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Penetrating hepatic trauma in children: operating room or not?
R A Dicker1, K H Sartorelli, W J McBrids
1Department of Surgery, University of Vermont College of Medicine, Burlington, USA.
Insights
Nonoperative management is not suitable for children with penetrating hepatic injuries due to high rates of associated organ damage. Surgical intervention remains the standard of care for pediatric patients with these severe injuries.
Area of Science:
- Pediatric Surgery
- Trauma Management
- Hepatic Injuries
Background:
- Nonoperative management is standard for blunt hepatic trauma.
- Adults with selective penetrating hepatic injuries may be managed nonoperatively.
- The efficacy of nonoperative management for pediatric penetrating hepatic injuries is unclear.
Purpose of the Study:
- To evaluate the therapeutic management of children with penetrating injuries to the hepatic bed.
- To determine if nonoperative management is a reasonable consideration for pediatric penetrating hepatic injuries.
Main Methods:
- Reviewed the National Pediatric Trauma Registry (NPTR) database (1985-1994).
- Selected cases using ICD-9 codes (864.00-864.10) for hepatic injuries and CPT codes for interventions.
- Analyzed data from 1,147 pediatric hepatic injuries, including 132 penetrating injuries.
Main Results:
- 132 pediatric penetrating hepatic injuries were identified (76% gunshot, 24% stab wounds).
- Only 5% of these children were managed nonoperatively; 15% had negative laparotomies.
- A high percentage (80%) sustained additional injuries requiring surgical repair, with significant rates of hollow viscous, diaphragmatic, and hepatic repairs.
Conclusions:
- Penetrating hepatic injuries in children are frequently associated with other organ injuries requiring surgical intervention.
- Unlike adults, the smaller abdominal cavity in children increases the risk of multiple injuries.
- Surgical intervention should remain the standard of care for pediatric penetrating hepatic bed injuries.
Abstract:
Nonoperative management has become widely accepted as the standard of care for patients with blunt hepatic trauma. Recent studies among adults have supported the use of nonoperative management of selective penetrating wounds to the hepatic bed in stable patients. The therapeutic management of children with penetrating injuries to the hepatic bed were evaluated to ascertain whether nonoperative management was a reasonable consideration in their care. The database of the National Pediatric Trauma Registry (NPTR) was reviewed for the period 1985-1994. ICD-9 codes 864.00 to 864.10 were used to select injury site, diagnosis, and, combined with Current Procedural Terminology (CPT) code data, to ascertain therapeutic interventions. The NPTR is a compilation of data from 61 pediatric trauma centers, currently held at Tufts University. The charts of 29,000 children were reviewed; of these, 1,147 sustained hepatic injuries, 132 (12%) of whom had a penetrating injury. The mechanism of injury was gunshot wound in 100 patients (76%) and stab wound in 32 (24%). The mean age of the children who had a penetrating injury was 12.7 years (range, in utero to 19 years). Six children were managed nonoperatively (5%), and 20 (15%) had negative laparotomy findings. Overall, 106 children sustained additional injuries that required surgical repair. There were 50 hollow viscous injury repair, 19 diaphragmatic repairs, 5 nephrectomies, 4 splenectomies, 4 pancreatic resections, and 43 significant hepatic repairs. The overall mortality rate was 9.8% (13 deaths). Nine of these patients died within 24 hours of injury. These data indicate that penetrating injury to the hepatic bed in children is associated with a high percentage of other organ injuries that require surgical intervention. This seems to be in direct contrast with the findings for adults, for whom the hepatic mass appears protective because of its larger size. The close anatomic proximity of the organs in a child's abdomen appears to make surgical intervention necessary for the majority of children with penetrating injury to the hepatic bed, and indicates that this approach should remain the standard of care for pediatric patients.