Management of liver trauma in urban university hospitals in India: an observational multicentre cohort study

Background Low- and middle-income countries (LMICs) contribute to 90% of injuries occurring in the world. The liver is one of the commonest organs injured in abdominal trauma. This study aims to highlight the demographic and management profile of liver injury patients, presenting to four urban Indian university hospitals in India. Methods This is a retrospective registry-based study. Data of patients with liver injury either isolated or concomitant with other injuries was used using the ICD-10 code S36.1 for liver injury. The severity of injury was graded based on the World Society of Emergency Surgery (WSES) grading for liver injuries. Results A total of 368 liver injury patients were analysed. Eighty-nine percent were males, with road traffic injuries being the commonest mechanism. As per WSES liver injury grade, there were 127 (34.5%) grade I, 96 (26.1%) grade II, 70 (19.0%) grade III and 66 (17.9%) grade IV injuries. The overall mortality was 16.6%. Two hundred sixty-two patients (71.2%) were managed non-operatively (NOM), and 106 (38.8%) were operated. 90.1% of those managed non-operatively survived. Conclusion In this multicentre cohort of liver injury patients from urban university hospitals in India, the commonest profile of patient was a young male, with a blunt injury to the abdomen due to a road traffic accident. Success rate of non-operative management of liver injury is comparable to other countries.


Introduction
Injuries account for 4.8 million lives globally, and deaths due to road traffic injuries alone are among the top 10 causes of mortality [1,2]. Seven to ten percent of all injuries that occur involve the abdominal region, making it the third most common region injured following traumatic brain injury (TBI) and extremity injury [3,4].
Liver and spleen injuries are the commonest damages in blunt abdominal trauma [5].
Promising outcomes of non-operative management (NOM), in paediatric splenic injuries, have shifted the definitive treatment of these injuries from operative management (OM) to NOM [6,7]. Higher grade injuries to the liver can be conserved if the patient is hemodynamically stable [8,9]. NOM is based on the understanding that an injury which appears severe may not necessarily exsanguinate and haemostasis does occur naturally, at least in some cases. NOM is now possible because of multidetector computerised tomography (CT) scan, intervention radiology and intensive care monitoring along with a paradigm shift in the concept of haemostasis [10]. This has decreased the mortality and morbidity in patients with high-grade liver trauma. OM of liver injury is only considered for those who are hemodynamically unstable or if NOM fails [8].
LMICs like India contribute to 90% of all the global injury burden, which is a critical public health issue [11]. Most published literature from India is anecdotal or single-centre studies with small database [12][13][14][15][16]. A multicentre hospital-based registry can help in better understanding the outcomes in the management of organ-specific injuries. In 2013, a four-university hospital registry study, called Towards Improved Trauma Care Outcomes in India (TITCO), was initiated to observe the demography, injury aetiology, management and outcomes of injured patients in urban India [17]. The aim of this study is to conduct a subgroup analysis of patients with liver injuries, managed in one such a large multicentre hospital-based registry in urban India.

Study design
This is a retrospective registry-based study with data extracted from a prospective cohort study called Towards Improved Trauma Care Outcomes in India (TITCO). The TITCO study is a multicentre research consortium of university hospitals formed to develop a trauma registry in India.

Setting
The study was conducted in four public university hospitals in India between October 2013 and December 2015. The hospitals included in the study are from three metropolitan cities, namely Mumbai, Delhi and Kolkata. The hospitals were King Edward Memorial Hospital (KEMH) and Lokmanya Tilak Municipal General Hospital (LTMGH) in Mumbai, Jai Prakash Narayan Apex Trauma Centre (JPNATC) in New Delhi and the Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital (SSKM) in Kolkata.
The urban referral trauma centres are situated in Kolkata, Mumbai (2 centres) and Delhi, cities with populations of more than 10 million. Except for the JPNATC, which is a standalone trauma centre, the others are trauma units providing trauma care as a part of a general hospital. The user fees are nominal and classified as free to public. The hospitals mainly serve the lower socioeconomic strata of the population in their respective area. Each of these hospitals receives 40 to 100 major trauma patients per week. They have round the clock emergency services, imaging, operating theatres and sub-speciality available.

Source and method of participant selection
All admitted patients that presented with history of trauma on arrival to any of the study hospitals were included in the TITCO registry. Data of patients with liver trauma either isolated or concomitant with other injuries was extracted using the ICD-10 code S36.1 for liver injury.

