Abdominal injuries in children

The problem of abdominal trauma in children is briefly reviewed to show how the etiology, diagnosis and treatment differ from those in adults. Although in many ways management is the same in both groups, certain problems more commonly affect children, and the approach to diagnosis and treatment must be adapted to their needs. The importance of frequent clinical assessment and the rather limited role of peritoneal lavage in children with abdominal trauma are stressed. Experience with splenic injuries in 63 patients treated between 1974 and 1979 is reviewed to provide guidelines for conservative management to assist surgeons who seldom treat children. Since splenectomy in pediatric patients carries a risk of overwhelming infection, distinguishing those whose spleens can be salvaged is extremely important.

Blunt splenic trauma: diagnosis and management

To examine the morbidity and mortality associated with blunt splenic injuries, the authors reviewed the results in 106 such patients treated in the Sunnybrook Regional Trauma Unit between June 1, 1976 and June 30, 1983. Initial assessment included peritoneal lavage in 86 patients. No patient with known or suspected splenic injury was treated nonoperatively nor were any patients found to have had splenic injuries missed at the initial assessment. Seventy-one splenectomies and 35 splenorrhaphies were performed. The overall mortality was 25% and 10 surviving patients had serious complications. The splenic injury itself was never the cause of death. Only one patient who initially underwent splenorrhaphy later required splenectomy. It is concluded that blunt splenic injury is rarely the cause of death or serious morbidity when a policy of immediate diagnosis and operative treatment is carried out. Furthermore, in selected patients, splenorrhaphy is a safe and effective treatment.

Splenogonadal relation

The gonad-related accessory spleen is a rare anomaly. We report an unusual variant of this condition, featuring two accessory spleens - inguinal and scrotal. This anomaly is important in the differential diagnosis of mass lesions, and the surgical implications are discussed.

[Injuries of the pancreas]

During the period 1968-1982, thirteen patients were treated surgically for a posttraumatic lesion of the pancreas. Eleven of them had a blunt abdominal trauma. These series of 13 patients show the diagnostic difficulties of the pancreatic lesion, often minimised or even missed. An open abdominal trauma needs an immediate exploration; surgery in blunt abdominal trauma is guided by biology, ultrasonography and scanning. ERCP may be very useful in these difficult cases. All different types of pancreatic lesions, divided into immediate and late sequelae are illustrated. Their appropriate treatment will be discussed. Good results can only be achieved if primary treatment of the pancreatic trauma is adequate and radical.

[Isolation of islet cell transplants and their efficiency in various host organs]

Pancreatic islets were isolated and transplanted in various forms into the spleen, kidney or liver of totally pancreatectomized dogs. After proving viability the endocrine efficiency was documented. According to the histological findings the best results can be obtained by grafting intrahepatically . The impact on human islet transplantation is considered.

Nonoperative management of splenic trauma. Conservative or radical treatment?

In a four-year experience with selective nonoperative management of splenic trauma in adults and children, 24 (35%) of 68 patients with documented splenic trauma were initially treated nonoperatively. In only one patient was an operation and laparotomy ultimately required. There was no morbidity or mortality in the nonoperative group. In the operative group (44 patients), 4% died after operation, largely of multiple injuries. Confirmation of splenic injury and follow-up of patients were mostly performed by splenic scintiscans. There was no significant difference in length of hospitalization between operative and nonoperative groups. Operative splenic repair and preservation of the spleen to prevent postsplenectomy sepsis often requires considerable experience and may be a lengthy, tedious procedure. Nonoperative therapy in adults and children is an attractive alternative in a selective group of patients.

[Wandering spleen. Apropos of a case in a 4-year-old girl]

The case of a 4 year-old girl with ectopic spleen is reported. The diagnostic values of ultrasonography and scintigraphy are emphasized.

Splenic preservation

The current principle of splenic preservation in both adults and children is now well accepted, and the reason for this is outlined. The surgical anatomy is briefly discussed and a method of handling the patient with splenic trauma is described. Splenic preservation is vital as regards protection of the child against infection, both in cases involving trauma and for other conditions previously treated by splenectomy.

Long-term follow-up result of portopulmonary shunt by splenopneumopexy on membranous obstruction of the inferior vena cava

A patient with membranous obstruction of the inferior vena cava (MOVC) who underwent portopulmonary shunting by splenopneumopexy 13 years before developed hepatocellular carcinoma (HCC). Postmortem studies revealed HCC in the bilateral lobes of the liver with cirrhosis and complete MOVC. There were numerous new vessel formations in the portion of the splenopneumopexy, which proved persistence of the patency. Clinically, postshunt encephalopathy, hepatic deterioration, and cardiac-respiratory dysfunction in the long-term follow-up period were not noticed. Factors that contributed to the occurrence of HCC are also discussed.

Splenic repair by fibrin tissue adhesive and collagen fleece

A new biogenic tissue adhesive has been used for repair of traumatic and incidental splenic lesions in 108 patients. The theoretical basis of fibrin adhesive application and technical details of this method, including the combination with a collagen fleece, are described. Complete hemostasis was achieved in 100 patients. In incidental splenic lesions the success rate of the method was 94%, and the overall salvage rate 87%. The corresponding figures for traumatic lesions were 87% and 60%, respectively. Postoperative complications developed in five patients, necessitating relaparotomy in four. In three of these patients complications were not related to the splenic repair. It can be concluded that the use of fibrin tissue adhesive is a safe and reliable method for repair in the majority of incidental and traumatic splenic injuries.