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Su YC, Ou CY, Yang TH, Hung KS, Wu CH, Wang CJ, Yen YT, Shan YS. Abdominal pain is a main manifestation of delayed bleeding after splenic injury in patients receiving non-operative management. Sci Rep 2022; 12:19871. [PMID: 36400820 PMCID: PMC9674598 DOI: 10.1038/s41598-022-24399-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022] Open
Abstract
Delayed bleeding is a major issue in patients with high-grade splenic injuries who receive non-operative management (NOM). While only few studies addressed the clinical manifestations of delayed bleeding in these patients. We reviewed the patients with high-grade splenic injuries presented with delayed bleeding, defined as the need for salvage procedures following NOM. There were 138 patients received NOM in study period. Fourteen of 107 patients in the SAE group and 3 of 31 patients in the non-embolization group had delayed bleeding. Among the 17 delayed bleeding episodes, 6 and 11 patients were salvaged by splenectomy and SAE, respectively. Ten (58.9%, 10/17) patients experienced bleeding episodes in the intensive care unit (ICU), whereas seven (41.1%, 7/17) experienced those in the ward or at home. The clinical manifestations of delayed bleeding were a decline in haemoglobin levels (47.1%, 8/17), hypotension (35.3%, 6/17), tachycardia (47.1%, 8/17), new abdominal pain (29.4%, 5/17), and worsening abdominal pain (17.6%, 3/17). For the bleeding episodes detected in the ICU, a decline in haemoglobin (60%, 6/10) was the main manifestation. New abdominal pain (71.43%, 5/7) was the main presentation when the patients left the ICU. In conclusion, abdominal pain was the main early clinical presentation of delayed bleeding following discharge from the ICU or hospital.
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Affiliation(s)
- Yu-Cheng Su
- grid.64523.360000 0004 0532 3255School of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chia-Yu Ou
- grid.64523.360000 0004 0532 3255Department of Surgery, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Tsung-Han Yang
- grid.64523.360000 0004 0532 3255Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, No. 138, Sheng Li Road, Tainan, Taiwan
| | - Kuo-Shu Hung
- grid.64523.360000 0004 0532 3255Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, No. 138, Sheng Li Road, Tainan, Taiwan
| | - Chun-Hsien Wu
- grid.412040.30000 0004 0639 0054Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chih-Jung Wang
- grid.64523.360000 0004 0532 3255Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, No. 138, Sheng Li Road, Tainan, Taiwan
| | - Yi-Ting Yen
- grid.64523.360000 0004 0532 3255Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, No. 138, Sheng Li Road, Tainan, Taiwan
| | - Yan-Shen Shan
- grid.412040.30000 0004 0639 0054Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan ,grid.64523.360000 0004 0532 3255Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Boscà-Ramon A, Ratnam L, Cavenagh T, Chun JY, Morgan R, Gonsalves M, Das R, Ameli-Renani S, Pavlidis V, Hawthorn B, Ntagiantas N, Mailli L. Impact of site of occlusion in proximal splenic artery embolisation for blunt splenic trauma. CVIR Endovasc 2022; 5:43. [PMID: 35986797 PMCID: PMC9391208 DOI: 10.1186/s42155-022-00315-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/29/2022] [Indexed: 11/29/2022] Open
Abstract
Background Proximal splenic artery embolisation (PSAE) can be performed in stable patients with Association for the Surgery of Trauma (AAST) grade III-V splenic injury. PSAE reduces splenic perfusion but maintains viability of the spleen and pancreas via the collateral circulation. The hypothesized ideal location is between the dorsal pancreatic artery (DPA) and great pancreatic artery (GPA). This study compares the outcomes resulting from PSAE embolisation in different locations along the splenic artery. Materials and methods Retrospective review was performed of PSAE for blunt splenic trauma (2015–2020). Embolisation locations were divided into: Type I, proximal to DPA; Type II, DPA-GPA; Type III, distal to GPA. Fifty-eight patients underwent 59 PSAE: Type I (7); Type II (27); Type III (25). Data was collected on technical and clinical success, post-embolisation pancreatitis and splenic perfusion. Statistical significance was assessed using a chi-squared test. Results Technical success was achieved in 100% of cases. Clinical success was 100% for Type I/II embolisation and 88% for Type III: one patient underwent reintervention and two had splenectomies for ongoing instability. Clinical success was significantly higher in Type II embolisation compared to Type III (p = 0.02). No episodes of pancreatitis occurred post-embolisation. Where post-procedural imaging was obtained, splenic perfusion remained 100% in Type I and II embolisation and 94% in Type III. Splenic perfusion was significantly higher in the theorized ideal Type II group compared to Type I and III combined (p = 0.01). Conclusion The results support the proposed optimal embolisation location as being between the DPA and GPA.
