Seminars in Pediatric Surgery 29 (2020) 150949

Contents lists available at ScienceDirect

Seminars in Pediatric Surgery

journal homepage: www.elsevier.com/locate/sempedsurg

Strategies in liver Trauma

Vincent Duron, MD a,1, Steven Stylianos, MD b,2,∗
a
Assistant Professor of Surgery, Division of Pediatric Surgery, Columbia University Vagelos College of Physicians & Surgeons, 3959 Broadway, CHN 215, New
York, NY 10032
b
Chief, Division of Pediatric Surgery, Rudolph N Schullinger Professor of Surgery, Columbia University Vagelos College of Physicians & Surgeons,
Surgeon-in-Chief, Morgan Stanley Children’s Hospital, 3959 Broadway – Rm 204 N, New York, NY 10032

a r t i c l e i n f o a b s t r a c t

Keywords: The management of pediatric liver trauma has evolved significantly over the last few decades. While
Liver injury surgical intervention was frequently and mostly unsuccessfully practiced during the first half of the last
Pediatric
century, the 1960s were witness to the birth and gradual acceptance of non-operative management of
Blunt organ injury
these injuries.
In 20 0 0, the American Pediatric Surgical Association (APSA) Trauma Committee disseminated evidenced-
based guidelines to help guide the non-operative management of pediatric blunt solid organ injury. The
guidelines significantly contributed to conformity in the management of these patients. Since then, a
number of well-designed studies have questioned the strict categorization of these injuries and have led
to a renewed reliance on clinical signs of the patient’s hemodynamic status.
In 2019, APSA introduced an updated set of guidelines emphasizing the use of physiologic status rather
than radiologic grade as a driver of clinical decision making for these injuries. This review will focus on
liver injuries, in particular blunt injury, as this mechanism is by far the most commonly seen in children.
Procedures required when non-operative management fails will be detailed, including surgery, angioem-
bolization, and less commonly employed interventions. Finally, the updated inpatient and post-discharge
aspects of care will be reviewed, including hemoglobin monitoring, bedrest, length of hospital stay, and
activity restriction.
© 2020 Elsevier Inc. All rights reserved.

Introduction of death in children older than a year.4 In younger children, play-

Trauma is a leading cause of morbidity and mortality in child-
hood. Blunt trauma is the most common form of injury in pe-
diatric patients and accounts for 80–90% of abdominal injuries.
The liver is the most common organ injured in blunt abdominal
trauma followed by the spleen.1 , 2 Low velocity mechanisms, such
as falls and sports injuries, are the most frequent mechanism of
injury. Children’s smaller size puts them at greater risk of multi-
ple organ injuries and their underdeveloped rib cage and relative
lack of soft tissue padding provides less protection of the upper
abdominal organs.3 Motor vehicle collisions (MVC), although less
frequently a cause of abdominal injury than in adults, cause more
severe injury. In fact, although childhood motor vehicle death rates
have declined by ~40% since 20 0 0, MVCs remain the leading cause
∗
Corresponding author
E-mail addresses: vd2312@cumc.columbia.edu
ss128@cumc.columbia.edu (S. Stylianos).
1
Tel. 212–342–8586
2
212–342–8586
ground injuries are a common cause of liver injuries, however in-
flicted injury or non-accidental trauma should be considered when
the history or mechanism is not clear. Injury in school age chil-
dren is often related to sports and recreational activities such as bi-
cycling and skateboarding. Adolescents engage in more risk-taking
behavior and have access to motorized vehicles, resulting in a more
severe injury pattern, as is seen in injuries associated with mo-
tocross and all-terrain vehicles (ATV).5
Although penetrating liver injury occurs, it is much less fre-
quent than blunt liver injury, and so will not be the focus of
this review. Management of blunt liver injuries has evolved signifi-
cantly in the last few decades and owes much to the initial change
in management of blunt splenic injuries.6–11 During the first half of
the 19th century, surgical intervention for blunt solid organ injury
was frequent as clinicians depended solely on vitals, physical exam,
and abdominal radiographs to direct management. In the 1960s,
(V. Duron), successful and safe non-operative management (NOM) was first
demonstrated in the Hospital for Sick Children in Toronto.12 De-
spite this, adoption of this practice was slow.13 As imaging for ab-

https://doi.org/10.1016/j.sempedsurg.2020.150949
1055-8586/© 2020 Elsevier Inc. All rights reserved.

Downloaded for Ana Isabel Barros (ana1996barros@gmail.com) at Pedro Hispano Hospital from ClinicalKey.com by Elsevier on
January 30, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
2 V. Duron and S. Stylianos / Seminars in Pediatric Surgery 29 (2020) 150949

Table 1
American Association for the Surgery of Trauma (AAST) Liver Injury Scoring Scale.

Grade§ Injury Injury Description

I Hematoma Subcapsular, <10% surface area

Laceration Capsular tear, <1 cm, parenchymal depth
II Hematoma Subcapsular, 10–50% surface area, intraparencymal <10 cm in diameter
Laceration Capsular tear, 1–3 cm parenchymal depth, <10 cm in length
III Hematoma Subcapsular, >50% surface area ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >10 cm or expanding
Laceration >3 cm parenchymal depth
IV Laceration Parenchymal disruption involving 25–75% of hepatic lobe or 1–3 Couinaud’s segments
V Laceration Parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud’s segments within a single lobe
Vascular Juxtahepatic venous injuries; i.e. retrohepatic vena cava or central major hepatic veins
VI Vascular Hepatic avulsion
§
For multiple injuries, advance one grade up to Grade IIIReproduced and adapted with permission from Moore EE, Shackford SR, Pachter HL, et al. Organ injury
scaling: spleen, liver, and kidney. J Trauma 1989;29(12):1664–6.

dominal injury improved, with the advent of ultrasonography and
CT particularly, less severe injuries were able to be distinguished
from more severe ones. In 1989, a solid organ injury grading sys-
tem was developed by the American Association for the Surgery
of Trauma (AAST), including for blunt liver injuries14 (Table 1). The
CT grade of injury was then incorporated into NOM of liver injuries
of both adults and children and in 20 0 0, the APSA Committee on
Trauma developed guidelines based on multi-institutional review
and expert consensus to direct the treatment for each grade of iso-
lated liver and spleen injury.15 At present, more than 90% of solid
organ injuries in children are “treated” using NOM.16
In 2015, the approach for treatment of these injuries was revis-
ited and refocused on management based on physiologic variables
rather than grade, as evidenced in the Arizona-Texas-Oklahoma-
dominal bruising, abdominal wound, and abdominal tenderness,
were present significantly more often in those requiring abdomi-
nal surgery.24
Signs of hypovolemic shock including poor perfusion, tachycar-
dia and mental status changes in abdominal trauma are ominous
findings suggesting significant bleeding and require urgent eval-
uation and management. The evaluation of circulatory status in
children is particularly challenging. Children may be on the brink
of hemodynamic collapse and only be tachycardic. Hypotension
is a late sign of hypovolemia.25 , 26 Furthermore, hypotension in
children is often not related to hypovolemia. In fact, hypotension
secondary to isolated head injury in children occurs with nearly
the same frequency as hypotension secondary to hemorrhage.26 ,
27 This again emphasizes the importance of physical exam in chil-

