Splenectomy Rate Research Articles

National Variation in Outcomes and Costs for Splenic Injury and the Impact of Trauma Systems

To measure national variation in splenectomy rates, mortality, and costs for hospitalized patients with splenic injury and the impact of state trauma systems on these outcomes. Using the HCUP State Inpatient Database for 2001, 2004, and 2007, all patients hospitalized with splenic injury were identified from 19 participating states. Multivariate regression was performed to compare splenectomy rates, inpatient mortality, and costs between states. Inclusiveness of statewide trauma systems was categorized based on the proportion of hospitals designated as a trauma center. Of 33,131 patients, 26.2% underwent splenectomy, 6.1% died, and median hospital costs were $14,317. After adjusting for patient, injury, and hospital characteristics, there was a 1.7-fold variation (RR 1.67; 95% CI, 1.39-2.01) among the 19 states in rates of splenectomy. Adjusted inpatient mortality varied more than 2-fold between the highest and lowest states (RR 2.43; 95% CI, 1.76-3.37). Adjusted hospital costs varied over 60% between the highest and lowest states (cost ratio 1.61; 95% CI, 1.41-1.83). States with the most inclusive trauma systems had significantly lower splenectomy rate (RR 0.79; 95% CI, 0.68-0.92) and lower mortality (RR 0.71; 95% CI, 0.58-0.87), but similar hospital costs (CR 1.05; 95% CI, 0.95-1.16) compared to states with exclusive or no trauma systems. Significant geographic variation in the management, outcome, and costs for splenic injury exists in the United States, and may reflect differences in quality of care. Inclusive trauma systems seem to improve outcomes without increasing hospital costs.

Hospitalizations in Pediatric Patients with Immune Thrombocytopenia

Abstract 170 Introduction:Immune thrombocytopenia (ITP) is a hemorrhagic disorder characterized by low platelet counts, spontaneous bruising, mucosal bleeding, and intracranial hemorrhage. In children ≤ 15 years old, the ITP incidence rate is approximately 2–5 cases per 100,000 person-years, with 30% of such cases considered as chronic ITP, which is characterized by persistently low platelet counts for at least 12 months after initial diagnosis. The disease burden of chronic ITP has not been well studied. Herein, we utilized an all-payer inpatient care database for pediatric discharges in the US to examine resource utilization, costs, and important clinical outcomes in hospitalized children with a diagnosis of ITP. Methods: The 2006 Kids’ Inpatient Database (KID) was selected for this analysis. The KID is developed within the Healthcare Cost and Utilization Project (HCUP) sponsored by the federal Agency for Healthcare Research and Quality (AHRQ). Systematic random sampling is used to select 80% of all non-birth pediatric discharges, 10% of all non-complicated births, and 80% of all complicated births from all participating community and non-rehabilitation hospitals for inclusion. The 2006 KID database contains data on over 3 million unweighted discharges collected from over 3,700 hospitals in 38 states. This large sample size enables analyses of relatively rare conditions, such as pediatric ITP. ITP-related discharges were identified with the ICD-9-CM diagnosis code of 287.31, regardless of whether it was the principal diagnosis. We developed national estimates of the following: average total inpatient cost; average length of stay (LOS); incidence rates of costly procedures such as total splenectomy and blood transfusions (through ICD-9 procedure codes); incidence rates of serious complications such as septicemia, bacteremia, intracranial hemorrhage (through hospital DRG codes), and in-hospital death. Hospital charges were converted to costs using hospital-specific cost-to-charge ratios available in the database. In addition, subgroup analyses by the following age groups were conducted: 1 to 5, 6 to 9, 10 to 13, and 14 to 17, as well as by whether the ICD-9 code for ITP was the primary diagnosis or a secondary diagnosis on the discharge summary. Results: Approximately 4,274 (0.26%) of all non-birth-related discharges among patients aged 1–17 were in patients with ITP, including 3,633 identified with ITP as the principal diagnosis and 641 as a secondary diagnosis. The majority of hospitalizations in ITP patients occurred in large, teaching hospitals, and slightly over half were for girls. Close to 50% of the ITP hospitalizations occurred through emergency room admissions or transfers from other hospitals or healthcare facilities. The overall incidence of intracranial hemorrhage among ITP hospitalizations was 0.43%, confirming earlier studies. Total splenectomy occurred in approximately 1 in 25 (4.3%) such hospitalizations. The mortality rate during ITP hospitalizations was 0.38%, compared to 0.23% for all other hospitalizations; the difference was not statistically significant. The average LOS for ITP hospitalizations was shorter than for all other hospitalizations in the KID (2.4 vs. 3.6 days, p < 0.0001), but no significant difference in mean total inpatient costs was noted ($6,869 for ITP vs. $6,515 for all others), indicating that the complexity of hospitalization, and correspondingly the intensity of treatment, might have been greater in patients with ITP. A higher complication rate, greater resource utilization, and total costs were all associated with increasing age, with the oldest pediatric age group (14–17 years) experiencing the highest rate of blood transfusions and total splenectomy, the longest LOS, and the greatest total costs (p < 0.0001 for all). Hospitalizations in which ITP was listed as a secondary diagnosis were associated with significantly greater resource use and total costs compared with those where ITP was the primary diagnosis (p < 0.0001). Conclusion: Although hospitalizations in pediatric patients with ITP were not associated with greater LOS or mortality, they appeared to be associated with a greater intensity of resource use and per-day cost. Older age and ITP as a secondary diagnosis contributed to longer stay, more resource use, and higher total cost during hospitalization. Disclosures:Lu:Amgen: Consultancy, Equity Ownership, Research Funding. Danese:Amgen: Consultancy, Research Funding. Herbert:Amgen: Consultancy, Research Funding. Eisen:Amgen: Employment, Equity Ownership. Deuson:Amgen: Employment, Equity Ownership.

