EXPERIENCE WITH MANAGING LIVER TRAUMA IN SOUTHEASTERN NIGERIA

Abstract

Background

All over the world, liver trauma occurs as a result of blunt or penetrating abdominal injury.

Aim and Objective

To review the management, morbidity and mortality of liver trauma in our resource-deprived centre, and to see how we can improve these outcomes, our poor facilities notwithstanding.

Type of Study

This is a descriptive epidemiology.

Place of Study

Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria.

Patients and Methods

Patients who were treated for liver trauma in our centre between 2004 and 2010 were reviewed for aetiology of injury, management, morbidity and mortality.

Results

Of the 162 patients who were treated for liver trauma during the period, only 156 patients were recruited into the study. One hundred and nineteen (119) were males and 37 were females. Majority were blunt injuries while others were penetrating injuries. The blunt injuries were usually solitary, affecting only the liver whereas the penetrating injuries occasionally involved both the liver and some other organ(s). The commonest cause of blunt injuries was road traffic accident followed by fall from height. The commonest cause of penetrating injury was gunshot wound, followed by stab wound.

Conclusion

Morbidity and mortality following liver trauma can be reduced by applying prompt and appropriate management modalities within the ambit of available resources. However, outcome will improve if adequate facilities are available.

Introduction

Liver trauma occurs all over the world, and, regardless of the level of development of the area, the aetiological factors are similar. Majority of liver traumas are due to blunt abdominal injuries1 and there is evidence that these blunt abdominal injuries leading to liver trauma is on the increase.2 This increase is more glaring in our community where, because of the poor and inadequate transportation system, people have resorted to patronizing ‘okada’, a notorious transport system in which commercial motorcycles are used to convey people from place to place at reckless speed and with utter disregard for highway codes.

Management of blunt or penetrating injuries to the liver remains a significant challenge.3 This is because the liver, being a highly vascular organ and strategically located, is difficult to manage even with adequate facilities.4 This difficulty increases in a resource-deprived centre such as ours where we do not have any form of pre-hospital services. Adequate diagnostic tools help the surgeon to sharpen indications for surgery or for non-operative management. Major vessel injuries (like the inferior vena cava and hepatic veins can be associated with severe liver injuries and are potentially devastating and associated with high mortality.5 Peri-hepatic packing procedure, which is the basic damage control technique for the treatment of hepatic haemorrhage, is one of the cornerstones of the surgical strategy for abdominal trauma.6

In spite of good clinical acumen, complex liver injuries are best identified at laparotomy.>7 Operative management depends on the magnitude of parenchymal destruction as well as associated vascular disruption.8 Hepatotomy with selective vascular ligation,9,10,11,12,13,14,15 debridement of devitalized tissues, hepatorrhaphy using suture, and suturing of the Glisson’s capsule after packing the liver wound with omental pedicle are all part of the various approaches towards the surgical treatment of liver trauma.

Computed tomography (CT) scans are used to assess patients of blunt trauma for abdominal injury when reasons for immediate laparotomy are not present. If the injury is not severe, and if facilities for regular evaluation are readily available, victims with mild liver trauma can be managed non-operatively.16. The definitive management strategy to be adopted in each case depends on proper assessment of the grade of liver injury. The grades are given in Table I17.

Reports

Patients and Methods

All the patients who were treated for liver trauma in our centre from September 15, 2004 to September 14, 2010 (a six-year period) were reviewed. The names of these patients were obtained from the ward registers and theatre registers and the folders containing their medical records were retrieved from the Medical Records Department. From each patient’s folder, the following details were extracted: age of patient, sex, cause of liver trauma, treatment given and, outcome.

