Contrast blush in pediatric blunt splenic trauma does not warrant the routine use of angiography and embolization

Management of Pediatric Solid Organ Injuries

Solid organ injury (SOI) is common in children who experience abdominal trauma, and the management of such injuries has evolved significantly over the past several decades. In 2000, the American Pediatric Surgical Association (APSA) published the first societal guidelines for the management of blunt spleen and/or liver injury (BLSI), advocating for optimized resource utilization while maintaining patient safety. Nonoperative management (NOM) has become the mainstay of treatment for SOI, and since the publication of the APSA guidelines, numerous groups have evaluated how invasive procedures, hospitalization, and activity restrictions may be safely minimized in children with SOI. Here, we review the current evidence-based management guidelines in place for the treatment of injuries to the spleen, liver, kidney, and pancreas in children, including initial evaluation, inpatient management, and long-term care, as well as gaps that exist in the current literature that may be targeted for further optimization of protocols for pediatric SOI.

Follow-up computed tomography and unexpected hemostasis in non-operative management of pediatric blunt liver and spleen injury

PURPOSE

While follow-up CT and prophylactic embolization with angiography are often conducted during non-operative management (NOM) for BLSI, particularly in a high-grade injury, the utility of early repeated CT for preventing unexpected hemorrhage remains unclear. This study aimed to elucidate whether early follow-up computerized tomography (CT) within 7 days after admission would decrease unexpected hemostatic procedures on pediatric blunt liver and spleen injury (BLSI).

METHODS

A post-hoc analysis of a multicenter observational cohort study on pediatric patients with BLSI (2008-2019) was conducted on those who underwent NOM, in whom the timing of follow-up CT were decided by treating physicians. The incidence of unexpected hemostatic procedure (laparotomy and/or emergency angiography for ruptured pseudoaneurysm) and complications related to BLSI were compared between patients with and without early follow-up CT within 7 days. Inverse probability weighting with propensity scores adjusted patient demographics, comorbidities, mechanism and severity of injury, initial resuscitation, and institutional characteristics.

RESULTS

Among 1320 included patients, 552 underwent early follow-up CT. Approximately 25% of patients underwent angiography on the day of admission. The incidence of unexpected hemostasis was similar between patients with and without early repeat CT (8 [1.4%] vs. 6 [0.8%]; adjusted OR, 1.44 [0.62-3.34]; p = 0.40). Patients with repeat CT scans more frequently underwent multiple angiographies (OR, 2.79 [1.32-5.88]) and had more complications related to BLSI, particularly bile leak (OR, 1.73 [1.04-2.87]).

CONCLUSION

Follow-up CT scans within 7 days was not associated with reduced unexpected hemostasis in NOM for pediatric BLSI.

Utilization of Angiography in Pediatric Blunt Abdominal Injury at Adult versus Pediatric Trauma Centers

INTRODUCTION

Angiography has been widely accepted as an adjunct in the management of blunt abdominal trauma in adults. However, the role of angiography with or without angioembolization (AE) is still being defined in pediatric solid organ injury. We sought to compare the use of angiography in solid organ injury (SOI) at pediatric trauma centers (PTCs) versus an adult trauma center (ATC) in a large metropolitan city.

METHODS

Data were drawn from a collaborative effort of three Trauma centers (one adult and two pediatric) in Atlanta, GA. All pediatric patients (ages 1-18) treated for SOI between January 1, 2016 and December 31, 2021 were included (n = 350). Registry data obtained included demographics, mechanism of injury, injury grade, injury severity score (ISS), procedures performed, and transfusions. Multivariate regression analysis was used to identify factors associated with angiography.

RESULTS

A total of 350 patients were identified during the study period with 101 treated at ATC and 249 treated at the two PTCs. The median age at the ATC was 17 y (IQR 16, 18) compared to nine (6, 13) at the PTCs. ISS was significantly higher at the ATC 22 (14, 34) compared to 16 (9, 22) at PTCs (P < 0.001). At the ATC, 11 (10.9%) patients underwent angiography, 4 (4.9%) of which underwent AE compared to seven (2.8%) patients who underwent angiography and AE at PTCs. In the multivariate analysis, factors associated with angiography use included age (OR 1.44, 95% CI 1.09-1.90, P = 0.010) and ISS (OR 1.05, 95% CI 1.02-1.09, P = 0.004). Through setting, ATC versus PTC was significant on univariable analysis, it did not remain a significant predictor of angiography on multivariable regression.

