The non-operative management of splenic trauma

Revitalize splenic functions. Following a splenectomy for trauma, a small amount of splenic autotransplantation was performed

INTRODUCTION

The spleen is a responsible significant part of the immune system; after Splenectomy following trauma, the immune system changes; splenic autotransplantation can preserve the immune system after trauma and Splenectomy.

BACKGROUND

Patients can be protected from immune dysfunction by autotransplanting splenic tissues after splenectomy following trauma because their immune systems and spleens are changed. Patients can gain their immune function after splenic autotransplantation.

METHODS

Patient classification methods are into three categories, Group A, 6 cases with auto-translation; Group B, 6 cases without transplantation; Group C, seven regular people serving as the control.

AIM OF WORK

The aim of the work is not to compare outcome methods or compare types of autotransplantation; This work aims to document postoperative radiological, immunological, clinical, and hematological investigations. We concentrated on the results of investigations more than the types of operation or approach or types of autotransplantation.

RESULTS

We showed that, after comparing each group with normal individuals subjects, patients who did not undergo autotransplantation had significantly higher platelet counts, a more significant percentage of micronucleated reticulocytes, increased levels of naive B lymphocytes, changes in class-switched memory and class-unswitched memory B cells, and higher levels of PD1 on CD8 + T lymphocytes. Nevertheless, neither splenic autotransplant patients nor the average general population showed any appreciable variations in any of the parameters.

CONCLUSIONS

Spleen's activities with adequate hemocatheter activity and recovery of the immunological deficit after splenic autotransplantation.

Single segment of spleen autotransplantation, after splenectomy for trauma, can restore splenic functions

Background

Splenectomy is sometimes necessary after abdominal trauma, but splenectomized patients are at risk of sepsis due to impaired immunological functions.

To overcome this risk, autotransplantation of the spleen by using a new technique has been proposed, but so far, a demonstration of functionality of the transplanted tissue is lacking.

Methods

We therefore evaluated 5 patients who underwent a splenic autotransplant in comparison with 5 splenectomized patients without splenic autotransplant and 7 normal subjects.

Results

We confirmed that the patients not undergoing autotransplantation, when compared to normal subjects, had a higher platelet count, higher percentage of micronucleated reticulocytes (p = 0.002), increased levels of naive B lymphocytes (p = 0.01), a defect of class-switched memory (p = 0.001) and class-unswitched memory B cells (p = 0.002), and increased levels of PD1 on T lymphocytes CD8+ (p = 0.08). In contrast, no significant differences for any of the abovementioned parameters were recorded between patients who underwent spleen autotransplantation and normal subjects.

Conclusion

These findings suggest that splenic autotransplantation is able to restore an adequate hemocatheretic activity as well as recover the immunological deficit after splenectomy.

Non-operative advances: what has happened in the last 50 years in paediatric surgery?

Paediatric surgeons remain paediatric clinicians who have the unique skill set to treat children with surgical problems that may require operative intervention. Many of the advances in paediatric surgical care have occurred outside the operating theatre and have involved significant input from medical, nursing and allied health colleagues. The establishment of neonatal intensive care units, especially those focusing on the care of surgical infants, has greatly enhanced the survival rates and long-term outcomes of those infants with major congenital anomalies requiring surgical repair. Educational initiatives such as the advanced trauma life support and emergency management of severe burns courses have facilitated improved understanding and clinical care. Paediatric surgeons have led with the non-operative management of solid organ injury following blunt abdominal trauma. Nano-crystalline burn wound dressings have enabled a reduced frequency of painful dressing changes in addition to effective antimicrobial efficacy and enhanced burn wound healing. Burns care has evolved so that many children may now be treated almost exclusively in an ambulatory care setting or as day case-only patients, with novel technologies allowing accurate prediction of burn would outcome and planning of elective operative intervention to achieve burn wound closure.

Evolution of non-operative management for blunt splenic trauma in children

Until the late 1960s, splenectomy was routinely performed in children who had sustained blunt splenic injury. There was based on the ability to perform splenectomy without obvious consequence; the cited 90-100% mortality for splenic trauma and the possibility of delayed rupture of the spleen. In contrast, contemporary findings in immunology and surgery demonstrated that non-operative management was not only feasible but desirable in view of the potential for overwhelming post-plenectomy infection. The history of universal splenectomy following blunt splenic trauma has been reviewed and we outline the findings that have resulted in the current standard of non-operative management following blunt splenic trauma.

