Paediatric blunt liver trauma in a Dutch level 1 trauma center

Paediatric blunt hepatic trauma treatment is changing from operative treatment (OT) to non-operative treatment (NOT). In 2000 the American Pediatric Surgical Association has published guidelines for NOT of these injuries. Little is known about the treatment of paediatric liver trauma in the Netherlands.

Data of all patients aged 18 years and younger admitted to our hospital for blunt hepatic trauma in the past 18 years were retrospectively analysed using a prospective trauma registry. The mechanism of injury, treatment, ICU admission time, total admission time, morbidity and mortality were assessed. Subsequently the group was divided into patients treated before and after 2000.

Eighty patients were identified: 52M, 28F with a mean age of 12 years (range 2-18). Thirty patients sustained isolated liver injury. Concomitant injuries were fractures of long bones (28), abdominal (25), chest (24) and head injuries (18). Mean ISS score was 18 (range 4-57). Mortality was 8%. Mechanisms of injury consisted of bicycle (25%), car (20%), and motorcycle accidents (15%), pedestrian hit by vehicle (15%), fall from height (14%) and accidents associated with animals (11%). Haemodynamically stable patients underwent NOT (55). 25 patients (31%) underwent a laparotomy, which in 20 cases (80%) was related to hepatic injury. Although the groups treated before and after 2000 did not differ haemodynamically on admission to hospital, a shift to NOT is evident: 24/37 (63%) patients underwent NOT before 2000 versus 38/45 (84%) after 2000 (p=0.04). Complications following NOT were rare. Late onset bleeding did not occur. Two patients developed an infected biloma, requiring a laparotomy. Mean ICU stay before 2000 was 4.2 days (range 0-25 days) and 2.6 days (range 0-17 days) after 2000. Total hospital time did not decrease: 14 days (range 1-39 days) before 2000 and 14 days (range 1-60 days) after 2000. The overall mortality was 8%. All deaths occurred in the operative group and were spread evenly over both periods.

In blunt paediatric liver trauma, the incidence and trauma mechanism seem age-related. A shift to NOT is found in the treatment of paediatric blunt hepatic trauma. NOT is the preferred treatment for the haemodynamically stable patient. Complications are rare and the success rate is 96%. The mean ICU stay has decreased but the total admission time could possibly be shortened.