|Year : 2020 | Volume
| Issue : 4 | Page : 1322-1327
Different treatment modalities in traumatic splenic injuries
Ahmed S El Gammal1, Ahmed M Abo Ghida2, Ahmed M Nabil1
1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Itay El Baroud General Hospital, Itay El Baroud, Egypt
|Date of Submission||22-Apr-2020|
|Date of Decision||21-Jun-2020|
|Date of Acceptance||26-Jun-2020|
|Date of Web Publication||24-Dec-2020|
Ahmed M Abo Ghida
MBBCh, Itay El Baroud General Hospital, Itay El Baroud
Source of Support: None, Conflict of Interest: None
To evaluate surgical and nonoperative splenic conservation modalities in traumatic splenic injuries.
Splenic injury is common, affecting up to 32% of patients with blunt abdominal trauma. Nonoperative management (NOM) of hemodynamically stable patients with blunt splenic injury has become the standard of care in pediatric and adult populations. Successful outcome following NOM is reported as up to 97% of patients regardless of the grade of splenic injury.
Patients and methods
This was a prospective study including 150 patients) 88 patients and the other one contained 62 patients (at Menoufia University Hospital, General Surgery Department, and Itay El Baroud General Hospital, General Surgery Department, during December 2018 to October 2019. Patients were divided into two groups: group I included patients who were hemodynamically stable, without signs of peritonitis, and group II included patients who were hemodynamically unstable and were managed operatively according to grade of injury by splenectomy, partial splenectomy, and selenography of a tear. Full history taking, clinical examination, complete blood count, and ultrasound sonographic examination were done.
In the current study, the first group consists of 88 patients and only 22 needed blood transfusion, but in the second group, all patients needed blood transfusion. Moreover, in the first group, the minimum hospital stay was 5 days, the maximum was 9 days, and the mean were 6.40 ± 1.35, whereas in the second group, the minimum of hospital stay was 5 days, and the maximum was 7 days, with mean of 6.0 ± 0.79.
NOM for blunt splenic trauma in hemodynamically stable patients is safe, effective, and associated with low morbidity and no mortality. However, NOM should be practiced in hospitals where an efficient ICU is available.
Keywords: complication, modalities, nonoperative management, splenectomy
|How to cite this article:|
El Gammal AS, Abo Ghida AM, Nabil AM. Different treatment modalities in traumatic splenic injuries. Menoufia Med J 2020;33:1322-7
| Introduction|| |
The spleen is one of the most commonly injured organs in blunt abdominal trauma and is frequently injured in penetrating trauma to the left upper quadrant. Splenic injury is common, affecting up to 32% of patients with blunt abdominal trauma. In motor vehicle accidents, lateral impact seems to be an additional risk factor for splenic involvement, with the person seated closer to the side of collision placed at greater risk. Complications of postsplenectomy, especially intra-abdominal hemorrhage, can be fatal, with delayed or inadequate treatment having a high mortality rate, and the recognition of the fundamental role of the spleen in the immune response has led to greater efforts to preserve the spleen after injury. Until recently, the accepted treatment for splenic trauma, even for minor injuries, used to be splenectomy. This aggressive approach was based on the belief that, in adulthood, the spleen does not contribute any major function and conservative treatment was associated with potential life-threatening hemorrhage. With increasing recognition of the spleen's role in immunological function and awareness of overwhelming postsplenectomy sepsis (OPSI), nonoperative management (NOM) of hemodynamically stable patients with blunt splenic injury has become the standard of care in pediatric and adult populations. Successful outcome following NOM is reported as up to 97% of patients regardless of the grade of splenic injury. However, this changed policy toward splenic conservation requires careful risk–benefit analysis in the face of potentially life-threatening hemorrhage from delayed splenic rupture and the possibility of transfusion-induced viral infections. Pelvi-abdominal ultrasound is efficient in the diagnosis of splenic injuries; it can detect intraperitoneal hemorrhage, splenic tears, and the vascularization of the spleen. Moreover, computed tomography (CT) scan is indicated when patient is hemodynamically stable. CT also guides management of injuries, and a finding of high-grade splenic injury on CT scan seems to increase the rate of operation and correlate with hemodynamic instability. However, even most of the patients with blush still can be managed successfully with NOM. In order for nonoperative treatment (NOT) of splenic injuries to be the standard goal of therapy in hemodynamically stable patients, it is necessary to have an accurate knowledge of patient selection criteria for NOM, as well as a precise assessment of the factors precluding conservative therapy. This becomes tangible owing to diagnostic and therapeutic angiography addition. Knowing all these factors set the trend in splenectomy-conservative therapy debate; it is currently considered that traumatic splenic injury is no longer an absolute indication for splenectomy; thus, a proper reviewing of indications for emergency surgery in traumatic hemoperitoneum is needed. Controversy exists about how to appropriately select patients for NOT as bleeding from splenic injuries can incur significant morbidity and mortality. Therefore, the aim of this study was to explain different treatment modalities in traumatic splenic injuries and to differentiate between cases of splenic injuries.
| Patients and methods|| |
This was a prospective study including 150 patients who attended the Menoufia University Hospital, General Surgery Department, and Itay El Baroud General Hospital, General Surgery Department, and met the inclusion criteria in the duration from December 2018 to October 2019.
