Increased risk of hepatocellular carcinoma in patients with traumatic liver injury: Real-world data from a nationwide population-based study.

ABSTRACT: Hepatocellular carcinoma (HCC) is the sixth most common cancer globally, and liver is one of the most commonly injured organs after blunt abdominal trauma. The traumatic liver injury-HCC risk relationship remains unclear.We extracted data of patients with traumatic liver injury between 2000 and 2013 from Taiwan National Health Insurance Research Database (n = 15,966) and those of age-, gender-, occupation-, and index year-matched individuals without traumatic liver injury from the general population (n = 63,864). Cox proportional hazard models were employed to determine the hazard ratios (HRs) and 95% confidence intervals (CIs) for HCC occurrence in the traumatic liver injury cohort compared with that in the comparison cohort.Patients with traumatic liver injury had an increased HCC risk (adjusted HR 2.13, 95% CI 1.59-2.85); this increased risk was more pronounced within 1 year after injury (adjusted HR 8.84, 95% CI 4.29-18.2). After >1 year of injury, HCC risk remained 1.53-fold higher in patients with traumatic liver injury than in those without traumatic liver injury (95% CI 1.08-2.15).People with traumatic liver injury demonstrate a high HCC risk, particularly within the first year of the injury.

Liver Damage Produced by Malnutrition is Improved by Dietary Supplementation in Mice: Assessment of a Supplement Based on Buriti (A Cerrado Fruit) and Dairy By-products.

BACKGROUND: Malnutrition induced by dietary restriction produces several metabolic changes that affect body weight, the digestive system, and annex organs, including the liver. Malnutrition generates an inflammatory state and increases oxidative stress. The liver is one of the body vital organs, becoming necessary to analyze the impact of food supplementation on the repair of possible changes that may occur in this organ due to malnutrition. AIMS: To evaluate the effects of a low-cost supplementation derived from Buriti and dairy byproducts on liver recovery in malnourished mice, focusing on the expression of oxidative stressrelated genes, as well as biochemical and histological parameters. METHODS: Swiss mice were divided into six groups and submitted to two treatment phases: food restriction, for malnutrition onset; and renutrition, with mice being fed with different diets. RESULTS: Our results indicate that dietary supplementation was successful in recovering liver damage caused by malnutrition in animal models. The new supplement has been shown to recover liver damage with similar or superior results compared to the commercial reference supplement on the market. CONCLUSION: Our work presents a new composition of low cost food supplement based on buriti and dairy by-products, proven to be effective in the malnutrition treatment of malnutrition. The improvements were proven through the recovery of body weight, reduction of inflammation and oxidative stress.

The additional value of the arterial phase in the CT assessment of liver vascular injuries after high-energy blunt trauma.

PURPOSE: In the literature, no consensus exists about which CT protocol is to be adopted in patients who underwent high-energy blunt trauma. The aim of the study is to evaluate the additional value of the arterial phase in the CT assessment of vascular injuries of the liver. METHODS: Admission CT examinations for patients with traumatic injury of the liver due to high-energy blunt trauma, performed between 2011 and 2017 in two major trauma centres, were retrospectively reviewed. Images were analysed for presence or absence of liver parenchymal injury, intrahepatic contained vascular injuries and active bleeding in the arterial and portal venous phase of the CT study. RESULTS: Two hundred twelve patients have been identified. Parenchymal injuries were detected as isolated in 90.6% of cases, whereas they were associated with vascular injuries in 9.4% of cases: contained vascular injuries in 3.3% and active bleeding in 6.1%. Out of all parenchymal injuries detected on the CT portal venous phase, 90.5% were also detectable in the arterial phases (p < 0.0001). All of the contained vascular injuries were visible in the CT arterial phase, whereas they were detectable in 28.5% of cases also during the venous phase (p = 0.02). All 13 cases of active bleeding were detected on the CT venous phase, and 76.9% of these cases were also revealed in the arterial phase, thus confirming their arterial origin (p = 0.22). CONCLUSION: The addiction of the arterial phase to the venous phase in the CT assessment of patients who underwent high-energy blunt trauma allows an accurate identification and characterization of traumatic vascular injuries, so distinguishing between patients suitable for conservative management and those requiring interventional or surgical treatment.

Biliovascuar complications: a price to pay for non-operative management of major liver trauma.