In-house direct supervision by an attending is associated with differences in the care of patients with a blunt splenic injury

There continues to be controversy over the added value of direct supervision of residents, particularly its effect on patient outcomes. The purpose of this study was to compare direct and indirect resident supervision for the management of blunt spleen injuries and to evaluate differences in patient care. All patients with blunt splenic injury admitted off hours over a 6.5-year period to a regional level I trauma center were analyzed. Data analyzed included patient demographics, injury characteristics, hospital course, and treatment modality. Direct supervision was defined as the presence of a surgical attending on call in the hospital. Indirect supervision was defined as the surgical attending taking the call from home. Primary analysis consisted of a comparison of outcomes and compliance with a protocol for nonoperative management (NOM) between these groups. There were 506 total cases, of which 274 (54%) were directly supervised, 157 (31%) had indirect supervision, and 75 (15%) presented when a fellow was the most senior person in house. The mean injury severity score was 21, patients averaged 34 years of age. The splenic salvage rate was 89.7% and the mortality rate was 8.5%. The primary comparison revealed a significantly higher percentage of patients going to operation with direct supervision. Direct supervision was associated with significantly greater protocol compliance for NOM (82% vs 95%; P < .001). Indirect supervision was associated with a greater use of intensive care unit (ICU) resources and protocol noncompliance with the use of splenic artery embolization. The overall success of NOM was 98.6%. Failure of NOM was associated with lack of protocol compliance. Failure of NOM was 9.6% in patients with protocol deviation and 0.3% with protocol adherence. There were no differences in mortality or splenectomy rates between the groups. This study shows that there were significant differences in the management of blunt splenic injury depending on the type of supervision. Indirect supervision was associated with less compliance with a management protocol, fewer patients undergoing initial operation, more ICU use, increased hospital charges, and a greater use of splenic artery embolization without indication. These results emphasize the value of direct supervision in the management of a select group of trauma patients.

Thrombopoietin receptor agonist (TPO-RA) usage and treatment patterns among patients with chronic immune thrombocytopenic purpura (cITP) in a large U.S.-managed care plan.