The study was approved by the ethical committee of Menoufia Faculty of Medicine and Itay El Baroud General Hospital. An informed consent obtained from all patient's guardian before the study was commenced.
Splenic injuries caused by blunt abdominal trauma and isolated splenic injuries were included.
Splenic injuries associated with other abdominal injuries were excluded.
All patients were subjected to the following:
Full history taking with stress on the cause, mechanism, time of trauma, and presence of any local or systemic symptoms; general examination of the patient (pulse, blood pressure, respiratory and rate, temperature); and local examination of the abdomen.
Patients planned for conservative measures were put on absolute bed rest for 48–70 h in ICU. Monitoring (every half an hour in first 4 h, every 1 h in second 8 h and 8 h for the resting 24 h) for pulse, blood pressure, respiratory rate, and temperature chart was done. Serial physical examinations are mandatory to detect changes in tenderness or the onset of new peritoneal signs in patients who are awake and alert. Hemodynamic monitoring every 12 h in first 24 h and every day in the period of hospital stay was done. Serial follow-up ultrasound was done every 2 h in first 12 h, every 4 h in the second 12 h, and every day in the period of hospital stay and abdominal CT in the next day after being stable (excludes associated abdominal injuries and detects site, extent, and grade of splenic injury according to AAST splenic injury scale).
Follow-up was done in our clinic for 4–6 weeks to detect any complication. Assessment of the injury was done for patients who were subjected to surgery. If the injury is superficial (II and III), suture splenorrhaphy was done, and if the injury is deep or there is an avulsed part of the spleen (IV and V), splenectomy was done. Tubal drains were put in the splenic bed and in the pelvis. Patients were admitted to ICU postoperatively until stabilization of their general condition and then transferred to the surgical ward.
Postoperative follow-up included close monitoring of pulse, blood pressure, respiratory rate, and temperature chart every 1/2 h in the first of 4 h, every 1 h in second 8 h, and every 2 h in the resting 24 h. Drains were assessed every 1 h in first 8 h and then every 2 h in the resting 24 h. If there is blood collected more than 100 ml/h, the abdomen was re-explored.
Laboratory investigation included ABO grouping, complete blood count including hemoglobin (Hb) level and hematocrit (HCT) using Sysmex KX-21 automatized hematology analyzer (Sysmex Corporation, Wakinohama-kaigandori, Japan), and ultrasound sonographic (FAST scan) evaluation; CXR and CT abdomen were done if the patient was hemodynamically stable. All previous data was analyzed, and according to that, patients were divided into two groups. The first group included patients who were hemodynamically stable, without signs of peritonitis, and were managed conservatively by bed rest, close monitoring of the vital signs of the patient, resuscitation, and meticulous follow-up for up to 7–10 days. The second group included patients who were hemodynamically unstable and were managed operatively according to grade of injury by splenectomy, partial splenectomy, and splenorrhaphy of a tear.
Follow-up after discharge in outpatient clinic was by imaging (ultrasound) for 4 weeks to detect any complication such as abscess formation, delayed rupture spleen after 2 weeks, or wound problems.
Results were tabulated and statistically analyzed by using a personal computer using Microsoft Excel 2016 and SPSS, version 21 (SPSS Inc., Chicago, Illinois, USA). Statistical analysis was done using descriptive statistics, for example percentage, mean, and SD, and analytical statistics, which included Monte Carlo and Fisher exact for χ2 test and t test. A value of P value less than 0.05 was considered statistically significant.
| Results|| |
The number of patients in this study were 150 patients classified in two groups: the first one contained 88 patients and the other one contained 62 patients. The first group was conservatively managed, and the second one was managed operatively with splenorrhaphy and splenectomy. The first group of patients consists of 66 (75%) males and 22 (25%) females and had a mean age of 23 ± 9.23 years. The second group of patients consist of 47 (75.8%) males and 15 (24.2%) females and had a mean age of 35 ± 11.12 years. Regarding mechanism of trauma, in the first group, 22 patients were due to falling from height (FFH) (25%) and 66 patients due to road traffic accident (RTA) (75%), whereas in the second group, 16 (25.8%) patients were owing to FFH and 46 (74.2%) patients owing to RTA. Moreover, the first group had mean Hb level of 10.05 ± 1.28 g/dl and mean HCT of 31.39 ± 2.92% (24.50 ± 34.70). The second group had mean Hb level of 7.45 ± 1.09 g/dl and mean HCT of 24.29 ± 2.35% (20.40 ± 28.60). However, there was no significant different between the studied groups regarding age, sex, mechanism of trauma, HCT, and Hb (P>0.05) [Table 1].