BACKGROUND: With non-operative management of major liver trauma, there has been an increased incidence of biliovascular complications which are reported variably. METHODS: Fifty-six patients with age of 29.79±11.40 years and M:F 8.3:1, with grade III or more liver trauma were evaluated after stabilization for the development of liver related complications. Patients with active contrast extravasation at admission were managed with immediate angioembolization. Patients with prolonged hospital stay underwent repeat CT prior to discharge. Radiological, endoscopic and surgical interventions were carried out as appropriate. RESULTS: Ninety-eight percent had blunt abdominal injury. Mean injury severity score was 25.68±10.389. Four (7%) required damage control laparotomy. CECT showed grade III injuries in 52%, grade IV in 30.4%, and grade V in 18%. 11% had laceration extending to porta. Seventeen patients had 21 liver-related complications: 4 biliary, 12 vascular and 1 combined biliary and vascular. Liver related complications were- 3.5% in grade III, 52% in grade IV and 70% in grade V. One patient with active arterio-portal fistula required urgent angioembolization while other arterial pseudoaneurysms were detected 7.23±5.14 days after trauma. Angioembolization was successful in 83% patients. On univariate and multivariate analysis, PRBC requirement and injury grade were the predictors of bilivascular complications. Laceration extending to porta was a predictor for biliary complications and not vascular. Repeat CT picked up 13 complications in 10 patients. CONCLUSIONS: Biliovascular complications are managed by multidisciplinary approach. Lacerations extending to porta and grade IV/V injuries have a higher chance of developing biliovascular complications and should be observed closely.

Assessment of serum bile acid profiles as biomarkers of liver injury and liver disease in humans.

To assess the potential of individual bile acids (IBA) and their profiles as mechanistic biomarkers of liver injury for humans in real world situations, we interrogated samples collected under minimum controlled conditions (ie subjects were not fasted). Total bile acids (TBA) have been considered to be biomarkers of liver injury for decades, and more recently, monitoring of IBA has been proposed for differentiation of variety of etiologies of liver injury. We established a LC-MS/MS methodology to analyze nine IBA, generated reference ranges, and examined effects of age, gender, and ethnicity for each IBA. Furthermore, we evaluated the ability of IBA and their profiles to detect hepatic injury in subjects with a broad range of liver impairments. To date, our study utilized the largest total cohort of samples (N = 645) that were divided into 2 groups, healthy or liver impaired, to evaluate IBA as biomarkers. The TBA serum levels in the Asian ethnic group trended higher when compared to other ethnic groups, and the serum concentrations of IBA, such as glycocholic acid (GCA), glycochenodeoxycholic acid (GCDCA), chenodeoxycholic acid (CDCA), and taurochenoxycholic acid (TCDCA) were significantly increased. To our knowledge, this report is the first to describe ethnic differences in serum concentrations of IBAs. In patients with hepatic impairments, with the exception of deoxycholic acid (DCA), the concentrations of IBAs were significantly elevated when compared with healthy subjects. The conjugated bile acids displayed greater differences between healthy subjects and subjects with hepatic impairments than non-conjugated bile acids. Furthermore, the subjects with hepatic impairments exhibited distinct profiles (signatures) of IBAs that clustered subjects according the nature of their liver impairments. Although additional studies are needed, our data suggested that the analysis of IBA has the potential to become useful for differentiation of various forms of liver injury.

Early mobilization of patients with non-operative liver and spleen injuries is safe and cost effective.

PURPOSE: There is no standard protocol for the management of non-operative liver or spleen injuries (LSI). In 2011, our institution changed the non-operative management (NOM) protocol of LSI from prolonged bed rest (PBR) to early mobilization (EM). We aim to show that EM safely decreases length of stay (LOS), ICU LOS, and cost. METHODS: We conducted a retrospective review in which non-operative LSI patients observed PBR from January 2008 through July 2011 and were mobilized early from August 2011 through December 2014. Endpoints assessed were length of bed rest, hospital LOS, ICU LOS, failure of NOM, cost, angiography/embolization, and mortality. RESULTS: There were a total of 184 patients with LSI who met study criteria and were not excluded. 77 patients utilized PBR between 2008 and 2011 and 107 followed EM protocol between 2011 and 2014. There was no significant difference in the male to female ratio, age, ISS, anticoagulant use, or MOI. Both groups had similar injury profiles. PBR included 34 liver injuries, 45 splenic injuries and two patients with both. EM included 63 liver injuries, 55 splenic injuries and 11 patients with both (for liver injury p = 0.053, for splenic injury p = 0.37, and for combined p = 0.08). LOS and cost were significantly decreased in the EM cohort. LOS was shortened by 1.07 days (p = 0.005) and cost of hospitalization was reduced by $7077 (p = 0.046). There was no difference in NOM failure, angiography/embolization, or mortality. CONCLUSION: EM in non-operative LSI is safe and cost-effective. It results in decreased LOS and cost without increasing failure of NOM, angiography, embolization, or mortality.

