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Huang HC, Teng TC, Ming YC, Lin JJ, Liao CH, Hsieh CH, Li PH, Fu CY. Older Children with Torso Trauma Could Be Managed by Adult Trauma Surgeons in Collaboration with Pediatric Surgeons. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9030444. [PMID: 35327816 PMCID: PMC8947374 DOI: 10.3390/children9030444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 11/16/2022]
Abstract
Background: The purpose of this study is to assess the roles of pediatric surgeons and adult trauma surgeons in the management of pediatric torso trauma patients in a Level I adult trauma center. Methods: From 2015 to 2019, pediatric torso trauma patients (age < 18 years) were studied. A comparison between patients who did and did not undergo surgery was performed. Older children (age: 10−18 years) were compared with young adults (age: 18−35 years) selected with the same criteria using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). Results: A total of 226 patients were included in the study. Patients who underwent surgery for torso trauma (N = 61) were significantly older than patients who did not undergo surgery (N = 165) (13.1 vs. 10.4 years, p = 0.019). Both PSM and IPTW showed that the older children and young adult groups had similar proportions of patients requiring surgery (32.6% vs. 32.6%, standard difference (SD) = 0.000), proportions of patients who required torso angioembolization (8.7% vs. 9.8%, SD = 0.072), length of hospital stay (LOS) (8.1 vs. 8.0 days, SD = 0.026), and intensive care unit admission LOS (2.6 vs. 2.7 days, SD = 0.033). However, 7.1% of older children received critical care from pediatric surgeons. Additionally, 31.9% of younger children were cared for by pediatric surgeons/pediatricians. Conclusions: Adult trauma surgeons can feasibly perform surgeries for older children with torso trauma in collaboration with pediatric surgeons who provide critical care.
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Affiliation(s)
- Hsiang-Chieh Huang
- Department of Pediatric Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (H.-C.H.); (Y.-C.M.)
| | - Tzu-Chi Teng
- Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan;
| | - Yung-Ching Ming
- Department of Pediatric Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (H.-C.H.); (Y.-C.M.)
| | - Jainn-Jim Lin
- Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan;
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (C.-H.L.); (C.-H.H.)
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (C.-H.L.); (C.-H.H.)
| | - Pei-Hua Li
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (C.-H.L.); (C.-H.H.)
- Correspondence: (P.-H.L.); (C.-Y.F.); Tel.: +886-3-3281200 (ext. 3651) (C.-Y.F.); Fax: +886-3-3289582 (C.-Y.F.)
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (C.-H.L.); (C.-H.H.)
- Correspondence: (P.-H.L.); (C.-Y.F.); Tel.: +886-3-3281200 (ext. 3651) (C.-Y.F.); Fax: +886-3-3289582 (C.-Y.F.)
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Lin B, Matsushima K, De Leon L, Piccinini A, Recinos G, Love B, Inaba K, Demetriades D. Early Venous Thromboembolism Prophylaxis for Isolated High-Grade Blunt Splenic Injury. J Surg Res 2019; 243:340-345. [DOI: 10.1016/j.jss.2019.05.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/23/2019] [Accepted: 05/30/2019] [Indexed: 11/30/2022]
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Western Trauma Association Critical Decisions in Trauma: Management of adult blunt splenic trauma-2016 updates. J Trauma Acute Care Surg 2018; 82:787-793. [PMID: 27893644 DOI: 10.1097/ta.0000000000001323] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Johnsen NV, Betzold RD, Guillamondegui OD, Dennis BM, Stassen NA, Bhullar I, Ibrahim JA. Surgical Management of Solid Organ Injuries. Surg Clin North Am 2017; 97:1077-1105. [PMID: 28958359 DOI: 10.1016/j.suc.2017.06.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.
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Affiliation(s)
- Niels V Johnsen
- Urological Surgery, Department of Urological Surgery, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN 37232, USA
| | - Richard D Betzold
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Oscar D Guillamondegui
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Bradley M Dennis
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA.
| | - Nicole A Stassen
- Surgical Critical Care Fellowship and Surgical Sub-Internship, University of Rochester, Kessler Family Burn Trauma Intensive Care Unit, 601 Elmwood Avenue, Box Surg, Rochester, NY 14642, USA
| | - Indermeet Bhullar
- Orlando Health Physicians Surgical Group, Orlando Regional Medical Center, 86 West Underwood, Suite 201, Orlando, FL 32806, USA
| | - Joseph A Ibrahim
- Orlando Health Physicians Surgical Group, Orlando Regional Medical Center, 86 West Underwood, Suite 201, Orlando, FL 32806, USA
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5
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Abstract
PURPOSE OF REVIEW To review the current care of the patient with an injured spleen. RECENT FINDINGS The initial care of the patient with splenic injury is dictated by their hemodynamic presentation and the institution's resources. Although most high-grade injuries require splenectomy, up to 38% are successfully managed nonoperatively. Angioembolization has increased splenic salvage with a minimum of complications. In the absence of injuries that mandate longer hospital stays, patients with low-grade injuries are successfully discharged in 1-2 days and high-grade injuries in 3-4 days. Delayed splenic hemorrhage remains a feared complication, but fortunately the 180-day readmission rate for splenectomy is low with the majority of those returning within 8 days of injury. SUMMARY Nonoperative management (NOM) is the standard of care for the hemodynamically stable patient with an isolated blunt splenic injury. Splenic salvage can be safely increased, even in higher grade injuries, with the use of angioembolization. Patients managed nonoperatively are successfully discharged as early as 1-2 days for low-grade injuries and as early as 3-4 days for higher grade. Safe management of the patient with blunt splenic injury requires careful selection for NOM, meticulous monitoring and follow-up.
