Gastroenterol Res

Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access

Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc

Journal website http://www.gastrores.org

Original Article

Volume 3, Number 1, February 2010, pages 9-18

Treatment of Liver Trauma: Operative or Conservative Management

**Table 1.** Distribution of Mortality by Type of Initial Treatment (Operative, Conservative and Failure) and Grade of the Injury
Grade	Operative	Conservative	Failure	Total Mortality
^*Percentage of mortality by initial treatment group and grade of injury
^†Percentage of mortality by grade of injury.
^**Number total of patients by group (operative, conservative and failure)
^#one patient in each group (grade II and V) died in conservative treatment failure
I (n = 23)	5 (21.7)	-	18 (78.3)	-	-	-
II (n = 34)	12 (35.3)	3 (25)	22 (64.7)	2 (9.1)	1 (4.5)#	6 (14.7)
III (n = 56)	22 (39.3)	3 (13.6)	34 (60.7)	-	6 (17.6)	3 (5.3)
IV (n = 19)	8 (42.1)	4 (50)	11 (57.9)	1 (9.1)	4 (36.4)	5 (26.3)
V (n = 11)	9 (81.8)	6 (66.6)	2 (18.2)	1 (50)	2 (100)#	8 (63.6)
Total:	56** (39.2)	16 (28.5)	87** (60.8)	4 (4.5)	13**	22 (15.3)

Table 1. Distribution of Mortality by Type of Initial Treatment (Operative, Conservative and Failure) and Grade of the Injury

Grade

Operative

Conservative

Failure

Total Mortality

N (%)

Mortality*

N (%)

Mortality*

N (%)†

^*Percentage of mortality by initial treatment group and grade of injury

^†Percentage of mortality by grade of injury.

^**Number total of patients by group (operative, conservative and failure)

^#one patient in each group (grade II and V) died in conservative treatment failure

I (n = 23)

5 (21.7)

18 (78.3)

II (n = 34)

12 (35.3)

3 (25)

22 (64.7)

2 (9.1)

1 (4.5)#

6 (14.7)

III (n = 56)

22 (39.3)

3 (13.6)

34 (60.7)

6 (17.6)

3 (5.3)

IV (n = 19)

8 (42.1)

4 (50)

11 (57.9)

1 (9.1)

4 (36.4)

5 (26.3)

V (n = 11)

9 (81.8)

6 (66.6)

2 (18.2)

1 (50)

2 (100)#

8 (63.6)

Total:

56** (39.2)

16 (28.5)

87** (60.8)

4 (4.5)

13**

22 (15.3)

**Table 2.** Summary of Outcome by Treatment Group
	Operative	Conservative†	Total	Failure
^*12 patients died during the first 48 hours.
^†On data analysis of the conservative group, the group of failure of conservative treatment was included.
Morbidity
YES	20 (35.7)	10 (11.5)	30 (20.9)	5 (38.5)
NO	36 (64.3)	77 (88.5)	113 (79.1)	8 (61.5)
Mortality
YES	16 (28.6)*	4 (4.5)	20 (13.9)*	2 (15.4)
NO	40 (71.4)	83 (95.5)	123 (86.1)	11 (84.6)
Stay	20.4 ± 22.3	15.2 ± 12.9	17.3 ± 17.1	16.1 ± 9.5

Table 2. Summary of Outcome by Treatment Group

Operative

Conservative†

Total

Failure

N=56 (%)

N=87 (%)

N=143 (%)

N=13 (%)

^*12 patients died during the first 48 hours.

^†On data analysis of the conservative group, the group of failure of conservative treatment was included.

