Contemporary epidemiologic overview of adult liver trauma management across the United States: Analysis of the American College of Surgeons Trauma Quality Improvement Program database

Abstract

Introduction

Multiple definitive and temporizing management techniques have been devised for liver trauma, and we have shifted toward nonoperative management as endovascular capabilities have evolved. Despite management guidelines, no large-scale data on implementation exist. This study characterizes current nationwide liver trauma management.

Methods

This was an analysis of 2017–2020 American College of Surgeons Trauma Quality Improvement Program. Adult patients with liver trauma were included, with the exclusion of those with severe extra-abdominal injuries (Abbreviated Injury Scale >3). Nonoperative management was defined as no exploratory laparotomy (ex-lap) within 6 hours. Primary outcomes were management strategies employed and failure of nonoperative management (ex-lap after 6 hours), stratified by injury mechanism, American Association for the Surgery of Trauma liver injury grade, and American College of Surgeons trauma center verification level. Secondary outcomes were mortality, survivor-only length of stay, and in-hospital complications. Interfacility transfer patients were subanalyzed.

Results

A total of 96,652 patients with liver trauma were identified, of which 60,199 were included [24% penetrating; 74% blunt]. In total, 60% grade I/II injuries, 21% grade III, 14% grade IV, 5% grade V, and 0.2% grade VI. Mean age 39 ± 17 years, 65% male, 58% White, ISS was 17[12–24], liver-AIS 2[2–4], and lowest systolic blood pressure within 1-hour was 84 ± 31 mm Hg. Mortality was 5%, hospital length of stay was 6 [2–13] days, and intensive care unit length of stay 3 [2–6] days. Both blunt and penetrating liver injuries of all severities were more likely to undergo operative management at higher American College of Surgeons trauma center verification levels. Of 13,672 patients who were transferred, 92% underwent nonoperative management, 1.3% angioembolization, and only 3.4% failed nonoperative management.

Conclusion

Liver trauma remains a major public health burden with mortality approaching 66% among severely injured patients, and current management shows significant nationwide variability. Blunt liver trauma is primarily being managed nonoperatively, and angioembolization is assuming a growing role. Very few patients who were transferred to greater levels of care required operative intervention, having implications for resource allocation.