Surgical treatment in hepatic trauma: factors associated with hospitalization time

ABSTRACT Objective: the aim of this study was to identify associated factors with the increased length of hospital stay for patients undergoing surgical treatment for liver trauma, and predictors of mortality as well as the epidemiology of this trauma. Methods: retrospective study of 191 patients admitted to the Cajuru University Hospital, a reference in the treatment of multiple trauma patients, between 2010 and 2017, with epidemiological, clinicopathological and therapeutic variables analyzed using the STATA version 15.0 program. Results: most of the included patients were men with a mean age of 29 years. Firearm injury represents the most common trauma mechanism. The right hepatic lobe was injured in 51.2% of the cases, and hepatorraphy was the most commonly used surgical correction. The length of hospital stay was an average of 11 (0-78) days and the length of stay in the intensive care unit was 5 (0-52) days. Predictors for longer hospital stay were the mechanisms of trauma, hemodynamic instability at admission, number of associated injuries, degree of liver damage and affected lobe, used surgical technique, presence of complications, need for reoperation and other surgical procedures. Mortality rate was 22.7%. Conclusions: the study corroborated the epidemiology reported by the literature. Greater severity of liver trauma and associated injuries characterize patients undergoing surgical treatment, who have increased hospital stay due to the penetrating trauma, hemodynamic instability, hepatic packaging, complications and reoperations.


INTRODUCTION
H epatic trauma corresponds to 5% of admissions in reference centers for the care of the polytraumatized 1-3 . Abdominal traumas especially affect the liver due to its size and anatomical position, the most common mechanism being penetrating trauma [3][4][5][6] .
Treatment of hepatic trauma may be nonoperative or surgical, according to hemodynamic status, associated lesions, and degree of injury, according to the classification of the American Association for the Surgery of Trauma (AAST) 6 . In the last years, non-operative treatment has gained space in the management of hepatic trauma due to greater accessibility to imaging 7,8 .
The non-operative treatment of any solid viscus needs to be performed in a center with availability of imaging, intensive care unit (ICU), and surgical staff 9 .
Surgical treatment is usually indicated for patients who are hemodynamically unstable, with signs of peritonitis or injury to other intra-abdominal structures, or when non-operative management has failed. The objective is to control bleeding and to repair lesions, favoring the survival of critically ill patients, even if associated with a greater number of complications, such as hepatic abscess and biliary fistulas 4,8,10 .
Considering the high morbidity and mortality and the high costs for public health when caring for the polytraumatized, we sought to identify predictors of increased hospitalization time of hepatic trauma patients undergoing surgical treatment, as well as to describe its epidemiology and to identify factors associated with higher mortality. We also analyzed the presence of associated lesions, surgical technique employed in the injury management, the need for other surgical procedures, reoperation, as well as the length of ICU and total hospital stay, and death. We considered hemodynamic instability a systolic blood pressure (SBP) less than 90 mmHg at admission.

METHODS
We divided the patients into two groups: the first consisting of patients who were discharged from the hospital and the second with those who died. The division was performed to reduce the confounding bias for analysis of factors associated with longer hospitalization time.
We described results as means, medians, minimum and maximum values, and standard deviations

RESULTS
We included 191 records in the study, of whom we excluded two due to incomplete data. Of the 189 remaining cases, the majority were male (90.5%), and the mean age was 29 years . The most common mechanism of trauma was gunshot wound (59.8%), followed by stabbing wound (25.4%), automobile accidents (11.1%), trampling (2.1%), and fall from height (1.6%) ( Table 1). Complications occurred in 40.2% of patients, the non-surgical ones being the most frequent (28.6%).
Among the surgical, sepsis with abdominal focus was the main one (23 patients, 12.2%), followed by biliary fistula (9.5%) and intra-abdominal abscess (4.8%).  (Table 3). There was no significant difference regarding sex and imaging at admission.
As for the affected liver lobe, we observed that among the patients who were discharged, the presence of a sole lesion in the left lobe was a factor for shorter stay, both the hospital one and in the ICU, when compared to those who had only the right lobe affected and those injured in both lobes (Table 3).
Patients undergoing hepatorrhaphy and intrahepatic balloon insertion also displayed longer hospital stay than those not submitted to such technique, though with no difference for the ICU stay time. It is worth noting that this technique was not used in isolation in any patient.
When considering each variable individually, we found that the factors significantly associated with death were hemodynamic instability at admission

DISCUSSION
Liver trauma is more common in men aged 20 to 40 years 4,12 . Blunt mechanisms are more frequent than penetrating ones 4,12 . However, in patients undergoing surgical treatment, the penetrating mechanism is the most common (78.5%) 10 . The right lobe of the liver is the most affected 9,10 . Our findings corroborate these data. Tarchouli 14 . The mortality rate of liver trauma ranges from 4.5% to 40%, correlating with severe injuries (grades III, IV, V, and VI), hemorrhagic shock, multiple associated lesions, and the mechanism of trauma, being higher when treatment is surgical 1,10,13,14 .
The duration of hospitalization of individuals with liver trauma can vary between two and 42 days, with an average of 10 days of hospitalization in the intensive care unit 14