Predictors of outcome in patients requiring surgery for liver trauma

Transcription

1 Injury, Int. J. Care Injured (2007) 38, Predictors of outcome in patients requiring surgery for liver trauma W.L. Sikhondze, T.E. Madiba *, N.M. Naidoo, D.J.J. Muckart Department of Surgery, University of KwaZulu-Natal and King Edward VIII Hospital, Durban, South Africa Accepted 31 August 2006 KEYWORDS Liver; Trauma; Predictor; Outcome Summary Introduction: Severe bleeding from liver injury is one of the major causes of mortality in patients with abdominal trauma. The study was undertaken to assess factors that influence outcome following liver trauma. Patients and methods: This is a prospective study of patients with liver injury treated in one surgical ward at King Edward VIII Hospital over a 7-year period (from 1998 to 2004). Data collected included demographics, intra-operative findings, operative management and outcome. Results: Of a total of 478 patients with abdominal trauma, 105 (22%) were found to have liver injuries, of whom only 7 were female. Their mean age was years. Injuries were due to firearms (70), stabs (26) and blunt trauma (9). Nineteen patients presented with shock (systolic BP 90 mmhg). All patients underwent laparotomy. Delay before surgery was 6 h in 58 patients and >6 h in 47 patients. Forty patients required ICU management (38%) and the mean ICU stay was days. Twenty patients (19%) needed a re-laparotomy for various reasons. The complication rate was 37% and the mortality rate was 20% (23% for firearms, 44% for blunt trauma and 4% for stabs). The mortality rate in patients with shock was 58% compared to 12% in those who were not shocked ( p < ). Mortality rate was 2, 23 and 63% for Injury Severity Score (ISS) 9, and >20, respectively (group 1 versus group 2 p = 0.015; group 1 versus group 3 p < and group 2 versus group 3 p = 0.001). Mortality rates for delay 6 h and delay >6 h were 28 and 9%, respectively ( p = 0.008). Associated injuries led to a higher mortality (3% versus 27%; p = 0.006). Hospital stay was days. Presented at the 41st Congress of the International Society of Surgery, Durban, South Africa, August * Corresponding author at: Department of Surgery, University of KwaZulu-Natal, Private Bag 7, Congella, 4013 Durban, South Africa. Tel.: ; fax: address: madiba@ukzn.ac.za (T.E. Madiba) /$ see front matter # 2006 Elsevier Ltd. All rights reserved. doi: /j.injury

2 66 W.L. Sikhondze et al. Conclusions: Liver injuries occurred in 22% of abdominal injuries. Injury mechanism, delay before surgery, shock on admission, grade of injury, associated injury and ISS are significantly associated with outcome. # 2006 Elsevier Ltd. All rights reserved. Introduction Despite its relatively protected position, the liver is the most frequently injured solid intra-abdominal organ. 4,9,14 Associated injuries to other organs, uncontrolled haemorrhage from the liver and subsequent development of septic complications significantly contribute to morbidity and death. 1 Mortality rates have fallen from 66% in World War II to current levels of 28%. 7,27,30 Reducing the morbidity and mortality from haemorrhagic shock and subsequent sepsis remain the main challenges in the management of liver trauma. 7 The aim of this study was to document the outcome of the management of liver trauma and to establish factors that influence outcome. Liver injuries found at laparotomy were managed on their merit. Our policy is minimal surgery for minor injuries. Drainage is used only for minimal bleeding or bile leak. Management of major injury includes suture of the laceration, non-anatomic resection and packing depending on the extent of the injury. Data were analysed using the Statistical Package for the Social Sciences (SPSS) version The Chisquared method was used to assess the influence of shock and delay on outcome and, where numbers were very small, Fisher s exact test was used. The one-way ANOVA test was used to assess the influence of injury mechanism, grade of liver injury and Injury Severity Score on outcome. A p-value of <0.05 was taken as statistically significant. Patients and methods The surgical service at King Edward VIII Hospital consists of three surgical wards. This is a prospective study undertaken in a single surgical ward at King Edward VIII Hospital over a 7-year period from 1998 to Patients underwent resuscitation prior to being submitted to laparotomy. In a proportion of patients the laparotomy formed part of the resuscitation. A prophylactic antibiotic policy was employed. Local policy for the management of patients with blunt trauma to the abdomen with suspected solid visceral injury, but with no clinical features suggestive of hollow visceral injury, is nonoperative management (assuming no haemodynamic instability), i.e. strict bed rest, close observation, regular full blood count and CT scan of the abdomen. Clinical data including demographics, intraoperative findings, operative management and outcome were collected onto a proforma and subsequently entered into a computer database. Delay before surgery included both pre-hospital and inhospital duration. Hypovolaemic shock was defined as a systolic BP 90 mmhg. Injuries were graded according to the Organ Injury Scale as described by the American Association for the Surgery of Trauma. 