Management of Blunt Liver Trauma in Pediatric Age Group.

doi:10.21203/rs.3.rs-4966383/v1

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Management of Blunt Liver Trauma in Pediatric Age Group.

https://doi.org/10.21203/rs.3.rs-4966383/v1

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Background

Liver injuries take second place among all the injuries of the abdominal organs and represents 15–20%. Mortality from open liver injuries reaches 12%, while from closed injuries it amounts to 72% (Coccolini F et al. 2020).

Aim

to assess the outcome of management of blunt liver trauma in the pediatric age group at the department of hepato- pancreatico-biliary surgery at the national liver institute.

Methods

This study was conducted at National Liver Institute, Menoufiya University and included 54 pediatrics with hepatic trauma from October 2021 to October 2023. Data collected included demographics, clinical data, imaging findings, lab findings, management plane and outcome.

Results

Fifty-four patients were included in this study. Thirty-seven (68.52%) patients were males and 17 (31.48%) patients were females. Mean age for all patients was 10.02 ± 4.34. Twenty-six (48.15%) patients were hemodynamically stable and 28(51.85%) patients were hemodynamically unstable. The mode of trauma was compression in 7(12.96%) patients, falling from height in 8 (14.81%) patients, hit by hard object in 5(9.26%) patients and car accidents in 34(62.96%) patients. Eight (14.81%) patients had grade II liver trauma, 32(59.26%) patients had grade III liver trauma, 13(24.07%) patients had grade IV liver trauma, only one patient (1.85%) had grade VI liver trauma.

Conclusion

In highly experienced liver centers, even advanced grades of pediatric liver injuries still can be approached and managed non-operatively. Diligent ICU monitoring especially in the first 24 hours after trauma is critical to detect any early signs of clinical deterioration that may warrant urgent surgical intervention. In our single center experience, most of our patients were managed conservatively with excellent.

abdominal trauma

blunt trauma

liver trauma

pediatric trauma

liver laceration

liver contusion

In the last century, there was constant debate regarding the most appropriate management of these often critically ill patients. This is because hepatic injuries carry the potential for catastrophic exsanguinations due to the highly vascular nature of this organ. Mortality and morbidity rise dramatically after high grade liver injury, but often these result from the associated injuries incurred due to the mechanism and severity of the injury (Duron V et al 2020).

Because of the large size of the liver, its friable parenchyma, its thin capsule and its relatively fixed position in relation to the spine make the liver particularly more prone to injury. The right lobe is injured more commonly than the left, as a result of its large size and proximity to the ribs (Van As AB & Millar AJ 2017).

Most liver injuries (> 85%) involve segments 6, 7 and 8 of the liver due to simple compression against the fixed ribs, spine or posterior abdominal wall, also pressure through the right hemi- thorax may propagate through the diaphragm causing a contusion of the dome of the right lobe of the liver. Furthermore ligamentous attachment of the liver to the diaphragm and the posterior abdominal wall can act as sites of shear forces during deceleration injury (Van As AB & Millar AJ 2017).

The incidence of liver trauma varies between countries due to social, regulatory and environmental conditions. In Europe, 80–90% of all hepatic injuries are due to blunt trauma, with the majority of cases being due to road traffic accidents, sporting injuries and falls. This situation is similar to that seen in Australia. In contrast, the United States and South Africa have relatively high rates of penetrating trauma. Yet even in these countries there is evidence that the ratio of blunt to penetrating injury is increasing (Duron V et al 2020).

Several classification systems have been proposed in an attempt to incorporate the etiology, anatomy and extent of injury and correlate it with subsequent clinical management and outcome (Gakawaya 2004).

The widely accepted Organ Injury Scale is based on anatomical criteria that quantify the disruption of the liver parenchyma and defines six major sources of morbidity and mortality due to the likelihood of associated solid or hollow-organ injuries (Tarchouli M et al 2018).

