Nonoperative treatment of civilian gunshot wound of the liver: a prospective series of cases

Background

The conservative approach of blunt hepatic trauma and low-energy (stab) penetrating injuries is well established. Routine surgical exploration remains the standard practice for all penetrating solid organ injuries. Nonoperative treatment of patients who suffered civilian (medium-energy) gunshot wound (GSW) of the torso, including the liver, although controversial, could be conducted without surgery in selected patients presenting to the emergency room hemodynamically stable and without evidence of peritonism. The physical examination and abdominal computed tomography (CT) are essential to guide the initial therapy. The nonoperative management is attractive once it avoids the morbidity of a nontherapeutic laparotomy, reported to be as high as 41.3%.

Objective

To analyse the feasibility, safety and acute complications of nonoperative, protocol-driven treatment of GSW of the liver.

Methods

A prospective, observational, protocol-driven study with patients who suffered civilian GSW of the liver, admitted to the emergency room between 1998 and 2006. All patients had a single, right thoracoabdominal GSW. All patients had one initial abdominal CT scan and were observed in a semi-ICU (emergency room), with noninvasive monitoring and serial physical examination, for at least 24 hours.

Results

Twenty-four consecutive patients (mean age 24.3 (range 16–47) years) were enrolled and treated initially without surgery, and 22 were hemodynamically stable (Table 1). Twenty patients were maintained with conservative treatment. Sixteen of these patients (78.94%), had minor liver injuries (grade I/II/III – American Association for the Surgery of Trauma (AAST)), whereas four patients sustained major grade IV/V injuries. Two patients with major liver injuries were hemodynamically unstable with rapid response to saline infusion and were maintained in the protocol (Tables 2 and 3). The aspartate aminotransferase (AST) and alanine aminotransferase (ALT) mean values were proportionally higher according to the grade of the liver injury (Table 4). Chest injuries were noted in 10 patients (47.36%) and pleural drainage under water seal was necessary in nine of them. Two patients sustained an associated renal injury with microscopic hematuria. Laparotomy was performed in four patients because of two main indications: persistent right hippocondrius pain (n = 2) and a projectile inside the pelvis on CT (n = 2). In this group, two laparotomies were nontherapeutic and two revealed small diaphragmatic injuries. All four liver injuries were minor and without active bleeding.

Table 1 Hemodynamic stability according to the grade of injury in all 24 patients

Table 2 Liver segments injuries on abdominal computed tomography in 20 nonsurgical patients

Table 3 Abdominal computed tomography findings in 20 nonsurgical patients

Table 4 AST and ALT mean admission values in surgical and nonsurgical patients

Conclusion

Civilian GSW of the liver can be treated without surgery in selected adult patients presenting to the emergency room as hemodynamically stable, with Glasgow Coma Scale score of 15, without evidence of peritonism, and in trauma centers with a defined protocol based on findings from an abdominal CT scan. Treatment could be done in a semi-ICU, with noninvasive monitoring and serial physical examination. The grade of liver injury and the presence of perihepatic fluid (hemoperitoneum) does not contraindicate the conservative approach. Pulmonary trauma was the most commonly associated injury and was treated with pleural drainage under water seal. Renal-associated injury could be treated without surgery. The values of AST and ALT could be correlated with the grade of liver injury. More large prospective series are warranted.