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Decreased mortality, laparotomy, and embolization rates for liver injuries during a 13-year period in a major Scandinavian trauma center
  1. Iver Anders Gaski1,
  2. Jorunn Skattum2,
  3. Adam Brooks3,
  4. Tomohide Koyama2,
  5. Torsten Eken4,
  6. Paal Aksel Naess1,
  7. Christine Gaarder2
  1. 1 Department of Traumatology, Oslo University Hospital Ulleval and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
  2. 2 Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
  3. 3 Department of Hepatobiliary, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
  4. 4 Department of Anesthesiology, Oslo University Hospital Ulleval and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
  1. Correspondence to Mr Iver Anders Gaski; iagaski{at}gmail.com

Abstract

Background Although non-operative management (NOM) has become the treatment of choice in hemodynamically normal patients with liver injuries, the optimal management of Organ Injury Scale (OIS) grades 4 and 5 injuries is still controversial. Oslo University Hospital Ulleval (OUHU) has since 2008 performed angiography only with signs of bleeding. Simultaneously, damage control resuscitation was implemented. Would these changes result in a decreased laparotomy rate and need for angioembolization (AE), as well as decreased mortality?

Methods We performed a retrospective study on all adult patients with liver injuries admitted at OUHU between 2002 and 2014. The total study population and patients with OIS grades 4 and 5 liver injuries underwent comparison between the periods before (P1) and after (P2) August 1, 2008.

Results 583 patients were included (P1: 237, P2: 346), with a median Injury Severity Score (ISS) of 29. The total population and the subgroup of OIS 4 and 5 injuries were comparable in age, gender, mechanism of injury, injury severity and physiology. Overall laparotomy rates decreased from P1 to P2 (35%–24%; p<0.01), as did the AE rate (11%–5%; p<0.01). The 30-day crude mortality decreased from 14% to 7% (p<0.05). A logistic regression model predicted an OR of 0.45 (95% CI 0.21 to 0.98) for dying when admitted in P2. In OIS grades 4 and 5 injuries (n=149, median ISS 34), similar reduction in AE rate was seen (30%–12%; p<0.05). The NOM rate for OIS grades 4 and 5 injuries was 70%, with 98% success rate. For the 30% requiring surgery, the mortality remained high (P1 52%; P2 40%), despite more balanced transfusion strategy.

Discussion Changes in resuscitation and treatment protocols were associated with decreased laparotomy, and AE rates as well as overall mortality. NOM is safe in 70% of patients with OIS grades 4 and 5 injuries, in contrast to the critically ill 30% requiring surgery who still have poor outcome.

Level of evidence IV.

  • liver injury
  • traumatic hemorrhage
  • angiography
  • transfusions

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0

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Footnotes

  • Contributors IAG, PAN, and CG designed the study and conducted the literature search. IAG, TE, TK, PAN, and CG collected the data. IAG, PAN, and CG analyzed the data. All authors interpreted the data, and participated in writing, revising, and editing the article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Approval for the study was obtained from the Institutional Data Protection Officer at Oslo University Hospital.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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