P. Dasari1, G. P. Wools2, L. S. Burkhalter2, F. G. Qureshi1,2 1University Of Texas Southwestern Medical Center,Pediatric Surgery,Dallas, TX, USA 2Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA
Introduction:
Management of blunt traumatic Retroperitoneal Hematomas (RPH) in adults is dependent on anatomical classification. Zone 1 is central, contains the aorta, inferior vena cava, renal vessel origins, partial duodenum/pancreas and requires mandatory exploration. Zone 2 includes the paranephric areas, renal vessels, kidneys, ureters, adrenals/colon and is explored for expanding hematoma. Zone 3 includes iliac vessels, distal ureters, sigmoid/ rectum and may need surgical or radiologic interventional. This strategy has been used in children but has not been studied. The aim of this study is to evaluate the management and outcome of children with retroperitoneal hematomas after blunt trauma.
Methods:
With IRB approval, 10 year (2007-2016) retrospective review of all children with RPH from blunt trauma was performed. RPH zone was determined by imaging and/or operative findings. Mechanism of injury, laparotomy, RPH explorations, and outcomes were collected. Descriptive statistics provided mean, standard deviation, median and range. Comparative statistics identified univariate correlations using Fischer’s exact test.
Results:
We identified 32 patients (84% male, mean age 10±4) with 43 RPH injuries, 14 zone 1, 25 zone 2 and 4 zone 3 injuries (table 1). Mechanisms included motor vehicle collision (75%), struck by object (19%), and pedestrian struck (6%). Nine (28%) patients were unstable on arrival and two expired in the emergency room. Laparotomy was performed in 17 patients, 10 immediately for instability, shock or peritonitis. 13 (30%) RPH zone injuries were explored; two zone 1, nine zone 2 and two zone 3. Four zone explorations required intervention: none in zone 1, four zone 2 (three nephrectomies, one packing) and none in zone 3. RPH exploration had no post-operative surgical complications. Overall mortality was five (16%): two zone 1 before laparotomy (traumatic brain injury, TBI); two zone 1 after laparotomy (TBI and uncontrolled liver hemorrhage); and one zone 2 after laparotomy from chest injury. Mortality was higher in unstable patients (p=0.0006). No mortality occurred from RPH exsanguination and RPH exploration did not impact mortality.
Conclusion:
Only a third of pediatric RPH injuries were explored which identified injuries requiring intervention in zone 2 but not zone 1 or 3. RPH injury in children may require a different treatment paradigm compared to adults. Zone 1 injuries in an otherwise stable pediatric patient without peritonitis may benefit from non-operative management. Further larger scale studies will be required to understand the role of surgical intervention in RPH injury in children.
