Blunt hepatic injury: A paradigm shift from operative to nonoperative management in the 1990s

Ajai K. Malhotra, Timothy Fabian, Martin Croce, Timothy J. Gavin, Kenneth A. Kudsk, Gayle Minard, F. Elizabeth Pritchard

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229 Citations (Scopus)

Abstract

Objective: To analyze the outcome of hemodynamically stable patients with blunt hepatic injury managed nonoperatively, and to examine the impact of this approach on the outcome of all patients with blunt hepatic injury. Summary Background Data: Until recently, operative management has been the standard for liver injury. A prospective trial from the authors' institution had shown that nonoperative management could safely be applied to hemodynamically stable patients with blunt hepatic injury. The present study reviewed the authors' institutional experience with blunt hepatic trauma since that trial and compared the results with prior institutional experience. Methods: Six hundred sixty-one patients with blunt hepatic trauma during the 5-year period ending December 1998 were reviewed (NONOP2). The outcomes were compared with two previous studies from this institution: operative 1985 to 1990 (OP) and nonoperative 1993 to 1994 (NONOP1). Results: All 168 OP patients were managed operatively. Twenty-four (18%) of 136 NONOP1 patients and 101 (15%) of the 661 NONOP2 patients required immediate exploration for hemodynamic instability. Forty-two (7%) patients failed nonoperative management; 20 were liver-related. Liver-related failures of nonoperative management were associated with higher-grade injuries and with larger amounts of hemoperitoneum on computed tomography scanning. Twenty- four-hour transfusions, abdominal infections, and hospital length of stay were all significantly lower in the NONOP1 and NONOP2 groups versus the OP cohort. The liver-related death rate was constant at 4% in the three cohorts over the three time periods. Conclusions: Although urgent surgery continues to be the standard for hemodynamically compromised patients with blunt hepatic trauma, there has been a paradigm shift in the management of hemodynamically stable patients. Approximately 85% of all patients with blunt hepatic trauma are stable. In this group, nonoperative management significantly improves outcomes over operative management in terms of decreased abdominal infections, decreased transfusions, and decreased lengths of hospital stay.

Original languageEnglish (US)
Pages (from-to)804-813
Number of pages10
JournalAnnals of surgery
Volume231
Issue number6
DOIs
StatePublished - Jun 1 2000

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Nonpenetrating Wounds
Liver
Length of Stay
Wounds and Injuries
Hemoperitoneum
Liver Failure
Infection
Hemodynamics
Tomography

All Science Journal Classification (ASJC) codes

  • Surgery

Cite this

Malhotra, A. K., Fabian, T., Croce, M., Gavin, T. J., Kudsk, K. A., Minard, G., & Pritchard, F. E. (2000). Blunt hepatic injury: A paradigm shift from operative to nonoperative management in the 1990s. Annals of surgery, 231(6), 804-813. https://doi.org/10.1097/00000658-200006000-00004

Blunt hepatic injury : A paradigm shift from operative to nonoperative management in the 1990s. / Malhotra, Ajai K.; Fabian, Timothy; Croce, Martin; Gavin, Timothy J.; Kudsk, Kenneth A.; Minard, Gayle; Pritchard, F. Elizabeth.

In: Annals of surgery, Vol. 231, No. 6, 01.06.2000, p. 804-813.

Research output: Contribution to journalArticle

Malhotra, AK, Fabian, T, Croce, M, Gavin, TJ, Kudsk, KA, Minard, G & Pritchard, FE 2000, 'Blunt hepatic injury: A paradigm shift from operative to nonoperative management in the 1990s', Annals of surgery, vol. 231, no. 6, pp. 804-813. https://doi.org/10.1097/00000658-200006000-00004
Malhotra, Ajai K. ; Fabian, Timothy ; Croce, Martin ; Gavin, Timothy J. ; Kudsk, Kenneth A. ; Minard, Gayle ; Pritchard, F. Elizabeth. / Blunt hepatic injury : A paradigm shift from operative to nonoperative management in the 1990s. In: Annals of surgery. 2000 ; Vol. 231, No. 6. pp. 804-813.
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abstract = "Objective: To analyze the outcome of hemodynamically stable patients with blunt hepatic injury managed nonoperatively, and to examine the impact of this approach on the outcome of all patients with blunt hepatic injury. Summary Background Data: Until recently, operative management has been the standard for liver injury. A prospective trial from the authors' institution had shown that nonoperative management could safely be applied to hemodynamically stable patients with blunt hepatic injury. The present study reviewed the authors' institutional experience with blunt hepatic trauma since that trial and compared the results with prior institutional experience. Methods: Six hundred sixty-one patients with blunt hepatic trauma during the 5-year period ending December 1998 were reviewed (NONOP2). The outcomes were compared with two previous studies from this institution: operative 1985 to 1990 (OP) and nonoperative 1993 to 1994 (NONOP1). Results: All 168 OP patients were managed operatively. Twenty-four (18{\%}) of 136 NONOP1 patients and 101 (15{\%}) of the 661 NONOP2 patients required immediate exploration for hemodynamic instability. Forty-two (7{\%}) patients failed nonoperative management; 20 were liver-related. Liver-related failures of nonoperative management were associated with higher-grade injuries and with larger amounts of hemoperitoneum on computed tomography scanning. Twenty- four-hour transfusions, abdominal infections, and hospital length of stay were all significantly lower in the NONOP1 and NONOP2 groups versus the OP cohort. The liver-related death rate was constant at 4{\%} in the three cohorts over the three time periods. Conclusions: Although urgent surgery continues to be the standard for hemodynamically compromised patients with blunt hepatic trauma, there has been a paradigm shift in the management of hemodynamically stable patients. Approximately 85{\%} of all patients with blunt hepatic trauma are stable. In this group, nonoperative management significantly improves outcomes over operative management in terms of decreased abdominal infections, decreased transfusions, and decreased lengths of hospital stay.",
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AU - Malhotra, Ajai K.

