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Liver injuries in children: The role of selective non-operative management

Faouzi Nouira, Kerkeni Yosra, Ben Amor Anissa, Ben Ahmed Yosra, Charieg Aouatef, Khemakhem Rachid, Ghorbe Soufiane, Jlidi Said, Ben Kahlifa Sonia, Chaouachi Beji

Unity of Pediatric Surgery, Children’s Hospital, Tunis, Tunisia

 

Correspondence

Nouira Faouzi
Unity of Pediatric Surgery “B”
Children’s Hospital, 1007 Tunis, Tunisia
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.
Tel: 00216 20323704

 

Abstract

Aims: Liver injuries occur commonly in blunt abdominal trauma. This study set out to describe the causes and the role of selective non-operative management of liver injuries in children.

Materials and Methods: A retrospective review of 51 patients with a discharge diagnosis of traumatic liver injuries at Tunis Children’s Hospital, over a 14-year period from 1996 to 2009.

Results: We identified 51 patients with liver trauma. The median age was 7 years. Boys accounted for 58% (n= 30), and the most common cause was traffic accident. Head injuries were the most common associated injuries. Forty nine patients (96%) required non-operative management without complications. The mean in-hospital stay was 10 days in this group. The ultrasound demonstrated complete resolution and healing after 3-6 months. Two patients underwent surgery. The mortality rate was 0,2 %.

Conclusion: Safe, non-operative management involves careful serial examination, a CT scanning facility and close monitoring of the patient in a fully equipped high-dependency unit with trained staff to run it. Even though most patients can be treated non-operatively the challenge is to identify the severely injured child early and institute aggressive resuscitation and expedite laparotomy.

Key words: children, liver trauma, blunt liver injury

 

Introduction

Trauma remains the leading cause of mortality in the pediatric population [1, 2]. Liver injuries occur commonly in blunt abdominal trauma. During the last 100 years the management and approach to blunt liver and other solid visceral injuries has fluctuated from surgical caution at the turn of the century as advocated by Beckman’s ‘‘intelligent conservatism’’ in the 1920s followed by aggressive surgical intervention throughout most of the century, and finally a move back towards an initial non-operative approach for most [1, 2].

This study set out to describe the causes and the role of selective non-operative management of liver injuries in children.

Material and Methods

The records of all children presenting to Tunis Children’s Hospital with traumatic liver injuries, over the 14-year period (January 1996 to December 2009) were reviewed. Information was gathered about the clinical presentation, associated injuries, grade of injury, transfusion requirements and hemodynamic stability.

Those patients who remained hemodynamically unstable after initial resuscitation underwent laparotomy, the remainder were treated non-operatively in a high care setting. The outcome of both the operative and nonoperative groups has been reviewed with resultant complications. Liver injuries were graded according to the American Association for the Surgery of Trauma (AAST) (table 1) [2].

Table 1: Liver injury scale classification

GRADE

INJURY DESCRIPTION

I

Hematoma subcapsular, nonexpanding, < 10% of surface area

Laceration capsular tear, non bleeding, with < 1cm deep parenchymal disruption

II

Hematoma subcapsular, nonexpanding, hematoma 10-15%, intraparenchymal, intraparenchymal, nonexpanding < 2cm in diameter

Laceration < 3 cm of parenchymal depth, < 10 cm in length

III

Hematoma subcapsular, >50% of surface area or expanding; ruptured subcapsular hematoma with active bleeing; intraparenchymal hematoma > 2 cm Laceration > 3 cm of parenchymal depth

IV

Hematoma ruptured central hematoma

Laceration parenchymal destruction > 75% of hepatic lobe

V

Laceration parenchymal destruction > 75% of hepatic lobe

Vascular juxtahepatic venous injuries (retrohepatic cava/major hepatic veins)

VI

Hepatic avulsion

Computed tomography scanning has been available at our hospital as the investigation of choice in diagnosing blunt liver trauma since 2006, after which 18 patients underwent CT scans and subsequent grading. Prior to this the diagnosis was confirmed by abdominal ultrasound. Unfortunately, no grading system was devised for liver ultrasound but our results suggested that a high proportion of small contusions and lacerations of the liver and spleen are more likely to be demonstrated by liver ultrasound than by CT, however, direct comparisons regarding specificity, sensitivity and accuracy have been few.

The decision to operate was based on the following criteria; hemodynamic instability following volume and blood resuscitation, symptoms and signs of ongoing haemorrhage or associated intra-abdominal injuries requiring surgery (hollow viscus and diaphragmatic injuries and selected cases of renal vascular injuries). The decision remained a clinical one, not significantly influenced by radiological findings. Those children presenting with massive hemorrhage (requiring >40 ml/kg blood) not responding to adequate intravenous resuscitation and transfusion were taken for emergency laparotomy. Those who responded to initial resuscitative measures and remained hemodynamically stable were taken for a liver ultrasound or CT scan.