Until the beginning of the 1990s, explorative laparotomy was the standard of care for liver injuries. Although urgent surgery continues to be the standard of care for patients with penetrating hepatic trauma or hemodynamically unstable patients with blunt hepatic trauma, there has been a paradigm shift in the management of hemodynamically stable patients. In the last two decades, the majority of these patients have been initially treated non- operatively. The first reports in the literature of adult patients treated non-operatively after having sustained blunt hepatic trauma were published in the early 1980s. The widespread use of a conservative treatment strategy started with the introduction of the CT scan for diagnosing and assessing the severity of abdominal trauma which made detection and determination of the extent of liver injuries possible (Van Vugt et al. 2009).

The main indication of the operative approach to liver injury is hemodynamic instability, not the grading of the injury. Although a higher grade injury has higher potential for failure of non- operative management, hemodynamic instability remains the most important branch of the decision tree indicating operative intervention. Rebleeding, constant decline of hemoglobin, increased transfusion requirement and the failure of angio- embolization of actively bleeding vessels are the few factors which indicate the need for laparotomy. The operative approach has also evolved over the last two decades. Direct suture ligation of the parenchymal bleeding vessel, perihepatic packing, and repair of venous injury under total vascular isolation and damage control surgery with utilization of preoperative and/or postoperative angioembolization are the preferred methods, compared to anatomical resection of the liver and use of the atriocaval shunt (Thomas MN et al. 2023).

Hepatic injuries are associated with high mortalities, but it remains very difficult to prognosticate for individual patients, because mortality is often determined by numerous factors including the nature of the hepatic injury itself, grade of hepatic injury, associated injuries incurred, practices and experiences of the treating institution and the physiological characteristics of the patients themselves (Duron V et al 2020).

Study Design: This retrospective study was conducted at the Department of Surgery, Faculty of Medicine, Menoufia University, from October 2021 to October 2023. The study was approved by the institutional ethics committee (approval number 11/2015 SURG32). Informed consent was obtained from all patients included in the study.

Patient Selection: Patients who were below 18 years old and had blunt liver trauma during the study period were included. The diagnosis of hepatic trauma was confirmed through imaging studies such as ultrasound, computed tomography (CT). Patients with incomplete medical records or with penetrating liver trauma were excluded.

Data Collection: Data were collected retrospectively from patient medical records. The following information was extracted:

Demographic data: age, gender.
Mode of trauma: Compression, Falling from height, Hit by hard object, RTA (car accident).
Imaging findings: type of trauma, grade of trauma, associated injury.
Laboratory finding: HB, INR, bilirubin.
Management plane : conservative or operative
Outcomes: length of hospital stay, start of oral diet, postoperative complications, management.

Ethical Considerations

This study was conducted following the principles of the Declaration of Helsinki. The confidentiality of all patients was maintained throughout the study.

Demographic Characteristics:

Fifty-four patients were included in this study. Thirty-seven (68.52%) patients were males and 17 (31.48%) patients were females. Mean age for all patients was 10.02 ± 4.34.

Our patients were classified according to their management into 2 main groups:

1. Conservative management group (CM) including 45 patients (83%).

2. Operative management group (OM) including 9 patients (17%).

both groups were compared. There was no statistically significant difference. Thirty (66.67%) male patients and 15(33.33%) female patients were managed conservatively while 7 (77.78%)‎ male patients (66.67%) and 2 (22.22%)‎ female patients were managed operatively with no statistically significant difference. The mean age was 10.11 ‎±‎ 4.30 in the CM group and 9.56± 4.77 in the OM group with no statistically significant difference between both groups.

Clinical Data:

Twenty-six (48.15%) patients were hemodynamically stable and 28(51.85%) patients were hemodynamically unstable. Thirteen (24.07%) patients presented with tachycardia, 13(24.07%) patients presented with tachypnea and tachycardia and 2(3.7%) patients presented with hypotensive tachypnea and tachycardia. The mode of trauma was compression in 7(12.96%) patients , falling from height in 8 (14.81%) patients, hit by hard object in 5(9.26%) patients and car accidents in 34(62.96%) patients. Eight (14.81%) patients had grade II liver trauma, 32(59.26%) patients had grade III liver trauma, 13(24.07%) patients had grade IV liver trauma , only one patient (1.85%) had grade VI liver trauma . only 26(48.15%) patients had associated injuries (fracture rib, splenic laceration, bone fracture, lung contusion), while 28(51.85%) patients suffered from isolated liver trauma. Seven (12.96%) patients had bi-lobar liver injury, 8(14.81%) patients had left lobe liver trauma, 39 (72.22%) patients had right lobe liver trauma. nine(16.67%) patients had liver hematoma, 41(75.93%) patients had liver laceration , 4(7.41%) patients had both types of injury.