AU - Fabian, Timothy

AU - Croce, Martin

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AU - Minard, Gayle

AU - Pritchard, F. Elizabeth

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N2 - Objective: To analyze the outcome of hemodynamically stable patients with blunt hepatic injury managed nonoperatively, and to examine the impact of this approach on the outcome of all patients with blunt hepatic injury. Summary Background Data: Until recently, operative management has been the standard for liver injury. A prospective trial from the authors' institution had shown that nonoperative management could safely be applied to hemodynamically stable patients with blunt hepatic injury. The present study reviewed the authors' institutional experience with blunt hepatic trauma since that trial and compared the results with prior institutional experience. Methods: Six hundred sixty-one patients with blunt hepatic trauma during the 5-year period ending December 1998 were reviewed (NONOP2). The outcomes were compared with two previous studies from this institution: operative 1985 to 1990 (OP) and nonoperative 1993 to 1994 (NONOP1). Results: All 168 OP patients were managed operatively. Twenty-four (18%) of 136 NONOP1 patients and 101 (15%) of the 661 NONOP2 patients required immediate exploration for hemodynamic instability. Forty-two (7%) patients failed nonoperative management; 20 were liver-related. Liver-related failures of nonoperative management were associated with higher-grade injuries and with larger amounts of hemoperitoneum on computed tomography scanning. Twenty- four-hour transfusions, abdominal infections, and hospital length of stay were all significantly lower in the NONOP1 and NONOP2 groups versus the OP cohort. The liver-related death rate was constant at 4% in the three cohorts over the three time periods. Conclusions: Although urgent surgery continues to be the standard for hemodynamically compromised patients with blunt hepatic trauma, there has been a paradigm shift in the management of hemodynamically stable patients. Approximately 85% of all patients with blunt hepatic trauma are stable. In this group, nonoperative management significantly improves outcomes over operative management in terms of decreased abdominal infections, decreased transfusions, and decreased lengths of hospital stay.

AB - Objective: To analyze the outcome of hemodynamically stable patients with blunt hepatic injury managed nonoperatively, and to examine the impact of this approach on the outcome of all patients with blunt hepatic injury. Summary Background Data: Until recently, operative management has been the standard for liver injury. A prospective trial from the authors' institution had shown that nonoperative management could safely be applied to hemodynamically stable patients with blunt hepatic injury. The present study reviewed the authors' institutional experience with blunt hepatic trauma since that trial and compared the results with prior institutional experience. Methods: Six hundred sixty-one patients with blunt hepatic trauma during the 5-year period ending December 1998 were reviewed (NONOP2). The outcomes were compared with two previous studies from this institution: operative 1985 to 1990 (OP) and nonoperative 1993 to 1994 (NONOP1). Results: All 168 OP patients were managed operatively. Twenty-four (18%) of 136 NONOP1 patients and 101 (15%) of the 661 NONOP2 patients required immediate exploration for hemodynamic instability. Forty-two (7%) patients failed nonoperative management; 20 were liver-related. Liver-related failures of nonoperative management were associated with higher-grade injuries and with larger amounts of hemoperitoneum on computed tomography scanning. Twenty- four-hour transfusions, abdominal infections, and hospital length of stay were all significantly lower in the NONOP1 and NONOP2 groups versus the OP cohort. The liver-related death rate was constant at 4% in the three cohorts over the three time periods. Conclusions: Although urgent surgery continues to be the standard for hemodynamically compromised patients with blunt hepatic trauma, there has been a paradigm shift in the management of hemodynamically stable patients. Approximately 85% of all patients with blunt hepatic trauma are stable. In this group, nonoperative management significantly improves outcomes over operative management in terms of decreased abdominal infections, decreased transfusions, and decreased lengths of hospital stay.

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