Indications for Operative and Nonoperative Management of Severe Blunt Hepatic Injuries

Abstract

To reassess the current strategy of management of severe blunt hepatic injuries (BHI), JAST type IIIb or AAST grade IV/V, we reviewed all of the BHI patients during the past 16 years in our hospital. Among these, 34 hemodynamically stable patients after fluid resuscitation were managed nonoperatively. Three of the 34 patients required a delayed laparotomy within 15 hours of arrival in the ER, and all surgical indications were related to hemodynamic instability due to hepatic vein injures indicating that these should be managed with surgery. When contrast extravasation or pseudoaneurysm associated with BHI was identified on angiography, transarterial embolization (TAE) was performed in a superselective manner. Thirteen patients who underwent TAE for BHI did not experience recurrent arterial bleeding. During the study period, 24 patients with severe BHI were managed operatively. The survival rate was markedly higher in the patients treated with hepatectomy (94%, 16/17) than in those treated with perihepatic packing (PHP) (14%, 1/7). Logistic regression analysis identified pelvic-ring fractures and severe chest injuries (≥AIS4) as negative independent contributors to survival. Hepatectomy was safe and appropriate for BHI patients without extra-abdominal injuries. However, coagulopathic BHI patients should be managed through a multidisciplinary approach that includes aggressive correction of coagulopathic disorders, PHP with staged laparotomy, and postoperative TAE.