Minimizing variance in Care of Pediatric Blunt Solid Organ Injury through Utilization of a hemodynamic-driven protocol: a multi-institution study.

BACKGROUND: An expedited recovery protocol for management of pediatric blunt solid organ injury (spleen, liver, and kidney) was instituted across two Level 1 Trauma Centers, managed by nine pediatric surgeons within three hospital systems. METHODS: Data were collected for 18months on consecutive patients after protocol implementation. Patient demographics (including grade of injury), surgeon compliance, National Surgical Quality Improvement Program (NSQIP) complications, direct hospital cost, length of stay, time in the ICU, phlebotomy, and re-admission were compared to an 18-month control period immediately preceding study initiation. RESULTS: A total of 106 patients were treated (control=55, protocol=51). Demographics were similar among groups, and compliance was 78%. Hospital stay (4.6 vs. 3.5days, p=0.04), ICU stay (1.9 vs. 1.0days, p=0.02), and total phlebotomy (7.7 vs. 5.3 draws, p=0.007) were significantly less in the protocol group. A decrease in direct hospital costs was also observed ($11,965 vs. $8795, p=0.09). Complication rates (1.8% vs. 3.9%, p=0.86, no deaths) were similar. CONCLUSIONS: An expedited, hemodynamic-driven, pediatric solid organ injury protocol is achievable across hospital systems and surgeons. Through implementation we maintained quality while impacting length of stay, ICU utilization, phlebotomy, and cost. Future protocols should work to further limit resource utilization. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level II.

Focused assessment with sonography for trauma (FAST) identifies liver injury following cardiopulmonary resuscitation.

Liver trauma is a recognised rare complication of cardiopulmonary resuscitation (CPR) and may be difficult to detect. We report a case of intraperitoneal haemorrhage due to liver injury following CPR in a 50-year-old man admitted to the intensive care unit. The haemorrhage was diagnosed with focused assessment with sonography for trauma (FAST). FAST can rapidly and easily diagnose liver injury. FAST is recommended for excluding haemoperitoneum in patients who are haemodynamically unstable after resuscitation.

Prospective validation of the shock index pediatric-adjusted (SIPA) in blunt liver and spleen trauma: An ATOMAC+ study.

BACKGROUND: Age-adjusted pediatric shock index (SIPA) does not require knowledge of age-adjusted blood pressure norms, yet correlates with mortality, serious injury, and need for transfusion in trauma. No prospective studies support its validity. METHODS: A multicenter prospective observational study of patients 4-16years presenting April 2013-January 2016 with blunt liver and/or spleen injury (BLSI). SIPA (maximum heart rate/minimum systolic blood pressure) thresholds of >1.22, >1.0, and >0.9 in the emergency department were used for 4-6, 7-12 and 13-16year-olds, respectively. Patients with ISS ≤15 were excluded to conform to the original paper. Discrimination outcomes were compared between SIPA and shock index (SI). RESULTS: Of 1008 patients, 386 met inclusion. SI was elevated in 321, and SIPA elevated in 282. The percentage of patients with elevated index (SI or SIPA) and blood transfusion within 24 hours (30% vs 34%), BLSI grade ≥3 requiring transfusion (28% vs 32%), operative intervention (14% vs 16%) and ICU admission (64% vs 67%) was higher in the SIPA group. CONCLUSION: SIPA was validated in this multi-institutional prospective study and identified a higher percentage of children requiring additional resources than SI in BLSI patients. SIPA may be useful for determining necessary resources for injured patients with BLSI. LEVEL OF EVIDENCE: Level II prognosis.

Development and assessment of kerateine nanoparticles for use as a hemostatic agent.