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Dreizin D, Yu T, Motley K, Li G, Morrison JJ, Liang Y. Blunt splenic injury: Assessment of follow-up CT utility using quantitative volumetry. FRONTIERS IN RADIOLOGY 2022; 2. [PMID: 36120383 PMCID: PMC9479763 DOI: 10.3389/fradi.2022.941863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose: Trials of non-operative management (NOM) have become the standard of care for blunt splenic injury (BSI) in hemodynamically stable patients. However, there is a lack of consensus regarding the utility of follow-up CT exams and relevant CT features. The purpose of this study is to determine imaging predictors of splenectomy on follow-up CT using quantitative volumetric measurements. Methods: Adult patients who underwent a trial of non-operative management (NOM) with follow-up CT performed for BSI between 2017 and 2019 were included (n = 51). Six patients (12% of cohort) underwent splenectomy; 45 underwent successful splenic salvage. Voxelwise measurements of splenic laceration, hemoperitoneum, and subcapsular hematoma were derived from portal venous phase images of admission and follow-up scans using 3D slicer. Presence/absence of pseudoaneurysm on admission and follow-up CT was assessed using arterial phase images. Multivariable logistic regression was used to determine independent predictors of decision to perform splenectomy. Results: Factors significantly associated with splenectomy in bivariate analysis incorporated in multivariate logistic regression included final hemoperitoneum volume (p = 0.003), final subcapsular hematoma volume (p = 0.001), change in subcapsular hematoma volume between scans (p = 0.09) and new/persistent pseudoaneurysm (p = 0.003). Independent predictors of splenectomy in the logistic regression were final hemoperitoneum volume (unit OR = 1.43 for each 100 mL change; 95% CI: 0.99–2.06) and new/persistent pseudoaneurysm (OR = 160.3; 95% CI: 0.91–28315.3). The AUC of the model incorporating both variables was significantly higher than AAST grading (0.91 vs. 0.59, p = 0.025). Mean combined effective dose for admission and follow up CT scans was 37.4 mSv. Conclusion: Follow-up CT provides clinically valuable information regarding the decision to perform splenectomy in BSI patients managed non-operatively. Hemoperitoneum volume and new or persistent pseudoaneurysm at follow-up are independent predictors of splenectomy.
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Affiliation(s)
- David Dreizin
- Trauma and Emergency Radiology, Department of Diagnostic Radiology and Nuclear Medicine, School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, United States
- CORRESPONDENCE: David Dreizin
| | - Theresa Yu
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Kaitlynn Motley
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Guang Li
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Jonathan J. Morrison
- Vascular Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Yuanyuan Liang
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
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Erez L, Schiby G, Amiel I, Naor S, Keren N, Rosin D, Barshack I, Canaani J. Association of Preoperative Clinical, Laboratory, Imaging, and Pathologic Data With Clinically Beneficial Pathology Among Routine Splenectomy Specimens. JAMA Netw Open 2021; 4:e2120946. [PMID: 34398203 PMCID: PMC8369355 DOI: 10.1001/jamanetworkopen.2021.20946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Previous studies have shown that uniform pathologic review of all splenectomy surgical specimens reveals new clinically actionable diagnoses only in a minority of cases. OBJECTIVE To examine whether the aggregate of clinical, laboratory, imaging, and pathologic preoperative data is associated with a clinically beneficial pathologic study for routine splenectomy surgical specimens. DESIGN, SETTING, AND PARTICIPANTS This single-center retrospective cohort study included all patients who underwent splenectomy from January 1, 2013, through December 31, 2018, at a single center. Clinical, imaging, and pathologic data were extracted from the institution's electronic medical records system. Data analysis was conducted from June to November 2020. EXPOSURES Undergoing splenectomy for trauma or diagnostic or therapeutic indications. MAIN OUTCOMES AND MEASURES Spleen pathology study resulting in a new medical diagnosis or change in medical management. RESULTS Overall, 90 patients (53 [59%] men) with a median (range) age of 59 (19-90) years underwent splenectomy for therapeutic purposes in 41 patients (45%), trauma in 24 patients (27%), diagnostic purposes in 15 patients (17%), and combined therapeutic and diagnostic purposes in 9 patients (10%). In 14 patients (15%) a new malignant neoplasm was found, and in 8 patients (9%), a new nonneoplastic medical condition was diagnosed. A new pathologic diagnosis resulted in change in medical management in 16 patients (18%). In patients without a prior diagnosis of cancer, 41 of 56 pathology biopsies (73%) were found to be normal whereas in 7 biopsies (13%), a new diagnosis of a hematologic malignant neoplasm was revealed (P < .001). Patients with clinical splenomegaly were significantly more likely to have a new pathologic diagnosis of cancer compared with patients without splenomegaly (15 of 26 [58%] vs 4 of 64 [7%]; P < .001). In 39 of 43 patients (91%) with normal presurgery imaging studies, normal spleen pathology was revealed, whereas in 14 of 17 patients (82%) with abnormal imaging studies, a new hematological malignant neoplasm was diagnosed following pathologic review of the spleen specimen (P < .001). Patients with gross abnormalities on macroscopic examination had a significantly increased likelihood of a hematological cancer diagnosis (17 of 40 [43%]) and a solid cancer diagnosis (4 [10%]) compared with patients with grossly normal specimens (4 of 49 [8%]; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study, routine pathologic review of spleen specimens was clinically beneficial in patients with splenomegaly, abnormal imaging results, a prior diagnosis of cancer, and with grossly abnormal spleens.