CONCLUSIONS

Our study demonstrated increased utilization of angiography for the management of SOI in pediatric patients treated at ATCs versus PTCs. On regression analysis, age and ISS remained significant predictors for angiography utilization, while setting (ATC versus PTC) was notably not a significant predictor. This data would suggest that differences in angiography utilization for pediatric SOI at PTCs and ATCs are influenced by differing patient populations (older and higher ISS), with otherwise uniform use. These findings provide a basis for future treatment algorithm revisions for pediatric blunt abdominal trauma that include angiography and provide support for the development of formal guidelines.

Updated APSA Guidelines for the Management of Blunt Liver and Spleen Injuries

BACKGROUND

Non-operative management of blunt liver and spleen injuries was championed initially in children with the first management guideline published in 2000 by the American Pediatric Surgical Association (APSA). Multiple articles have expanded on the original guidelines and additional therapy has been investigated to improve care for these patients. Based on a literature review and current consensus, the management guidelines for the treatment of blunt liver and spleen injuries are presented.

METHODS

A recent literature review by the APSA Outcomes committee [2] was utilized as the basis for the guideline recommendations. A task force was assembled from the APSA Committee on Trauma to review the original guidelines, the literature reported by the Outcomes Committee and then to develop an easy to implement guideline.

RESULTS

The updated guidelines for the management of blunt liver and spleen injuries are divided into 4 sections: Admission, Procedures, Set Free and Aftercare. Admission to the intensive care unit is based on abnormal vital signs after resuscitation with stable patients admitted to the ward with minimal restrictions. Procedure recommendations include transfusions for low hemoglobin (<7 mg/dL) or signs of ongoing bleeding. Angioembolization and operative exploration is limited to those patients with clinical signs of continued bleeding after resuscitation. Discharge is based on clinical condition and not grade of injury. Activity restrictions remain the same while follow-up imaging is only indicated for symptomatic patients.

CONCLUSION

The updated APSA guidelines for the management of blunt liver and spleen injuries present an easy-to-follow management strategy for children.

LEVEL OF EVIDENCE

Level 5.

European Pediatric Surgeons' Association Survey on the Use of Splenic Embolization in Blunt Splenic Trauma in Children

INTRODUCTION

 This article assesses (1) access to splenic embolization (SE), (2) indications for SE, and (3) post-embolization management in high-grade splenic trauma in children.

MATERIALS AND METHODS

 An online questionnaire was sent in 2021 to all members of European Pediatric Surgeons' Association.

RESULTS

 There were a total of 157 responses (50 countries, 83% academic hospitals). Among them, 68% have access to SE (SE) and 32% do not (nSE). For a hemodynamic stable patient with high-grade isolated splenic trauma without contrast extravasation (CE) on computed tomography (CT) scan, 99% SE and 95% nSE respondents use nonoperative management (NOM). In cases with CE, NOM decreases to 50% (p = 0.01) and 51% (p = 0.007) in SE and nSE centers, respectively. SE respondents report a significant reduction of NOM in stable patients with an associated spine injury requiring urgent surgery in prone position, both without and with CE (90 and 28%, respectively). For these respondents, in stable patients the association of a femur fracture only tends to decrease the NOM, both without and with CE (93 and 39%, respectively). There was no significant difference in NOM in group nSE with associated injuries with or without CE. After proximal SE with preserved spleen vascularization on ultrasound Doppler, 44% respondents prescribe antibiotics and/or immunizations.

CONCLUSION

 Two-thirds of respondents have access to SE. For SE respondents, SE is used even in stable patients when CE showed on initial CT scan and its use increased with the concomitant need for spinal surgery. There is currently a variation in the use of SE and antibiotics/immunizations following SE.