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Bhullar IS, Frykberg ER, Siragusa D, Chesire D, Paul J, Tepas JJ, Kerwin AJ. Age Does Not Affect Outcomes of Nonoperative Management of Blunt Splenic Trauma. J Am Coll Surg 2012; 214:958-64. [DOI: 10.1016/j.jamcollsurg.2012.03.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 03/09/2012] [Accepted: 03/09/2012] [Indexed: 11/29/2022]
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Norrman G, Tingstedt B, Ekelund M, Andersson R. Nonoperative Management of Blunt Splenic Trauma: Also Feasible and Safe in Centers with Low Trauma Incidence and in the Presence of Established Risk Factors. Eur J Trauma Emerg Surg 2008; 35:102. [PMID: 26814761 DOI: 10.1007/s00068-008-8108-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Accepted: 09/22/2008] [Indexed: 11/29/2022]
Abstract
BACKGROUND Treatment of blunt splenic trauma has undergone dramatic changes over the last few decades. Nonoperative management (NOM) is now the preferred treatment of choice, when possible. The outcome of NOM has been evaluated. This study evaluates the results following the management of blunt splenic injury in adults in a Swedish university hospital with a low blunt abdominal trauma incidence. METHOD Fifty patients with blunt splenic trauma were treated at the Department of Surgery, Lund University Hospital from January 1994 to December 2003. One patient was excluded due to a diagnostic delay of > 24 h. Charts were reviewed retrospectively to examine demographics, injury severity score (ISS), splenic injury grade, diagnostics, treatment and outcome measures. RESULTS Thirty-nine patients (80%) were initially treated nonoperatively (NOM), and ten (20%) patients underwent immediate surgery (operative management, OM). Only one (3%) patient failed NOM and required surgery nine days after admission (failure of NOM, FNOM). The patients in the OM group had higher ISS (p < 0.001), higher grade of splenic injury (p < 0.001), and were hemodynamically unstable to a greater extent (p < 0.001). This was accompanied by increased transfusion requirements (p < 0.001), longer stay in the ICU unit (p < 0.001) and higher costs (p = 0.001). Twenty-seven patients were successfully treated without surgery. No serious complication was found on routine radiological follow-up. CONCLUSION Most patients in this study were managed conservatively with a low failure rate of NOM. NOM of blunt splenic trauma could thus be performed in a seemingly safe and effective manner, even in the presence of established risk factors. Routine follow-up with CT scan did not appear to add clinically relevant information affecting patient management.
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Affiliation(s)
| | | | | | - Roland Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University Hospital, Lund, Sweden. .,Department of Surgery, Clinical Sciences Lund, Lund University Hospital, 221 85, Lund, Sweden.
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Observation For Nonoperative Management of the Spleen: How Long is Long Enough? ACTA ACUST UNITED AC 2008; 65:1354-8. [DOI: 10.1097/ta.0b013e31818e8fde] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Western Trauma Association (WTA) critical decisions in trauma: management of adult blunt splenic trauma. ACTA ACUST UNITED AC 2008; 65:1007-11. [PMID: 19001966 DOI: 10.1097/ta.0b013e31818a93bf] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Pucci E, Brody F, Zemon H, Ponsky T, Venbrux A. Laparoscopic Splenectomy for Delayed Splenic Rupture After Embolization. ACTA ACUST UNITED AC 2007; 63:687-90. [PMID: 17413515 DOI: 10.1097/01.ta.0000235299.77320.6b] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Edward Pucci
- Department of Surgery, The George Washington University Medical Center, Washington, DC, USA
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11
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Richardson JD. Changes in the Management of Injuries to the Liver and Spleen. J Am Coll Surg 2005; 200:648-69. [PMID: 15848355 DOI: 10.1016/j.jamcollsurg.2004.11.005] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2004] [Accepted: 11/02/2004] [Indexed: 12/13/2022]
Affiliation(s)
- J David Richardson
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
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Affiliation(s)
- A B Peitzman
- Section of Trauma/Surgical Critical Care and Division of General Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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13
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Mackersie RC. Abdominal Trauma. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Shanmuganathan K, Mirvis SE, Boyd-Kranis R, Takada T, Scalea TM. Nonsurgical management of blunt splenic injury: use of CT criteria to select patients for splenic arteriography and potential endovascular therapy. Radiology 2000; 217:75-82. [PMID: 11012426 DOI: 10.1148/radiology.217.1.r00oc0875] [Citation(s) in RCA: 168] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine if contrast material-enhanced spiral computed tomography (CT) can be used to select patients with blunt splenic injuries to undergo arteriographic embolization. MATERIALS AND METHODS During a 15-month period, 78 patients who were hemodynamically stable and required no immediate surgery underwent contrast-enhanced spiral CT followed by splenic arteriography. CT scans were assessed for splenic vascular contrast material extravasation or posttraumatic splenic vascular lesions. Medical records were reviewed for splenic arteriographic results and clinical outcome. RESULTS There were 25 grade I, 12 grade II, 27 grade III, 12 grade IV, and two grade V splenic injuries. CT showed active contrast material extravasation in seven patients and splenic vascular lesions in 19 patients. At CT, splenic vascular contrast material extravasation was 100% (seven of seven patients) and a posttraumatic splenic vascular lesion was 83% (10 of 12 patients) sensitive on the basis of arteriographic or surgical outcome in predicting the need for transcatheter embolization or splenic surgery. Overall, CT had a sensitivity of 81% (17 of 21 patients), a specificity of 84% (48 of 57 patients), negative and positive predictive values of 92% (48 of 52 patients) and 65% (17 of 26 patients), respectively, and an accuracy of 83% (65 of 78 patients) in predicting the need for splenic injury treatment. CONCLUSION Contrast-enhanced spiral CT plays a valuable role in selecting hemodynamically stable patients with splenic vascular injury who may be treated with transcatheter therapy and potentially improves the success rate of nonsurgical management.
