Factors of Failure for Nonoperative Management of Blunt Liver and Splenic Injuries

A review of the literature describing the management of hepatic and splenic injuries indicates that as many as 67% of exploratory celiotomies for blunt trauma are reported as nontherapeutic. Avoiding unnecessary surgery through nonoperative management offers an attractive alternative. Nonetheless, nonoperative management should not be considered unless the patient meets the following criteria: (1) hemodynamic stability, with or without minimal fluid resuscitation; (2) no demonstrable peritoneal signs on abdominal examination; and (3) the absence on computed tomography (CT) scan of any intraperitoneal or retroperitoneal injuries that require operative intervention. Although a patient may meet these criteria, several additional factors can serve as predictors of failure of nonoperative management. Such predictors among patients with hepatic injuries are hemodynamic instability, liver injury of American Association for the Surgery of Trauma grades IV and V (especially when accompanied by hemodynamic instability), and pooling of contrast on CT scan. Formerly thought to be a predictor of failure of nonoperative management, periportal tracking has not been cited as such in recent reports of hepatic injuries. Among patients with blunt splenic injuries, such predictors include hemodynamic instability, injury of grade IV or higher, large associated hemoperitoneum, and contrast blush on CT scan. Although preexisting splenic disease and age older than 55 years have traditionally been considered predictors of failure, recent reports have shown that these characteristics do not appear to be associated with an increased need for surgical intervention.