Pediatric trauma and the role of the interventional radiologist

PURPOSE

While interventional radiologists occupy a critical role in adult trauma management, the role of interventionalist in pediatric trauma continues to evolve. The indications for transarterial embolization (TAE) are significantly different in pediatric patients in whom non-operative management (NOM) has a much more prominent role than in adults. Contrast extravasation on imaging may not require acute surgical or interventional management as it would in an adult. There are also areas in which pediatric interventional radiology is increasingly useful such as pelvic TAE in failed management, or splenic embolization to treat bleeding without the loss of splenic function inherent to surgical splenectomy. The rapid evolution of techniques and devices in pediatric patients is also changing what interventions are possible in pediatric trauma management which necessitates frequent reassessment of the guidelines and interventional radiology's role in caring for these patients.

CONCLUSION

This review seeks to consolidate the recent literature to describe the evolving role of the interventional radiologist in pediatric trauma management.

Immune function and the role of vaccination after splenic artery embolization for blunt splenic injury

The spleen is the most commonly injured solid organ following blunt abdominal trauma. Over recent decades, splenic artery embolization (SAE) has become the mainstay treatment for haemodynamically stable patients with high-grade blunt splenic trauma, with splenectomy the mainstay of treatment for unstable patients. Splenic function is complex but the spleen has an important role in immune function, particularly in protection against encapsulated bacteria. Established evidence suggests that following splenectomy immune function is impaired resulting in increased susceptibility to overwhelming post-splenectomy infection, however, immune function may be preserved following SAE. This review will discuss the current state of the literature on immune function following different treatments of blunt splenic injury, and the controversies surrounding what constitutes a quantitative test of splenic immune function.

Use of angioembolization in pediatric polytrauma patients: WITH BLUNT SPLENIC INJURYAngioembolization in Pediatric Blunt Splenic Injury

BACKGROUND/PURPOSE

We sought to analyze the use of angioembolization (AE) after pediatric splenic injuries at adult and pediatric trauma centers (ATCs/PTCs).

METHODS

The National Trauma Data Bank (2010-2015) was queried for patients (<18 years) who experienced blunt splenic trauma. Multivariate logistic regression was used to determine the association of AE with splenectomy. Propensity score matching was used to explore the relationship between trauma center designation and AE utilization.

RESULTS

14,027 encounters met inclusion criteria. 514 (3.7%) patients underwent AE. When compared to PTCs, patients were older, had a higher ISS, and more often presented in shock at ATCs (p<0.001 for all). Regression models demonstrated no difference in mortality between cohorts. Odds of splenectomy were lower for patients undergoing AE (OR 0.16 [CI: 0.08-0.31]), however this effect was mostly driven by utilization at ATCs. Using a 1:1 propensity score matching model, patients treated at ATCs were 4 times more likely to undergo AE and 7 times more likely to require a splenectomy compared to PTCs (p<0.001). Over 6 years, PTCs performed only 27 splenectomies and 23 AEs (1.1% and 0.9%, respectively).

CONCLUSIONS

AE was associated with improved splenic salvage at ATCs in select patients but appeared overutilized when compared to outcomes at PTCs. PTCs accomplished a higher splenic salvage rate with a lower AE utilization.

LEVEL OF EVIDENCE

III - Retrospective cohort study.

Utility of Angioembolization in Patients with Abdominal and Pelvic Traumatic Bleeding: Descriptive Observational Analysis from a Level 1 Trauma Center

Background

Massive bleeding is a major preventable cause of early death in trauma. It often requires surgical and/or endovascular intervention. We aimed to describe the utilization of angioembolization in patients with abdominal and pelvic traumatic bleeding at a level 1 trauma center.

Methods

We conducted a retrospective analysis for all trauma patients who underwent angioembolization post-traumatic bleeding between January 2012 and April 2018. Patients’ data and details of injuries, angiography procedures and outcomes were extracted from the Qatar national trauma registry.

