Treatment and outcome of traumatic biliary injuries in children

Background/Purpose

Traumatic biliary tract injuries in children are rare but may result in significant morbidity. The objective of this study was to review the occurrence of traumatic biliary tract injuries in children, management strategies, and outcome.

Methods

We conducted a retrospective review of patients with biliary tract injury using the trauma registry at our level 1 pediatric trauma center from 2002–2012.

Results

Twelve out of 13,582 trauma patients were identified, representing 0.09% of all trauma patients. All were secondary to blunt trauma. Mean age was 9.7 years [range 4–15], and mean Injury Severity Score was 31 ± 14, with overall survival of 92%. Biliary injuries included major ductal injury (6), minor ductal injury with biloma (4), gallbladder injury (2), and intrahepatic ductal injury (1). Major ductal injuries were managed by endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent (5) and Roux-en-Y hepaticojejunostomy (1). Associated gallbladder injury was managed by cholecystectomy. In addition, the associated biloma was managed with percutaneous drainage (7), laparoscopic drainage (2), or during laparotomy (3). Two patients with ductal injuries developed late strictures after initial management with ERCP and stent placement. One of the two patients ultimately required a left hepatectomy, and the other has been managed conservatively without evidence of cholangitis. Two patients required placement of additional drains and prolonged antibiotics for superinfection following biloma drainage.

Conclusion

Biliary tract injuries are rare in children, and many are amenable to adjunctive therapy, including ERCP and biliary stent placement with or without placement of a peritoneal drain. Patients with a discrete ductal injury are at higher risk for stricture and require close follow up. Hepaticojejunostomy remains the definitive repair for large extrahepatic biliary tract injuries or transections.     

Fecal continence following complex anorectal trauma in children

Background

Complex injuries involving the anus and rectum are uncommon in children. We sought to examine long-term fecal continence following repair of these injuries.

Methods

We conducted a retrospective review using our trauma registry from 2003 to 2012 of children with traumatic injuries to the anus or rectum at a level I pediatric trauma center. Patients with an injury requiring surgical repair that involved the anal sphincters and/or rectum were selected for a detailed review.

Results

Twenty-one patients (21/13,149 activations, 0.2%) who had an injury to the anus (n = 9), rectum (n = 8), or destructive injury to both the anus and rectum (n = 4) were identified. Eleven (52%) patients were male, and the median age at time of injury was 9 (range 1–14) years. Penetrating trauma accounted for 48% of injuries. Three (14%) patients had accompanying injury to the urinary tract, and 6 (60%) females had vaginal injuries. All patients with an injury involving the rectum and destructive anal injuries were managed with fecal diversion. No patient with an isolated anal injury underwent fecal diversion. Four (19%) patients developed wound infections. The majority (90%) of patients were continent at last follow-up. One patient who sustained a gunshot injury to the pelvis with sacral nerve involvement is incontinent, but remains artificially clean on an intense bowel management program with enemas, and one patient with a destructive crush injury still has a colostomy.

Conclusions

With anatomic reconstruction of the anal sphincter mechanism, most patients with traumatic anorectal injuries will experience long-term fecal continence. Follow-up is needed as occasionally these patients, specifically those with nerve or crush injury, may require a formal bowel management program.     

Visceral injuries in nonaccidental trauma: spectrum of injury and outcomes

BACKGROUND: Nonaccidental trauma (NAT) causes significant morbidity and mortality in children. The purpose of this study was to characterize visceral injuries associated with NAT and the management and outcomes of children with these injuries. METHODS: During a 7-year period, children admitted to our regional pediatric trauma center with a diagnosis of NAT were identified and their injuries characterized. RESULTS: NAT accounted for 7% (n = 265 of 3705) of all trauma admissions during the period of study. Visceral injuries were diagnosed in 9% (n = 24 of 265) of NAT patients. Compared with the remaining NAT population, children with visceral injuries were similar in age and sex but had higher injury severity scores (21 vs. 17, P < .05). There was a high coincidence of thoracic trauma and nonburn integumental injuries in abdominally injured NAT patients. Children with visceral injuries were more likely to undergo emergent operations (46% [11 of 24] vs. 5% [15 of 241], P < .0001) than those without. However, there was no difference in Intensive Care Unit stay, hospital stay, or overall mortality for children with visceral injuries compared with those without. CONCLUSIONS: Visceral injuries are not uncommon in NAT, and these injuries often require emergent operative intervention. Thus, prompt evaluation and treatment by a surgeon remains a critical step in the management of children with NAT.     