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Affiliation(s)
- K Shanmuganathan
- Department of Radiology, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201, USA.
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Krause KR, Howells GA, Bair HA, Glover JL, Madrazo BL, Wasvary HJ, Bendick PJ. Nonoperative Management of Blunt Splenic Injury in Adults 55 Years and Older: A Twenty-Year Experience. Am Surg 2000. [DOI: 10.1177/000313480006600707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The nonoperative management of splenic injury secondary to blunt trauma in older patients remains controversial. We have reviewed our experience from January 1978 to December 1997 with selective nonoperative management of blunt splenic injury in adults 55 years and older. Criteria for nonoperative management included hemodynamic stability with any transient hypotension corrected using less than 2000 cm3 crystalloid infusion, a negative abdominal physical examination ruling out associated injuries, and a blood transfusion requirement of no more than 2 units attributable to the splenic injury. During the study period, 18 patients over age 55 with radiographic confirmation of a splenic injury met the above criteria for nonoperative management. Their mean age was 72 years (range 56–86), and 13 of the 18 were female (72%). The mean Injury Severity Score was 15 (range 4–29), with the mechanism of injury equally divided between automobile crashes (9) and falls (9). During a similar time period, 15 patients 55 years or older with splenic injury composed an operative group; these patients did not differ with respect to age (mean 68 years), sex (60% female), or mechanism of injury. CT scans of 8 patients managed nonoperatively were available and graded using the American Association for the Surgery of Trauma classification, with a mean score of 2.3 (range 2–3). Eight of the 18 nonsurgical patients received blood transfusions. None of the 18 patients who met the criteria for nonoperative management “failed” the protocol, and none were taken to the operating room for abdominal exploration. Two patients (11%) died of associated thoracic injuries after lengthy hospital stays, one at 10 days and one at 24 days. We conclude from our data that nonoperative management of blunt splenic injury in patients age 55 years and older is indicated provided they are hemodynamically stable, do not require significant blood transfusion, and have no other associated abdominal injuries.
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Affiliation(s)
- Kevin R. Krause
- Department of Surgery, William Beaumont Hospital, Royal Oak, Michigan
| | - Greg A. Howells
- Division of Trauma Surgery, William Beaumont Hospital, Royal Oak, Michigan
| | - Holly A. Bair
- Division of Trauma Surgery, William Beaumont Hospital, Royal Oak, Michigan
| | - John L. Glover
- Department of Surgery, William Beaumont Hospital, Royal Oak, Michigan
| | | | - Harry J. Wasvary
- Department of Surgery, William Beaumont Hospital, Royal Oak, Michigan
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Duverger V, Muller L, Szymszyczyn P, Vergos M. [Surgical abstention in closed injuries of the spleen]. ANNALES DE CHIRURGIE 2000; 125:380-4. [PMID: 10900742 DOI: 10.1016/s0003-3944(00)00211-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Splenic conservation avoids the overwhelming postsplenectomy infection. The high percentage of patients treated by noninvasive procedures would be due to the simple clinical course of splenic trauma and precision of diagnosis, using CT scan. Only clinical evaluation could provide further information on the indications for surgical treatment, as there is no available score regarding the value of CT scan for choosing the therapeutical option. Non-operative management of splenic ruptures should be considered in selected patients in whom hemodynamics is stable and closely monitored.
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Affiliation(s)
- V Duverger
- Service de chirurgie viscérale et vasculaire, HIA Bégin, Saint-Mandé, France
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17
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Cocanour CS, Moore FA, Ware DN, Marvin RG, Duke JH. Age should not be a consideration for nonoperative management of blunt splenic injury. THE JOURNAL OF TRAUMA 2000; 48:606-10; discussion 610-2. [PMID: 10780591 DOI: 10.1097/00005373-200004000-00005] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Operative management of blunt splenic injury is recommended for adults > or = 55 years. Because this is not our practice, we did a retrospective review to compare outcomes of patients > or = 55 years old versus patients < 55 years old. METHODS During a 5-year period ending in July of 1998, 461 patients (3%) admitted to our Level I trauma center had a blunt splenic injury. Eighty-six patients (19%) died within 24 hours of massive injuries, leaving 375 patients for evaluation. Data were obtained from our trauma registry and medical records. RESULTS A total of 29 patients (8%) were > or = 55 years old (mean age, 67 +/- 2 years; mean injury severity score [ISS] 25 +/- 2). Of these, 18 patients (62%) underwent nonoperative management (NOM). A total of 346 patients (92%) were < 55 years old (mean age, 28 +/- 0.6; mean ISS, 20 +/- 1). Of these, 198 patients (57%) underwent NOM. The failure rate was not different between the two age groups (17% vs. 14%). However, the ISS and mortality rate were significantly higher in the older age group that failed (ISS, 29.3 +/- 2.6 vs. 19.5 +/- 2.1; mortality: 67% vs. 4%). None of the deaths could be attributed to splenic injury. CONCLUSION Adults > or = 55 years old with blunt splenic injury are successfully treated by NOM. Although older adults had significantly greater injuries, they had similar failure rates of NOM when compared with younger adults. Older adults had significantly higher mortality, but this was not a result of their splenic injury. Therefore, age should not be a criteria for NOM of blunt splenic injury.