Results

A total of 175 trauma patients underwent angioembolization during the study period (103 for solid organ injury, 51 for pelvic injury and 21 for other injuries). The majority were young males. The main cause of injury was blunt trauma in 95.4% of the patients. The most common indication of angioembolization was evident active bleeding on the initial CT scan (contrast pool or blushes). Blood transfusion was needed in two-third of patients. The hepatic injury cases had higher ISS, higher shock index and more blood transfusion. Absorbable particles (Gelfoam) were the most commonly used embolic material. The overall technical and clinical success rate was 93.7% and 95%, respectively, with low rebleeding and complication rates. The hospital and ICU length of stay were 13 and 6 days, respectively. The median injury to intervention time was 320 min while hospital arrival to intervention time was 274 min. The median follow-up time was 215 days. The overall cohort mortality was 15%.

Conclusion

Angioembolization is an effective intervention to stop bleeding and support nonoperative management for both solid organ injuries and pelvic trauma. It has a high success rate with a careful selection and proper implementation.

Contemporary Management of Pediatric Blunt Splenic Trauma: A National Trauma Databank Analysis

PURPOSE

To quantify changes in the management of pediatric patients with isolated splenic injury from 2007 to 2015.

MATERIALS AND METHODS

Patients under 18 years old with registered splenic injury in the National Trauma Data Bank (2007-2015) were identified. Splenic injuries were categorized into 5 management types: nonoperative management (NOM), embolization, splenic repair, splenectomy, or a combination therapy. Linear mixed models accounting for confounding variables were used to examine the direct impact of management on length of stay (LOS), intensive care unit (ICU) days, and ventilator days.

RESULTS

Of included patients (n = 24,128), 90.3% (n = 21,789), 5.6% (n = 1,361), and 2.7% (n = 640) had NOM, splenectomy, and embolization, respectively. From 2007 to 2015, the rate of embolization increased from 1.5% to 3.5%, and the rate of splenectomy decreased from 6.9% to 4.4%. Combining injury grades, NOM was associated with the shortest LOS (5.1 days), ICU days (1.9 days), and ventilator days (0.5 day). Moreover, splenectomy was associated with longer LOS (10.1 days), ICU days (4.5 days), and ventilator days (2.1 days) than NOM. The average failure rate of NOM was 1.5% (180 failures/12,378 cases). Average embolization failure was 1.3% (6 failures/456 cases). Splenic artery embolization was associated with lower mortality than splenectomy (OR: 0.10, P <.001). No statistically significant difference was observed in mortality between embolization and NOM (OR: 0.96, P = 1.0).

CONCLUSIONS

In pediatric splenic injury, NOM is the most utilized and associated with favorable outcomes, most notably in grades III to V pediatric splenic injury. If intervention is needed, embolization is effective and increasingly utilized most significantly in lower grade injuries.

Association between contrast extravasation on computed tomography scans and pseudoaneurysm formation in pediatric blunt splenic and hepatic injury: A multi-institutional observational study

PURPOSE

We aimed to examine the association between contrast extravasation (CE) on initial computed tomography (CT) scan and pseudoaneurysm (PSA) development in pediatric blunt splenic and/or liver injury.

METHODS

We conducted a multi-institutional retrospective study in cases of blunt splenic and/or hepatic injury who underwent an initial attempt of nonoperative management. A logistic regression model was used to compare PSA formation and CE on initial CT scan, and the area under the receiver operating characteristic curve (AUC) with and without CE was used to assess the predictive performance of CE for PSA formation.

RESULTS

Of 236 cases enrolled from 10 institutions, PSA formation was observed in 17 (7.2%). Multivariate analysis showed a significant association between CE on initial CT scan and increased incidence of PSA formation (odds ratio, 4.96; 95% confidence interval, 1.37-18.0). There was no statistically significant association between the grade of injury and PSA formation. The AUC improved from 0.75 (0.64-0.87) to 0.80 (0.70-0.91) with CE.