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Affiliation(s)
- Lee Erez
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ginette Schiby
- Department of Pathology, Chaim Sheba Medical Center, Tel-Hashomer, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Imri Amiel
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shachar Naor
- Department of Pathology, Chaim Sheba Medical Center, Tel-Hashomer, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Keren
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Danny Rosin
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iris Barshack
- Department of Pathology, Chaim Sheba Medical Center, Tel-Hashomer, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Canaani
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Rong JJ, Liang M, Xuan FQ, Sun JY, Zhao LJ, Zheng HZ, Tian XX, Liu D, Zhang QY, Peng CF, Li F, Wang XZ, Han YL, Yu WT. Thrombin-loaded alginate-calcium microspheres: A novel hemostatic embolic material for transcatheter arterial embolization. Int J Biol Macromol 2017; 104:1302-1312. [DOI: 10.1016/j.ijbiomac.2017.03.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 02/24/2017] [Accepted: 03/03/2017] [Indexed: 11/27/2022]
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Auto-Transplantation of Splenic Fragments After Total Splenectomy in Patients with Severe Splenic Trauma Lesions: A Clinical Study. Trauma Mon 2017. [DOI: 10.5812/traumamon.63242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Fair KA, Connelly CR, Hart KD, Schreiber MA, Watters JM. Splenectomy is associated with higher infection and pneumonia rates among trauma laparotomy patients. Am J Surg 2017; 213:856-861. [PMID: 28433229 DOI: 10.1016/j.amjsurg.2017.04.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/09/2017] [Accepted: 04/01/2017] [Indexed: 12/13/2022]
Abstract
Splenectomy increases lifetime risk of thromboembolism (VTE) and is associated with long-term infectious complications, primarily, overwhelming post-splenectomy infection (OPSI). Our objective was to evaluate risk of VTE and infection at index hospitalization post-splenectomy. Retrospective review of all patients who received a laparotomy in the NTDB. Propensity score matching for splenectomy was performed, based on ISS, abdominal abbreviated injury score >3, GCS, sex and mechanism. Major complications, VTE, and infection rates were compared. Multiple logistic regression models were utilized to evaluate splenectomy-associated complications. 93,221 laparotomies were performed and 17% underwent splenectomy. Multiple logistic regression models did not demonstrate an association between splenectomy and major complications (OR 0.96, 95% CI 0.91-1.03, p = 0.25) or VTE (OR 1.05, 95% CI 0.96-1.14, p = 0.33). Splenectomy was independently associated with infection (OR 1.07, 95% CI 1.00-1.14, p = 0.045). Subgroup analysis of patients with infection demonstrated that splenectomy was most strongly associated with pneumonia (OR 1.41, 95% CI 1.26-1.57, p < 0.001). Splenectomy is not associated with higher overall complication or VTE rates during index hospitalization. However, splenectomy is associated with a higher rate of pneumonia.
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Affiliation(s)
- Kelly A Fair
- Oregon Health & Science University, Division of Trauma and Acute Care Surgery, Portland, OR, USA.
| | - Christopher R Connelly
- Oregon Health & Science University, Division of Trauma and Acute Care Surgery, Portland, OR, USA
| | - Kyle D Hart
- Oregon Health & Science University, Division of Trauma and Acute Care Surgery, Portland, OR, USA
| | - Martin A Schreiber
- Oregon Health & Science University, Division of Trauma and Acute Care Surgery, Portland, OR, USA
| | - Jennifer M Watters
- Oregon Health & Science University, Division of Trauma and Acute Care Surgery, Portland, OR, USA
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9
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Abstract
OBJECTIVE The purpose of this article is to define the role of splenic embolization in trauma patients and in patients presenting for treatment of thrombocytopenia and portal hypertension. This article reviews the indications, technical considerations, outcomes, and complications of splenic artery embolization. CONCLUSION Transcatheter splenic artery embolization has a major role in the management of traumatic splenic injuries and as an adjunctive procedure in the treatment of thrombocytopenia and portal hypertension.
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Wagner P, Marshall D, Aldred B. An Unusual Case of Hypotension and Electrocardiographic Changes. Air Med J 2015; 34:292-294. [PMID: 26354307 DOI: 10.1016/j.amj.2015.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 04/07/2015] [Accepted: 04/29/2015] [Indexed: 06/05/2023]
Affiliation(s)
| | - Dawn Marshall
- Rosalind Franklin University of Medicine and Science, North Chicago, IL
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11
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Affiliation(s)
- G Martin
- Service de chirurgie digestive, CHU Estaing, place Lucie-Aubrac, 63003 Clermont-Ferrand, France.
| | - K Slim
- Service de chirurgie digestive, CHU Estaing, place Lucie-Aubrac, 63003 Clermont-Ferrand, France
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Abstract
Despite a history of previous splenectomy, splenic tissue can regenerate and present with symptoms of abdominal pain secondary to splenic rupture. Regrowth of splenic tissue after splenectomy for trauma and splenectomy for idiopathic thrombocytopenia purpura have been reported. However, rupture of splenic tissue, either spontaneous or traumatic, that requires a second surgical intervention for hemoperitoneum caused by a ruptured splenic nodule or splenosis has rarely been reported. We report the case of a 43-year-old man in whom hemoperitoneum developed 25 years after he underwent an open splenectomy, after a motor vehicle accident, that required removal of a recurrent ruptured splenotic nodule.