One-year experience in a regional pediatric trauma center

During 1982, 267 children with life-threatening injuries were admitted to the Maryland Regional Pediatric Trauma Center at the Johns Hopkins Hospital. Seventy-three percent of patients arrived directly from the injury scene by helicopter (46%), ambulance (50%), or other (4%). Mechanisms of injury included motor vehicle accidents (MVA; 55%), falls (27%), assaults (8%), and sports and other injuries (10%). In 75% of MVA the child was a pedestrian. Fifty-one percent of injuries were single organ system, 29% involved two systems, and 20% involved three or more systems. Remarkably, the mortality of 6.7% was not affected by the number of organ systems involved, but was directly related to the presence or absence of head injury. Fourteen of seventeen deaths resulted from head injury. Eighty percent of documented liver and spleen injuries were managed nonoperatively. This nonoperative plan of management simplified the optimal treatment of head injury. The high frequency of head injury has mandated a more aggressive approach to the management of brain trauma including intracranial monitoring to facilitate control of cerebral edema. Our data demonstrate that an excellent quality of life may be anticipated even in children with severe head injury.     

Management strategies in isolated pancreatic trauma

Aim  In the absence of damage to other organs, pancreatic injury is rare. We have reviewed our experience with isolated pancreatic injury. Methods  Patients treated for isolated pancreatic trauma at our unit were identified prospectively and then retrospectively entered onto a database. The mode of presentation, mechanism of injury and management strategies were reviewed. Results  Seven male and four female patients, median age 30 years (range 13–51 years) were treated. All suffered blunt abdominal trauma with different mechanisms of injury, each being characterised by a direct blow to the central abdomen. In two patients, somatostatin analogue treatment used as primary treatment resulted in early resolution of symptoms and signs. Six patients underwent surgery at various stages post-injury. At a median follow-up of 58 months (range 22–106 months), eight patients are asymptomatic, two patients have chronic pain following distal pancreatectomy and one patient has occasional discomfort. Conclusion  Confirmation of the mechanism of trauma and suspicion of pancreatic injury are essential for early diagnosis and appropriate management. Early contrast computed tomography examination is vital in the recognition of these injuries. Somatostatin analogue therapy may have an important role in the treatment regimen, especially when patients present early after sustaining a pancreatic injury. Only selected patients require open surgery.     

The significance of contrast blush on computed tomography in children with splenic injuries

Purpose

Most children and adults with blunt splenic injuries are treated nonoperatively by well-established management protocols. The “blush sign” is an active pooling of contrast material within or around the spleen seen during intravenous enhanced computed tomography (CT) scan. Adult treatment algorithms often include the “blush sign” as an indication for embolization or surgical intervention. This study was designed to evaluate the implications of the “blush sign” in children with blunt splenic injuries.

Methods

A review was performed of all children with blunt splenic injuries treated between January 1996 and December 2001 at a level I pediatric trauma center using an established solid organ injury protocol. The demographic, CT imaging, and outcome data were recorded. Treatment was categorized as operative or nonoperative. A single pediatric radiologist retrospectively reviewed all available CT scans to confirm injury grade and the presence or absence of a “blush sign.”

Results

There were 133 eligible children admitted with blunt splenic trauma, with a mean age of 9.1 years (range, 1 to 15), including 86 children with an abdominal CT available for review. A “blush sign” on initial CT scan was noted in 6 children, all with grade 3 or above splenic injuries, 5 of who were treated nonoperatively. In this series, the single child with a “blush sign” who did not respond to nonoperative treatment had a severe polytrauma requiring urgent splenectomy and left nephrectomy. None of the children died of their splenic injury.

Conclusions

Although associated with higher grades of injury, the blush sign did not mandate embolization or surgical intervention in children with blunt splenic trauma in this series. Severe splenic injuries with a blush sign on the initial CT scan may be successfully treated nonoperatively when using an established treatment protocol. Management should be based primarily on physiological response to injury rather than the radiologic features of the injury.     

