Splenic Injury In Adults Research Articles

Blunt splenic injury: Operation versus angiographic embolization

Splenic injuries, like other blunt traumatic injuries, are increasingly treated with non-operative management. Angiographic embolization (AE) has emerged as an alternative modality for treatment of splenic injuries. We hypothesized that splenic embolization would lead to equivalent, if not improved, outcomes in terms of mortality, total costs, complications, and duration of stay. A retrospective review of a prospective data set was performed for all adult splenic injuries admitted to our level I trauma center from 2000 through 2003. Demographics, number of red cell units, emergency department hemodynamics, costs, and outcomes were examined. The operative group included those who underwent computed tomography (CT) first then went to the operating room (OR) (CT+OR) or those who went directly to the OR. There were 25 CT+OR and 24 AE patients of 164 blunt splenic injuries. After univariate analysis, higher injury severity score (ISS), lower systolic blood pressure, lower pH, and higher packed red blood cell transfusions were associated with increased mortality and duration of stay. The splenic Abbreviated Injury Scale (AIS; mean +/- SD) was the same for AE compared to CT+OR patients (3.8 +/- 0.4 vs 3.5 +/- 0.9). Although the AE group was older (50 +/- 20 vs 36 +/- 13 years, P < .01), Glasgow Comma Score (13 +/- 4 vs 11 +/- 5), age, highest heart rate (109 +/- 24 vs 120 +/- 43), and splenic AIS were not predictive of the need for an operation. Abdominal complications were lower in the AE group compared to the CT+OR (13% vs 29%), but mortality was not different (8% vs 4%). Total costs were similar for both groups after adjustment for ISS, GCS, pH, pretreatment transfusions, and spleen AIS (AE, $49,300 +/- $40,460 vs CT+OR, $54,590 +/- $34,760). The non-operative failure rate in this study was 2%. AE of splenic injuries is safe and associated with fewer complications. The spleen AIS, heart rate, age, and GCS did not correlate with the need for an operation. Higher ISS, lower blood pressure, lower pH, and increased number of packed red blood cell transfusions were better indicators of the need for an operation versus embolization.

Management of Blunt Splenic Injury in Patients with Concurrent Infectious Mononucleosis

Selective nonoperative management is appropriate for most blunt splenic injuries in adults and children, but the efficacy of this approach is unknown when injury occurs in patients with concurrent infectious mononucleosis. We have reviewed our experience during the past 23 years with the selective nonoperative management of blunt splenic injury in these patients. Medical record review identified nine patients with blunt splenic injury and infectious mononucleosis from 1978 to 2001, representing 3.3 per cent of our total trauma population with blunt splenic injury treated during that interval. Two patients underwent immediate splenectomy because of hemodynamic instability. Seven patients were admitted with the intent to treat nonoperatively. Five patients were successfully managed nonoperatively. Two patients failed nonoperative management and underwent splenectomy, one because of hemodynamic instability and one because of an infected splenic hematoma. Concurrent infectious mononucleosis does not preclude the successful nonoperative management of blunt splenic injury. This small subset of patients may be managed nonoperatively using the same criteria as for patients whose splenic injuries are not complicated by infectious mononucleosis.

Prospective evaluation of criteria for the nonoperative management of blunt splenic trauma