Memphis-Arkansas Consortium (ATOMAC) guidelines. The ATOMAC
algorithm was developed over a two year period, included a critical
evaluation of the literature, and was verified by the Grading of Rec-
ommendations, Assessment, Development, and Evaluation (GRADE)
methodology.7 In 2019, APSA acknowledged this paradigm shift in
the treatment of these injuries and offered a new set of guide-
lines for the management of blunt liver and spleen injuries based
on the patient’s physiologic response to injury and intervention7 ,
17–22 (Fig 1).
Assessment and diagnosis
Initial assessment
The initial management of a trauma patient should always be-
gin with a primary survey, regardless of mechanism or injury.3
While most liver injuries may be managed non-operatively, the
consequences of missing an associated injury may be devastating.
As such, accurate diagnosis is essential. Important information to
obtain from pre-hospital staff includes vitals in the field, mecha-
nism of injury, and whether protective or restraint devices were
used. For MVCs, knowledge of the damage to the vehicle and sever-
ity of injuries of other passengers is also important. A history of
blunt force trauma to the upper abdomen or chest should raise
concern for possible liver injury.
Children who are alert and communicative will complain of sig-
nificant abdominal pain, some complaining of shortness of breath.
Referred shoulder pain is commonly encountered in liver injury
(known as Kehr’s sign). An abnormal physical exam continues to
be one of the most reliable indicators of abdominal injury in chil-
dren.23 Findings such as tenderness, abrasions, or contusions, “han-
dlebar mark” or “seat belt sign” are suggestive of an underlying
abdominal injury. A recent retrospective study at an American Col-
lege of Surgeons-certified level 1 pediatric trauma center found
that physical examination findings, such as the seat belt sign, ab-
dren and the attention to accompanying injuries such as rib, lum-
bar and long bone fractures as adjuncts in keen clinical assessment
and diagnosis of intra-abdominal injury.
Diagnostic modalities
A number of studies have been performed on the use of lab-
oratory testing in predicting intra-abdominal injury. Several stud-
ies have proposed that an abnormal physical exam with aspartate
aminotransferase (AST) and/or alanine aminotransferase (ALT) ele-
vation predicts the presence of an intra-abdominal injury.28 , 29 A
recent moderately large retrospective study aimed to determine
if the combination of physical examination, serum transaminases
along with Focused Assessment with Sonography in Trauma (FAST)
would effectively rule out major hepatic injuries after blunt ab-
dominal trauma in hemodynamically stable pediatric patients. Us-
ing ROC curve analysis, they found that optimum ALT and AST
thresholds were 90 U/L and 120 U/L, respectively. The sensitivity
of FAST alone was 50% while that of physical exam alone was 40%.
Combining physical exam with AST/ALT and FAST had an overall
sensitivity of 97%, a specificity of 95%, a positive predictive value
of 87%, and a negative predictive value of 98%.30
The FAST exam allows a rapid evaluation of the abdominal and
thoracic cavities to infer the presence of bleeding by diagnosing
free peritoneal or pericardial fluid. Originally developed for the
evaluation of hemodynamically unstable patients, it has gained
widespread acceptance in adult trauma and is frequently used in
their initial assessment. The application of this modality in pedi-
atric trauma patients however is less clear. Several studies have
demonstrated that FAST is neither sensitive nor specific in iden-
tifying abdominal injuries in children.31 As discussed previously,
combining FAST with abnormal laboratory values however may
be helpful. One study found that a positive FAST combined with
AST or ALT level higher than 100IU/L was associated with a sen-
sitivity of 88%, specificity 98%, PPV 94%, NPV 96% and accuracy

Downloaded for Ana Isabel Barros (ana1996barros@gmail.com) at Pedro Hispano Hospital from ClinicalKey.com by Elsevier on
January 30, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
 V. Duron and S. Stylianos / Seminars in Pediatric Surgery 29 (2020) 150949 3

Fig 1. Updated Liver /Spleen Injury APSA guidelines.

96% in detected an intra-abdominal injury, making it an effective
screening tool for intra-abdominal injury in children.32 As such, the
role of FAST should be considered as an adjunct to history, physi-
cal examination and laboratory studies to help determine whether
further evaluation is required.
CT scanning with intravenous contrast remains to this day the
gold standard for diagnosing intra-abdominal injuries in hemody-
namically stable children, identifying over 90% of liver injuries. The
radiation exposure from a CT is however significant and warrants
appropriate patient selection. The actual long term effects of ex-
posure to ionizing radiation from medical imaging are unknown
but estimates based on atomic bomb studies have suggested that
the incidence of fatal cancer could be as high as one per 10 0 0 CT
scans performed in a five year old child.33 , 34 A population-based
study from the UK’s NHS database has shown an increased rate
of brain cancer and leukemia in children exposed to repeated CT
scans.35 Children are more vulnerable to the effects of radiation ex-
posure with their smaller size allowing for a larger absorbed dose
per unit area in organs that have an increased number of divid-
ing cells. Furthermore, due to their young age, they are at higher
risk of suffering the effects of a radiation-induced malignancy as
the latency period is around 20 years. Given these concerns, it is
important for the clinician to be judicious in the use of CT and for
the radiologist to use the lowest possible dose of radiation with
dose reduction software, as is encouraged by the Image Gently R ing and clinical judgement remains the primary driver of success
campaign.36
Management of liver injury patient
Since the APSA Committee on Trauma published their guide-
lines for the management of isolated spleen and liver injuries in
20 0 0, emphasis has shifted from management based on grade to-
wards an approach based on physiologic status.7 In this revised
model, injuries are managed according to hemodynamic status and
signs of on-going bleeding - not anatomic grade of injury. Imaging
is still used to evaluate the abdomen, diagnose a blunt splenic or
liver injury, and rule out other injuries. The patient’s clinical status
is then used to guide therapy.
Non-Operative management
Management of the stable pediatric patient with blunt liver injury
Non-operative management of hemodynamically stable children
and adolescents with isolated blunt liver injury is now the stan-
dard of care, confirmed in retrospective and prospective studies to
be safe in multiply injured patients.6 , 37 , 38 In patients with other
intra-abdominal injuries, these may take priority over the liver or
spleen injury, and require operative intervention, such as certain
hollow-viscus, bladder, ureter or pancreatic injuries.39 , 40
Those that present with blunt liver injury after the typical pe-
riod of observation can present management problems. There are
no studies specifically addressing management of late presenta-
tions of pediatric patients with liver injury. These patients often
present with complications such as pain, re-injury, or pleural effu-
sion.41 In the absence of pertinent data in the literature, patients
that present within 48 hrs of injury should be treated as if it were
an acute injury.
An actual definition of hemodynamic stability in a child sus-
pected of having recent or ongoing bleeding however is challeng-
or failure. In adult trauma patients with hemorrhage, blood pres-
sure, heart rate, and lactic acid parameters have been proposed,
however none are universally accepted in pediatric trauma pa-
tients. The recently published pediatric specific shock index may
provide some guidance in defining hemodynamic stability, how-
ever it is not widely used in their initial management.42
Current APSA guidelines using physiological variables to guide
resuscitation and label a patient as candidate for non-operative
management if they have normal vital signs and does not have
signs of ongoing bleeding after initial resuscitation, defined as
an 20 ml/kg isotonic intravenous fluid bolus. No single clinical
variable or test can predict that a child is at risk of needing a

