Surgeon choice in management of pediatric abdominal trauma

Abstract

Background: No guidelines exist for management of hemodynamically stable children with suspected hollow viscus injury. We sought to determine factors contributing to surgeon management of these patients.

Methods: Surgeon members of the Eastern Association for the Surgery of Trauma and American Pediatric Surgical Association completed a survey on 3 blunt abdominal injury scenarios: (1) isolated, (2) with multisystem injury, and (3) with traumatic brain injury (TBI), and a penetrating injury scenario. Multivariable logistic regression was used to determine factors associated with initial management of observation vs. operation for blunt injury and observation vs. local wound exploration versus laparoscopy for penetrating injury.

Results: Of 394 surgeons (response rate 22.3%), 50.3% were pediatric surgeons. For scenarios 1-3, 32.2%, 49.3%, and 60.7% of surgeons chose operation over observation, respectively. Compared to isolated blunt injury, surgeons were more likely to choose operation for patients with multisystem injury (aOR 2.20, 95%CI: 1.78-2.72) or TBI (aOR 3.60, 95%CI: 2.79-4.66). Pediatric surgeons were less likely to choose operation (aOR 0.32, 95%CI: 0.22-0.44). For penetrating injury, 39.1%, 29.5%, and 31.5% of surgeons chose observation, local wound exploration, and laparoscopy, respectively.

Conclusions: Large variation exists in management of hemodynamically stable children with suspected hollow viscus injury. Although patient injury characteristics account for some variation, surgeon factors such as type of surgeon also play a role. Evidence-based practice guidelines should be developed to standardize care.

Type of study: Cross-Sectional Survey.

Level of evidence: N/A.

Keywords: Abdominal trauma; Children; Hollow viscus injury; Laparoscopy; Non-operative management; Surgeon type.

Figure 1.

Choice of surgeons in management of children with blunt abdominal injury. In each case, proportions are shown from top to bottom as: immediate exploratory laparotomy, immediate diagnostic laparoscopy, observation followed by exploratory laparotomy, and observation followed by diagnostic laparoscopy.

Figure 2.

Choice of surgeons in management of a child with penetrating abdominal injury.

Figure 3.

Reasons for choice of (A) laparoscopy or (B) laparotomy in management of children with abdominal trauma.

Figure 4.

Reasons for conversion to laparotomy in a child with blunt abdominal trauma.