e16586 Background: Little is known about real-world usage of TPO-RAs and treatment patterns for patients with cITP. Methods: Using medical/pharmacy claims and enrollment data of a large US managed care plan, adults being treated for cITP (ICD-9 287.31) were identified from Aug 2008 to Dec 2009. Patients were stratified into cohorts based on the treatments for cITP prescribed. Patients treated with chemotherapy were excluded, as were those with hepatitis, HIV or heparin-induced thrombocytopenia. Patients were followed from start of treatment until death, plan disenrollment, or March 2010. Sequence and rates of ITP treatments and splenectomy were assessed. Results: A total of 927 patients met study criteria. Corticosteroids were the most frequent first-line therapy (86.8%) while the most common second-line options were rituximab, IVIG, anti-D, or splenectomy, recorded for 24.7%, 18.3%, 14.6%, and 8.9%. Treatment with TPO-RA increased in later lines of therapy: second line (6.9%), third line (13.1%), fourth line (26.2%). About 21.4% received > 3 therapies; 2.3% of patients received > 5 therapies. The proportion of patients aged > 65 years was similar (≈ 25% in each group) among TPO-RA-treated patients and patients initiating other treatments, although the anti-D and splenectomy cohorts were slightly younger (8.3% and 17.0% respectively). Splenectomy was recorded in 12.7% of the total study population. Among TPO-RA-treated patients, 3.7% of eltrombopag- and 6.2% of romiplostim-treated patients had splenectomy prior to TPO-RA treatment; 11.5% of eligible eltrombopag- and 23.3% of eligible romiplostim- treated patients had post-TPO-RA splenectomies. Among TPO-RA users, 10.5% received both eltrombopag and romiplostim during their course of treatment. Conclusions: Wide practice variations, likely influenced by personal experience with different treatment options, were observed for management of cITP after initial treatment with corticosteroids. TPO-RAs were used mainly in later lines of therapy. Evidence-based treatment algorithms and guidelines for management of cITP may optimize treatment strategies, especially with introduction of new agents.

Partial Splenectomy for Hereditary Spherocytosis

Partial Splenectomy for Hereditary Spherocytosis

Predictors for splenectomy among patients with primary chronic immune thrombocytopenia: a population-based cohort study from Denmark

We conducted a nationwide cohort study of adult Danish patients with primary chronic immune thrombocytopenia (cITP) to examine selected patient and clinical characteristics as predictors for splenectomy. We analyzed data from the Danish National Patient Registry and patient medical records from 1996 to 2007. Using Cox regression analyses, we calculated incidence rate ratios (IRRs) and associated 95% confidence intervals (CI) for splenectomy. We included 371 adult cITP patients. Of these, 87 patients (23%) underwent a splenectomy during a median of 3.6 years of follow-up. The majority (84%) of cITP patients who underwent splenectomy had splenectomy within the first year after cITP diagnosis. Predictors for splenectomy included age ≤ 75 years (adjusted 1-year IRR = 6.79 (95% CI, 2.10-21.90)) at least one platelet count ≤ 30 × 10(9)/L (i.e., high disease activity; adjusted 1-year IRR = 2.67 (95% CI, 1.37-5.22)) during follow-up and year of cITP diagnosis in early period (1996-2001; adjusted 1 year IRR = 2.37 (95% CI, 1.46-3.85)). Presence of chronic comorbidity was associated with lower rates of splenectomy (adjusted 1 year IRR = 0.58 (95% CI, 0.33-1.05)). Our findings suggest that high disease activity and absence of chronic comorbidity may be associated with higher rates of splenectomy, and that contraindications for splenectomy (i.e., patients' perceived frailty) cause the physicians to use the procedure cautiously.

High Case Volumes and Surgical Fellowships Are Associated with Improved Outcomes for Bariatric Surgery Patients: A Justification of Current Credentialing Initiatives for Practice and Training

Recent years have seen the establishment of bariatric surgery credentialing processes, center-of-excellence programs, and fellowship training positions. The effects of center-of-excellence status and of the presence of training programs have not previously been examined. The objective of this study was to examine the effects of case volume, center-of-excellence status, and training programs on early outcomes of bariatric surgery. Data were obtained from the Nationwide Inpatient Sample from 1998 to 2006. Quantification of patient comorbidities was made using the Charlson Index. Using logistic regression modeling, annual case volumes were analyzed for an association with each institution's center-of-excellence status and training program status. Risk-adjusted outcomes measures were calculated for these hospital-level parameters. Data from 102,069 bariatric operations were obtained. Adjusting for comorbidities, greater bariatric case volume was associated with improvements in the incidence of total complications (odds ratio [OR] 0.99937 for each single case increase, p = 0.01), in-hospital mortality (OR 0.99717, p < 0.01), and most other complications. Hospitals with a Fellowship Council-affiliated gastrointestinal surgery training program were associated with risk-adjusted improvements in rates of splenectomy (OR 0.2853, p < 0.001) and bacterial pneumonias (OR 0.65898, p = 0.02). Center-of-excellence status, irrespective of the accrediting entity, had minimal independent association with outcomes. A surgical residency program had a varying association with outcomes. The hypothesized positive volume-outcomes relationship of bariatric surgery is shown without arbitrarily categorizing hospitals to case volume groups, by analysis of volume as a continuous variable. Institutions with a dedicated fellowship training program have also been shown, in part, to be associated with improved outcomes. The concept of volume-dependent center-of-excellence programs is supported, although no independent association with the credentialing process is noted.

