In Brief

The liver is the most commonly injured abdominal organ after blunt orpenetrating abdominal trauma. The widely variable nature of the injury con-tributes to the extensive literature on this subject and is the main reason forthe number of operative alternatives available to the trauma surgeon today.Even though nonoperative treatment has been the standard of care in thepediatric population for more than 20 years, nonoperative treatment of bluntliver injuries in the adult population is still surrounded by controversy.However, in the last decade nonoperative treatment is becoming the standardof care for patients with blunt liver injuries in major trauma centers acrossthe United States. The driving forces behind this major change include (1)better and faster imaging techniques, (2) a better understanding of the nat-ural history of the liver injury, (3) easy access to alternative forms of diag-nosis and treatment of the associated complications by less invasive tech-niques, (4) the knowledge that many hepatic injuries found at laparotomy arenot actively bleeding and require no operative treatment, and (5) a growingbody of evidence that suggests that this is a safe alternative for these patients.

What has fostered this new reassessment of the treatment of patientswith blunt liver injuries has been the increasing role and availability ofhigh-speed conventional and helical computed tomography and ultra-sonography in the initial evaluation of the hemodynamically stablepatient with blunt abdominal trauma. The use of computed tomographyscanning allows the specific diagnosis of many abdominal injuries thatotherwise would go undetected or that otherwise would have requiredlaparotomy to identify.

The rapid and sophisticated initial evaluation at the scene with expedi-tious transfer of these patients to a level I trauma center has also changeddramatically our ability to expand our capabilities for nonoperative man-agement of patients with complex blunt liver injuries. The rising injuryseverity score and complex associated injuries encountered in thesepatients demand even more complex diagnostic and therapeutic strategies.The rewards are extremely gratifying, as reflected by a dramatic decreasein liver trauma–related mortality rates across the nation. Unfortunately,there has been a proportional and dramatic fiscal cost associated with thisapproach that undoubtedly will be examined closely in the years ahead asmore fiscal constraints and regulations are implemented.

Special and controversial areas in the treatment of patients with complex

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blunt liver injuries include elderly patients, patients receiving anticoagu-lant therapy, and patients with extensive liver injuries. As experience growsin the years ahead, we believe that proper guidelines will be described forthis subset of patients. At this point in time, we rely on our institutionalexperience and the small but growing clinical experience.

In this issue of Current Problems in Surgery, we present this evolutionand transition in the management of patients with complex blunt liverinjuries and try to answer the 3 basic questions that are still not com-pletely answered at this point regarding the management of these patients:

1. Is nonoperative treatment of patients with blunt liver injuries safe forall grades of injuries and for all patients?

2. Can patients with an initially hemodynamically unstable condition beresuscitated and then treated like their stable counterparts?

3. Can patients in whom nonoperative treatment ultimately fails be iden-tified before complications arise?

Because this monograph is dedicated to the evolution of the nonopera-tive treatment of complex blunt liver injuries, this is necessarily an incom-plete discussion; however, a section is dedicated to the current and futurerole of surgery in the subset of patients for whom initial nonoperativetreatment fails. Even though excellent reports from premier institutions inthe United States and abroad have described in some detail this approachin patients with complex blunt liver injuries, we do not as yet have suffi-cient data to verify the efficiency and efficacy of this approach.

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