THE ANALYSIS OF RESULTS OF SURGICAL TREATMENT OF ABDOMINAL INJURIES IN CHILDREN WITH POLYTRAUMA.
Federal Scientific Clinical Center of Miners’ Health Protection
Leninsk-Kuznetsky, Russia
The traumatism in children is the serious social problem. The frequency of injuries to abdominal organs and the retroperitoneal space in children varies in quite wide range from 1-5 % till 20 % of the cases. These figures are 4-6 times higher than the mean values of mortality in any other injuries and, according to WHO, take the first place among all lethal outcomes in childhood [10, 11].
Polytrauma is the most severe type of trauma which presents a combination of two or more injuries, one of which or their combination has the threat for life of a victim and presents immediate cause of development of traumatic disease [1, 2, 3, 12]. The development of the mutual burdening phenomenon in polytrauma complicates the timely diagnostics and worsens prognosis [1, 2, 3]. The difficulty of diagnostics of severity of state and injuries in severe abdominal concomitant injury is defined by the number of the unfavorable factors including shock, disturbance of consciousness, acute blood loss, extensiveness of injuries to different systems and organs that in case of combination result in overlapping, inversion and full absence of the clinical manifestations which are also typical for abdominal injury [3, 5, 7, 8]. Rapid confirmation of accurate diagnosis and definition of further tactics of management are the high priority objectives for physician.
For diagnostics in this category of the patients the instrumental techniques performed after clinical examination by specialists of allied skills (surgeon, traumatologist, neurosurgeon, resuscitator) have the important significance [5, 6]. At the present time the most informative technique is videolaparoscopy, which allows to select rational management tactics in some cases, with refusal from extensive laparotomy in some children. Sometimes unjustified laparotomy can result in breakdown of the compensation abilities of the body and the following lethal outcome.
The objective of the study – to carry out the analysis of the results of surgical treatment in children with abdominal injuries and polytrauma.
MATERIALS AND METHODS
The base of our study is the analysis of the results of treatment of 84 children with abdominal injuries in polytrauma during 2000 – 2012. The proportion of the boys prevailed – 60.7 % (51 persons). The age of the patients is from 1 till 18. The mean age was 12.2 ± 2.4.
According to ISS the severity of polytrauma in the patients with abdominal injuries was 29.3 ± 14.2. Also the study included such characteristics as mechanism of injury, type of transportation of patient and combination of nosological entities. The examination included the clinical laboratory assessment, plain X-ray of the chest, abdominal ultrasound and diagnostic laparoscopy. The standard surgical tactics included laparoscopy, laparotomy according to indications, pleural cavity drain, stabilization of bone fractures in skeletal trauma, creation of burr holes in TBI. The sequence of the surgical interventions was defined according to location of dominating pathology. The analysis of complication and pre-hospital mortality was performed.
The statistical data processing was performed with the standard software Statistic for Windows 6.0. The comparison of the analyzed values was performed with the parametric method. Student t-test was used for evaluation of the reliability of differences between the groups.
RESULTS AND DISCUSSION
According to the information from different authors pediatric polytrauma accounts for 5-12 % in the general group of injuries. According to our data the number of the patients with polytrauma was 8 % from the total number of the patients with injuries. The abdominal injuries in polytrauma were noted in 43.3 % according to our data. The largest proportion of injuries was in spring (26 %) and in summer (48 %) months. The cause of concomitant injuries was catatrauma in 14.3 % of the cases (12 patients) and road traffic accident in 85.7 % (72 patients). In road traffic accidents the victims suffered from auto-pedestrian accident in 80.5 % of the cases (58 patients) and from trauma inside car in 19.5 % (14 patients) (Table 1).
Table 1
Demographic data, type of accident
|
Demographic data, type of accident |
Absolute amount |
|
Mean age (years) |
12 ± 2.4 |
|
Gender: Boys girls
|
51 (60.7 %) 33 (39.3 %) |
|
Road traffic accident: - pedestrian accident - trauma inside vehicle |
72 (85.7 %) 58 (80.5 %) 14 (19.5 %) |
|
Catatrauma |
12 (14.3 %) |
The victims were transported to our center immediately from accident site with ambulance car or with preceding traffic, and also transported from other medical prophylactic institutions with the reanimobile from our center (Table 2).
