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Historic perspective
During the past 2 decades, treatment of blunt hepatic
injuries has dramatically changed. A shift occurred from
operative management emphasizing nonresectional techniques
and packing in the 1980s to selective nonoperative
management in the 1990s and now to nonoperative management
with selective operative management. Decreased mortality
associated with nonoperative management can be credited to
astute observations made by trauma surgeons in concert with
the use of computed tomography (CT) to aid in the diagnosis
of hepatic injuries, availability of angioembolization for
treatment of bleeding hepatic injuries, and appreciation of
the coagulopathy of trauma.3–6 Table 1 summarizes the
success of nonoperative management and its associated low
hepatic-related morbidity and mortality.7–11 Only studies
with more than 50 adult patients with blunt hepatic trauma
treated by nonoperative management were included. A recent
review of the National Trauma Data Base noted that 86.3% of
hepatic injuries are now managed without operative
intervention,12 an even higher percentage than previous
studies reported.7,9 Not surprisingly, more complications
related to nonoperative management are being diagnosed. The
following algorithm focuses on nonoperative management of
blunt hepatic trauma.
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