Written by Jason Lesnick
Observation is highly effective in select hemodynamically stable patients who have liver injuries with active extravasation and was associated with fewer additional interventions in these patients relative to those deemed to require angioembolization.
Why does this matter?
Traumatic liver injuries have a high rate of morbidity and mortality, and there are existing Eastern Association for the Surgery of Trauma (EAST) and Western Trauma Association (WTA) guidelines recommending immediate angioembolization in hemodynamically stable patients when active extravasation (blush) is seen on CT imaging of hepatic injuries.
I be-liver in you to improve with observation!
This prospective, multicenter, observational study enrolled 192 patients who had liver injuries with blush on CT imaging obtained within 2 hours of arrival and were hemodynamically stable as determined by the attending surgeon. The patients were split into groups for either initial angioembolization (AE, 32% of patients), observation (OBS, 40% of patients), or operative management with initial management decided by the attending surgeon.
Patients had propensity score matching used to minimize confounders between groups including matching for penetrating mechanism, AAST (American Association for the Surgery of Trauma) liver injury score, initial vital signs, and transfusion within 4 hours of arrival.
The primary outcome was liver-related complications (hepatic necrosis, hepatic abscess, biloma, bile leak, and/or perihepatic fluid collections), with secondary outcomes of mortality, ICU and overall LOS, and need for additional interventions.
After matching, the AE group had a longer overall LOS (8 vs. 6 days, p = 0.01), were more likely to receive additional blood products following the first 4 hours after arrival (32% vs. 0%, p = 0.001), and had a greater number of IR-placed drains for liver-related complications – abscess or biloma – (24% vs. 0%, p = 0.01) compared to the OBS group. There was no difference in mortality or ICU days.
This study suggests that an initial OBS first strategy is reasonable in select hemodynamically stable patients with CT-identified extravasation for traumatic liver injuries but that more studies are needed to further evaluate these approaches.
This sort of downstream knowledge is always useful so that we are better able to set up our colleagues for success by counseling our patients about potential future management options once we have identified an emergent diagnosis.
An observation-first strategy for liver injuries with “blush” on computed tomography is safe and effective. J Trauma Acute Care Surg. 2023 Feb 1;94(2):281-287. doi: 10.1097/TA.0000000000003786. Epub 2022 Sep 23.
Editor’s note: Propensity score matching helps, but there is no getting around selection bias in this study; the surgeon chose the treatment. Maybe there were more complications in the intervention group because they had worse injuries. This study shows that observation may be a viable option for select patients with blush. ~Clay Smith