Table 2
Type of transportation and time of admission from injury accident
|
Type of transportation |
Time of admission from injury accident |
Absolute amount |
% |
|
Transportation by special team with reanimobile:
Ambulance Preceding traffic |
First 24 hours
1-3 days After 3 days
40 ± 10.4 min. 45 ± 8.4 min.
|
22
12 5
37 8 |
26.2
14.5 5.7
44 9.5 |
|
Total |
|
84 |
100 |
According to ISS the severity of polytrauma was 29.3 ± 14.2. The greatest difficulties in the confirmation of diagnosis were associated mostly with the fact that the more clear manifestations of polytrauma disguise the clinical manifestations of abdominal trauma. According to our data 21 patients (25 %) had injuries in two anatomic regions, 43 patients (51.2 %) – in three regions, 15 patients (7.9 %) – in four and 5 patients (5.9 %) in five.
In most cases the abdominal trauma combined with traumatic brain and skeletal injury – in 52 patients (61.9 %). The disorders of consciousness were noted in 70 % of the cases. 33 patients (53.2 %) had combination of abdominal and thoracic trauma. Among injuries to the chest organs and structures the rib fractures were noted in 5 patients, scapula fractures – in 2, clavicle fracture – in 3, closed heart injuries – in 2, pulmonary bleeding – in 11, hemo- and pneumothorax – in 8, pulmonary bleeding which required diagnostic thoracoscopy – in 1.
For the diagnostics of injuries we use the team method with participation of specialists: resuscitators, surgeons, traumatologists, neurosurgeons. Depending on the state of severity of a patient the volume of the examination was full, partial or minimal in conditions of the anti-shock room or the surgery room.
According to our data the clinical manifestations of intraabdominal bleeding were noted only in 17 patients (20.2 %). The red blood indicators on admission corresponded to the age norm in 59.5 % of the cases (50 patients). The most informative and constant value was increase in leukocyte number in 92.8 % (78 patients). Considering the fact that clinical and laboratory values do not have high reliability, the identification of internal damages in victims with polytrauma is more based on results of the objective methods of diagnostics. The algorithm of the surgical tactics is presented in the figure 1.
Fig. 1
The algorithm of surgical tactics
The technique of choice is the abdominal ultrasound. Its administration favors the early diagnostics of injuries. We performed the abdominal ultrasound for 9 patients. Among them in 2 patients the signs of intraabdominal bleeding were found that were indications for surgical intervention. 7 patients had injuries to the anterior abdominal wall and absence of free fluid in the abdominal cavity that did not require surgical treatment.
At the present time the computer tomography (CT) of the abdominal cavity is the most informative technique. However one should note that the possibilities of CT realization are limited in children, because their age requires anesthesiology in patients of young age group. Also the necessity of transportation of patient to X-ray department appears. It complicates the possibility of anti-shock therapy realization that is not acceptable for patients with unstable hemodynamics. According to our data CT was performed for 1 patient with polytrauma who was admitted with stable hemodynamics. The hematoma was found in the right lobe of the liver. The hemoperitoneum was absent and it defined the tactics of conservative therapy.
The videolaparoscopy is the most informative technique according to the literature and our data. We consider that the indications for videolaparoscopy include shock state, presence of scratches, wounds and concussions at the anterior abdominal wall or in the lumbar region, hypotension, combination with thoracic trauma, severe fractures of pelvic bones, traumatic brain injury, spine injury, hemoperitoneum in ultrasound examination. Contraindications for videolaparoscopy are agonal state and expressed adhesive process. In concomitant injuries the sequence of surgical interventions were defined with location of dominating pathology. The diagnostic laparoscopy was performed as the first stage in patients with dominating abdominal trauma or in concomitant injury of locomotorium. Then the traumatologists decided about possibility of realization of single-step osteosynthesis. The diagnostic laparoscopy was performed as the second stage during the single-step interventions after decompressive skull trepanation or thoracoscopy (thoracotomy). We performed laparoscopy in 75 patients (89.3 %). The characteristics of injuries identified in videolaparoscopy were shown in the table 3.
