TY - JOUR
T1 - An observation-first strategy for liver injuries with "blush" on computed tomography is safe and effective
AU - Samuels, Jason M.
AU - Carmichael, Heather
AU - McIntyre, Robert
AU - Urban, Shane
AU - Ballow, Shana
AU - Dirks, Rachel C.
AU - Spalding, M. C.
AU - Lariccia, Aimee
AU - Farrell, Michael S.
AU - Stein, Deborah M.
AU - Truitt, Michael S.
AU - Grossman Verner, Heather M.
AU - Mentzer, Caleb J.
AU - Mack, T. J.
AU - Ball, Chad G.
AU - Mukherjee, Kaushik
AU - Mladenov, Georgi
AU - Haase, Daniel J.
AU - Abdou, Hossam
AU - Schroeppel, Thomas J.
AU - Rodriquez, Jennifer
AU - Nahmias, Jeffry
AU - Tay, Erika
AU - Bala, Miklosh
AU - Keric, Natasha
AU - Crigger, Morgan
AU - Dhillon, Navpreet K.
AU - Ley, Eric J.
AU - Egodage, Tanya
AU - Williamson, John
AU - Cardenas, Tatiana C.P.
AU - Eugene, Vadine
AU - Patel, Kumash
AU - Costello, Kristen
AU - Bonne, Stephanie
AU - Elgammal, Fatima S.
AU - Dorlac, Warren
AU - Pederson, Claire
AU - Burlew, Clay Cothren
AU - Werner, Nicole L.
AU - Haan, James M.
AU - Lightwine, Kelly
AU - Semon, Gregory
AU - Spoor, Kristen
AU - Velopulos, Catherine
AU - Harmon, Laura A.
N1 - Publisher Copyright:
© Wolters Kluwer Health, Inc. All rights reserved.
PY - 2023/2/1
Y1 - 2023/2/1
N2 - INTRODUCTION The management of liver injuries in hemodynamically stable patients is variable and includes primary treatment strategies of observation (OBS), angiography (interventional radiology [IR]) with angioembolization (AE), or operative intervention (OR). We aimed to evaluate the management of patients with liver injuries with active extravasation on computed tomography (CT) imaging, hypothesizing that AE will have more complications without improving outcomes compared with OBS. METHODS This is a prospective, multicenter, observational study. Patients who underwent CT within 2 hours after arrival with extravasation (e.g., blush) on imaging were included. Exclusion criteria included cirrhosis, nontraumatic hemorrhage, transfers from outside facilities, and pregnancy. No hemodynamic exclusion criteria were used. The primary outcome was liver-specific complications. Secondary outcomes include length of stay and mortality. Angioembolization patients were compared with patients treated without AE. Propensity score matching was used to match based on penetrating mechanism, liver injury severity, arrival vital signs, and early transfusion. RESULTS Twenty-three centers enrolled 192 patients. Forty percent of patients (n = 77) were initially OBS. Eleven OBS patients (14%) failed nonoperative management and went to IR or OR. Sixty-one patients (32%) were managed with IR, and 42 (69%) of these had AE as an initial intervention. Fifty-four patients (28%) went to OR+/- IR. After propensity score matching (n = 34 per group), there was no difference in baseline characteristics between AE and OBS. The AE group experienced more complications with a higher rate of IR-placed drains for abscess or biloma (22% vs. 0%, p = 0.01) and an increased overall length of stay (p = 0.01). No difference was noted in transfusions or mortality. CONCLUSION Observation is highly effective with few requiring additional interventions. Angioembolization was associated with higher rate of secondary drain placement for abscesses or biloma. Given this, a trial of OBS and avoidance of empiric AE may be warranted in hemodynamically stable, liver-injured patient with extravasation on CT. LEVEL OF EVIDENCE Therapeutic/Care Management; Level II.
AB - INTRODUCTION The management of liver injuries in hemodynamically stable patients is variable and includes primary treatment strategies of observation (OBS), angiography (interventional radiology [IR]) with angioembolization (AE), or operative intervention (OR). We aimed to evaluate the management of patients with liver injuries with active extravasation on computed tomography (CT) imaging, hypothesizing that AE will have more complications without improving outcomes compared with OBS. METHODS This is a prospective, multicenter, observational study. Patients who underwent CT within 2 hours after arrival with extravasation (e.g., blush) on imaging were included. Exclusion criteria included cirrhosis, nontraumatic hemorrhage, transfers from outside facilities, and pregnancy. No hemodynamic exclusion criteria were used. The primary outcome was liver-specific complications. Secondary outcomes include length of stay and mortality. Angioembolization patients were compared with patients treated without AE. Propensity score matching was used to match based on penetrating mechanism, liver injury severity, arrival vital signs, and early transfusion. RESULTS Twenty-three centers enrolled 192 patients. Forty percent of patients (n = 77) were initially OBS. Eleven OBS patients (14%) failed nonoperative management and went to IR or OR. Sixty-one patients (32%) were managed with IR, and 42 (69%) of these had AE as an initial intervention. Fifty-four patients (28%) went to OR+/- IR. After propensity score matching (n = 34 per group), there was no difference in baseline characteristics between AE and OBS. The AE group experienced more complications with a higher rate of IR-placed drains for abscess or biloma (22% vs. 0%, p = 0.01) and an increased overall length of stay (p = 0.01). No difference was noted in transfusions or mortality. CONCLUSION Observation is highly effective with few requiring additional interventions. Angioembolization was associated with higher rate of secondary drain placement for abscesses or biloma. Given this, a trial of OBS and avoidance of empiric AE may be warranted in hemodynamically stable, liver-injured patient with extravasation on CT. LEVEL OF EVIDENCE Therapeutic/Care Management; Level II.
UR - https://www.scopus.com/pages/publications/85147106614
UR - https://www.scopus.com/pages/publications/85147106614#tab=citedBy
U2 - 10.1097/TA.0000000000003786
DO - 10.1097/TA.0000000000003786
M3 - Article
C2 - 36149844
AN - SCOPUS:85147106614
SN - 2163-0755
VL - 94
SP - 281
EP - 287
JO - Journal of Trauma and Acute Care Surgery
JF - Journal of Trauma and Acute Care Surgery
IS - 2
ER -