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Konstantakos AK, Barnoski AL, Plaisier BR, Yowler CJ, Fallon WF, Malangoni MA. Optimizing the management of blunt splenic injury in adults and children. Surgery 1999. [DOI: 10.1016/s0039-6060(99)70139-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kluger Y, Rabau M, Rub R, Weinbroum A, Chaushu G, Ben-Avraham R, Dayan D. Comparative study of splenic wound healing in young and adult rats. THE JOURNAL OF TRAUMA 1999; 47:261-4. [PMID: 10452459 DOI: 10.1097/00005373-199908000-00007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nonoperative management (NOM) of splenic injuries is a common practice in stable trauma patients. Nevertheless, age-related differences in the success rate of NOM have prompted inclusion of age among the criteria of patient selection. Elucidation of the cellular mechanism of splenic wound healing in the young versus that of adults may explain why age can be related to the success of NOM in splenic injuries. METHODS A laceration was made in the splenic antihilar surface of 40 young and 40 adult male rats. Postoperatively, at specified intervals extending until day 21, spleens were removed, fixed, and examined by routine histopathology. In addition, sections were stained histochemically for collagen fibers and immunohistochemically for myofibroblast histomorphometry. RESULTS The intense local hemorrhage was resorbed within 48 hours in the young rats, and within 7 days in the adults. Disappearance of germinal centers and other splenic alterations started on the first day in both groups, but regeneration of splenic parenchyma was accomplished after 14 days in the young, whereas in the adults, on day 21 it was still incomplete. Maximal myofibroblast accumulation at the laceration site was seen after two days in the young, whereas in adults only on day 4 (p < 0.0001). Collagen scars were not present in either group. Thickening of the damaged capsule, composed of collagen fibers with yellowish-green polarization colors, was observed only in adult rats. CONCLUSION Splenic wounds heal by regeneration and not by collagen scarring. In the young, myofibroblasts accumulate in the site of injury faster than in adults. These cells may enhance contraction and increase the rate of wound healing until parenchymatic regeneration is completed. Our results may indirectly explain the higher success rate of NOM of splenic injury in young patients.
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Affiliation(s)
- Y Kluger
- Rabin Trauma Center, Department of Surgery, Tel-Aviv Medical Center, Israel
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20
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Newman PG, Rozycki GS. Diagnosis of visceral organ injury. Eur Surg 1999. [DOI: 10.1007/bf02619789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Affiliation(s)
- W W Coon
- Department of Surgery, University of Michigan Medical Center, Ann Arbor, USA
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22
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Bain IM, Kirby RM. 10 year experience of splenic injury: an increasing place for conservative management after blunt trauma. Injury 1998; 29:177-82. [PMID: 9709417 DOI: 10.1016/s0020-1383(97)00170-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
It has been suggested that over 30 per cent of splenic injuries are suitable for conservative management by non-operative treatment and splenorrhaphy; splenic conservation avoids the risk of overwhelming post-splenectomy infection. In this study, injuries of the spleen have been retrospectively analysed for a 10 year period. In the first 5 years the spleen was conserved in only 6/45 (15 per cent) of patients with blunt injury (three non-operative, three splenorrhaphy). In the second 5 years of the study, the spleen was conserved in significantly more patients with blunt trauma, 25 of 61 (41 per cent). This change has been a result of increased non-operative management which has been successful in the majority of cases (20/22). This has been associated with the increased use of abdominal ultrasound. The rate of splenorrhaphy has not changed significantly, five patients compared with three in the previous 5 years. Non-operative management may be increasingly appropriate as less severe splenic injuries are being detected with an increased use of ultrasound. Splenic injury is not a mandatory indication for laparotomy; non-operative management of splenic injuries should be considered in selected patients who are haemodynamically stable and can be closely monitored.
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Affiliation(s)
- I M Bain
- Department of Surgery, North Staffordshire Hospital, Stoke-on-Trent, UK
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Abstract
Based upon the anatomicosurgical segments of the spleen, suggested by DiDio and demonstrated in cadavers, classified and named by Neder (1958) and Zappalá (1958, 1959, 1963), the normal segmental organization was anatomically and radiologically confirmed in 51 human spleens, after studying corrosion casts and radiograms of intraparenchymal vessels (Christo, 1959 a, b, 1960, 1962, 1963, 1993). From 1958 to 1965, pioneer segmental resections were performed successfully in 34 dogs and in 9 patients to safely remove traumatic injured splenic segments. At the same time, the overwhelming postsplenectomy infection (OPSI) became well identified. Consequently, to save normally functioning splenic parenchyma became the most important issue in the management of splenic injuries. The anatomical basis for partial splenectomy and splenic segmentectomy is discussed. The term "splenorrhaphy" was employed to designate all conservative or parenchyma saving operations of spleen based upon its vascular supply: from topical packings to splenic sutures including "cappings" and partial splenectomies. From analysis of 38 consecutive reports in 20 years, covering 4,076 patients, it was concluded that "splenorrhaphies" had been electively employed in 46% of the injuries and partial splenectomies were identified in 8.6% of these surgical interventions. However, the critical minimal mass of splenic tissue to be preserved after partial splenectomies is still to be defined. Postoperative complications directly related to "splenorrhaphies" are rare. Uncommonly performed after splenectomies, the heterotopical splenic autotransplantation has presented dubious results. Trials with nonoperative management of splenic blunt trauma injuries have been safer among children, whose spleens are predominantly transversally disrupted and have a higher relationship "capsular resistance/parenchymal bulk". Splenectomies have been most frequently the ultimate result of delayed laparotomy and underlying risks of growing blood requirements may surpass the advantages of preventing OPSI.