Expanding spectrum of the association between Type 1 Gaucher disease and cancers: A series of patients with up to 3 sequential cancers of multiple types—Correlation with genotype and phenotype

In Gaucher disease (GD), inherited deficiency of lysosomal glucocerebrosidase due to mutations in GBA1 gene results in accumulation of glucosylceramide in tissue macrophages, systemic macrophage activation, and a complex multisystemic phenotype. We and others have reported an increased risk of multiple myeloma and other malignancies in non-neuronopathic Type 1 GD (GD1). Here, we describe a subset of GD1 patients with multiple malignancies. In our cohort of 403 patients with GD1, nine patients (2.2%) developed two or three different types of cancers either consecutively or simultaneously. Patients were characterized by age at diagnosis of GD1, GBA1 genotype, disease severity, age at cancer diagnosis, enzyme replacement therapy (ERT) status, and splenectomy status. Of the nine patients, six developed two types of malignancies and three had three cancers each. Overall, the hematologic malignancies comprised lymphoma/leukemia (4) and multiple myeloma (4). Nonhematologic malignancies included colon (2), lung (2), thyroid (2), and prostate cancer (1). Of the seven patients who received ERT, the first cancer was diagnosed before initiation of ERT in all but one. Asplenic patients were more likely to have single or multiple cancers compared with patients with intact spleens (P < 0.0072 and P < 0.0203, respectively). Our data strengthen the association of GD1 and cancer and suggest that patients may be at risk of developing multiple malignancies. We found an association between splenectomy and multiple cancers in GD1. It will be of interest to determine whether timely ERT and declining rates of splenectomy will translate into declining rates of multiple and single cancers.

Complications and treatment of patients with -thalassemia in France: results of the National Registry

beta-thalassemia is a rare disease in France, encountered mainly in patients originating from Italy and North Africa. In the setting of the recent French plan for rare diseases, a National Registry for thalassemia has been developed since 2005. Epidemiological and clinical data have been collected on living patients with beta-thalassemia major or intermedia, including those who underwent hematopoietic stem cell transplantation. A standardized questionnaire was sent to clinicians throughout the national professional networks involved in the management of thalassemic patients and data were updated every 18 months. A cross-sectional study was performed in February 2009. Data on 378 patients (267 with thalassemia major) with a median age of 20 were recorded. Hematopoietic stem cell transplantation was performed in 52 patients. Stature, rates of parenthood, splenectomy, and cholecystectomy were no different between non-transplanted thalassemia major and thalassemia intermedia patients, after adjustment for age. Among the 215 non-transplanted thalassemia major patients, the median serum ferritin level was 1240 ng/mL and the rates of iron-related complications were 10%, 6%, 10% and 48% for cardiac failure, diabetes, hypothyroidism, and hypogonadism, respectively. From 2005 to 2008, a dramatic switch in chelation treatment, from deferoxamine to deferasirox, was observed. The rates of complications of iron overload in French thalassemia major patients appeared similar to those reported in other developed countries in which this condition is not endemic. There were no significant differences in height and parenthood rates between patients with the major and the intermedia forms of the disease, underlining the progress in clinical care. Future developments will focus on mortality and morbidity under oral chelation treatment.

Extreme Thrombocytosis in Trauma Patients: Are Antiplatelet Agents the Answer?

