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The appropriate management of children with liver or spleen injuries and associated head injury after blunt trauma remains controversial. To evaluate the success rates for nonoperative management and the impact this approach has on both abdominal and head injury outcome, children recorded in the National Pediatric Trauma Registry were reviewed. From January 1, 1994 to April 1, 1995, 107 children (aged < 19) were identified with liver, spleen, and associated head injury from blunt trauma. Forty-five (42%) children had combined head and spleen injury, 51 (48%) had head and liver injury, and 11 (10%) had head, liver, and spleen injury. Only 18 (17%) required laparotomy (head and spleen injury, 9 (8%); head and liver injury, 5 (5%); and head, liver, and spleen injury, 4 (4%)). Overall, there were no differences in Glasgow Coma Scale scores for children requiring laparotomy compared with those managed conservatively (13 vs. 14, p > 0.05). For all groups, the mean Injury Severity Score was significantly higher for children requiring laparotomy (19 vs. 31, p < 0.05). However, when comparison of the groups was stratified for type of injury and severity, the transfusion requirements, mortality, and abdominal and neurologic morbidity were all improved in children managed nonoperatively. Contrary to previous guidelines in the literature for selection of patients for nonoperative management of blunt solid organ abdominal injury, the association of altered mental status from head injury with liver and spleen injuries should not impact the decision for observational management.

Nonoperative management has become widely accepted as the standard of care for patients with blunt hepatic trauma. Recent studies among adults have supported the use of nonoperative management of selective penetrating wounds to the hepatic bed in stable patients. The therapeutic management of children with penetrating injuries to the hepatic bed were evaluated to ascertain whether nonoperative management was a reasonable consideration in their care. The database of the National Pediatric Trauma Registry (NPTR) was reviewed for the period 1985-1994. ICD-9 codes 864.00 to 864.10 were used to select injury site, diagnosis, and, combined with Current Procedural Terminology (CPT) code data, to ascertain therapeutic interventions. The NPTR is a compilation of data from 61 pediatric trauma centers, currently held at Tufts University. The charts of 29,000 children were reviewed; of these, 1,147 sustained hepatic injuries, 132 (12%) of whom had a penetrating injury. The mechanism 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 injury was 12.7 years (range, in utero to 19 years). Six children were managed nonoperatively (5%), and 20 (15%) had negative laparotomy findings. Overall, 106 children sustained additional injuries that required surgical repair. There were 50 hollow viscous injury repair, 19 diaphragmatic repairs, 5 nephrectomies, 4 splenectomies, 4 pancreatic resections, and 43 significant hepatic repairs. The overall mortality rate was 9.8% (13 deaths). Nine of these patients died within 24 hours of injury. 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 contrast with the findings for adults, for whom the hepatic mass appears protective because of its larger size. The close anatomic proximity of the organs in a child's abdomen appears to make surgical intervention necessary for the majority of children with penetrating injury to the hepatic bed, and indicates that this approach should remain the standard of care for pediatric patients.

Selective nonoperative management of hepatic injuries from blunt trauma has become an accepted practice over the past 10 years. A case of nonoperative management of a major hepatic injury in a person with Hemophilia A is reported. Treatment with aggressive blood component therapy resulted in a successful outcome.

This report describes the treatment and outcome of 66 infants with biliary atresia. Mean age was 79.8 +/- 33.2 days. Diagnosis was achieved by 99mTc DISIDA scanning. Hepatoportoenterostomy (HPE) was performed in 48 cases and hepatoportocholecystostomy in four, with microscopic ducts at the porta hepatis. Fourteen infants without microscopic ducts did not undergo HPE. Patients were staged according to the postoperative result. HPE was successful in 25% of patients (group A), resulted in improvement in 19% (group B), failed in 43% (group C), and was short-term in 13% (group D). In patients less than 90 days of age, the HPE success rate was 31%; 23% improved, and 33% showed no improvement. Age (less than 90 days) and bile clearance were prognostic determinants of success. Reoperation was useful only in patients with a previously successful HPE. Ten of 20 patients referred for liver transplantation survived (50%) (7/11) survived after liver transplantation and 3/9 on the waiting list). Fourteen of 15 patients in group A remain anicteric and well without liver transplantation. Patients in group B have had extended survival (greater than 3 years) but eventually required transplantation. Patients in group C and children more than 90 days old at diagnosis require early liver transplantation. HPE is a useful procedure when performed in infants less than 90 days of age who have biliary atresia.