In the CM group, 28(62.22%) patients had car accidents , 8(17.78%) patients fell from height , 5(11.11%) patients had mode of trauma in form of compression and 4 (8.89%)patients were hit by hard object. in the OM group, 6 (66.67% )patients had car accidents ,2 (22.22%) patients had mode of trauma in form of compression and 1 (11.11%)patient was hit by hard object With no statistically significant difference. In the CM group ,30(66.67%) patients had grade III liver trauma ,8 (17.78%) patients had grade II liver trauma , 7 (15.56%) patients had grade IV liver trauma , in the OM group , 6(66.67%) patients had grade IV liver trauma ,2 (22.22%) patients had grade III liver trauma, one( 11.11%) patient had grade IV liver trauma with statistically significant difference (P=0.001). In the CM group ,21 (46.67%) patients had associated trauma , in OM group , 5(55.56%) patients had associated trauma with no statistically significant difference., in the CM group, 33(73.33%) patients had right lobe liver trauma , 6 (13.33%)patients had left lobe liver trauma ,6(13.33%) patients had bi-lobar liver trauma ,in the OM group, 6 (66.67%) patients had right lobe liver trauma , 2 (22.22%) patients had left lobe liver trauma , one ( 11.11%) patient had bi-lobar liver trauma with no statistically significant difference. In the CM group , 32(71.11%) patients had hepatic laceration, 9 (20%) patients had hepatic hematoma,4 (8.89%) patients had both types of liver trauma , in the OM group , all patients 9 (100%) had hepatic laceration with no statistically significant difference.

Management:

Two (3.7%) patients underwent formal right hepatectomy, one patient (1.85%) underwent hepatoraphy, 2 patients (3.7%) underwent left lateral resection and 2 patients (3.7%) underwent posterior sectionectomy. Ten (18.52%) patients received blood transfusion. Sixteen (30.19%) patients started oral feeding at day one, 31(58.49%) patients started oral feeding at day two and 6(11.32%) patients started oral feeding at day three.

Outcome findings:

There was only one case of mortality( 11.11%) in the OM group due to air embolism during exploration due to hepatic veins injury , in the CM group , only one case (2.22%)was complicated by bile leak in the OM group ,only one case(11.11%) was complicated by bile leak with no statistically significant difference(Table 13). Bile leak was treated with ERCP and stenting.

The mean length of ICU stay was 1.92 days , The mean length of ward stay 5.17 days , The mean length of full stay was 6.98 days

Even with today's modern surgical techniques and sophisticated intensive care units, management of the traumatic liver injury still represents a major challenge to the most highly experienced trauma surgeons. In the last century, there was constant debate regarding the most appropriate management of these often critically ill patients (Duron V et al 2020).

In the last 15 years, the treatment of liver trauma has progressively evolved. At the beginning of the 1990's several articles reported the possibility of non-surgical treatment in patients with hemodynamic stability. The aim of this type of treatment is to not only decrease the number of non-therapeutic laparotomies but also to achieve a reduction in the values of morbidity and mortality (Sreeramulu et al., 2012).

Non operative management (NOM) of liver injury has generally become the most frequent treatment. Current rates of success for NOM for hepatic trauma of selected patients have been reported to be safe and efficient (Hamdy et al., 2012).

In this study, 83% of the patients (45 patients) were managed conservatively while 17% of patients (9 patients) needed surgical intervention. This is lower than (Asfar et al., 2014) where 83% of the patients (98 patients) treated conservatively with 4.08% (4 patients) treated operatively.

The mortality incidence was 1.85% in OM group which differs from the study performed by (Bernardo et al., 2010) in which the incidence was 28.57% and the study performed by (Sreeramulu et al., 2012) in which the incidence was 20.8%.