Downloaded for Ana Isabel Barros (ana1996barros@gmail.com) at Pedro Hispano Hospital from ClinicalKey.com by Elsevier on
January 30, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
4 V. Duron and S. Stylianos / Seminars in Pediatric Surgery 29 (2020) 150949
blood transfusion or operation, so current guidelines rely mostly
on physician evaluation.42 It does appear that a surgeon’s ability
to accurately determine if a child has or has not recently bled is
accurate enough to guide therapy.25 Indeed, numerous prospective
studies support management based on hemodynamic status rather
than CT grade of injury.20 , 22 , 43 , 44 If a patient is deemed to be
a fluid responder and/or not have signs of ongoing bleeding, then
they may be admitted to a non-ICU level floor for NOM, regard-
less of injury grade. Many patients with low-grade liver injuries
fit into this category. This practice model contrasts to the previ-
ous injury grade guided management in which grade IV or higher
injuries were necessarily admitted to the ICU, resulting in over uti-
lization of healthcare resources without identifiable benefit.43 , 45
Hemodynamically stable patients have a low risk of requiring
urgent transfusion and a type and screen is adequate at most facili-
ties. In facilities without the ability to transfuse type-specific blood
quickly, transfer to another facility should be strongly considered -
even in this stable sub-group of patients. Vitals signs should be re-
peated frequently, a CBC should be repeated at 6hr after admission,
and if vitals are stable then the patient should be able to ambulate
and have a regular diet.
ICU admission should be reserved for children who show signs
of ongoing bleeding and may require intervention or transfusion.43 ,
45 Those who present with clinically significant hypovolemia but
respond to resuscitation should be admitted to the ICU or trans-
ferred to a facility with a pediatric ICU. Vital signs, admission
hemoglobin, and pediatric specific shock index on admission have
shown reliability to identify children who require an intervention.7 ,
42 , 43 , 45 A small portion of children with a liver injury that are
initially stable will continue to bleed. Some cases of early de-
layed bleeding (<48 hrs after injury) may actually represent ini-
tial failure to detect continued bleeding.25 , 41 Several studies, in-
cluding a systematic review, suggest a transfusion threshold for a
hemoglobin of 7.0 g/dL is safe and reasonable in injured children.7 ,
43 , 46
Nil per os (NPO) status
For isolated liver injuries, without concern for ongoing bleed-
ing, children should be allowed to have clear fluids and advance
their diet as deemed appropriate. Those with concern for ongoing
bleeding, abnormal vital signs, or drifting Hb should remain NPO in
case a procedure is required. Previous studies have recommended
NPO status for those with severe abdominal trauma as patients
with high grade injuries and significant hemoperitoneum would
be expected to have an ileus.43 Multiply injured patients should
be treated on a case-by-case basis.
Frequency of hemoglobin check
Hemoglobin checks should be performed as indicated by the
patient’s clinical status. Most of those who fail NOM do so due to
their hemodynamic status.18 , 47 Several studies now support either
a single 6-hour post-injury hemoglobin or no serial hemoglobin
checks after the initial value is obtained.20 , 25 , 48 The 2019 APSA
guidelines recommend a CBC on admission and/or 6 hrs after in-
jury. If there is concern for ongoing bleeding or if vitals are abnor-
mal, then subsequent Hb checks are warranted.
Bedrest
Several recent studies have confirmed the safety of an abbrevi-
ated period of bedrest.6 , 22 , 37 , 49 In one study it was estimated
that over 35,0 0 0 days of hospitalization could have been elimi-
nated with an abbreviated bedrest protocol.49 No evidence sug-
gests bedrest prevents re-bleeding in children. Bedrest should be
Downloaded for Ana Isabel Barros (ana1996barros@gmail.com) at Pedro Hispano Hospital from ClinicalKey.com by Elsevier on
January 30, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
ordered in patients with concern for ongoing bleeding and until vi-
tals are normal. Floor patients and patients with stable vital signs
and Hb levels should not be on bedrest.
Length of stay
Studies suggest that very few patients with blunt solid organ
injury who have stopped bleeding will re-bleed in the short term
after trauma.7 , 25 , 41 The incidence of late bleeding is extremely
rare.41 , 50 Factors identified that might increase the risk of fail-
ure of non-operative management and might potentially increase
the risk of early discharge include a contrast blush on CT scan,51 ,
52 handlebar injury47 , 53 , 54 and more than one abdominal solid
organ injury - especially the pancreas.47 , 53 Discharge after an ab-
breviated period of hospitalization (<24 hrs in some cases) has
been demonstrated to be safe in those with isolated low-grade in-
juries.6 , 22 , 37 , 43 , 49 , 54 The 2019 APSA guidelines advocate early
discharge of patients when they are tolerating a regular diet, have
minimal abdominal pain, are ambulating, and have normal vital
signs. Since delayed bleeds have been reported, often outside of
the APSA guideline period, standardized education for the fam-
ily and patient remains an important component of discharge in-
structions. Patients should be coached specifically on the signs and
symptoms of delayed bleeding and other complications.
Management of the pediatric blunt liver injury patient with
ongoing bleeding
Non-responders, i.e. those who have abnormal vital signs af-
ter an initial 20 mL/kg bolus of isotonic fluid, should be admin-
istered a 10–20 mL/kg packed red blood cell transfusion. Other
sources of shock and bleeding should be ruled out and the surgeon
should decide if surgery or interventional radiologic treatment is
indicated.7 , 44 , 55 If the patient responds to the blood transfu-
sion, he/she should remain in the ICU and continue to have serial
Hb checks until stable. During this time, the patient remains on
bedrest and NPO. A recurrent episode of hypotension should war-
rant further procedure, including surgery or angioembolization.
Pediatric trauma patients requiring transfusion have been
shown to demonstrate coagulopathy at presentation.56 Bolusing
with crystalloid fluid should be limited and a massive transfu-
sion protocol should be initiated.44 While adult studies support a
hemostatic resuscitation with the early activation of a 1:1:1 mas-
sive transfusion protocol, the data is less consistent in pediatric
