Liver Trauma in Children By Eduardo

M. Suson,

Donald

Klotz,

Jr.,

and

Peter

K. Kottmeier

RAUMA HAS REMAINED one of the leading causes of death in childhood.’ A persistently high admission rate of children’with traumatic injuries to the Pediatric Surgical Service at Downstate Medical Center led us to review the injuries and causes of death in these children. An analysis of the children admitted for abdominal injury showed that liver trauma was more frequently found than in most other recent reports.2,3 Multisystem trauma was common, leading to extensive inJuries and not infrequently to the delay of early diagnosis and treatment of the liver injury. Blunt abdominal trauma in 32 of 35 children dominated this series, in contrast to liver injury reported in adolescents and adults.4,5 Although the mortality rate of 207, appears acceptable compared with other reports, our review indicates that more children could be saved with earlier diagnosis and improved operative management.6

T

CLINICAL Frclm

1964 to 1973. 115 celiotomies

mttted to the Pediatric liver. Children

Surgical

MATERIAL

were performed

Service.

on children

35 of these children

with isolated genitourinary

tract injury

under the age of 13 years ad-

(31”,,)

requiring

had sustained

operative

trauma

interventton

to the

were not

included in this study.

Sex. ,4ge, and Race Sixty per cent of these children trauma

mortality

were males, a sex ratio

rate in Brooklyn

injuries.

I? yr. with a mean age of 5.4 yr. Blacks and Hispanics proximates

Physical

with

the over-all

pediatrtc

The ages ranged from 6 wh tc,

represented

66”,, of the series. whtch

ap-

the general admission ratm in Pedtatrics at our institution.

and Laboratory

Either abdominal Abnormal

Findings

on Admission

pain or tenderness was present on admission

bowel sounds, absent or hypoactive,

curred in only 8”,,. probably Tachycardta, abdominal

related to the short interval

was present

bleeding,

non. and all patients The remainder

in a significant

In eight patients

inpc of significance,

in additton

counts over 15,000 cells/cu

From the Pediatric .vtute Medical

before

Service.

the 23rd

.dddres.\ Ji)r reprint v/ Sur,~erj~, State

requests:

l~niversitv

I4

Eduurdu

of .Yrw

indicated

with

o/‘.Sur~er~ A.

tntra-

on explora-

to liver trauma

cavity

alone.

later. The only IaborJtory

associated

genttourinary

while useful to detect associated

Department

oc-

admission.

major

was found

half (48”,,) of the patients

were not helpful

.4 rtenue, Brooklyn.

.4nnual Meeting

tian, San Franc~isco. CaliJY. October

in patients

findings,

problems.

450 Clarkson

and

massive bleeding

were not related

in approximately

mm. X-ray

Surgical

Center,

Vomiting

and hospital

with a systolic blood pressure

of patients

system injuries as outlined

to hematuria

found pulmonary

(70”,,) ol children.

had more than 250 cc of free blood in the peritoneal

associated

jury. was the presence of leukocytosis the commonly

or hypotension.

number

of the clinical findings on admission

were based on the multiple

between accident

with hypotension.

with tachycardia

in the majority

in 95”,, of the patients.

were found

with a pulse rate over I?0 per minute,

under 90 mm Hg.

Presented

compatible

due to acttvity-related

in the diagnosis

State

l’niverrit~

but tind-

tract

in-

with whtte blood injurieb. such 3,

of the liver

of .&‘ew 1 ark

inlury

Dow-

k’. IlN3.

of‘ the .Americ,an

.Acadent,,

o/ PediatriL~s. Sur,rtc,al

Se6

22, 1974. M.

Susan.

F.orh Downctate

M.D.. Medical

Pediatric, Center,

Sur@cal

Serviw,

450 Clarkson

I)epartment

.A ve.. BmoXIvu.

\‘. I’. I I703 ,c 197.5 b.,, Grtme & Stratton.

Inc..

Journal of Pediatric Surgery, Vol. 10, No. 3 (June), 1975

411

412

SUSON,

Table I.

Liver Trauma

in 35 Children:

KLOTZ,

AND

KOTTMEIER

Cause of Injury

NO.

Mortality

Blunt 32 Patients Vehicular

24

4

Fall

3

1

Crush

1

Battered children

4

1

Knife

1

1

Gloss

1

Penetrating

Fence

1 35

7 = 20%

Abdominal findings were difficult to interpret in patients with associated cerebral trauma, and abdominal paracentesis was, therefore, considered to be mandatory in these patients. Abdominal paracentesis was performed upon 24 patients, and in 19 patients with free intra-abdominal blood the tap was positive, and negative in the other five. In four of the latter group more than 100 ml of free blood was found at operation. With the exception of one patient, all abdominal paracenteses were performed through either one- or two-quadrant taps. In one patient a four-quadrant tap was performed which resulted in a gallbladder perforation with bile leakage.

