injuries were evaluated at our Level I trauma center between July 1994 and May 1999. Eighty-eight per cent of the injuries were blunt with a mean Injury Severity Score (ISS) of 24.3 +/- 0.8 and a survival probability (Ps) of 90.0 +/- 1.5 per cent. The overall mortality was 6.4 per cent. A comparison between patients with minor liver injuries and patients with more severe injuries [Abbreviated Injury Score (AIS) <3 vs >3] demonstrated no difference in mortality between the two groups despite a Ps of 93.8 +/- 1.3 per cent in patients with an AIS <3 versus 84.1 +/- 3.3 per cent in patients with an AIS >3. The most common complication in our patient population was posthemorrhagic anemia, which was seen in 10.8 per cent of cases. Severity of injury did not result in a significant difference in the complication rate. Patients who underwent laparotomy had a statistically higher ISS, a lower Ps, and a mortality rate of 11.5 per cent compared with 3.7 per cent (P = 0.03) in patients managed nonoperatively. However, a comparison of patients undergoing laparotomy with those who did not and who had equivalent ISS demonstrated no difference in mortality. Our results demonstrated that a preplanned management strategy was a successful way in which to treat patients with traumatic liver injuries. Although nonoperative management of liver injuries has been common practice a management plan that involves a multimodal surgical strategy is essential.