trauma patients. A retrospective study of 100 pediatric trauma pa-
tients undergoing massive transfusion did not demonstrate a rela-
tionship between higher plasma/PRBC and platelet/PRBC ratios and
survival.57
Although 40 mL/kg PackedRBC is a volume at which risk of
death has been found to increase significantly and is considered
a reasonable threshold for failure of NOM by consensus studies, it
is best to begin mobilizing the operating room or IR personnel as
soon as blood transfusion begins as waiting for this threshold may
be precarious.38 , 58
Failure of non-operative management
Very few children fail non-operative management for blunt
solid organ injury, and even fewer for blunt liver injuries, with
a mean of 3% laparotomy rate for blunt liver injuries.9 , 47 Unlike
adults, when children fail NOM they generally do it early.18 , 47 ,
59 One large multi-institutional retrospective review of 1800 pe-
diatric solid organ injuries found that among over 10 0 0 blunt liver
and spleen injuries in the series, only 19 patients failed NOM for
shock or bleeding. The median time to operation for all patients
 V. Duron and S. Stylianos / Seminars in Pediatric Surgery 29 (2020) 150949
Fig 2. Liver Injury with Contrast Blush.
Fig 3. Liver Angioembolization.
was 3 hrs with 87% failing by 24 hrs. Only 0.6% of the total num-
ber of patients failed NOM >24 hrs.47 Large database studies have
confirmed that those children who require operative intervention
are usually identified within the first 6–12 hrs of their hospital
course.6 , 43 , 47 , 60–62 Risk factors for failure at pediatric trauma
centers include higher Injury Severity Scale, lower Glasgow Coma
Scale (GCS) at presentation, higher organ injury grade and/or mul-
tiple organs injured, and older age.9 , 47 , 63
Procedures
Angioembolization
Angioembolization (AE) for blunt solid organ injury is rare and
for liver injury it is even less common, with only a handful of cases
reported in children.64–68 Although AE rates have increased since
the implementation of non-operative blunt solid organ injury man-
agement, the rate of AE in children with these injuries remains
very low.69 Controversy exists in regards to the presence of con-
trast extravasation on CT as a sign of ongoing bleeding requiring
intervention. Several small series have demonstrated no association
between contrast blush and the need for intervention or failure of
non-operative management.70 , 71 In contrast, a recent systematic
review of nine studies including 117 pediatric patients with spleen
or liver injury with contrast extravasation found a failure rate of
22.5% for non-operative treatment without AE versus only 6.5% for
non-operative treatment with AE. The authors advocate the use of
contrast blush as a trigger for early consideration of AE in these
patients51 (Fig 2).
Selective AE may be a highly effective adjunct to non-operative
treatment of pediatric blunt liver injury, however stabilization with
PRBC and a trial at NOM should be considered first. (Fig 3) Most
pediatric trauma surgeons do not use routine AE in the presence
of contrast blush unless there are clinical signs of ongoing bleed-
ing. Significant complications can occur after AE of liver injury in-
cluding post-operative pain, contrast-induced kidney injury, hem-
Downloaded for Ana Isabel Barros (ana1996barros@gmail.com) at Pedro Hispano Hospital from ClinicalKey.com by Elsevier on
January 30, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
5
orrhage, intra-abdominal abscess, bile leaks, gallbladder ischemia,
and hepatic necrosis. Femoral artery injury is particularly problem-
atic in smaller children. Management of such complications can of-
ten be performed with percutaneous and endoscopic techniques,
however they remain significant.72–74 The decision to use AE ver-
sus operative intervention in a patient who is failing NOM will de-
pend on institutional resources and how quickly they can be mo-
bilized. However, no child with an actively bleeding liver injury
should be transported to an interventional radiology suite in shock.
Initial damage control laparotomy with perihepatic packing and
temporary closure should be undertaken. Control of major vascular
injury should be considered if easily accessible, but search for an
elusive or retro-hepatic source of bleeding should not take prece-
dence over well-placed packs. Once adequately resuscitated with
blood and coagulation products, AE should be considered for on-
going arterial bleeding. Some authors advocate primary hepatic AE
in the setting of high grade liver injury, contrast blush, and relative
hemodynamic stability maintained with blood products.65 Extreme
caution and effective resource mobilization is required when taking
an actively bleeding pediatric liver trauma patient to the angiogra-
phy suite remote from the operating room should there be further
decompensation.
Surgical management
Although some high volume adult trauma centers report im-
proved outcomes, the mortality rate for complex liver injury re-
quiring surgical intervention remains >50% in most centers.75–77
Juxtahepatic caval injuries are particularly lethal with mortality
rates ranging from 60 to 80%.78 , 79
Damage control surgery includes an abbreviated operation with
control of obvious vascular injuries and perihepatic packing (stop
the bleeding and close), ICU resuscitation (i.e. correcting hypother-
mia, coagulation and oxygen delivery issues) and a return to the
operating room for the definitive operation once the hemodynamic
and metabolic status are optimized (usually 24 to 72 hrs after the
trauma). Supradiaphragmatic intravenous access is essential. The
aim of damage control surgery is to interrupt and avoid the lethal
triad of hypothermia, acidosis and coagulopathy. This technique
is superior in postoperative outcome to more invasive procedures
such as clamping, hepatectomy, direct coagulation and ligation but
the decision must be made quickly before the lethal triad occurs.
Proper packing is essential. The key to packing the liver is plac-
ing packs above and below the liver, with packs placed strategi-
cally between the liver and diaphragm, abdominal sidewall, and
infra-hepatic structures. The aim of the packs is to compress the
parenchyma with care to avoid critical compression of the infe-
rior vena cava. If bleeding stops, it is best to leave the packs in
place without further manipulation. It is important not to dissect
deeper into the injured parenchyma nor attempt mass ligatures or
excessive cautery as this can often lead to increased blood loss and
wasted time.80 The fascia should be left open with the use of tem-
porary abdominal closure techniques, including Vacuum Assisted