Management of thoracic trauma

Managing major thoracic trauma begins with identifying and anticipating injuries associated with the mechanism of injury. The key aims are to reduce early mortality and the impact of associated complications to expedite recovery and restore the patient to their pre-injury state. While imaging is imperative to identify the extent of thoracic trauma, some pathology may require immediate treatment. The majority can be managed with adequate pleural drainage, but respiratory failure and poor gas exchange may require either non-invasive or invasive ventilation. Ventilation strategies to protect from complications such as barotrauma, volutrauma and ventilator-induced lung injury are important to consider. The management of pain is vital in reducing respiratory complications. A multimodal strategy using local, regional and systemic analgesia may mitigate respiratory side effects of opioid use. With optimal pain management, physiotherapy can be fully utilised to reduce respiratory complications and enhance early recovery. Thoracic surgeons should be consulted early for consideration of surgical management of specific injuries. With a greater understanding of the mechanisms of injury and the appropriate use of available resources, favourable outcomes can be reached in this cohort of patients. Overall, a multidisciplinary and holistic approach results in the best patient outcomes.     

PATTERNS OF INJURY FROM MAJOR TRAUMA IN VICTORIA

Basic demographic and injury data were collected on all major trauma patients (ISS > 15) presenting to 25 Victorian hospitals over a 1 year period (March 1992-February 1993). A total of 1076 patients were identified with an Injury Severity Score (ISS) > 15. Of these, 957 resulted from blunt trauma, 68 from penetrating trauma and 51 from burns. Most serious blunt injury was transport-related (n= 652) but falls made up a significant proportion (n= 206). The pattern of injury in blunt trauma demonstrated in this study showed a preponderance of serious head, thoracic and limb injuries with less frequent occurrences of abdominal, spine and facial injuries. In major penetrating trauma, serious injuries of the thorax and abdomen were more frequent. Head injury is the most common cause of morbidity in major trauma patients. Motor vehicle accidents caused the majority of head injuries but, proportionately, head injury was more common in pedal cycle, pedestrian, motorcycle injuries and falls. The low frequency of major abdominal trauma has important implications for surgical training and resource allocation. In Victoria, various injury prevention interventions have been introduced such as compulsory wearing of bicycle helmets, a safer home environment and behavioural modifications through advertising. Injury prevention strategies must continue to target the populations at risk and assess the impact of interventions by accurate injury surveillance.     

Blunt Abdominal Trauma Requiring Laparotomy: an Analysis of 342 Polytraumatized Patients

Abstract Introduction: Hemorrhage due to abdominal trauma is one of the most frequent causes of early mortality in polytraumatized patients. Therefore, the initial management of abdominal trauma is an important factor in determining the outcome. The aim of this study was to evaluate the clinical course in multiple trauma patients who sustained abdominal trauma requiring operative intervention. Patients and Methods: In this retrospective analysis, a database containing prospectively collected data on polytraumatized patients from a European level I trauma center was used. The following inclusion criteria were applied: (1) operative intervention for blunt abdominal injuries with positive intraoperative findings, (2) injury severity score (ISS) > 18, and (3) age 16–65 years. Results: The inclusion criteria were met by 342 patients (229 male and 113 female patients, mean ISS 39.9±8.9). The most frequently observed intra-abdominal injuries were to the spleen (62.1%) and the liver (47.7%). The most common extra-abdominal injury observed in combination with abdominal trauma was trauma to the chest (71.9%). One hundred forty-three patients (41%) died during their hospital stay. The most frequent reasons for death were hemorrhagic shock (26.7%), ARDS (27.6%) and head trauma (23.2%). The severity of liver injury correlated positively with mortality. In contrast, no correlation between splenic injuries and mortality was observed. Significantly more deaths were attributed to primarily extra-abdominal injuries (111 patients, 77.6%) and then to intra-abdominal injuries (12 patients, 8.4%). In 20 patients (14%), a combination of intra- and extra-abdominal injuries caused posttraumatic death. Conclusion: Mortality was significantly higher for extra-abdominal injuries and their associated complications compared to intra-abdominal injuries. These findings should be considered in the development of treatment algorithms for blunt trauma.     

