Liver trauma in children with Syrian Civil War: How should treatment management?

Abstract

Objectives: Patients with liver injuries should be considered multidisciplinary cases, and the decision to operate should be made according to each patient’s clinical and hemodynamic stability. In this study, we aimed to describe treatment management approaches and appropriate operation times for children with liver injuries resulting from the Syrian Civil War. Methods: A total 32 patients who were admitted o a pediatric surgery clinic between 2010 and 2020 with liver injuries resulting from Syrian Civil War were examined retrospectively. Patients were evaluated according to age, gender, type of injury, accompanying trauma, treatment modality, and mortality. Results: A total of 21 patients were injured with shrapnel, while 11 patients suffered from blast effect injury. The mean pediatric trauma score of the patients was 5.2, while the mean pediatric trauma score of the six patients who died was 3.11. Liver suturing was performed in three patients due to bleeding. A segmentectomy was performed in one patient with active bleeding in segment 7. This bleeding was stopped by binding the branches of the hepatic artery. Two patients who were operated on in Syria and to whom packing was applied due to uncontrolled bleeding were referred to Turkey. One patient with inferior vena cava injury died due to excessive blood loss and instability at the time of admission, and six patients died due to accompanying head trauma and/or multiple body trauma. Conclusion:The main purpose in emergency operations is to stop bleeding. Rarely, however, suturing or even segment resection in the bleeding area may be required.

Keywords

• Blast effect
• liver
• laceration
• shrapnel
• Syrian Civil War

References

1. 1. Cywes S, Bass D, Rode H et al. Blunt liver trauma in children. Injury. 1991;22[4]:310-4.
2. 2. Van As AB, Millar AJ. Management of paediatric liver trauma. Pediatric surgery international. 2017;33[4]:445-53.
3. 3. Stalker HP, Kaufman R A, Towbin, R.. Patterns of liver injury in childhood: CT analysis. American Journal of Roentgenology, 1986,147(6), 1199-1205.
4. 4. Dicker RA, Sartorelli KH, McBride WJ et al. Penetrating hepatic trauma in children: operating room or not? Journal of pediatric surgery. 1996;31[8]:1189-93.
5. 5. Hadjis N. Liver hyperplasia, hypertrophy and atrophy: clinical relevance. Surgery of the liver and biliary tract. 1988.
6. 6. Kaptanoglu L, Kurt N, Sikar HE. Current approach to liver traumas. International Journal of Surgery. 2017;39:255-9.
7. 7. Poletti PA, Mirvis SE, Shanmuganathan K et al. CT criteria for management of blunt liver trauma: correlation with angiographic and surgical findings. Radiology. 2000;216[2]:418-27.
8. 8. Richardson JD, Franklin GA, Lukan JK et al. Evolution in the management of hepatic trauma: a 25-year perspective. Annals of surgery. 2000;232[3]:324.

9. 9. Ruess L., Sivit C J, Eichelberger MR et al.. Blunt hepatic and splenic trauma in children: correlation of a CT injury severity scale with clinical outcome. Pediatric radiology, 1995: 25(5), 321-325.
10. 10. Sivit CJ. Imaging children with abdominal trauma. American Journal of Roentgenology, 2009:192(5), 1179-1189.
11. 11. Tepas JJ, Mollitt DL, Talbert JL et al. The pediatric trauma score as a predictor of injury severity in the injured child. J Pediatr Surg 1987;22[1]:14–8.
12. 12. Peitzman AB, Richardson JD. Surgical treatment of injuries to the solid abdominal organs: a 50-year perspective from the Journal of Trauma. Journal of Trauma and Acute Care Surgery. 2010;69[5]:1011-21.
13. 13. Tinkoff G, Esposito TJ, Reed J et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. Journal of the American College of Surgeons. 2008;207[5]:646-55.
14. 14. Price M, Gohdes A, Ball P. Updated statistical analysis of documentation of killings in the Syrian Arab Republic. Human Rights Data Analysis Group, Geneva. 2014.
15. 15. Holcomb JB, McMullin NR, Pearse L, et al. Causes of death in U.S. SpecialOperations Forces inthe globalwar onterrorism: 2001-2004. Ann Surg 2007;245(06):986–991
16. 16. Aharonson-Daniel L, Waisman Y, Dannon YL et al. Epidemiology of terror-related versus non-terror-related traumatic injury in children. Pediatrics 2003;112(04):e280
17. 17. C. Giannou MB, A.Molde. War Surgery. Geneva, Switzerland: ICRC; 2013.
18. 18. Naaman O, Yulevich A, Sweed Y. Syria civil war pediatric casualties treated at a single medical center. J Pediatr Surg 2019. Doi:10.1016/j.jpedsurg.2019.02.022
19. 19. Newgard CD, Meier EN, Bulger EM et al;ROCInvestigators.Revisiting the “Golden Hour”: an evaluation of out-of-hospital time in shock and traumatic brain injury. Ann Emerg Med 2015;66(01):30–41
20. 20. Creamer KM, Edwards MJ, Shields CH et al. Pediatric wartime admissions to US military combat support hospitals in Afghanistan and Iraq: learning from the first 2,000 admissions. J Trauma 2009;67(04):762–768
21. 21. Duane TM, Como JJ, Bochicchio GV et al. Reevaluating the management and outcomes of severe blunt liver injury, J. Trauma 57 (2004) 494e500.
22. 22. Carrillo E, Platz A, Miller F et al. Non‐operative management of blunt hepatic trauma. British Journal of surgery. 1998;85[4]:461-8.
23. 23. Meredith JW, Young JS, Bowling J et al. Nonoperative management of blunt hepatic trauma: the exception or the rule? The Journal of trauma. 1994;36[4]:529-34; discussion 34-5.
24. 24. M Gage Ochsner M. Factors of failure for nonoperative management of blunt liver and splenic injuries. World journal of surgery. 2001;25[11]:1393-6.
25. 25. Coburn MC, Pfeifer J, DeLuca FG. Nonoperative management of splenic and hepatic trauma in the multiply injured pediatric and adolescent patient. Archives of Surgery. 1995;130[3]:332-8.
26. 26. Bond SJ, Eichelberger MR, Gotschall CS et al. Nonoperative management of blunt hepatic and splenic injury in children. Annals of surgery. 1996;223[3]:286.
27. 27. Pal KMI, Khan A. Nonoperative manegement of penetrating liver trauma. Injury 2000:31:199-201