Observation-first versus angioembolization-first approach in stable patients with blunt liver trauma: A WTA multicenter study

Peter D Nguyen; Jeffry Nahmias; Negaar Aryan; Jason M Samuels; Michael Cripps; Heather Carmichael; Robert McIntyre Jr; Shane Urban; Clay Cothren Burlew; Catherine Velopulos; Shana Ballow; Rachel C Dirks; M C Spalding; Aimee LaRiccia; Michael S Farrell; Deborah M Stein; Michael S Truitt; Heather M Grossman Verner; Caleb J Mentzer; T J Mack; Chad G Ball; Kaushik Mukherjee; Georgi Mladenov; Daniel J Haase; Hossam Abdou; Thomas J Schroeppel; Jennifer Rodriquez; Miklosh Bala; Natasha Keric; Morgan Crigger; Navpreet K Dhillon; Eric J Ley; Tanya Egodage; John Williamson; Tatiana Cp Cardenas; Vadine Eugene; Kumash Patel; Kristen Costello; Stephanie Bonne; Fatima S Elgammal; Warren Dorlac; Claire Pederson; Nicole L Werner; James M Haan; Kelly Lightwine; Gregory Semon; Kristen Spoor; Laura A Harmon; Areg Grigorian

doi:10.1097/TA.0000000000004372

Observation-first versus angioembolization-first approach in stable patients with blunt liver trauma: A WTA multicenter study

J Trauma Acute Care Surg. 2024 Nov 1;97(5):764-769. doi: 10.1097/TA.0000000000004372. Epub 2024 May 27.

Authors

Peter D Nguyen¹, Jeffry Nahmias, Negaar Aryan, Jason M Samuels, Michael Cripps, Heather Carmichael, Robert McIntyre Jr, Shane Urban, Clay Cothren Burlew, Catherine Velopulos, Shana Ballow, Rachel C Dirks, M C Spalding, Aimee LaRiccia, Michael S Farrell, Deborah M Stein, Michael S Truitt, Heather M Grossman Verner, Caleb J Mentzer, T J Mack, Chad G Ball, Kaushik Mukherjee, Georgi Mladenov, Daniel J Haase, Hossam Abdou, Thomas J Schroeppel, Jennifer Rodriquez, Miklosh Bala, Natasha Keric, Morgan Crigger, Navpreet K Dhillon, Eric J Ley, Tanya Egodage, John Williamson, Tatiana Cp Cardenas, Vadine Eugene, Kumash Patel, Kristen Costello, Stephanie Bonne, Fatima S Elgammal, Warren Dorlac, Claire Pederson, Nicole L Werner, James M Haan, Kelly Lightwine, Gregory Semon, Kristen Spoor, Laura A Harmon, Areg Grigorian

