Splenic trauma

Nonoperative management of solid abdominal organ injuries: From past to present

BACKGROUND AND AIMS

Today, a significant proportion of solid abdominal organ injuries, whether caused by penetrating or blunt trauma, are managed nonoperatively. However, the controversy over operative versus nonoperative management started more than a hundred years ago. The aim of this review is to highlight some of the key past observations and summarize the current knowledge and guidelines in the management of solid abdominal organ injuries.

MATERIALS AND METHODS

A non-systematic search through historical articles and references on the management practices of abdominal injuries was conducted utilizing early printed volumes of major surgical and medical journals from the late 19th century onwards.

RESULTS

Until the late 19th century, the standard treatment of penetrating abdominal injuries was nonoperative. The first article advocating formal laparotomy for abdominal gunshot wounds was published in 1881 by Sims. After World War I, the policy of mandatory laparotomy became standard practice for penetrating abdominal trauma. During the latter half of the 20th century, the concept of selective nonoperative management, initially for anterior abdominal stab wounds and later also gunshot wounds, was adopted by major trauma centers in South Africa, the United States, and little later in Europe. In blunt solid abdominal organ injuries, the evolution from surgery to nonoperative management in hemodynamically stable patients aided by the development of modern imaging techniques was rapid from 1980s onwards.

CONCLUSION

With the help of modern imaging techniques and adjunctive radiological and endoscopic interventions, a major shift from mandatory to selective surgical approach to solid abdominal organ injuries has occurred during the last 30-50 years.

[Intraoperative and postoperative complications of splenectomy]

Spleen is being surgically removed because of trauma, in diagnostic and-or therapeutical purposes because of the benignant and malignant diseases. The percentage of morbidity during and after splenectomy is relatively low. During surgery might occur bleeding, trauma of the pancreatic tail, stomach, lineal flexure of the colon, left hemidiafragm, left suprarenal gland and upper pole of the left kidney, which must be correspondingly reclaimed during the same intervention. In the early postoperative period, postoperative bleeding, subfrenic abscess, pulmonal atelectasis, bronchopneumonia and left pleural extravasations might occur. Especially is important notification of these events in due time and adequate conservative and surgical treatment. After splenectomy, there is an increase of the number of trombocytes, which might lead to the tromboembolic complications. In the prevention of these complications in the postoperative period prolonged antiagregation therapy is suggested. Postsplenectomy sepsis is very late, general complication of splenectomy, which occurs because of the lower immunity in the child age. To prevent these complications, partial splenectomies, reimplantations of the spleen, prolonged application of the penicillin medicines after splenectomy and antipneumococcal vaccine are performed.

Nonoperative Management of Solid Abdominal Visceral Injury: Part I. Spleen

The relatively recent recognition of the immunological consequences of splenectomy in both children and adults, coupled with an increased use of noninvasive methods of detecting splenic injuries, has resulted in the development of a nonoperative approach to selected patients with blunt splenic trauma. Currently, nonoperative management of pediatric splenic injuries is the treatment of choice, with success rates greater than 90%. Due to the increased severity of injury in adult trauma patients, this method of treatment is applicable in only 50% of older patients with mild to moderate splenic trauma. As experience with nonoperative treatment has accumulated, the need for large blood transfusions, missed intestinal injuries, and delayed splenic rupture have been found to be uncommon events. However, patients selected for nonoperative management must be monitored in a setting where the treating surgeon is readily available for both serial examinations and operative intervention should nonoperative management fail.

Anatomy of vasculature of 850 spleen specimens and its application in partial splenectomy

BACKGROUND

Anatomic knowledge of vasculature of the splenic lobe and segment is of great clinical significance in partial resections and transplantation of the spleen.

METHODS

The methods of two-colored corrosion casting, roentgenography, and anatomic dissection were used to evaluate the vasculature of the splenic hilum and intraspleen. On this basis splenic lobectomy and segmentectomy were performed on 42 patients with traumatized spleens.

RESULTS

In the observation of 850 spleen specimens the spleen showed a single lobar artery in 7 cases (0.8%), two lobar arteries in 730 cases (86%), three lobar arteries in 104 cases (12.2%), and multiple lobar arteries (i.e., more than three lobar arteries) in 9 cases (1%). In a subgroup of 276 specimens 17%, 53%, 24%, 4%, 1%, and 1% of spleen specimens had three, four, five, six, seven, and eight segmental arteries, respectively. The result from a subgroup of 280 specimens indicated that mean percentages of the existence of the superior and inferior polar arteries and of the coexistence of both polar arteries were 31.3%, 38.8%, and 13.3%, respectively. Relative avascular planes between segments or lobes were seen. Basic steps of splenic lobectomy or segmentectomy include mobilization of the injured spleen, ligation of vessels in the lobe or segment, transection of the splenic parenchyma, and sutures of the cut surface of the remaining spleen. The postoperative courses of all 42 patients undergoing partial splenectomy were uneventful. No postoperative bleeding and necrosis of the remaining spleen or infectious complications were registered.