Pediatric splenic injuries with a contrast blush: successful nonoperative management without angiography and embolization

Background

The presence of a contrast blush on computed tomography (CT) in adult splenic trauma is a risk factor for failure of nonoperative management. Arterial embolization is believed to reduce this failure rate. The significance of a blush in pediatric trauma is unknown. The authors evaluated the outcome of children with blunt splenic trauma and contrast extravasation.

Methods

The trauma registry was queried for all pediatric patients with blunt splenic injuries. Admission CT was reviewed for injury grade and presence of an arterial blush by a radiologist blinded to patient outcome. Hospital and office charts were reviewed for success of nonoperative management, late splenic rupture, and other complications.

Results

One hundred seven children with blunt splenic trauma were identified over a 6-year period. Mean injury grade was 2.9. Six patients required emergency splenectomy. An additional 7 patients met hemodynamic criteria for surgical intervention (3 splenectomies, 4 splenorrhaphies). Admission CT was available in 63 patients. An arterial blush was identified in 5 (9.7%). Four remained stable and were treated conservatively. One underwent splenectomy for hemodynamic instability. There were no cases of delayed splenic rupture, failed nonoperative treatment, or long-term complications.

Conclusions

Contrast blush in children with blunt splenic trauma is rare, and its presence alone does not appear to predict delayed rupture or failure of nonoperative treatment. Based on this limited series, splenic artery embolization does not have a place in the management of splenic injuries in children.     

Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center

PURPOSE: In the last 20 years the management of high grade, blunt renal trauma at our institution has evolved from primarily an operative approach to an expectant nonoperative approach. To evaluate our experience with the expectant nonoperative management of high grade, blunt renal trauma in children, we reviewed our 20-year experience regarding evaluation, management and outcomes in patients treated at our institution. MATERIALS AND METHODS: We retrospectively studied all patients sustaining renal trauma between 1983 and 2003. Medical records were reviewed for mechanism of injury, assigned grade of renal injury, patient treatment, indications for and timing of surgery, and outcome. Injuries were categorized as either low grade (I to III) or high grade (IV to V). RESULTS: We reviewed the medical records of 164 consecutive children who sustained blunt renal trauma between 1983 and 2003. A total of 38 patients were excluded for inadequate information. Of the remaining 126 children 60% had low grade and 40% had high grade renal injuries. A total of 11 patients (8.7%) required surgical or endoscopic intervention for renal causes, including 2 for congenital renal abnormalities and 1 for clot retention. Eight patients (6.3%) required surgical intervention for isolated renal trauma, of whom 2 (1.6%) required immediate surgical intervention for hemodynamic instability and 6 (4.8%) were treated with a delayed retroperitoneal approach. Only 4 patients (3.2%) required nephrectomy. All patients receiving operative intervention had high grade renal injury. CONCLUSIONS: Initial nonsurgical management of high grade blunt renal trauma in children is effective and is recommended for the hemodynamically stable child. When a child has persistent symptomatic urinary extravasation delayed retroperitoneal drainage may become necessary to reduce morbidity. Minimally invasive techniques should be considered before open operative intervention. Early operative management is rarely indicated for an isolated renal injury, except in the child who is hemodynamically unstable.     

Management of duodenal injuries in children

Background/purpose

The natural history and management of pediatric duodenal injuries are incompletely described. This study sought to review injury mechanism, surgical management, and outcomes from a collected series of pediatric duodenal injuries.

Methods

A retrospective chart review was conducted for a 10-year period of all children less than 18 years old treated for duodenal injuries at 2 pediatric trauma centers.

Results

Forty-two children were treated for duodenal injuries. There were 33 blunt and 9 penetrating injuries. Injuries were classified using the Organ Injury Scale for the Duodenum. Twenty-four patients underwent operative management by primary repair (18), duodenal resection and gastrojejunostomy (4), or pyloric exclusion (2). Duodenal hematomas were treated nonoperatively in 94% of cases. The average ISS for operative versus nonoperative cases was 23 and 10, respectively. Delay in diagnosis or operative intervention (>24 hours) was associated with increased complication rate (43% v 29%) and hospitalization (32 v 20 days). Nine children requiring surgery experienced delays and were most highly associated with foreign body, child abuse, and bicycle injuries. There were no deaths caused by duodenal injuries.