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Affiliation(s)
- Jay A Redan
- Florida Hospital-Celebration Health, Department of Surgery, 400 Celebration Place, Suite A-140, Celebration, FL 34747, USA.
| | - Francisco R Halili
- Florida Hospital-Celebration Health, Department of Surgery, Celebration, FL, USA
| | - Jill S Villarosa
- Florida Hospital-Celebration Health, Department of Surgery, Celebration, FL, USA
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Liu J, Xiao S, Wu S, Ou W, He J, Gao S, Liu Z. Disruption of splenic circulation using microbubble-enhanced ultrasound and prothrombin: a preliminary study. ULTRASOUND IN MEDICINE & BIOLOGY 2012; 38:1930-1937. [PMID: 22929654 DOI: 10.1016/j.ultrasmedbio.2012.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 07/10/2012] [Accepted: 07/18/2012] [Indexed: 06/01/2023]
Abstract
The spleen is a solid organ in which splenomegaly frequently develops and to which abdominal blunt trauma occurs. In this study, we demonstrated the potential therapeutic effect of microbubble-enhanced ultrasound (MEUS) combined with prothrombin to disrupt splenic circulation. A high-pressure-amplitude therapeutic ultrasound (TUS) device was used to treat 36 surgically exposed spleens in healthy New Zealand rabbits. Eighteen spleens were treated with either MEUS (n = 9) or MEUS combined with prothrombin (n = 9). The other 18 spleens were treated with TUS only or sham ultrasound exposure and served as the controls. The TUS was operated at a frequency of 831 kHz and a peak negative pressure of 4.8 MPa. Prothrombin was administered intravenously at 20 IU/kg. Contrast-enhanced ultrasound (CEUS) and acoustic quantification were performed to assess splenic blood perfusion. We found significant blood perfusion slowdown and drop-off in the MEUS-treated spleens. The peak intensity dropped from 20.2 ± 2.70 dB to 11.6 ± 4.58 dB immediately after treatment. The spleens treated with the combination of MEUS and prothrombin showed consistently poor perfusion within 1 h. In histologic examination of the MEUS-treated spleens, we found significant dilatation of splenic sinuses, hemorrhage, interstitial edema and thrombosis. This study demonstrated that the vascular effects induced by microbubble-enhanced, high-pressure ultrasound can slow down or block blood perfusion in the rabbit spleen. Prothrombin helps to enhance and extend the effects for up to 1 h.
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Affiliation(s)
- Jianhua Liu
- Department of Function, Guangzhou First Municipal People's Hospital, Guangzhou Medical College, Guangzhou, China
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Dreizin D, Munera F. Blunt polytrauma: evaluation with 64-section whole-body CT angiography. Radiographics 2012; 32:609-31. [PMID: 22582350 DOI: 10.1148/rg.323115099] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Blunt polytrauma remains a leading cause of death and disability worldwide. With the major advances in computed tomography (CT) technology over the past decade, whole-body CT is increasingly recognized as the emerging standard for providing rapid and accurate diagnoses within the narrow therapeutic window afforded to trauma victims with multiple severe injuries. With a single continuous acquisition, whole-body CT angiography is able to demonstrate all potentially injured organs, as well as vascular and bone structures, from the circle of Willis to the symphysis pubis. As its use becomes more widespread, the large volume of information inherent to whole-body CT poses new challenges to radiologists in providing efficient and timely interpretation. An awareness of trauma scoring systems and injury mechanisms is essential to maintain an appropriate level of suspicion in the search for multiple injuries, and the use of multiplanar reformation and three-dimensional postprocessing techniques is important to maximize efficiency in the search. Knowledge of the key injuries that require urgent surgical or percutaneous intervention, including major vascular injuries and active hemorrhage, diaphragmatic rupture, unstable spinal fractures, pancreatic injuries with ductal involvement, and injuries to the mesentery and hollow viscera, is also necessary.
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Affiliation(s)
- David Dreizin
- Department of Radiology, University of Miami Leonard Miller School of Medicine, University of Miami Health System, Jackson Memorial Hospital, and Ryder Trauma Center, 1611 NW 12th Ave, West Wing 279, Miami, FL 33136, USA
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Böyük A, Gümüş M, Önder A, Kapan M, Aliosmanoğlu I, Taşkesen F, Arıkanoğlu Z, Gedik E. Splenic injuries: factors affecting the outcome of non-operative management. Eur J Trauma Emerg Surg 2012; 38:269-74. [PMID: 26815958 DOI: 10.1007/s00068-011-0156-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 09/23/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to evaluate the outcome of non-operative management (NOM) in patients with splenic injuries and to determine the predictive factors of NOM failure. METHODS Two hundred and six patients with splenic injury were admitted between January 2005 and April 2011. Of the 206 patients with splenic injury, 47 patients met the inclusion criteria of NOM. The mechanism of injury, grade of splenic injury, other intra- and extra-abdominal injuries, systolic blood pressure on admission, hemoglobin levels, number of transfusions, Injury Severity Score (ISS), Glasgow Coma Scale score, and hospitalization period were recorded. The patients were divided into two groups: those with NOM and those in whom the failure of NOM led to laparotomy. The patients were monitored for vital signs, abdominal findings, and laboratory data. NOM was abandoned in cases of hemodynamic instability, ongoing bleeding, or development of peritonitis. Independent predictive factors of NOM failure were identified. The patients managed non-operatively were compared with the patients for whom NOM failed. RESULTS NOM was successful in 40 of 47 patients. There were differences between the two groups for ISS, hemoglobin levels, need for blood transfusion, and the number of associated extra-abdominal injuries. The grade of splenic injury was determined to be an important and significant independent predictive factor for the success of NOM of splenic injuries. CONCLUSIONS The grade of splenic injury is an important and significant independent predictor factor for the success of NOM. NOM is not recommended in patients with high-grade splenic injury.