Paediatric trauma at an adult trauma centre

BACKGROUND

Trauma in children remains the commonest cause of mortality. The majority of injured children who reach hospital survive, indicating that additional more sensitive outcome measures should be utilized to evaluate paediatric trauma care, including morbidity and missed injury rates. Limited contemporary data have been presented reviewing the care of injured children at an adult trauma centre (ATC).

METHODS

A review was undertaken of injured children who warranted activation of the trauma team, treated within the emergency department of an ATC (Royal North Shore Hospital) situated in the Lower North Shore area of Sydney. Data were collected prospectively and patients followed through to death or discharge from the ATC or another institution to which they had been transferred.

RESULTS

A total of 93 children were admitted to the ATC between January 1999 and April 2002. Mean age was 9 years 3 months (range 5 weeks-15 years 9 months) and 70% were male. The median injury severity score was 15 (range 1-75) and there were three deaths. Forty-two children were transferred to a paediatric trauma centre (PTC), including three children who had been transferred to the ATC from another hospital. There was one missed injury and one iatrogenic urethral injury.

CONCLUSIONS

The majority of children with trauma were treated safely and appropriately at the ATC. The missed injury rate was < 1% and there were no adverse long-term sequelae of initial treatment. Three secondary transfers could have been avoided by more appropriate coordination of the initial referral to a PTC.

Conservative management of splenic trauma: history and current trends

Evolution of the present-day policy of conservative management of ruptured spleen has been hailed as one of the most notable advances in pediatric surgery. Until 1971, routine splenectomy used to be the sacrosanct treatment for splenic trauma. It was universally believed that non-operative management carried a high mortality of 90 to 100%. Sporadic reports of successful conservative treatment appeared in the early twentieth century, but regrettably, these were ignored. Likewise, experimental studies pointing to the danger of post-splenectomy sepsis were also disregarded. Dominant surgical opinion continued to practice removal of the injured spleen. In 1968, Upadhyaya and Simpson, based on a well-designed clinical analysis of 52 children made a convincing plea for conservative management. In 1971, Upadhyaya et al. presented results of a corroborative experimental study, which provided the conclusive evidence that isolated splenic tears are well tolerated and heal spontaneously by first intention. Seeing the surge of publications that followed this presentation, it becomes apparent that this study constituted the real turning point that changed the world opinion in favour of salvage of the ruptured spleen. By 1979, numerous authors had reported the safety of non-operative management in hundreds of children all over the world. Currently, the policy of routine splenectomy has been universally abandoned; and the reported salvage rate of ruptured spleen is more than 90%. This paper traces the historical perspectives in the management of injured spleen from the times of Aristotle to the present day.

Risk of hemorrhage and appropriate use of blood transfusions in pediatric blunt splenic injuries

OBJECTIVE

To define changes in hematocrit (Hct) and the indications for blood transfusion in pediatric blunt splenic injury.

DESIGN

Retrospective case series

MATERIALS AND METHODS

All children with blunt splenic injuries from 1990 to 1995 were studied (n = 74). Transfusion practices were reviewed for the whole group. Thirty children with isolated splenic injuries who were not transfused were analyzed to document Hct changes (mean +/- 95% confidence intervals).

MEASUREMENTS AND RESULTS

The Hct at presentation was 37 +/- 2%, which rapidly dropped to 31 +/- 2% (p < 0.05) within 24 hours. After remaining stable at that level for the next 5 days, the Hct rose to 33 +/- 4% on day 6 (p = not significant), 35 +/- 4% on day 7 (p = not significant), and 38 +/- 2% (p = not significant) on day 13 +/- 3. Fifteen children received transfusions, all but one of whom had suffered multiple injuries. The transfusion rate declined from 38% of children in 1990 to 10% in 1995.

CONCLUSIONS

After the initial drop within the first 24 hours, the Hct remains stable and rises with time to reach the baseline by day 6. Transfusion rates have declined over time, and transfusions are now used almost exclusively in severely injured children with multiple injuries.