Uncontrolled bleeding frequently occurs in some emergencies which can result in severe injury and even death. Keratin hydrogel has been found that it had good ahemostatic efficacy in the previous studies. However, an ideal hemostatic agent should not require mixing or preparation in advance, and hydrogel is not easy to store and carry. In the present study, the kerateine was firstly extracted from human hair, and then was prepared nanoparticles by a modified emulsion diffusion method. The synthesized nanoparticles showed spherical morphology with an average diameter of approximately 200 nm. The results of Fourier transform infrared spectroscopy and X-ray diffraction indicated that the chemical structure of kerateine did not change but the crystal form may be transformed in the nanoparticles. In addition, kerateine nanoparticles displayed a faster clotting time in vitro study than the kerateine extracts. Furthermore, kerateine nanoparticles significantly reduced the blood loss and coagulation time in the liver puncture and tail amputation in rat models. Our results indicated that kerateine nanoparticles could quickly form a high viscosity gel onto the wound and accelerate the blood coagulation based on their high specific surface area. Therefore, kerateine nanoparticles have great potential for hemostatic application.

Impact of haemorrhagic shock intensity on the dynamic of alarmins release in porcine poly-trauma animal model.

PURPOSE: Traumatic insults result in an altered inflammatory response, in which alarmins release has a central role. The impact of haemorrhagic shock intensity on the long-term kinetics of alarmins is not yet fully elucidated. We investigated these aspects in a combined trauma (chest, abdominal, and extremities injury) porcine model with different severities and durations of haemorrhagic shock. METHODS: After induction of combined trauma (tibia fracture, lung contusion, and liver laceration), haemorrhagic shock was induced at different intensities: moderate haemorrhage (MH; n = 15): mean arterial pressure (MAP) <30 ± 5 mmHg [maximum loss of total blood volume (TBVmax): 45 %] for 90 min, and severe haemorrhage (SH; n = 10): MAP <25 ± 5 mmHg (TBVmax 50 %) for 120 min. Resuscitation was performed using a standardized crystalloid infusion protocol. Animals were mechanically ventilated and underwent ICU-monitoring for 48 h (MH) and 48.5 h (SH). Blood samples were collected over the clinical time course, and systemic levels of serum alarmins [High-Mobility Group Protein B-1 (HMGB-1) and Heat Shock Protein 70 (HSP70)] were measured using an ELISA kit. RESULTS: Heart rate, systemic blood pressure, lactate, and base excess were significantly altered as a function of haemorrhagic shock in both trauma groups (MH and SH). Systemic HMGB-1 levels were significantly elevated in both trauma groups when compared to the sham group. Haemorrhagic shock severity and duration were positively correlated with HMGB-1 levels and compared to baseline values, concentrations remained significantly increased in SH when compared to MH. On the other hand, we observed a significant decrease in the systemic HSP70 levels of trauma groups (MH, and SH) when compared to the sham group, which was significantly decreased compared to baseline values in SH over the entire time course. CONCLUSION: Our data show that haemorrhagic shock duration and severity affect the systemic levels of HMGB-1 and HSP70. This early alarmins release after trauma can be used to guide the treatment strategies (e.g. surgical procedures) of polytrauma patients.

Interhospital transfer of liver trauma in New Mexico: a state of austere resources.

BACKGROUND: There is debate in the trauma literature regarding the effect of prolonged prehospital transport on morbidity and mortality. This study analyzes the management of hepatic trauma patients requiring surgery and compares the outcomes of the group that was transferred to the University of New Mexico Hospital (UNMH) from outside institutions, to the directly admitted group. MATERIALS AND METHODS: The UNMH Trauma Database was queried from 2005-2012. Of 674 patients who sustained liver injuries, 163 required surgery: 46 patients (28.2%) underwent interhospital transfer, and 117 (71.8%) were directly admitted. Variables examined included transfer status, trauma mechanism, transport type, injury severity score (ISS), liver injury grade, and associated injuries. Outcome variables included length of stay (LOS) and 30-day mortality. Outcomes of the transfer group (TG) and direct admit group (DAG) were compared. RESULTS: Both TG and DAG had the same median age (31 y, P = 0.33). The blunt-to-penetrating ratio was the same for each group (48% blunt: 52% penetrating, P = 1.0). Median ISS was 25 for the TG and 26 for the DAG. Grade III or higher injury occurred in 29 (63%) of the TG and in 68 (58%) of the DAG (P = 0.56). Median hospital LOS was 14 d for TG and 9 d for DAG (P = 0.15). Median intensive care unit LOS was 4 d for both groups (P = 0.71). Thirty-day mortality was 20% in each group (P = 0.27). Using a multiple logistic regression model for the outcome of mortality, only age, ISS, and liver injury grade, not transfer status or transport type, had a significant effect on mortality. CONCLUSIONS: There was no significant difference in liver injury grade, ISS, LOS, and mortality between TG and DAG. In the patient population of our study, transfer status did not affect outcome.

