CT images of hepatic lesions and the results of non - operative management of blunt liver trauma at 108 military central hospital from 2015 to 2019

Journal of military pharmaco-medicine n 0 1-2020 207 CT IMAGES OF HEPATIC LESIONS AND THE RESULTS OF NON-OPERATIVE MANAGEMENT OF BLUNT LIVER TRAUMA AT 108 MILITARY CENTRAL HOSPITAL FROM 2015 TO 2019 Nguyen Van Quynh1; Nguyen Thanh Tam2; Nguyen Trong Hoe1 SUMMARY Objectives: To study CT images of hepatic lesions and the results of non-operative management of blunt liver trauma. Subjects and methods: Descriptive, retrospective and prospective study without comparative group on 67 patients diagnosed with blunt liver trauma who were managed by non-operation from July, 2015 to July, 2019. Results: CT-scan images: Lesions in right hepatic lobe accounted for 95.5%; grade 2 of blunt liver trauma was 26.9%, grade 3 was 65.7%. Morphology of blunt liver trauma: Contusion-parenchymal hematoma was 83.6%, sub-capsular was 61.2% and laceration was 49.3%, many patients had the combination of several morphologies of hepatic lesions. Length of hospital stay was 10.1 ± 5.2 days. 18 patients had received 2 to 8 units of red blood cells (250 mL/unit) during treatment period. The complication rate was 3%. The overall success rate of non-operative management was 98.5%. Conclusion: Hepatic lesions often occured in right hepatic lobe; grade 2, 3 of blunt liver trauma were 92.5%. Contusion-parenchymal hematoma was the most common. The complication rate was low, the success rate was high. Non-operative management of liver rupture due to blunt abdominal trauma was safe, no dead. * Keywords: Liver trauma; Blunt abdominal trauma; Non-operative management; CT images. INTRODUCTION Liver rupture due to blunt abdominal trauma (liver trauma) is very popular, ranking the second after splenic trauma, has tendency to increase nowadays. In the last four decades, the great progress of computer tomography (CT) has developed the basis of non-operative management. As a result, not only saving patient’s life but also preserving injuried organs, hence many unnecessary surgical interventions, which can be aggravating factors, are going to be avoided. At 108 Military Central Hospital, non-operative management of blunt liver trauma has created an innovation in cure, and gained many positive results. However, they have not been evaluated and reported. Therefore, we performed this thesis with the aims: To study CT images and the result of non-operative management of blunt liver trauma at 108 Military Central Hospital from 2015 to 2019. 1. 103 Military Hospital 2. 108 Military Central Hospital Corresponding author: Nguyen Van Quynh (quynh44ahvqy@gmail.com) Date received: 27/11/2019 Date accepted: 23/12/2019 Journal of military pharmaco-medicine n 0 1-2020 208 SUBJECTS AND METHODS 1. Subjects. The study included 67 cases diagnosed with liver rupture definitely due to CT images at Digestive Surgery Institute, 108 Military Central Hospital from 7 - 2015 to 7 - 2019. 2. Methods. - Descriptive, retrospective and prospective study without comparative group. - Classification of blunt liver trauma according to AAST (1994). - Collecting information according to a general medical record form with contents about clinical features: Age, gender, mechanism of injury, hemodynamic state, clinical presentations, associated injuries, complete blood count, biochemical blood test and ultrasound on admission; CT images: position, grade and morphology of blunt liver trauma; results of non-operative management: blood transfusion, length of hospital stay, complications during treatment and the general results of non-operative management. - Success means: Ensure discharge criteria, do not have complications or complications do not need surgical intervention or angioembolization. Failure means: Complications that require surgical intervention or angioembolization or death during treatment. - Discharge criteria: Clinically, the patient had no pain, no fever, no jaundice, hemodynamically stable, edible, soft and flat abdomen; paraclinical tests: complete blood count, liver enzymes, bilirubine return to normal, abdominal ultrasound shows good progression, fluidization. - Processing data by the medical statistics program SPSS 20.0. RESULTS AND DISCUSSION 1. Clinical features. - Age: The mean age was 32.9 ± 13.3, most of the patients belonged to the age group of 10 - 50 (59 cases = 86.6%). - Gender: Male was 64.2%, female was 35.8%. Men suffered more than women (64.2% vs. 35.8%), because traffic participants are mainly men who often drink alcohol. - Mechanism of injury: Traffic accident in 54 cases (80.6%), domestic accident 10 cases (14.9%) and industrial accident 3 cases (4.5%). - Hemodynamic state: Patients with hemodynamically stable on admission were 66 cases (98.5%). This was explained by the fact that many patients who hospitalized were received pre-hospital care at the grassroots-line hospital. - Clinical presentations: Abdominal pain was 100%, abdominal distension was 46.3%, abdominal wall injury was 35.8%. Abdominal pain was the most common symptom, however, this is only a subjective sign of the patient, it is difficult to evaluate accurately. Abdominal distension is a prognostic factor of emergency surgery. - Associated injuries: Thoracic injury accounted for 29.9%, extremity fracture 19.4%, spleen 11.9%. 29 patients with isolated liver trauma made up 43.3% and 38 patients (56.7%) with associated injuries. Associated extra-abdominal injuries such as chest trauma, extremity does not affect Journal of military pharmaco-medicine n 0 1-2020 209 the indication of non-operative management of liver trauma, but it remains an obstacle in treatment period due to severe pain, loss of blood and prolong the length of hospital stay. - Liver enzyme on admission: AST 466.1 ± 352.8 U/L, ALT 421.2 ± 338.4 U/L. Liver enzyme tests are valuable when clinically unknown, ultrasound can not detect injury, especially in the baseline hospital which do not have professional conditions, facilities for diagnosis to help physicians to decide the next step such as taking CT or transfer patiens to the upline. - Ultrasound: Ultrasound detected parenchymal injury in 59 patients (88.1%) and hemoperitoneum in 53 patients (79.1%). The role of ultrasound in detecting liver damage as well as other organs is limited, when ultrasound detects intra-abdominal fluid, CT should be taken to determine the damage if the patient's condition allows. 