Buci et al.

World Journal of Emergency Surgery (2017) 12:24

DOI 10.1186/s13017-017-0135-4

RESEARCH ARTICLE Open Access

The rate of success of the conservative

management of liver trauma in a
developing country
S. Buci1* , M. Torba1, A. Gjata2, I. Kajo3, Gj. Bushi1 and K. Kagjini1

Abstract
Background: The conservative treatment of liver trauma has made important progress over the last 10 years at the
Trauma University Hospital in Tirana, Albania. The percentage of success was 58.7%. The aims of this study were to
analyze the conservative treatment of liver trauma and to compare the results with those in the literature.
Methods: This study was conducted prospectively from January 2009 to December 2012. We analyzed 173 patients
admitted to our hospital with liver trauma. Liver injuries were evaluated according to the American Association for
the Surgery of Trauma and the World Society of Emergency Surgery classification, while the anatomic gravity of the
associated injuries was defined using the Injury Severity Score system. The potential mortality was estimated with
the Revised Trauma Score.
Results: Out of the 173 patients with liver trauma, 83.2% were male. The main cause of liver trauma was motor
vehicle crashes (50.9%). Blunt trauma was the cause of liver injury in 129 cases (74.6%), and penetrating trauma
occurred in 44 cases (25.4%). Initially, the decision was to manage 88 cases (50.9%) via the conservative approach.
Of these, 73 cases (42.2%) were successfully treated with conservative treatment, while in 15 cases (17.2%), this
approach failed. The success rate of conservative treatment by grade of injuries was as follows: grade I (38.4%),
grade II (30.1%), grade III (28.8%), and grade IV (2.7%). The likelihood of the success of conservative treatment had a
significant correlation with the grade of the liver injury (p < 0.00001), associated intra-abdominal injuries (p = 0.00051),
and complications (z = 2.3169, p = 0.02051). The overall mortality rate of liver trauma was 13.2%.
Conclusions: The likelihood of success in using conservative treatment had a significant correlation with the grade of
liver injury and associated intra-abdominal injuries. The limited hospital resources and low level of consensus on
conservative treatment had a negative impact on the level of success.
Keywords: Liver trauma, Grade of injuries, Conservative treatment, Success

Background injury depends on the hemodynamic status of the trau-

Currently, the conservative management of liver trauma matized patients and the associated injuries.
is considered the “Gold Standard.” More than 80% of pa- The World Society of Emergency Surgery (WSES) liver
tients with non-severe liver injuries are treated success- trauma classification considers not only the anatomic
fully without surgery [1–4]. Nance and Cohn support American Association for the Surgery of Trauma (AAST)
the use of conservative treatment in hemodynamically classification but also, more importantly, the hemodynamic
stable patients who do not exhibit signs of peritoneal ir- status and the associated injuries [6] (Table 1).
ritation [5]. In Albania, the conservative treatment of The abdominal echography procedure is essential in
liver trauma has made important progress over the last the emergency department for patients with hemodynamic
decade. The diagnostic and therapeutic strategy for liver instability. Currently, computerized tomography is the
preferred method to evaluate blunt liver trauma in
* Correspondence: buciskender@gmail.com
hemodynamically stable patients or in patients who have
1
Service of General Surgery, Trauma University Hospital, Tirana, Albania been stabilized after an initial fluid resuscitation [7].
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Buci et al. World Journal of Emergency Surgery (2017) 12:24 Page 2 of 7

Table 1 WSES liver trauma classification

WSES grade Blunt/penetrating AAST Hemodynamic CT scan First-line treatment
(stab/guns)
Minor WSES grade I B/P I–II Stable
SW/GSW
Moderate WSES grade II B/P III Stable Yes NOM*
SW/GSW Local Exploration in SW Serial Clinical/Laboratory/
Radiological Evaluation
Severe WSES grade III B/P IV–V Stable
SW/GSW
WSES grade IV B/P I–VI Unstable No OM
SW/GSW
SW stab wound, GSW gunshot wound, OM operative management, * NOM non-operative management