Morbidity

YES

20 (35.7)

10 (11.5)

30 (20.9)

5 (38.5)

36 (64.3)

77 (88.5)

113 (79.1)

8 (61.5)

Mortality

YES

16 (28.6)*

4 (4.5)

20 (13.9)*

2 (15.4)

40 (71.4)

83 (95.5)

123 (86.1)

11 (84.6)

Stay

20.4 ± 22.3

15.2 ± 12.9

17.3 ± 17.1

16.1 ± 9.5

**Table 3.** Risk factors for treatment by Uni-multivariante Analysis
Univariante Analysis
^*Values expressed as mean ± standard deviation. Abbreviations: ISS: injury severity score; RBC: red blood cell; FFP: fresh frozen plasma; PLT: Platelet, OR: odds ratio; CI: confidence interval.
Variable	Final conservative management (n =74)	Final surgical treatment (n = 69)	P
Initial injury grade			< 0.0001
No injury	1	32
I	17	4
II	22	5
III	27	20
IV	7	6
V	0	2
Final injury grade			< 0.0001
I	18	5
II	21	13
III	28	28
IV	7	12
V	0	11
Morbidity			< 0.0001
Yes	5	25
No	69	44
Mortality			< 0.0001
Yes	2	18
No	72	51
Hepatic Mortality			< 0.0001
Yes	1	13
No	73	56
ISS *	23.1 ± 15	30.1 ± 13.1	< 0.0001
RBC *	5.2 ± 7.5	11.2 ± 10.6	0.002
FFP *	0.4 ± 1.6	2.6 ± 3.1	< 0.0001
PLT *	0.02 ± 0.1	0.5 ± 1.1	< 0.0001
^*Values expressed as mean ± standard deviation. Abbreviations: ISS: injury severity score; RBC: red blood cell; FFP: fresh frozen plasma; PLT: Platelet, OR: odds ratio; CI: confidence interval.
Variable	p	OR	95% CI
Inicial grade injury	< 0.0001	3.8	2.05	7.08
Final grade injury	< 0.0001	0.2	0.08	0.4

Table 3. Risk factors for treatment by Uni-multivariante Analysis

Univariante Analysis

^*Values expressed as mean ± standard deviation. Abbreviations: ISS: injury severity score; RBC: red blood cell; FFP: fresh frozen plasma; PLT: Platelet, OR: odds ratio; CI: confidence interval.

Variable

Final conservative management (n =74)

Final surgical treatment (n = 69)

Initial injury grade

< 0.0001

No injury

III

Final injury grade

< 0.0001

III

Morbidity

< 0.0001

Yes

Mortality

< 0.0001

Yes

Hepatic Mortality

< 0.0001

Yes

ISS *

23.1 ± 15

30.1 ± 13.1

< 0.0001

RBC *

5.2 ± 7.5

11.2 ± 10.6

0.002

FFP *

0.4 ± 1.6

2.6 ± 3.1

< 0.0001

PLT *

0.02 ± 0.1

0.5 ± 1.1

< 0.0001

Multivariante Analysis (Multiple Logistic Regression Model)

^*Values expressed as mean ± standard deviation. Abbreviations: ISS: injury severity score; RBC: red blood cell; FFP: fresh frozen plasma; PLT: Platelet, OR: odds ratio; CI: confidence interval.

Variable

95% CI

Inicial grade injury

< 0.0001

3.8

2.05

7.08

Final grade injury

< 0.0001

0.2

0.08

0.4

**Table 4.** Comparison of Patients With Low and High Injury Grade
Multivariante Analysis (Multiple Logistic Regression Model)
^*Values expressed as mean ± standard desviation
Abbreviations: RBC: red blood cell; FFP: fresh frozen plasma; PLT: Platelet, OR: odds ratio; CI: confidence interval
Univariante Analysis
Variable	Grade I-II-III	Grade IV-V	P
Hemodynamic instability			0.008
Yes	23	19
No	23	4
Vascular injury			0.001
Yes	0	7
No	46	16
Surgical technique			< 0.0001
Exploratory laparotomy	13	1
Packing	0	8
Vascular suture	20	5
Electrocoagulation	6	0
Hepatic resection	6	9
Pringle			< 0.0001
Yes	4	15
No	42	8
Mortality			0.005
Yes	7	11
No	39	12
Hepatic mortality			< 0.0001
Yes	3	10
No	43	13
Hemoperitoneum*	1377 ± 897	2939 ± 1351	< 0.0001
Lesion size *	5.1 ± 2.2	9 ± 2.8	< 0.0001
RBC *	6.2 ± 6.5	18.7 ± 12.3	< 0.0001
FFP *	.1.1 ± 2.3	3.03 ± 3	< 0.0001
PLT *	0.07 ± 0.3	1.1 ± 1.9	< 0.0001
Hospital Stay	18.9 ± 18.1	11.4 ± 10.7	0.003
^*Values expressed as mean ± standard desviation
Abbreviations: RBC: red blood cell; FFP: fresh frozen plasma; PLT: Platelet, OR: odds ratio; CI: confidence interval
Variable	p	OR	95 % CI
Hemoperitoneum	0.02	1	1	1
Lesion size	0.013	2.8	1.2	6.4