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Affiliation(s)
- A Böyük
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey.
| | - M Gümüş
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey
| | - A Önder
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey
| | - M Kapan
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey
| | - I Aliosmanoğlu
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey
| | - F Taşkesen
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey
| | - Z Arıkanoğlu
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey
| | - E Gedik
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey
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Sajtos E, Balint A, Brath E, Nemeth N, Peto K, Kovacs J, Galuska L, Varga J, Fodor Z, Furka I, Miko I. Long-term following-up of viability of spleen autotransplants in the Beagle canine model. Acta Cir Bras 2012; 27:95-101. [PMID: 22378362 DOI: 10.1590/s0102-86502012000200001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 12/20/2011] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To examine the possible late complications of splenectomy or spleen autotransplantation in large laboratory animal model, in which we need non-invasive or minimal-invasive methods for long-term monitoring of the experimental animals. METHODS Experimental groups of beagle dogs were: non-operated control, sham-operated control, splenectomy, spleen autotransplantation with 5 or 10 spleen-chips taken into the greater omentum (Furka's technique). Prior to operations, on the 1(st) postoperative week, monthly till the 6(th) as well as in the 9(th) and 12(th) month, hemorheological examinations were performed. In postoperative 12(th) month colloid scintigraphy and diagnostic laparoscopy were carried out. At the end of the investigation comparative morphological examinations were performed, too. RESULTS From the 4(th)-5(th) postoperative month filtration function of spleen-autotransplants showed particular restoration compared to splenectomy group. However, the functional results did not reach the values of the control or sham-operated groups. Sham-operated control's scintigraphy nicely showed activity in the spleen. In spleen autotransplantation-groups scintigraphy indicated well the activity of spleen-chips. During diagnostic laparoscopy spleen-chips with their blood supply were found. Histologically, the structure of spleen-autotransplants was similar to normal splenic tissue. CONCLUSIONS The autotransplants are regenerated, their functions have been partly restored, and thus spleen autotransplantation may prevent the possible complications of splenectomy. These parameters and the presented investigative protocol are suitable for long-term following-up of viability of the spleen-autotransplants.
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Affiliation(s)
- Erika Sajtos
- Department of Operative Techniques and Surgical Research, Medical and Health Science Center, University of Debrecen, Hungary.
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Chalya PL, Mabula JB, Giiti G, Chandika AB, Dass RM, McHembe MD, Gilyoma JM. Splenic injuries at Bugando Medical Centre in northwestern Tanzania: a tertiary hospital experience. BMC Res Notes 2012; 5:59. [PMID: 22269803 PMCID: PMC3274421 DOI: 10.1186/1756-0500-5-59] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 01/23/2012] [Indexed: 11/17/2022] Open
Abstract
Background Splenic injuries constitute a continuing diagnostic and therapeutic challenge to the trauma or general surgeons practicing in developing countries where sophisticated imaging facilities are either not available or exorbitantly expensive. The purpose of this review was to describe our own experience in the management of the splenic injuries outlining the aetiological spectrum, injury characteristics and treatment outcome of splenic injuries in our local environment and to identify predictors of outcome among these patients. Methods A prospective descriptive study of splenic injury patients was carried out at Bugando Medical Centre in Northwestern Tanzania between March 2009 and February 2011. Statistical data analysis was done using SPSS software version 17.0. Results A total of 118 patients were studied. The male to female ratio was 6.4:1. Their ages ranged from 8 to 74 years with a median age of 22 years. The modal age group was 21-30 years. The majority of patients (89.8%) had blunt trauma and road traffic accidents (63.6%) were the most frequent cause of injuries. Most patients sustained grade III (39.0%) and IV (38.1%) splenic injuries. Majority of patients (86.4%) were treated operatively with splenectomy (97.1%) being the most frequently performed procedure. Postoperative complications were recorded in 30.5% of cases. The overall length of hospital stay (LOS) ranged from 1 day to 120 days with a median of 18 days. Mortality rate was 19.5%. Patients who had severe trauma (Kampala Trauma Score II ≤ 6) and those with associated injuries stayed longer in the hospital (P < 0.001), whereas age of the patient, associated injuries, trauma scores (KTS II), grade of splenic injuries, admission systolic blood pressure ≤ 90 mmHg, estimated blood loss > 2000 mls, HIV infection with CD4 ≤ 200 cells/μl and presence of postoperative complications were significantly associated with mortality (P < 0.001). Conclusion Trauma resulting from road traffic accidents (RTAs) remains the most common cause of splenic injuries in our setting. Most of the splenic injuries were Grade III & IV and splenectomy was performed in majority of the cases. Non-operative management can be adopted in patients with blunt isolated and low grade splenic injuries but operative management is still indispensable in this part of Tanzania. Urgent preventive measures targeting at reducing the occurrence of RTAs is necessary to reduce the incidence of splenic injuries in our centre.