The conservative treatment of liver injury can be initi- is treated with an intervention [Yes = 1; No = 0]); ISS
ated when there is a possibility of monitoring the trau- (anatomical; the higher the number, the more severe the
matized patient clinically, biologically, and radiologically injury); and RTS (psychological; the lower the number,
in the correct manner and when there is a close collab- the more severe the condition of the patient).
oration between surgeons, intensivists, and radiologists. Treatment for each patient was chosen based on the
The failure of conservative treatment occurs in 15% of set of indicators for laparotomy and under the consider-
cases, often in patients with extrahepatic injuries or ation for conservative treatment. The indicators were (1)
white laparotomy [8, 9]. hemodynamic stability, (2) presence/absence of periton-
The objectives of this study were to analyze the con- eal irritation signs, (3) identification and evaluation of
servative management of liver trauma, the likelihood for CT scan grade of liver injuries, (4) hemoperitoneum
success, and the causes of failure and to compare the re- <500 ml, and (5) the absence of injury to cavitare organs
sults with those in the literature. [10, 11], based on the algorithm for the non-operative
management of blunt hepatic trauma [12].
Methods Based on these criteria, patients were divided into two
This is a prospective study performed from January 2009 main groups: group A (including 88 patients who met
to December 2012. We analyzed 173 patients with hepa- the conditions for conservative treatment) and group B
tobiliary trauma who were admitted to the Trauma (including 85 patients who had indications for immedi-
University Hospital, Tirana, Albania. Liver injuries were ate laparotomy).
evaluated according to AAST and WSES classifications
via ultrasonography and CT scan. The anatomic gravity
of the associated injuries was defined using the Injury Results
Severity Score (ISS) system. The potential mortality was The average age of patients with hepatic trauma was
estimated using the Revised Trauma Score (RTS). A 23.4 years old (ranging from 6 to 75), including 83.2%
simple ordinary least square regression (OLS) of several male and 16.8% female patients.
factors on the success of conservative treatment of In our study, blunt trauma was the cause of liver in-
trauma injury patient reveals the results of the following jury in 129 cases (74.6%), while penetrating trauma
table. For this analysis, the variables are Surviv (whether occurred in 44 cases (25.4%).
the patient survives the treatment of the injury [No = 0; The causes of hepatic trauma were motor vehicle
Yes = 1]); Age (age of the patient [6–15 years old = 1; crashes in 88 cases (50.9%), falls from height in 32 cases
16–25 years old = 2; 26–35 years old = 3; 36–45 years (18.4%), gunshot wounds in 24 cases (13.8%), sharp tools
old = 4; 46–55 years old = 5; 56–65 years old = 6; 66– in 19 cases (11%), direct blows in 8 cases (4.7%), iatro-
75 years old = 7]); Gender (gender [Male = 1; Female = genic in 1 case (0.6%), and hepatic trauma from an elec-
0]); Cinjur (if only the liver is injured, then the value is trical arc in 1 case (0.6%) (Tables 2 and 3).
0. For all other combinations, like the liver and head and Alanine aminotransferase (ALT) >100 U/l and aspar-
the liver and thorax, the variable takes the value of 1); tate aminotransferase (AST) >200 U/l were found in 96
Grade (grade [the six-grade scale standard is used: patients (55.5%), and ALT >1000 U/l and AST >1100 U/
Minor = 1; Moderate = 2; Serious = 3; Severe = 4; Critical l were found in 2 patients (1.6%).
= 5; Un-survivable = 6]); Conserv (conservative treat- Diagnostic peritoneal lavage (DPL) was used in10 pa-
ment of the patient [Yes = 1; No = 0]); Interv (the patient tients (5.6%). In 6 patients, we found intestine leak.
Buci et al. World Journal of Emergency Surgery (2017) 12:24 Page 3 of 7

