Determinants of splenectomy in splenic injuries following blunt abdominal trauma.
The objective of this study was to find out the determinants of splenectomy in patients with isolated splenic injuries from blunt abdominal trauma in our community, with a view to increasing the rate of splenic preservation.
Patients and methods
Ours was a hospital-based retrospective descriptive study of isolated splenic injuries from blunt abdominal trauma diagnosed and graded with abdomino-pelvic ultrasound between 1998 and 2007 in the surgical unit of Wesley Guild Hospital, Ilesa, which is a satellite hospital of Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria. The hospital serves the health needs of Ekiti State, Ilesa and neighbouring towns. Patients' age and gender, mechanism of injury, pulse rate and blood pressure at presentation, duration of injury before presentation, delay before surgery for those operated on, packed cell volume at presentation, pre-operative transfusion, intra-operative transfusion, amount of haemoperitoneum in those who had surgery, grade of splenic injury (using splenic organ injury scaling system), time of surgery, surgeon hierarchy, assistant surgeon hierarchy and treatment modality were entered onto the pro forma designed for the study.
Treatment modalities were classified into non-operative, operative salvage and splenectomy. Non-operative management was instituted in those patients with sustainable post resuscitative haemodynamic stability and stable or improving serial abdominal ultrasound findings; those who did not satisfy these criteria were offered operative treatment. Those without sufficient data were excluded from the study.
Statistical analysis was done with SPSS 15 for Windows, using descriptive statistics and linear regression, with significance taken at p<0.05.
Fifty-five patients met the inclusion criteria. There were 36 males and 19 females, with a male:female ratio of 1.9:1. Their median age was 14 years (range 3 - 60). Table I shows the mechanism of injury with respect to age in decades. The prevalence of isolated splenic injury in blunt abdominal trauma decreases with age, with marked differences in the mechanism. Motor vehicle accident (MVA) injury and falling from heights occurred in 50 (91%) patients. In the first 2 decades of life, MVA trauma accounted for 40% of splenic injuries, and falls for 49%. All splenic injuries as a result of falling from a height arose in the first 2 decades. Between the 3rd and 6th decades, MVA trauma accounted for 95% of injuries, the remainder being due to falls and a single case of assault.
The majority of patients suffered moderate to severe splenic trauma, with 40 (73%) sustaining injuries between grades III and V. Higher grades of injury resulted from MVA trauma and falling from heights (Table II). Twelve (22%) patients out of the initial 20 were eventually managed non-operatively. Failed conservative therapy in 6 patients was due to failing haematocrit and haemodynamic instability. Forty-three (78%) patients underwent laparotomy, with operative salvage in 10 (18%) and splenectomy in 33 (60%) (Table III). There was one postoperative death in the splenectomy group due to acute respiratory distress syndrome from anaesthesia complications. Splenic salvage was achievable in 93% of grade II and 44% of grade III injuries, with electrocautery, and vertical mattress suturing technique with occasional omental overlay or wrapping. None of the patients had angio-embolisation because of lack of facilities.
Non-operative and operative salvage decreased with age (Table IV). Of those in the first 2 decades of life, 17 (49%) splenic injuries were either managed non-operatively or underwent splenorrhaphy, compared with only 5 (25%) in the older decades. Moreover, the rate of splenectomy was higher in those who had their treatment at night (Fig. 1) and in those who sustained their injuries from MVA causes and falling from heights (Table V). Linear regression analysis (Table VI) showed that the significant determinants of splenectomy in this study were the grade of splenic injury and the experience of the surgeon and his assistant: the more experienced the surgeon and his assistant, the higher the rate of splenic preservation at surgery.