19 The severity of injury was documented using the Injury Severity Score (ISS) 31 and patients were grouped into three categories (group 1, ISS 9; group 2, ISS = and group 3, ISS > 20). Results A total of 478 patients sustained abdominal trauma during this period. There were 105 with liver injury, of whom 98 were males, giving a male to female ratio of 14:1. The mean age was years (range years). Firearms caused 70 of the injuries (67%) followed by stabs in 26 patients (25%) and blunt trauma in 9 patients (9%). All patients presented with varying degrees of peritonism. Disembowelment occurred in 6 of 26 patients with stab wounds. Hypovolaemic shock was present in 19 patients (18%). Four of these patients underwent laparotomy as a form of resuscitation. Diagnosis of hepatic trauma was made at laparotomy in all patients and none were managed nonoperatively. Total delay before surgery was h; with delay of 6 h in 58 patients (56%) and >6 h in 47 patients (44%). There were 84 patients (80%) with haemoperitoneum (range ml). The Injury Severity Score (ISS) ranged from 4 to 50 with a mean of There were 46 patients in group 1, 43 patients in group 2 and 16 patients in group 3. There were 31 patients (30%) with isolated liver trauma and 74 with associated injuries (70%). The latter occurred in 13 stab injuries (50%), 44 firearm injuries (77%) and 7 blunt injuries (78%). Associated hollow visceral injury occurred in 63 patients (60%). Common associated organ injuries were colon (36), stomach (35%), diaphragm (27%), small bowel (24),

3 Predictors of outcome in liver trauma 67 Table 1 Management of liver injuries in 105 patients stratified according to grade of injury Grade Total Conservative Gelatine sponge Suture Pack Resection Mortality a (11) (16) (22) (22) (80) Total (20) Grades 1 4 vs grade 5; p < Values in parentheses are in %. spleen (13) and kidney (12). Management of the liver injury as stratified according to grade of injury at laparotomy is shown in Table 1. Surgical options for management of liver injuries at laparotomy included conservative management, application of absorbable gelatine sponge (Spongostan: Mascia Brunelli Spa, Milano, Italy; Surgicel: Ethicon, Branswick, NJ, USA), suture of the liver injury, perihepatic packing and resection. Resection was nonanatomical. Postoperative complications arose in 39 patients (37%) and included pulmonary infection (16%), multiple organ dysfunction syndrome (13%), peritonitis (including anastomotic dehiscence and abscess) in 13 patients, wound sepsis (6%) and fistula (6%). These figures overlap as some patients developed more than one complication. There was no difference in complication rate between the different grades of injury. Tables 2 and 3 address the influence of various factors on morbidity and mortality rates. There was no difference in morbidity between the three injury mechanisms. Patients with the lowest ISS (group 1) had the lowest morbidity. Nine out of 31 patients with isolated liver injuries developed complications (30%) compared to 29 out of 74 with associated injuries (39%) ( p = 0.501). There was no difference in morbidity between patients with associated hollow visceral injury and those without associated hollow visceral injury ( p = 0.835) but patients with hollow visceral injury had a higher mortality ( p = 0.045). Shock on admission, delay before surgery and the use of drains had no influence on morbidity. Forty patients required intensive care management (38%) and their ICU stay was days. Twelve patients (63%) who presented in shock required ICU compared to 28 (32%) of those who were not in shock ( p = 0.017). Twenty (19%) patients required a re-laparotomy for various reasons including removal of packs (7), no improvement (6), peritonitis (3), intra-abdominal abscess formation (2) and intestinal obstruction (1). There were no complications directly specific to liver injury such as bile leaks. Twenty-one patients died (20%); 44% following blunt trauma, 23% following firearm injury and 4% for stab wounds ( p = for stabs versus blunt trauma; p = for stabs versus firearms and p = for firearms versus blunt trauma). Mortality rates among patients in groups 1, 2 and 3 were 2, 23 and 63%, respectively (group 1 versus group 2 p = 0.015; group 2 versus group 3 p = 0.001; and group 1 versus group 3 p < ). Eleven patients (58%) with shock on admission died compared