Results

One hundred and sixty-two patients were identified as having been treated for liver trauma during the period but since only 156 folders could be retrieved, only 156 patients were recruited into this study. There were 119 males (76.3%) and 37 (23.7%) females, giving a M : F ratio of 3.2 : 1. Their ages ranged from 21 years to 65 years, with a mean at 38 years and standard deviation of 1.58 years. Eighty-four (84) patients (53.9%) had blunt abdominal injuries, 80 of which resulted from road traffic accidents, three (3) from fall from a height, and one (1) from a kick to the abdomen during a fight. The remaining 72 patients (46.2%) had penetrating injuries, 66 of which resulted from gunshot wounds during robbery attacks, and two (2) from accidental discharge, in each case, by a policeman. Four (4) of the penetrating injuries resulted from stab wounds sustained, in each case, during a fight (Table II). The investigations that were done included haemoglobin estimation, grouping and cross-matching of blood, urinalysis, serum urea, electrolyte and creatinine estimation, abdomino-pelvic ultrasound scans, and plain radiographs of chest and abdomen. None of the patients had computed tomography (CT) scan, angiogram, or any radiological intervention procedure. All the patients had exploratory laparotomy. The procedures carried out in theatre included one or a combination of the following: hepatotomy, debridement, haemostasis using either sutures or surgicel, or both; hepatorrhaphy with omental patch and, in 15 cases, additional peri-hepatic packing. Laparotomy revealed that twenty-seven (27) patients had Grade I injuries, 44 had Grade II injuries, 33 had Grade III injuries, twenty-nine (29) had Grade IV injuries, and twenty-three (23) had Grade V injuries. None had Grade VI injury (Table III). One of the Grade V injury patients died on-table during laparotomy. He had severe injuries to the major hepatic veins, having been shot at close range by a police officer who used an AK-47 rifle. He died of excessive haemorrhage which was beyond pressure application and blood replacement. Of the twenty-three Grade V injuries, four died less than 36 hours after removal of the peri-hepatic pack which had been inserted 48 hours previously. These four deaths occurred because of re-bleeding which led to disseminated intravascular coagulation (DIC). Coagulation failure occurred in these patients because the blood bank could not meet up with the urgent demand for fresh blood and the anaesthetists would not accept the patients into theatre for re-insertion of packs because blood was not available. Two other Grade V injury patients died on post-operative (post-op) days 9 and 11, of liver failure resulting from fulminant sepsis. Four of the Grade IV patients died within the first 13 days post-op because of biliary leakage and biliary peritonitis, bringing the total number of deaths to eleven (11). The rest of the patients did well, although the higher the grade of injury, the greater the morbidity (bleeding and sepsis), and the greater the need for more blood transfusion and antibiotics. None developed liver abscess or intra-peritoneal abscess.

The average operative time was 2 hours 15 minutes and the average blood loss was 900ml. None of the patients had re-operation.

After discharge, the longest follow-up was for 13 months for one patient. The rest defaulted after varying periods of three to six months follow-up.

Conclusions

A mortality of 7.1% (11 deaths out of 156 patients) could have been lower if not for the poor working environment in our centre, especially after comparing our mortality with results from better equipped centres.31, 32 Our result however encourages us to keep doing what we can to help the patients with liver trauma. We are hopeful that, with improved facilities, especially the provision of ultrasound at the Accident and Emergency Department and the training of all surgeons to perform focused abdominal sonography for trauma (FAST) as advocated by Brown et al,32, 33 our patient care will improve. This will reflect in lower morbidity and mortality or no mortality at all. Radiologists require continued relevant training and update courses so as to be abreast with advances in contrast enhanced harmonic imaging, Doppler technology and spatial resolution as highlighted by Ugwu and Erondu.35 Governments at various levels (Local, State, and Federal) should intensify efforts at providing security for the people who frequently are under siege by armed robbers. When these robbers operate, they do not seem to be deterred by anybody. Law enforcement agents and Road Safety officials should enforce the highway codes to the letter and bring every culprit to book. These measures, which will bring down the rates of gunshot wounds and of road traffic accidents, will correspondingly bring down the incidence of trauma to the liver, thereby reducing the demand on scarce resources.

Discussion

From this study, liver trauma is not rare in our community. Our Medical Records Department needs to improve their record keeping so that folders can be retrieved whenever they are needed. An incidence of 156 cases of liver trauma in six years gives an average of 26 cases per year. More males were affected than females because more males are involved in hazardous and risky driving habits, including rough-riding of commercial motorcycles, generally called ‘okada’, a now popular form of transportation in Nigeria. More males are attacked by armed robbers than females because males, as the bread-winners, are the ones that keep the money. They are also the ones that engage in big business ventures that require movement of large amounts of cash. Armed robbers therefore go for them. Males are also more involved in fights that are associated with the use of sharp objects like knife.

