Prevalence of non-operative management failure in pediatric patients with traumatic abdominal solid organ injuries: A systematic review and meta-analysis

Abstract

Background: Abdominal solid organ (ASO) trauma of the spleen, kidney, and liver is common in children and often accompanies other traumatic injuries, posing significant clinical challenges. Non-operative management (NOM) is preferred according to current guidelines for both low- and high-grade lesions when hemodynamic stability is achievable. Aggressive surgical treatment can lead to chronic organ dysfunction, surgical related complications and long-term sequelae, while NOM failure may result in critical bleeding and multiorgan failure. This systematic review aimed to describe the prevalence of NOM failure in pediatric patients with traumatic ASO injuries and its predictors.

Methods: A systematic literature search was conducted in PubMed, Scopus, and Cochrane Library from inception to August 2024. Studies were extracted for the prevalence of NOM failure and prespecified predictors. Study quality was assessed using the Joanna Briggs Institute's critical appraisal tool for prevalence reporting. A proportion meta-analysis provided a pooled estimate of NOM failure. Subgroup analysis for specific organs and meta-regressions for candidate predictors was performed. Multimodel inference estimated predictor importance in multivariable modeling.

Results: The search yielded 67 studies evaluating the NOM course of 37,340 children. The pooled prevalence of NOM failure was 0.04 (95 % CI: 0.03-0.06). Multimodel inference showed that NOM failure prevalence increased with higher injury severity score (ISS), AAST grade, and age. The confidence in these results was rated moderate. Complications had a pooled prevalence of 0.09 and missed injuries 0.03.

Conclusions: NOM failure in pediatric post-traumatic ASO injuries is relatively infrequent, with high organ salvage rates achievable even in high-grade and multisystem trauma. Younger children achieve higher NOM success, suggesting potential for more conservative strategies. Complications requiring non-surgical interventions and missed injuries are not negligible, indicating the need for strict monitoring, in particular if aggressive preservation is the objective.

Keywords: Abdominal injuries; Multiple trauma; Splenic rupture; Trauma centers; Trauma severity indices.