Cause of Injury (Table I ) The multisystem involvement can be explained by considering the underlying mechanism of injury, which in the vast majority (32 children) was blunt in nature, caused predominantly by vehicles striking pedestrians, falls from height, or violent abuse of children. All these mechanisms tend to produce multisystem injuries which are not only devastating in their physical effects but also complicate prompt. early diagnosis and treatment. Penetrating injuries were rare (only three) leading to death in one patient.

Associated Injuries (Table 2) The violent blunt trauma led to where chest and rib fractures are sustained chest injuries, including thorax. Of importance is the high consciousness in four children on

a variety of associated injuries. In contrast to splenic injuries. relatively rare, more than half of children with liver trauma fractures of the ribs, pulmonary contusion or hemopneumoincidence of associated cerebral injuries (ten cases) with unadmission. Extremity fractures were present in I2 children.

Table 2. Liver Trauma

in 35 Children:

System

Chest

Associated Injuries

in 28 Patients NO.

18

Fracture

4

contusion

a

Hemopneumothorax

6

Cerebral

10

Fractures

12

Gastrointestinal

11

Genitourinory

6

Major vessels

5

Spleen

4

Diaphragm

4

Pancreas

3

Retroperitoneol hemorrhage

5

Biliary tract

5

Mesentery-Omentum

5

413

LIVER TRAUMA

Other significant

associated

spread multisystem associated major to the mortality

injuries

involvement

vessel injuries,

the combined

hepatic

there

vascular

to illustrate

the wide-

were only five children

lesions contributed

with

significantly

of Liver Trauma

The finding of major liver trauma

I

but are tabulated

Although

rate.

Extent and Location multisystem

were less frequent

in these children.

injury.

Major

in 27 of these 35 patients

liver injury

is defined

cm, and the source of more than 250 ml of blood.

patients and the left in five patients, curred

in the right

minor

injury

and both

lobe in five children

emphasizes

as a laceration Major

hepatic

the severity of the blunt

longer

injury

than

involved

3 cm, deeper the right

lobes in three others.

Minor

and in the left lobe in two others.

the site was not recorded.

Liver

damage,

both

major

than

lobe in I9 trauma

In one child

and minor,

ocwith

was. therefore.

found more than three times as often on the right side.

Major

Vessel Injury (Table 3)

Liver and associated major vessel injury was present in five children. In four, and due to penetrating

injury

in one other

fervor vena cava. renal vein, and celiac artery stab wound. patient

The

No.

patient

exsanguinated

2 an avulsion

found. A right lobectomy exsanguinated

in patient

during

Injuries repaired.

of the inferior

The common the operative

accident

No.

after resection 5. with

major

of the right

cava repalr were performed.

a In

but the patient

due to a shortage

of whole

of both lobes

veins and transection

of the

and the vascular

to the left main hepatic duct. Although

he died postoperatively

from

pulmonary

the

complications

trauma. of the caudate

successful repair in a child has been previously In patient

injuries.

of the vena cava were

and the left lobe was reanastomosed

Patient No. 4 with injuries to the left and right hepatic

cava. and a fracture

of the vascular

sustained avulsions

vena cava and hepatic

bile duct was sutured procedure,

secondary to extensive pulmonary vena cava survived

repair

the in-

girl who sustained

during the operation.

The right lobe was removed,

patlent survived

I, a l2-yr-old

table. The cause of death was partially

transfusion

to blunt trauma included

vena cava were performed,

Patient No. 3 was an X-yr-old boy who in a vehicular triad.

No.

secondary

vessels involved

of the right lobe of the liver and a laceration

of the liver. with lacerations portal

The

an attempted

and a repalr of the inferior

on the operating

blood and inadequate

child.

injury

repair

of the intrahepatic

of vena cava.

,4 slmllar

reported.’

to the right

kidney,

lobes and laceration

lobe to facilitate

a right

lobe of the liver.

hepatic-lobe

resectlon,

tear of the

inferior

nephrectomy.

vena

and vena

The patient also survived.

Liver Resection Hepatic

resections

right lobectomies who died after

were performed

upon

eight patients.

were done in four patients. liver resections.

both

lobes were involved

other child only the right lobe was removed. Table 3. Liver Trauma

Age (Y~I

in 35 Children: Injury

1. 12 (stab)

Rt. lobe; inf. vent CCIVCI;

2. 11

Avulrion rt. lobe;

In six survivors

and left lobectomies Both patients

complete

in two others.

or partial

In two patients.

in one of these patients,

and

In the

who died had associated

major

vessel

Maior Vessel Injury (Four blunt, One penetrating) Op. Repair

ReXlIt

Attempted repair

Died exsang. O.R.

