Tropical Doctor > Volume 38, Number 4 > Pp. 210-213

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Articles

Conservative management of splenic injury in the tropics

Jerzy Kuzma MD PhD      Vincent Atua MBBS  

Modilon General Hospital and Faculty of Health Science of Divine Word University, Madang, Papua New Guinea

Correspondence to: J Kuzma, Modilon General Hospital and Faculty of Health Science of Divine Word University, PO Box 483, Madang, Papua New Guinea Email: jkuzma{at}dg.com.pg

	SUMMARY

Top SUMMARY Introduction Patients and methods Results Discussion References

 
We undertook this study in order to determine whether the conservative management of splenic injuries is a safe practice in a low-volume tropical hospital. We evaluated 69 consecutive patients with splenic injury prospectively. The outcome measures were morbidity and mortality rates, overall hospital stay and blood transfusion requirements. Spleen preservation was achieved in 85% (59) of cases. Of the 16 patients who underwent splenic surgery, six had splenorraphy (38%). The overall mortality was 4.3% (3) and the deaths were not related to the conservative management. Our findings suggest that not only is the conservative management of splenic injuries safe, but also that the repair of an enlarged spleen (splenorrhaphy) is safe and feasible in tropical hospital settings. The findings in this study provide further evidence that the conservative management of splenic injury in a tropical hospital without computed tomography scan is a safe practice.

	Introduction

Top SUMMARY Introduction Patients and methods Results Discussion References

 
Trauma due to accidents and violence is the third highest cause of deaths in men between the second and fourth decade of life in Papua New Guinea.¹ It has been noted that the spleen is the most common intra-abdominal organ is to be injured by blunt trauma.^2,3 Until the last two decades, splenectomy remained the definite treatment for major splenic injuries. However, with the recognition that splenectomy is associated with a higher risk of overwhelming post-splenectomy sepsis,⁴ and in malarial endemic areas with increased incidence of malaria infections,⁵ the trend has shifted towards splenic conservation.

Several studies from developed countries indicate that in the last decade the splenic preservation rate has increased by up to about 70% in adults⁶ and 85% in children,^7,8 without an associated increase in morbidity and mortality. In these studies, however, the non-operative protocols for the management of splenic injury included assessment by computed tomography (CT) scan.^8,9 In developing countries CT is a luxury, and clinical diagnosis and management of splenic injuries is dependent more upon the acumen of the clinicians. Although several reports of the conservative management of splenic injury from the developing countries are available,^2,10–13 there is insufficient evidence of safety and the feasibility of splenorrhaphy on the enlarged spleen.

The primary aim of our study was to determine whether the conservative management of splenic injury is a safe practice in the setting of a low-volume tropical hospital without the aid CT scan. The secondary aim was to investigate whether splenorrhaphy on the injured enlarged spleen is safe and feasible.

	Patients and methods

Top SUMMARY Introduction Patients and methods Results Discussion References

 
Study design and patient selection

This was a non-randomized, prospective study and included all consecutive patients diagnosed with splenic injury who were admitted to the surgical unit between June 2004 and February 2007. The two inclusion criteria were: (1) a history of blunt injury to the left upper abdomen with pain and/or tenderness in the left upper abdominal quadrant; and (2) fluid collection on ultra-sonography in at least one of three examined intra-abdominal regions, which included the peri-splenic area, pelvis and reno-hepatic pouch. Written informed consent was obtained from each participating patient. Patients were excluded if informed consent was not obtained. Ethical approval was given by the research ethics committee of Divine Word University.

Outcome measures

The outcome measures of treatment modalities in patients with traumatic splenic injury were morbidity and mortality rates, overall hospital stay and blood transfusion requirements. Overall hospital stay was expressed in days spent in hospital from admission to discharge, including the hospitalization period of patients readmitted within 30 days of the first admission.