CONCLUSION

Active CE on initial CT scan was an independent predictor of PSA formation. Selective use of follow-up CT in children who showed CE on initial CT may provide early identification of PSA formation, regardless of injury grade.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Defining the role of angioembolization in pediatric isolated blunt solid organ injury

PURPOSE

To determine the incidence and outcomes of angiography in pediatric patients with blunt solid organ injury (SOI).

METHODS

The National Trauma Data Bank (2010-2014) was queried for patients ≤19 years who experienced isolated blunt SOI. Multivariate logistic regression was used to evaluate characteristics associated with radiological and surgical intervention.

RESULTS

Patients with isolated blunt injuries to the spleen (n = 7542), liver (n = 4549), and kidney (n = 2640) were identified. Use of angiography increased yearly from 1.6% to 3.1% of cases (p = 0.001) and was associated with older age (OR 2.61 [CI: 1.94-3.50], p < 0.001) and grade III or higher injury (OR 4.63 [CI: 3.11-6.90], p < 0.001). Odds of angiography were 4.9 times higher at adult trauma centers (TCs) than pediatric TCs overall, and almost 9 times higher for isolated splenic trauma (p < 0.001 for each). There was no improvement in splenic salvage after angiography for high grade injuries (3.5% vs. 4.8%, p = NS). Only 1.8% of cases began within 30 min of arrival (median time = 3.6 h).

CONCLUSION

Variability exists in the utilization of angiography in pediatric blunt SOI between adult and pediatric TCs, with no improvement in splenic salvage.

LEVEL OF EVIDENCE

Level III - Treatment study.

Update: Splenic Artery Embolization in Blunt Abdominal Trauma

The spleen is the most commonly injured organ after blunt abdominal trauma. Nonoperative management with splenic arterial embolization (SAE) is the current standard of care for hemodynamically stable patients. Current data favor the use of proximal and coil embolization techniques in adults, while observation is suggested in the pediatric population. In this review, the authors describe the most recent evidence informing the clinical indications, techniques, and complications for SAE.

Non-operative management of solid organ injuries in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee systematic review

PURPOSE

The American Pediatric Surgical Association (APSA) guidelines for the treatment of isolated solid organ injury (SOI) in children were published in 2000 and have been widely adopted. The aim of this systematic review by the APSA Outcomes and Evidence Based Practice Committee was to evaluate the published evidence regarding treatment of solid organ injuries in children.

METHODS

A comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Four principal questions were examined based upon the previously published consensus APSA guidelines regarding length of stay (LOS), activity level, interventional radiologic procedures, and follow-up imaging. A literature search was performed including multiple databases from 1996 to 2016.

RESULTS

LOS for children with isolated solid organ injuries should be based upon clinical findings and may not be related to grade of injury. Total LOS may be less than recommended by the previously published APSA guidelines. Restricting activity to grade of injury plus two weeks is safe but shorter periods of activity restriction have not been adequately studied. Prophylactic embolization of SOI in stable patients with image-confirmed arterial extravasation is not indicated and should be reserved for patients with evidence of ongoing bleeding. Routine follow-up imaging for asymptomatic, uncomplicated, low-grade injured children with abdominal blunt trauma is not warranted. Limited data are available to support the need for follow-up imaging for high grade injuries.

CONCLUSION

Based upon review of the recent literature, we recommend an update to the current APSA guidelines that includes: hospital length of stay based on physiology, shorter activity restrictions may be safe, minimizing post-injury imaging for lower injury grades and embolization only in patients with evidence of ongoing hemorrhage.

TYPE OF STUDY

Systematic Review.

LEVELS OF EVIDENCE

Levels 2-4.

Pelvic angiography is effective for emergency pediatric patients with pelvic fractures: a propensity-score-matching study with a nationwide trauma registry in Japan

Purpose

The aim of this study was to evaluate the association between the implementation of pelvic angiography (PA) and outcome in emergency pediatric patients with pelvic fracture.

Methods

We extracted data on pelvic fracture patients aged ≤ 19 years between 2004 and 2015 from a nationwide trauma registry in Japan. The main outcome was hospital mortality. We assessed the relationship between implementation of PA and hospital mortality using one-to-one propensity-score-matching analysis to reduce potential confounding effects in comparing the PA group with the non-PA group.