Meguid AA, Bair HA, Howells GA, et al (William Beaumont Hospital, Royal Oak, MI) There has been significant evolution in the management of blunt splenic trauma over the past 30 years. The trend toward nonoperative management of blunt splenic injury in adults has now been accepted as the standard of care in pediatric patients as well. However, recent reports have shown increased mortality rates and failure rates associated with nonoperative management of blunt splenic injury and have prompted questions regarding the appropriate criteria for nonoperative management. The authors of this study have prospectively applied criteria developed from 15 years of experience in the nonoperative management of blunt splenic injury. These criteria are hemodynamic stability on admission or after initial resuscitation with up to 2 L of crystalloid infusion, no physical findings or any associated injuries necessitating laparotomy, and a transfusion requirement attributable to the splenic injury of 2 units or less. The most recent results with application of these criteria to the treatment of blunt splenic trauma are presented. From 1994 through 2000, a total of 99 patients presented with splenic injury. Of these patients, 31 (31%) patients underwent splenectomy resulting from hemodynamic instability, leaving 68 patients for inclusion in this report. During the observation period, 8 (12%) of the 68 patients who initially met criteria for nonoperative management had hemodynamic instability develop and underwent splenectomy. All the nonoperative management failures occurred within 72 hours of admission. There was no mortality associated with splenic injury in the nonoperative management group or in the group that failed nonoperative management, and neither group had associated morbidities from the splenic injury. There were no significant differences between the nonoperative management group and the failed nonoperative management group in terms of demographics, clinical findings, or outcome measures. It would appear from these findings that established criteria for intervention and careful observation in an intensive care setting for a minimum of 72 hours will reduce the morbidity or mortality associated with blunt splenic trauma in adults.

Management of Adult Splenic Injury: A 20-Year Perspective

The objective of this study was to identify changes in the management of blunt splenic injury in adults. Hospital discharge abstract data from Maine were used to identify patients > or = 16 years old discharged between January 1, 1981 and December 31, 2000 with International Classification of Diseases (9th revision) codes indicating splenic injury. Incidence of operative intervention and outcomes for trauma hospitals and other hospitals were determined. The number of splenic injuries was about 75 per year for the first 15 years increasing to 96 per year in the last 5-year period. The rate of operative intervention declined from 71 to 41 per cent and was lower at the trauma hospitals during the last two 5-year periods (41% vs 53%). The rate of operative intervention > 24 hours after admission was 2.2 per cent during the last 10 years of study. The rate of splenorrhaphy remained stable at about 12 per cent throughout the study period. Mortality rates were higher at the trauma hospitals as were the numbers of patients with very severe injuries (Injury Severity Score > 25). There has been a marked decrease in rate of operative intervention for splenic injury in adults especially in the last 10 years. Rates of operative intervention were lower at the trauma hospitals despite higher injury severity. Frequency of delayed intervention was low and did not increase with lower operative rate.

Prospective Evaluation of Criteria for the Nonoperative Management of Blunt Splenic Trauma

Recent reports have shown an increased mortality associated with the nonoperative management of blunt splenic injury. We have prospectively applied criteria developed from our previous 15-year experience for the nonoperative management (NOM) of blunt splenic injury. These criteria consist of 1) hemodynamic stability on admission or after initial resuscitation with up to two liters of crystalloid infusion, 2) no physical findings or any associated injuries necessitating laparotomy, and 3) a transfusion requirement attributable to the splenic injury of 2 units or less. From 1994 through 2000 a total of 99 patients presented with blunt splenic injury. Thirty-one patients (31%) underwent splenectomy secondary to hemodynamic instability. During the observation period eight of the 68 patients (12%) who initially met criteria for NOM developed hemodynamic instability and underwent splenectomy. All NOM failures occurred within 72 hours of admission. There was no mortality associated with splenic injury in the NOM (Group I) or in the group failing NOM (Group II), and no associated morbidities from the splenic injury were seen in either group. No significant differences were seen between Groups I and II in terms of age, gender, mechanism of injury, Injury Severity Score, admitting systolic blood pressure, admitting hemoglobin, transfusion requirements, intensive care unit length of stay, or total hospital length of stay (all P > 0.200). We conclude that established criteria for intervention and careful observation in an intensive care setting for at least 72 hours will minimize morbidity or mortality associated with blunt splenic injury in adults.

Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma.

The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults. Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively. Fifteen percent of patients were 55 years of age or older. A similar proportion of patients > or = 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients > or = 55 was significantly greater than patients < 55 (43% vs. 23%). Patients > or = 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women > or = 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05). Patients > or = 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > or = 55 had significantly greater mortality and failure of NOM than women < 55.

Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma.

Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The purpose of this multi-institutional study was to determine which factors predict successful observation of blunt splenic injury in adults. A total of 1,488 adults (>15 years of age) with blunt splenic injury from 27 trauma centers in 1997 were studied through the Multi-institutional Trials Committee of the Eastern Association for the Surgery of Trauma. Statistical analysis was performed with analysis of variance and extended chi2 test. Data are expressed as mean +/- SD; a value of p < 0.05 was considered significant. A total of 38.5 % of patients went directly to the operating room (group I); 61.5% of patients were admitted with planned nonoperative management. Of the patients admitted with planned observation, 10.8% failed and required laparotomy; 82.1% of patients with an Injury Severity Score (ISS) < 15 and 46.6% of patients with ISS > 15 were successfully observed. Frequency of immediate operation correlated with American Association for the Surgery of Trauma (AAST) grades of splenic injury: I (23.9%), II (22.4%), III (38.1%), IV (73.7%), and V (94.9%) (p < 0.05). Of patients initially managed nonoperatively, the failure rate increased significantly by AAST grade of splenic injury: I (4.8%), II (9.5%), III (19.6%), IV (33.3%), and V (75.0%) (p < 0.05). A total of 60.9% of the patients failed nonoperative management within 24 hours of admission; 8% failed 9 days or later after injury. Laparotomy was ultimately performed in 19.9% of patients with small hemoperitoneum, 49.4% of patients with moderate hemoperitoneum, and 72.6% of patients with large hemoperitoneum. In this multicenter study, 38.5% of adults with blunt splenic injury went directly to laparotomy. Ultimately, 54.8% of patients were successfully managed nonoperatively; the failure rate of planned observation was 10.8%, with 60.9% of failures occurring in the first 24 hours. Successful nonoperative management was associated with higher blood pressure and hematocrit, and less severe injury based on ISS, Glasgow Coma Scale, grade of splenic injury, and quantity of hemoperitoneum.

Nonoperative Management of Blunt Splenic Injury in Adults 55 Years and Older: A Twenty-Year Experience

The nonoperative management of splenic injury secondary to blunt trauma in older patients remains controversial. We have reviewed our experience from January 1978 to December 1997 with selective nonoperative management of blunt splenic injury in adults 55 years and older. Criteria for nonoperative management included hemodynamic stability with any transient hypotension corrected using less than 2000 cm3 crystalloid infusion, a negative abdominal physical examination ruling out associated injuries, and a blood transfusion requirement of no more than 2 units attributable to the splenic injury. During the study period, 18 patients over age 55 with radiographic confirmation of a splenic injury met the above criteria for nonoperative management. Their mean age was 72 years (range 56–86), and 13 of the 18 were female (72%). The mean Injury Severity Score was 15 (range 4–29), with the mechanism of injury equally divided between automobile crashes (9) and falls (9). During a similar time period, 15 patients 55 years or older with splenic injury composed an operative group; these patients did not differ with respect to age (mean 68 years), sex (60% female), or mechanism of injury. CT scans of 8 patients managed nonoperatively were available and graded using the American Association for the Surgery of Trauma classification, with a mean score of 2.3 (range 2–3). Eight of the 18 nonsurgical patients received blood transfusions. None of the 18 patients who met the criteria for nonoperative management “failed” the protocol, and none were taken to the operating room for abdominal exploration. Two patients (11%) died of associated thoracic injuries after lengthy hospital stays, one at 10 days and one at 24 days. We conclude from our data that nonoperative management of blunt splenic injury in patients age 55 years and older is indicated provided they are hemodynamically stable, do not require significant blood transfusion, and have no other associated abdominal injuries.