|Table 1: Comparison between the two groups according to demographic data, mechanism of trauma, and complete blood count|
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The ultrasound was done for the two groups: in the first group, 22 (25%) patients had minimal collection, 45 (51.1%) patients had mild collection, and 21 (23.9%) patients had moderate collection. However, in the second group, 32 (51.6%) patients had moderate collection and 30 (48.4%) patients had massive collection. Regarding the hemodynamic in our study, 80 (90.9%) patients were hemodynamically stable and eight (9.1%) patients were hemodynamically unstable in the conservative group. However, all of the operative patients were hemodynamically unstable. Regarding complication, in the first group, 80 (90.9%) patients were managed nonoperatively and had no complication, and eight (9.1%) had complications, which deteriorated and underwent splenectomy. However, in the second group, 13 (21%) patients develop complications: seven had wound infection and six acquired chest infection. Moreover, there was a significant difference between the studied groups regarding ultrasound and hemodynamic (P < 0.05) and no significant difference regarding treatment and complication (P>0.05) [Table 2].
|Table 2: Comparison between the two groups according to ultrasound, hemodynamics and complication|
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In the current study, 22 (25%) patients had associated injuries in the first group and 30 (48.4%) patients had associated injuries in the second group. However, in the first one only 22 (25%) patients needed blood transfusion, whereas in the second, all patients needed blood transfusion (100%). Moreover, in the first group, the minimum hospital stay was 5 days, and the maximum was 9 days, and the mean was 6.40 ± 1.35, whereas in the second group, the minimum hospital stay was 5 days, and the maximum was 7 days, and the mean was 6.0 ± 0.79. There was no significant different between the studied groups regarding blood transfusion (P = 0.001) and no significant difference regarding associated injury, hospital stay, and mortality (P>0.05) [Table 3].
|Table 3: Comparison between the two groups according to associated injury, blood transfusion, hospital stay and mortality|
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| Discussion|| |
The total number of patients in this study were 150 classified into two groups. The first one consisted of 88 patients who met the selection criteria of NOM and admitted to ICU and were managed conservative, whereas the second group contained 62 patients and were unstable and managed operatively with splenorrhaphy and total splenectomy. The patients of the first group were 66 (75%) males and 22 (25%) females. The second group of patients contained 47 (75.8%) males and 15 (24.2%) females [Table 3]. The male predominance in both groups agreed with the study of Zabolotny et al. , in which male represented 84% and female 16%, and also agreed with the study of Davies et al. , in which male represented 71% and females 29%. The male predominance was owing to that males were more active and because of their risky work.
The mechanism of trauma in the first group was 22 (25%) patients owing to FFH and 66 (75%) patients owing to RTA. However, in the second group, 16 (25.8%) patients were owing to FFH and 46 (74.2%) patients owing to RTA. So, in this study, the main mechanism of trauma was RTA and then FFH. These results coincided with the study by Osifo et al. , where RTA was the mechanism of trauma in 50% of the patient, and the second most common mechanism was FFH. However, this disagreed with the study by Kristoffersen and Mooney, where the main mechanism of trauma was FFH. According to hemodynamics, all patients of the first group were stable early, and then eight (9.1%) patients became unstable and 82 (90.9%) patients were still stable. However, all the second group patients were unstable (100%) and underwent urgent surgery. This coincided with study by Scapellato et al. , and Wahl et al. , in which hemodynamically stable patients were treated with NOM and hemodynamically unstable patients were treated with splenectomy.
Moreover, in the current study, ultrasound was done for the two groups: in the first group, 22 (25%) patients had minimal collection, 45 (51.1%) patients had mild collection, and 21 (23.9%) patients had moderate collection, whereas in the second group, 32 (51.6%) patients had moderate collection and 30 (48.4%) patients had massive collection. With increase in the amount of blood collection in the abdomen by ultrasound, the risk of failure of NOM increased. In the first group, 22 (25%) patients had associated injuries in the form of fractured rib, hemothorax fracture of the homers, and head trauma, whereas in the second group, 30 (48.4%) patients had associated injuries in form of hemothorax, head injuries, musculoskeletal injuries, and other intra-abdominal injuries. Associated injuries led to more blood transfusion, more length of hospital stay, and increase in failure of NOM. This coincided with the study of Koca et al. and the study of Coppola and Gilbert.