Splenic injury in children: a 10 year experience

The aim of this report was to review retrospectively the management of splenic trauma at a major Australian tertiary referral centre (Westmead Hospital) over a 10 year period. Forty-nine patients (0-15 years of age) with documented blunt splenic trauma were identified. The causes of splenic injury were road trauma (73%) and falls (27%). There were 22 minor injuries (Injury severity score [ISS] < 16) and 27 severe injuries (ISS > or = 16). All nine deaths were related to road trauma (mean ISS = 59). The investigation most commonly used was CT scanning (47%). Peritoneal lavage was performed in six patients (12%). Management involved non-operative care in 29 patients (57%), exploratory laparotomy alone in 5 (10%), splenic salvage in 2 (4%) and splenectomy in 13 (26%). This experience supports the view that non-operative management of splenic injury in haemodynamically stable children is safe and is the preferred treatment. Experienced assessment and meticulous observation is necessary. Laparotomy is indicated if there is continuing haemodynamic instability despite resuscitation. Operative management is aimed at splenic salvage with splenectomy being reserved for uncontrolled haemorrhage.

Recurrent traumatic splenic rupture two years after non-operative treatment of splenic trauma

Non-operative and conservative surgical management are now the preferred methods of treatment for blunt splenic trauma in children and adults. These conservative strategies evolved as the risk of late septic complications following splenectomy for trauma became apparent. Although recurrent splenic trauma following conservative management of the ruptured spleen is rare, its surgical management may pose some difficult problems. We present a case in which a second episode of splenic trauma required surgery, two years after the successful non-operative management of the first splenic injury.

Spleen Injury in Sports

In brief People who sustain sports-related spleen injuries develop constant pain in the left flank or left upper quadrant that may worsen when they move or breathe deeply. CT is the most effective diagnostic tool, but other diagnostic imaging techniques and blood tests aid in diagnosis. Most patients can be treated nonsurgically in an intensive care or step-down unit with bed rest, intravenous therapy, and careful monitoring.

[Under what conditions can splenic rupture be treated conservatively?]

In children even a certain splenic rupture allows an expectant attitude provided that circulation is stable, abdominal symptoms recede, and an intensive care over several days including ultrasound sonography is assured. We were able to proceed in this manner in five out of 37 children; without an operation we reached the restitution of the spleen.

Management of splenic trauma in childhood

The management of splenic trauma at the Royal Children's Hospital from January 1973 to January 1984 is reviewed. During the period studied there was a trend toward non-operative management in uncomplicated cases, and where laparotomy was required splenic repair rather than splenectomy was performed. Guidelines are given for the selection of patients who can be treated in safety without operation.

Changing trends in the diagnosis and management of rupture of the spleen

In this series of 80 consecutive patients with injured spleens scintigraphy was the diagnostic mainstay and was performed in 63 patients. Fifty-five patients were initially managed without operation. Two of them, however, underwent laparotomy respectively 1 and 2 days after admission because of increasing symptoms and signs. Twenty-seven patients underwent laparotomy, with successful conservative surgery in 8 and splenectomy in 19. However, in at least five of these it was thought in retrospect that repair of the spleen might have been possible. There were no deaths or serious morbidity from the injury to the spleen. It is concluded that no operation or operative repair of the spleen is the treatment of choice in the majority of patients with blunt injuries. In order to avoid loss of life as well as loss of the spleen, strict adherence to an aggressive, exact diagnostic process, using non-invasive diagnostic imaging and close clinical observation, as well as experienced, painstaking surgical techniques, is necessary.

Management of injury to the spleen in adults. Results of early operation and observation

Seventy-seven adults with splenic trauma were treated at a Level I Trauma Center during a 4-year period. Sixty-seven patients had early operation (55 splenectomy, nine splenorrhaphy, three partial splenectomy). Ten adults with stable vital signs were initially managed by observation without operation. Patients who had other intra-abdominal injuries were more likely to have an early operation and splenectomy. Patients who had a lesser transfusion requirement were more likely to have initial nonoperative management. Only three of the 10 patients who were managed initially by observation avoided eventual operation. Six of the seven patients who failed observation management required splenectomy. Patients with isolated splenic injuries had a significantly shorter hospital stay after an early operation than after observation without operation (p less than 0.05). We recommend early operation for the management of splenic injury in adults. Observation of isolated splenic injuries frequently is unsuccessful in adults and unnecessarily prolongs hospital stay.

Experience with the management of splenic injuries

This paper reviews the experience of treating 128 patients with splenic trauma over a 10 year period. All patients were aged under 16 years and all except one had sustained non-penetrating abdominal injuries. The diagnosis was established at operation or by spleen scan or by angiography but the decision to operate was made on clinical grounds. Patients who were stable on admission or after initial resuscitation were managed expectantly. In patients requiring surgery for massive bleeding or for other injuries the spleen was repaired whenever possible. Only 29% of patients required operation and in three quarters of these patients the spleen was able to be preserved. Delayed rupture of the spleen did not occur in the non-operative group and septic complications have not been observed in any survivors. There were 14 deaths in the series, 11 from severe head injury and three from massive haemorrhage.

