Injury, Int. J. Care Injured (2006) 37, 66—71
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Liver injuries in children: The role of selective non-operative management A. Landau, A.B. van As *, A. Numanoglu, A.J.W. Millar, H. Rode Trauma Unit, Department of Pediatric Surgery, Red Cross Children’s Hospital, University of Cape Town, Cape Town, Rondebosch 7701, South Africa Accepted 18 July 2005
KEYWORDS Blunt trauma; Children; Liver; Rupture; Conservative; Management
Abstract Introduction: This review article on the management of blunt liver injury in children is based on the authors’ experience of 311 patients over a 22-year period. Material and methods: All children presenting to our institution with confirmed blunt liver trauma were studied retrospectively. Hospital folders of 311 patients were analysed. Information was gathered about the clinical presentation, associated injuries, grade of injury, transfusion requirements and haemodynamic stability to examine factors influencing outcome. Results: The age of patients ranged between 3 weeks and 12 years (mean of 7 years). Injuries as a result of motor vehicle accidents (MVAs) were the most common (268; 232 pedestrian and 36 passenger), other causes were falls (26) assaults or child abuse(15), bicycle handle bar injury (2). One hundred and thirty-six patients sustained an isolated hepatic injury and 175 had multiple injuries. Associated injuries included 147 head injuries, 131 fractures, 66 thoracic and 143 intra-abdominal (74 spleen, 45 renal, 4 pancreatic and 4 hollow viscus). Two patients died soon after arrival, 21 underwent laparotomy, 13 of which were liver related, while 288 were treated non-operatively. One hundred and six patients required blood transfusion (mean of 21.3 ml/kg); 30% of the nonoperative group and 100% of the operative group. There were three fatalities from the operative group (1% total mortality), one secondary to a severe, head injury, one liver haemorrhage and one from multi-organ failure Discussion: The vast majority (93%) was successfully treated non-operatively with only 4% coming to liver related laparotomy, complications were lower, transfusions less and the in-hospital occupancy was shorter. Complication rate was 8% and mortality was 1%. Conclusion: We confirm the success selective non-operative management of blunt liver trauma as adopted by this institution 20 years ago. It is now proven treatment in
* Corresponding author. Tel.: +27 21 6585012; fax: +27 21 6856632. E-mail address:
[email protected] (A.B. van As). 0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2005.07.013
Liver injuries in children: The role of selective non-operative management
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an appropriate centre. However, the challenge is to identify the severely injured child early and institute aggressive resuscitation and expedite laparotomy when indicated. # 2005 Elsevier Ltd. All rights reserved.
Introduction This is a review article on the management of blunt liver trauma in children, based on the authors’ experience over a 22-year period from the years 1978 to 2000.9,10 Prior to this, our laparotomy findings showed that seventy percent of liver injuries had stopped bleeding spontaneously at the time of laparotomy,10 and therefore, a selective non-operative approach was adopted. Today the selective, non-operative management of blunt liver trauma in haemodynamically stable patients is well established and accepted in most paediatric surgical centres,1,3,10,11,14,16,20,22 however, as recently as 20 years ago this was not the case. The management of choice at the time was aggressive approach of mandatory operative repair7 based on the thinking that a significant hepatic injury will not heal spontaneously, and therefore, the earlier the surgical intervention the better.13 However, in retrospect, the often unnecessary and sometimes technically difficult surgery led to increased morbidity and mortality that resulted in the adoption of a more conservative approach pioneered by, amongst others in this institution during the 1970s.14 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. The Red Cross Children’s Hospital is a paediatric hospital catering for patients under the age of 13 years. The dedicated trauma unit, the only one of its kind in Southern Africa, serves a regional population of approximately 3 million, with an annual
patient load of about ten thousand patients. Therefore, we have been in a unique position to review the management and outcome of specific childhood trauma.