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Affiliation(s)
- M C Christo
- Department of Surgery, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brasil
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Smith JS, Cooney RN, Mucha P. Nonoperative management of the ruptured spleen: a revalidation of criteria. Surgery 1996; 120:745-50; discussion 750-1. [PMID: 8862387 DOI: 10.1016/s0039-6060(96)80026-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Our goal was to revalidate this institution's original criteria for safe nonoperative management of splenic injury. METHODS This was a prospective series between October 1991 and December 1995 entering all patients with splenic injury to a modified algorithm. Patients were taken to the operating room if hemodynamically unstable (systolic blood pressure less than 90 mm Hg; pulse greater than 110 beats per minute) after 2 liters of fluid resuscitation, positive abdominal examination findings, American Association for the Surgery of Trauma Organ Injury Scale Grade IV or V injuries by computed tomographic scan (unless younger than 15 years old), or associated severe head injuries (unless younger than 15 years old), or age greater than 55. The remainder of the patients were closely observed. RESULTS One hundred seventy-three patients were entered-six were excluded by death before operating room salvage, and one was excluded because of operation for a ruptured thoracic aorta. Therefore 166 patients were reviewed. Seventy splenectomies and 18 splenorrhaphies were performed, and 78 patients were treated nonoperatively (58% splenic salvage). Two failures occurred in the nonoperative group: a 16-year-old with a grade IV hilar injury was operated on on the eighth day after injury because of a continually falling hematocrit, and a 25-year-old with unresolved tachycardia was operated on at 6 hours (97% success rate). The patients in the operative group had a greater severity of injury as determined by mean Injury Severity Score of 32, 18 deaths, a mean transfusion requirement of 14 units of blood compared with mean injury severity score of 21, two deaths from brain injury, and no transfusions given in 58 of the 78 nonoperative cases. CONCLUSIONS Prospectively applied, these guidelines allow the safe nonoperative management of patients with blunt splenic injury.
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Affiliation(s)
- J S Smith
- Trauma/Critical Care Surgery Unit, University Hospital, Milton S. Hershey Medical Center, Hershey, PA 17033, USA
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25
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Nonoperative Management of Solid Abdominal Visceral Injury: Part I. Spleen. J Intensive Care Med 1996. [DOI: 10.1177/088506669601100502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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26
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Goletti O, Ghiselli G, Lippolis PV, Di Sarli M, Macaluso C, Pinto F, Chiarugi M, Cavina E. Intrasplenic posttraumatic pseudoaneurysm: echo color doppler diagnosis. THE JOURNAL OF TRAUMA 1996; 41:542-5. [PMID: 8810980 DOI: 10.1097/00005373-199609000-00029] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Nonsurgical conservative treatment of blunt splenic trauma has gained widespread consensus in the last few years. It has been demonstrated that 60% of patients with blunt abdominal trauma with spleen lesion achieve the best therapy by using conservative therapy. Despite the accuracy of ultrasonography (US) and computed tomography in detecting and grading the spleen lesions, the evolution of the lesion is often unexpected. In 15 to 30% of patients, a two-stage splenic rupture may be expected within 2 weeks. Delayed complications, such as splenic abscesses and pseudoaneurysms of the splenic artery and its branches, have been observed. To prevent complications, a short follow-up has been scheduled for these patients by using US and US color Doppler. The authors propose routine echo Doppler evaluation for all patients affected by intraparenchymal hematoma after blunt abdominal trauma.
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Affiliation(s)
- O Goletti
- Emergency Surgery Department, University of Pisa, Italy
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27
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Abstract
This article examines the current management of trauma to the spleen. The incidence, mechanism, classification, diagnosis, treatment and complications of splenic trauma are reviewed. Modern radiological investigations are assessed in view of the recent vogue for non-operative management. The effects of splenectomy and particularly of overwhelming postsplenectomy sepsis are discussed. The role of non-operative management of splenic injuries in children and in adults without associated injuries is emphasized. Means of repairing and preserving the spleen are detailed. Prompt splenectomy is necessary in seriously traumatized patients, especially those with head or multiple injuries.
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Affiliation(s)
- R H Wilson
- Department of Surgery, Queen's University of Belfast, UK
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28
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Lewis FW, Moloo N, Stiegmann GV, Goff JS. Splenic injury complicating therapeutic upper gastrointestinal endoscopy and ERCP. Gastrointest Endosc 1991; 37:632-3. [PMID: 1756925 DOI: 10.1016/s0016-5107(91)70872-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- F W Lewis
- Department of Medicine, University of Colorado Health Sciences Center, Denver
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29
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Abstract
There is growing awareness that the majority of traumatic splenic injuries should be managed non-operatively. This review of all traumatic spleen injuries at a large community teaching hospital over a 10-year period (1978-1988) confirms that principle. The study generated selection criteria and principles of non-operative management. Of a total of 91 patients, 23 were initially treated non-operatively. The average age was 27 years and all but two were adults. Splenic injury was confirmed by computed tomography scan in 20 patients (87 per cent) and by liver/spleen scan in three patients (13 per cent). Of the 23 patients, 21 (91 per cent) were successfully treated non-operatively. Of these, 14 had intraparenchymal or subcapsular haematomas and seven had splenic lacerations with haemoperitoneum. Two patients (9 per cent) initially treated non-operatively required splenectomy. Haemodynamically stable adult patients with blunt splenic injuries can be managed non-operatively if monitored in a setting where immediate operative intervention is available. Operative intervention is indicated not only in haemodynamically unstable patients, but also in patients who require more than four units of blood during a 48-h period.