Table 4. Comparison of Patients With Low and High Injury Grade

^*Values expressed as mean ± standard desviation

Abbreviations: RBC: red blood cell; FFP: fresh frozen plasma; PLT: Platelet, OR: odds ratio; CI: confidence interval

Univariante Analysis

Variable

Grade I-II-III

Grade IV-V

Hemodynamic instability

0.008

Yes

Vascular injury

0.001

Yes

Surgical technique

< 0.0001

Exploratory laparotomy

Packing

Vascular suture

Electrocoagulation

Hepatic resection

Pringle

< 0.0001

Yes

Mortality

0.005

Yes

Hepatic mortality

< 0.0001

Yes

Hemoperitoneum*

1377 ± 897

2939 ± 1351

< 0.0001

Lesion size *

5.1 ± 2.2

9 ± 2.8

< 0.0001

RBC *

6.2 ± 6.5

18.7 ± 12.3

< 0.0001

FFP *

.1.1 ± 2.3

3.03 ± 3

< 0.0001

PLT *

0.07 ± 0.3

1.1 ± 1.9

< 0.0001

Hospital Stay

18.9 ± 18.1

11.4 ± 10.7

0.003

Multivariante Analysis (Multiple Logistic Regression Model)

^*Values expressed as mean ± standard desviation

Abbreviations: RBC: red blood cell; FFP: fresh frozen plasma; PLT: Platelet, OR: odds ratio; CI: confidence interval

Variable

95 % CI

Hemoperitoneum

0.02

Lesion size

0.013

2.8

1.2

6.4

**Table 5.** Comparison of Patients in Two Periods
Variable	1992-1999 N = 88 (%)	2000-2008 N = 55 (%)	P
^*Values expressed as mean ± standard desviation
Abbreviations: ISS: injury severity score; DPL: diagnostic peritoneal lavage; RBC: red blood cell; FFP: fresh frozen plasma; PLT: Platelet
Age (yrs)*	30.8 ± 13	33.9 ± 17.1	0.441
Male sex	68 (77.3)	46 (83.6)	0.242
Hospital stay*	15.1 ± 13.4	20.8 ± 21.3	0.071
ISS*	25.8 ± 12.2	25.8 ± 11.8	0.896
Etiology			0.038
Traffic accidents	60 (68.2)	45 (81.8)
Stab wounds	14 (15.9)	1 (1.8)
Falls	10 (11.4)	6 (10.9)
Firearms	3 (3.4)	0 (0)
Others	1 (1.1)	3 (5.5)
Diagnostic technique			< 0.0001
No	8 (9.1)	0 (0)
Ultrasound	72 (81.8)	16 (29.1)
TC	4 (4.55)	39 (70.9)
DPL*	4 (4.55)	0 (0)
Injury grade			0.022
I	8 (9.1)	15 (27.3)
II	20 (22.7)	14 (25.5)
III	40 (45.5)	16 (29.1)
IV	11 (12.5)	8 (14.5)
V	9 (10.2)	2 (3.6)
Abdominal injuries			0.092
Yes	32 (36.4)	27 (49.1)
No	56 (63.6)	28 (50.9)
Extrabdominal injuries			0.041
Yes	61 (69.3)	9 (16.4)
No	27 (30.7)	46 (83.6)
Hemodynamic inestability	31 (35.2)	15 (27.3)	0.211
Treatment			0.077
Nonoperative management	49 (55.7)	38 (69.1)
Surgery	39 (44.3)	17 (30.9)
Surgical technique			0.087
Exploratory laparotomy	9 (10.2)	5 (9.1)
Packing	3 (3.4)	5 (9.1)
Vascular suture	21 (23.8)	4 (7.3)
Electrocoagulation	5 (5.7)	1 (1.8)
Hepatic resection	6 (6.8)	9 (16.4)
Failure of conservative treatment	8 (16.3)	5 (13.1)	0.482
Morbidity			0.015
Yes	24 (27.3)	6 (10.9)
No	64 (72.7)	49 (89.1)
Mortality			0.532
Yes	12 (13.6)	8 (14.5)
No	76 (86.4)	47 (85.5)
Hepatic Mortality			0.534
Yes	9 (10.2)	5 (9.1)
No	79 (89.8)	50 (90.9)
RBC *	7.6 ± 8.2	13.7 ± 12.3	0.033
FFP *	1.3 ± 2.6	2.4 ± 2.6	0.003
PLT *	0.3 ± 1.9	0.8 ± 0.9	< 0.0001