Optimizing the management of blunt splenic injury in adults and children

The treatment for splenic injury is evolving to an increased use of nonoperative management. We studied patients with blunt injury to the spleen to determine the overall success with splenic salvage and the reason that adults and children have different outcomes. Patient records were reviewed retrospectively for information and parameters that may influence outcome. Patients were categorized by age and type of management. Two hundred sixty-seven patients (222 adults; 45 children < 16 years old) with blunt splenic trauma were treated over a 7.5-year period. Adults had a significantly higher injury severity score (ISS; 27.2 +/- 0.9 vs 19.9 +/- 2.0; P < .05), splenic injury score (SIS; 2.8 +/- 0.1 vs 2.3 +/- 0.1; P < .01), and mortality rate (11.7% vs 2.2%; P < .05) compared with children. Eighty-six adults and 3 children had emergent operation; 23 patients had splenorrhaphy. Nonoperative management was selected initially in 178 patients; 83% (105 adults and 42 children) were treated successfully. The ISS and SIS of patients in whom nonoperative management failed were different from those patients in whom treatment was successful (ISS, 27.5 +/- 2.1 vs 20.6 +/- 1.0; SIS, 3.6 +/- 0.2 vs 2.1 +/- 0.1; P < .05) but were similar to those patients who needed initial emergent operation. Adults and children who had successful nonoperative management had similar ISSs (21.4 +/- 1.1 vs 18.4 +/- 2.0) and SISs (2.0 +/- 0.1 vs 2.3 +/- 0.1). Overall splenic salvage was achieved in 64% of patients (57% of adults and 96 % of children). Salvage increased from 50% to 85% during the study period. Splenic preservation is possible in most adults and children with blunt injury with the appropriate use of both operative salvage and nonoperative treatment. The higher salvage rate and decreased need for operation in children is due to their lower severity of overall injury and splenic injury. Operative salvage has become less common in adults because more patients are selected for nonoperative management.

Optimizing the management of blunt splenic injury in adults and children

Background: The treatment for splenic injury is evolving to an increased use of nonoperative management. We studied patients with blunt injury to the spleen to determine the overall success with splenic salvage and the reason that adults and children have different outcomes. Methods: Patient records were reviewed retrospectively for information and parameters that may influence outcome. Patients were categorized by age and type of management. Results: Two hundred sixty-seven patients (222 adults; 45 children < 16 years old) with blunt splenic trauma were treated over a 7.5-year period. Adults had a significantly higher injury severity score (ISS; 27.2 ± 0.9 vs 19.9 ± 2.0; P < .05), splenic injury score (SIS; 2.8 ± 0.1 vs 2.3 ± 0.1; P < .01), and mortality rate (11.7% vs 2.2%; P < .05) compared with children. Eighty-six adults and 3 children had emergent operation; 23 patients had splenorrhaphy. Nonoperative management was selected initially in 178 patients; 83% (105 adults and 42 children) were treated successfully. The ISS and SIS of patients in whom nonoperative management failed were different from those patients in whom treatment was successful (ISS, 27.5 ± 2.1 vs 20.6 ± 1.0; SIS, 3.6 ± 0.2 vs 2.1 ± 0.1; P < .05) but were similar to those patients who needed initial emergent operation. Adults and children who had successful nonoperative management had similar ISSs (21.4 ± 1.1 vs 18.4 ± 2.0) and SISs (2.0 ± 0.1 vs 2.3 ± 0.1). Overall splenic salvage was achieved in 64% of patients (57% of adults and 96% of children). Salvage increased from 50% to 85% during the study period. Conclusions: Splenic preservation is possible in most adults and children with blunt injury with the appropriate use of both operative salvage and nonoperative treatment. The higher salvage rate and decreased need for operation in children is due to their lower severity of overall injury and splenic injury. Operative salvage has become less common in adults because more patients are selected for nonoperative management. (Surgery 1999:126:805-13.)

Delayed complications of nonoperative management of blunt adult splenic trauma.