Closure R
appliances, SilasticR
sheeting, or surgical towels. This
will expedite getting the patient back to the ICU for further re-
suscitation. (Fig 4) Signs of continued hemorrhage should prompt a
return to the operating room for further inspection, packing and/or
angiography.
In the patient who has stabilized with packing, definitive treat-
ment may be considered if the injury is thought to be easily ac-
cessible. A recent review of advanced operative techniques in the
management of complex liver injury was offered by Dr. Peitzman
and Marsh from Pittsburgh.81 An experienced co-surgeon or hepa-
tobiliary surgeon and good anesthetic support are crucial to max-
imize chances of success. They recommend initial management of
deep parenchymal fractures with compression, followed by suture
6 V. Duron and S. Stylianos / Seminars in Pediatric Surgery 29 (2020) 150949
Fig 4. Damage Control Laparotomy.
ligation of bleeding vessels, and the avoidance of deep liver su-
tures.
Occlusion of the portal triad (i.e. Pringle Maneuver) between
two fingers or with a non-crushing vascular clamp or vessel loops
is a temporary maneuver while the abdomen is inspected, clots
cleared and resuscitation continues. This maneuver helps differ-
entiate between hepatic arterial and portal venous bleeding (de-
creases when the clamp is engaged) and hepatic venous bleeding.
Ideally, intermittent clamping of the porta hepatis should be per-
formed to decrease the degree of hepatic ischemia. Partial vascu-
lar isolation and ligation of a branch of hepatic artery, portal vein
or even hepatic vein as an addition to the initial damage control
operation with delayed parenchymal resection has been used in
severe liver injury.82 This aggressive approach requires advanced
liver surgery skills and can worsen the metabolic and hemody-
namic derangements. Dr. Pachter, during his address at the 70th
Annual Meeting of the AAST described his approach to complex
liver injury. First manually compress the injury and resuscitate.
Then perform these five sequential steps: 1. The Pringle Maneu-
ver 2. Rapid hepatotomy to injury site for ligation of bleeding ves-
sels and lacerated bile ducts 3. Debridement of non-viable hep-
atic tissue 4. Placement of an omental pack into the injury site
5. Closed suction drainage for grades III-V injuries.83 Large frac-
tures may be treated with anatomic or non-anatomic resection, as
long as enough residual liver remains. Resection can be sped up
with the use of mechanical staplers. While the definitive opera-
tion must control bleeding and bile leak, debride nonviable tissue,
and adequately drain the resected margin, control of hemorrhage is
the primary concern in an emergency operation and packing with
rapid control of bleeding remains primordial.
Total hepatic vascular isolation
Total vascular isolation (portal triad, infra- and supra-hepatic
vena cava and aorta) was devised to allow bloodless major hep-
atectomies in the elective setting - particularly for patients with
tumors in the paracaval region. Even in a controlled setting how-
ever, total vascular isolation is invasive and contributes to signif-
icant hemodynamic changes. The trend in tumor and transplant
liver surgery is limiting the use of this technique. Total vascular
isolation in trauma requires an exit strategy for getting the injured
patient out of the operating room. Prompt repair of rare juxtacaval
injuries in children may not be feasible, therefore, early packing
during an abbreviated laparotomy is again more likely to be help-
ful to the pediatric trauma surgeon. (Fig 5)
Downloaded for Ana Isabel Barros (ana1996barros@gmail.com) at Pedro Hispano Hospital from ClinicalKey.com by Elsevier on
January 30, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
Fig 5. Total Hepatic Vascular Control.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) in
severe liver injury
REBOA describes the rapid retrograde insertion of a balloon
catheter through the femoral artery advanced and inflated at the
level of the diaphragmatic descending aorta with the goal of con-
trolling inflow and allow time for hemostasis. Moore et al. com-
pared resuscitative thoracotomy and aortic cross clamping (RT)
with REBOA in adult trauma patients in profound hemorrhagic
shock and found that REBOA had fewer early deaths and im-
proved overall survival as compared with RT (37% versus 10%,
P = 0.003).84 REBOA is feasible and controls non-compressible
truncal hemorrhage in trauma patients in profound shock. In se-
vere liver trauma, endovascular balloon catheters in the aorta and
cava can be useful for temporary vascular occlusion to allow access
to a juxtacaval injury. The extremely rare need for this intervention
in children however makes it challenging to develop the expertise
and rapidly assemble the resources necessary to use REBOA in pe-
diatric trauma centers. (Fig 6)
Post-Discharge care
Activity restriction
Activity restriction was part of the initial APSA guidelines.15
Typical classroom activities, however, would not violate these
rules. In several prospective studies, no school-related complica-
tions were observed when children were given an excuse from
gym class but allowed to return to school when comfortable
enough to do so.6 , 22 , 54 There are no comparative data, how-
ever, to evaluate the safety of early versus delayed return to school.
With appropriate activity and contact restrictions, children may re-
turn to school when comfortable and able. The initial evidence
for full activity restriction was based on expert opinion. Since cur-
 V. Duron and S. Stylianos / Seminars in Pediatric Surgery 29 (2020) 150949
Fig 6. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA).
rently no literature documenting the safety of shorter activity re-
striction has been published, the initial APSA grade based guide-
lines of limited activity for grade plus two weeks continues to be
recommended by the 2019 APSA guidelines.
CLINIC follow UP
There is little data allowing follow up recommendations, which
mostly come from consensus opinion. As low grade injuries are felt
to be at extremely low risk of complication, telephone call follow-
up for grade 1 and 2 injury at two to four weeks is appropriate.
An office visit at two to four weeks should be scheduled with a
pediatric surgeon for grade 3 to 5 injuries. A telephone follow-up
at 60 days post injury or prior to resuming full activity is advis-
able. High grade liver injuries would appear to be at more risk
for post-injury complications than high grade spleen injuries. The
most common complication identified is a bile leak or biloma, fol-