2. CT images of blunt liver trauma. * Position of hepatic lesions: Right hepatic lobe was the most common injuried lobe with 64 cases (95.5%) (including 3 patients [4.5%] with lesions in both lobes); left lobe: 3 patients (4.5%). The right hepatic lobe is more vulnerable than the left lobe, especially the posterior segment [4, 5]. This was explained by their large size and proximity to the ribs. It was the compression of the ribs, spine and posterior abdominal wall that leads to lesions of sub-segment VI, VII, VIII (> 85%) [6]. * Grade of blunt liver trauma: Grade 1: 1 patient (1.5%); grade 2: 18 patients (26.9%); grade 3: 44 patients (65.7%); grade 4: 4 patients (6.0%). Coccolini et al suggested that most of blunt liver traumas were grade 1, 2 and 3 [7], and hepatic lesions in blunt liver trauma could be classified into three groups: minor (grade 1, 2), moderate (grade 3) and large (grade 4, 5). In the study by Afifi et al, grade 2 of blunt liver trauma was the most common, followed by grade 1 and 3, most grade of blunt liver trauma were from 1 to 3 [8]. Table 1: Morphology of blunt liver trauma. Morphology Number of cases Percentage (%) Sub-capsular haematoma 41 61.2 Contusion - parenchymal haematoma 56 83.6 Laceration 33 49.3 Active hemorrhage 7 10.4 Periportal low attenuation 5 7.5 Signs of contusion-parenchymal hematoma was the most common morphology of blunt liver trauma. According to many authors, contusion- parenchymal hematoma is the most common sign on CT [1]. Signs of sub- capsular hematoma ranked second after contusion-parenchymal hematoma. In grade 4, 5 of liver trauma, big lacerations in parenchymal liver often coincide with division areas of liver which do not have much blood vessels, so it can not lead to Journal of military pharmaco-medicine n 0 1-2020 210 bleed severely. Therefore, signs of laceration is not an indication of operative management if hemodynamic on admission is stable [2]. 7 cases had signs of active hemorrhage and 5 cases had signs of periportal low attenuation on CT images, but hemodynamic on admission was stable and these patients were successful treated with non-operative management. 3. The results of non-operative management. Table 2: The amount of blood transfusion. Type Volume (mL) Min (mL) Max (mL) Red blood cells 240.3 ± 470.8 500 2,100 Frozen plasma 116.4 ± 238.9 250 1,000 In the study, 18 patients were transfused from 2 to 8 units of red blood cells (a unit is equal to 250 mL). The mean amount of red blood cells was 240.3 ± 470.8 mL/person. The length of hospital stay was 10.1 ± 5.2 days, including the duration of treatment of combined injuries in other departments, which was longer than figures in Nguyen Ngoc Hung's study (2012) and Ngo Quang Duy's study (2013), which was only 8.8 ± 5.3 days and 6.35 ± 3.13 days, respectively [2, 3]. The higher grade of blunt liver trauma, the longer length of hospital stay. But notably, researches by A Landau (2006), Nguyen Ngoc Hung (2012) showed that the average length of hospital stay of the operative management group was longer than the non-operative management group [2, 9]. - Complications during treatment: In this study, only two cases occurred complications, accounted for 3%, of whom, one case had bile leak requiring emergency surgery and one case of liver failure, less than the data for complications in Nguyen Ngoc Hung’s study (2012) and Ngo Quang Duy's study (2013), which were 10.96% and 17.24%, respectively [2, 3]. There were no cases of missing or late diagnosis of surgery-required injuries, because this is the end-line hospital with qualified and experienced surgeons as well as modern diagnostic and monitoring equipment which help to diagnose more accurately and indicate surgery timely if needed. - The general result of non-operative management: The study had 4 cases of grade 4 of blunt liver trauma, 3 cases were stable during non-operative management period, 1 case of hepatic failure was treated conservative intensively until discharge without surgical intervention. In the study, the success rate of non-operative management was 98.5%. The failure rate was only 1.5%. This result was similar to Nguyen Ngoc Hung's study (2012) with the success rate was 93.5%, higher than Ngo Quang Duy's study (2013) with the success rate was 90.5% [2, 3]. In the study by Coccolini et al, most grade 1, 2 and 3 of blunt liver trauma were successfully treated by non-operative management. The benefits of non-operative management were lower hospital cost, early discharge, fewer intra-abdominal complications, and reduced blood transfusion rate [5, 7, 8]. Journal of military pharmaco-medicine n 0 1-2020 211 CONCLUSION Through 67 patients with blunt liver trauma treated by non-operative management at 108 Military Central Hospital from July 2015 to July 2019, we concluded: - CT images of blunt liver trauma: Hepatic lesions often occured in right hepatic lobe (95.5%), grade 2, 3 of blunt liver trauma according to AAST (1994) was the most common (92.5%). Contusion- parenchymal hematoma was the most prevalent morphology of blunt liver trauma (83.6%). - The result of non-operative management of blunt liver trauma: The complication rate was low (3%), the success rate was high (98.5%). Non- operative management of liver rupture due to blunt abdominal trauma was safe, no dead. REFERENCES 1. Trần Bình Giang. Chấn thương bụng. Nhà xuất bản Khoa học Kỹ thuật. Hà Nội. 2014. 2. 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