Once the diagnosis was confirmed the patients were closely monitored in a high care or intensive care unit. Non-operative management of these patients included close monitoring of hemodynamic status, serial hemoglobin, electrolytes, liver function tests, serum lactate and transfusion requirements. Those patients who subsequently became hemodynamically unstable, indicating a secondary or ongoing hemorrhage were taken for laparotomy. The group that remained clinically stable was discharged after about 1 week of in-hospital observations. Ultrasound imaging was chiefly reserved for follow-up monitoring.

Results

There were 51patients admitted with liver injuries during the fourteen year period reviewed: 30 boys and 21girls with a sex ratio of 1, 4. The median age was 7 years (range 1–13). There was a wide spectrum of liver injury’s causes. The most frequent causes were traffic accident (50%) represented essentially by pedestrian injuries. The other causes were home accident (39%), especially bicycle accidents, farm accident (6%), and scholar accident (5%) (table 2). The major symptom in the emergency room was abdominal pain. Thirty-one patients were stable and only 5 children were in an hemodynamic choc. Abdominal ultrasonography was made for all patients; however abdominal tomography was made for only 18 patients. Seventeen patients were found to have grade I injuries, twenty three grade II, eight grade III, two grade IV, and one grade VI (table 3). Of the total number of cases, ten had an isolated hepatic injury and three had polytrauma. There were fifteen head injuries, twelve thoracic injuries, eleven fractures, two spleen injuries and two kidney injuries (table 4). Forty nine patients (96%) required nonoperative management without complications. The mean in-hospital stay was 10 days in this group. The ultrasound demonstrated complete resolution and healing after 3-6 months.

Table 2: Mechanism of injury

Mechanism of injury

Number of children

Frequency

Traffic accident

26

50%

Home accident

20

39%

Farm accident

3

6%

Scholar accident

2

5%



Table 3: Liver injury scores and number of children

Grade

Number of children

Frequency

Number of death

Number of patients who underwent surgery

I

17

34%

0

0

II

23

45%

0

1

III

8

15%

0

0

IV

2

4%

0

0

V

0

0

0

0

VI

1

2%

1

1

 

Table 4: Associated injuries

Associated injuries

Number

Head injury

15

Thoracic injury

13

Fractures

11

Spleen injuries

2

Kidney injuries

2

Isolated hepatic injury

10

 

Only two patients underwent surgery. The decision to operate was based on the hemodynamic instability following volume and blood resuscitation. For the first one we found a 2 cm laceration of the right liver. For the second one we found an hepatic avulsion which necessitate the packing technique of the bleeding with laparotomy pads; unfortunately he died after four days of an uncontrollable bleeding.

Discussion

Worldwide, trauma is the leading cause of death and disability in children [3, 4, 5]. Blunt liver trauma is uncommon, but it is associated with significant morbidity and mortality. Although blunt liver trauma accounts for 15- 20% of abdominal injuries, it is responsible for more than 50% of deaths resulting from blunt abdominal trauma [6]. In keeping with other centers the majority of our patients sustained their injuries as pedestrian (related motor vehicle accidents) [7, 8].

The management protocol for blunt hepatic trauma at our hospital changed 20 years ago from an early operative approach to the more conservative non-operative management outlined in this study. Improved pediatric resuscitative measures in a dedicated pediatric trauma unit together with better imaging and intensive care facilities made easier non-operative measures.

Over the last 14 years, 96% of our patients with confirmed blunt liver trauma were successfully managed non-operatively and only 4% underwent liver related laparotomy. The vast majority (96%) of these patients therefore do not require surgery despite in many cases a severe injury as demonstrated by various imaging techniques. The decision about whether to operate was thus a clinical one based on hemodynamic stability, signs of ongoing hemorrhage or evidence of hollow viscus injury. Most patients presented with multiple injuries. Head injuries were the most common associated injuries [9, 10].

The radiological investigation of choice in the hemodynamically stable patient is AAST graded computer tomography. However, far too much emphasis has been placed on the CT-grade in the literature as a prognostic predictor. CT confirmed the diagnosis of a blunt liver injury but we and others have shown poor correlation between liver grade injury and clinical outcome, [11] including the need for blood transfusion and/or laparotomy. [12] The CT findings alone should therefore not influence the decision on whether or not to operate. Ultrasound imaging was chiefly reserved for follow-up monitoring [13].

For those patients who require operative intervention, control of the hemorrhage is the priority. In inexperienced hands correct perihepatic packing would be the preferred approach [14]. This technique is generally simple and effective and should be employed before transfer of the patient for definitive procedure. However, frequently the injuries are complex (as our patient who died) requiring more technically difficult procedures to gain vascular control [15], presenting a challenge to even the most experienced surgeon.

Conclusion

The decision to institute the non-operative management of blunt liver trauma in children has been successfully borne out by our experience in the subsequent 14 years. Ninety-six percent of patients were successfully treated non-operatively, with only 4% liver related laparotomies with no complications and the duration of in-hospital stay shorter. Safe, nonoperative management involves careful serial examination, a CT scanning facility and close monitoring of the patient in a fully equipped high-dependency unit with trained staff to run it. Even though most patients can be treated non-operatively the challenge is to identify the severely injured child early and institute aggressive resuscitation and expedite laparotomy.

 

 

 

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