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“While small lacerations of the liver substance may be, and no doubt are, recovered from without operative interference: if the laceration be extensive and vessels of any magnitude are torn, hemorrhage will, owing to the structural arrangement of the liver, go on continuously.” J.H. Pringle, 1908 1 Operative therapy has been the standard of care for liver injuries from the beginning of the century until the beginning of the 1990s. This has been based on the dual rationale of hemostasis and bile drainage. In 1991 we reported a prospective comparative trial of methods of liver drainage in 482 consecutive patients with liver injuries undergoing operative management. 2 In that trial it was shown that lack of bile drainage did not adversely affect outcome. A “paradigm shift” is said to occur when the rules governing a process are fundamentally changed, and such is the case with the treatment of liver injuries. Since the early 1980s, sporadic reports of adult patients with blunt hepatic trauma treated nonoperatively have appeared in the literature. 3–18 Two large series of nonoperative management, one of 495 patients collected from a literature review 19 and the other of 404 patients from the collective experience of 13 level 1 trauma centers, 20 were reported in 1995 and 1996, respectively. However, there were drawbacks to these larger studies. First, the numbers of patients from the individual series or centers were small (16–72 patients). Second, the criteria for nonoperative management were not uniform, so the percentage of patients with blunt hepatic injury who were treated nonoperatively varied from 17% to 60%. Finally, nearly all reports either described only the nonoperatively managed patients, or compared them with operatively managed patients in the same period. Those characteristics make it difficult to compare the results of operative versus nonoperative therapy because the groups are not comparable relative to the degree of hepatic injury. Similarly, we cannot draw valid conclusions about the total impact that this new method of management has had on the overall outcome of blunt hepatic trauma. In an attempt to address some of the questions about nonoperative management, we previously conducted a prospective pilot study in which all hemodynamically stable patients with blunt hepatic trauma, regardless of grade of injury or amount of hemoperitoneum, were managed nonoperatively. 17 The outcomes of nonoperatively managed patients were compared with a matched cohort of patients who had been operatively managed from the previous study. 2 Encouraged by the results, nonoperative management has been applied to all hemodynamically stable patients with blunt hepatic injury at our institution since that time. The current study consists of 661 consecutive patients with blunt hepatic trauma during the recent 5-year period during which all hemodynamically stable patients were managed nonoperatively. Results of management in the most recent cohort are compared with the two previous studies to assess the impact of this fundamental change in therapy. This study was performed to address two specific issues: first, the outcome of hemodynamically stable patients with blunt hepatic injury managed nonoperatively, and second, the impact of this approach on the outcome of all blunt hepatic injuries.

Objective: Computed tomographic angiography (CTA) by 16-channel multidetector scanner is increasingly replacing conventional digital subtraction angiography (DSA) for diagnosing or excluding blunt carotid/vertebral injuries (BCVI). To date there has been only 1 study in which all patients received both examinations. That study reported a high accuracy for 16-detector CTA. The current prospective parallel comparative study aims at validating this high accuracy and examining the rates of evaluability of CTA performed with a 16-detector scanner with image reconstruction by modem imaging software. Methods: Patients at risk for BCVI (facial/cervical-spinal fractures; unexplained neurologic deficit; anisocoria; lateral neck soft tissue injury; clinical suspicion) underwent both CTA (16-channel multidetector scanner) and DSA. Results of the 2 studies and the clinical course were prospectively recorded. Results: During the 40-month study period ending March 2007, approximately 7000 blunt trauma patients were evaluated and of these 119 (1.7%) consecutive patients meeting inclusion criteria were screened by CTA. Ninety-two patients underwent confirmatory DSA. Twenty-three (22%) DSA identified 26 BCVI (vertebral, 13; carotid, 13). Among these 23 CTAs, 17 identified 19 BCVIs (vertebral, 10; carotid, 9) (true positives), and 6 failed to identify 7 BCVIs (vertebral, 3; carotid, 4) (false negatives). Sixty-nine of the 92 DSA were normal. Of these 69 CTAs, 10 were falsely suspicious for 11 BCVIs (vertebral, 7; carotid, 4) (false positives), and 56 were normal (true negatives). The remaining 3 CTAs were nonevaluable (mistimed contrast, 1; streak artifact, 2). Sixteen of 89 (18%) evaluable CTAs, were suboptimal (mistimed contrast, 9; streak artifacts, 4; motion artifact, 2; body habitus, 1). Excluding the 3 nonevaluable CTAs, the sensitivity, specificity, positive and negative predictive values of CTA for diagnosing or excluding BCVI were 74%, 86%, 65%, and 90% respectively. One patient with grade II carotid artery injuries (by CTA and DSA) on antiplatelet agent developed stroke related to carotid artery injuries. Conclusions: Current CTA technology cannot reliably diagnose or exclude BCVI. Twenty percent of CTAs are either nonevaluable or suboptimal. Until more data are available and the technique is standardized, the current trend towards using CTA to screen for and/or diagnose these rare but potentially devastating injuries is dangerous.