Non-operative management versus operative management in high-grade blunt hepatic injury

Abstract

ABSTRACT: BackgroundSurgery usedtobe the treatment of choice in cases ofblunt hepatic injury,butthis approach gradually changedoverthe lasttwodecades asincreasing non-operative management(NOM) of splenic injury led to its use for hepatic injury. The improvementin critical care monitoringand computed tomographic scanning, as well as the more frequent use of interventional radiology techniques, has helped to bring aboutthis change to non-operative management. Liver trauma ranges from a small capsular tear, without parenchymal laceration, to massiveparenchymal injury with major hepatic vein/retrohepatic vena cava lesions. In 1994, the Organ Injury Scaling Committee of the AmericanAssociation for the Surgery of Trauma (AAST) revised the Hepatic Injury Scale to have a range from grade I to VI. Minor injuries (grade Ior II) are the most frequent liver injuries (80% to 90% of all cases); severe injuries are grade III-V lesions; grade VI lesions are frequentlyincompatible with survival. In the medical literature, the majority of patients who have undergone NOM have low-grade liver injuries. Thesafety of NOM in high-grade liver lesions, AAST grade IV and V, remains a subject of debate as a high incidence of liver and collateral extraabdominal complications are still described.ObjectivesTo assess the eKects of non-operative management compared to operative management in high-grade (grade III-V) blunt hepatic injury.Search methodsThe search for studies was run on 14 April 2014. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library,Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), EmbaseClassic+Embase (Ovid), PubMed, ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), clinical trials registries, conference proceedings, andwe screened reference lists.Selection criteriaAll randomised trials that compare non-operative management versus operative management in high-grade blunt hepatic injury.Data collection and analysisTwo authors independently applied the selection criteria to relevant study reports. We used standard methodological procedures asdefined by the Cochrane Collaboration.Main resultsWe were unable to find any randomised controlled trials of non-operative management versus operative management in high-grade blunthepatic injury.Authors' conclusionsIn order to further explore the preliminary findings provided by animal models and observational clinical studies that suggests there maybe a beneficial eKect of non-operative management versus operative management in high-grade blunt hepatic injury, large, high qualityrandomised trials are needed