Materials and methods The records of all children presenting to our unit with blunt liver trauma over the 22-year period (from 1978 till 2000) were reviewed. Information was gathered about the clinical presentation, associated injuries, grade of injury, transfusion requirements and haemodynamic stability. Those patients who remained haemodynamically unstable after initial resuscitation underwent laparotomy, the remainder were treated non-operatively in a high care setting. The outcome of both the operative and non-operative groups has been reviewed together with resultant complications. The mechanism of injury is usually violent compression of the right chest wall and/or upper abdomen as in the case of pedestrian motor vehicle accidents (MVAs), the most common cause of blunt liver trauma. The American Association of Trauma (AAST)25 adopted a classification based on a computed tomography (CT) scan grading system (see Table 1). Computed tomography scanning has been available at our hospital as the investigation of choice in diagnosing blunt liver trauma since 1988, after which 81 patients underwent CT scans and subsequent grading. Prior to this the diagnosis was confirmed by liver scintigraphy. Unfortunately, no grading system was devised for liver scintigraphy 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
Table 1 Grouping of patients according to the American association for the surgery of trauma2 Grade
Extent of the liver injury
Number of patients
1 2
Small subcapsular haematoma or superficial laceration Subcapsular haematoma covering 10—50% of surface area or a 1—3 cm laceration less than 10 cm in length. Large (>50%) or ruptured subcapsular haematoma, an intraparenchymal haematoma >2 cm, or a laceration >3 cm in depth. Ruptured intraparenchymal haematoma or lobar parenchymal disruption involving 25—50% of the lobe Lobar parenchymal disruption >50% or juxta-hepatic venous injury Hepatic avulsion
18 39
3 4 5 6
18 5 1 0
68 scintigraphy than by CT, however, direct comparisons regarding specificity, sensitivity and accuracy have been few. The decision to operate was based on the following criteria; haemodynamic 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 haemorrhage (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 haemodynamically stable were taken for an isotope liver-spleen scintigraphy scan 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 haemodynamic status, serial haemoglobin, electrolytes, liver function tests, serum lactate and transfusion requirements, and therefore, should not be referred to as ‘‘conservative’’ management. Those patients who subsequently became haemodynamically unstable, indicating a secondary or ongoing haemorrhage were taken for laparotomy. The group that remained clinically stable were discharged after about 1 week of in-hospital observations. Ultrasound imaging was chiefly reserved for follow-up monitoring. Diagnostic peritoneal lavage (DPL) was not used as a diagnostic tool in these patients as in many cases the DPL will be positive, yet it would not alter one’s decision on whether or not to operate.
Results Three hundred and eleven children were found to have confirmed liver trauma. The ages ranged from 3 weeks to 12 years (mean of 7 years). The majority of injuries were a result of motor vehicle related accidents; 232 pedestrian and 36 passenger, followed by 24 falls, 15 assaults or child abuse cases, 2 crush injuries and 2 bicycle injuries (see Fig. 1). Of the total number 136 had an isolated hepatic injury whilst the majority, 175 suffered multiple injuries (Fig. 2). There were 147 head injuries, 131 fractures, 66 thoracic injuries and 143 other associated intra-abdominal injuries–—74 spleen, 45 renal, 4 pancreatic and 4 hollow viscus (Table 2). Of the 311 patients two died soon after arrival, one from a severe head injury and the other from exsan-
A. Landau et al.
Figure 1
Figure 2
Cause of liver injuries.
Associated injuries.