Table 5. Comparison of Patients in Two Periods

Variable

1992-1999
N = 88 (%)

2000-2008
N = 55 (%)

^*Values expressed as mean ± standard desviation

Abbreviations: ISS: injury severity score; DPL: diagnostic peritoneal lavage; RBC: red blood cell; FFP: fresh frozen plasma; PLT: Platelet

Age (yrs)*

30.8 ± 13

33.9 ± 17.1

0.441

Male sex

68 (77.3)

46 (83.6)

0.242

Hospital stay*

15.1 ± 13.4

20.8 ± 21.3

0.071

ISS*

25.8 ± 12.2

25.8 ± 11.8

0.896

Etiology

0.038

Traffic accidents

60 (68.2)

45 (81.8)

Stab wounds

14 (15.9)

1 (1.8)

Falls

10 (11.4)

6 (10.9)

Firearms

3 (3.4)

0 (0)

Others

1 (1.1)

3 (5.5)

Diagnostic technique

< 0.0001

8 (9.1)

0 (0)

Ultrasound

72 (81.8)

16 (29.1)

4 (4.55)

39 (70.9)

DPL*

4 (4.55)

0 (0)

Injury grade

0.022

8 (9.1)

15 (27.3)

20 (22.7)

14 (25.5)

III

40 (45.5)

16 (29.1)

11 (12.5)

8 (14.5)

9 (10.2)

2 (3.6)

Abdominal injuries

0.092

Yes

32 (36.4)

27 (49.1)

56 (63.6)

28 (50.9)

Extrabdominal injuries

0.041

Yes

61 (69.3)

9 (16.4)

27 (30.7)

46 (83.6)

Hemodynamic inestability

31 (35.2)

15 (27.3)

0.211

Treatment

0.077

Nonoperative management

49 (55.7)

38 (69.1)

Surgery

39 (44.3)

17 (30.9)

Surgical technique

0.087

Exploratory laparotomy

9 (10.2)

5 (9.1)

Packing

3 (3.4)

5 (9.1)

Vascular suture

21 (23.8)

4 (7.3)

Electrocoagulation

5 (5.7)

1 (1.8)

Hepatic resection

6 (6.8)

9 (16.4)

Failure of conservative treatment

8 (16.3)

5 (13.1)

0.482

Morbidity

0.015

Yes

24 (27.3)

6 (10.9)

64 (72.7)

49 (89.1)

Mortality

0.532

Yes

12 (13.6)

8 (14.5)

76 (86.4)

47 (85.5)

Hepatic Mortality

0.534

Yes

9 (10.2)

5 (9.1)

79 (89.8)

50 (90.9)

RBC *

7.6 ± 8.2

13.7 ± 12.3

0.033

FFP *

1.3 ± 2.6

2.4 ± 2.6

0.003

PLT *

0.3 ± 1.9

0.8 ± 0.9

< 0.0001