Results

In total, 1351 patients were eligible for our analysis, with 221 patients (16.4%) included in the PA group and 1130 patients (83.6%) included in the non-PA group. For all patients, the proportion of hospital mortality was higher in the PA group than in the non-PA group [13.6% (30/221) vs 7.1% (80/1130), crude odds ratio (OR) 2.062 (95% confidence interval (CI), 1.318–3.224); p = 0.002]. In the propensity-score-matched patients, the proportion of hospital mortality was lower in the PA group than in the non-PA group [10.5% (22/200) vs 18.2% (38/200), p = 0.027]. This finding was confirmed in both the multivariable logistic regression model [adjusted OR 0.392 (95% CI, 0.171–0.896); p = 0.026] and the conditional logistic regression model [conditional OR 0.484 (95% CI, 0.261–0.896); p = 0.021].

Conclusion

The implementation of PA was significantly associated with lower hospital mortality among emergency pediatric patients with pelvic fractures compared with the non-implementation of PA.

Management Issues in Critically Ill Pediatric Patients with Trauma

The management of critically ill pediatric patients with trauma poses many challenges because of the infrequency and diversity of severe injuries and a paucity of high-level evidence to guide care for these uncommon events. This article discusses recent recommendations for early resuscitation and blood component therapy for hypovolemic pediatric patients with trauma. It also highlights the specific types of injuries that lead to severe injury in children and presents challenges related to their management.

Splenic trauma: WSES classification and guidelines for adult and pediatric patients

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

The use of angiography in pediatric blunt abdominal trauma patients

BACKGROUND

Angiography is a common treatment used in adults with blunt abdominal trauma and/or severe pelvic fractures. The Committee on Trauma of the American College of Surgeons has recently advocated for this resource to be urgently available at pediatric trauma centers; however, its usefulness in the pediatric setting is unclear. The purpose of this study was to determine the incidence of angiography in the treatment of blunt abdominal trauma among injured children.

METHODS

An analysis was performed using an established public use data set of children (younger than 18 years) treated at 20 participating trauma centers for blunt torso trauma through the Pediatric Emergency Care Applied Research Network. Patients who underwent angiography of the abdomen or pelvis were identified and analyzed.

RESULTS

Of the 12,044 children evaluated for blunt abdominal trauma included within the data set, 973 sustained abdominopelvic injuries. Of these, only 26 (3%) underwent angiography. The median age was 14 years, 65% were males, with a mortality rate of 19%. Overall, 29 angiographic procedures were performed: 21 abdominal, 8 pelvic, with 3 patients undergoing both abdominal and pelvic. Eleven patients underwent embolization of a bleeding vessel, all of which were related to the spleen. No hepatic, renal, or pelvic vessels required embolization. The median time to angiography from emergency department evaluation was 7.3 hours. In addition to angiography, 50% also required surgical intervention, of which 31% underwent a laparotomy. Thirty-five percent of these patients required blood product transfusion, and 42% were admitted to the intensive care unit.

CONCLUSION

The emergent use of angiography with embolization is uncommon in pediatric patients with blunt abdominal injuries. The requirement that pediatric trauma centers have access to interventional radiology within 30 minutes may be unnecessary.

LEVEL OF EVIDENCE

Epidemiologic study, level III; therapeutic study, level IV.

Nonoperative Management of the Damaged Spleen: A Community Surgeon Looks Back

Blunt spleen injury is usually managed nonoperatively. An 8-year retrospective analysis by one community surgeon was done to provide an overview of the role of CT, angiography, and transfusion in the management algorithm. A total of 2750 patients were screened and 125 patients were identified with spleen injury. Of these 125 patients, 72 were managed without surgery. These were young (mean age 32 ± 16 years) patients with mean Injury Severity Score of 16 ± 8. Angiography was used in 14 patients. These patients received more blood (5 ± 6 vs 2 ± units of packed red blood cells) than their nonangiogram counterparts. Overall failure of nonoperative care was 3 per cent. Community surgeons can provide safe nonoperative care and current adjuncts including angi-ography may enhance splenic salvage.