guinating haemorrhage after delayed hospital presentation. Of the remaining 309 patients 21 underwent emergency or early laparotomy (Table 3). Only three of these had a pre-op CTscan. Two hundred and eighty-eight responded to initial resuscitation. Liver scintigraphy, computer tomography, or laparotomy demonstrated an injury to the right lobe only in 172 cases, the left lobe in 76, both the left and right lobes in 38 and a central or falciform ligament injury in 22 cases. CT scanning results were graded according to the Hepatic Injury Scale established by the American Association for the Surgery of Trauma. Eighteen patients were found to have grade 1 injuries, 39 grade 2, 18 grade 3, 5 grade 4 injuries and 1 patient a grade 5 injury (Table 1, Figs. 1 and 2). The mean in-hospital stay was 7 days (4—49 days). Of the total group 106 patients required blood transfusion (mean of 21.3 ml/kg), 30% of Table 2
Associated injuries
Head injuries Fractures Thoracic injuries
147 131 66
Intra-abdominal Spleen Kidney Pancreatic Hollow viscus
74 45 4 4
Liver injuries in children: The role of selective non-operative management
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Table 3 Management of liver injuries Died soon after arrival Non-operative Operative Total
2 288 21 311
the non-operative group (mean of 19 ml/kg) and 100% of the operative group (mean of 31 ml/kg) (Pictures 1 and 2). There were 12 complications in the non-operative group including 2 ruptured subcapsular haematomas (one requiring delayed laparotomy) 7 abscesses, 1 pancreatic pseudocyst, and one patient developed fat embolism syndrome. Fourteen of the operative group of 21 patients were taken for emergency laparotomy with liver injury being the primary indication, 13 presented early after injury (mean time of 6-h post injury) and one patient underwent a delayed laparotomy for a ruptured subcapsular haematoma. One patient suffered severe head trauma and the remaining six patients had other visceral injuries. The visceral injuries included injuries to the small bowel (2), stomach (1), the rectum (1) and two patients had severe renal injuries, both requiring nephrectomy. There were three fatalities, one due to severe head injury and two liver related. The first of whom was found to have a grade 4 injury and died from hypovolaemic shock on the operating table, the second from multi-organ failure requiring multiple relooks after the liver was packed in a secondary hospital. Of the operative group there were 13 early complications including 2 abscesses, 1 pancreatic fistula, 2 haematemesis (1 haemobilia and 1 stress ulcer) and 5 patients’ clinical course were complicated by persistent bile leaks.
Picture 1 Abdominal contrast-CT scan of a 10-year-old girl with a massive subscapsular haematoma, which has partially liquefied.
Picture 2 Abdominal contrast CT-scan of a 7-year-old boy with a liver rupture grade 2 and an associated splenic rupture.
Long-term follow-up proved limited in our group as many patients were lost to follow-up. For those who did return the imaging modality of choice was ultrasound which demonstrated complete resolution and healing after 3—9 months. Data from the police mortuary in Cape Town was only available for the years 1996—2000. During this 5-year period 818 children under the age of thirteen were autopsied, of which 70 had associated blunt liver trauma.
Discussion Worldwide, trauma is the leading cause of death and disability in children15,24,28 and our experience at the Red Cross Hospital is no exception. In keeping with other centres the majority of our patients sustained their injuries as pedestrian–—related motor vehicle accidents.6,26 Unlike similar studies1,23 we only encountered two so-called ‘‘handle bar’’ bicycle injuries in Cape Town. The community that we serve has poor recreational and sporting facilities resulting in children often playing in the roads where they are at risk. These problems are being addressed by way of education and social upliftment programmes. Reflecting our hospital data 74% were pedestrian MVA related. Nine cases were train related, and the remainder passenger MVA and assault. Of the 70 patients only 2 suffered isolated liver trauma, the majority having multiple associated injuries. Unfortunately, the details of the circumstances preceding the two deaths were not available. During the 22 years of this study an average of 14 patients were seen annually in our trauma unit, the mortuary saw an average of 24 deaths per annum with associated
