International Journal of Surgery 39 (2017) 255e259

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International Journal of Surgery

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Original Research

Current approach to liver traumas

Levent Kaptanoglu*, Necmi Kurt, Hasan Ediz Sikar
Kartal Research and Education Hospital, Turkey

h i g h l i g h t s

Requirement for surgery should be determined by hemodynamic stability.

For best evaluation and treatment of these liver trauma patients a multidisciplanary approach is highly recommended.

Stable patients with reliable examinations and available resources can be managed nonoperatively. Unstable patients belong in the operating room.

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Liver injuries remain major obstacle for successful treatment, due to size and location of
Received 5 December 2016 the liver. Requirement for surgery should be determined by clinical factors, most notably hemodynamical
Received in revised form state. In this present study we tried to declare our approach to liver traumas. We also tried to emphasize
6 February 2017
the importance of conservative treatment, since surgeries for liver traumas carry high mortality rates.
Accepted 9 February 2017
Available online 11 February 2017
Presentation of case: Patients admitted to the Department of Emergency Surgery at Kartal Research and
Education Hospital, due to liver trauma were retrospectively analyzed between 2003 and 2013. Patient
demographics, hepatic panel, APTT (activated partial thromboplastin time), PT (prothrombin time), INR
Keywords:
Liver trauma
(international normalized ratio), fibrinogen, biochemistry panel were recorded. Hemodynamic instability
Conservative approach was the most prominent factor for surgery decision, in the lead of current Advanced Trauma Life Support
Major resection (ATLS) protocols. Operation records and imaging modalities revealed liver injuries according to the Organ
Injury Scale of the American Association for the Surgery of Trauma.
300 patients admitted to emergency department were included in our study (187 males and 113 fe-
males). Mean age was 47 years (range, 12e87). The overall mortality rate was 13% (40 out of 300). Major
factor responsible for mortality rates and outcome was stability of cases on admission. 188 (% 63) patients
were counted as stable, whereas 112 (% 37) cases were found unstable (blood pressure  90, after
massive resuscitation). 192 patients were observed conservatively, whereas 108 cases received abdom-
inal surgery. High levels of AST, ALT, LDH, INR, creatinine and low levels of fibrinogen and low platelet
counts on admission were found to be associated with mortality and these cases also had Grade 4 and 5
injuries. Hemodynamic instability on admission and the type and grade of injury played major role in
mortality rates). Packing was performed in 35 patients, with Grade 4 and 5 injuries. Mortality rate was %
13 (40 out of 300).
Conclusion: A multidisciplinary approach to the management of hepatic injuries has evolved over the last
few decades, but the basic principles of trauma continue to be observed. Diagnostic and therapeutic
endeavors are chosen based mainly on the stability of the patient. Stable patients with reliable exami-
nations and available resources can be managed nonoperatively. Unstable patients require surgery. Our
current approach to liver traumas is non operative technique, if possible.
© 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction

Injuries to the liver remain major obstacle for successful treat-

* Corresponding author. Kartal Research and Education Hospital, Department of
General Surgery, Turkey.
E-mail address: leventkaptanoglu@yahoo.com (L. Kaptanoglu).
ment, due to frequency and size and location of the liver (35%e45%)
[1]. In the early part of the 20th century aggressive operative
treatment was popular, whereas following World War II recent
return to the frequent use of nonoperative strategies have replaced

