Demographics and Liver trauma Profile (Table 1)
Out of the 16047 trauma patients in the TITCO registry, 1134 (7.1%) patients suffered abdominal trauma, of which 368 (32.5%) had liver trauma. Age range varied between 2 to 80 years with the mean age of 26 years with 328 (89%) being males. The main mechanism of injury was road traffic injury (RTI) accounting for 57% of the patients. Among the RTI, the largest group were motorcyclist injuries (30.48%). More than half the patients were transferred patients from other referral centres (58.2 %). 91.5% of the cohort with liver injuries had blunt injuries. 88 (24.5%) patients presented on arrival with SBP of ≤ 90 mmHg.
Most of liver trauma patients belonged to WSES grades I-III grades (75%). 9 patients could not be classified as WSES grade as their systolic blood pressure was missing. The most common intra-abdominal injuries associated with liver trauma were spleen (17%) and kidney (14%) (Fig 1). 85 patients had an associated TBI of which 38 (44.7%) had moderate to severe TBI based on GCS.
Management & Outcome in liver injury (Fig 2)
Diagnostic modalities
Focused Assessment Sonography for Trauma (FAST) was done in 345 patients (93.8%) and a CT scan was done in 310 (84.24%) patients included in the study.
Overall mortality
Overall, 30 day in-hospital mortality rate in this cohort of liver injury with/without other injuries was 16.6% (61 out of 368).
Non-operative management
Out of 368 patients with liver trauma and other associated injuries, 262 (71.2%) patients had NOM. The NOM as per various WSES grade of liver injury is shown in Table 2. Among these, 236 patients (90.1%) were successfully managed (survived) (Fig 2). As per the WSES grades of injury the NOM success rates were, grade 1- 90.2%, grade 2 - 90.6%, grade 3 - 93.1% and grade 4 - 81.6%.
Death occurred in 26 patients (9.9%). 4 of them died within 24 hrs of arrival, 11 died between 24 hrs to seven days after arrival and 11 died after 7 days from arrival (time data of one patient was missing). Of those who died, 7 patients had severe TBI (<8 GCS and intracranial injuries), 5 patients had mild TBI (>12 GCS), 2 patients had hypotension and TBI, 5 patients had hypotension without TBI and seven of those who died had no hypotension on arrival and no TBI.
Operative management
106 patients underwent emergency laparotomy which included various procedures such as packing both perihepatic and intraparenchymal haemostatic packs, direct suture ligation of lacerations, anatomic or nonanatomic segmental hepatectomy for liver injury, splenectomy, nephrectomy and bowel suturing for associated injuries. Of the 106 laparotomies, 43(40.5%) were for liver and/or other intra-abdominal organs, 45(42.5%) were for other intra-abdominal organs only(non-liver reasons) and 18(17.0%) were for cause unspecified (Table 2). 22 (20.8%) patients with penetrating injury underwent OM. Of these 22 penetrating injuries 3 patients died. Among the operated 106 patients, 13 patients (12%) were taken to operating room within 1 hour of admission while the rest underwent surgery within 24 hours of admission. 46 (43.4%) patients did not get a CT scan done before surgery.
As per the WSES grades of injury, of those who underwent OM; 25 (23.6%) had Grade 1, 32 (30.9%) were Grade 2, 12 (11.3%) were Grade 3 and 33 (37.7%) Grade 4 liver injuries. Of the 69 Grade I-III liver injury patients, 24 were operated for liver and/or other associated intra-abdominal organ injury, of which 8 had penetrating injury. The rest 45 were operated for other intra-abdominal organ injury (non-liver) or for unspecified reasons (table 2).
The operative management cohort differed from the non-operative cohort significantly in their mean SBP 99(26.2%) vs. 111(21.0%), proportion of penetrating injury 21.7% vs. 4.4%, heart rate 103 (2.4) vs. 97 (18.5)] & ISS 14(9-22) vs. 17(12-22)]. Univariate analysis showed no difference between these two cohorts in their age and GCS (Table 3). The injury severity score (ISS) in the NOM group was higher, compared to those who underwent laparotomy. One-third of the patients who underwent laparotomy died (35 out of 106). The causes of death in these patients cannot purely be assigned to liver trauma as they had multiple injuries. 14 of them died within 24 hours of arrival, 16 died between 24 hours to 7 days after arrival and 8 died after 7 days (time data of one patient was missing).