The pioneering work of paediatric surgeons from about 30 years ago established that splenic injury can be managed non-operatively. (17,18) Although the paediatric spleen differs structurally from that of an adult, a similar approach has been adopted in adult splenic trauma. Advances in medical imaging have allowed not only accurate delineation of the grade of injury, but also therapeutic intervention in the form of angiography and embolisation - a useful adjunct in those not responding to non-operative management.19-21
Operative management is reserved for patients not responding to conservative treatment or angiography and embolisation. The indications for abandoning conservative management are: persistent haemodynamic instability with falling haematocrit or persistent contract blush after angioembolisation. At surgery, the emphasis is on splenic salvage because of the risk of OPSI. (8,22) Following the first report of OPSI in 1952, several reviews reported an incidence of 2.2 - 4.4% per year in children, and less than 1% in adults, with a reported mortality rate of 0.58%. (5,17) Vaccination against encapsulated organisms is recommended at least 2 weeks before an elective splenectomy to prevent OPSI; however, this is not practicable in splenectomy for trauma, which makes post-splenectomy vaccination mandatory for all splenectomised patients for trauma before their discharge from hospital, with re-vaccination every 5 - 10 years and additional antibiotic prophylaxis to compensate for the documented occasional vaccination failure. (23-25) Moreover, antibiotic prophylaxis is the recommended regimen in pregnancy, when pneumococcal vaccination is better avoided until after delivery.
The effectiveness of vaccination is limited in children, but there is a need for antibiotic prophylaxis before the age of 2 years because of the blunted response to polysaccharide vaccines; consequently, full vaccination is usually given after the second birthday. (25) Post-vaccination health education should be given to all splenectomised patients regarding the risk, the importance of prompt diagnosis and treatment of infection, and the need for strong compliance with antimalaria prophylaxis. It is also essential for them to carry an identification card. (25) However, in our environment, the majority of patients post splenectomy fail to attend the follow-up clinic, making further management in those patients problematic. For these reasons, every attempt must be made for splenic salvage.
[FIGURE 1 OMITTED]
In our study, the rate of total splenectomy was higher in patients who sustained their trauma in MVAs and falling from a height, possibly as a result of the high energy transfer on impact causing physiological damage needing surgical management. Conversely, a low energy impact may account for the higher rate of splenic preservation in patients whose mechanism of injury was sport-related. The magnitude of energy transferred at the time of injury seems to determine the severity of splenic trauma and the need for splenectomy. The majority of patients who had sustained a grade III injury, and all those with grade IV and V injuries, belonged to the groups sustaining high energy impact. There is a need for effective motor vehicle safety legislation; while better parental control will help to reduce the incidence of injuries from falls, as these all occurred in children <20 years old. (26)
Splenic salvage surgery should be considered in those who sustained intermediate isolated splenic injury, when the indication for surgery is not damage control in haemodynamically unstable patients. (27-29) This is necessary in a developing economy such as ours, with endemic malaria and occasional cases of tickbite fever, to reduce the incidence and severity of malaria, OPSI and other infestations post splenectomy, (23,25,30) as the majority of patients are lost to follow-up or fail to attend follow-up clinics. Consequently, these patients would not receive appropriate vaccination or have access to prophylactic antimicrobials.
The time of operative intervention in our review shows an increase in the night-time splenectomy rate; this may be due to a number of factors, e.g. supporting staff fatigue from the preceding daylight hours' duties, and the fact that most of the emergency surgery at night is performed by junior surgeons who may be unfamiliar with splenic salvage techniques. A linear regression analysis to identify the main determinants of splenectomy in our environment showed three significant factors: the grade of splenic injury, surgeon experience, and assistant experience.
Although one would expect the grade of splenic injury to be determined by the force of impact, the mechanism of injury was not a statistically significant factor in our study. Failure of splenic protective features such as the airbag effect of the stomach medially, the inferior lobe of the left lung superiorly, and the transverse colon inferiorly, could be reasons. Moreover, failure of the anchoring seatbelt effect of the diaphragm on the phrenicolienal and gastrolienal ligaments, holding the spleen against the body wall at the time of impact, may predispose the spleen to high deceleration or acceleration stresses. The rate of response of these protective mechanisms and the rapidity of injury may largely determine the degree of splenic trauma.
While higher grades of injury could be associated with haemodynamic instability from blood loss, the vital signs and the packed cell volume at presentation were not significant determinants in our study, which agrees with the findings by Potoka et al. in the USA. (9) There is a need to further evaluate these findings by means of prospective studies.