Table 2 Hemodynamic status Table 4 Hepatic injuries according to AAST grade

Initial hemodynamic status No. of patients Percentage Grade Number of cases Percentage
Hemodynamic instability 47 27.1 I 36 20.8
Stabilized after intravenous 84 48.6 II 60 34.7
liquid administration
III 47 27.2
Hemodynamic stability 42 24.3
IV 21 12.1
V 8 4.6
In our study, 62 patients (35.9%) were transfused with VI 1 0.6
1 unit of blood, 41 (23.8%) were transfused with 2 units,
30 (17.9%) were transfused with 3 units, 22 (12.8%) were was performed in 6 patients (7%). Extrahepatic injuries
transfused with 4 units, and 17 (9.6%) were transfused included the stomach (n = 10, 12.3%), the small intestine
with more than 4 units (Table 4). and duodenum (n = 12, 14.8%), the large intestine and
The injury frequencies, according to the Couinaud rectum (n = 9, 11.1%), the spleen (n = 16, 19.7%), the kid-
segment, were as follows: I segment (n = 8) 2.5%, II seg- neys (n = 12, 14.8%), the pancreas (n = 4, 4.9%), the dia-
ment (n = 10) 3.1%, III segment (n = 16) 5%, IV segment phragm (n = 35, 43.2%), the intra-abdominal esophagus
(n = 32) 10%, V segment (n = 49) 15.3%, VI segment (n = (n = 1, 1.2%), the cholecyst (n = 3, 3.7%), and the urinary
76) 23.8%, VII segment (n = 65) 20.3%, and VIII segment bladder (n = 2, 2.5%).
(n = 64) 20%. We observed that 10.9% of the patients who were
The frequency of liver injury according to the WSES treated in a conservative manner had an ISS of ≥20. We
were WSES grade I (n = 65) 37.6%, WSES grade II (n = also observed that in this group of patients, 86.3% had
55) 31.8%, WSES grade III (n = 6) 3.5%, and WSES grade an RTS of >5 (Tables 8, 9, 10, and 11).
IV (n = 47) 27.1%. The chances of successful conservative treatment sig-
Isolated hepatic injuries were detected in 45 cases nificantly depend on the grade of liver injury (p <
(26.1%), and combined hepatic injuries were present in 0.00001). There is also a statistically significant connec-
128 cases (73.9%). tion between the successful conservative treatment of
Hepatic injuries were associated with intra-abdominal liver trauma and a combination of injuries with other or-
hollow organ injuries in 33 cases (19.1%) and with par- gans (p value = 0.00051) and complications (z = 2.3169,
enchymal injuries in 31 cases (17.9%) (Table 5). p = 0.02051) (Table 12).
Hepatic injuries were associated with extra-abdominal The OLS shows that the patient age, gender, combined
injuries, including the head in 27 cases (15.6%), the injury, and grade of injury (anatomical, physiological,
thorax and diaphragm in 80 cases (46.2%), the heart in 2 and locational) account for more than 30% of the vari-
cases (1.2%), the vertebral column in 3 cases (1.7%), pel- ation in the success of conservative treatment (as seen
vic fracture in 12 cases (6.9%), and limb fractures in 19 with an adjusted R-squared = 0.319). From the variables
cases (11%) (Tables 6 and 7). under consideration, it is clear that patient age, combin-
In group A (conservative treatment of 88 patients), 73 ation of injuries with other organs besides the liver,
patients (42.2%) benefitted from successful conservative
treatment. Unsuccessful conservative treatment due to Table 5 The mechanism of trauma and associated abdominal
further complications was seen in 15 patients (17.2%). In injuries
patients with isolated liver injuries, conservative treat- Organ Blunt Penetrating Total Percentage
trauma trauma
ment was successful in 27 cases (58.7%).
Spleen 14 2 16 9.2
In group B, 100 patients underwent laparotomy. An
immediate laparotomy was performed in 85 patients Kidneys 9 3 12 6.9
(49.1%), a laparotomy for hepatic injury was performed Pancreas 2 2 4 2.3
in 30 patients (30%), laparotomy for extrahepatic injury Stomach 3 7 10 5.8
was performed in 70 patients (70%), perihepatic packing Small intestine + 3 9 12 6.9
was performed in 10 patients (11.7%), and relaparotomy duodenum
Large intestine + 3 6 9 5.2
Table 3 Hematocrit level (at the time of arrival in the ER) rectum
Initial hematocrit level No. of patients Percentage Diaphragm 8 27 35 20.2
Up to 37 124 71.7 Esophagus 0 1 1 0.6
37-30 34 19.7 Urinary bladder 1 0 2 1.2
Under 30 15 8.6 Total 43 57 100 58.3
Buci et al. World Journal of Emergency Surgery (2017) 12:24 Page 4 of 7

