{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T09:58:53Z","timestamp":1785405533301,"version":"3.56.0"},"reference-count":25,"publisher":"AOSIS","issue":"1","license":[{"start":{"date-parts":[[2026,7,20]],"date-time":"2026-07-20T00:00:00Z","timestamp":1784505600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:p>Background:\u00a0Non-operative management (NOM) has become the standard of care for haemodynamically stable patients with liver trauma, yet robust data from low- and middle-income countries (LMICs) remain scarce, particularly in settings with a high burden of penetrating trauma.\nMethods:\u00a0This single-centre retrospective cohort study analysed 251 adult patients with liver injuries managed non-operatively at a major trauma centre in Johannesburg, South Africa, between January 2017 and December 2023. The primary outcome was in-hospital mortality. Secondary outcomes included 30-day survival and associated injury patterns.\nResults:\u00a0Overall mortality was 1.20% (3\/251; Wilson 95% confidence interval [CI]: 0.41\u20133.45). All deaths occurred within 30 days. Admission lactate was the only variable significantly associated with mortality in the univariate analysis (odds ratio [OR]: 1.53 per 1 mmol\/L increase, 95% CI: 1.11\u20132.10,\u00a0p\u00a0= 0.009). Sensitivity analysis using Firth\u2019s penalised logistic regression yielded consistent results (penalised OR: 1.48, 95% CI: 1.08\u20132.03,\u00a0p\u00a0= 0.015). The American Association for the Surgery of Trauma (AAST) liver injury grade showed no association with mortality. Chest injuries were the most common associated injury (42.6%). Associated injury patterns were consistent across Grades III\u2013V.\nConclusion:\u00a0In appropriately selected haemodynamically stable patients, NOM achieved excellent outcomes despite a substantial polytrauma burden. Physiology, rather than anatomic grade or associated injury pattern, determined survival. These findings support physiology-led selection in resource-constrained environments.\nContribution:\u00a0This study provides key insights into the real-world outcomes of non-operative management (NOM) of liver trauma in a high-volume, resource-constrained South African trauma centre. It demonstrates exceptionally low mortality (1.20%) with physiology-led patient selection despite a high burden of penetrating trauma and polytrauma. The primary contribution is evidence that admission lactate is a strong predictor of mortality, while anatomic injury grade (AAST) is not. These findings reinforce physiology-guided decision-making in LMIC settings and align directly with the journal\u2019s focus on clinical practice and surgical outcomes in Southern Africa.<\/jats:p>","DOI":"10.4102\/jcmsa.v4i1.422","type":"journal-article","created":{"date-parts":[[2026,7,17]],"date-time":"2026-07-17T10:48:45Z","timestamp":1784285325000},"update-policy":"https:\/\/doi.org\/10.4102\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Outcomes of non-operative management of liver trauma in a low- and middle-income country: A single-centre experience from South Africa"],"prefix":"10.4102","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5255-9100","authenticated-orcid":false,"given":"Isabella M.","family":"Joubert","sequence":"first","affiliation":[{"id":[{"id":"https:\/\/ror.org\/03rp50x72","id-type":"ROR","asserted-by":"publisher"}],"name":"University of the Witwatersrand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9299-8431","authenticated-orcid":false,"given":"Mozamil","family":"Mohamed","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/03rp50x72","id-type":"ROR","asserted-by":"publisher"}],"name":"University of the Witwatersrand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7459-3388","authenticated-orcid":false,"given":"Maeyane S.","family":"Moeng","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/03rp50x72","id-type":"ROR","asserted-by":"publisher"}],"name":"University of the Witwatersrand"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2580","published-online":{"date-parts":[[2026,7,20]]},"reference":[{"key":"ref0","unstructured":"World Health Organization. Injuries and violence: The facts. Geneva: World Health Organization; 2024."},{"key":"ref1","doi-asserted-by":"crossref","unstructured":"Dixon J, Smith M, Jenkins L, et al. Preventable trauma deaths in the Western Cape of South Africa. PLoS Glob Public Health. 2024;4(5):e0003122. https:\/\/doi.org\/10.1371\/journal.pgph.0003122","DOI":"10.1371\/journal.pgph.0003122"},{"key":"ref2","unstructured":"Hardcastle TC, Oosthuizen G, Clarke DL, Lutge E. Trauma care in South Africa: An overview. S Afr Med J. 2015;105(9):789\u2013792."},{"key":"ref3","doi-asserted-by":"crossref","unstructured":"Coccolini F, Coimbra R, Ordo\u00f1ez C, et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg. 2020;15:24. https:\/\/doi.org\/10.1186\/s13017-020-00302-7","DOI":"10.1186\/s13017-020-00302-7"},{"key":"ref4","doi-asserted-by":"crossref","unstructured":"Kozar RA, Crandall M, Shanmuganathan K, et al. Organ injury scaling 2018 update: Spleen, liver, and kidney. J Trauma Acute Care Surg. 2018;85(6):1119\u20131122. https:\/\/doi.org\/10.1097\/TA.0000000000002058","DOI":"10.1097\/TA.0000000000002058"},{"key":"ref5","doi-asserted-by":"crossref","unstructured":"Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA. Organ injury scaling: Spleen and liver (1994 revision). J Trauma. 1995;38(3):323\u2013327. https:\/\/doi.org\/10.1097\/00005373-199503000-00001","DOI":"10.1097\/00005373-199503000-00001"},{"key":"ref6","doi-asserted-by":"crossref","unstructured":"Stassen NA, Bhullar I, Cheng JD, et al. Nonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S288\u2013S293. https:\/\/doi.org\/10.1097\/TA.0b013e318270160d","DOI":"10.1097\/TA.0b013e318270160d"},{"key":"ref7","doi-asserted-by":"crossref","unstructured":"Hommes M, Nicol AJ, Van der Vlies CH, et al. Management of blunt liver trauma in 134 severely injured patients in a high-volume trauma centre in South Africa. Injury. 2015;46(5):837\u2013842. https:\/\/doi.org\/10.1016\/j.injury.2014.11.019","DOI":"10.1016\/j.injury.2014.11.019"},{"key":"ref8","doi-asserted-by":"crossref","unstructured":"Brooks A, Davies B, Smethhurst M, et al. Evolution of non-operative management of liver trauma. Trauma Surg Acute Care Open. 2020;5(1):e000551. https:\/\/doi.org\/10.1136\/tsaco-2020-000551","DOI":"10.1136\/tsaco-2020-000551"},{"key":"ref9","doi-asserted-by":"crossref","unstructured":"Van der Wilden GM, Velmahos GC, Emhoff TA, et al. Successful nonoperative management of the most severe blunt liver injuries. Arch Surg. 2012;147(5):423\u2013428. https:\/\/doi.org\/10.1001\/archsurg.2012.147","DOI":"10.1001\/archsurg.2012.147"},{"key":"ref10","unstructured":"Saqib Y, Talving P, Branco BC, et al. Safety and efficacy of non-operative management in high-grade liver trauma: A systematic review. Eur J Trauma Emerg Surg. 2020;46(5):1055\u20131064."},{"key":"ref11","doi-asserted-by":"crossref","unstructured":"Virdis F, Reccia I, Di Saverio S, et al. Clinical outcomes of non-operative management and observation in non-angioembolised hepatic trauma: A systematic review. Chin J Traumatol. 2022;25(4):201\u2013208. https:\/\/doi.org\/10.1016\/j.cjtee.2022.04.004","DOI":"10.1016\/j.cjtee.2022.04.004"},{"key":"ref12","doi-asserted-by":"crossref","unstructured":"Saltzherr TP, Van der Vlies CH, Van Lienden KP, et al. Improved outcomes in the non-operative management of liver injuries. Br J Surg. 2011;98(6):839\u2013846. https:\/\/doi.org\/10.1111\/j.1477-2574.2011.00293.x","DOI":"10.1111\/j.1477-2574.2011.00293.x"},{"key":"ref13","doi-asserted-by":"crossref","unstructured":"Wilson EB. Probable inference, the law of succession, and statistical inference. J Am Stat Assoc. 1927;22(158):209\u2013212. https:\/\/doi.org\/10.1080\/01621459.1927.10502953","DOI":"10.1080\/01621459.1927.10502953"},{"key":"ref14","doi-asserted-by":"crossref","unstructured":"Peitzman AB, Heil B, Rivera L, et al. Blunt splenic injury in adults: Multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma. 2000;49(2):177\u2013185. https:\/\/doi.org\/10.1097\/00005373-200008000-00002","DOI":"10.1097\/00005373-200008000-00002"},{"key":"ref15","unstructured":"Laing GL, Bruce JL, Skinner DL, et al. The burden of trauma at a district hospital in South Africa. S Afr Med J. 2014;104(9):611\u2013615."},{"key":"ref16","unstructured":"Muckart DJ, Bhagwanjee S. American College of Surgeons trauma quality improvement programme versus South African trauma systems. S Afr Med J. 2016;106(10):1010\u20131012."},{"key":"ref17","doi-asserted-by":"crossref","unstructured":"Nicol AJ, Hommes M, Primrose R, et al. Packing for control of hemorrhage in major liver trauma. World J Surg. 2007;31(3):569\u2013574. https:\/\/doi.org\/10.1007\/s00268-006-0070-0","DOI":"10.1007\/s00268-006-0070-0"},{"key":"ref18","unstructured":"Clarke DL, Thomson SR, Madiba TE, et al. Selective nonoperative management of liver trauma in a developing world environment. Br J Surg. 2005;92(7):906\u2013910."},{"key":"ref19","doi-asserted-by":"crossref","unstructured":"Clarke DL, Allorto NL, Thomson SR. An audit of failed nonoperative management of abdominal trauma. Injury. 2010;41(5):488\u2013491. https:\/\/doi.org\/10.1016\/j.injury.2009.10.022","DOI":"10.1016\/j.injury.2009.10.022"},{"key":"ref20","doi-asserted-by":"crossref","unstructured":"Navsaria PH, Nicol AJ, Edu S, et al. Selective nonoperative management of liver gunshot injuries. Ann Surg. 2009;249(4):653\u2013656. https:\/\/doi.org\/10.1097\/SLA.0b013e31819ed98d","DOI":"10.1097\/SLA.0b013e31819ed98d"},{"key":"ref21","unstructured":"Van Waes OJ, Cheriex KC, Navsaria PH, et al. Management of penetrating liver trauma in low-resource settings. World J Surg. 2012;36(4):807\u2013813."},{"key":"ref22","unstructured":"Lepp\u00e4niemi A, Mentula P. Nonoperative management of abdominal trauma: A systematic review. Scand J Surg. 2015;104(3):146\u2013152."},{"key":"ref23","doi-asserted-by":"crossref","unstructured":"Vincent JL, Quintairos e Silva A, Couto L Jr, Taccone FS. The value of blood lactate kinetics in critically ill patients: A systematic review. Crit Care. 2016;20(1):257. https:\/\/doi.org\/10.1186\/s13054-016-1403-5","DOI":"10.1186\/s13054-016-1403-5"},{"key":"ref24","unstructured":"Dezman ZDW, Comer AC, Narayan M, Scalea TM, Hirshon JM, Smith GS. Lactate and other biomarkers as predictors of mortality in trauma patients: A systematic review. 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