Conclusions

Duodenal injuries in children were predominantly blunt and had a low mortality rate. When surgery was required, primary repair was usually feasible.     

HANDLEBAR INJURIES IN CHILDREN: PATTERNS AND PREVENTION

Background : Bicycle handlebar injuries in children are a significant cause of abdominal trauma. The present study documents 32 children with handlebar injuries who were managed at the Royal Children's Hospital over a 5-year period, and suggests a design change to bicycle handlebars which may reduce the severity of injury. Methods : A retrospective review of all the children admitted to the Royal Children's Hospital with handlebar injuries between January 1990 and January 1995 was undertaken. The age, sex, nature of injury, length of hospital stay and management were recorded. Results : Thirty-two children with blunt abdominal trauma or lacerations resulting from handlebar injuries were identified. Injuries included: splenic trauma (9); liver trauma (4); traumatic pancreatitis (3); transection of the pancreas (2); renal contusions (2); duodenal haematoma (1); and bowel perforation (3). In addition, there were three urethral injuries and five lacerations involving the abdominal wall and inguino-scrotal region. The presence of external bruising was a poor indicator of underlying organ damage. Thirteen operations were performed and the mean hospital stay for the series was 9 days. Conclusions : Handlebar injuries are a significant cause of both blunt abdominal trauma and lacerations to the contact area. The infrequent finding of external bruising in the presence of major organ damage suggests that, although the velocity at impact may be relatively low, the small cross-sectional area of the end of the handlebar is a major factor contributing to organ damage. Moreover, we suspect that the high proportion of lacerations observed in this type of trauma result from the sharp metallic end of the handlebar cutting through the soft rubber handle. Manufacturers of bicycles should be made aware of these findings and should adjust the design of the handlebars accordingly.     

Traumatic adrenal haemorrhage in children

BACKGROUND: Adrenal injuries following blunt abdominal trauma is uncommon. Recent increased detection of traumatic adrenal haemorrhage (TAH) prompted this study. METHODS: Cases were identified from retrospective search of the trauma and medical imaging database for the period 1998-2004. Medical records were reviewed and data analysed to identify mechanism of injury, imaging findings, associated injuries, presence of hypotension, length of stay and follow up. RESULTS: Eleven children were identified with TAH. Right adrenal was commonly injured. Motor vehicle injury was the commonest mechanism. All injuries were identified on initial computed tomography, and all but one had associated abdominal injuries. There were no deaths. Ultrasound showed resolution within 3 months in six patients. CONCLUSION: TAH is an uncommon injury that is rarely isolated. Although initial diagnosis is made on computed tomography, ultrasound appears adequate for follow up. TAH appears to be an incidental finding that resolves on follow-up imaging.     

The incidence,spectrum and outcomes of traumatic bladder injuries within the Pietermaritzburg Metropolitan Trauma Service

IntroductionThe purpose of this study is to provide a comprehensive overview of the incidence, spectrum and outcomes of traumatic bladder injury in Pietermaritzburg, South Africa, and to identify the current optimal investigation and management of patients with traumatic bladder injuries.MethodsThe Pietermaritzburg Metropolitan Trauma Service (PMTS) trauma registry was interrogated retrospectively for all traumatic bladder injuries between 1 January 2012 and 31 October 2014.ResultsOf 8129 patients treated by the PMTS over the study period, 58 patients (0.7% or 6.5 cases per 1,000,000 population per year) had bladder injuries, 65% caused by penetrating trauma and 35% by blunt trauma. The majority (60%) were intraperitoneal bladder ruptures (IBRs), followed by 22% extraperitoneal bladder ruptures (EBRs). There was a high rate of associated injury, with blunt trauma being associated with pelvic fracture and penetrating trauma being associated with rectum and small intestine injuries. The mortality rate was 5%. Most bladder injuries were diagnosed at surgery or by computed tomography (CT) scan. All IBRs were managed operatively, as well as 38% of EBRs; the remaining EBRs were managed by catheter drainage and observation. In the majority of operative repairs, the bladder was closed in two layers, and was drained with only a urethral catheter. Most patients (91%) were managed definitively by the surgeons on the trauma service.ConclusionTraumatic bladder rupture caused by blunt or penetrating trauma is rare and mortality is due to associated injuries. CT scan is the investigative modality of choice. In our environment IBR is more common than EBR and requires operative management. Most EBRs can be managed non-operatively, and then require routine follow-up cystography. Simple traumatic bladder injuries can be managed definitively by trauma surgeons. A dedicated urological surgeon should be consulted for complex injuries.     