http://dx.doi.org/10.1016/j.ijsu.2017.02.015
1743-9191/© 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
256 L. Kaptanoglu et al. / International Journal of Surgery 39 (2017) 255e259
current approach for treating hepatobiliary trauma [2e11]. Better
abdominal imaging led to nonoperative management [13,14]. Only
failure of observational strategies and penetrating hepatic injuries
has generally remained standard with reliance on an operative
approach [12e16].
Requirement for surgery should be determined by clinical fac-
tors, most notably hemodynamic stability, rather than CT findings.
For best evaluation and treatment of these liver trauma patients a
multidisciplanary approach is highly recommended. Patients with
abdominal trauma who are unstable at presentation or become
unstable in the trauma bay despite resuscitative efforts should be
taken immediately to the operating room for laparotomy. In
contrast, the stable patient should undergo a rapid physical ex-
amination and further investigation [19].
In this present study we tried to declare our approach to liver
traumas.
2. Material and method
Patients admitted to the Department of Emergency Surgery at
Kartal Research and Education Hospital, due to liver trauma were
retrospectively analyzed between 2003 and 2013. Patient de-
mographics, hepatic panel (AST (aspartate minotransferase), ALT
(alanine aminotransferase), LDH (lactate dehydrogenase), APTT
(activated partial thromboplastin time), PT (prothrombin time), INR
(international normalized ratio), fibrinogen, biochemistry panel
(urea, creatinine, hemoglobin levels, platelet counts, and white
blood cell counts) were recorded. All cases were randomized in
three groups, according to injury type (blunt, stab wound and gun
shot). Hemodynamic instability was the most prominent factor for
surgery decision, in the lead of current Advanced Trauma Life
Support (ATLS) protocols [5]. Operative findings (grade of hepatic
injury, type of surgery), accompanied abdominal and extra
abdominal injuries, requirement of blood transfusion and mortality
rates were recorded. Operation records and imaging modalities
revealed liver injuries according to the Organ Injury Scale of the
American Association for the Surgery of Trauma. [6]. Localization of
injuries in segments were also recorded.
During surgeries, what we call no touch technique, simple he-
mostatic methods (coagulation, sponge application, topical agents),
hepatorrhaphy, segmentectomy and lobectomy were performed.
Segmentectomies were applied to peripheral parts, some of them
were already detached. We performed very little number of lo-
bectomies, with high mortality rates.
2.1. Statistical method
PASW 18.0 for Windows (SPSS, Chicago, IL, USA) was utilized for
statistical analysis. The chi-squared test or Fischer's exact test was
used to compare categorical data. For the parametric distribution,
Student's t-test was used to compare the mean values of two
groups. For nonparametric variables, the Kruskal-Wallis test or
Mann-Whitney U test was used to analysis was performed using
Pearson or Spearman.
3. Results
Between 2003 and 2013, 300 patients admitted to emergency
department were included in our study (187 males and 113 fe-
males). Mean age was 47 years (range, 12e87). The overall mor-
tality rate was 13% (40 out of 300). Patients blood chemisty and
hepatic panel revealed no major abnormalities, besides slight
elevation of white blood cell count (WBC) and moderate elevation
of AST, ALT, LDH levels. APTT, PT, INR, fibrinogen, urea and creati-
nine levels showed foreseable changes on admission (Table 1). Age
and gender showed no statistical difference. Most frequent mech-
anisms of injury was as follows; blunt trauma (160, %53), stab
wounds (88, % 29) and gun shot wounds (52, % 18).
Major factor remained in mortality rates and outcome was
stability of cases on admission. 188 (%63) patients were counted as
stabile, whereas 112 (%37) cases were found unstable (blood
pressure  90, after massive resuscitation).
192 patients were observed conservatively, whereas 108 cases
received abdominal surgery. No touch technique was applied to 31
patients, whereas simple hemostasis in 33, hepatoraphy in 24,
segment resection in 12 and finally lobectomy in 8 cases,
respectively.
According to surgery findings, 10 diaphragm, 9 stomach, 7 kid-
ney, 7 spleen, 14 colon, 38 small intestine, 3 duodenum, 12 gall-
bladder and 8 pancreas injuries were accompanied liver injuries
(Table 2). ISS scores were in range 30e55.
Injuries to scletal system [13], chest trauma [23], cranial injury
[17] and retroperitoneal injury [18] were coexisting traumas beside
liver injuries (Table 2). ISS score were in range 45e60.
Operative findings revealed 103 Grade 1, 89 Grade 2, 73 Grade 3,
21 grade 4 and 14 Grade 5 injuries regarding Organ Injury Scale of
the American Association for the Surgery of Trauma (Table 2).
High levels of AST, ALT, LDH, INR, creatinine and low levels of
fibrinogen and low platelet counts on admission were found to be
associated with mortality (Table 3) and these cases also had Grade 4
and 5 injuries.
Approximately 0e20 units of blood were transfused preopera-
tively (mean: 3.5 ± 2.5) and it was statistically correlated with the
grade of liver injury (p ¼ 0.003) (Table 3).
Hemodynamic instability on admission and the type and grade
of injury played major role in mortality rates (Table 4). Packing was
performed in 35 patients, with Grade 4 and 5 injuries.
Mortality rate was %13 (40 out of 300). The mean age in the
mortality group was 42 (range, 20e55) years.
Table 5 reveales segmenter distribution of liver injuries.
4. Discussion
By the late 1980s it was clear that although some problems
remained with management of hemorrhage from the liver, many
patients were undergoing celiotomy for injuries that did not
require operative treatment. In our institution our approach was
similar, since we did not have experience and auxiliary methods to
observe the patient. The lack of imaging techniques led us to
perform diagnostic peritoneal lavages, which was extremely sen-
sitive. With improved usage of CT scans, requirement for DPL was
no longer necessary. CT scans also permitted evaluation of other
Table 1
Demographic/clinical and laboratory data.
Parameter Mean value
Age (year) 47 (12e87)
Hb 12 ± 1.7 (gr/dl)
White Blood Cell 13700 ± 2300/l
Platelet 220000 ± 45000/l
Urea 32 ± 14 mmol/l
Creatinine 1.1 ± 0.5 mg/dl
ALT 150 ± 90 U/L
AST 120 ± 70 U/L
LDH 300 ± 220 U/l
aPTT 30 ± 2 s
PT 14 ± 1 s
INR 1.2 ± 0.7
Fibrinogen 180 ± 70 g/l
Transfusion Requirement 3.5 ± 2.5 (0e20) units
 L. Kaptanoglu et al. / International Journal of Surgery 39 (2017) 255e259 257

