The effectiveness of non-operative treatment in high-grade liver and spleen injury in children

Background: Although nonoperative treatment approach is preferred for blunt liver and spleen trauma in childhood, there are significant differences in the algorithms used between clinics. Along with the absence of grade V liver and spleen injury in the American Pediatric Surgical Association (APSA) guideline, approach to high-grade liver and spleen injury is still controversial. The aim of this study is to present our experience in non-operative treatment approach to patients with high-grade liver and spleen injury.
Materials and Methods: Patients who referred to Marmara University Hospital’s emergency department between January 2012 and January 2017 due to liver and spleen injury related to blunt abdominal trauma and followed up in our clinic were included in the study. The data were analyzed retrospectively in terms of age, sex, type of trauma, degree of organ damage, accompanying organ damage, duration of intensive care and hospital stay, need for transfusion, and treatment method (operative-nonoperative). Grade I, II, III organ damage is classified as low grade while grade IV and V organ lesions classified as high grade.
Results: 88 out of 2800 patients who were diagnosed by radiological imaging as liver and spleen injuries due to blunt abdominal trauma and were hospitalized to our clinic were included in the study. 41 of these patients had isolated liver injury while 39 had isolated spleen injury and 8 had injuries in both organs. 30 (34%) of the patients had accompanying organ injury. 83 (94%) patients underwent non-operative treatment and surgical approach was required for 5 patients (6%). Patients with high-grade liver injury had significantly higher duration of hospitalization, duration of ICU stay and transfusion requirement compared to patients with low-grade liver injury (p values are; 0.001, 0.001, and ˂0.001, respectively). Surgical approach was more frequent among patients with high-grade liver injury than patients with low-grade injury (p = 0.045). There was no difference among patients with high and low-grade spleen injury in terms of age, sex, duration of hospitalization, duration of ICU stay, transfusion requirement, and accompanying organ injury (p values were: 0.254, 0.739, 0.114, 0.135, 0.057, 0.721 respectively). Similarly, there was no difference in terms of nonoperative or operative treatment among these two groups (p = 0.488).
Conclusion: Non-operative treatment is feasible treatment method in patients with high grade blunt liver and spleen injury. However pediatric surgeons should consider that patients with high-grade liver damage may require more surgical treatment than those with low-grade liver damage.

Yüksek dereceli karaciðer ve dalak hasarýnda nonoperatif tedavinin etkinliði

Amaç: Her ne kadar çocukluk çaðýnda künt karaciðer ve dalak travmasýnda nonoperatif tedavi yaklaþýmý tercih edilir olsa da, klinikler arasýnda kullanýlan algoritmalarda ciddi farklýlýklar bulunmaktadýr. Amerikan Pediatrik Cerrahi Birliði (APSA) rehberinin grade V karaciðer ve dalak hasarýný içermemesi ile birlikte, yüksek dereceli karaciðer ve dalak hasarýna yaklaþým halen tartýþmalýdýr. Bu çalýþmanýn amacý; yüksek dereceli karaciðer ve dalak hasarý olan hastalara nonoperatif tedavi yaklaþýmýyla ilgili tecrübelerimizi sunmaktýr.
Gereç ve Yöntem: Ocak 2012-Ocak 2017 tarihleri arasýnda Marmara Üniversitesi hastanesi acil servisine baþvuran hastalardan künt batýn travmasýna baðlý karaciðer ve dalak hasarý nedeniyle kliniðimizde takip edilen hastalar çalýþmaya dahil edilmiþtir. Hastalarýn yaþ, cinsiyet, travma þekli, organ hasarýnýn derecesi, eþlik eden organ hasarý, yoðun bakýmda ve hastanede kalýþ süresi, transfüzyon ihtiyacý olmasý, tedavi yöntemi (operatif-nonoperatif) þeklinde olan verileri geriye dönük olarak analiz edilmiþtir. Grade I, II, III derece olan organ hasarlarý düþük dereceli olarak; grade IV, V olan organ hasarlarý ise yüksek dereceli olarak sýnýflandýrýmýþtýr.
Bulgular: Acil servisimize baþvuran 2800 çocuk travma olgusundan künt batýn travmasýna baðlý radyolojik görüntülemelerinde karaciðer ve dalak hasarý tesbit edilip kliniðimizde yatýrýlan 88 hasta çalýþmaya dahil edilmiþtir. 41 hastada izole karaciðer hasarý, 39 hastada izole dalak hasarý, 8 hastada ise her iki organda hasar izlenmiþtir. Her iki organda hasar izlenen hastalarda yüksek dereceli hasarý olan organ hangisiyse o gruba dahil edilmiþtir. Yüksek dereceli (29), düþük dereceli (17) karaciðer hasarý izlenmiþtir. Yüksek dereceli (21), düþük dereceli (21) dalak hasarý izlenmiþtir. Hastalarýn 34%’ünde (30 hastada) eþlik eden organ hasarý izlenmiþtir. Nonoperatif tedavi 83 hastaya (94%) uygulanabilmiþtir, 5 hastaya (6%) ise cerrahi uygulanmasý gerekmiþtir. Yüksek dereceli karaciðer hasarý olan hastalarda düþük dereceli karaciðer hasarý olanlara göre, hastanede yatýþ süresi, YBÜ’de yatýþ süresi ve transfüzyon ihtiyacý anlamlý ölçüde yüksek bulunmuþtur (p deðerleri sýrasýyla; 0.001, 0.001, ˂0.001’dir). Yüksek dereceli karaciðer hasarý olan hastalarda düþük dereceli karaciðer hasarý olanlara göre daha fazla cerrahi yaklaþým uygulanmýþtýr (p=0.045). Yüksek ve düþük dereceli dalak yaralanmalarýnda her iki grup arasýnda yaþ, cinsiyet, hastanede yatýþ süresi, YBÜ’de yatýþ süresi, transfüzyon ihtiyacý, eþlik eden organ hasarý açýsýndan fark bulunmamýþtýr (p deðerleri sýrasýyla; 0.254, 0.739, 0.114, 0.135, 0.057, 0.721’dir). Benzer þeklilde yüksek dereceli dalak hasarý olanlarla düþük dereceli dalak hasarý olanlar arasýnda nonoperatif veya operatif tedavi yaklaþýmý açýsýndan da fark izlenmemiþtir (p=0.488).
Sonuç: Yüksek dereceli künt karaciðer ve dalak hasarý olan hastalarda nonoperatif tedavi uygulanabilir bir yöntemdir. Ancak yüksek dereceli karaciðer hasarý olanlarda düþük dereceli karaciðer hasarý olanlara göre cerrahi tedaviye daha fazla baþvurulabileceði dikkate alýnmalýdýr.