Lobectomy, CCIW

Died exsang. O.R.

Reanost. It. lobe; COVB;

Died postop. pulmonary

renal vein; celioc art. inf. vencl cova 3. 8

Both lobes; inf. vent COW; portal triad; hep. veins

4. 6

Lt. and rt. lobe; intrahep. vencl CWCI

5. 6

Avulsion rt. lobe; inf. vent COYO;kidney

portal triad; hep. veins Res. caud. lobe;

Survived

CCIYCI; cholecystostomy Res. rt. lobe; covci; nephrectomy

Survived

414

SUSON,

KLOTZ,

AND KOTTMEIER

injury but in only one patient was the cause of death due to liver injury per se. Packing of liver injury and bleeding sites was not used in this series with but one exception where gelfoam was placed on the liver surface.

Seven ofthe 35 patients with liver injury died, a mortality rate of 200,. The cause of death was directly related to the liver injury and to a shortage of bank blood in one of these three. Only two of the eight patients with liver resection succumbed and these were two of the five patients with associated major vessel injuries. Three of the five patients with associated major vascular injury survived the operative repair. but one of these died later of pulmonary complications. In four of the seven deaths the cause was primarily due to the associated injury, and three of these patients died of pulmonary complications. These pulmonary complications did not appear to be related to the hepatic injury itself but directly due to the associated pulmonary injury, predominantly pulmonary contusion and hemorrhage. One of two patients who developed disseminated intravascular clotting postoperatively died.

Postoperative

Complications

Postoperative complications developed in 21 patients, related either to the type of injury tained or to the operative procedure performed. Wound infections, sepsis, intra-abdominal

susab-

scesses, prolonged ileus, and GI bleedmg all appear to be related to both the initial injury and the operative procedure. The postoperative pulmonary and cerebral complications are probably related almost entirely to the initial injury itself. Prolonged jaundice and cholangitis were associated in two cases with the use of intraductal biliary drainage, which was used in the beginning of this series, but has since been stopped. Others have reported similar complications with this procedure. DISCUSSION

A review of our experience reveals a higher than anticipated frequency of liver trauma in children with abdominal injury. Unlike adolescents and adults, children under the age of I3 yr are more likely to incur blunt liver trauma,4*5 a finding supported by our experience where 32 of 35 children sustained blunt trauma to the liver. The cause of the blunt injury, whether vehicular, falls, or “battered children.” usually leads to extensive injuries involving multiple systems. The multisystem involvement in these children not only caused a multitude of associated injuries, but because of the often more apparent associated injury, significant intra-abdominal bleeding was obscured and the diagnosis of liver injury delayed. The interval between accident and admission in 90% of our children was less than 30 min and did not, therefore, contribute to a delay of diagnosis or therapy. Exceptions were “battered children,“*,9 where the very nature of the injury, with uncooperative parents, delayed admission to the Emergency Room as long as 48 hr postinjury. On admission most children were found to have abdominal tenderness or pain. Unfortunately, neither pain nor tenderness are reliable findings in children with suspected intra-abdominal injuries, since even minor abdominal wall contusions can present in children with identical findings. Similarly, abnormal bowel sounds found on admission in almost all patients, can present in the absence of significant intra-abdominal injuries. The finding of vomiting in only S”,/,of these patients may be a reflection of the short period between injury and arrival at the Emergency Room. While tachycardia may also occur in an apprehensive child without major injury, in this series, tachycardia and hypo-