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Affiliation(s)
- Phillipo L Chalya
- Department of Surgery, Catholic University of Health and Allied Sciences-Bugando, Mwanza, Tanzania.
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Renzulli P, Gross T, Schnüriger B, Schoepfer AM, Inderbitzin D, Exadaktylos AK, Hoppe H, Candinas D. Management of blunt injuries to the spleen. Br J Surg 2010; 97:1696-703. [DOI: 10.1002/bjs.7203] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Non-operative management (NOM) of blunt splenic injuries is nowadays considered the standard treatment. The present study identified selection criteria for primary operative management (OM) and planned NOM.
Methods
All adult patients with blunt splenic injuries treated at Berne University Hospital, Switzerland, between 2000 and 2008 were reviewed.
Results
There were 206 patients (146 men) with a mean(s.d.) age of 38·2(19·1) years and an Injury Severity Score of 30·9(11·6). The American Association for the Surgery of Trauma classification of the splenic injury was grade 1 in 43 patients (20·9 per cent), grade 2 in 52 (25·2 per cent), grade 3 in 60 (29·1 per cent), grade 4 in 42 (20·4 per cent) and grade 5 in nine (4·4 per cent). Forty-seven patients (22·8 per cent) required immediate surgery. Transfusion of at least 5 units of red cells (odds ratio (OR) 13·72, 95 per cent confidence interval 5·08 to 37·01), Glasgow Coma Scale score below 11 (OR 9·88, 1·77 to 55·16) and age 55 years or more (OR 3·29, 1·07 to 10·08) were associated with primary OM. The rate of primary OM decreased from 33·3 to 11·9 per cent after the introduction of transcatheter arterial embolization in 2005. Overall, 159 patients (77·2 per cent) qualified for NOM, which was successful in 143 (89·9 per cent). The splenic salvage rate was 69·4 per cent. In multivariable analysis age at least 40 years was the only factor independently related to failure of NOM (OR 13·58, 2·76 to 66·71).
Conclusion
NOM of blunt splenic injuries has a low failure rate. Advanced age is independently associated with an increased failure rate.
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Affiliation(s)
- P Renzulli
- Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, and University of Berne, Switzerland
| | - T Gross
- Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, and University of Berne, Switzerland
| | - B Schnüriger
- Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, and University of Berne, Switzerland
- Department of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, California, USA
| | - A M Schoepfer
- Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, and University of Berne, Switzerland
- Farncombe Family Institute of Digestive Health Research, McMaster University, Hamilton, Ontario, Canada
| | - D Inderbitzin
- Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, and University of Berne, Switzerland
| | - A K Exadaktylos
- Department of Emergency Medicine, Inselspital, Berne University Hospital, and University of Berne, Switzerland
| | - H Hoppe
- Department of Diagnostic Radiology, Inselspital, Berne University Hospital, and University of Berne, Switzerland
| | - D Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, and University of Berne, Switzerland
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Izu BS, Ryan M, Markert RJ, Ekeh AP, McCarthy MC. Impact of splenic injury guidelines on hospital stay and charges in patients with isolated splenic injury. Surgery 2009; 146:787-91; discussion 791-3. [PMID: 19789039 DOI: 10.1016/j.surg.2009.06.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2009] [Accepted: 06/25/2009] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of this study was to assess the impact of care guidelines for patients with isolated blunt splenic trauma on length of stay (LOS) and patient charges. METHODS We conducted a review of the hospital trauma registry and identified patients admitted with blunt splenic injury from 2000 to 2007. Splenic injury guidelines were initiated in November 2004. Patients with other major injuries were excluded. Patients were grouped according to their American Association for the Surgery of Trauma (AAST) splenic injury grade, I-V. Hospital LOS, intensive care unit (ICU) LOS, and patient charges before and after the guidelines were compared. RESULTS We identified 137 patients with isolated splenic injuries. Sixty-three patients were admitted before and 70 patients after implementation of the guidelines. ICU and hospital LOS were significantly decreased after the guidelines (ICU LOS, 1.35 days before, 0.80 after [P < .01]; and hospital LOS, 4.17 before, 3.27 after [P < .01]). When grouped by AAST grade, grade II injuries had a decrease in hospital LOS (4.5 before vs 2.29 after; P < .01) and ICU LOS (1.43 before vs 0.29 after; P < .01). Adjusted hospital charges showed no significant increase overall after the guideline implementation (mean hospital charges before $23,047 vs after, $24,116; P = .62). CONCLUSION Implementing guidelines for the observation of blunt splenic injury decreased the overall hospital LOS and ICU LOS at our institution, but hospital charges remained the same. Trauma programs should institute splenic injury guidelines to reduce resources needed for the care of isolated splenic injuries.