Table 6 Success of conservative management according to Table 8 The causes of failure of conservative treatment
AAST grade Complications No. of patients Percentage
Grade Number of cases Percentage Secondary hemorrhage 3 3.4
I 28 38.4 Biliary peritonitis 2 2.3
II 22 30.1 Intrahepatic biloma 1 1.1
III 21 28.8 Extrahepatic biloma 2 2.3
IV 2 2.7 Hollow organ injuries 2 2.3
V 0 0 Liver compartment syndrome 1 1.1
VI 0 0 Gangrenous cholecystitis 2 2.3
Peritoneal inflammatory syndrome 2 2.3
grade of injury, and RTS (psychological trauma) are sta-
Total 15 17.2
tistically important. This is verifiable from the above
table that presents both the p values and the t values.
The overall mortality rate of liver trauma was 13.2%. channels, the perihepatic space, and the Douglas pouch)
is a significant risk factor for the failure of conservative
Discussion treatment [19]. Due to limited resources for transfusion
Our study demonstrated that liver injuries occurred in in our hospital, we interrupted conservative treatment in
17% of patients with abdominal trauma. Shanmuganathan patients who had a considerable need for transfusion
et al. have reported that liver injuries occurred in 20% of and when the amount of hemoperitoneum was deter-
patients with blunt abdominal trauma [13]. We found that mined to be progressively increasing.
male to female ratio was 5:1. Beel et al. found that the From group A of 88 patients selected for conservative
male to female ratio varies from 15:1 [14]. Approximately management, 15 patients showed complications that ne-
15–20 years ago, all traumatic liver injuries were treated cessitated surgery. Group B consisted of 85 patients who
surgically, but in 50–80% of cases, no active bleeding was underwent immediate laporatomy due to the following
found [15, 16]. We also found liver injuries with no active indications: hemodynamic instability, associated intra-
bleeding during laparotomy for associated injuries. abdominal injuries, and penetrating trauma. It is worth
In our study, the hemodynamic status was the main emphasizing that a case with penetrating liver trauma
criterion in determining the therapeutic approach. Ap- caused by hunting rifle wounds was managed conserva-
proximately 85% of patients with blunt liver trauma are tively. Ten patients underwent perihepatic packing; of
hemodynamically stable or stabilize after receiving intra- these, a second laparotomy was performed in 6 patients
venous liquids [17], which corresponds with the findings and 4 patients did not survive.
in our study. Richardson et al. commented that many In our study, we found that gunshot wounds and
experienced surgeons in trauma surgery apply surgical wounds caused by sharp tools had an incidence of
treatment in hemodynamically stable patients and they 24.8%.
have concluded that conservative treatment has a posi- This percentage was significant and contributed to a
tive impact on patient survival [18]. In hemodynamically reduction in the number of patients managed conserva-
stable patients, a helical CT examination with oral and tively. The gunshot wounds were penetrating in 35–70%
venous contrast was performed to determine the grade of cases [20], and the wounds caused by sharp tools were
of the liver injury, the amount of hemoperitoneum, the not penetrating in 35–61% of cases [21, 22].
presence of pseudoaneurysms, and the presence of other Diagnostic peritoneal lavage (DPL) is another valid tool
intraperitoneal injuries. to determine the presence or nature of intraperitoneal liq-
Hemoperitoneum was observed in repeated ultrasound uids. We used this procedure in a few cases. DPL, de-
examinations, and in some cases, re-evaluation was done scribed by Root in 1965, remains an important tool in the
via CT scan. Malhotra et al. reports that a large amount
of hemoperitoneum (when blood is present in the lateral Table 9 Complications of conservative treatment of patients with
combined liver trauma according to some authors
Table 7 Management according the WSES grade Complications References Our study (%)
WSES Conservative Laparotomy Secondary hemorrhage 5% [30] 3.4
WSES grade I 50 (76.9%) 15 (23.1%) Missed injuries 3–5% [28, 35] 2.3
WSES grade II 21 (38.2%) 34 (61.8%) Hemobilia 0.3–1.2% [36, 37] 1
WSES grade III 2 (33.3%) 4 (66.7%) Bilhemia 0.2–1% [38] 1
WSES grade IV 0 (0%) 47 (100%) Bile leakage 3–20% 6.8
Buci et al. World Journal of Emergency Surgery (2017) 12:24 Page 5 of 7