CONCLUSIONS

Anatomically the spleen is defined with two primary lobes (the superior lobe and inferior lobe), one accessory lobe, and three to five segments. This new classification facilitates surgeons to perform partial resections of the spleen and allotransplantation of the hemispleen from a living related donor in human beings.

[Pneumococcus-induced septicemia in normal and splenectomized rabbits]

A new rabbit model to study the consequences of splenectomy in host resistance to induced pneumococcal septicaemia is presented. A simple, fast, non-invasive and complication-free technique of bacterial inoculation into the rabbit airways, using transcutaneous cannulation of the trachea, is also described. Sixteen normal and 24 splenectomised animals were used. The optimal dose of pneumonococcus (serotype B, type III) was found to be 1 x 10(7) organisms. The above dose of bacteria given transtracheally failed to cause signs of pneumonia or death in any of the normal rabbits. However the same dose introduced using the same technique resulted reproducibly in the death of the low-resistance splenectomised animals.

Immunorestorative effects of reimplanted splenic tissue and splenosis

Different immune functions were analysed in detail in 41 patients who had been splenectomized after a traumatic rupture of the spleen within four years after surgical intervention. Patients were assigned to one of the following groups as judged by liver/spleen scintigraphy: (1) patients with reimplanted splenic tissue, (2) patients with splenosis, and (3) patients without splenic tissue. Leukocytosis and an increased number of total lymphocytes as well as B-cells were observed in patients of all groups. In addition, the number of circulating T-suppressor cells was significantly increased in patients with no detectable splenic tissue. In contrast, serum concentrations of immunoglobulins and complement components were in the normal range; similarly, phagocytosis-associated functions of the patients' neutrophils and monocytes were found to be unimpaired (chemiluminescence and particle uptake). However, in all groups of splenectomized patients a deficiency in specific serum opsonic activity against a strain of Escherichia coli (O:102, H:6) could be detected. We conclude that neither splenosis nor autologous reimplantation of splenic tissue restores opsonic deficiency caused by splenectomy.

Management of splenic injuries

The structure and function of the spleen are reviewed in the context of providing a rational basis for splenic salvage after trauma. Guidelines for operative and nonoperative management are provided, and the results of treatment from recent large series are summarized.

Splenic artery aneurysm embolisation--the preferred technique to surgery

A case of embolisation of a splenic artery aneurysm is presented. The aneurysm and proximal splenic artery were successfully occluded with steel coils and there were no associated complications. Transcatheter embolisation-should be the treatment of choice for splenic artery aneurysms. The procedure carries less morbidity than surgery and more importantly allows preservation of the spleen and its function.

Splenic repair for trauma

The risks of overwhelming post-splenectomy infection (OPSI) are now well documented both in children and adults. Although the incidence of OPSI is comparatively low following splenectomy for trauma, it has a high mortality. Splenectomy is no longer the treatment of choice for splenic injury and splenic salvage is recommended whenever feasible. Since 1982, in the Isle of Wight hospitals, 13 cases of splenic injury following trauma have been treated applying various salvage procedures and are reported here.

Splenic reticuloendothelial function after splenectomy, spleen repair, and spleen autotransplantation

Overwhelming infection after splenectomy remains a problem despite the introduction of vaccine and antimicrobial prophylaxis. To evaluate prospectively various procedures proposed for salvage of the spleen, we measured reticuloendothelial function for two to five years in 51 patients who had initially presented with abdominal trauma and suspected splenic rupture. The mean percentage of pocked erythrocytes and the clearance of antibody-coated autologous erythrocytes in 8 patients who had splenic repair and in 6 who had partial splenectomy were the same as in 11 controls with intraabdominal injury that did not involve the spleen. The mean percentage of pocked erythrocytes remained significantly elevated in 19 patients who had undergone total splenectomy without autotransplantation of splenic tissue. One of seven patients who underwent splenic autotransplantation had a normal level of pocked erythrocytes 18 months after surgery, and a second patient had only a slight elevation at 24 months. The mean (+/- SEM) half-time clearance of labeled erythrocytes was significantly longer in the group that had total splenectomy without autotransplantation (421.1 +/- 74.5 hours) than in the autotransplantation group (91.6 +/- 20.0) or in the controls (5.4 +/- 2.0). We conclude that reticuloendothelial function was better preserved after partial splenectomy and splenic repair than after splenic autotransplantation, but that autotransplantation was superior to total splenectomy and appeared to be safe. Splenic autotransplantation deserves further study in patients who have had splenic trauma when other surgical maneuvers to save the spleen are not possible.