70 liver trauma. Therefore, even though our mortality was only 1% many severely injured children died before admission to hospital. 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 paediatric resuscitative measures in a dedicated paediatric trauma unit together with better imaging and intensive care facilities have facilitated non-operative measures. This study analysed our results over the subsequent 20-year period and the following discussion will draw conclusions based on these experiences with a view to management recommendations of children presenting with blunt liver trauma. Over the last 20 years, 93% of our patients with confirmed blunt liver trauma were successfully managed non-operatively and only 4% underwent liver related laparotomy. The vast majority (93%) 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 haemodynamic stability, signs of ongoing haemorrhage or evidence of hollow viscus injury. Most patients presented with multiple injuries23,27 and one should be aware of the error of focussing on the head injury or long bone fractures and risk missing a blunt abdominal injury. The radiological investigation of choice in the haemodynamically 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,29 including the need for blood transfusion and/or laparotomy.17 The CT findings alone should therefore not influence the decision on whether or not to operate. Hackman et al.17 looked at 152 children critically and found CT results to be inexact in measuring injury severity and differentiating an expanding from a nonexpanding haematoma–—important determinants of grades 2—4 injuries. Croce et al.8 compared 37 patients who underwent pre-operative CT scans to operative findings. The CT and operative grades were inconsistent in 84%, with equal errors in overand under-estimation. Only those patients who remained haemodynamically stable underwent CTscans. Of this group 70% were found to have minor injuries or grades 1 and 2. The remaining 30% were reported as severe or grades 3—5 injuries. Three patients underwent CT scans who came to liver related laparotomy, one
A. Landau et al. patient required a delayed laparotomy after a ruptured subcapsular haematoma, the remaining two patients demonstrated grades IV and V liver injury both of whom required early laparotomy and were probably inappropriately scanned as they were still haemodynamically unstable when transported to the CT scanner. With the exception of the ruptured subcapsular haematoma all those patients requiring liver-related laparotomies presented or became shocked within 12 h after the injury. At surgery they (13 of the 21) were all found to have significant injuries, with often difficult control of haemorrhage. Control of a lacerated liver can be very challenging even in the most experienced hands and should ideally only be undertaken in a specialist centre with post-operative intensive care facilities. There should be no delay in initiating resuscitative measures and transfusion. It is critical that the severely injured child is identified early and if there is no response to resuscitation, laparotomy should be performed without any delay. Two patients died from massive haemorrhage after a lengthy delay in presentation, one in the resuscitation room and one died at surgery. Cool peripheries and a tachycardia are signs of shock in the injured child.1 Urgent resuscitative measures were only instituted in both these children after a drop in blood pressure was recorded. However, it has to be stressed that a fall in blood pressure in children is a late and often pre-terminal sign indicating massive haemorrhage and shock. Non-operative management should not be termed ‘‘conservative’’ management as these patients are potentially unstable and require intensive monitoring. Accordingly, this management should only be instituted in a hospital (preferably in a paediatric surgical centre18 with the necessary staff and facilities to investigate adequately and perform laparotomy in case the patient’s condition does not stabilise or deteriorates. For those patients who require operative intervention, control of the haemorrhage is the priority. In inexperienced hands correct peri-hepatic packing would be the preferred approach.12 This technique is generally simple and effective and should be employed before transfer of the patient for definitive procedure.4 However, frequently the injuries are complex requiring more technically difficult procedures to gain vascular control,5,19,30 presenting a challenge to even the most experienced surgeon. Once vascular control has been achieved other injuries, including bile leaks can be assessed and dealt with.21,31 Not surprisingly those patients who came to laparotomy had a higher incidence of complications compared with those treated non-operatively. All patients in this group required blood transfusions as
Liver injuries in children: The role of selective non-operative management compared to only 30% of the non-operative group. The duration of hospital stay was also significantly less in the latter group (7 days compared to 23 days). All patients were advised to refrain from contact sport for 3—6 months after the injury, however, few patients returned for follow-up.
Conclusion The decision of the Red Cross Children’s Hospital department of surgery in 1978 to institute the nonoperative management of blunt liver trauma in children has been successfully borne out by our experience in the subsequent 20 years. Ninety-three percent of patients were successfully treated nonoperatively, with only 4% liver related laparotomies– —complications were less frequent, transfusion requirements less and the duration of in-hospital stay shorter. Patients with blunt liver injuries should be treated in a specialist centre with experienced paediatric surgeons available. 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. The prognosis of blunt liver trauma in children presenting to hospital is good (Mortality 1%) and the complication rate low (8%).
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