lowed by hepatic artery pseudoaneurysm with hemobilia. In the
two most recent studies characterizing diagnosis and management
of these injuries, almost all were identified prior to discharge from
the hospital within seven days of injury.72 , 73 Still, readmission af-
ter blunt abdominal trauma appears to be uncommon.85 Patients
should instructed to return to the emergency department for in-
creasing pain, pallor, dizziness, difficulty breathing, vomiting, wors-
ening shoulder pain, signs and symptoms of jaundice, gastrointesti-
nal bleeding or black tarry stools.50 , 86 Finally pleural effusions af-
ter solid organ injury are not uncommon and may require treat-
ment.86
Follow-Up imaging
While routine reimaging in children is clearly not indicated,
rare cases may still benefit from reimaging. The category of pa-
Downloaded for Ana Isabel Barros (ana1996barros@gmail.com) at Pedro Hispano Hospital from ClinicalKey.com by Elsevier on
January 30, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
7
tients who might benefit has not been clearly defined but a small
number of patients with grade 4 or 5 liver injury have shown sig-
nificant complications. Fortunately, obvious clinical symptoms of-
ten prompt those few re-imaging studies. As the use of contrast
enhanced ultrasound (CEUS) increases, it may become a more vi-
able option for post-injury imaging.87
Complications
Biloma: the incidence of bile leak or biloma after NOM of pedi-
atric liver injury ranges from 3 to 5% - less than that reported in
the adult literature. It has been observed only in Grade 3 injuries
or higher and all have been identified within a week of injury.72 ,
73 Persistent or worsening right upper quadrant pain, low grade
fever and jaundice should trigger obtaining a right upper quad-
rant US. HIDA scan is usually diagnostic. Percutaneous or laparo-
scopic drainage of bile collections will often be needed, and ERCP
with sphincterotomy and stent placement may be required to en-
sure continued adequate drainage of the bile duct.72 , 73 Antibiotics
may be warranted after drainage if there is the concern for bacte-
rial infection.88
Hepatic artery pseudoaneurysm
In adult trauma literature, hepatic artery pseudoaneurysm
(HPA) with hemobilia is rare, occurring in <3% of liver injuries. It
is more often associated with penetrating than blunt hepatic injury
and can almost always be controlled by hepatic artery emboliza-
tion.89 Pediatric literature would suggest it is very rare in pediatric
trauma as well.90 However, even though HPA is rare with respect
to overall hepatic injury, in one study, almost 25% of Grade 4 pedi-
atric hepatic injuries had a HPA present when imaged.72 Screening
with CEUS has shown an incidence as high as 17% in both liver and
spleen injuries.87 Management with embolization if possible would
be recommended whenever an aneurysm results in hemobilia and
significant blood loss.
Conclusion
Overall, outcomes from liver injury continue to improve. Liver
injury in children is most often from blunt trauma and is by and
large treated non-operatively. Recent updates to the non-operative
management guidelines of pediatric liver injury include a heavier
emphasis on physiologic status rather than radiologic grade with
the hope of more precisely targeting interventions and limiting
healthcare resources. Complex liver injuries are rare and occupy
a special place in solid organ injury, requiring quick and creative
strategies that may involve surgical, image-guided and endoscopic-
assisted interventions.
References
1. Miele V, Piccolo CL, Trinci M, et al. Diagnostic imaging of blunt abdominal
trauma in pediatric patients. Radiol Med. 2016;121(5):409–430.
2. Stylianos S, Ford HR. Outcomes in pediatric trauma care. Semin Pediatr Surg.
2008;17(2):110–115.
3. American College of Surgeons TCoT. ATLS Advanced Trauma Life Support Stu-
dent Course Manual. 10th Edition ed. Chicago, IL: American College of Surgeons;
2018.
4. Centers for Disease C, Prevention. Vital signs: unintentional injury deaths
among persons aged 0-19 years - United States, 20 0 0-20 09. MMWR Morb Mor-
tal Wkly Rep. 2012;61:270–276.
5. Denning GM, Harland KK, Jennissen CA. Age-based risk factors for pediatric
ATV-related fatalities. Pediatrics . 2014;134(6):1094–1102.
6. St Peter SD, Sharp SW, Snyder CL, et al. Prospective validation of an abbrevi-
ated bedrest protocol in the management of blunt spleen and liver injury in
children. J Pediatr Surg. 2011;46(1):173–177.
7. Notrica DM, Eubanks 3rd JW, Tuggle DW, et al. Nonoperative management of
blunt liver and spleen injury in children: evaluation of the ATOMAC guideline
using GRADE. J Trauma Acute Care Surg. 2015;79(4):683–693.
8 V. Duron and S. Stylianos / Seminars in Pediatric Surgery 29 (2020) 150949
8. Davies DA, Pearl RH, Ein SH, et al. Management of blunt splenic in-
jury in children: evolution of the nonoperative approach. J Pediatr Surg.
20 09;44(5):10 05–10 08.
9. Wisner DH, Kuppermann N, Cooper A, et al. Management of children with
solid organ injuries after blunt torso trauma. J Trauma Acute Care Surg.
2015;79(2):206–214 quiz 332.
10. Notrica DM. Pediatric blunt abdominal trauma: current management. Curr Opin
Crit Care. 2015;21(6):531–537.
11. Graziano KD, Juang D, Notrica D, et al. Prospective observational study with
an abbreviated protocol in the management of blunt renal injury in children. J
Pediatr Surg. 2014;49(1):198–200 discussion -1.
12. Upadhyaya P, Simpson JS. Splenic trauma in children. Surg Gynecol Obstet.
1968;126(4):781–790.
13. Aronson DZ, Scherz AW, Einhorn AH, et al. Nonoperative management of
splenic trauma in children: a report of six consecutive cases. Pediatrics .
1977;60(4):482–485.
14. Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen, liver,
and kidney. J Trauma. 1989;29(12):1664–1666.
15. Stylianos S. Evidence-based guidelines for resource utilization in children with
isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg.
20 0 0;35(2):164–167.
16. Gaines BA. Intra-abdominal solid organ injury in children: diagnosis and treat-
ment. J Trauma. 2009;67(2 Suppl):S135–S139.
17. Governors APSABo. Updated APSA Blunt Liver/Spleen Injury
Guidelines 2019, https://eapsa.org/apsa/media/Documents/APSA_
Solid- Organ- Injury- Guidelines- 2019.pdf; 2019 [accessed January, 30.2020].
18. Acker SN, Petrun B, Partrick DA, et al. Lack of utility of repeat monitoring of
hemoglobin and hematocrit following blunt solid organ injury in children. J
Trauma Acute Care Surg. 2015;79(6):991–994 discussion 4.
19. Gates RL, Price M, Cameron DB, et al. Non-operative management of solid
organ injuries in children: an American Pediatric Surgical Association Out-