Pediatric splenic trauma: predicting the success of nonoperative therapy

The charts of all pediatric patients discharged from the Massachusetts General Hospital with a diagnosis of a ruptured spleen were reviewed over a six-year period to determine if any factors could be used to predict which children could be managed safely without operation. Seventy-five percent of these injuries were so managed. The patients who required surgical intervention were older (mean age, 17 years), had multiple injuries (mean ISS, 41), presented with more blood loss (mean hematocrit, 23.5%), and suffered their injuries as a result of a motor vehicle accident. The patients who were successfully managed nonoperatively were younger (mean age, 12 years), had fewer associated injuries (mean ISS, 18), required fewer blood transfusions, and suffered their traumas secondary to falls, sporting events, or altercations. We propose that the injury severity score, the number of units of blood transfused, patient age, as well as the type of trauma suffered be used to predict which patients can be safely managed nonoperatively.

Splenorrhaphy in the management of splenic injury

A retrospective study of 301 adult splenic injuries presenting to the Princess Alexandra Hospital during a 15 year period, from 1970 to 1984, was conducted. Particular attention was paid to the last 5 years during which 25% of the ruptured spleens were preserved. The details of the preserved spleens are discussed. Respiratory infections were the only complications in this same selected group of patients; the complication rate being higher in the splenectomy group (15.8%) than the splenorrhaphy group (6.25%). None of the cases of splenorrhaphy required re-operation for continued haemorrhage. Twenty-five per cent of all cases of splenic injury had associated intra-abdominal injury which, of its own nature, would require laparotomy. A policy of operative management for splenic injury in adults with major trauma is therefore proposed because of the rate of associated intra-abdominal injuries. When laparotomy is performed, splenorrhaphy should be considered because of the now widely acknowledged risks of diminished immunological competence and overwhelming sepsis in asplenic individuals.

Does splenectomy predispose to meningococcal sepsis? An experimental study and clinical review

Splenectomy is a recognized factor predisposing to the late complication of serious sepsis. The meningococcus has been listed as an important organism in postsplenectomy infection. A survey of the literature, however, revealed a total of only 13 documented case reports over a 31-year period, including ten pediatric cases. No documented cases of meningococcal sepsis in children following splenectomy for trauma were found. In an experimental mouse meningococcal infection model, the intraperitoneal LD50 was similar between normal and splenectomized mice (4 X 10(8) v 4 X 10(7) cfu, respectively; P = not significant). Bacteremic patterns were similar in both groups. Uniform survival was seen in normal and splenectomized mice after various intravenous challenge doses of meningococci up to 10(6) cfu. This was associated with efficient bacterial clearance in both groups. It appears unlikely that the defect resulting from splenectomy alone is an important predisposing factor in meningococcal sepsis.

Autotransplantation of splenic tissue

Autotransplantation of splenic fragments has already been carried out in humans. The optimal size of the particles and amount of tissue required for this procedure has yet to be found. In normal young pigs and miniature piglets, autologous splenic tissue was transplanted into the greater omentum. The regenerated splenic mass, splenic blood flow, and histology were studied six months later. Implanting small splenic particles produced comparable results to implanting thin slices of splenic tissue. The mass of regenerated splenic tissue was only 3.1 g after implanting the whole spleen and 4.5 g after transplanting half of the spleen, which means 5.3% and 7.8% respectively of the weight of control spleens. The blood flow per gram in the regenerated splenic tissue was much lower than in the normal spleen. The blood flow in the whole of the splenic tissue is important for the clearance function of the spleen. Six months after transplanting the whole or half of the spleen, the blood flow to the regenerated splenic tissue was only 1% of that in the control minipigs. When half of the spleen was left in situ, as a model for a partial splenectomy, and the other half transplanted, the regenerated mass was only 3.4% of all splenic tissue and the blood flow 1.5% of the total splenic blood flow. In this model the regenerated splenic mass was independent of the size of the implants and the mass of implanted tissue. The extremely low blood flow indicates an inadequate clearance function and thus the protective function would probably be negligible.

