Need for a National Database for Splenic Trauma?

Abstract

We would agree with the authors that the incidence of blunt splenic injury seen in district general hospitals seems to be decreasing and there is an increasing move towards non-operative management in such cases. We note in their paper that mean in-hospital stay for patients not undergoing surgery was 13 days but this ranged widely from 3–25 days. We have similar experiences in our practice and comparable dilemmas surrounding the management of such patients. We wonder what criteria were used to allow the patients to be safely discharged from hospital and why there was such a wide range of hospital stay. We also wonder what general advice was given to patients following discharge from hospital and specifically what advice was given around resumption of driving, daily activities and contact sports, etc. Several published papers and traditional advice recommend strict bed rest for up to 7 days following non-operative management of splenic trauma, 6 weeks before return to physical activity and 6 months before contact sports should be recommenced.1,2. However, these protocols are based on little evidence. In their large case series, Crawford et al.3 found only a 2% ‘late’ failure rate of a non-operative management strategy (failure occurring 3 days or more after admission) but all of these patients were still in hospital as a result of associated injuries. They concluded, therefore, that ‘in-hospital observation beyond the third day after injury is not necessary for most patients with splenic injury, who have no other reason to remain hospitalised’. However, other authors have reported failure rates of between 5–37%,4–7 Sanders and Civil8 finding the failures occurring on average on the fourth hospitalised day. Advice to remain free from physical activity for 6 weeks is largely based on in vitro experiments that have shown splenic wounds allowed to heal by secondary intention develop a ‘wound break strength’ (the physiological index of wound healing) equal to that of a normal spleen at 6 weeks following initial insult.9 Detrimental effects of an earlier return to physical activity before 6 weeks has yet to be shown in vivo. Advice to remain free from contact sports for 6 months is based on level 3 evidence and professional opinion rather than any scientific evidence. Interestingly, Pachter et al.10 recommended obtaining a follow-up computed tomography (CT) scan at 8 weeks' post-injury in patients keen to return to contact sports, only permitting a return to sport if the CT demonstrated complete resolution. Were there any cases of delayed rupture in the patients from the Royal Glamorgan Hospital? Radiological follow-up following non-operative management of splenic injury remains controversial. In this series, the authors followed up 6 patients with ultrasound and 4 patients with a varying number of CT scans. Although they comment on the significant radiation exposure to these patients, we wonder what criteria were used for determining which imaging modality to use and the timing and number of follow-up imaging in their patients. Follow-up imaging aims to exclude the development of progressive haematomas and pseudo-aneurysms of the splenic hilar vessels. Lyass et al.,11 in their published series, found only 1 patient (3%) whose splenic injury had deteriorated; however, a conservative management strategy in this case was continued and was ultimately successful. They concluded that: ‘follow-up imaging can be omitted in clinically stable patients with blunt splenic trauma of grades 1–3’. These findings correspond with those of Shafi et al.,12 who found a deterioration in radiological findings in 5% of patients, only one of whom required intervention. Sinha and colleagues did not comment on the outcome of the follow-up radiological investigations in their reported series or if there were any cases of late rupture in the non-operative group. Thus the role of follow-up imaging remains controversial. A number of bodies recommend a vaccination programme for asplenic patients and those undergoing elective splenectomy, so as to reduce the risks of sepsis.13 It is recommended that pneumococcal vaccine should be given at least 2 weeks prior to elective splenectomy, if possible, to allow for a peak functional antibody response, as hyposplenic/asplenic patients have been found to have a reduced ability to mount an antibody response to vaccines.14 As rates of failure of non-operative management of splenic trauma vary between 5–40%, we speculate whether all patients admitted with splenic trauma and treated conservatively should undergo routine vaccination immediately, as up to 40% may eventually require a splenectomy. As single-unit experience in the management of splenic trauma is likely to be limited, we wonder if a national database should be established, for patients with splenic injuries managed non-operatively, to allow surgeons both to manage and advise these patients, based on an increasingly established evidence base.