To determine the incidence and type of delayed complications from nonoperative management of adult splenic injury. Retrospective medical record review. University teaching hospital, level I trauma center. Two hundred eighty patients were admitted to the adult trauma service with blunt splenic injury during a 4-year period. Men constituted 66% of the population. The mean (+/-SEM) age was 32.2+/-1.0 years and the mean (+/-SEM) Injury Severity Score was 22.8+/-0.9. Fifty-nine patients (21%) died of multiple injuries within 48 hours and were eliminated from the study. One hundred thirty-four patients (48%) were treated operatively within the first 48 hours after injury and 87 patients (31%) were managed nonoperatively. We reviewed the number of units of blood transfused, intensive care unit length of stay, overall length of stay, outcome, and complications occurring more than 48 hours after injury directly attributable to the splenic injury. Patients managed nonoperatively had a significantly lower Injury Severity Score (P<.05) than patients treated operatively. Length of stay was significantly decreased in both the number of intensive care unit days as well as total length of stay (P<.05). The number of units of blood transfused was also significantly decreased in patients managed nonoperatively (P<.05). Seven patients (8%) managed nonoperatively developed delayed complications requiring intervention. Five patients had overt bleeding that occurred at 4 days (3 patients), 6 days (1 patient), and 8 days (1 patient) after injury. Three patients underwent splenectomy, 1 had a splenic artery pseudoaneurysm embolization, and 1 had 2 areas of bleeding embolization. Two patients developed splenic abscesses at approximately 1 month after injury; both were treated by splenectomy. Significant numbers of delayed splenic complications do occur with nonoperative management of splenic injuries and are potentially life-threatening.

Blunt splenic injury in adults: clinical and CT criteria for management, with emphasis on active extravasation.

To evaluate and determine the relevance of clinical and computed tomographic (CT) criteria, particularly extravasation, for prediction of clinical outcome in adults with splenic injuries. Retrospective blinded review was performed of the records of 270 patients with splenic injury during a 5-year period. Of these, 120 died or underwent surgery without CT and 150 underwent dynamic bolus-enhanced CT. Fifty of the latter underwent immediate surgery and 100 initially were treated without surgery, according to CT and clinical criteria: morphologic grade of injury, amount of hemoperitoneum, active extravasation, and injury severity score (a clinical measure of multiorgan trauma). Of the clinical criteria, injury severity score had the best correlation with outcome. Of the CT criteria, active extravasation correlated best with the need for splenic surgery. Of 96 patients selected for nonsurgical treatment and who did not have active extravasation, 83 recovered without surgery or other intervention. Nonsurgical therapy failed in 15 of the 100 patients. The splenic salvage rate was 59.3% overall and was 92% among the 100 patients with initial nonsurgical management. Standard clinical criteria allow triage of patients into immediate surgery or initial nonsurgical groups. CT criteria, especially absence of active extravasation, can help predict successful nonsurgical management of splenic injuries.

Management of blunt splenic trauma: Significant differences between adults and children

Background . Although highly successful in children, nonoperative management of blunt splenic injury in adults is less defined. The purpose of this study was to determine whether mechanism of injury, grade of splenic injury, associated injuries, and pattern of injury differ between adults and children (younger than 15 years of age). Methods . Four hundred eleven patients (293 adults and 118 pediatric patients) with blunt splenic injury were admitted to an affiliated adult/pediatric trauma program from 1989 to 1994. Computed tomography (CT) scans were interpreted in a blinded fashion. Mechanism of injury was significantly different for adults versus children (p < 0.05): motor vehicle crash (66.9% versus 23.7%), motorcycle (8.8% versus 0.8%), sports (2.4% versus 16.9%), falls (8.8% versus 25.4%), pedestrian/automobile (4.4% versus 11.0%), bicycle (1.4% versus 9.3%), and other (7.3% versus 12.7%). Results . Higher injury severity scores, lower Glasgow Coma Scales, and higher mortality indicated that the adults were more severely injured than the children. Fifty-nine percent of the adults and 7% of the children required immediate laparotomy for splenic injury. Both CT grade and quantity of blood on CT predicted the need for exploration in adults but not in children. An injury severity score above 15 and high-energy mechanisms correlated with the need for operative intervention. Conclusions . Rather than children simply being physically different, they are injured differently than adults, hence the high rate of nonoperative management.

Pediatric blunt abdominal trauma: Role of computed tomography vascular blush

Nonoperative management of blunt abdominal trauma is widely accepted in pediatric patients. There are few factors prospectively available to predict reliably which children will not respond to nonoperative treatment. Computed tomography scans demonstrating a vascular contrast blush are associated with arterial bleeding and the failure of nonoperative management of splenic injuries in adults. The authors describe five hemondynamically stable pediatric patients who have intraabdominal injury and a characteristic vascular contrast blush who acutely did not respond to nonoperative treatment. Vascular blush may be an indication for early laparotomy in pediatric trauma patients.

