NESS - Successful Non-operative Management Of The Most Severe Blunt Liver Injuries: A Multicenter Study Of The Research Consortium Of New England Centers For Trauma (ReCONECT)

Successful Non-operative Management Of The Most Severe Blunt Liver Injuries: A Multicenter Study Of The Research Consortium Of New England Centers For Trauma (ReCONECT)
*Gwendolyn M. van der Wilden¹, George C Velmahos¹, Timothy Emhoff², *Samielle Brancato³, *Charles Adams⁴, *Georgios Georgakis⁵, Lenworth Jacobs⁵, Ronald Gross⁶, Suresh Agarwal⁷, Peter Burke⁷, *Adrian Maung⁸, *Dirk Johnson⁸, Robert Winchell⁹, *Hasan Alam¹, *Jonathan Gates¹⁰, *Walter Cholewczynski¹¹, Michael Rosenblatt¹², *Yuchiao Chang¹
¹Massachusetts General Hospital, Boston, MA;²University of Massachusetts Medical Center, Worcester, MA;³Brown University /Rhode Island Hospital, Providence, RI;⁴Brown University/Rhode Island Hospital, Providence, RI;⁵Hartford Hospital, Hartford, CT;⁶Baystate Medical Center, Springfield, MA;⁷Boston Medical Center, Boston, MA;⁸Yale New Haven Hospital, New Haven, CT;⁹Maine Medical Center, Portland, ME;¹⁰Brigham and Womens Hospital, Boston, MA;¹¹Bridgeport Hospital, Bridgeport, CT;¹²Lahey Clinic, Burlington, MA

Objective: To determine the rate and predictors of failure of non-operative management (NOM) in grade IV and V blunt liver injury (BLI).
Design: Retrospective case series.
Setting: Ten trauma centers in New England
Patients: A total of 393 adult patients with a grade IV or V BLI who where admitted between January 1, 2000, and January 31, 2010.
Main Outcome Measures: Failure of NOM (f-NOM), defined as the need for a delayed operation.
Results: A total of 131 patients (33%) were operated on immediately, typically because of hemodynamic instability. Of the remaining 262 patients who were offered a trial of NOM, treatment failed in 23 patients (9%) but only in 17 (6%) because of the liver (ongoing bleeding in 7, biliary peritonitis in 10). Multivariate analysis identified 2 independent predictors of f-NOM: Systolic blood pressure on admission ≤ 100 mmHg and other abdominal organ injury. With both factors present f-NOM happened in 23% of the patients; with both factors absent in 4%. None of the f-NOM patients suffered life-threatening events because of f-NOM, and the mortality rate was similar between successful NOM (5%) and f-NOM patients (9%, p = 0.52). Of the patients with successful NOM, liver-specific complications developed in 10% and were managed definitively without major sequelae.
Conclusions: NOM can be offered safely even in the most severe BLI. Only 6% of NOM patients required a delayed operation because of liver-related issues and typically not for ongoing bleeding. Nearly two out of three severe BLI patients were discharged without a laparotomy.

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