The impact of solid organ injury management on the US health care system.

BACKGROUND: Since the 1980s, there has been a paradigm shift toward nonoperative management of stable patients with solid organ injury. The impact of this practice change on national health care expenditure has not been well characterized. METHODS: Hospital discharge data from the Healthcare Cost Utilization Project Nationwide Inpatient Sample from every other year spanning 1994 to 2010 were studied using patients with a primary diagnosis of splenic and liver injury. Cost analysis was performed using cost-to-charge ratios, where actual costs of hospitalization with current management practices were compared with theoretical costs projecting 1994 practice patterns. Length of stay (LOS) was evaluated similarly to costs. Mortality risk was established using the validated Trauma Mortality Prediction Model. RESULTS: Data from 29,409 adult patients with splenic injury and 14,704 with liver injury were used for cost and LOS analysis. The proportion of patients undergoing nonoperative management increased from 38% to 67% for splenic injury and from 62% to 81% for liver injury. The mean cost for splenic injury dropped by $8,421 per patient, a net reduction in total costs per admission of 29.5% (p < 0.0001), resulting in a mean estimated $12 million per year reduction in cost of care in 2008 alone. For liver injury, cost has been reduced by $8,822 per patient, a 27.7% reduction (p < 0.0001), with a net $17 million per year savings. LOS has been reduced by a mean ± SE of 1.9 ± 0.7 days per splenic injury (p = 0.0001) and 2.2 ± 0.9 days for liver injury (p = 0.0001). Mortality rate of high-risk patients (Trauma Mortality Prediction Model > 0.3) treated conservatively for splenic injury fell from 30% to 20% and from 64% to 18% for liver injury. CONCLUSION: The trend toward nonoperative management of solid organ injury has resulted in a substantial decrease in health care expenditure and LOS while improving mortality for high-risk patients. Advances in trauma care can have significant impact on the cost of health care. LEVEL OF EVIDENCE: Economic analysis, level III.

Assessment of the efficacy and potential complications of transjugular liver biopsy in canine cadavers.

BACKGROUND: Transjugular liver biopsy (TJLB) is used in humans at risk of bleeding. There are no reports of its use in veterinary medicine. OBJECTIVE: To assess the efficacy and potential complications of TJLB in canine cadavers, and compare with samples obtained via needle liver biopsy (NLB) and surgical liver biopsy (SLB). ANIMALS: Twenty-five medium and large breed canine cadavers. METHODS: Prospective study. TJLBs were procured through the right jugular vein. After biopsy, intravenous contrast and gross inspection were used to assess the biopsy site. Minor and major complications were recorded. NLBs and SLBs were then obtained. Histopathology was performed, and TJLB and NLB were compared for number of complete portal tracts (CPTs), length, and fragmentation. Pathologic process and autolysis were assessed in all samples. RESULTS: All TJLBs yielded liver tissue. The proportion of minor complications was 12/25 (48%), and major complications 16/25 (64%); 13/16 (81%) of the major complications were liver capsule perforation. In 21/25 (84%), the histopathology in the SLB was reflected in the TJLBs. For cases with minimal autolysis, median number of CPTs in TJLBs was 7.5, compared with 4 in NLBs (P = .018). Median length of TJLB specimen was 28 mm compared to 22 mm in NLBs (P = .007). Fragmentation rate was median of 1.25 for TJLB compared to 1.50 in NLBs (P = .11). CONCLUSIONS AND CLINICAL IMPORTANCE: TJLB is technically feasible and achieves comparable results to NLB and SLB. The number of complications, in particular liver capsule perforation, was greater than expected. Further studies are indicated before clinical use is recommended.

The quantification of liver anatomical changes and assessment of occupant liver injury patterns.

