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Operative intervention for pediatric liver injuries: avoiding delay in treatment
S L Moulton1, F P Lynch, D B Hoyt
1Division of Trauma, Children's Hospital, San Diego, CA.
Insights
Identifying key factors in blunt pediatric liver injuries helps determine operative management needs. This study highlights severe injury characteristics and early transfusion as predictors for surgical intervention in children.
Area of Science:
- Pediatric Surgery
- Trauma Surgery
- Hepatobiliary Surgery
Background:
- Blunt pediatric liver injuries require careful management decisions.
- Nonoperative management is increasingly favored, necessitating identification of factors predicting operative need.
Purpose of the Study:
- To identify physiological and anatomic factors guiding operative management of blunt pediatric liver injuries.
- To differentiate characteristics between nonoperative and operative cases.
Main Methods:
- Retrospective review of 106 pediatric trauma patients with liver injuries over 6 years.
- Comparison of patient groups managed nonoperatively versus operatively.
- Analysis of injury severity scores, imaging findings, transfusion requirements, and operative findings.
Main Results:
- Twenty-one patients with blunt liver injuries underwent laparotomy.
- Operative patients exhibited lower trauma scores, significant lobar disruption with pelvic hematomas, and required early transfusion.
- Major hepatic vein or retrohepatic vena caval injuries were found in 45% of operative blunt liver injury cases, with high mortality.
Conclusions:
- Factors like significant lobar disruption, pelvic hematomas, and early transfusion predict the need for operative intervention in blunt pediatric liver injuries.
- Identifying these factors is crucial for timely surgical decision-making and improving outcomes.
- Selective nonoperative management can be safely applied when these operative indicators are absent.
Abstract:
To identify the physiological and anatomic factors that characterize the need for operative management of blunt pediatric liver injuries, the case records of 106 pediatric trauma victims with liver injuries over a 6-year period were reviewed. Sixty-nine patients were managed without operation (nonoperative) and 37 underwent operation, 7 with penetrating and 30 with blunt liver injuries. Of these 30 patients, 21 underwent laparotomy due to blunt liver injuries (operative); the remaining 9 patients required operation due to associated intraabdominal injuries. Nine (45%) of the 21 operative patients had major hepatic vein or retrohepatic vena caval injuries, 7 of whom died. Overall mortality was 9.4% (10/106). When nonoperative and operative groups were compared, those who underwent laparotomy due to blunt liver injuries: (1) had significantly lower Champion and Pediatric Trauma Scores due to multisystem injury; (2) had 25% or greater lobar disruption with pelvic blood collections on computed tomography scan; (3) underwent early transfusion within 2 hours of admission (18/21); and (4) were frequently found to have a major hepatic vein or retrohepatic vena caval injury at the time of operation. Only one patient successfully managed without operation received greater than 30 mL/kg of blood products within 24 hours of admission. As selective nonoperative management of pediatric liver injuries gains widespread acceptance, the identification of factors that predict the need for operative intervention will limit the potential risks of delay in treatment.