Regarding the mechanism of trauma, the most common mechanism of injury in the study was road traffic accident (34 patients; 62.96%) which matches a study performed in Theodore Bilharz Research Institute, Cairo University by (Hamdy et al., 2012) in which victims of road traffic accident compromised 57% of their population. These results, in both studies performed in Egypt, point to a major problem of motor vehicle accidents in Egypt.

Focused Assessment with Sonography for trauma (FAST) ultrasound scan was done for all patients in this study. We did not depend on it to decide the management plan. The amount of fluid collection was assessed and in the CM group it decreased.

In this study, the most common site of liver trauma was the right lobe (72%) which resembles (Sreeramulu et al., 2012) study where the most common site was also the right lobe (85%). The prevalence of right lobe injury may be due to its large size and proximity to the ribs.

In this study 3.7% patients underwent formal right hepatectomy, 1.8% patients underwent hepatoraphy, 3.7% patients underwent left lateral resection and 3.7% patients underwent posterior sectionectomy.

In (Hamdy et al., 2012) study, 40% of the operative group underwent suture hepatorraphy compared to 50% of the operative group in our study. Also, 40% underwent damage control therapy by packing compared to 17% in our study.

All patients were followed up in the outpatient clinic for 1–3 months by clinical examination and imaging (U/S & C.T.). All of the patients showed progressive decrease of amount of fluid collection and progressive healing of liver injury.

In this study, 10 (18%) of patients required blood transfusion. It is significant different from (Asfar et al., 2014) study, in which, 70% of the patients (81 out of 117 patients) required blood transfusion and (Bernardo et al., 2010) study where only 54.5% of the patients (78 out of 143 patients) required blood transfusion.

Fifty-five percentage of the patients in the operative group and 11.11% of the patients in the conservative group required blood transfusion while it was 91% of patients in OM group and 31.1% of patients in CM group respectively, in (Bernardo et al., 2010) study.

Complications, in form of bile leak, were equal between both groups, one case in each group. This is lower than (Asensio et al., 2007) study where 77% of patients who developed complications.

All patients were admitted to ICU in the first 24 hours. Longer ICU stay was considered in case of hemodynamic instability or HB drop