Affiliation

¹ From the Division of Division of Trauma, Burns and Surgical Critical Care, Department of Surgery (P.D.N., J.N., N.A., A.G.), University of California, Irvine, Orange, California; Section of Surgical Sciences (J.M.S.), Vanderbilt University Medical Center, Nashville, TN; Department of Surgery, University of Colorado, Aurora, Colorado (M.C., H.C., R.M., S.U., C.C.B., C.V.); Department of Surgery (S.B., R.C.D.), UCSF-Fresno, Fresno, California; Division of Trauma and Acute Care Surgery (M.C.S.), Mount Carmel East; Trauma, Critical Care and Acute Care Surgery (A.L.), Grant Medical Center, Columbus, Ohio; Department of Surgery (M.S.F.), Lehigh Valley Health Network, Allentown, Pennsylvania; Departments of Emergency Medicine and Surgery, Program in Trauma (D.M.S.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Graduate Medical Education (M.S.T., H.M.G.V.), Methodist Dallas Medical Center, Dallas, Texas; Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery (C.J.M., T.J.M.), Spartanburg Regional Medical Center, Spartanburg, South Carolina; Department of Surgery (C.G.B.), University of Calgary, Calgary, Alberta, Canada; Division of Acute Care Surgery (K.M., G.M.), Loma Linda University Health, Loma Linda, California; Department of Surgery (D.J.H., H.A.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Trauma and Acute Care Surgery (T.J.S., J.R.), UCHealth Memorial Hospital, Colorado Springs, Colorado; Department of General Surgery (M.B.), Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Division of Trauma, Acute Care Surgery and Surgical Critical Care (N.K., M.C.), Banner-University Medical Center Phoenix, Phoenix, Arizona; Division of Trauma and Critical Care, Department of Surgery (N.K.D., E.J.L.), Cedars-Sinai Medical Center, Los Angeles, California; Department of Surgery (T.E., J.W.), Cooper University Hospital, Camden, New Jersey; Department of Surgery and Perioperative Care (T.C.P.C., V.E.), Dell Medical School, University of Texas at Austin, Austin, Texas; Division of Trauma Acute Care Surgery, Department of Surgery (K.P., K.C.), Banner Thunderbird Medical Center, Glendale, Arizona; Division of Trauma and Surgical Critical Care, Department of Surgery (S.B.), Hackensack University Medical Center, Hackensack, New Jersey; Division of Trauma and Surgical Critical Care, Department of Surgery (F.S.E.), Rutgers New Jersey Medical School, Newark, New Jersey; Department of Trauma and Acute Care Surgery (W.D., C.P.), Medical Center of the Rockies, Loveland, Colorado; University of Wisconsin-Madison School of Medicine and Public Health (N.L.W.), Madison, Wisconsin; Department of Trauma (J.M.H., K.L.), Ascension Via Christi Saint Francis, Wichita, Kansas; Department of Surgery (G.S.), Miami Valley Hospital, Wright State University, Dayton, Ohio; Department of Surgery (K.S.), Prisma Health-Upstate, Greenville, South Carolina; and Department of Surgery (L.A.H.), Boulder Community Hospital, Boulder, Colorado.

PMID: 39443838
DOI: 10.1097/TA.0000000000004372

Abstract

Background: Prior studies evaluating observation versus angioembolization (AE) for blunt liver injuries (BLT) with contrast extravasation (CE) on computed tomography imaging have yielded inconsistent conclusions, primarily due to limitations in single-center and/or retrospective study design. Therefore, this multicenter study aims to compare an observation versus AE-first approach for BLT, hypothesizing decreased liver-related complications (LRCs) with observation.

Methods: We conducted a post hoc analysis of a multicenter, prospective observational study (2019-2021) across 23 centers. Adult patients with BLT + CE undergoing observation or AE within 8 hours of arrival were included. The primary outcome was LRCs, defined as perihepatic fluid collection, bile leak/biloma, pseudoaneurysm, hepatic necrosis, and/or hepatic abscess. A multivariable logistic regression analysis was used to evaluate risk factors associated with LRCs.

Results: From 128 patients presenting with BLT + CE on imaging, 71 (55.5%) underwent observation-first and 57 (45.5%) AE-first management. Both groups were comparable in age, vitals, mechanism of injury, and shock index (all p > 0.05), however the AE group had increased frequency of American Association for the Surgery of Trauma Grade IV injuries (51.0% vs. 22.0%, p = 0.002). The AE cohort demonstrated increased rates of in-hospital LRCs (36.8% vs. 12.7%, p = 0.038), emergency department representation (25.0% vs. 10.0%, p = 0.025), and hospital readmission for LRCs (12.3% vs. 1.4%, p = 0.012). However, the two cohorts had similar mortality rates (5.7% vs. 5.3%, p = 0.912). After adjusting for age, ISS, and grade of liver injury, an AE-first approach had a similar associated risk of LRCs compared with observation-first management (odds ratio, 1.949; 95% confidence interval, 0.673-5.643; p = 0.219).

Conclusion: Patients with blunt liver injury and CE undergoing an observation-first approach were associated with a similar adjusted risk of LRCs and rate of mortality compared with AE-first approach. Overall, this calls for reevaluation of the role of routine AE in blunt liver trauma patients with CE. Future prospective randomized trials are needed to confirm these findings.

Level of evidence: Therapeutic/Care Management, Level IV.

Publication types

Multicenter Study
Observational Study
Comparative Study

MeSH terms

Adult
Embolization, Therapeutic* / methods
Female
Humans
Injury Severity Score
Liver* / injuries
Male
Middle Aged
Prospective Studies
Tomography, X-Ray Computed
Watchful Waiting
Wounds, Nonpenetrating* / complications
Wounds, Nonpenetrating* / mortality
Wounds, Nonpenetrating* / therapy