Patient management

The diagnosis and management of splenic injury was based on the mechanism of trauma, physical examination and ultra-sonography performed along the guidelines of focused assessment with sonography for trauma (FAST).¹⁴ In line with the recommendations of the early management of severe trauma, all patients underwent primary and secondary assessments and fluid resuscitation. Patients were monitored hourly for any signs of acute blood loss, recording pulse rate, blood pressure and respiratory rate. Physical examinations including abdominal examinations were done twice a day with haemoglobin monitored on a daily basis. The monitoring described above continued for the first three days from the admission and then, when patients were haemodynamically stable, observations were taken less frequently.

The revised trauma score (0–12)¹⁵ was used to assess the severity of the injury on the day of admission. Patients who were haemodynamically stable and who had no peritoneal signs were assigned non-operative treatment. The presence of one or more of the following criteria was used as an indicator for operative treatment:

• haemodynamic instability despite adequate fluid resuscitation and minimal blood transfusion (up to two units);
  
• an increase in the area and intensity of abdominal tenderness and/or rebound tenderness or diffuse peritoneal signs;
  
• an associated head injury which precluded adequate abdominal assessment (Glasgow coma score <9);
  
• insufficient availability of blood supply in worsening patients;
  
• diagnostic doubts about injury to hollow organs.
  

All laparotomies were performed with the intent of splenic preservation and the classification of splenic trauma was adapted from Moore et al.¹⁶ Splenorrhaphy (splenic repair) was the treatment of choice provided that:

• it could be performed without incurring significant blood loss;
  
• it would ensure good haemostasis;
  
• the time taken to perform time consuming splenic repair would not result in harmful delay in treating other serious injuries;
  
• there were no other exacerbating conditions such as portal hypertension or coagulopathy.
  

An oozing or bleeding spleen laceration was sutured with U-stitches on pledgets trimmed from free pieces of omentum or haemostatic material. If required, haemostatic material and/or a pedicled flap of omentum were packed over the splenic rupture.

Antibiotic prophylaxis (amoxicillin 1 g given intravenously) was routinely administered before each operation. The patients were operated upon and followed postoperatively by two senior surgeons. Postoperative management included intravenous fluid replacement, opioid analgesics and, later, substituted with paracetamol when patients tolerated oral feeding. The patients were started on a liquid diet gradually in the absence of multi-organ injuries on the first postoperative day. Routine postoperative care, such as early mobilization and chest physiotherapy, was applied. Postoperative blood transfusion was given as required and nasogastric tubes and peritoneal drains were not inserted as a part of routine management. The patients who were not operated upon observed a bed rest regime for approximately seven days from the time of the injury, whereas the patients who were operated upon were mobilized early.

Data collection and analysis

Demographic data were collected on a pre-designed form which included age, sex, weight, mechanism and time from receipt of injury in hours, revised trauma score, clinical findings, ultra-sonography findings following FAST protocol, associated injuries, haemoglobin level, vitals records, amount of fluid received and blood transfused, overall hospital stay and complications. Statistical analysis was performed using software SPSS for Windows version 12 (SPSS, Chicago, IL, USA). Quantitative data were expressed as means with standard deviations. Continuous data were compared between groups by two-tailed Student's t-test for independent samples. Comparisons of categorical data were done using Pearson chi-square test (two-tailed). P < 0.05 was considered statistically significant.

	Results

Top SUMMARY Introduction Patients and methods Results Discussion References

 
A total of 69 patients were enrolled in the study. Initially 59 patients were assigned to non-operative management group; however, six of them deteriorated or failed to improve and were qualified for operation. In total, 53 (77%) patients were managed non-operatively and 16 (23%) underwent an operation.

The mean age of the participants was 27 years (range: 7–60 years) and the male: female ratio was 0.7 (28:41). On admission, the demographic profile for the two groups was comparable (Table 1). However, the mean revised trauma score, the mean systolic blood pressure and haemoglobin level were significantly higher in the conservatively managed versus the operatively managed groups (Table 1).