Table 2 Table 4
Clinical features. Significant factors effective on mortality.

n % Mortality Group P

Type of injury n %
Blunt Trauma 160 53
Type of inury
Stab Wound 88 29
Blunt Trauma 6 15
Gunshot Wound 52 18
Stab Wound 8 20
Hemodynamic stability
Gunshot Wound 25 65 p < 0.05
Stable 188 63
Hemodynamic stability
Unstable 112 37
Stable 10 25
Organ injury scale
Unstable 30 75 p < 0.05
Grade 1 103 34
Organ injury scale
Grade 2 89 30
Grade 1 None
Grade 3 73 24
Grade 2 None
Grade 4 21 7
Grade 3 6 15
Grade 5 14 5
Grade 4 20 50 p < 0.05
Type of surgical technique
Grade 5 14 35 p < 0.05
No Touch Technique 31 29
Type of surgery
Simple Hemostasis 33 31
No Touch Technique None
Hepatoraphy 24 22
Simple Hemostasis 7 18
Segmentectomy 12 11
Hepatoraphy 18 45
Lobectomy 8 7
Segmentectomy 9 23 p < 0.05
Concomitant intraabdominal/extraabdominal injuries
Lobectomy 6 14 p < 0.05
Diaphragm 10 9
Concomitant intra-and extraabdominal injuries
Stomach 9 8
Diaphragm 6 15 p < 0.05
Kidney 7 6
Stomach 2 5
Spleen 7 6
Kidney 2 5
Colon 14 13
Spleen 4 10 p < 0.05
_
Small Intestine 38 35
Colon 6 15
Duodenum 3 2 _
Small Intestine 13 33
Gallbladder 12 11
Duodenum 2 5 p < 0.05
Pancreas 8 7
Gallbladder 2 5
Muscloscletal System 13 18
Pancreas 3 7 p < 0.05
Chest Trauma 23 33
Muscloscletal System 2 5
Cranial Injury 17 24
Chest Trauma 11 28 p < 0.05
Retroperitoneal Injury 18 25
Cranial Injury 15 38 p < 0.05
Reroperitoneal Injury 12 29 p < 0.05

intraabdominal injuries. 192 patients in our study were observed
conservatively.
A literature review of collected contemparory series disclosed
that about 80%e90% of hepatic injuries can be safely managed
without operation [20e24], which supports our algorithm.
The principles for non operative treatment are fairly well stan-
dardized. The key factor in determining whether conservative
approach can be safely used is hemodynamic stability [25]. Most
trauma centers will permit up to four units of blood transfusion to
be given before celiotomy is required. In our institution, 2 h of
massive resussuciation and need more than 5 units of blood, is
bridge to surgery. CT scans may reveal the grade of liver injuries, but
many patients with high-grade injuries on CT scan do not need
operation. Patients who are selected for no surgery should be in an
intensive care unit environment with careful monitoring of vital
signs and hemoglobin level for the first several days postinjury [26].
We also followed our patients in an intensive care unit.
There have been a few reports on the use of non operative
PS: Kruskal-Wallis test or Mann-Whitney U test was used to analysis was performed
using Pearson or Spearman.
methods for penetrating hepatic injuries. Stab wounds to the right
upper quadrant can be safely managed in an evaluable patient who
is stable and does not exhibit findings of peritonitis. In 1998,
Demetriades et al. [27] reported on 16 patients with GSW managed
nonoperatively from a much larger group of patients who required
operation. In 2009, Navsaria et al. [28] treated 63 patients with
GSW with conservative methods. In our study penetrating injuries
were also unstable on admission, therefore majority of them
required surgery. Also especially gunshot wounds carried high
mortality rates.
In our study 192 patients were observed conservatively. We
used to operate all patients with suspicious liver injuries. Unfor-
tunately, our false laparotomy rate was high. With improved im-
aging techniques and better intensive care units and
recommendations of Turkish trauma association, we changed our