The roles of the surgeon and assistant surgeon could be influenced by their interest and experience in splenic salvage surgery, (15) the availability of prosthetic material such as mesh for splenic salvage surgery, (31-33) and the availability of technology that facilitates splenic salvage surgery, such as an argon beam coagulator (34,35) or intra-operative laboratory back-up. (36,37) Such factors warrant further appraisal with prospective studies.
Although the overriding challenge to a surgeon and his assistant intra-operatively is to save life, it is also to determine the most appropriate operative procedure best suited for the individual patient. The risk attached to attempts at splenic salvage must be weighed against the hazard of continued bleeding and the need for re-laparotomy and further blood transfusions. The risk of OPSI or other disease states, especially in the African context, must also be borne in mind. Not only are trauma prevention strategies essential, but also the training of junior surgical staff in methods of splenic salvage.
Failure of splenic protective mechanisms, rather than the mechanism of injury, may be responsible for the grade of splenic injury in blunt abdominal trauma. Motor vehicle safety legislation and parental control may contribute to reducing the causes of high energy transfer to the spleen in blunt abdominal trauma. Splenic salvage surgery should be considered for patients who sustain intermediate isolated splenic injuries, when the indication for surgery is not damage control in haemodynamically unstable patients. Junior surgeons therefore need to be familiar with splenic conservation techniques, which is necessary in a developing country such as ours, to reduce the incidence of OPSI, and minimise the severity of malaria and tick-borne diseases, in view of the fact that the majority of patients fail to attend follow-up clinics.
(1.) Nwabunike T. Closed and penetrating abdominal injuries in Nigerian Igbos. Injury 1984;15(6): 372-375.
(2.) Udoeyop UW, Iwatt AR. Abdominal trauma in south-eastern Nigeria. Cent Afr J Med 1991; 37(12): 409-415.
(3.) Dupuy DE, Raptopoulos V, Fink MP. Current concepts in splenic trauma. J Intensive Care Med 1995; 10(2): 76-90.
(4.) Harbrecht BG. Is anything new in adult blunt splenic trauma? Am J Surg 2005; 190(2): 273-278.
(5.) Peitzman AB, Ford HR, Harbrecht BG, Potoka DA, Townsend RN. Injury to the spleen. Curr Probl Surg 2001; 38(12): 932-1008.
(6.) Rodriguez Gomez M, Oehler U, Helpap B. Fulminant infection outcome after splenectomy. Pathologe 1997; 18(3): 257-260.
(7.) Gruntova I, Janousek S, Parizkova R, Chalupa P. Our experience with prevention of infection in patients post splenectomy. Klin Mikrobiol Infekc Lek 2005; 11(2): 51-55.
(8.) Clancy TV, Weintritt DC, Ramshaw DG, Churchill MP, Covington DL, Maxwell JG. Splenic salvage in adults at a level II community hospital trauma center. Am Surg 1996; 62(12): 1045-1049.
(9.) Potoka DA, Schall LC, Ford HR. Risk factors for splenectomy in children with blunt splenic trauma. JPediatr Surg 2002; 37(3): 294-299.
(10.) Dent D, Alsabrook G, Erickson BA, et al. Blunt splenic injuries: high nonoperative management rate can be achieved with selective embolization. J Trauma 2004; 56(5): 1063-1067.
(11.) Sclafani SJ, Weisberg A, Scalea TM, Phillips TF, Duncan AO. Blunt splenic injuries: nonsurgical treatment with CT, arteriography, and transcatheter arterial embolization of the splenic artery. Radiology 1991; 181(1): 189196.
(12.) Beal SL, Spisso JM. The risk of splenorrhaphy. Arch Surg 1988; 123(9): 1158-1163.
(13.) Buntain WL, Lynn HB. Splenorrhaphy: changing concepts for the traumatized spleen. Surgery 1979; 86(5): 748-760.
(14.) Adesunkanmi AR, Oginni LM, Oyelami OA, Badru OS. Road traffic accidents to african children: assessment of severity using the injury severity score (ISS). Injury 2000; 31(4): 225-228.
