Multidisciplinary Approach for the Management of Complex Hepatic Injuries AAST-OIS Grades IV—V: A Prospective Study

Abstract

Background: Complex hepatic injuries grades IV—V are highly lethal. The objective of this study is to assess the multidisciplinary approach for their management and to evaluate if survival could be improved with this approach. Study Design: Prospective 54-month study of all patients sustaining hepatic injuries grades IV—V managed operatively at a Level I Trauma Center. Main outcome measure: survival. Statistical analysis: univariate and stepwise logistic regression. Results: Seventy-five patients sustained penetrating (47/63%) and blunt (28/37%) injuries. Seven (9%) patients underwent emergency department thoracotomy with a mortality of 100%. Out of the 75 patients, 52 (69%) sustained grade IV, and 23 (31%) grade V. The estimated blood loss was 3,539±-3,040 ml. The overall survival was 69%, adjusted survival excluding patients requiring emergency department thoracotomy was 76%. Survival stratified to injury grade: grade IV 42/52–81%, grade V 10/23–43%. Mortality grade IV versus V injuries (p <0.002; RR 2.94; 95% CI 1.52–5.70). Risk factors for mortality: packed red blood cells transfused in operating room (p=0.024), estimated blood loss (p<0.001), dysryhthmia (p<0.0001), acidosis (p=0.051), hypothermia (p=0.04). The benefit of angiography and angioembolization indicated: 12% mortality (2/17) among those that received it versus a 36% mortality (21/58) among those that did not (p=0.074; RR 0.32; 95% CI 0.08–1.25). Stepwise logistic regression identified as significant independent predictors of outcome: estimated blood loss (p=0.0017; RR 1.24; 95% CI 1.08–1.41) and number of packed red blood cells transfused in the operating room (p=0.0358; RR 1.16; 95% CI 1.01–1.34). Conclusions: The multidisciplinary approach to the management of these severe grades of injuries appears to improve survival in these highly lethal injuries. A prospective multi-institutional study is needed to validate this approach.