Author Contribution

All authors reviewed manuscript

Ahmed I. and Bechingham I., Liver Trauma. Journal of trauma, 9: 171-180, 2007.
Bala M., Abu Gazalla S., Faroja M. et al., Complications of high grade liver injuries: management and outcome with focus on bile leaks. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 20:20, 2012.
Chien L., Lo S. and Yeh S., Incidence of liver trauma and relative risk factors for mortality: a population-based study. J Chin Med Assoc., 76(10): 576-582, 2013.
Dondelinger R., Trotteur G., Ghaye B., Szapiro D., Traumatic injuries: Radiological hemostatic intervention at admission. Euro Radiol, 12: 979-993, 2002.
Francisco L., Asunción L., Antonio C. et al., Post- traumatic hepatic artery pseudoaneurysm treated with endovascular embolization and thrombin injection. World J Hepatol. 2(2): 87–90, 2010.
Ghimire P., Yogi N. and Ghimire P., Non-operative management of blunt abdominal trauma in a tertiary care hospital of Nepal. Nepal Journal of Medical Science, 2(1): 38- 41, 2013.
Grala P., Skrzywanek P. and Sowier A., Biliary fistulasresulting from blunt hepatic injury treated by endoscopic diversion of the bile flow. Acta Chir Belg., 109(1): 47-51, 2009.
Hamdy H., Nasr M., Abou Eisha H., Sherif O. et al., Evaluation of management options for traumatic liver injuries. Egyptian Journal of Surgery (EJS), 31: 16-23, 2012.
Heuer M., Taeger G., Kaiser G. et al., Prognostic Factors of Liver Injury in Polytraumatic Patients. Results from 895 Severe Abdominal Trauma Cases. J Gastrointestin Liver Dis, 18(2): 197-203, 2009.
Joshi S., Joshi S. and Athavale S., Some interesting observations on the surface features of the liver and their clinical implications. S Singapore, 50(7): 715-719, 2009.
Kaoutzanis C., Evangelakis E., Kokkinos C. et al., Case report – vascular general: Successful repair of injured hepatic veins and inferior vena cava following blunt traumatic injury, by using cardiopulmonary bypass and hypothermic circulatory arrest. Interactive CardioVascular and Thoracic Surgery, 12: 84- 86, 2011.
Kogure K., Kuwano H., Yorifuji H. et al., The Caudate Processus Hepatic Vein: A Boundary Hepatic Vein Between the Caudate Lobe and the Right Liver. Annals of surgery, 247(2): 288-293, 2008.
Tarchouli M, Elabsi M, Njoumi N, Essarghini M, Echarrab M, Chkoff MR. Liver trauma: What current management?. Hepatobiliary Pancreat Dis Int. 2018;17(1):39-44. doi:10.1016/j.hbpd.2018.01.013
Krstina D. and Aleksandar K., The blunt liver trauma –review of current diagnostic and management strategies. Sana- med, 8(2):151-157, 2013.
Laing G., Clarke D., Ferndale L. et al., Hemobilia following blunt liver injury. S Afr J surg, 50(4):136-137, 2012.
Lucas C. and Ledgerwood A., Treatment of Liver Injuries: An Overview. In: Ivatury R. (Ed.), Operative Techniques for Severe Liver Injury, Springer Science and Business Media New York, p. 9-28, 2015.
Mama N., Jemni H., Achour N. et al., Abdominal trauma imaging. In : Derbel F. (Ed.), Abdominal surgery, InTech, p. 3- 52, 2012.
Mujuni E., Wangoda R., Ongom M., Acute traumatic coagulopathy among major trauma patients in an urban tertiary hospital in sub Saharan Africa. BMC Emergency medicine, 12:16, 2012.
Nguyen C., Saksobhavivat N., Shanmuganathan K. et al., MDCT diagnosis of post-traumatic hepatic arterio-portal fistulas. Emerg Radiol, 20(3): 225-232, 2013.
Oliveria D., Feitosa R. and Correia M., Segmentation of liver, its vessels and lesions from CT images for surgical planning. BioMedical Engineering OnLine, 10:30, 2011.
Ozbek O., Solak Y., Batur A. et al., Hepatic pseudoaneurysm secondary to blunt trauma successfully treated with percutaneous transhepatic intervention. BMJ case reports, 6239, 2012.
Parray F., Wani M., Malik A. et al., Evaluating a conservative approach to managing liver injuries in Kashmir, India. J Emerg Trauma Shock, 4(4):483-7, 2011.
Radhiana H., Azian A., Razali M. et al., Computed Tomography (CT) in blunt liver injury: A pictorial essay. Med J Malaysia, 65: 4, 2011.
Ramia J., Ramiro C., De la Plaza R. et al., Complications associated with Non-operative management of blunt hepatic injury: a Review. The open Emergency Medicine Journal, 5: 8- 11, 2013.
Saleem A. and Baron T., Endoscopic management of biliary leak following gunshot wound to the liver. J interv Gastroenterol., 2(2): 84-85, 2012.
Sreeramula P., Venkatachalapathy T. and Anantharaj, Blunt trauma liver-conservative or surgical management: A retrospective study. J trauma treat, 1(8): 146, 2012.
Tripathi A., Gupta S., Gupta K. and Patil R., Gunshot injury of the neck – An unusual case of survival. Indian J Dent Adv, 4(4): 1034-1038, 2012.
Wallis A., Kelly M. and Jones L., Angiography and embolisation for solid abdominal organ injury in adults - a current perspective. World Journal of Emergency Surgery, 5: 18, 2010.
Wong Y., Wang L., See L. et al., Contrast material extravasation on contrast-enhanced helical computed tomographic scan of blunt abdominal trauma: its significance on the choice, time and outcome of treatment. Journal of trauma, 54: 164-170, 2003.

No competing interests reported.

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Management of Blunt Liver Trauma in Pediatric Age Group.

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Abstract

Background

Aim

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Results

Conclusion

Introduction

Methods

Results

Clinical Data:

Outcome findings:

Discussion

Conclusion

Declarations

Author Contribution

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