Data collection
Project officers included those with a master in science, who were then trained in the methods of data selection for the study in a workshop format, for a period of 1 week. These trained project officers at each hospital worked 8-h shifts with a rotating schedule between day, evening and night shifts through all days of the week. Data from patients admitted outside of the shift hours was collected retrospectively from the hospital medical records. The patients were followed up until discharge, death or to a maximum of 30 days. If discharged before 30 days, the patients were considered to be alive at 30 days. There was no follow-up after patient discharge or after the 30 days.

Study variables
The primary outcome was 30-day in-hospital mortality following liver injury. Patients who died during their hospital stay up to 30 days were recorded. Those discharged before 30 days were considered to be alive at 30 days. The data set was analysed for patients' demographic profile, mechanism of injury, severity, management and outcome.
The data also included serially recorded parameters like pulse, systolic blood pressure (SBP), Glasgow Coma Score (GCS) and interventions done, if any. Those patients with a systolic blood pressure of ≤ 90 mmHg were considered as hemodynamically unstable having hypotension.
The severity of injury has been graded based on the World Society of Emergency Surgery (WSES) guidelines. WSES grading of liver injuries has been graded based on the American Association of Surgery for Trauma (AAST) scale (anatomical classification of liver injuries) and the hemodynamic stability (physiological parameter) for grading liver injuries from I-IV [8]. The classification has been added as an additional file (see Additional file 1). Management of liver injury in these four centres was not as per the WSES guidelines for liver trauma. WSES liver injury grades were first published in 2015, by which time the participating centres finished data collection.
Patients' management was divided and labelled as operative management (OM) in those who underwent laparotomy and NOM in those who were conservatively managed without a laparotomy. Those patients who survived NOM were labelled as successfully managed. The patients who died after NOM were labelled as NOM failure. The overall management of these patients along with the treatment for other associated injuries was recorded.

Quantitative variables
All continuous variables were represented as mean with their standard deviation and categorical variables as counts and proportions. ISS was represented as median with inter-quartile range.

Results
Demographics and liver trauma profile (Table 1) Out of the 16,047 trauma patients in the TITCO registry, 1134 (7.1%) patients suffered abdominal trauma, of which 368 (32.5%) had liver trauma. Age range varied between 2 and 80 years with the mean age of 26 years with 328 (89%) being males. The main mechanism of injury was road traffic injury (RTI) accounting for 57% of the patients. Among the RTI, the largest group were motorcyclist injuries (30.48%). More than half of the patients were transferred patients from other referral centres (58.2%). 91.5% of the cohort with liver injuries had blunt injuries. Eighty-eight (24.5%) patients presented on arrival with SBP of ≤ 90 mmHg.
Most of liver trauma patients belonged to WSES grades I-III (75%). Nine patients could not be classified as WSES grade as their systolic blood pressure was missing. The most common intra-abdominal injuries associated with liver trauma were spleen (17%) and kidney (14%) (Fig. 1). Eighty-five patients had an associated TBI of which 38 (44.7%) had moderate to severe TBI based on GCS.
Management and outcome in liver injury (Fig. 2) Diagnostic modalities Focused Assessment with Sonography in Trauma (FAST) was done in 345 patients (93.8%), and a CT scan was done in 310 (84.24%) patients included in the study.

Overall mortality
Overall, 30-day in-hospital mortality rate in this cohort of liver injury with/without other injuries was 16.6% (61 out of 368).  (Fig. 2). As per the WSES grades of injury, the NOM success rates were grade I-90.2%, grade II-90.6%, grade III-93.1% and grade IV-81.6%. Death occurred in 26 patients (9.9%). Four of them died within 24 h of arrival, 11 died between 24 h and 7 days after arrival and 11 died after 7 days from arrival (time data of one patient was missing). Of those who died, 7 patients had severe TBI (< 8 GCS and

Operative management
One hundred six patients underwent emergency laparotomy which included various procedures such as packing both perihepatic and intraparenchymal haemostatic packs, direct suture ligation of lacerations, anatomic or nonanatomic segmental hepatectomy for liver injury, splenectomy, nephrectomy and bowel suturing for associated injuries. Of the 106 laparotomies, 43 (40.5%) were for liver and/or other intra-abdominal organs, 45 (42.5%) were for other intra-abdominal organs only (non-liver reasons) and 18(17.0%) were for cause unspecified (Table 2). Twenty-two (20.8%) patients with penetrating injury underwent OM. Of these 22 penetrating injuries, 3 patients died. Among the operated 106 patients, 13 patients (12%) were taken to the operating room within 1 h of admission while the rest underwent surgery within 24 h of admission. Forty-six (43.4%) patients did not get a CT scan done before surgery. As per the WSES grades of injury, of those who underwent OM, 25 (23.6%) had grade I, 32 (30.9%) were grade II, 12 (11.3%) were grade III and 33 (37.7%) were grade IV liver injuries. Of the 69 grade I-III liver injury patients, 24 were operated for liver and/or other associated intra-abdominal organ injury, of which 8 had penetrating injury. The rest 45 were operated for other intraabdominal organ injury (non-liver) or for unspecified reasons ( Table 2).