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Affiliation(s)
- H I Koury
- Department of Surgery, Good Samaritan Hospital, Cincinnatti, Ohio
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30
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31
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Sugrue M, Knox A, Sarre R, McIntosh N, Toouli J. Management of splenic trauma: a new CT-guided splenic injury grading system. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1991; 61:349-53. [PMID: 2025187 DOI: 10.1111/j.1445-2197.1991.tb00231.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The aim of this study was to assess a newly developed computerized tomography (CT)-based splenic injury index in predicting the outcome of splenic injury. Twelve patients with isolated splenic injuries were studied. Splenic parenchymal injury was graded from 1 to 4 based on CT. The splenic injury index was obtained by multiplying the parenchymal score by the volume haemoperitoneum, which was measured on the CT scanner. The 12 patients with CT-proven splenic injuries had a mean injury index of 193.5 +/- 191 (mean +/- s.d.). The 3 patients who failed conservative management had a mean index of 475 +/- 50, compared with an index of 99.5 +/- 100 in the nine managed non-operatively (P less than 0.001). This new CT-based splenic injury index allows morphological assessment of splenic injury and may predict the outcome of splenic trauma.
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Affiliation(s)
- M Sugrue
- Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia
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32
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Abstract
Splenic salvage following blunt injury can fail when parenchymal bleeding is uncontrollable. To define the usefulness of an argon beam coagulator for hemostasis, we used the instrument in a laboratory trial of partial splenic resection. New Zealand white rabbits, weighing 4 to 5 kg, had sharp excision of the lower half of the spleen. No sutures were used to control hemorrhage from the cut splenic surface or the hilar vessels. Hemostasis was achieved with 2 to 4 seconds of electrocoagulation delivered by a beam of argon gas. All animals survived the procedure and were in good health when killed between the fourth and sixth week following the procedure. At necropsy, the spleen was viable in all animals with no abscess or hematoma. Minimal adhesions from the treated splenic surface to the omentum were found. The scar at the cut surface was 1 mm in depth, and the histology of the remainder of the spleen was normal. In this simulated splenic injury model, argon beam coagulation was uniformly successful in achieving hemostasis. Minimal tissue destruction and lack of infection were noted. The argon beam coagulator may be useful in patients with severe splenic injuries and other situations requiring partial splenectomy.
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Affiliation(s)
- S Stylianos
- Division of Pediatric Surgery, Tufts University School of Medicine, Floating Hospital, Boston, MA
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33
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Williams MD, Young DH, Schiller WR. Trend toward nonoperative management of splenic injuries. Am J Surg 1990; 160:588-92; discussion 592-3. [PMID: 2252118 DOI: 10.1016/s0002-9610(05)80751-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Treatment of splenic injuries has evolved over the past decade to reflect more effort to conserve function of the spleen. Records of 169 patients admitted over a 6-year period were identified as documenting the treatment of splenic injuries. We collected data regarding patient age, gender, degree of hemodynamic stability, number of units of blood required, severity of splenic injury, Injury Severity Score, and results of treatment. There were 143 adults (age greater than 16 years) and 26 pediatric patients (age less than 17 years), with mean age in the 2 groups of 31.6 and 11.4 years, respectively. Males comprised 72% of the group, and blunt injury occurred in 154 of the 169 patients. In the adults, splenectomy, splenorrhaphy, laparotomy without operative treatment of the spleen, and nonoperative management were observed 48%, 30%, 14%, and 8% of the time and in the pediatric group 31%, 27%, 19%, and 23% of the time, respectively. By using operative splenic repair techniques and increased use of nonoperative management, the splenic salvage rate has increased in the last 6 years from 41% to 61% without an increase in morbidity and mortality. Incidence of spleen salvage correlated with severity of spleen and overall injury and cardiovascular stability.
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Affiliation(s)
- M D Williams
- Trauma Center, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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34
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Abstract
In an effort to reduce the rate of nontherapeutic celiotomy yet avoid the possibility of missed injuries, surgeons are evaluating protocols for nonoperative management of abdominal trauma. Discussion of this controversial issue includes specific approaches to the diagnosis and management of splenic injury, gunshot wounds, and stab wounds.
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35
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Abstract
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.
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Affiliation(s)
- S R Shackford
- Department of Surgery, University of Vermont, Burlington
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36
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Feliciano DV, Spjut-Patrinely V, Burch JM, Mattox KL, Bitondo CG, Cruse-Martocci P, Jordan GL. Splenorrhaphy. The alternative. Ann Surg 1990; 211:569-80; discussion 580-2. [PMID: 2339918 PMCID: PMC1358226 DOI: 10.1097/00000658-199005000-00007] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
From 1980 to 1989, 240 adult patients underwent splenorrhaphy at one urban trauma center. This represents 43.4% of all splenic injuries seen during this time interval. Splenic injuries were graded I to V, and splenorrhaphy was attempted except when the spleen was shattered or when multiple injuries with associated hypotension were present. Penetrating wounds, blunt trauma, or iatrogenic/unknown etiologies were present in 54.2%, 41.6%, and 4.2% of patients, respectively. Grade I or II injuries were present in 51.7% of patients, grade III in 34.6%, grade IV or V in 9.6%, and unknown grade in 4.1%. The technique of splenorrhaphy was simple suture (usually chromic) with or without the addition of topical hemostatic agents in 200 patients (83.3%), topical agents alone in 12 (5%), unknown type of repair in 12 (5%), compression, cautery, or nonbleeding injury in 9 (3.8%), and partial or hemisplenectomy in 7 (2.9%). Postoperative rebleeding occurred in three patients (1.3%) with grade II, III, and IV injuries, respectively, and led to splenectomy at reoperation. In another patient who had a hemisplenectomy performed for a grade IV injury, subphrenic abscesses and septic shock led to the death of the patient. Splenorrhaphy can be safely performed in properly selected adult patients after a variety of injuries. The risk of rebleeding is practically nil when the spleen is fully mobilized and visualized during repair.