Nonoperative Management of Blunt Solid Organ Injury in Pediatric Surgery

In the last decade, higher rates of nonoperative management of liver, spleen, and kidney injuries have been achieved. An algorithmic approach may improve success on a national level. Factors for success include management strategy based on physiologic status of the child, early attempt at resuscitation using blood products, and appropriate use of adjuncts. Shorter hospitalizations are appropriate for children who have not bled significantly, and discharge instructions facilitate the safety of early discharge. Although routine imaging is not required for liver or spleen injury, symptoms should prompt reevaluation. Reimaging of renal injuries remains in common use.

The lost art of the splenorrhaphy

BACKGROUND

In the case of the hemodynamically unstable child, splenorrhaphy is preferred to splenectomy to avert postsplenectomy sepsis. However, successful splenorrhaphy requires familiarity with the procedure. We sought to determine how many splenectomies or splenorrhaphies for trauma the average pediatric surgeon can be expected to perform during their career.

METHODS

The Pediatric Health Information System (PHIS) Database was queried for patients ≤18years coded with an International Classification of Diseases 9th Edition diagnosis code of a splenic injury from 2004 to 2013. Age, gender, grade of splenic injury, and operations performed were extracted. Numbers of pediatric surgeons per hospital were obtained.

RESULTS

9567 children were identified. 2.1% underwent a splenectomy and 0.8% underwent a splenorrhaphy. The average surgeon performed 0.6 (SD=0.6) splenectomies and 0.2 (SD=0.4) splenorrhaphies for trauma. If these rates remain constant over time, the average surgeon would perform 1.8 (SD =1.7) splenectomies and 0.6 (SD =1.1) splenorrhaphies for trauma over a 30-year surgical career.

CONCLUSION

Nonoperative management is associated with a host of benefits, but has resulted in a decrease in the experience level of the pediatric surgeons expected to perform an emergency splenectomy or splenorrhaphy when the unusual occasion arises.

Pediatric blunt abdominal trauma: current management

PURPOSE OF REVIEW

Nonoperative management of pediatric blunt abdominal injury has changed significantly in the last few years.

RECENT FINDINGS

Improved resource utilization in the diagnosis of pediatric abdominal injury has been described. Hemodynamic status, rather than grade of injury, now guides care. Stable patients spend less time in the hospital, return to school upon discharge, and are allowed lower hemoglobin levels prior to transfusion. ICUs are reserved for those with recent or ongoing bleeding, previously unstable patients, or children with concomitant injuries necessitating ICU. Risk factors for failure and evidence for adjuncts to nonoperative management are emerging. Operative management of certain pancreatic injuries may have more favorable outcomes than nonoperative management.

SUMMARY

Sufficient evidence has become available to radically change the management of pediatric abdominal injury, which is being incorporated into new evidence-based management algorithms.

Angioembolization for solid organ injury: A brief review

INTRODUCTION

Non-operative management is the standard of care for blunt solid organ injuries in stable patients. Angioembolization is an important technique that improves success rates of non-operative management. We aimed to provide a brief review of the indications, effectiveness and complications associated with angioembolization for solid organ injuries.

METHODS

We conducted a literature search of the PubMed database using the terms "trauma", "angioembolization", and "solid organ embolization" limited to studies published in the English language. Abstracts and full text were manually reviewed to identify suitable articles.

RESULTS

The current brief review is based on content from the more recently published articles related to angioembolization for solid organ injuries after trauma.

DISCUSSION

Angioembolization is appropriate for hemodynamically stable patients with contrast extravasation on CT scan or high-grade injury to a solid organ. Non-operative management success rates have improved with the adoption of angioembolization. The complications associated with angioembolization are acceptable in the context of avoiding a laparotomy, and are often related to the severity of the injury.

CONCLUSION

Angioembolization is a natural extension of the move towards non-operative management for solid organ injuries. Randomized controlled trials are required to fully characterize the indications and efficacy of its use.