Nonoperative management of penetrating abdominal solid organ injuries in children

Nonoperative management (NOM) of penetrating solid organ injuries (SOI) has not been well described in the pediatric population. The objective of this study was to characterize the epidemiology, injury patterns, and factors associated with trial and failure of NOM.

This is a retrospective cohort analysis of the National Trauma Data Bank for the period of 2007-2014. The study population included patients ≤18 y with penetrating injury to the liver, spleen, or kidney. NOM was defined as no operative intervention (exploratory laparotomy or operation involving the liver, spleen, or kidney) < 4 h of emergency department arrival. Failed NOM was defined as operative intervention ≥4 h after emergency department arrival. Multivariate logistic regression explored clinical factors potentially associated with trial and failure of NOM.

Of 943,000 pediatric trauma patients included in the National Trauma Data Bank, 3005 (0.32%) met our inclusion criteria. Median age was 17.0 y; 88.8% were male. Gunshot wounds (GSW) accounted for 71.7% of injury mechanisms and stab wounds accounted for the remaining 28.3%. Median injury severity score was 9 (interquartile range: 5-13). Two thousand one hundred and twenty-one (70.6%) patients sustained kidney injury, 1210 (40.3%) liver injury, and 159 (5.3%) splenic injury. NOM was pursued in 615 (20.5%) patients. Factors significantly associated with immediate operative intervention included GSW, hypotension, and associated hollow viscus injury. Failed NOM was identified in 175 patients (28.5%). Factors significantly associated with failed NOM included GSW, high-grade SOI, and associated hollow viscus injury. Overall mortality was 26 (0.9%).

NOM can be safe in a carefully selected group of pediatric patients with penetrating SOI. Future prospective studies are warranted to validate its feasibility.