Table 3 Table 5
Significant clinical/demographic and laboratory findings for mortality. Distribution of injuries according to
segments.
Mortality Group Grade P values
Segment N
Age (year) 42 (20e55) 4e5
Platelet 120000 ± 45000/l 4e5 p < 0.05 1 7
Urea 40 ± 5 mmol/l 4e5 p < 0.05 2 12
Creatinine 1.4 ± 0.2 mg/dl 3e4e5 p < 0.05 3 18
ALT 200 ± 40 U/l 4e5 p < 0.05 4 16
AST 160 ± 30 U/l 4e5 p < 0.05 5 21
LDH 400 ± 120 U/l 4e5 p < 0.05 6 20
INR 1.5 ± 0.4 3e4e5 p < 0.05 7 11
Fibrinogen 140 ± 30 g/l 4e5 p < 0.05 8 3
Transfusion requirement 3.5 ± 2.5 (0e20) units 4e5 p < 0.05 Total 108
258 L. Kaptanoglu et al. / International Journal of Surgery 39 (2017) 255e259
treatment strategy. Our current approach to hepatic trauma has
evolved to nonoperative management. Some groups have realized
[29] that more than 50% of liver injuries stop bleeding spontane-
ously [30], the precedent of successful nonoperative management
in pediatric patients [31], knowledge that the liver has tremendous
capacity to heal after injury, and [32,33] improvements in liver
imaging with CT. Criteria for nonoperative management include
foremost, hemodynamic stability, absence of other abdominal in-
juries that require laparotomy, immediate availability of resources
including a fully staffed operating room, and a vigilant surgeon.
Grade I and II hepatic injuries should be observed in a monitored
setting with serial hematocrit evaluations and bed rest. Higher-
grade injuries in stable patients should be observed in an inten-
sive care unit setting with optimization of all coagulation factors. In
some series twenty-five percent of patients with blunt hepatic
injury managed nonoperatively, 92% of whom have grade IV or V
injury, will require an intervention for complications [34,35]
Interventional radiology may be needed to perform an angiogram
and embolization for bleeding or to percutaneously drain an ab-
scess or biloma. In our series 108 unstable patients received
surgery.
Operations are often challenging. Experienced surgeons should
be available, if possible. Damage control with packing is appro-
priate only for medical bleeding (coagulopathy, acidosis, hypo-
thermia). Anesthesia must ensure that blood products are already
in the room. The massive transfusion protocol should be activated
so that the blood bank is always ahead of the patient's needs for
packed red blood cells, fresh frozen plasma, platelets, and cry-
oprecipitate. Most minor venous bleeding and small lacerations to
the parenchyma can be stopped spontaneously. Hemostatic agents
such as surgicell, thrombin-soaked gel foam, or fibrin glue are
useful adjuncts. The argon beam coagulator is also an effective
means of hemostasis in this case. If these simple maneuvers are
effective, the operation should be truncated and the patient taken
to the intensive care unit for further resuscitation. In an unstable
patient, delay to control of hemorrhage will negatively affect
outcome. As an independent predictor of outcome, the mortality
doubles (25%e50%) as the patient's transfusion requirement in-
creases from 10 to 20 units of packed red blood cells acutely. In our
study requirement for massive blood transfusion carried high
mortality rates.
We applied various surgical techniques, including no touch,
simple hemostasis, hepatoraphy, segmental resection, lobectomy
and packing. Fortunately most cases in our series were manipulated
with simple methods. We used to perform major resections.
Therefore our mortality rate was high. After changing our strategy,
we only perform segmentectomies and lobectomies rarely. In many
cases, this involves the completion of an already extensive avulsion
injury. Trunkey stated in 2004, ‘‘there is a disturbing trend in the
literature for too many liver injuries to be managed nonoperatively
or without debridement or resection. This has led to increased
morbidity.’’ [35] This is corroborated by a report from Menegaux
and colleagues [36], evaluating the impact of a protocol that
emphasized a conservative approach, with less frequent use of
resection, whether anatomic or nonanatomic. The perioperative
mortality increased from 24% to 34% with the less aggressive
operative approach. The frequency of liver resection is 2%e5% in
most series, including our own from 2008 [37]. The mortality for
liver resection was 80% in 1900. With advances in operative tech-
nique, McClelland and Shires33 reported in 1965 that 10% of 259
patients were treated by liver resection, with 20% mortality. Twenty
years ago, Cogbill and colleagues [38] and Beal reported greater
than 50% mortality for liver resection for trauma, with an operative
mortality of 46% for grade IV injury and 80% for grade V injury. As
recently as 2004, Duane and colleagues [39] reported an operative
mortality of 66% for trauma patients undergoing laparotomy for
grade IV and V liver injury; 59% of these were from uncontrolled
bleeding. As outlined in the articles in this issue, our understanding
of liver anatomy, technologic advances (diagnostic and operative),