Table 3
Characteristics of injuries identified during laparoscopy
|
Injury |
Absolute amount |
|
Spleen hematoma |
1 (1.3 %) |
|
Liver hematoma |
1 (1.3 %) |
|
Superficial rupture of spleen without ongoing bleeding |
1 (1.3 %) |
|
Mesentery hematoma |
2 (2.6 %) |
|
Omentum hematoma |
5 (6.7%) |
|
Disruption of congenital adhesions of ileocecal angle |
1 (1.3 %) |
|
Retroperitoneal hematoma |
10 (13.3 %) |
|
Anterior abdominal wall contusion |
5 (6.7 %) |
|
Internal organ injuries with ongoing bleeding, or signs of hollow organ perforation |
49 (65.5 %) |
|
Total |
75 (100 %) |
In 26 patients (34.7 %) the videolaparoscopy was the final stage of surgical intervention. In presence of hematoma in liver (1 child) and in spleen (1 child) the conservative treatment was performed with dynamic ultrasound control. Over time the decrease in the size of the hematoma and the following dissolution before discharge were noted. In 1 patient during laparoscopy the superficial disrupture of the lower pole of the spleen without continuous bleeding was found. This patient received electrocoagulation of the disrupture of the spleen with drain of the abdominal cavity. Surgical treatment was not required in further.
The indication for laparotomy was presence of blood in the small pelvis and in lateral channels from both sides that testified about severe injury to the internal organs. The presence of non-clear effusion was the indirect sign of the injury to the hollow organ. In 49 patients (65.3 %) the diagnostic laparoscopy showed the injuries to the hollow organs with continuous bleeding that required laparotomy (Table 4).
Table 4
Characteristics of injuries identified during laparotomy
|
Injury |
Absolute amount |
|
Liver injury |
12 (24.5 %) |
|
Liver injury with gall bladder rupture |
1 (2.0 %) |
|
Liver and spleen injury |
3 (6.1 %) |
|
Spleen injury: - Rupture sealing - Splenectomy - Omental disruption with bleeding |
4 (8.2 %) 15 (30.7 %) 2 (4.0 %) |
|
Small bowel disruption |
4 (8.2 %) |
|
Colon disruption |
3 (6.1 %) |
|
Mesentery disruption with bleeding |
4 (8.2 %) |
|
Bladder disruption |
1 (2.0 %) |
|
Total |
49 (100 %) |
The analysis of the structure and the characteristics of the abdominal injuries showed that the most frequent injured organs found during surgery were the parenchymal organs (liver, spleen) (in 71.4 % of the cases). In all cases the injuries of III-IV degrees according to E. Moore and the degree II according to the classification by Bairov G.A. were noted. For these patients the sealing of liver ruptures with Ï- or Z-formed sutures was performed. One should note that 1 patient had the combination of liver rupture with gall bladder rupture that required cholecystectomy. 3 patients had injuries to the liver and the spleen. For these patients closure of liver wounds and splenectomy were performed.
According to our data in spleen injuries the organ-saving operations were performed in 21.0 % of the cases (in 4 patients).
The clinical case 1
The child, age of 12.
DIAGNOSIS: Polytrauma. Closed traumatic brain injury. Severe brain contusion. Closed abdominal trauma with injury to spleen, intraabdominal bleeding. Closed chest trauma. Closed fractures of 1st, 3d and 4th ribs to the left. Closed fracture of left scapula body. Left lung contusion. Hemopneumothorax to the left. Closed fracture of both bones in middle third of leg with fragments displacement. Traumatic shock of the second degree.
Road accident. She was hit by car. Admission to medical facility was after 40 minutes.
The state was severe on admission. Unconsciousness. The skin was pale, with satisfactory moisture. There were scratches in the region of the face, and a bruise in the region of chin. The visible mucosae were pale, with lower moisture. The tongue was dry, with white fur. The chest was of a regular shape. Lung noise dullness to the left. During auscultation the breathing harsh to the right, and hardly weak to the left over the whole surface. The respiratory rate – 28 per min. Heart tones were muffled. Heart beat - 120 per min. Arterial pressure – 100/60 mm Hg. The abdomen was symmetrical, participating in breathing. Abdomen is soft and achievable in all places during palpation. No local muscle tension in muscles of the anterior abdominal wall. No dullness in during percussion. Lower intestinal peristalsis in auscultation. The liver is near the edge of costal arch in percussion and palpation. The spleen was not palpated. No peritoneal symptoms. Pathologic formations in abdomen were not identified. Catheter urina was yellow.