Liver injuries can be significant in vehicle crashes. In this study, the liver anatomy was quantified in both adult and pediatric populations as a function of gender and age. Five anatomical liver measurements were determined using CT scans of 260 normal livers. These measurements include the area and volume, and the length, width, and girth of the liver (IRB HUM00041441). To characterize geometrical shape, an inscribed sphere and circumscribed ellipsoid were fitted on the measurements. In the pediatric population the liver area and volume continuously increased with age. When normalized by patient weight, volume measurements show a decrease in volume with age, suggesting that the liver occupies a smaller proportion of the body with age. In the adult population, liver measurements varied with gender. The superior and inferior locations of the liver were also recorded with respect to the spine. The lower portion was at the L3 in small children and at L2 as children approached puberty. It stayed in that area through the 60+ group, offering more ribcage protection. Liver injury patterns were also assessed in crash occupants. Seventy-two occupants with moderate to severe (AIS 2+) liver injuries were investigated. A new methodology was presented and consisted of quantifying blood volumes. The results were compared to overall liver volume and injury scales. No clear distinction on the injury pattern was observed by age group. Liver injuries were more commonly associated with AIS 2+ thoracic injuries in adults than in children. Most injuries occurred in the right lobe.

Focused Assessment with Sonography for Trauma in patients with confirmed liver lesions.

BACKGROUND AND AIMS: The objective was to determine the sensitivity and specificity of Focused Assessment with Sonography for Trauma (FAST) in patients with confirmed liver lesions and also to compare results from surgeons trained in FAST with results from radiologists trained in general abdominal ultrasound as part of the specialist training. Explorative laparotomy or CT served as gold standard. MATERIALS AND METHODS: This retrospective study included all patients admitted to our institution from 2003 to 2010 registered with the diagnosis "Injury of the liver or gallbladder". Of 405 patients, 135 patients were eligible for analysis. Seventy-two patients were examined by radiologists and 63 by surgeons. RESULTS: We found FAST to have a sensitivity, specificity, PPV, and NPV of 79.6%, 100%, 100%, and 68.9%. There was no statistically significant difference between FAST performed by radiologists and surgeons trained in FAST. CONCLUSION: FAST remains an important screening tool in abdominal trauma including liver lesions, and can be performed at a satisfactory level by surgeons trained in the FAST procedure only.

[Comparative assessment of the reparative process of wounds of the liver and kidneys depending on the kind of plastic material in experiment].

In 52 rabbits a morphological assessment was made of regeneration of wounds of the liver and kidneys after their plasty with a seromuscle flap of the stomach on the vascular pedicle (26 rabbits), of hepatorhaphy and omentonephroplasty (26 rabbits) within the period from 1 to 360 days and was compared with literature data concerning reparation of the liver and kidney of the rabbit with the application of bio- and polymer materials for covering their wounds. The influence of plastic properties of the materials used on the productivity of the inflammatory-reparative process was established. In suturing the wounds of parenchymatous organs it is necessary to use plastic materials stimulating regeneration. The application of seromuscle flap of the stomach for these purposes improves the inflammatory-reparative process making it more productive as compared with bio- and polymer materials.

Comparison of transcutaneous contrast-enhanced ultrasound-guided injected hemostatic agents with traditional surgery treatment for liver, spleen and kidney trauma: a retrospective study.

BACKGROUND/AIMS: There is lack of studies on the effectiveness of transcutaneous contrast-enhanced ultrasound-guided injections of hemostatic agents for liver. spleen and kidney trauma. We compared treatment by hemostatic agents to surgical treatment in a retrospective interventional human study. METHODOLOGY: The study enrolled a total of 135 subjects from emergency unit of the Chinese People's Liberation Army General Hospital in Beijing. Within the cohort, 62 patients received contrast enhanced ultrasound-guided injection of hemostatic agents and the rest received surgical treatments. RESULTS: The injury severity score was lower in the hemostatic agent treatment group than surgical treatment group (p<0.05), but Glasgow coma scale scores did not reach statistical significance. The patients in the surgical treatment group had significantly higher hospital fees than those in the hemostatic treatment group (p<0.05), although the length of hospitalization did not significantly differ between two groups. Safety outcome variables pre- and post-treatment remained within normal limits in both groups. CONCLUSIONS: Hemostatic agents were more cost-effective than surgery to treat patients with liver, spleen and kidney trauma. However, given the limited sample size, subsequent studies drawing upon larger populations from multiple medical centers are necessary for follow-up.