to 10 (12%) without shock ( p < ). Among 58 patients with delay of 6 h 16 (28%) died, compared Table 2 Influence of injury mechanism, injury severity on morbidity and mortality Morbidity Mortality n % n % Injury mechanism Stab (n = 26) Firearm (n = 70) Blunt (n = 9) Injury Severity Score Group 1 (ISS 9; n = 46) Group 2 (ISS = 10 20; n = 43) Group 3 (ISS > 20; n = 16) Injury mechanism: morbidity stab vs firearm! p = 0.484; stab vs blunt! p = 0.132; firearm vs blunt! p = 0.548; mortality stabs vs blunt! p = 0.013; stab vs firearm! p = 0.101; blunt vs firearm! p = Injury Severity Score: morbidity group 1 vs group 2! p < ; group 1 vs group 3! p = 0.001; group 2 vs group 3! p = 1.0; mortality group 1 vs group 2! p = 0.015; group 1 vs group 3! p < ; group 2 vs group 3! p =

4 68 W.L. Sikhondze et al. Table 3 Influence of shock, delay, associated injuries and use of drain on morbidity and mortality Factor Morbidity Mortality n % n % Shock Shock (n = 19) No shock (n = 86) Delay Delay 6 h(n = 58) Delay >6 h(n = 47) Associated injury Isolated injuries (n = 31) Associated injuries (n = 74) Associated HVI (n = 63) No associated HVI (n = 42) Drains Drain (n = 39) No drain (n = 66) HVI = hollow visceral injury. Morbidity: shock vs no shock! p = 0.301; 6 h vs >6 h delay! p = 0.305; isolated vs associated injury! p = 0.501; associated HVI vs no HVI! p = 0.835; drain vs no drain! p = Mortality: shock vs no shock! p < ; 6 h vs >6 h delay! p = 0.008; isolated vs associated injury! p = 0.006; associated HVI vs no HVI! p = 0.045; drain vs no drain! p = 1.0. to 4 (9%) out 47 of those whose delay was >6h ( p = 0.008). Patients with grade 5 injuries had a significantly higher mortality rate compared to patients with grades 1 4 injuries ( p < ). Significantly more patients with associated injuries died compared to those with isolated injury (3% versus 27%; p = 0.006). Table 4 shows the mortality rate increases with the number of associated injuries per patient. The average hospital stay was (range 1 62) days. Discussion The liver is the most commonly injured intraabdominal solid organ following trauma. 4,14 Due to its anatomical location, severe liver injuries usually lead to exsanguinating haemorrhage which is the most common cause of death. 16 Liver injuries accounted for 22% of abdominal injuries in this Table 4 Mortality stratified according to associated intra-abdominal injuries Associated organs Morbidity Mortality Injuries/patient No. of patients n % n % study, the majority associated with penetrating trauma. This is not in keeping with the world literature in which penetrating trauma is responsible for only 1 11% and blunt trauma for 23 50% of liver injuries. 7,14,18,27 The reason for this discrepancy is that firearm injuries are common in this country, an unfortunate continuing trend. 21 The average time before surgery was h, which is longer than that reported by others. 6 In Durban, as in the rest of the country, the period taken for an injured patient to reach hospital tends to be longer than the accepted norms. This is due to occasionally inadequate emergency medical services. The majority of liver injuries (70 90%) are minor (grades 1 and 2) and require minimal treatment. 3,11 Minor injuries accounted for 62.5% of injuries in this study. The average Injury Severity Score of 15 was much lower than the reported by Gür et al. 14 We believe that stab wounds and low velocity firearm injuries tend to cause less anatomical disruption than blunt trauma, which may explain the low ISS in the current study. The dominant injury mechanism in the study by Gür et al. 14 was blunt trauma. The recognition that 50 80% of liver injuries stop bleeding spontaneously, coupled with better imaging of the injured liver by computerised tomography (CT), has led to the acceptance of non-operative management with resultant decrease in mortality rates. 25 This is especially more applicable to blunt liver injuries, 6 although selective non-operative management of liver injuries is now becoming

5 Predictors of outcome in liver trauma 69 acceptable for firearm injuries as well. 5,20,24 Specific criteria have been suggested to aid the surgeon in the selection of patients suitable for conservative management. 10,24,26 The critical factor is haemodynamic stability. 26 The majority of injuries were firearm injuries and this may explain the lack of nonoperative management of liver injuries in this study. Firearms, especially high velocity weapons, are known to cause devastating injuries and few can fulfil these stated criteria although this has been described. 24 Prompt, expeditious and appropriate operative management of liver injuries will reduce peri-operative morbidity and mortality. The objectives in the operative management of liver trauma are to control the bleeding and bile leak, remove devitalised tissue, control infection in patients with associated hollow visceral injury and to establish adequate drainage of the abdomen. 