PENETRATING HEPATIC-TRAUMA IN CHILDREN - OPERATING-ROOM OR NOT

Nonoperative management has become widely accepted as the standard of care for patients with blunt hepatic trauma. Recent studies among adul ts have supported the use of nonoperative management of selective pene trating wounds to the hepatic bed in stable patients. The therapeutic management of children with penetrating injuries to the hepatic bed we re evaluated to ascertain whether nonoperative management was a reason able consideration in their care. The database of the National Pediatr ic Trauma Registry (NPTR) was reviewed for the period 1985-1994. ICD-g codes 864.00 to 864.10 were used to select injury site, diagnosis, an d, combined with Current Procedural Terminology (CPT) code data, to as certain therapeutic interventions. The NPTR is a compilation of data f rom 61 pediatric trauma centers, currently held at Tufts University. T he charts of 29,000 children were reviewed; of these, 1,147 sustained hepatic injuries, 132 (12%) of whom had a penetrating injury. The mech anism of injury was gunshot wound in 100 patients (76%) and stab wound in 32 (24%). The mean age of the children who had a penetrating injur y was 12.7 years (range, in utero to 19 years). Six children were mana ged nonoperatively (5%), and 20 (15%) had negative laparotomy findings . Overall, 106 children sustained additional injuries that required su rgical repair. There were 50 hollow viscous injury repair, 19 diaphrag matic repairs, 5 nephrectomies, 4 splenectomies, 4 pancreatic resectio ns, and 43 significant hepatic repairs. The overall mortality rate was 9.8% (13 deaths). Nine of these patients died within 24 hours of inju ry. These data indicate that penetrating injury to the hepatic bed in children is associated with a high percentage of other organ injuries that require surgical intervention. This seems to be in direct contras t with the findings for adults, for whom the hepatic mass appears prot ective because of its larger size. The close anatomic proximity of the organs in a child's abdomen appears to make surgical intervention nec essary for the majority of children with penetrating injury to the hep atic bed, and indicates that this approach should remain the standard of care for pediatric patients. Copyright (C) 1996 by W.B. Saunders Co mpany