Discussion
To our knowledge, this is the first analysis of an Indian multicentre cohort of liver injury patients and has one of the largest cohorts analysed in India and probably across LMICs.
In our study, a third of all the abdominal trauma patients had liver injury. More than half were RTI, and the majority were blunt type of injury to the abdomen. In our study, the proportion of liver injuries within the abdominal region was 33% and is similar to other studies   [18][19][20]. However, this is lower than the proportion of 42-52% reported from studies from Africa and Italy [4,21]. In India, blunt abdominal trauma due to RTI is the commonest mechanism of injury except in the state of Jammu and Kashmir (a conflict zone) which has a higher proportion of penetrating abdominal trauma [19]. In countries where assault is common, penetrating injuries are the most common cause of abdominal injury thence liver injuries [22][23][24]. The mean age was 26 years with a predominance of males (89%). This could be as liver injury occurs most commonly in young adults who extensively travel for work and engage in sporting activities compared to women [25]. Our cohort also reflects this, with RTIs being more common in males, compared to females who predominantly have falls. Consequently, liver injuries are common in males.
In our cohort of liver injury patients, 90-93% of the WSES grade I-III liver injuries were successfully managed using non-operative management (NOM) strategy. In WSES grade IV liver injuries, this number of NOM success was reduced to 84%. Progress in the management of liver trauma towards the end of the twentieth century has reduced the mortality [7]. Serial imaging, advancements in critical care and adjunctive therapies like angiography, percutaneous drainage and endoscopy/ endoscopic retrograde cholangiopancreatography management of hepatic injuries have resulted in improved outcomes [9]. Literature suggests most liver injuries of grades I-III are treated by NOM with 82-100% success [9,26,27]. However, studies comparing OM vs. NOM in high-grade liver injury are still evolving [28]. Our comparisons of the two cohorts showed poor outcomes in those undergoing OM. On admission, the OM cohort had poor physiological variables compared to NOM, suggesting this cohort to have more serious injuries. Median ISS of OM cohort (ISS = 14) was significantly less compared to that of NOM cohort (ISS = 17). ISS is a poor predictor of severity in LMICs. This has been repeatedly demonstrated in predictor studies on mortality in trauma [29,30].
In our study, approximately 50% of WSES grade IV liver trauma were managed non-operatively. This is unlike the guidelines and other literature where such kind of injuries would have been operated [9,31]. In our study, we have classified them as WSES grade IV based on the on-arrival systolic blood pressure < 90 mmHg and any grade of injury. Systolic blood pressure is a dynamic process and changes as the patient is being resuscitated. In our opinion, the reasons for non-operative management of these grade IV liver injuries may have been due to (i) improvement of systolic blood pressure after resuscitation (responders or borderline unstable patients), (ii) unavailability of blood and blood products and (iii) lack of protocol directed treatment. Apart from these, 4 of these grade IV liver injury patients had associated severe TBI, which may be a relative contraindication to operate in some centres as the outcomes are poor in patients with severe TBI with hypovolemic shock. Eight of the WSES grade IV injury patients were operated within an hour and the rest within the first 24 h. These delays in LMICs like ours are due to the overwhelming number of emergencies, shortage of human resources and lack of protocol adherence [32,33].

Limitations
Data regarding the patients requiring adjunctive procedure for management of liver injury were not recorded in this study. We do not have data regarding the cause of mortality in patients who were initially managed nonoperatively. Morbidity of NOM was not recorded. The results of this study are generalisable to the urban university hospitals in India and perhaps the other similar university hospitals in LMICs.

Conclusion
In this multicentre cohort of trauma patients from urban university hospitals in India, one third of those with a blunt trauma to the abdomen suffered a liver injury. Operative management was undertaken in less than one third of those with liver injury. Success rate of nonoperative management of liver injury is comparable to other countries.

Funding
The data collection was funded by the Swedish National Board of Health and Welfare and the Laerdal Foundation. There is no funding to report on this submission. Open Access funding provided by Karolinska Institute.

Availability of data and materials
The data are available to whoever wants them by emailing the corresponding author or the last author (MGW). They can write their aim or objective, and then, the authors can decide if that study can be done without duplication of the work.
Ethics approval and consent to participate The TITCO project was granted waivers of informed consent from all study centres. The study received approval from the institutional ethics committee of the four centres involved in the study.