15 Manual compression, Pringle manoeuvre and continued resuscitation with blood component therapy are essential to control the bleeding. 15 Damage control in the form of perihepatic packing is ideal for patients who are in extremis or those undergoing initial laparotomy at a district hospital. 15 There are also a variety of manoeuvres to stop bleeding ranging from suturing, diathermy and laser, fibrin glue and resection. 15 The other aspects of management are secondary to control of haemorrhage but are equally crucial. While some authors have previously advocated an extensive surgical approach such as anatomic resection, performed through conventional anatomic planes, 29 recent trends have been toward a more minimal surgical procedure such as non-anatomic resection to remove ischaemic parts of the liver. 6,8,15 The morbidity rate associated with liver injury varies significantly depending on the mechanism of injury and ranges from 5 to 24%. 6,7 Mechanism of injury, delay before surgery, shock on admission, grade of injury, associated injury and the use of drains had no effect on morbidity in this series. After haemorrhage, sepsis remains the major factor for liver related morbidity. 7 The severity of liver injury, the number of associated abdominal injuries and shock have been demonstrated to correlate with an increasing rate of sepsis. 7,12,23 Other studies, 7 including the present series, did not show this trend. Although associated hollow visceral injury might be assumed to be associated with increased bacterial contamination and therefore sepsis, 7 it was not shown to be so by the present study. A high ISS was associated with a high morbidity. The literature quotes liver injury specific complications at 7%. 7 There were no liver injury specific complications in this study. The failure of associated injury and the use of drains to influence morbidity in this study is contrary to what the literature suggests. 7,22,23 There is conclusive evidence that open drainage is not advisable for liver injuries 13 and that sump drainage is hazardous and should not be used. 7 The use of closed drainage to evacuate blood and bile, however, remains controversial. 7 In a prospective randomised study Mullins et al. 22 found a liver related septic complication rate of 8% for both drainage and no drainage. Gilmore et al. 13 on the other hand found more complications with drainage than without drainage. There is a slightly higher incidence of peri-hepatic abscess with no drainage than with drainage. 7 There is now growing consensus that drainage is not necessary for mild injuries (grades 1 and 2) if there is no bleeding or bile leak. 2,7 Mortality from liver injuries is generally in two phases: early deaths arise from haemorrhage and hypovolaemic shock from either the liver or associated major vascular injuries and late deaths from sepsis and multiple organ dysfunction syndrome (MODS). 7 The majority of early deaths from blunt trauma are primarily due to brain injury although haemorrhage does play an important role with major liver fracture, and late deaths can be attributed to closed head injury and sepsis with MODS. 7 The mortality rate associated with liver injuries varies according to mechanism of injury and ranges between 1 and 40% but this figure may double or even treble with associated intra-abdominal injuries. 3,6,7,14,19,28 The mortality rate of 20% in this series falls within this range. Although representing only 8% of the patient population, blunt trauma comprised 20% of all deaths in this study and had the highest mortality rate compared to firearm and stab wounds. Blunt injury impacts on a larger surface area of the liver and is therefore more likely to produce a higher grade of injury. Although blunt injury caused the highest mortality the numbers were too small to conclude that it is a predictor of mortality. Furthermore, any associated injury tends to be more severe resulting in higher mortality rate compared to penetrating injury. 7 Mortality rate was highest for grade 5 injuries. This is not surprising as grade 5 injury is associated with massive force causing extensive damage. Also not surprising was the high mortality rate associated with the highest category of Injury Severity Score. Patients that were admitted in shock had a higher mortality rate compared to those admitted without shock. This is due to the fact that shock results from severe exsanguinating haemorrhage, resulting in metabolic instability and MODS. This trend has been observed in other series. 17 Patients with a delay of 6 h or less before surgery had a higher mortality compared to those with delay