have made hepatic resection routine and safe in many centers.
Strong and colleagues [40] reported a liver related mortality of 8%
and hepatic complication rate of 19% following liver resection for
trauma. Tsugawa and colleagues [41] reported on 100 patients
undergoing liver resection for trauma, 20% of the liver injuries in
their series, which is unusually high. After resection, liver-related
mortality was 24% and morbidity was 25%. The mortality for
grade IV and V hepatic injuries, which generally comprise only 15%
of liver injuries, is greater than 50% in most series.
In our series also Grade 4 and 5 injuries carried high mortality
rates. We avoided to perform major resections and
segmentectomies.
Coexisting injuries also remains major obstacle for successful
treatment. Especially cranial and chest injuries carry high risk for
morbidity and mortality. In our study, especially coexisting factors
mentioned above showed high mortality rates. Some groups re-
ported that coexisting injuries are independent factors. Liver injury
_
paves the road for prognosis [42]). Injuries to other abdominal or-
gans carry extra risk for morbidity, especially retroperitoneal and
duodenal injuries shows high mortalities, with high ISS scores. In
our study retroperitoneal and intestinal injuries revealed high
mortality rates.
Laboratory data also reflects outcome and prognosis of these
patients. Elevated serum liver enzymes, AST and ALT, are known to
be associated with blunt traumatic liver injury. Tan et al. [43] have
reported that there is an important relationship between ALT, AST
and hepatic injuries after blunt abdominal trauma and also patients
with normal ALT, AST and LDH are unlikely to have major liver
injury. Nishida et al. [42] have shown that ALT is an independent
risk factor for mortality in their multivariate analysis. In our study
there was slight to moderate elevation of hepatic enzymes, which
was surprise for us. We were unable to explain this status.
Distribution of segmental injuries showed no extraordinary
order. Due to its localization right lobe was predominant in these
injuries.
Since 2008 after validation of clinical data previously published,
a multidisciplinary approach remain major success in the man-
agement of liver trauma patients [44e47]. Our institution is in
favour of this approach. Recently Boese et al. reported nonoperative
management methods of liver trauma in their systematic review
[48]. They also agreed, that conservative treatment has become the
standard approach for blunt hepatic injuries. Our institutional
management has evolved in the same direction. Boese et al. tried to
identify the incidence and prognostic factors for failure of conser-
vative treatment. 6 factors, including blood pressure, fluid resus-
citation, blood transfusion, peritoneal signs, Injury Severity Score
(ISS) and associated intra-abdominal injuries fulfilled criteria of
adverse prognosis. In our present study, signs of heodynamic
instability, accompanied organ injuries and high ISS scores were
signs for failure of conservative approach. These cases required
surgery.
5. Summary
A multidisciplinary approach to the management of hepatic
injuries has evolved over the last few decades, but the basic prin-
ciples of trauma continue to be observed. Diagnostic and thera-
peutic endeavors are chosen based mainly on the stability of the
patient. Stable patients with reliable examinations and available
resources can be managed nonoperatively. Unstable patients
belong in the operating room and should never be taken to the CT
 L. Kaptanoglu et al. / International Journal of Surgery 39 (2017) 255e259
scanner. Once in the operating room, simple maneuvers are
attempted first followed by an early decision to proceed with
resection if necessary. More experienced liver surgeons are
invaluable resources when they are exposure and vascular control.
Interventional radiological techniques can prevent and treat com-
plications of nonoperative and operative management of liver in-
juries. Successful management of patients with complex liver
trauma depends on aggressive correction of hypothermia, coagul-
opathy, and acidosis, and rapid critical decision making and expe-
rienced judgment. Liver resection, either anatomic or nonanatomic,
should be used in appropriate patients with complex liver injury
(25% in our series), and can be accomplished with low morbidity
and mortality. The stapling devices and clear understanding of
hepatic anatomy facilitate operative management.
Ethical approval
This study is approved by Ethic's Committee of Kartal Research
and Education Hospital. (Ref Number: 133567, 2009).
Sources of funding
There is no source of funding.
Author contribution
Necmi Kurt designed the study and helped in writing. Hasan
Ediz Sikar collected the data and analyzed and helped in writing.
Levent Kaptanoglu designed and wrote ths research.
Conflicts of interest
There is no conflict of interest.
Guarantor
Levent Kapanoglu, Assoc. Professor of Surgery.
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