A four-year experience with splenectomy versus splenorrhaphy

From 1980 to 1984, 326 patients requiring splenectomy or splenorrhaphy were treated at one urban trauma center. Splenic injuries were graded in severity from one to five at the time of celiotomy. Splenorrhaphy was attempted in all patients, except when the spleen was shattered or avulsed or when multiple injuries were present. The mechanisms of injury were: penetrating wounds in 51.2%, blunt trauma in 46%, and iatrogenic mishaps in 2.8% of patients. Grade 1 or 2 injuries were present in 23.9%, Grade 3, 4, or 5 injuries were present in 59.8%. Spleens removed or repaired with unknown grading or removed as part of distal pancreatectomies accounted for 16.3% of patients. Excluding uninjured spleens removed with pancreatectomies, 55.4% (169) of injured spleens required splenectomy and 44.6% (136) had a splenorrhaphy performed. Splenorrhaphy was most commonly performed with chronic suture with or without the addition of topical agents. Grade 1 and 2 injuries were repaired in 88.5%; Grade 3 injuries were repaired in 61.5%; and Grade 4 and 5 injuries were repaired in 7.7% of patients. Splenectomy is generally performed in patients with multiple associated intraabdominal injuries and the more severe grades of splenic injury, and has a mortality rate 13.5 times as great as that for patients undergoing splenorrhaphy. Splenorrhaphy can be performed in approximately 50% of patients with injured spleens and has practically no risk of rebleeding.

Fatal overwhelming postsplenectomy infection

A total of 776 patients underwent splenectomy at the Massachusetts General Hospital between 1962 and 1972. Follow-up information was obtained on 637 patients (82 percent), including 584 adults and 53 children. There was a total of 4,837 person-years of follow-up with a mean observation interval of 8.4 years. Four cases of fatal overwhelming postsplenectomy infection were identified. In our pediatric population, the incidence of fatal overwhelming postsplenectomy infection was 3.77 percent, which was significantly higher than the incidence of 0.34 percent in our asplenic adults. Overwhelming postsplenectomy infection is a unique clinical entity distinguishable from other infections. It may occur during the lifetime of any asplenic patient and especially in those patients who have had a splenectomy in childhood. In asplenic adults, the incidence is low. The aggressive approach to splenic preservation in the adult should be tempered by these results.

Antibody responses to meningococcal polysaccharide vaccine in adults without a spleen

Asplenic persons are at risk for the development of overwhelming sepsis from certain encapsulated bacteria, including meningococci. Since it is not known if asplenic persons can have antibody responses, this study compared such responses following bivalent groups A and C meningococcal polysaccharide vaccine in 22 asplenic subjects and healthy control subjects. There were no adverse reactions to the vaccine. Antibody responses were measured using a solid-phase radioimmune assay; results were compiled for both seroconversions and changes in mean antibody titers of IgG, IgA, and IgM classes. Subjects who underwent splenectomy for trauma and control subjects with spleens showed a polyclonal antibody response to both vaccine antigens. Those persons who underwent splenectomy for nonlymphoid tumors had nearly as good a response as normal subjects. By contrast, asplenic subjects with lymphoid tumors who had received prior chemotherapy and radiotherapy had poor responses to both antigens. It is concluded that meningococcal vaccine is immunogenic in asplenic persons, with the aforementioned exceptions, and that this vaccine should be routinely administered to such persons.

Posttraumatic splenic replantation in children

Previous work in our laboratories showed that canine omental replantation of splenic wafers leads to reproducible viability, restoration of filtrative function, bacterial clearance, and normal antibody formation. An identical technique has been employed in children whose spleen could not be repaired since 1979. During a 3-yr follow-up viability of the replanted segments was documented with return of filtrative function, normal immunoglobulin, and antibody response. Splenic preservation through operative repair or selective nonoperative observation should remain the primary goal after splenic trauma. If this is not possible, splenic replantation represents an alternative approach in the treatment of splenic trauma.

Splenic capping: an experimental study of a new technique for splenorrhaphy using woven polyglycolic acid mesh

The use of polyglycolic acid (PGA) stretchable mesh applied to the experimentally injured canine spleen can achieve satisfactory immediate hemostasis by tamponade and simplifies the use of sutures to control remaining areas of hemorrhage. PGA mesh with 1/4" and 1/8" openings was utilized for splenorrhaphy in 12 adult mongrel dogs subjected to sharp splenic trauma. By gross and histologic examination, the PGA mesh material appears to undergo progressive absorption to complete absorption by 85 days. For the 12 animals and 30 operative procedures the only complications of the use of the mesh were the occurrence of an intrasplenic seroma in a single animal at 6 weeks after operation and three wound infections. With this material, rapid, simple canine splenic injury repair can be achieved. PGA mesh further assists in the healing process, and in maintaining maximum splenic architecture and function. The material used in this study was manufactured and supplied by Davis & Geck, American Cyanamid, Danbury, Connecticut.