Behandlungsstrategien bei Verletzungen von Milz und Leber im Kindesalter

 

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Zusammenfassung

Verletzungen von Milz und Leber im Kindesalter werden durch alterstypische Stürze, Sport- oder Verkehrsunfälle verursacht. Bei isolierten Verletzungen hat sich die nicht operative Therapie (NOM) etabliert und es stehen evidenzbasierte Leitlinien zur Verfügung. Die Kompression der Organe durch die geschlossene Bauchdecke im begrenzten intraabdominellen Raum ist die pathophysiologische Erklärung für das Sistieren der Blutung. Voraussetzung für eine nichtoperative Therapie ist die bildgestützte Klassifikation der Verletzungen nach der Organ Injury Scale (OIS) und ein hämodynamisch stabiler Patient. Die Kreislaufstabilität des Patienten wird – falls notwendig – durch Bluttransfusionen, Volumensubstitution und Katecholamine gewährleistet. Bei Gefäßstielabrissen, kompletten Devaskularisierungen mit fehlendem Perfusionsnachweis oder bei instabilen Patienten – trotz Ausreizung der konservativen Therapiemaßnahmen – ist die notfallmäßige operative Therapie zwingend. Bei dieser hat die organerhaltende Chirurgie für Milz und Leber einen hohen Stellenwert. Insbesondere im Wachstumsalter ist die Milz essenziell für die Ausbildung der immunologischen Kompetenz. Die Leberruptur kann durch Verletzungen der Gallengangstrukturen kompliziert sein, die einer operativen Rekonstruktion bedürfen. Handelt es sich um eine Milz- oder Leberverletzung im Rahmen einer Mehrfachverletzung oder eines Polytraumas, so muss eine individuelle Therapieentscheidung getroffen werden. Hierfür existieren keine evaluierten Therapierichtlinien und die Rate der operativen Maßnahmen steigt. Für alle Verletzungsarten gilt, dass der kindertraumatologisch spezialisierte Chirurg durch seine Kenntnisse über anatomische und altersspezifische Besonderheiten des verletzten Kindes im multidisziplinären Team die besten Therapieergebnisse erzielt.

Abstract

Traumatic injuries of the spleen and liver are typically caused by age-related falls or sports and traffic accidents. Today, the non-operative management for isolated injuries is established and evidence-based guidelines are available. The intact abdominal wall and the limited space within the peritoneum produce a compression which is the pathophysiological explanation for the limitation of the haemorrhage. Precondition for the non-operative therapy is the radiology-based classification of the injury (organ injury scale) and a haemodynamically stable patient. Haemodynamic stability is, if necessary maintained with blood transfusion, volume substitutes and the administration of catecholamines. In cases of hilar vascular injury and devascularisation or haemodynamic instability of the patient, despite utilisation of the measures mentioned above, urgent operative therapy needs to be performed. Organ sparing surgery is the therapy of choice for both liver and spleen. The spleen is required for the development of a competent immune system in the growing organism. Liver injuries can be further complicated by injury to the bile system, which might require operative reconstruction. If a patient suffers from multiple injuries and spleen or liver are involved, the decision on the management needs to be taken individually, no guidelines exist but the rate for operative therapy increases. Independent of the dimensions of injury, an experienced paediatric surgeon with his multidisciplinary team, considering the anatomic and age specific characteristics of a child, achieves the best therapeutic results.

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