View this table: [in this window] [in a new window]   Table 1 Patients' characteristics at the admission

 
The dominating mechanism of splenic injury was domestic violence in 36 of the 69 participants (52%). In the women, domestic violence was the cause of 78% (32 out of 41) of the splenic injuries. Other causes included: fall from a height (11); motor vehicle accident (8); assault (7); sport (4) and cassowary attack (2). The characteristic for this series was a long mean time from the time of the injury to the hospital admission –22.03 (±20.15) hours.

In total, the spleen preservation was achieved in 59 patients (85.5%) including 53 (76.8%) managed non-operatively and six by splenorrhaphy. All spleens managed by splenorrhaphy were enlarged. In this splenorrhaphy subgroup the grade of splenic injury was three grade 2 splenic injuries and three grade 3 splenic injuries. Splenectomy was performed in 10 patients (14.5%).

The overall mortality rate was 4.3% (3). The causes of deaths were as follows: multi-organ failure as a late consequence of haemorrhagic shock on the first postoperative day in the splenectomized patient; and two from haemorrhagic shock immediately after admission before treatment could be instituted. None of these deaths was due to non-operative management failure. The morbidity rate was 13.2% (seven out of 53) for the conservatively managed and 18.8% (three out of 16) for the operatively managed group – the difference was not statistically significant (chi-squared test, P = 0.581).

The average requirement for blood transfusion in the conservative management group versus the operative management group was 0.81 (±1.02) and 2.94 (±1.73) units, respectively (P < 0.001). There were no significant differences in the mean overall hospital stay and associated injury to one or more organs between the conservative management group and the operative management group.

	Discussion

Top SUMMARY Introduction Patients and methods Results Discussion References

 
Although considerable success has been reported for non-operative treatment of splenic injury,^6–11,13 a correct assessment of blunt abdominal injury remains one of the challenges in trauma care. In this study, the spleen preservation was achieved in 85% of patients. This is in line with findings of others in similar settings who have reported splenic preservation rates for adults of from 60% to 75%.^2,10,11,13 The current data from developed countries with access to advanced imaging modalities indicate that the use of non-operative management has increased the splenic preservation rate to about 70% in adults⁶ and to over 85% in children.^7,8 The high rate of splenic preservation shown in our study could be partly due to the fact that the majority of the spleen injuries were caused by a low-velocity trauma, i.e. seen in domestic violence and assaults. Studies from developed countries have reported a higher rate of high-velocity trauma.

The overall mortality in our study was 4.3%, which concurs with other studies reporting mortality from splenic injury at below 10%,^6,8,13 with most early deaths caused by haemorrhagic shock.^2,3 In this series, late presentation of many patients could have been a contributing factor to the relatively low mortality achieved – we can assume that a proportion of patients with severe bleeding from splenic injury did not reach the hospital.

The low mortality rate and comparable complication rate in conservative and operative management groups reported in our series indicate that the conservative management of splenic injury in haemodynamically stable patients who do not have generalized peritonitis is a safe practice. Our findings are in agreement with other reports from tropical countries, which show that patients with splenic injuries who are haemodynamically stable and without abdominal findings requiring laparotomy can be safely managed by a non-operative approach.^2,10,11,13

Our study found that splenorrhaphy did not increase the complication rate when compared with the splenectomy subgroup. However, a small number in the splenorraphy subgroup did not reach a statistical significance. Our findings are consistent with other authors.¹⁷ There has been a traditional belief that the enlarged spleen is not feasible for splenorrhaphy. However, all repaired splenic injuries in our study were performed on enlarged spleens without an increase in the number of significant complications. Similarly, Mabogunje¹⁸ concluded that splenorrhaphy was feasible in both normal-sized and enlarged spleens and it use, therefore, should be encouraged in tropical countries with endemic malaria where splenectomy is associated with increased frequency of malaria attacks.⁵

The results of our study not only show that the conservative management of splenic injuries is safe, but that the repair of the enlarged spleen is also feasible and safe in the absence of modern diagnostic tools such as CT scans in low-volume tropical hospitals.

	References

Top SUMMARY Introduction Patients and methods Results Discussion References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kuzma, J. Articles by Atua, V. Search for Related Content PubMed PubMed Citation Social Bookmarking                      What's this?