The child was examined by the surgeon on duty, traumatologist, resuscitator. At admission the resuscitation anti-shock measures were started. The child was transported to the operating room for further anti-shock procedures.
Clinical blood analysis – anemia (Hb – 88 g/L, red blood cells – 2.48 × 10/12/L, ht 28.8 %), leukocytosis up to 16.0 × 10/9/L.
Chest R-ãðàììà was performed in the operating room. There were signs of hemopneumothorax to the left. Puncture, draining of the left pleural cavity with active aspiration were performed. Emergent diagnostic laparoscopy was performed. In the abdomen hemoperitoneum of 200 ml was found, and the spleen rupture with blood leak in the region of lower pole of the spleen. The switch to median laparotomy was made considering the severity of the patient’s state. Injuries to hollow organs were not found. In the region of the low pole of the spleen along the anterior surface the wound with depth up to 2 cm with blood leak was found (Fig. 2).
Fig. 2
The spleen rupture
Spleen wound closure was carried out with absorbable sutures (Fig. 3). During operation blood reinfusion was performed.
Fig. 3
Sealing of the spleen rupture
After stabilization of the state the second step was performed, which included osteosynthesis of left tibia with strained nails. The total blood loss was 350 ml (25 % from total blood volume). The operation was finished with abdominal rhenium plating with silicon tube and with layer-by-layer closure of the wound from laparotomy.
The patient was in the ICU during 11 days. ALV continued for 5 days. Bulau drainage of left pleural space continued for 5 days. Postsurgical course was without complications. The patient was discharged at 25 day.
It ought to be noted that in polytrauma with spleen injury one shouldn’t aim to save the injured organ at all costs, because realization of organ-saving surgery results in additional blood loss and increase in time of operation (Chikaev V.F., Ibragimov R.A. et al., 2010). Considering the severity of state in 15 patients with polytrauma, splenectomy was performed. Blood reinfusion was performed for all patients with injury to liver and the spleen. Small bowel rupture was found in 4 (8.2 %) patients, colon rupture – in 3 (6.1 %). In injury to hollow organ we performed closure of disruption. We have experience in treatment of 1 patient with polytrauma with diagnosis of right rupture of diaphragm. For the child thoracotomy and closure of diaphragm rupture were performed.
Clinical case 2
Child, age of 14.
DIAGNOSIS: Polytrauma. Closed chest trauma. Closed non-complicated fractures of 9th, 10th and 11th ribs to the right. Contusion and rupture of 6th segment in the right lung. Right-sided hemo- and pneumothorax. Rupture of the right cupula of diaphragm. Closed injury to abdominal organs, subserosal hematoma of hepatic flexure of colon. Closed fracture of crest of right iliac bone, fracture of ischial bone with displacement. Fracture of right acetabular roof. Closed fracture of both bones of right forearm in distal third with displacement. Brain concussion.
After one day after trauma the child was admitted to Clinical Center of Miners’ Health Protection by the full readiness team with reanimobile. Kashtan anti-shock suit was used.
From anamnesis: auto road injury. The victim was in accident in a drunken state. He was as a passenger in a car. He was transported to a medical facility according to place of his residence, where diagnostic laparoscopy was performed. The hematoma was found in the region of hepatic flexure of the colon. There were 30 ml of blood in the abdominal cavity, with no signs of continuing bleeding. The drain in the subhepatic space was installed.
After additional examination in Clinical Center of Miners’ Health Protection:
Cervical X-ray in two views did not show bone injuries.
Brain MSCT – no pathology in brain and in cranial bones.
Rg-gram, SCT of pelvis - longitudinal fracture of the right ischial bone crest from the superior edge with transition to the right iliac bone. Longitudinal fracture with displacement of fragments. Fracture of acetabular roof with displacement. Fracture of ischial bone to the right with displacement.