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Affiliation(s)
- D V Feliciano
- Cora and Webb Mading Department of Surgery, Baylor College of Medicine, Houston, Texas
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37
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Malangoni MA, Cué JI, Fallat ME, Willing SJ, Richardson JD. Evaluation of splenic injury by computed tomography and its impact on treatment. Ann Surg 1990; 211:592-7; discussion 597-9. [PMID: 2339920 PMCID: PMC1358230 DOI: 10.1097/00000658-199005000-00009] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We reviewed 37 consecutive, hemodynamically stable patients (16 adults, 21 children) who had splenic injuries diagnosed by computed tomography (CT) scan to compare the CT evaluation with operative assessment of injury and eventual treatment. Computed tomographic scans and operative findings were graded by a splenic injury scoring system. Two patients were classified as having grade 1, 21 as grade 2, 11 as grade 3, and 3 as grade 4 splenic injuries. Computed tomography underestimated the degree of injury in 9 of 17 (53%) operated patients (mean CT score, 2.6; mean operative score, 3.3; p less than 0.01). Six of sixteen adults and 19 of 21 children were intentionally treated by observation. There were 5 treatments failures (20%), 3 due to bleeding and 1 each due to pancreatic injury and splenic abscess. The failure rate of observation was lower in children (16%) than in adults (33%), even though children had a higher Splenic Injury Score (2.4 versus 1.8). Patients who underwent an operation received twice as much blood as the observed group. There was no significant difference in Injury Severity Score or total fluid requirements between operated and observed patients. Operations increased in frequency in both adults and children as the injury score increased. This experience suggests that CT scan accurately determines the presence of splenic injury but commonly underestimates its severity. While children with grades 1 through 3 injuries are likely to be treated successfully with observation, adults who have more minor splenic injuries often fail observation and may be treated better by prompt operation.
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Affiliation(s)
- M A Malangoni
- Department of Surgery, University of Louisville School of Medicine, KY 40292
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38
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Gough DC. Trauma to the spleen. Arch Emerg Med 1989; 6:237-40. [PMID: 2514699 PMCID: PMC1285621 DOI: 10.1136/emj.6.4.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- D C Gough
- Royal Manchester Children's Hospital, Pendlebury, England
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39
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Smedira N, Schecter WP. Blunt Abdominal Trauma. Emerg Med Clin North Am 1989. [DOI: 10.1016/s0733-8627(20)30758-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Ward AJ, Gillatt DA. Delayed diagnosis of traumatic rupture of the spleen--a warning of the use of thoracic epidural analgesia in chest trauma. Injury 1989; 20:178-9. [PMID: 2599648 DOI: 10.1016/0020-1383(89)90096-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Epidural analgesia is useful in controlling the pain from chest injuries. However, a case is presented where analgesia delayed the diagnosis of a splenic haematoma. Diagnosis was complicated by an initial negative peritoneal lavage.
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Affiliation(s)
- A J Ward
- Departments of Orthopaedic and General Surgery, Southmead General Hospital, Bristol
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41
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Gauderer MW, Stellato TA, Hutton MC. Splenic injury: nonoperative management in three patients with infectious mononucleosis. J Pediatr Surg 1989; 24:118-20. [PMID: 2723983 DOI: 10.1016/s0022-3468(89)80314-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Three patients with infectious mononucleosis and splenic injury were managed nonoperatively. Mechanisms of injury included significant left upper quadrant trauma during a football game in a 17-year-old boy, a minor fall in a 16-year-old girl, and no apparent trauma in the remaining patient, a 28-year-old man. All had significant abdominal pain and two were hypotensive upon admission. All had computerized tomographic scan documentation of splenic enlargement, significant injury, and free peritoneal blood. Paracentesis was not performed. Only the first patient received transfused blood. The hospitalization period ranged from nine to 14 days. Gradual and finally complete healing (return to normal size) was documented in all three patients. Follow-up is 66, 14, and 10 months. Although clearly controversial and not free from danger, successful nonoperative management of the injured enlarged spleen in select patients with mononucleosis is possible in an appropriate setting.
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Affiliation(s)
- M W Gauderer
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
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42
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43
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Affiliation(s)
- J F Perry
- University of Minnesota Medical School, St. Paul
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44
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Malangoni MA, Evers BM, Peyton JC, Wellhausen SR. Reticuloendothelial clearance and splenic mononuclear cell populations after resection and autotransplantation. Am J Surg 1988; 155:298-302. [PMID: 3257658 DOI: 10.1016/s0002-9610(88)80720-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Although the preservation of splenic tissue may prevent overwhelming infection after splenectomy, the degree of protection conferred by small remnants has not been optimal. We investigated whether either splenic reticuloendothelial clearance of a blood flow-dependent colloid or macrophage and T-cell populations might be altered by resection or autotransplantation of the spleen. Our results have shown that bloodstream reticuloendothelial clearance of technetium 99m sulfur colloid is not impaired by splenectomy, partial resection of the spleen, or splenic autotransplantation. Such clearance is dependent on spleen weight and is not related to differences in either macrophage or helper or suppressor T-cell populations. This suggests that autotransplantation of the spleen is inferior to preservation of even a small hilar remnant and implies that repair or partial resection of the spleen will provide greater protection than autotransplantation.