Endovascular stenting of a penetrating axillary artery injury in a 14-year-old with 1-year follow-up

In the management of pediatric trauma, certain principles that are practiced in children who have sustained injuries more commonly seen in adults are extrapolated from the adult trauma literature. The increased use of computer tomography angiograms in the diagnosis of penetrating vascular trauma and endovascular therapy in treating vascular trauma in the adult population is being extended to the pediatric population. We present a case of a 14-year-old male with an axillary artery injury that was diagnosed by computer tomography angiogram and treated with an endovascular Stent graft with 1-year follow-up.     

Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes

Background

Nonoperative management (NOM) is an accepted treatment of pediatric solid organ injuries and is typically successful. Blunt pancreatic trauma tends to require operative intervention more frequently. We sought to identify predictors of failure of NOM and compare the outcome of operative management against NOM.

Methods

A retrospective analysis was performed from January 1993 to December 2002 of all children with blunt pancreatic injuries from the trauma registries of 7 designated level 1 pediatric trauma centers. Failure of NOM was defined as the need for intraabdominal operative intervention. Injuries were graded I to V, and ductal injury was defined as grades III to V. Parameters included mechanism of injury, injury severity score (ISS), organ grade, Glasgow Coma Scale score, and outcome. Data were analyzed by Fisher exact test and Mann-Whitney U test, with mean values ± SD and significance of P < .05.

Results

Pancreatic injuries were present in 173 (9.2%) of 1823 patients. Of these, 43 (26.0% [43/173]) required an operation. Valid morbidity data was obtained in 118 of 173 patients. ISS was significantly higher in all patients treated operatively. Patients with an injury of grade III to V failed NOM more frequently than all patients with pancreatic injury (P =.0169). Length of stay was longer, and the incidence of pseudocysts, drainage procedures, and pancreatitis was higher in NOM patients, although not significant.

Conclusions

Patients with pancreatic injuries had a NOM failure rate of 26.0%. ISS and injury grades III to V were predictors of NOM failure. Patients with pancreatic ductal injury require more aggressive management.     

Hepatic artery transection after blunt trauma: case presentation and review of the literature

Hepatic artery injuries sustained as a result of blunt abdominal trauma are rare. This case represents the first reported hepatic artery transection and the second hepatic artery injury described in children. Hepatic artery injuries are associated with high mortality, and their management is complex and controversial.     

Scapular fractures and concomitant injuries

Objective: The association of scapular fractures with other life-threatening injuries including blunt thoracic aortic injury is widely recognized.Few studies have investigated this presumed association...     

Factors predicting the need for splenectomy in children with blunt splenic trauma

Background/Purpose: Non‐operative management of blunt splenic trauma (BST) in children is the standard of care with a success rate of greater than 90%. This paper aims to determine the factors which could predict the need for operative intervention in children with BST. Methods: Prospectively entered data of 69 children with BST, between 1997 and 2008, from a single tertiary level trauma centre, were retrospectively analysed. A radiologist blinded to the outcome reviewed all computed tomography scans retrospectively. Results: Forty‐two children had isolated BST (61%) and 27 children had associated injuries (39%). All except one survived the injury and non‐operative treatment was successful in 91%. Six of the 69 children (9%) with BST underwent splenectomy. There was no independent correlation to age, gender, mechanism of injury (MOI), injury grade and the need for splenectomy, whereas haemodynamic instability within 6 h of injury defined as failed resuscitation had a 100% correlation. Conclusion: Haemodynamic instability, which failed to respond to resuscitation within 6 h, predicted the need for splenectomy in children with BST. Splenic injury grade assessed by computed tomography scan does not predict the need for splenectomy.