comes and Evidence Based Practice Committee systematic review. J Pediatr
Surg. 2019;54(8):1519–1526.
20. Golden J, Dossa A, Goodhue CJ, et al. Admission hematocrit predicts the need
for transfusion secondary to hemorrhage in pediatric blunt trauma patients. J
Trauma Acute Care Surg. 2015;79(4):555–562.
21. Ingram MC, Siddharthan RV, Morris AD, et al. Hepatic and splenic
blush on computed tomography in children following blunt abdominal
trauma: is intervention necessary? J Trauma Acute Care Surg. 2016;81(2):
266–270.
22. St Peter SD, Aguayo P, Juang D, et al. Follow up of prospective validation of
an abbreviated bedrest protocol in the management of blunt spleen and liver
injury in children. J Pediatr Surg. 2013;48(12):2437–2441.
23. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children
with intra-abdominal injuries after blunt trauma. Ann Emerg Med.
20 02;39(5):50 0–509.
24. Drucker NA, McDuffie L, Groh E, et al. Physical Examination is the Best Pre-
dictor of the Need for Abdominal Surgery in Children Following Motor Vehicle
Collision. J Emerg Med. 2018;54(1):1–7.
25. Notrica DM. Pediatric Blunt Solid Organ Injury: beyond the APSA Guidelines.
Curr Surg Rep. 2015;3(4):7.
26. Patrick DA, Bensard DD, Janik JS, et al. Is hypotension a reliable indicator of
blood loss from traumatic injury in children? The American Journal of Surgery.
2002;184(6):555–559.
27. Gardner AR, Diz DI, Tooze JA, et al. Injury patterns associated with hypotension
in pediatric trauma patients: a national trauma database review. J Trauma Acute
Care Surg. 2015;78(6):1143–1148.
28. Cotton BA, Beckert BW, Smith MK, et al. The utility of clinical and labo-
ratory data for predicting intraabdominal injury among children. J Trauma.
2004;56(5):1068–1074 discussion 74-5.
29. Streck Jr CJ, Jewett BM, Wahlquist AH, et al. Evaluation for intra-abdominal in-
jury in children after blunt torso trauma: can we reduce unnecessary abdom-
inal computed tomography by utilizing a clinical prediction model? J Trauma
Acute Care Surg. 2012;73(2):371–376 discussion 6.
30. Zeeshan M, Hamidi M, O’Keeffe T, et al. Pediatric Liver Injury: physical Ex-
amination, Fast and Serum Transaminases Can Serve as a Guide. J Surg Res.
2019;242:151–156.
31. Scaife ER, Rollins MD, Barnhart DC, et al. The role of focused abdominal
sonography for trauma (FAST) in pediatric trauma evaluation. J Pediatr Surg.
2013;48(6):1377–1383.
32. Sola JE, Cheung MC, Yang R, et al. Pediatric FAST and elevated liver transam-
inases: an effective screening tool in blunt abdominal trauma. J Surg Res.
2009;157(1):103–107.
33. Podberesky DJ, Angel E, Yoshizumi TT, et al. Comparison of radiation dose esti-
mates and scan performance in pediatric high-resolution thoracic CT for volu-
metric 320-detector row, helical 64-detector row, and noncontiguous axial scan
acquisitions. Acad Radiol. 2013;20(9):1152–1161.
34. Brody AS, Frush DP, Huda W, et al. American Academy of Pediatrics Sec-
tion on R. Radiation risk to children from computed tomography. Pediatrics .
2007;120(3):677–682.
35. Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in
childhood and subsequent risk of leukaemia and brain tumours: a retrospec-
tive cohort study. Lancet. 2012;380(9840):499–505.
36. Applegate KE, Cost NG. Image Gently: a campaign to reduce children’s and
adolescents’ risk for cancer during adulthood. J Adolesc Health. 2013;52(5
Suppl):S93–S97.
Downloaded for Ana Isabel Barros (ana1996barros@gmail.com) at Pedro Hispano Hospital from ClinicalKey.com by Elsevier on
January 30, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
37. St Peter SD, Keckler SJ, Spilde TL, et al. Justification for an abbreviated protocol
in the management of blunt spleen and liver injury in children. J Pediatr Surg.
2008;43(1):191–193 discussion 3-4.
38. Olthof DC, van der Vlies CH, Joosse P, et al. Consensus strategies for the non-
operative management of patients with blunt splenic injury: a Delphi study. J
Trauma Acute Care Surg. 2013;74(6):1567–1574.
39. Letton RW, Worrell V, ACoTBIIS Group. Delay in diagnosis and treatment of
blunt intestinal injury does not adversely affect prognosis in the pediatric
trauma patient. J Pediatr Surg. 2010;45(1):161–165 discussion 6.
40. Iqbal CW, St Peter SD, Tsao K, et al. Operative vs nonoperative management for
blunt pancreatic transection in children: multi-institutional outcomes. J Am Coll
Surg. 2014;218(2):157–162.
41. Davies DA, Fecteau A, Himidan S, et al. What’s the incidence of delayed splenic
bleeding in children after blunt trauma? An institutional experience and review
of the literature. J Trauma. 2009;67(3):573–577.
42. Acker SN, Ross JT, Partrick DA, et al. Pediatric specific shock index accurately
identifies severely injured children. J Pediatr Surg. 2015;50(2):331–334.
43. McVay MR, Kokoska ER, Jackson RJ, et al. Throwing out the "grade" book: man-
agement of isolated spleen and liver injury based on hemodynamic status. J
Pediatr Surg. 2008;43(6):1072–1076.
44. Duchesne JC, Heaney J, Guidry C, et al. Diluting the benefits of hemo-
static resuscitation: a multi-institutional analysis. J Trauma Acute Care Surg.
2013;75(1):76–82.
45. Fremgen HE, Bratton SL, Metzger RR, et al. Pediatric liver lacerations and
intensive care: evaluation of ICU triage strategies. Pediatr Crit Care Med.
2014;15(4):e183–e191.
46. Lacroix J, Hebert PC, Hutchison JS, et al. Transfusion strategies for patients in
pediatric intensive care units. N Engl J Med. 2007;356(16):1609–1619.
47. Holmes JHt, Wiebe DJ, Tataria M, et al. The failure of nonoperative manage-
ment in pediatric solid organ injury: a multi-institutional experience. J Trauma.
2005;59(6):1309–1313.
48. Golden J, Mitchell I, Kuzniewski S, et al. Reducing scheduled phlebotomy
in stable pediatric patients with blunt liver or spleen injury. J Pediatr Surg.
2014;49(5):759–762.
49. Dodgion CM, Gosain A, Rogers A, et al. National trends in pediatric blunt spleen
and liver injury management and potential benefits of an abbreviated bed rest
protocol. J Pediatr Surg. 2014;49(6):1004–1008 discussion 8.
50. Berman SS, Mooney EK, Weireter Jr LJ. Late fatal hemorrhage in pediatric liver
trauma. J Pediatr Surg. 1992;27(12):1546–1548.
51. van der Vlies CH, Saltzherr TP, Wilde JC, et al. The failure rate of non-
operative management in children with splenic or liver injury with con-
trast blush on computed tomography: a systematic review. J Pediatr Surg.
2010;45(5):1044–1049.
52. Nwomeh BC, Nadler EP, Meza MP, et al. Contrast extravasation predicts the
need for operative intervention in children with blunt splenic trauma. J Trauma.
2004;56(3):537–541.