The purpose of this study was to review the incidence of extreme thrombocytosis (ExT) (platelet count 1,000,000/microL or greater) in trauma patients and to examine the role of antiplatelet agents in its treatment. The Los Angeles County Medical Center trauma registry was used to obtain injury demographics, medications, and daily platelet counts for injured patients 16 years of age or older admitted between July 2005 and February 2008. Of 6,985 total trauma patients admitted during the study period, 95 developed ExT (1.4%). Average age was 29 years (range, 16-63 years), 89 per cent were male, 44 per cent had penetrating trauma, and mean Injury Severity Score was 24 (range, 1-57). Of the 95 patients with ExT, 41 were treated with aspirin (43%) and 54 were not (57%). The two groups did not differ with regard to basic demographics, injury patterns, vitals on admission, or splenectomy rate (34 vs 20%, P = 0.13). After adjusting for maximum platelet counts and duration of ExT, there was no difference between the treated and untreated groups in terms of mortality, complications, and intensive care unit or hospital lengths of stay. The incidence of ExT is approximately 1.4 per cent in trauma patients. Antiplatelet therapy does not affect ExT patient outcome. Further prospective studies are warranted.

Distribution of hepatitis C virus genotype in Iranian multiply transfused patients with thalassemia

Hepatitis C virus (HCV) infection is the most common transfusion-transmitted disease in multiply transfused patients worldwide. In this study, the aim was to investigate distribution of HCV genotypes in Iranian patients with thalassemia. Blood samples were received from 280 multiply transfused patients with thalassemia with chronic hepatitis C who were referred to us to start pegylated interferon-alpha plus ribavirin for duration of 48 weeks. HCV RNA viral load was detected using Amplicor test (Version 2, Roche Molecular Systems). Genotyping was performed by genotype-specific primers. HCV genotype distribution was 1 in 57%, 3 in 35%, 2 in 1%, and mixed in 4% (1 + 3 in 2.8%, 3 + 4 in 0.4%, mixed subtypes in 0.8%) cases. A total of 2.5% of isolates were nontypable. Genotype 1 was associated with higher rate of splenectomy and greater serum ferritin. Genotype 1 is the most frequently detected HCV genotype in Iranian patients with thalassemia and might cause more need for splenectomy and more severe iron overloading. Higher HCV viral load could be regarded as another risk factor for greater iron overloading.

Management of blunt splenic injury in children: evolution of the nonoperative approach

Background Nonoperative management of blunt splenic injury (BSI) was first proposed at our institution in 1948. Since that time, treatment of patients with BSI has evolved from routine splenectomy to an aggressive spleen-preserving philosophy. This report summarizes our institutional experience for the last 50 years. Methods All children (0-18 years) admitted to our pediatric trauma center with BSI during 4 eras (1956-1965, 1972-1977, 1981-1986, and 1992-2006) were retrospectively reviewed for demographics, injury patterns, management, and complications. Results During the 4 eras captured for the last 5 decades, 486 children experienced BSI. The mean age was 10 years with 347 males (71%). Nonoperative management rate increased from 42% to 97% with improvement in splenic salvage rate (42%-99%). Mean length of stay decreased from 17 to 5 days. In patients with isolated splenic injuries (50%), nonoperative management rate increased (36%-100%) and fewer received transfusions (60%-1%). Overall mortality rate improved (19%-6.6%, 8%-0.7% in isolated injuries). Conclusion The management of BSI in children has changed dramatically for the last 50 years. This study clearly demonstrates the safety of nonoperative management and documents progressively lower rates of splenectomy and transfusion, shorter hospitalization, and an extremely low risk of mortality.

Surgical treatment of spleen-related blood diseases

Objective To explore the surgical indexes, therapeutic efficacy and prevention of complications in treatment of some blood diseases by splenectomy (including laparoscopic splenecto- my). Methods The clinical data of 27 patients with blood diseases receiving splenectomy in our hospi-tal were retrospectively analyzed. Results The effective rate of splenectomy was 100% in 4 cases of hereditary spherocytosis, 76.47% in 17 cases of ITP and low in 6 cases of Non-Hodgkin's lymphoma.The postoperative incidence of complications was 7.41% (2/27). Conclusion Splenectomy is of the first choice for treatment of hereditary spherocytosis. Meanwhile, it is effective for most of the patients with ITP. It is an important approach for comprehensive of malignant lymphoma. Proper choice of indications and perioperative management are helpful for decreasing incidence of postoperative complications. Key words: Splenectomy; Blood disease; Indication; Complication

Transhiatal oesophagectomy: Techniques, tips and outcomes

To demonstrate our technique and valuable tips for transhiatal oesophagectomies. 215 patients underwent transhiatal oesophagectomies in our unit between 2000 and 2006. In-hospital mortality was 0.9%. Anastomotic leak in 12 patients (5.6%). Chyle leak was seen in five patients and recurrent nerve neuropraxia in six patients. Iatrogenic splenectomy rate was 6%. The median operative time was 151 minutes (range 93-276 minutes). Overall median length of hospital stay was 15 days (range 8-95 days). The median survival for all patients undergoing transhiatal oesophagectomy for invasive malignancy was 42.9 months and the one-year and five-year survival were 81% and 48% respectively. This is a safe and oncologically sound procedure. We feel that the tips can be helpful for anyone performing this procedure.