Rg-gram of left clavicle – fracture of left clavicle in the middle third with displacement of fragments.
Rg-gram of right forearm – fracture of both bones of the right forearm with displacement of fragments.
Rg-gram, chest SCT – fracture of 9th, 10th, 11th ribs to the right. Minimal pneumothorax, right hemothorax. Right lung contusion. Acute adult distress syndrome of degree 2. The high state of cupula of diaphragm to the right is defined (Fig. 4).
Fig. 4
The plain X-ray and CT of the chest cavity in the patient S., age of 14. High position of the cupula of diaphragm to the right
Emergent anterior lateral thoracotomy in 6th intercostal space to the right was performed. The pleural space contained about 300 ml of hemorrhagic fluid. The lineal rupture in the central part of the right cupula of diaphragm of 10 cm was found. The diaphragmatic surface of liver bulged through the place of rupture (Fig. 5).
Fig. 5
Thoracotomy, disruption of the right cupula of diaphragm through which the liver can be visualized
The following revision showed a rupture in the inferior lobe of the right lung in the view of 6th segment, with length of 2 cm. The diaphragm rupture was closed by type of duplication (Fig. 6).
Fig. 6
Thoracotomy, sealing of the right cupula of diaphragm
The lung rupture was closed with separate loop sutures (Fig. 7). The right pleural space was drained: the drain in the 8th intercostals space along the medial middle subaxillary line, the drain in 4th intercostals space along the anterior subaxillary line. Full wound closure.
Fig. 7
Thoracotomy, disruption of pulmonary tissue in the region of sixth segment of the right lung
The single-step surgery was performed – open reduction of left clavicle, external fixation with plate and screws. Open reduction of radial and ulnar bone, distal third of the right forearm, osteosynthesis with 2 K-wires. Skeletal traction of right calcaneal bone with K-wire of 5 kg.
The postsurgical period was complicated with course of posttraumatic inferior lobe pneumonia to the right. The child had 18 days of treatment in ICU. The subsequent treatment was in the department of pediatric traumatology and orthopedics. The patient was discharged in healthy state at 4 day.
According to our data the complications in the postsurgical course were noted in 7 patients (8.3 %): development of pneumonia in 6 patients, acute intestinal obstruction at the background of development of small bowel stenosis after closure of rupture that required relaparotomy and resection of stenosed part of small bowel with placement of end-to-end anastomosis – in 1 patient.
The mean number of bed-days was 25.9 ± 2.4 and 8.8 ± 1.2 in the ICU.
The hospital mortality in the group analyzed by us was in 4 patients (4.8 %). The immediate causes of mortality at the hospital stage were shock, blood loss (2 patients); the dominating abdominal trauma (injury to liver and spleen) was noted in combination with severe traumatic brain injury, with thoracic and skeletal trauma. These patients were admitted in agonal state. One patient had severe dominating traumatic brain injury with abdominal and skeletal trauma; the cause of death was sepsis and multiple organ insufficiency. 1 patient had severe traumatic brain injury, abdominal trauma (spleen rupture) and skeletal trauma in combination with carbon monoxide poisoning. The period of stay in ICU for these patients was 5-7 days.
CONCLUSION:
1. According to mechanical origin the first place is taken by road accident trauma (85.7 %).
2. The sequence of surgical interventions in children with polytrauma was determined by location of dominating pathology.
3. For definition of surgical tactics it is necessary to use the complex of diagnostic measures depending on the state of severity of patient. At the present time the most informative diagnostic method is videolaparoscopy. Videolaparoscopy is a method which allows to confirm or contradict dominating character of abdominal trauma, and to define further tactics of treatment avoiding from median laparotomy in some cases.
4. The injuries to parenchymal organs (liver and spleen) are the most frequent (in 71.4 % of the cases according to our data). In children with polytrauma and spleen injury the possibility of organ saving surgery is not excluded.
5. Severe abdominal trauma requiring emergent surgery (injuries to parenchymal organs of 3-6 degrees, injuries to hollow organs of 2-6 degree according to AAST classification) took place in 52 % of the patients according to our data.