In the current study, in the first group, 80 (90.9%) patients were managed nonoperatively, whereas eight (9.1%) patients became unstable and underwent splenectomy. In the second group, all patients were unstable and underwent splenectomy and splenorrhaphy. This result coincided with the study of Jamaladeen et al. , and the study of Vega et al. , in which success rate of NOM was 86 and 91%, respectively, but less than the result of Coppola and Gilbert (98%) and the result of Davies et al. (100%). This result was higher than study of Osifo et al. , in which success rate of NOM was 75%. Moreover, this was higher than the study by Atiya and El Sageer, where 11 patients were hemodynamically stable and nine patients were hemodynamically unstable. A total of 14 patients were treated conservatively, whereas six patients were treated surgically. Results concluded that in patients who are hemodynamically stable, NOM is safe and effective. Another study by Skattum et al. concluded that NOM continues to be reported as a successful approach in hemodynamically stable patients without other indications for laparotomy, achieving high success rates in both children and adults. Moreover, Lo et al. concluded that patients with splenic injuries who are hemodynamically stable can be managed nonoperatively with acceptable outcome. However, in the presence of concomitant trauma, there is an increasing trend toward operative management. The study done by Köksal et al. concluded that hemodynamic stability is the most important factor that could affect the selection of patients for NOM outcome regardless of the patient age and CT scan grading of the injury. These also agree with our study.
Regarding blood transfusion, there was a great difference between the two groups. In the first group, only 22 (25%) patients needed blood transfusion, whereas in the second group, all patients needed it (100%). This coincided with study of Zabolotny et al. , in which 10% of nonoperative patients received blood transfusion, whereas all operative patients received blood transfusion. In this study, increased requirement for blood transfusion was associated with high-grade splenic injuries and operative treatment, which coincided with the study of Koca et al. .
Köksal et al. concluded that the mean unit of blood transfusion in the patients with operative and NOM groups was 1.1 and 0.6. This did not agree with our study. The study done by Aseervatham and Muller concluded that transfusion requirement was lower in nonoperative group. Sinha et al. concluded that blood transfusion requirement was significantly higher among the operative group. Moreover, Lo et al. concluded that transfusion requirement was lower in nonoperative group than the surgical group.
Regarding hospital stay, the result was nearly equal for both groups. In the first group, the minimum hospital stay was 5 days, and the maximum was 9 days, with a mean of 6.40 ± 1.35, whereas in the second group, the minimum of hospital stay was 5 days, the maximum was 7 days, with a mean of 6.0 ± 0.79. This coincided with the study of Zabolotny et al. , in which average of hospital stay was 7.1 day, but this did not agree with the study of Stylianos and the APSA Liver/Spleen Trauma Study Group, which determined the length of hospital stay by splenic injury grade + 1 day, because after this period, some patients still had mild or moderated collection in the ultrasound, which was risky to discharge them home. Moreover, Sinha et al. concluded that the nonoperative group had a significantly longer hospital stay. The study done by Beuran et al. reported that hospital stay varies between 3 and 7 days when no other injuries are present to elicit a prolonged stay. However, the study done by Margherita Cadeddu et al. found the median length of stay in hospital was significantly higher in the operative group than in the nonoperative group, which did not agree with our study.
In the first group, 80 (90.9%) patients were managed nonoperatively and had no complication and eight (9.1%) patients had complications, which became unstable and underwent splenectomy. However, in the second group, 13 (21.0%) patients developed complication: seven wound infection and six early postoperative chest infection. So, complication was more common with operative management. This coincided with study of Oumar et al. , in which complication increased with operative management, and rate of complication with NOM was 4.8%.
Regarding mortality rate in our study, in the first group, all patients survived (100%), whereas in the second group, 59 (95.2%) patients survived and three (4.8%) patients died owing to subarachnoid hemorrhage and hemothorax. The mortality was usually owing to associated injury and not owing to splenic injury. This coincided with the study of Osifo et al. , in which mortality rate was 4.1% and the study of Coppola and Gilbert, in which mortality rate was 4.7, and this was because of delayed intervention by neurosurgeons.
Margherita Cadeddu et al. concluded that the mortality rate was similar between operative and nonoperative groups (9.3 vs. 6.8%, P = 0.49). However, Yikun et al. concluded that of 14 of 604 patients undergoing splenectomy, three patients died. Sinha et al. concluded that there were no deaths in the nonoperative group. In the operative group, one patient who sustained polytrauma remained unstable, developed a systole, and died in ICU on the first postoperative day. Atiya and El Sageer, found one patient only died in surgical group intraoperatively, and no mortality in nonoperative group.
| Conclusion|| |
The current study concluded that NOM for blunt splenic trauma in hemodynamically stable patients is safe, effective, and associated with low morbidity and no mortality. However, NOM should be practiced in hospitals where an efficient ICU is available.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]