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Arch Hellen Med, 19(3), May-June 2002, 226-244


Non operative management of blunt injuries
of solid intraperitoneal organs (liver spleen)

Department of Surgery, Medical School, University of Patras, Patras, Greece

Non operative management (NOM) of blunt hepatic and splenic injuries is the treatment modality of choice in hemodynamically stable trauma patients with no clinical or radiological (CT scan) evidence of other intra abdominal injuries requiring laparotomy. Abdominal CT scan is the method of choice for detecting and staging these injuries. The presence of a “contrast blush” on the initial or subsequent CT scan is indicative of active bleeding or of a false aneurysm; it mandates immediate angiography with the intent of angioembolization which increase the success rate of NOM. Patients treated non operatively are admitted to the intensive care unit under the care of experienced trauma team, for close monitoring, until continued bleeding can be safely ruled out. A drop in Ht merits repeat CT scan to determine if the injured organ (liver, spleen) is the source of blood loss. The treatment of this problem, by surgery or angioembolization, depends on the hemodynamic status of the patient. The ISS score, the age of the patient, the severity of the organ injury, the level of consciousness of the patient and the underlying organ pathology (spleen) are not inclusion or exclusion criteria for NOM, although a higher failure rate should be anticipated in patients with more severe organ injury. An absolute contraindication for NOM is the non availability at any time of a surgical team to handle the patient if NOM fails. The complications of NOM such as delayed bleeding, infection, bile collection or hemobilia, etc., have proven to be extremely rare, even with significant organ injury, and most of them can be managed by interventional radiologic or endoscopic techniques, making laparotomy unnecessary. Current data suggest that 50–80% of all adult trauma patients who have sustained blunt hepatic trauma and 60–65% of those with blunt splenic trauma are candidates for NOM, with a success rate of 90–95%. This approach can be accomplished with minimal transfusion, minimal morbidity (<5%) and minimal mortality (<1%). Recently, some stable patients with stab wounds, or apparent bullet trajectories involving only the liver or spleen have also been managed non operatively, with excellent results. Recent data suggest that the majority of hepatic and splenic injuries can and should be managed without operative intervention.

Key words: Liver, Non operative management, Spleen, Trauma.

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