Immune (Idiopathic) Thrombocytopenic Purpura (ITP): Treatment Pattern and Splenectomy Rate from a Multinational Prospective Observational Study

ITP is an autoimmune disease characterized by low platelet counts due to increased platelet destruction and inadequate platelet production. It is often a chronic disorder that requires long-term treatment. Current common treatment therapies for chronic ITP include corticosteroids, intravenous immunoglobulins (IVIG), rituximab, and anti-D antibody. Splenectomy may be required for those patients who do not respond or relapse after these medical therapies, or require intolerable doses to achieve safe platelet counts. Few studies have reported treatment pattern of current therapies for ITP. We report results of an international multi-center retrospective and prospective observational study of adult patients receiving treatments and/or splenectomy for chronic ITP. Patients with a diagnosis of ITP were enrolled from 100 community and academic centers. Date of 1st ITP diagnosis, treatments received and medical history were obtained retrospectively from patient chart data. ITP treatments, dose, response, and duration of response were collected prospectively for 12 months. Among 326 patients with ITP studied (mean age=54 years, male 40.2%), 24% received a splenectomy during this study. In patients who were not splenectomized (n=248), 77% received ITP medications with corticosteroids being the most frequently prescribed medication among patients who received 1 type of ITP treatment. IVIG was most frequently prescribed in patients who received 2 types of ITP treatments, and patients were most likely to receive a splenectomy after receiving 2 or more types of ITP treatments (table). In splenectomized patients, the average duration from ITP diagnosis to splenectomy was 2.79 years (n=74, SD=4.42, min=0, max=23.38). Prior to surgery, splenectomized patients were most likely to receive corticosteroids in patients receiving 1 type of treatment, and IVIG in patients receiving 2 types of ITP treatments. Following surgery, splenectomized patients were also most likely to receive corticosteroids in patients receiving 1 type of ITP medication, and rituximab in patients with 2 types of ITP medications. Overall, patients with ITP are exposed to numerous ITP treatments, among which, corticosteroids were most frequently used in both splenectomized and non-splenectomized patients. All patients receiving a splenectomy also required 1 or more ITP treatments following surgery. These results demonstrate that current ITP therapies are limited in efficacy and durability and often lead to patients receiving multiple types of ITP treatments. Novel ITP therapies with better efficacy and durable response are needed.Splenectomizedb(N=78)ITP Treatments ReceivedOverall (N=326)Pre-Splenectomy (N=74)Post-Splenectomy (N=74)Non-Splenectomized (N=248)058 (18)0058 (23)189 (27)23 (31)37 (50)83 (33)Exposure Rate n(%)282 (25)15 (20)17 (23)62 (25)349 (15)18 (24)11 (15)27 (11)4 or More48 (15)18 (24)9 (12)18 (7)1Corticosteroids (71%)Corticosteroids (57%)Corticosteroids (22%)Corticosteroids (76%)Most Frequently Used Therapy (%)a2IVIG (39%)IVIG (73%)Rituximab (24%)IVIG (52%)3Splenectomy (45%)IVIG (56%)IVIG (27%)IVIG (52%)4 or MoreSplenectomy (63%)Rituximab (11%)Vincristine (22%)Rituximab (78%)aMost frequently used treatment or therapy observed within that subgroup (receiving 1, 2, 3, 4 or more treatments). Percentages (%) are calculated as n divided by the total number of patients within the corresponding subgroup.b4 splenectomized patients were excluded from the analysis due to missing data.