Partial excision and drainage of post-traumatic splenic cysts

In areas of the world where malaria is endemic it is now advisable to conserve the spleen whenever possible following trauma. Post-traumatic cysts of the spleen may therefore be more commonly encountered. The experience in the four cases presented here shows that such cysts can be successfully managed without splenectomy. Evacuation of the cyst contents at laparotomy, followed by excision of the capsular component of the cyst and external drainage, gives good results.

Ruptured spleen in a malarious area: with emphasis on conservative management in both adults and children

Sixty-two consecutive cases of ruptured spleen occurring in a malarious area and reviewed. Nineteen died before treatment could be commenced. all patients who survived the initial hypotensive episode, and who were admitted to our unit, recovered, whether managed operatively or nonoperatively. We have conserved 26 spleens and removed 17. One splenectomised patient is known to have died subsequently from cerebral malaria. Although four cases of delayed rupture were seen, no conservatively treated patient had a delayed haemorrhage. Our policy is to avoid removal of the spleen in malarious areas in both adults and children.

Experimental splenosis: a comparative study in rats

The growth of the splenic remnant after partial splenectomy and autogenous splenic implants was compared in immature rats. Implants placed in the subcutaneous pouch of the anterior abdominal wall and the retroperitoneal space had none or minimal regeneration. Splenulus formed in the omental wrap were small, multiple and the combined weight was less than the original graft tissue, and more ectopic splenulus and intra-abdominal adhesions were formed. Splenic remnants after three-quarter splenectomy with an intact blood supply grew to 30-46% of the weight of the spleen of the control; and increased in size as the animal matured.

Splenic and hepatic trauma in children

The concepts for proper management of splenic and hepatic injuries have been evolving over the last several years. The recognition that aggressive surgical therapy in some instances was responsible for the number of life-threatening complications led to a reappraisal of the principles of care for these traumatic lesions. The emerging consensus of opinion is that often nonoperative therapy or more "conservative" operations are preferable. The accumulated experience to date supports the view that this more selective therapeutic approach will result in lower morbidity and mortality for children sustaining splenic or hepatic injuries. Fortunately, the recent technologic improvements in the field of radiology have enabled the clinician to diagnose and serially evaluate these major intra-abdominal injuries with a high degree of confidence.

Ruptured spleen--when to operate?

Sixty-three patients with splenic injuries were treated during a 5-yr period from 1974-1979. The decision to operate was based on the patient's clinical course, not on the presence of splenic injury alone. Those who were stable on admission or after initial resuscitation were treated nonoperatively. This consisted of strict bed rest, nasogastric suction, and i.v. fluids--including blood--as required. Those who bled massively were operated on promptly. At operation, the spleen was repaired if possible or excised if damaged beyond repair. Forty patients were treated nonoperatively. Sixteen of these required blood transfusions (mean 31.2 +/- 5.3 ml/kg). One patient in this group developed a large defect on spleen scan at 3 wk post injury. There was no other morbidity and no mortality following nonoperative treatment. Nineteen required operation all within 16 hr of admission. Fifteen underwent splenectomy, 2 partial splenectomy, and 1 splenorrhaphy. In 1 the bleeding had stopped. All required blood before operation (mean 80.4 +/- 10.1 ml/kg). Seven in this group died (6 from head injuries and 1 from bleeding). Thus surgery was avoided in 2 out of 3 and the spleen saved in 3 out of 4 patients with documented splenic injuries. We believe that where adequate facilities exist nonoperative treatment of splenic injuries is both safe and effective. When bleeding is massive from the beginning or replacement requirements exceed 40 ml/kg, operation is indicated.

Splenic trauma from blunt abdominal injury

Thirty-nine cases of splenic trauma from blunt abdominal injury are presented. Road trauma was the most common aetiological factor, and young adults were predominantly affected. Internal haemorrhage was the main determinant of the clinical picture, and nine cases of delayed haemorrhage following splenic trauma are reported. Associated injuries were present in two-thirds of cases and contributed to the high morbidity and mortality rate of splenic trauma. The operative and non-operative management of splenic trauma is discussed, and the roles of isotope spleen scans are demonstrated.