Gunshot injuries inflicted by policemen have, for a long time now, been a source of vexation and worry to our community. The trigger-hungry policemen who are involved in this menace do so for very flimsy reasons, ranging from a simple argument on the highway, to refusal of the victim to give them gratification. The police usually tag such event as “accidental discharge.”

Indeed, it is a great challenge to manage patients with liver injury in a centre without facilities for angiogram, CT-scan and magnetic resonance imaging (MRI).18,19,20,21,22,23,24,25,26,27,28

Majority of our patients had grades II and III liver injuries. Another significant group was the grade IV injury group which was associated with a higher morbidity and mortality, and greater challenge in management. None of our patients was treated non-operatively because of lack of adequate monitoring gadgets such as a readily available and dedicated ultrasound scan and a CT-scan adequately equipped with facilities for CT angiogram.18,19,21,22 All of the patients with Grades I and II injuries and some with Grade III injuries may have benefited from non-operative management if facilities were available first, to make an accurate diagnosis and then to follow up the patients with serial monitoring.12,13 The best we could do if we had to withhold laparotomy was haemodynamic monitoring which was not enough for us to make any accurate diagnosis. Asuquoet al29 were able to manage 30% of their patients with liver trauma non-operatively, using ultrasound scanning and haemodynamic monitoring. In their own series, Adesanyaet al30 were able to show that, with proper selection of patients with abdominal gunshot wounds, the incidence of negative laparotomies could be reduced provided there were basic facilities for monitoring such patients.

The major problem associated with liver trauma in our series was severe haemorrhage. This was highlighted by Sikhondzeet al31 in their own series in South Africa. The absence of a reliable blood transfusion service can be quite frustrating when managing a patient with high grade liver trauma. Therefore, a reliable blood bank must be available to supply fresh blood as the need arises. The policy of patients having to get their relatives to donate blood for them in times of need, suggests that the fate of the patient is in the hands of relatives who may be unwilling or unfit to donate blood. These are the stark realities associated with managing liver trauma in centres like ours.

Angiograms, CT-scan, nuclear imaging, and MRI may be considered too luxurious for a resource-poor centre like ours, but a reliable ultrasound scanning machine should always be available if any form of non-operative management of liver trauma is to be contemplated. In spite of all these handicaps, patients with liver trauma still come to us for treatment.

Limitation of this study

The retrospective nature of this study is the main limitation. The high morbidity and mortality outcomes recorded in this study would have been better if a unit dedicated to traumatology managed the cases.

Table 1: Liver Injury Scale(AAST)

Grade	Type of Injury	Type of Injury
I	HaematomaLaceration	Subcapsular, < 10% surface areaCapsular tear, < 1cm parenchymal depth
II	HaematomaLaceration	Subcapsular, 10% to 50% surface areaIntraparenchymal < 10cm in diameterCapsular tear, 1-3cm parenchymal depth, < 10 cm in length
III	HaematomaLaceration	Subcapsular, > 50% surface area of rupturedSubcapsular or parenchymal haematoma;intraparenchymal haematoma > 10 cm or expanding> 3 cm parenchymal depth
IV	Laceration	Parenchymal disruption involving 25% to 75% hepatic lobe or 1-3 Couinaud’s segments
V	LacerationVascular	Parenchymal disruption involving > 75% of hepatic lobe or > 3 Couinaud’s segments within a single lobeJuxtahepatic venous injuries; i.e. retrohepatic vena cava/central major hepatic veins
VI	Vascular	Hepatic avulsion
*Advance one grade for multiple injuries up to grade IIIAAST = American Association for the Surgery of Trauma

Table 2: Incidents that caused liver trauma

Incidents	Number of patients	Percentage
Blunt injuries
Road traffic accidents	80	51.3
Fall from height	3	1.9
Kick to the abdomen	1	0.6
Penetrating injuries
Gunshot wounds from armed robbery attacks	66	42.3
Accidental discharge	2	1.3
Stab wounds	4	2.6
Total	156	100

Table 3: Grades of Liver the injuries

Grade	No. of patients	Percentage
I	27	17.3
II	44	28.2
III	33	21.2
IV	29	18.6
V	23	14.7
VI	0	0
Total	156	100