Impact of a Statewide Quality Improvement Initiative in Improving the Management of Pediatric Splenic Injuries in Washington State

Evidence suggests that 90% of children with traumatic spleen injuries can be successfully managed nonoperatively. In Washington State, significant interhospital variation in pediatric spleen management led to the development and implementation of a statewide quality improvement initiative in 2002. We evaluated pediatric splenic injury management before and after the implementation of a statewide quality improvement initiative. Retrospective cohort study using data from the Washington Trauma Registry for years 1999-2001 (preintervention) and 2003-2005 (postintervention). Children ages 0 to 14 years who were hospitalized with a traumatic (noniatrogenic) splenic injury were included. Multivariable regression was used to control for patient and hospital characteristics. Splenectomies were more common, occurring in 13.6% of children, in the preintervention period, compared with 7.8% in the postintervention period (p = 0.027). After adjusting for patient, injury, and hospital characteristics, children remained less likely to receive a splenectomy in the postintervention period than in the preintervention period (odds ratio 0.39, 95% confidence interval 0.19-0.82). Children cared for at pediatric trauma hospitals were less likely to receive splenectomy in both the preintervention and postintervention periods, compared with children treated at general trauma hospitals (p < 0.001). Splenectomy remained less common among children treated at pediatric-designated hospitals (odds ratio, 0.21; 95% confidence interval, 0.08-0.58) than among children treated in general trauma hospitals after controlling for intervention period. The statewide quality improvement initiative was associated with a reduction in the rate of splenectomy in both pediatric and general trauma hospitals. However, general trauma hospitals remained more likely to perform splenectomies than hospitals with pediatric trauma designation.

L’embolisationprécoce dans le traitement non opératoire destraumatismes fermés de la rate. Étude rétrospectivemulticentrique

Splenic artery embolization has been used as an adjunct to the non-surgical management of blunt splenic injury. No consensus on its indications has emerged from the literature. This multicentric study aimed to evaluate the results of this technique in France. Between March 2000 and April 2006, 22 patients older than 15 years of age (mean age 29, range: 15-59) with splenicv rupture due to blunt trauma underwent splenic artery embolization in six Level I Trauma Centers in France. Splenic rupture was classified Moore II in 3 cases, Moore III in 12 cases, and Moore IV in 7 cases. Angiography was performed within 4 hours of admission in half of the cases. The main indications for splenic artery embolization were: extravasation of contrast medium on CT scan (10 cases, 45%); early pseudo-aneurysm (6 cases, 23%); hypotension despite fluid resuscitation and/or progressive need for transfusion (5 cases, 22%). There was no mortality. Nine patients experienced complications (41%) including 6 (27%) who developed left pleural effusion. Two patients eventually underwent splenectomy (one for persistent hemorrhage, one for splenic necrosis). The overall splenic salvage rate was 91%. Splenic artery embolization is a valuable techniche that hels to lower the rate of splenectomy for traumatic splenic rupture with relatively low morbidity.

Initial and Long-Term Outcomes of Splenectomy in Adult Immune Thrombocytopenic Purpura (ITP) Patients: A Systematic Review and Meta-Analysis.

Splenectomy serves as a common therapy in treating adults with chronic ITP. Laparoscopic splenectomy was introduced in 1991 with the goal of reducing complication rates. This study was designed to estimate both the initial surgical non-response rate and the long-term relapse rate of splenectomy in the post-laparoscopic era. A systematic literature review was conducted by searching PubMed for articles published between January 1, 1991 and October 3, 2006. Selection criteria included: chronic ITP, study enrollment in 1990 or later, ≥12 months of follow-up, ≥15 patients with ITP, ≥75% of patients at least 14 years of age, not HIV positive, and not undergoing a second splenectomy. Response rates for surgery were collected according to an author-defined platelet response criterion (platelet counts <50x109/L or <30x109/L in 75% of studies). Relapse rates post-splenectomy (using the same platelet response criteria) were also collected. A meta-analysis was conducted to estimate a pooled surgical non-response rate as well as a pooled relapse rate in responders by weighting the study-specific estimates by the inverse of their variances, using Stata 9™. The pooled relapse rate was converted to a probability using the exponential formula, e(-rate x time). We identified 161 articles for detailed review. Of these, 24 met our inclusion criteria, all of which were observational studies. These studies represent 1,138 laparoscopic splenectomies (66 or 5.8% were converted to open splenectomy during surgery), and 317 open or undefined splenectomies. The average surgical non-response rate across 21 studies reporting data was 12.2% (95% CI: 10.3–14.3%). The average long-term relapse rate per person year across all studies was 53 per 1,000 patient years (95% CI: 45.0–62.0%). This corresponds to a 5% per year failure rate, or 32% failure rate after 5 years, for all patients initiating surgery. Initial non-response rate to planned splenectomy is 12% in adults with ITP. For patients undergoing laparoscopic splenectomy, 6% required conversion to open splenectomy. The 5 year relapse rate post-splenectomy is 32%. Splenectomy, although the current standard of care, is not always initially successful and does not provide a durable response in all patients. The benefits and risks of splenectomy must be weighed in light of newer options of therapy currently available. [Display omitted]