(15.) Ohanaka EC, Osime U, Okonkwo CE. A five year review of splenic injuries in the University of Benin Teaching Hospital, Benin City, Nigeria. West Afr J Med 2001; 20(1): 48-51.
(16.) Alli N. Management of blunt abdominal trauma in Maiduguri: a retrospective study. Niger J Med 2005; 14(1): 17-22.
(17.) Franklin GA, Casos SR. Current advances in the surgical approach to abdominal trauma. Injury 2006; 37(12): 1143-1156.
(18.) Upadhyaya P. Conservative management of splenic trauma: history and current trends. Pediatr Surg Int 2003; 19(9-10): 617-627.
(19.) Lui B, Schlicht S, Vrazas J. Role of embolization in the management of splenic trauma. Australas Radiol 2004; 48(3): 401-403.
(20.) Root HD. Splenic injury: angiogram vs. operation. J Trauma 2007; 62 (6 Suppl): S27.
(21.) Silberzweig JE, Khorsandi AS. Use of splenic artery embolization (SAE) in their splenic injury algorithm. J Trauma 2006; 60(3): 686.
(22.) Abrantes WL, de Lucena MS, Schlobach MC. Conservative surgery of splenic trauma in children. Rev Assoc Med Bras 1994; 40(2): 113-117.
(23.) Davidson RN, Wall RA. Prevention and management of infections in patients without a spleen. Clin Microbiol Infect 2001; 7(12): 657-660.
(24.) El-Alfy MS, El-Sayed MH. Overwhelming postsplenectomy infection: is quality of patient knowledge enough for prevention? Hematol J 2004; 5(1): 77-80.
(25.) Working Party of the British Committee for Standards in Haematology Clinical Haematology Task Force. Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. BMJ 1996; 312(7028): 430-434.
(26.) Ugwu BT, Kidmas AT, Obekpa PO, Momoh JT. Management of childhood splenic trauma - the Jos experience. Cent Afr J Med 1997; 43(11): 331334.
(27.) Havlicek K. Present possibilities of surgical treatment in splenic injuries. Rozhl Chir 1992; 71(3-4): 185-197.
(28.) Carlin AM, Tyburski JG, Wilson RF, Steffes C. Factors affecting the outcome of patients with splenic trauma. Am Surg 2002; 68(3): 232-239.
(29.) Forsythe RM, Harbrecht BG, Peitzman AB. Blunt splenic trauma. Scand J Surg 2006; 95(3): 146-151.
(30.) Band RA, Gaieski DF, Goyal M, Perrone J. A 52-year-old man with malaise and a petechial rash. J Emerg Med 2008; 22 Aug [Epub ahead of print].
(31.) Berry MF, Rosato EF, Williams NN. Dexon mesh splenorrhaphy for intraoperative splenic injuries. Am Surg 2003; 69(2): 176-180.
(32.) Louredo AM, Alonso A, de Llano JJ, Diez LM, Alvarez JL, del Riego FJ. Usefulness of absorbable meshes in the management of splenic trauma. Cir Esp 2005; 77(3): 145-152.
(33.) Reddy CG, Chalasani V, Pathma-Nathan N. Splenic preservation: an additional haemostatic measure during mesh splenorrhaphy. ANZ J Surg 2004; 74(7): 596-597.
(34.) Dunham CM, Cornwell EE 3rd, Militello P. The role of the Argon Beam Coagulator in splenic salvage. Surg Gynecol Obstet 1991; 173(3): 179-182.
(35.) Stylianos S, Hoffman MA, Jacir NN, Harris BH. Sutureless hemisplenec tomy. J Pediatr Surg 1991; 26(1): 87-89.
(36.) Inokuchi S, Tajima T, Ikeda M, Nakajima I, Shotsu A, Mitomi T. Operative risk of splenic repair for isolated but complex splenic injuries due to blunt abdominal trauma. Nippon Geka Gakkai Zasshi 1992; 93(2): 177-182.
