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The nonoperative management of pediatric hepatic trauma
Insights
Nonoperative management is effective for pediatric blunt liver injuries when patients are carefully selected. This approach avoids surgery in most cases, with injuries resolving over several months.
Area of Science:
- Pediatric Surgery
- Trauma Management
- Abdominal Imaging
Background:
- Nonoperative therapy is standard for pediatric renal and splenic injuries.
- Surgical repair has been the traditional approach for blunt hepatic injuries in children.
- Limited data exists on nonoperative management for pediatric blunt liver trauma.
Purpose of the Study:
- To evaluate the efficacy and safety of nonoperative management for pediatric blunt hepatic injuries.
- To identify clinical criteria for selecting pediatric patients with liver trauma for nonoperative treatment.
- To describe the healing process of blunt liver injuries managed nonoperatively.
Main Methods:
- Retrospective review of 17 pediatric patients (2-13 years) with blunt liver trauma.
- Patient selection based on clinical assessment and initial computed tomography (CT) findings.
- Serial CT scans used to monitor injury progression and document healing.
Main Results:
- All 17 patients were successfully managed nonoperatively with initial resuscitation.
- 15 of 17 injuries resolved without surgical intervention.
- Mean resolution time was 4 months; one patient developed a late hematoma that resolved spontaneously.
Conclusions:
- Careful patient selection allows for successful nonoperative management of pediatric blunt hepatic injuries.
- Nonoperative treatment can avoid surgery in most cases of pediatric liver trauma.
- CT imaging is crucial for diagnosis, selection, and monitoring of healing in these injuries.
Abstract:
Although nonoperative therapy is well-accepted for renal and splenic injuries in children, this mode of treatment has not been widely advocated for children with blunt hepatic injury. Surgical repair or excision of the traumatized tissue has been the generally accepted standard of care. In the present series, 17 consecutive children between 2 and 13 years of age with liver trauma were managed by nonoperative means. Patients were carefully selected for treatment based on clinical criteria and initial computed tomography (CT) scan findings. The 17 patients with hepatic trauma identified by CT scan all responded to initial resuscitative measures. The children clinically remained stable and required only a limited number of transfusions. No immediate surgical intervention was necessary for isolated hepatic injuries. However, one patient required exploration due to an associated renal pedicle avulsion. One child required exploration on the fourth post-injury day because of a suspected infected hematoma. The remaining 15 injuries resolved without operation. Healing was documented on follow-up CT scans. The mean time required for resolution of the injury was 4 months. One child developed a late subhepatic hematoma which resolved without drainage. The progression of healing of hepatic parenchymal injuries was observed by serial CT scans. The liver injury progressed through stages of coalescence, resorption, and remodeling prior to final healing. Utilizing proper patient selection, many blunt liver injuries can be managed nonoperatively.