53. Potoka DA, Schall LC, Ford HR. Risk factors for splenectomy in children with
blunt splenic trauma. J Pediatr Surg. 2002;37(3):294–299.
54. Mehall JR, Ennis JS, Saltzman DA, et al. Prospective results of a standardized
algorithm based on hemodynamic status for managing pediatric solid organ
injury. J Am Coll Surg. 2001;193(4):347–353.
55. Acker SN, Ross JT, Partrick DA, et al. Injured children are resistant to the
adverse effects of early high volume crystalloid resuscitation. J Pediatr Surg.
2014;49(12):1852–1855.
56. Duchesne JC, Islam TM, Stuke L, et al. Hemostatic resuscitation during surgery
improves survival in patients with traumatic-induced coagulopathy. J Trauma.
2009;67(1):33–37 discussion 7-9.
57. Nosanov L, Inaba K, Okoye O, et al. The impact of blood product ratios in mas-
sively transfused pediatric trauma patients. Am J Surg. 2013;206(5):655–660.
58. Neff LP, Cannon JW, Morrison JJ, et al. Clearly defining pediatric massive trans-
fusion: cutting through the fog and friction with combat data. J Trauma Acute
Care Surg. 2015;78(1):22–28 discussion 8-9.
59. Rogers CG, Knight V, MacUra KJ, et al. High-grade renal injuries in children–is
conservative management possible? Urology . 2004;64(3):574–579.
60. Pryor JP, Stafford PW, Nance ML. Severe blunt hepatic trauma in children. J
Pediatr Surg. 2001;36(7):974–979.
61. Landau A, van As AB, Numanoglu A, et al. Liver injuries in children: the role of
selective non-operative management. Injury . 2006;37(1):66–71.
62. Nance ML, Holmes JHt, Wiebe DJ. Timeline to operative intervention for solid
organ injuries in children. J Trauma. 2006;61(6):1389–1392.
63. Bowman SM, Zimmerman FJ, Christakis DA, et al. The role of hospital profit
status in pediatric spleen injury management. Med Care. 2008;46(3):331–338.
64. Fallon SC, Coker MT, Hernandez JA, et al. Traumatic hepatic artery laceration
managed by transarterial embolization in a pediatric patient. J Pediatr Surg.
2013;48(5):E9–12.
65. Ong CC, Toh L, Lo RH, et al. Primary hepatic artery embolization in pediatric
blunt hepatic trauma. J Pediatr Surg. 2012;47(12):2316–2320.
66. Duron VP, Day KM, Steigman SA, et al. Maintaining low transfusion and an-
gioembolization rates in the age of nonoperative management of pediatric
blunt splenic injury. Am Surg. 2014;80(11):1159–1163.
67. Sweed Y, Engel A, Halberthal M. [Effectiveness of selective hepatic
artery embolization in a child after blunt hepatic trauma]. Harefuah .
1997;132(4):252–254 312, 1.
68. Monnin V, Sengel C, Thony F, et al. Place of arterial embolization in severe
blunt hepatic trauma: a multidisciplinary approach. Cardiovasc Intervent Radiol.
2008;31(5):875–882.
 V. Duron and S. Stylianos / Seminars in Pediatric Surgery 29 (2020) 150949
69. Lee J, Moriarty KP, Tashjian DB. Less is more: management of pediatric splenic
injury. Arch Surg. 2012;147(5):437–441.
70. Davies DA, Ein SH, Pearl R, et al. What is the significance of contrast "blush" in
pediatric blunt splenic trauma? J Pediatr Surg. 2010;45(5):916–920.
71. Cloutier DR, Baird TB, Gormley P, et al. Pediatric splenic injuries with a con-
trast blush: successful nonoperative management without angiography and
embolization. J Pediatr Surg. 2004;39(6):969–971.
72. Giss SR, Dobrilovic N, Brown RL, et al. Complications of nonoperative manage-
ment of pediatric blunt hepatic injury: diagnosis, management, and outcomes.
J Trauma. 2006;61(2):334–339.
73. Kulaylat AN, Stokes AL, Engbrecht BW, et al. Traumatic bile leaks from blunt
liver injury in children: a multidisciplinary and minimally invasive approach to
management. J Pediatr Surg. 2014;49(3):424–427.
74. Dabbs DN, Stein DM, Scalea TM. Major hepatic necrosis: a common com-
plication after angioembolization for treatment of high-grade liver injuries. J
Trauma. 2009;66(3):621–627 discussion 7-9.
75. Polanco P, Leon S, Pineda J, et al. Hepatic resection in the management of com-
plex injury to the liver. J Trauma. 2008;65(6):1264–1269 discussion 9-70.
76. Asensio JA, Demetriades D, Chahwan S, et al. Approach to the management of
complex hepatic injuries. J Trauma. 20 0 0;48(1):66–69.
77. Beal SL. Fatal hepatic hemorrhage: an unresolved problem in the management
of complex liver injuries. J Trauma. 1990;30(2):163–169.
78. Buckman Jr RF, Miraliakbari R, Badellino MM. Juxtahepatic venous in-
juries: a critical review of reported management strategies. J Trauma.
20 0 0;48(5):978–984.
79. Chen RJ, Fang JF, Lin BC, et al. Surgical management of juxtahepatic venous
injuries in blunt hepatic trauma. J Trauma. 1995;38(6):886–890.
80. Committee ACoSCoTLSS. Operative Exposure in Abdominal Trauma: Exposure
of Liver Injuries. ASSET (Advanced Surgical Skills for Exposure in Trauma) Lab
Manual. American College of Surgeons.
Downloaded for Ana Isabel Barros (ana1996barros@gmail.com) at Pedro Hispano Hospital from ClinicalKey.com by Elsevier on
January 30, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
9
81. Peitzman AB, Marsh JW. Advanced operative techniques in the management of
complex liver injury. J Trauma Acute Care Surg. 2012;73(3):765–770.
82. Latifi R, Khalaf H. Selective vascular isolation of the liver as part of initial dam-
age control for grade 5 liver injuries: shouldn’t we use it more frequently? Int
J Surg Case Rep. 2015;6C:292–295.
83. Pachter HL. Prometheus bound: evolution in the management of hepatic trau-
ma–from myth to reality. J Trauma Acute Care Surg. 2012;72(2):321–329.
84. Moore LJ, Brenner M, Kozar RA, et al. Implementation of resuscitative endovas-
cular balloon occlusion of the aorta as an alternative to resuscitative thora-
cotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg.
2015;79(4):523–530 discussion 30-2.
85. Cocanour CS. Blunt splenic injury. Curr Opin Crit Care. 2010;16(6):575–581.
86. Fisher JC, Moulton SL. Nonoperative management and delayed hemor-
rhage after pediatric liver injury: new issues to consider. J Pediatr Surg.
2004;39(4):619–622.
87. Durkin N, Deganello A, Sellars ME, et al. Post-traumatic liver and splenic pseu-
doaneurysms in children: diagnosis, management, and follow-up screening us-
ing contrast enhanced ultrasound (CEUS). J Pediatr Surg. 2016;51(2):289–292.
88. Soukup ES, Russell KW, Metzger R, et al. Treatment and outcome of traumatic
biliary injuries in children. J Pediatr Surg. 2014;49(2):345–348.
89. Forlee MV, Krige JE, Welman CJ, et al. Haemobilia after penetrating and blunt
liver injury: treatment with selective hepatic artery embolisation. Injury .
2004;35(1):23–28.
90. Safavi A, Beaudry P, Jamieson D, et al. Traumatic pseudoaneurysms of the
liver and spleen in children: is routine screening warranted? J Pediatr Surg.
2011;46(5):938–941.