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Blunt liver injury in childhood: evolution of therapy and current perspective
Insights
Nonoperative management is effective for most pediatric liver injuries from blunt abdominal trauma. This approach, aided by advanced imaging, leads to high survival rates with minimal complications in children.
Area of Science:
- Pediatric Surgery
- Trauma Surgery
- Hepatobiliary Surgery
Background:
- Blunt abdominal trauma is a significant cause of injury in children.
- Hepatic parenchymal injuries occur in a notable percentage of these cases.
- Optimal management strategies for pediatric liver trauma remain a focus of research.
Purpose of the Study:
- To evaluate the outcomes of managing hepatic parenchymal injuries in children with blunt abdominal trauma.
- To assess the feasibility and safety of a primarily nonoperative approach.
- To identify complications and survival rates associated with different management strategies.
Main Methods:
- Retrospective review of 188 children with serious blunt abdominal or multisystem trauma.
- Analysis of 53 children diagnosed with hepatic parenchymal injuries.
- Categorization of patients based on operative versus nonoperative management for hemorrhage control.
Main Results:
- 53 of 188 children (28%) had hepatic injuries; 8% required emergency laparotomy for hemorrhage.
- 51 of 53 children (96%) survived without liver-related morbidity.
- Complications included hemobilia (1) and bile peritonitis (3), mostly managed nonoperatively or with delayed reconstruction.
Conclusions:
- A selective, primarily nonoperative management strategy is feasible and effective for most pediatric liver injuries.
- Advanced imaging, such as computerized tomography scanning, facilitates nonoperative management.
- This approach offers high survival rates and low morbidity in pediatric liver trauma.
Abstract:
One hundred eighty-eight consecutive children with serious blunt abdominal or multisystem trauma were evaluated between August 1981 and July 1985. Of the 188 patients, 53 (28%) were found to have hepatic parenchymal injuries and are the basis of this report. Four of the 53 (8%) underwent emergency laparotomy for exsanguinating hemorrhage; two patients died, both of hepatic vein lacerations, and two are alive and well after right hepatic lobectomy. Forty-nine (92%) of the children with liver injuries did not require operation for hemorrhage. Four of these 49 patients developed serious complications; hemobilia occurred in one patient and bile peritonitis occurred in three. The one case of hemobilia was resolved without surgery. One child underwent a delayed operative biliary tract reconstruction that was successful. The other two children required a combination of debridement and drainage procedures. Fifty-one of the 53 children (96%) are currently alive without morbidity related to their liver injuries. Both children who died had multiple trauma including central nervous system injuries and had exsanguinating hemorrhage that required emergency laparotomy at initial evaluation. There were no children with "late" hemorrhage and none who developed septic complications. Nonoperative management of most childhood blunt abdominal trauma is possible. Widespread use of abdominal computerized tomography scanning has made this approach practical. This large series of consecutive liver injuries from a large pediatric trauma center illustrates the advantages and the risks of a selective but primarily nonoperative approach to liver trauma in children.