Table 10 Comparative data on secondary indications for surgical Table 12 OLS, “success of the conservative management” as
treatment after an initial determination to perform conservative the dependent variable
treatment Variables Coefficient Std. error t ratio p value
Secondary indications for Letoublon et al. Our study Const −0.233669 0.311065 −0.7512 0.4536
surgical treatment (186 patients) (%) (173 patients) (%)
Age 0.0493656 0.0196583 2.5112 0.0130
Peritoneal inflammatory 5.5 2.3
syndrome Gender 0.0253333 0.0731743 0.3462 0.7296
Secondary hemorrhage 1 3.4 Cinjur 0.136536 0.0745459 1.8316 0.0688
Liver compartment 1 1.1 Grade 0.0414623 0.0336495 1.2322 0.2196
syndrome
Resec −0.151871 0.134283 −1.1310 0.2597
Hollow organ injuries 1 2.3
ISS −0.0124758 0.0027189 −4.5885 <0.0001
Biliary peritonitis 0.5 2.3
RTS 0.0892609 0.0315478 2.8294 0.0052
Extrahepatic biloma 0 2.3
Mean dependent var. 0.445087 S.D. dependent var. 0.498418
Post-traumatic cholecystitis 0 2.3
Sum-squared resid. 27.91268 S.E. of regression 0.411300
Intrahepatic biloma 0 1.1
R-squared 0.346740 Adjusted R-squared 0.319026
Bilothorax 0.5 0
Abdominal compartment 1 0 the efficacy of conservative management of liver trauma
syndrome
in hemodynamically stable patients is between 87 and
Post-traumatic pancreatitis 0.5 0 98%, and the failure rate is between 10 and 25% [24, 25].
Injuries that were grade III or worse added substan-
hands of surgeons, especially in the absence of minimally tially to the failure of conservative management. We had
invasive equipment. DPL has a very high sensibility and only two patients with grade IV liver injury that were
specificity rate for intraperitoneal injuries, 95 and 99%, re- successfully managed conservatively. Malhotra et al.
spectively. However, this procedure is associated with found that in 14% of patients with grade IV injuries and
complications in 0.8–1.7% of cases [23]. 22.6% of patients with grade V injuries, conservative
Our study showed that conservative treatment turned treatment was not successful, and the failure rate in pa-
out to be successful in 42.2% of patients with combined tients with grades I, II, and III injuries was 3–7 and 5%
hepatic trauma and in 58.7% of patients with isolated [19]. The likelihood of the success of conservative treat-
hepatic trauma. These percentages recorded in our study ment had a significant correlation with the grade of liver
are lower than those reported elsewhere. It is our view injury. The coefficient of grade injury was −2.6, which
that these differences are related to two factors: (1) a means that for every increase in the grade of the in-
low level of consensus for conservative management and jury, the likelihood of the success of conservative
(2) limited hospital resources (limited interventional treatment drops to 2.6. In addition, the success of
radiology procedures). Conservative treatment failed in conservative treatment had a significant correlation
17.2% of cases. In some studies, it has been reported that with associated intra-abdominal injuries. Other factors
were statistically insignificant in the success of the
Table 11 Frequencies of several variables for both treatment conservative treatment.
modes (conservative and laparotomy)
The failure of the conservative treatment was often at-
Variable Conservative Laparotomy
tributed to the deterioration of hemodynamic parame-
Male 61 (42.4%) 83 (57.6%) ters, bile leakage, and the presence of overlapping septic
Female 12 (41.4%) 17 (58.6%) complications. Durham et al. and Hammond et al. have
>55 years old 8 (57.1%) 6 (42.9%) reported that secondary hemorrhage occurs in less than
<55 years old 65 (40.9%) 94 (59.1%) 5% of cases treated conservatively [26, 27]. We observed
ISS >20 8 (8.8) 83 (91.2%)
that the failure of conservative treatment due to second-
ary hemorrhage occurred in 3% of cases. Buckman et al.
ISS <20 65 (79.3%) 17 (20.7%)
showed that bile leakage can occur in 3–20% of patients
RTS >5 63 (63.6%) 36 (36.4%) who are managed conservatively [28, 29]. The frequency
RTS <5 10 (13.5%) 64 (86.5%) of hemobilia, as reported by Croce et al. and Walt et al.,
≤Grade IV 73 (42.1%) 100 (57.9%) ranges from 0.3 to 1.2% [28, 30]. A rare complication,
>Grade IV 0 (0%) 9 (100%) such as bilhemia, occurs in less than 1% of patients with
Complications 15 (20.5%) 11 (11%)
hepatic trauma [31]. Bilhemia is determined by the presence
of pseudoaneurysm (that is found in angio CT), increased
Mortality 1 (1.4%) 12 (12%)
bilirubin level, and a normal level of liver enzymes (ALT,
Buci et al. World Journal of Emergency Surgery (2017) 12:24 Page 6 of 7

AST). We found the same frequency of bilhemia and hemo- Author details
1
bilia. Subcapsular hematoma should be surgically treated Service of General Surgery, Trauma University Hospital, Tirana, Albania.
2
Department of Surgery, UHC “Mother Teresa”, Tirana, Albania. 3Department
only for two reasons: (1) to increase the value of ALT and of Internal Medicine, Trauma University Hospital, Tirana, Albania.
AST and (2) if the patient has Budd-Chiari syndrome
[32, 33]. In our study, only one patient underwent Received: 7 February 2017 Accepted: 22 May 2017

surgical intervention due to increases in ALT and

AST values.
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