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Affiliation(s)
- Brent S Izu
- Division of Trauma, Critical Care and Emergency General Surgery, Department of Surgery, Wright State University Boonshoft School of Medicine and Miami Valley Hospital, Dayton, OH 45409, USA.
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Giannopoulos GA, Katsoulis IE, Tzanakis NE, Patsaouras PA, Digalakis MK. Non-operative management of blunt abdominal trauma. Is it safe and feasible in a district general hospital? Scand J Trauma Resusc Emerg Med 2009; 17:22. [PMID: 19439091 PMCID: PMC2689852 DOI: 10.1186/1757-7241-17-22] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Accepted: 05/13/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate the feasibility and safety of non-operative management (NOM) of blunt abdominal trauma in a district general hospital with middle volume trauma case load. METHODS Prospective protocol-driven study including 30 consecutive patients who have been treated in our Department during a 30-month-period. Demographic, medical and trauma characteristics, type of treatment and outcome were examined. Patients were divided in 3 groups: those who underwent immediate laparotomy (OP group), those who had a successful NOM (NOM-S group) and those with a NOM failure (NOM-F group). RESULTS NOM was applied in 73.3% (22 patients) of all blunt abdominal injuries with a failure rate of 13.6% (3 patients). Injury severity score (ISS), admission hematocrit, hemodynamic status and need for transfusion were significantly different between NOM and OP group. NOM failure occurred mainly in patients with splenic trauma. CONCLUSION According to our experience, the hemodynamically stable or easily stabilized trauma patient can be admitted in a non-ICU ward with the provision of close monitoring. Splenic injury, especially with multiple-site free intra-abdominal fluid in abdominal computed tomography, carries a high risk for NOM failure. In this series, the main criterion for a laparotomy in a NOM patient was hemodynamic deterioration after a second rapid fluid load.
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De Rezende Neto JB, Guimarães TN, Madureira JL, Drumond DAF, Leal JC, Rocha A, Oliveira RG, Rizoli SB. Non-operative management of right side thoracoabdominal penetrating injuries--the value of testing chest tube effluent for bile. Injury 2009; 40:506-10. [PMID: 19342047 DOI: 10.1016/j.injury.2008.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Accepted: 11/11/2008] [Indexed: 02/02/2023]
Abstract
INTRODUCTION While mandatory surgery for all thoracoabdominal penetrating injuries is advocated by some, the high rate of unnecessary operations challenges this approach. However, the consequences of intrathoracic bile remains poorly investigated. We sought to evaluate the outcome of patients who underwent non-operative management of right side thoracoabdominal (RST) penetrating trauma, and the levels of bilirubin obtained from those patients' chest tube effluent. PATIENTS AND METHODS We managed non-operatively all stable patients with a single RST penetrating injury. Chest tube effluent samples were obtained six times within (4-8 h; 12-16 h; 20-24 h; 28-32 h; 36-40 h; 48 h and 72 h) of admission for bilirubin measurement and blood for complete blood count, bilirubin, alanine (ALT) and aspartate aminotransferases (AST) assays. For comparison we studied patients with single left thoracic penetrating injury. RESULTS Forty-two patients with RST injuries were included. All had liver and lung injuries confirmed by CT scans. Only one patient failed non-operative management. Chest tube bilirubin peaked at 48 h post-trauma (mean 3.3+/-4.1 mg/dL) and was always higher than both serum bilirubin (p<0.05) and chest tube effluent from control group (27 patients with left side thoracic trauma). Serum ALT and AST were higher in RST injury patients (p<0.05). One RST injury patient died of line sepsis. CONCLUSION Non-operative management of RST penetrating trauma appears to be safe. Bile originating from the liver injury reaches the right thoracic cavity but does not reflect the severity of that injury. The highest concentration was found in the patient failing non-operative management. The presence of intrathoracic bile in selected patients who sustain RST penetrating trauma, with liver injury, does not preclude non-operative management. Our study suggests that monitoring chest tube effluent bilirubin may provide helpful information when managing a patient non-operatively.
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Affiliation(s)
- João Baptista De Rezende Neto
- Department of Surgery Universidade Federal de Minas Gerais and Hospital Universitario Risoleta Tolentino Neves, Brazil
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Benissa N, Boufettal R, Kadiri Y, Lefriyekh MR, Kafih M, Fadil A, Zerouali NO. [Non operative management of blunt splenic trauma in adults]. ACTA ACUST UNITED AC 2008; 145:556-60. [PMID: 19106886 DOI: 10.1016/s0021-7697(08)74686-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Nonoperative management of blunt splenic injury allows preservation of the immune function of the spleen while avoiding unnecessary laparotomy. The aim of our study was to evaluate the feasibility and the results of conservative management of adult blunt splenic trauma in the context of a developing country. Nonoperative management was proposed for 52 out of 62 patients with blunt splenic trauma treated at the Casablanca University Hospital, Morocco. Motor vehicle-road accidents (88%) were the most common etiology. Multiple trauma was present in 79% of the cases. 15% of the cases had hemodynamic instability. Ultrasonography was performed in 52 patients; it showed splenic contusion in 45 patients and subcapsular hematoma in 7 patients. CT scan showed splenic contusion in 11 patients. Four cases ultimately required operative management with one death. Of the remaining 48 patients, 45 had an uneventful course with observation, but there were two deaths in the observation group.