The Significance of Inadvertent Splenectomy During Colorectal Cancer Resection

To examine the frequency, predictors, and outcomes following inadvertent splenectomy during colorectal cancer resection. Retrospective study. Linkage of the California Cancer Registry and the California Patient Discharge Database from the Office of Statewide Health Planning and Development. Californians undergoing colorectal cancer resection from 1995 through 2001. Inadvertent splenectomy was defined as splenectomy occurring during non-T4 or non-stage IV resection. Main Outcome Measure The rate of inadvertent splenectomy for the overall cohort and by tumor location (eg, splenic flexure, rectosigmoid). Multivariate risk-adjusted models identified predictors of inadvertent splenectomy and outcomes including length of stay and probability of death. A total of 41,999 non-T4, non-stage IV colorectal cancer resections were studied. Mean age was 70.4 years; 50.4% were male; and 75.6% were non-Hispanic white. Although the overall rate of inadvertent splenectomy was less than 1%, the rate was 6% for splenic flexure tumors. A multivariate risk-adjusted model predicting inadvertent splenectomy demonstrated a statistically significant (P < .001) higher odds ratio if the tumor was located in the transverse (3.6), splenic flexure (29.2), descending (11.4), sigmoid (2.7), or rectosigmoid (2.6) regions. Using a risk-adjusted model, inadvertent splenectomy increased length of stay by 37.4% (P < .001). Perhaps most important, risk-adjusted survival analysis showed splenectomy increased the probability of death by 40% (P < .001). To our knowledge, this is the first large study evaluating the rates and outcomes after inadvertent splenectomy. In the population-based cohort, tumor locations from the transverse colon to the rectosigmoid significantly increased the odds of inadvertent splenectomy. In addition, inadvertent splenectomy during colorectal cancer resection increased both length of stay and probability of death.

Variation in the Management of Pediatric Splenic Injuries in the United States

This study examines the existence and sources of variation in the management of pediatric splenic injuries among hospitals in the United States and the factors associated with splenectomy. Information on children 15 years of age and younger with a splenic injury diagnosis code was extracted from the Kids' Inpatient Database 2000, a pediatric inpatient database of 2,784 hospitals in 27 states covering 72% of the nation's population for the year 2000. Patient variables included age, sex, race, injury diagnoses, grade of splenic injury, splenic procedure code, and calculated Injury Severity Score. Hospital variables included pediatric status (free-standing, unit and adult), teaching status, annual pediatric splenic trauma volume, and national region. A multivariate logistic regression model was used to predict the factors associated with splenectomy based upon patient and hospital characteristics. In all, 2,191 children with splenic injuries were identified; 253 (12%) underwent splenectomy. The crude rate of splenectomy varied significantly among pediatric hospital types: 3% (11/339) at freestanding children's hospitals, 9% (45/525) at unit hospitals and 15% (197/1327) at adult hospitals (p < 0.001). Risk of splenectomy increased with the grade of splenic injury, patient age, and the presence of multiple injuries. Teaching hospitals and hospitals with higher patient volume were associated with lower risk for splenectomy. There was no relationship between splenectomy and gender, race, or national region. Despite adjustment for the above noted hospital and patient-specific variables, children treated at an adult hospital had 2.8 times the odds, and those treated at a unit pediatric hospital 2.6 times the odds, of undergoing splenectomy as those cared for at a free-standing pediatric hospital (p = 0.003 and 0.013, respectively). Nationally, children cared for at freestanding pediatric hospitals have a significantly lower risk of splenectomy than children treated at either adult hospitals or pediatric hospitals within an adult hospital. This may have implications for education, trauma triage and the establishment of practice guidelines.