Appropriate Management of Splenic Trauma

Abstract

The article by Mucha on blunt splenic trauma in adults, which was published in the June 1986 issue of the Proceedings (pages 472 to 477), reopens an old can of worms: which patients with presumed isolated splenic damage should undergo surgical exploration? His retrospective series was used to infer guidelines for nonoperative management in adults. The author concluded that “selective management of blunt splenic trauma is safe, rational, and effective.” I am not sure that the data warrant this conclusion. An old aphorism comes to mind: “we have lots of answers—what we need are the right questions.” I found vulnerable to misinterpretation the criteria that (1) patients with minimal or absent peritoneal signs on examination and (2) patients with less than a 2-unit blood transfusion requirement may qualify for observation. Physical examination of the abdomen after blunt trauma is subjective and can be unreliable. I have no doubt that a patient with trivial or absent splenic bleeding should have less alarming findings on initial examination than one with major hemoperitoneum. Nevertheless, all the in-between possibilities bother me. Has liberal diagnostic peritoneal lavage gone the way of the hula hoop already? Furthermore, a 2-unit transfusion end point for nonoperative management seems laudably conservative but has some confusing nuances. Does this mean transfusion back to the time that hemoglobin was determined in the emergency room or to an arbitrary level deemed physiologically tolerable (for example, 10 g/dl)? How often is the hemoglobin concentration measured in a “stable” patient? In this context, the average 17-year-old motorcycle operator with a precrash hemoglobin value of 16.4 g/dl may differ greatly from 68-year-old Uncle Fred who falls off the henhouse. Most importantly, within what time course does the 2-unit limit apply? Although “verification of a blunt splenic injury alone” by radiographic tests is mentioned, it might have been less vague to state in bold type that the nonoperative selection guidelines apply, if ever, only to patients so chosen. Rather than a trustworthy algorithm for therapy, we have one of the fruits of chart review—rearview mirror “correlations” that do not necessarily dictate the most effective or safest plan of action. This situation is the Achilles' heel of many retrospective clinical studies, and the surgical literature is replete with numerous precedents. Readers, especially nonsurgeons, may miss this point. Because the Mucha article has surely been read by now in almost every doctor's lounge in Minnesota, I worry that the three derivative guidelines may seduce nonsurgeons who have been deluged with prior authoritative publications preaching “save the spleen” but who practice beyond the security of a major medical center equipped with every known support resource (especially a huge blood bank and fully staffed operating rooms functional day or night) to follow the ostensibly rational decision for nonoperative management of “stable” patients with abdominal trauma. Not operating was successful in only a fourth of the Mayo patients overall—it failed in almost a third of the intentionally selected, presumably favorable, candidates. An outlying community hospital cannot likely match this success (or “luck”) and may encounter difficulty trying. Finally, “nucleotide,” which was used in the article in reference to spleen scanning, should be replaced by the term “radionuclide.” Radioactive isotopes used for spleen imaging are radionuclides. Appropriate Management of Splenic Trauma: Dr. Mucha repliesMayo Clinic ProceedingsVol. 61Issue 10PreviewIn response to Dr. Lee's comments, I share some of his concerns as they relate to misinterpretation of data. The primary intent of my article was to present an update of some of the attitudes that have evolved at the Mayo Clinic on the basis of recent experience with the management of blunt splenic trauma. The intent of the overview was not to dictate how other surgeons should practice in other settings but rather to describe what we are currently doing at our institution. Full-Text PDF