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Affiliation(s)
- N Benissa
- Service des urgences chirurgicales viscérales, pavillon 35, CHU Ibn Rochd - Casablanca, Maroc
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Gonzalez M, Bucher P, Ris F, Andereggen E, Morel P. Traumatisme de la rate : facteurs prédictifs d’échec du traitement non-opératoire. ACTA ACUST UNITED AC 2008; 145:561-7. [DOI: 10.1016/s0021-7697(08)74687-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Short-term outcomes of splenectomy avoidance in trauma patients. Am J Surg 2008; 196:213-7. [DOI: 10.1016/j.amjsurg.2007.07.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2007] [Revised: 07/10/2007] [Accepted: 07/10/2007] [Indexed: 11/23/2022]
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Sinha S, Raja SVV, Lewis MH. Recent changes in the management of blunt splenic injury: effect on splenic trauma patients and hospital implications. Ann R Coll Surg Engl 2008; 90:109-12. [PMID: 18325207 DOI: 10.1308/003588408x242033] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Management of blunt splenic injury has been controversial with an increasing trend towards splenic conservation. A retrospective study was performed to identify the effect of this changed policy on splenic trauma patients and its implications. PATIENTS AND METHODS Data regarding patient demography, mode of splenic injury, CT grading, blood transfusion requirement, operative findings hospital stay and follow-up were collected. Statistical analysis of the data was performed using nonparametric Mann-Whitney tests RESULTS Over an 8-year period, only 21 patients were admitted with blunt splenic injury. Ten patients were managed operatively and 11 non-operatively. Non-operative management failed in one patient due to continued bleeding. Using Buntain's CT grading, the majority of grades I and II splenic injuries were managed non-operatively and grades III and IV were managed operatively ( P = 0.008). Blood transfusion requirement was significantly higher among the operative group (P = 0.004) but the non-operative group had a significantly longer hospital stay (P = 0.029). Among those managed non-operatively (median age, 24.5 years), a number of patients were followed up with CT scans with significant radiation exposure and unknown longterm consequences. CONCLUSIONS Non-operative management of blunt splenic trauma in adults can be performed with an acceptable outcome. Although CT is classed as the 'gold standard', initial imaging for detection and evaluation of blunt splenic injury, ultrasound can play a major role in follow-up imaging and potentially avoids major radiation exposure.
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Affiliation(s)
- S Sinha
- Department of Surgery, Royal Glamorgan Hospital, Ynysmaerdy, Llantrisant, UK.
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One Hundred Consecutive Splenectomies for Trauma: Is Histologic Evaluation Really Necessary? ACTA ACUST UNITED AC 2008; 64:1139-41. [DOI: 10.1097/ta.0b013e318150782c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Brady RRW, Bandari M, Kerssens JJ, Paterson-Brown S, Parks RW. Splenic Trauma in Scotland: Demographics and Outcomes. World J Surg 2007; 31:2111-6. [PMID: 17849160 DOI: 10.1007/s00268-007-9218-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Splenic trauma is a common organ injury following blunt abdominal trauma. In order to establish the contemporary epidemiology of blunt splenic trauma in Scotland and to detect risk factors associated with patient outcomes, analysis of a multi-center database of trauma patients was performed. METHODS The study used data from a prospectively collated multicenter trauma database containing the details of 52,215 trauma patients admitted to participating Scottish hospitals over an 11-year period. RESULTS 672 (1.3%) patients (530 males, 142 females) with splenic trauma were identified; of them, 579 (86.2%) had blunt trauma and 93 (13.8%) had penetrating trauma. The mean age of patients with blunt splenic trauma was 35.7 years (33.8 years for males, 42.0 years for females). Increasing age and female sex was significantly associated with mortality. The most common mechanism for injury was road traffic accidents (71%). In the series, 93.8% of patients had concomitant injuries including head injuries (46.5%), thoracic injuries (37.7%) and liver injuries (30%). A total of 299 (51.6%) patients proceeded to laparotomy, and 256 (44.2%) patients required ICU support. The overall mortality was 33.5%, and the median Injury Severity Score was 48 in patients who died, compared to 22 in those who survived. Increased mortality was associated with concomitant aortic, cardiac, or abdominal injuries. A number of independent risk factors were associated with increased risk of mortality, including concomitant injuries, increased age, and increased Injury Severity Score. CONCLUSIONS The incidence of splenic trauma is low, but it accounts for significant mortality. Outcome in the present study was worse in those with advanced age and associated injuries.
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Affiliation(s)
- Richard R W Brady
- Academic Coloproctology, 4th Floor MRC Human Genetics Unit, Western General Hospital, Crewe Road, Edinburgh, Scotland EH4 2XU.
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