J Hepatobiliary Pancreat Surg (2007) 14:387–391 DOI 10.1007/s00534-006-1177-2 Operative and nonoperative management of blunt hepatic trauma in adults: a single-center report Stavros Gourgiotis, Vasilis Vougas, Stylianos Germanos, Nikitas Dimopoulos, Ioannis Bolanis, Spyros Drakopoulos, Panagiotis Alfaras, and Sotiris Baratsis First Surgical Department, “Evangelismos” General Hospital of Athens, Athens, Greece Offprint requests to: S. Gourgiotis 41 Zakinthinou Street, 15669, Papagou, Athens, Greece Received: May 26, 2006 / Accepted: August 28, 2006 Abstract Background/Purpose. Liver trauma, especially that as result of road traffic accidents, still remains a complicated problem in severely injured patients. The aim of this study was to ex- tract useful conclusions from the management in order to im- prove the final outcome of such patients. Methods. Details for 86 patients with blunt hepatic trauma who were examined and treated in our department during a 6-year period were analyzed. We retrospectively reviewed the severity of liver injury, associated injuries, treatment, and outcome. Results. Forty-nine liver injuries (57%) were of low severity (grades I and II), while 37 (43%) were of high severity (grades III, IV, and V). Liver trauma with associated injury of other organs was noted in 62 (72.1%) patients. Forty-three (50%) patients underwent an exploratory laparotomy within the first 24 h of admission. Thirty-five (71.4%) of the 49 patients with low-grade hepatic injuries were managed conservatively; no mortality occurred. Six (14%) of forty-three patients with liver trauma initially considered for conservative management required surgery due to hemodynamic instability. Five (13.5%) of 37 patients who were finally managed nonoperatively required adjunctive treatment for biloma, hematoma, or bil- iary leakage; no mortality occurred. The overall mortality rate was 9.3%; mortality rates of 5.8% and 3.5% were due to liver injuries and concomitant injuries, respectively. Conclusions. Severe hepatic injuries require surgical interven- tion due to hemodynamic instability. Low-grade injuries can be managed nonoperatively with excellent results, while patients with hepatic trauma with associated organ injuries require surgery, because they continue to have significantly higher mortality. Key words Hepatic trauma · Management · Associated injuries · Mortality Introduction The liver is the most commonly injured organ in patients with blunt abdominal trauma. Liver trauma has been the main cause of death in patients with severe abdominal injuries, with related mortality of 10%–15%. 1 The prevalence of liver injury has increased during the past three decades. 2,3 Initially, due to war actions and secondly as a result of urban accidents, this in- creased rate represents an absolute rise of liver injuries, together with better diagnosis through the liberal use of computed tomography (CT) and more advanced trauma treatment modalities. Until the beginning of the 1990s, liver injury cases were identified primarily by diagnostic peritoneal lavage, CT, or laparotomy. Historically, the accepted standard of care was uniform operation for suspected liver injuries, with repair of vascular, parenchymal, or biliary structures and drainage of the perihepatic spaces to control biliary leakage and to avoid potential perihe- patic sepsis. 2 The advent of improved and expeditious imaging technologies for the diagnosis and treatment of solid-organ injuries, accompanied by advances in critical-care monitoring, prompted a paradigm shift to- ward nonoperative management for the treatment of solid-organ injuries. Subsequently, the shift toward non- operative management yielded a decrease in total mor- tality rates. 2 At present, the reported success rate of nonoperative management of hepatic trauma ranges from 82% to 100%. 2–8 Furthermore, an absolute in- crease in the incidence of nonoperatively managed liver injuries is unequivocal. 4,5 This study was performed to address several im- portant issues regarding the management of liver inju- ries arising from blunt trauma, including total mortality with all forms of treatment, the risks from failure of nonoperative management, and the necessity for ad- junctive procedures to improve the outcome of such patients.