Selective non-operative management of traumatic liver injury in Palestine: a retrospective single-center cohort study

Non-operative management (NOM) is the preferred strategy for appropriately selected patients with traumatic liver injury, but evidence from Palestine and other under-represented trauma settings remains limited. This study described initial management selection, in-hospital outcomes, and resource use among patients with traumatic liver injury at a Palestinian trauma center.

This retrospective observational cohort study included consecutive patients with confirmed traumatic liver injury managed at Ibn Sina Specialized Hospital, Jenin, Palestine, between January 2021 and December 2025. Patients were classified according to initial management as NOM or initial laparotomy. The primary outcome among patients initially managed non-operatively was NOM success, defined as survival without delayed operative conversion during the index hospitalization. A secondary composite endpoint, termed an unfavorable NOM course, included biliary leak, any in-hospital complication, any documented endoscopic or drainage procedure, delayed surgery, or in-hospital death. Individual components were also reported separately.

A total of 58 patients were included; 48 (82.8%) underwent initial NOM and 10 (17.2%) underwent initial laparotomy. All 27 penetrating injuries were gunshot wounds. NOM success was observed in 48 of 48 patients (100%; exact 95% CI, 92.6%-100.0%), with no delayed operative conversion or in-hospital death after initial NOM. An unfavorable NOM course occurred in 6 of 48 patients (12.5%) and was driven by documented endoscopic or drainage procedures in four patients and in-hospital complications in three; component counts overlapped. Higher-grade AAST III-IV injury was associated with an unfavorable NOM course compared with AAST I-II injury (41.7% vs. 2.8%, P = 0.002), as well as greater complication burden, procedure use, ICU stay, hospital stay, and transfusion requirements. All unfavorable NOM courses occurred after gunshot injury.

No NOM failure or in-hospital death was observed among the selected patients initially managed non-operatively. However, the small cohort, limited event count, index-hospitalization follow-up, and absence of consistently recorded physiologic selection variables preclude definitive conclusions regarding safety or comparative effectiveness. Higher-grade AAST III-IV and gunshot injuries were associated with more complicated in-hospital NOM courses and greater resource use.