LIVER TRAUMA

41.5

tension were found only in association with significant intra-abdominal injury and blood loss. Leukocytosis (greater than 15,000 cells/m13) was found in 48”” of all children. Although leukocytosis may indicate some pathologic process, it is not indicative of visceral injuries, since leukocytosis can also occur with skeletal injury alone. Diagnostic angiography or radioactive scans to evaluate the extent of liver injury were not used in this series. Angiography can be very helpful in the diagnosis of late complications” after liver trauma, such as hematobilia. or the formation of A-V fistulae, but it does not appear to play a significant role, however, in the acutely injured child who is either unstable or in shock. Abdominal paracentesis may be helpful in patients in whom the diagnosis of intra-abdominal bleeding is difficult to establish, especially in children with associated cerebral injuries. Ten patients in this series sustained cerebral trauma with four patients unconscious on admission, all mandatory candidates for abdominal taps. Abdominal paracentesis was performed upon 24 patients: in 19 the paracentesis was positive for blood. but false negatives occurred in tive patients in whom over 100 cc of blood were found at celiotomy. It must be ernphasized that a positive tap, with nonclotting blood obtained from the peritoneal cavity, indicates free intraperitoneal blood, a negative or “dry” abdominal tap does not rule out either intra-abdominal injury or intra-abdominal bleeding. In only one patient cited previously, a single four-quadrant tap was performed which resulted in a perforation of the gallbladder with subsequent bile peritonitis. Abdominal taps should only be performed as single, or occasionally bilateral lower abdominal quadrant aspirations, especially in young children in whom both liver and spleen may sometimes project below the inferior costal margin. Peritoneal saline lavage, more sensitive than the abdominal “dry tap” was used in the later part of the series. While false negative taps are less likely to occur, false positive lavage may result in unnecessary operative procedures in patients with either minor or absent abdominal trauma. An analysis of the peritoneal lavage, with microscopic red blood cell count, rather than gross interpretation of the color of the lavage. may help to prevent needless exploration in patients with minor trauma. Major Hepatic Resection and Major C’essel Injury) A review of other reports’.’ and our own series indicates that exsanguination is a common cause of death in children with major liver injury, yet it appears to be the most preventable cause of death. In our experience, reactivation ot bleeding occurs mainly during the search for the site of the hepatic bleeding, or the attempt to repair major vessel trauma without prior vascular control. Vascular control and a wide operative exposure is essential in patients with either major hepatic trauma and/or vascular injury. Extension of the celiotomy excision, either vertical or horizontal into the right chest should be considered in all children with major right or bilateral hepatic injury, especially if associated vascular injury is suspected.

416

SUSON,

KLOTZ,

AND KOTTMEIER

The incision of the right diaphragm allows control of the suprahepatic inferior vena cava, mobilization of the liver with increased exposure, and prevention of potential air embolism. ‘OThe right colon and duodenum are then mobilized, the subhepatic inferior vena cava exposed and surrounded with a tape. This is followed by a modified Pringle maneuver,” with cross-clamping of the portal triad to prevent hepatic inflow and, if prolonged occlusion appears necessary, simultaneous occlusion of the superior mesenteric artery. Occlusion of the portal triad alone will lead to a marked venous congestion of the intestine which not only reduces the already inadequate blood volume but can interfere with the viability of the intestine. Both portal triad and superior mesenteric artery can be safely occluded 15-20 min, with intermittent release of the vascular occlusion when necessary. Although the safe time of hepatic ischemia has been reported to range between 20 and 30 min’* our experience with a young adult patient showed that portal triad and superior mesenteric artery occlusion was well tolerated without postoperative hepatic dysfunction after 90 min of occlusion with local hypothermia after accidental transection of the portal triad. While the use of intracaval shunts ‘2~‘3has been advocated in hepatic and vascular trauma, the differences in size of children sustaining liver trauma would necessitate the availability of numerous sizes of intracaval shunts. For this reason intracaval shunts were not used in our institution. The use of the modified Pringle maneuver as described, will bring the amount of bleeding during either hepatic resections, or during the repair of major vessel injury, within acceptable limits. After complete vascular control has been obtained and the liver resection is to be performed, additional maneuvers can further facilitate the resection. The use of large vascular clamps, especially in small children, compressing the liver parenchyma, will further reduce bleeding during the blunt finger dissection after the sharp incision of the capsule. If hepatic resection is contemplated, then ligation of either right or left hepatic artery will decrease bleeding encountered during the resection. Individual ligation of both vascular and biliary structures after blunt dissection is followed by interlocking chromic catgut sutures along the line of resection. No attempt is made to reperitonealize the liver parenchyma after hepatic resection. Perihepatic drainage, with either multiple Penrose or sump drains was used in most patients, and appears indicated after all major resections. Our experience with internal biliary drainage, although limited and statistically insignificant, indicates that the disadvantages (strictures or cholangitis) far outweigh its potential benefits in children.” The preoperative preparation of children suspected of having major intraabdominal trauma, including the possibility of major liver trauma, necessitates introduction of either intravenous catheters or cutdowns in upper extremities or jugular veins. Not only may two avenues be necessary to administer the amount of crystaloid solution or blood during major bleeding, the difficulty in estimating blood loss and functional blood volume requires the availability of central venous pressure readings during and after operative procedure.

417

1lVER TRAUMA

SUMMARY

A review of our experience with urban children who sustained blunt abdominal trauma revealed that liver trauma occurred in one-third of all children. The cause of trauma, predominantly blunt in nature, led to a multitude of associated injuries which not only caused visceral and skeletal injury endangering, the patient, but, more apparent even though less significant injuries delayed diagnosis and therapy of the underlying severe liver injury. Awareness of the possibility of liver injury in children with blunt abdominal trauma, prompt operative intervention with adequate vascular control prior to the attempted repair of liver or associated major vessel injuries should significantly increase the salvage of these pediatric trauma victims. REFERENCES 1, Vital ume

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