6 70 W.L. Sikhondze et al. of more than 6 h. This surprising statistic may be explained by the concept of natural triage. Patients who present with little delay will represent a spectrum of all grades of liver injury including severe damage with shock. Those with major trauma who are subjected to long delays will inevitably succumb to their injury without reaching hospital, leaving a higher proportion of less grave injuries in the delayed group and a higher survival rate. While early presentation was associated with a high mortality it cannot be concluded that delay before surgery is a predictor of outcome as the high early mortality is due to other factors discussed above. We are in agreement with Duane et al. 6 that the complex nature of the operative management for liver trauma renders the mortality high regardless of the choice of procedure. Furthermore any operative procedure used when all else has failed and the patient is extremely unstable, is likely to result in a poor outcome. 6 The surgeon must therefore be familiar with all the techniques including packing, and must tailor the surgical approach to the individual injury. 6,7 A familiarity with the indications, limitations and applications of the various approaches should also be developed. 7 In conclusion therefore shock on admission, high grade of injury, high Injury Severity Score (ISS) and presence of associated organ injury are associated with increased mortality rate and can be regarded as predictors of outcome. Further studies with large numbers are necessary to address the role of injury mechanisms as a predictor of outcome. References 1. Beal SL. Fatal hepatic haemorrhage: an unresolved problem in the management of complex liver injuries. J Trauma 1990;30: Bender JS, Geller RC, Heeran TF, et al. Intra-abdominal sepsis following liver trauma. J Trauma 1989;29: Cogbill TH, Moore EE, Jurcovich GJ, et al. Severe hepatic trauma. A multicentre experience with 1335 liver injuries. J Trauma 1988;28: Coughlin PA, Stringer MD, Lodge JPA, et al. Management of blunt liver trauma in a tertiary referral centre. Br J Surg 2004;91: Degiannis E, Psaras G, Smith MD. Abdominal gunshot wounds current status of selective non-operative management. S Afr J Surg 2004;42: Duane TM, Como JJ, Bochichio GV, Scalea TM. Re-evaluating the management and outcomes of severe blunt liver injury. J Trauma 2004;57: Fabian TC, Croce MA, Stanford GG, et al. Factors affecting morbidity following hepatic trauma. Ann Surg 1991;213: Fang JF, Chen RJ, Lin BC, et al. Blunt hepatic injury: minimal intervention in the policy of treatment. J Trauma 2000;49: Feliciano DV. Surgery for liver trauma. Surg Clin N Am 1989;69: Feliciano DV. Continuing evolution in the approach to severe liver trauma. Ann Surg 1992;216: Feliciano DV, Mattox KL, Jordan GI, et al. Management of 1000 consecutive cases of hepatic trauma ( ). Ann Surg 1986;204: Flint IM, Mays ET, Aaron WS, et al. Selectivity in the management of hepatic trauma. Ann Surg 1977;185: Gilmore D, McSwain NE, Browder JW. Hepatic trauma: to drain or not to drain. J Trauma 1987;27: Gür S, Örsel A, Atahan K, et al. Surgical treatment of liver trauma. Hepatogastroenterol 2003;50: Krige JEJ. Liver fracture and bleeding. Br J Surg 2000;87: Macfarlane R. The management of liver trauma. Postgrad Med J 1985;61: Madiba TE, Haffejee AA, John J. Renal trauma secondary to stab, blunt and firearm injuries a 5-year study. S Afr J Surg 2002;40: Monzon-torres BI, Ortega-Gonzalez M. Penetrating abdominal trauma. S Afr J Surg 2004;42: Moore EE, Shackford SE, Pachter HL, et al. Organ injury scaling: spleen, liver and kidney. J Trauma 1989;29: Muckart DJJ, Abdool-Carrim ATO, King B. Selective conservative management of abdominal gunshot wounds: a prospective study. Br J Surg 1990;77: Muckart DJJ, Meumann C, Botha JBC. The changing pattern of penetrating torso trauma in KwaZulu-Natal a clinical and pathological review. S Afr Med J 1995;85: Mullins RJ, Stone HH, Dunlop WE, Stone PR. Hepatic trauma: evaluation of routine drainage. South Med J 1985;78: Noyes LD, Doyle DJ, McSwain NE. Septic complications associated with the use of peritoneal drains in liver trauma. J Trauma 1998;28: Omoshoro-Jones JAO, Nicol AJ, Navsaria PH, et al. Selective non-operative management of liver gunshot injuries. Br J Surg 2005;92: Pachter HL, Hofsetter SR. The current status of non-operative management of adult blunt hepatic trauma. Am J Surg 1995;169: Parks RW, Chrysos E, Diamond T. Management of liver trauma. Br J Surg 1999;86: Richardson JD. Changes in the management of injuries to the liver and spleen. J Am Coll Surg 2005;2000: Schweizer W, Tanner S, Baer HU, et al. Management of traumatic liver injuries. Br J Surg 1993;80: Strong RW, Lynch SV, Wall DR, Liu CL. Anatomic resection for severe liver trauma. Surgery 1998;123: Trunkey DD. Hepatic trauma: contemporary management. Surg Clin N Am 2004;84: Yates DW. Scoring systems for trauma. Br Med J 1990;301: