Outcomes of non-operative management of liver trauma in a low- and middle-income country: A single-centre experience from South Africa

Background: Non-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. Methods: This 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. Results: Overall mortality was 1.20% (3/251; Wilson 95% confidence interval [CI]: 0.41–3.45). 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: 1.11–2.10, p = 0.009). Sensitivity analysis using Firth’s penalised logistic regression yielded consistent results (penalised OR: 1.48, 95% CI: 1.08–2.03, p = 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–V. Conclusion: In 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. Contribution: This 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’s focus on clinical practice and surgical outcomes in Southern Africa.