What is the approach for non-operative management (NOM) of traumatic liver injury?

Non-Operative Management of Traumatic Liver Injury

Non-operative management (NOM) should be the treatment of choice for all hemodynamically stable patients with traumatic liver injuries, regardless of injury grade, in the absence of other internal injuries requiring surgery. 1

Assessment and Classification

• The World Society of Emergency Surgery (WSES) classification system divides liver injuries into three categories based on AAST grade and hemodynamic status 1:

  • Minor (WSES grade I): AAST grade I-II, hemodynamically stable
  • Moderate (WSES grade II): AAST grade III, hemodynamically stable
  • Severe (WSES grade III): AAST grade IV-V, hemodynamically stable
  • Severe (WSES grade IV): Any AAST grade with hemodynamic instability

• Diagnostic approach is determined by the patient's hemodynamic status 1, 2:

  • E-FAST is rapid for detecting intra-abdominal free fluid in initial evaluation 1
  • CT scan with intravenous contrast is the gold standard and should always be performed in patients being considered for NOM 1

NOM Protocol

• NOM is contraindicated in patients with hemodynamic instability or peritonitis 1

• Requirements for successful NOM of moderate and severe injuries include 1:

  • Capability for precise diagnosis of injury severity
  • Intensive monitoring (continuous clinical observation, serial hemoglobin monitoring)
  • Around-the-clock availability of CT-scan, angiography, operating room
  • Immediate access to blood and blood products
  • Trained surgeons immediately available

• Serial clinical evaluations (physical exams and laboratory testing) must be performed to detect changes in clinical status during NOM 1

• Intensive care unit admission is required only for moderate (WSES II) and severe (WSES III) lesions 1

Interventional Procedures During NOM

• Angiography with embolization (AG/AE) may be considered as a first-line intervention in hemodynamically stable patients with arterial blush on CT scan 1

• In patients with ongoing resuscitative needs, angioembolization is considered an "extension" of resuscitation to reduce the need for transfusions and surgery 1

• In selected cases where an intra-abdominal injury is suspected in the days after initial trauma, interval laparoscopic exploration may be considered as an extension of NOM 1

Management of Complications

• Complications occur in 12-14% of patients after blunt hepatic trauma, particularly following high-grade injuries 1

• Diagnostic tools for complications include clinical examination, blood tests, ultrasound, and CT scan 1

• Common complications and their management:

  • Bleeding/re-bleeding: In 69% of cases, can be treated non-operatively 1
  • Delayed hemorrhage without severe hemodynamic compromise: Manage with AG/AE 1
  • Hepatic artery pseudoaneurysms: Manage with AG/AE to prevent rupture 1
  • Intrahepatic abscesses: Treat with percutaneous drainage 1
  • Biliary complications (occur in up to 30% of cases): Symptomatic or infected bilomas should be managed with percutaneous drainage 1
  • For complex biliary complications: Combination of percutaneous drainage and endoscopic techniques may be considered 1

Special Considerations

• NOM should be attempted in patients with concomitant head trauma and/or spinal cord injuries with reliable clinical exam, unless specific hemodynamic goals for neurotrauma cannot be achieved 1, 2

• In low-resource settings, NOM could be considered in patients with hemodynamic stability without evidence of associated injuries, with negative serial physical examinations and negative imaging and blood tests 1

• Success rates of NOM are high even for severe injuries:

  • Overall success rate of 97.2% in one study 3
  • Success rate of 92.4% specifically for high-grade liver trauma 4
  • Lower mortality rates compared to operative management (4.6% vs 17.6%) 4

Follow-up Care

• Mechanical thromboprophylaxis should be considered in all patients without absolute contraindications 1

• LMWH-based prophylaxis should be started as soon as possible following trauma 1

• Early mobilization should be achieved in stable patients 1

• In the absence of contraindications, enteral feeding should be started as soon as possible 1