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Affiliation(s)
- M A Malangoni
- Department of Surgery, University of Louisville School of Medicine, Kentucky 40292
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45
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Luna GK, Dellinger EP. Nonoperative observation therapy for splenic injuries: a safe therapeutic option? Am J Surg 1987; 153:462-8. [PMID: 3107414 DOI: 10.1016/0002-9610(87)90794-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Combining these reported and estimated incidences of mortality from overwhelming postsplenectomy infection, splenic salvage with nonoperative observation therapy and operative therapy, and the incidence of posttransfusion hepatitis and related mortality provides a conditional probability estimation of the risks of death with nonoperative observation therapy and operative therapy (Figure 4). The combined mortality rates for nonoperative observation and operative therapies are based on the following measured and estimated statistics: The post-transfusion hepatitis death rate per unit of blood transfused is 0.14 percent. Forty percent of children and 20 percent of adults who have successful nonoperative observation therapy receive an average of 2 units of blood. One hundred percent of children and adults in whom nonoperative observation therapy is unsuccessful receive an average of 4 units of blood. Twenty percent of children and adults who undergo operation initially receive an average of 2 units of blood. Ten percent of observed children require laparotomy and 75 percent of these patients then undergo splenectomy. Forty percent of adults who have nonoperative observation initially later require laparotomy, 93 percent of whom also require splenectomy. Ten percent of children and adults treated with initial operation later require splenectomy. Death from overwhelming postsplenectomy infection occurs in 0.026 percent of adults who undergo splenectomy and 0.052 percent of children who undergo splenectomy. Given these assumptions, the conditional probability of death in a child who initially undergoes nonoperative observation therapy is 0.17 percent compared with 0.06 percent for initial operative therapy. In adults, 0.26 percent of the observed patients die compared with 0.06 percent for those operated on initially. As stated, many of the percentages or probabilities listed are estimations based on the best available clinical data. The inability to establish a mortality rate from overwhelming postsplenectomy infection remotely resembling that reported for otherwise healthy patients required an unsubstantiated estimate. However, even when mortality rates from overwhelming postsplenectomy infection of 0.43 percent and 0.6 percent were substituted, early laparotomy still produced lower mortality rates. This continues to be true if one assumes that early laparotomy will result in 50 percent or even 100 percent of patients undergoing splenectomy, although in these cases the statistical differences would be less. We acknowledge that these statistics may exceed or underestimate the true risk of either treatment plan.(ABSTRACT TRUNCATED AT 400 WORDS)
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46
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Di Cataldo A, Puleo S, Li Destri G, Racalbuto A, Trombatore G, Latteri F, Rodolico G. Splenic trauma and overwhelming postsplenectomy infection. Br J Surg 1987; 74:343-5. [PMID: 3297232 DOI: 10.1002/bjs.1800740504] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Abstract
This review examines the incidence and implications of overwhelming infection in patients who have undergone splenectomy following trauma.
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47
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Kirurgisk JN. Splenic injury: a prospective multicentre study on non-operative and operative treatment. The Splenic Injury Study Group. Br J Surg 1987; 74:310-3. [PMID: 3580810 DOI: 10.1002/bjs.1800740428] [Citation(s) in RCA: 33] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
One hundred and forty-seven patients with splenic injury admitted to 18 different hospitals were included in a prospective multicentre study. The spleen was saved in 64 per cent. Out of the total series, 43 per cent of patients were not operated upon, 5 per cent had exploratory laparotomy only, and in 16 per cent splenic repair was performed. Treatment is discussed with reference to the nature of the splenic lesion, concomitant injuries, amount of blood transfusion given, and age of the patient. No deaths were definitely related to the splenic injury. The frequency of serious recurrent bleeding was not higher in the splenic salvage group when compared with the splenectomy group. Delayed bleeding was detected in 4 per cent of the patients. The mode of treatment varied considerably in different hospitals in that conservative treatment was performed in 14, splenic repair in 10 and splenectomy in 12 hospitals. Splenic salvage seems safe in most patients with a splenic injury. However, meticulous surveillance of the patient is mandatory.
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48
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Gall FP, Scheele J. [Differential indications of conservative and surgical possibilities of treating splenic rupture]. LANGENBECKS ARCHIV FUR CHIRURGIE 1986; 369:372-6. [PMID: 2433558 DOI: 10.1007/bf01274393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Conservative therapy of splenic trauma in the adult cannot be recommended, since 2/3 of patients with polytrauma will prove to have additional abdominal organ lacerations. The new methods of local haemostasis, suture and partial resection and their application and contraindications according to Barrett's classification of splenic trauma are discussed. Our own salvage rate has been 50% (70/140) in trauma and 77% (116/151) in iatrogenic lacerations during the past 5 years.
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49
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Liu LX, Xia SS, Shi HA. Spleen transplantation: III. Autotransplantation of splenic slices into omental pouches in adults after trauma. JOURNAL OF TONGJI MEDICAL UNIVERSITY = TONG JI YI KE DA XUE XUE BAO 1986; 6:251-5. [PMID: 3806745 DOI: 10.1007/bf02909754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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50
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Abstract
During the past decade, one of the most controversial issues in the surgical literature has been the question of what is the most appropriate management of splenic trauma. An increased understanding of the physiologic importance of splenic function must now be weighed against the life-threatening risk of exsanguinating splenic hemorrhage. In this article, postsplenectomy sepsis and mortality in adults and the selective management of blunt splenic trauma are discussed. Although the risks of postsplenectomy sepsis and serious infection are low, they do exist. A policy of individual assessment of cases is recommended when the merits of splenectomy versus those of splenic preservation are considered. Similarly, in cases of blunt splenic trauma, a policy of individual assessment is not only intellectually attractive but also safe, rational, and effective from a clinical standpoint. In selected cases of blunt splenic trauma, nonoperative management and splenorrhaphy are acceptable alternatives; however, in many instances splenectomy remains the most appropriate and only course of action.
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