(37.) Stylianos S, Egorova N, Guice KS, Arons RR, Oldham KT. Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for dissemination of American Pediatric Surgical Association benchmarks and guidelines. J Am Coll Surg 2006; 202(2): 247-251.
A.A. AKINKUOLIE, M.B.B.S., F.W.A.C.S.
O.O. LAWAL, M.B.B.S., F.M.C.S., F.W.A.C.S.
O.A. AROWOLO, M.B.B.S., F.W.A.C.S.
E.A. AGBAKWURU, B.SC., M.B.B.S., F.M.C.S., F.W.A.C.S., F.I.C.S.
A.R. K. ADESUNKANMI, M.B.B.S., F.M.C.S., F.W.A.C.S., F.I.C.S.
Department of Surgery, Obafemi Awolowo University, Ile-Ife, Nigeria
TABLE I. MECHANISM OF INJURY V. AGE IN DECADES Mechanism of injury Fall from Age in decades MVA height Assault Abuse Sports Total 1st decade 8 7 0 1 2 18 2nd decade 6 10 1 0 0 17 3rd decade 9 0 0 0 0 9 4th decade 6 0 1 0 0 7 5th decade 3 0 0 0 0 3 6th decade 1 0 0 0 0 1 Total 33 17 2 1 2 55 TABLE II. GRADE OF SPLENIC INJURY V. MECHANISM OF INJURY Grade of splenic injury Mechanism of injury Grade I Grade II Grade III Grade IV MVA 0 9 10 12 fall from height 0 4 6 7 assault 0 0 1 0 abuse 0 0 1 0 Sports 1 1 0 0 Total 1 14 18 19 Grade of splenic injury Mechanism of injury Grade V Total MVA 2 33 fall from height 0 17 assault 1 2 abuse 0 1 Sports 0 2 Total 3 55 TABLE III. MODALITY OF TREATMENT V. GRADE OF SPLENIC INJURY Modality of treatment Operative salvage Non-operative Failed non- Grade of splenic injury therapy operative Planned grade I 1 0 0 grade II 8 2 3 grade III 3 1 4 grade Iv 0 0 0 grade v 0 0 0 Total 12 3 7 Modality of treatment Splenectomy Failed non- Grade of splenic injury operative Planned Total grade I 0 0 1 grade II 0 1 14 grade III 3 7 18 grade Iv 0 19 19 grade v 0 3 3 Total 3 30 55 TABLE IV. MODALITY OF TREATMENT WITH AGE IN DECADES Modality of treatment Operative Age in decades Non-operative salvage Splenectomy Total 1st decade 7 5 6 18 2nd decade 3 2 12 17 3rd decade 1 1 7 9 4th decade 1 1 5 7 5th decade 0 0 3 3 6th decade 0 1 0 1 Total 12 10 33 55 TABLE V. MODALITY OF TREATMENT V. MECHANISM OF INJURY Modality of treatment Operative Mechanism of injury Non-operative salvage Splenectomy Total MVA 5 8 20 33 fall from height 5 1 11 17 assault 0 1 1 2 child abuse 0 0 1 1 Sports 2 0 0 2 Total 12 10 33 55 TABLE VI. DETERMINANTS OF SPLENECTOMY Factors p-value age in years 0.156 gender 0.840 Mechanism of injury 0.966 Pulse rate at presentation 0.143 Systolic blood pressure at presentation 0.977 Diastolic blood pressure at presentation 0.286 Duration of injury before presentation 0.583 Delay before surgery 0.775 Packed cell volume at presentation 0.278 Pre-operative transfusion 0.318 Intra-operative transfusion 0.412 amount of haemoperitoneum 0.325 Time of surgery 0.647 grade of splenic injury 0.002 Surgeon hierarchy 0.008 assistant surgeon hierarchy 0.001 p<0.05 linear regression.
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|Author:||Akinkuolie, A.A.; Lawal, O.O.; Arowolo, O.A.; Agbakwuru, E.A.; Adesunkanmi, A.R.K.|
|Publication:||South African Journal of Surgery|
|Date:||Feb 1, 2010|
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