Management outcomes in splenic injury: a statewide trauma center review.

Clinical pathways now highlight both observation and operation as acceptable initial therapeutic options for the management of patients with splenic injury. The purpose of this study was to evaluate treatment trends for splenic injury in all North Carolina trauma centers over a 6-year period. Splenic injuries in adults over a 6-year period (January 1988-December 1993) were identified in the North Carolina Trauma Registry using ICD-9-CM codes. Patients were divided into four groups by method of management: 1) no spleen operation, 2) splenectomy, 3) definitive splenorrhaphy, and 4) splenorrhaphy failure followed by splenectomy. The authors examined age, mechanism of injury, admitting blood pressure, and severity of injury by trauma score and injury severity score. Comparisons were made between adult (17-64 years of age) and geriatric (older than 65 years of age) patients and between patients with blunt and penetrating injury. Resource utilization (length of stay, hospital charges) and outcome (mortality) were compared. One thousand two hundred fifty-five patients were identified with splenic injury. Rate of splenic preservation increased over time and was achieved in more than 50% of patients through nonoperative management (40%) and splenorrhaphy (12%). Splenorrhaphy was not used commonly in either blunt or penetrating injury. Overall mortality was 13%. Geriatric patients had a higher mortality and resource utilization regardless of their mechanism of injury or method of management. Nonoperative management represents the prevailing method of splenic preservation in both the adult and geriatric population in North Carolina trauma center hospitals. Satisfactory outcomes and economic advantages accompany nonoperative management in this adult population.

Computed tomography is inaccurate in estimating the severity of adult splenic injury.

Computed tomography (CT) is increasingly utilized in evaluation of adult splenic injury (SI). CT correlation with operative findings, CT relationship to successful nonoperative (NO) management, and CT reading reproducibility were examined. Records of patients > or = 15 years old admitted over a 3-year period were reviewed. Computed tomography scans were graded by two radiologists blinded to clinical results. Computed tomography scans were performed on 49 of 77 patients with SI. Eighteen underwent initial operation (OR) and 31 initial NO. Operative patients had higher Injury Severity Scores and Abdominal Abbreviated Injury Scale scores (p < 0.0001). Grade II readings predominated in the NO group (55%). Nonoperative management was successful for 9 grade III and 3 grade IV readings. Computed tomography matched OR grade in 10 readings, underestimated it in 18, and overestimated it in 6. Computed tomography missed SI in five patients. Radiologists disagreed on 9 of 45 (20%) scans. Computed tomography poorly predicted operative findings. Interobserver variability was common. SI management should not be based solely on CT severity.

Blunt Hepatic and Splenic Trauma: Where Have All the Surgeons Gone?

To further define the computed tomographic (CT) criteria on which to guide the nonsurgical treatment of adult patients with blunt hepatic injury, the authors retrospectively reviewed abdominal CT scans obtained before surgery during a 35–month period. Blunt hepatic injury was diagnosed in 187 patients, and review revealed 37 patients in whom the liver was the site of sole or principal intraabdominal injury detected with the help of CT before surgery. A CT–based hepatic injury classification system partly derived from similar systems established with surgical assessment was devised to grade the severity of hepatic injury. CT–based injury scores ranging from grade 1 to 5 were compared with the clinical outcome in patients treated surgically and nonsurgically. Thirty–one patients (83.7%) were successfully treated without surgery, and four patients (10.8%) had findings at celiotomy that did not require further surgery. No patient who was initially treated without surgery required delayed celiotomy due to hepatic injury. The results indicate that even major hepatic injury up to and including grade 4 severity assessed with preoperative CT can usually be managed without surgery in hemodynamically stable patients. Nonsurgical management of blunt splenic injury in children is a well–established method to salvage splenic function; however, nonsurgical management of adult blunt splenic trauma remains controversial. To assess the value of preoperative abdominal CT in predicting the outcome of blunt splenic injury in adults, a CT based injury–severity score consisting of four grades was devised and applied in 39 adult patients with blunt splenic injury as the sole or predominant intraperitoneal injury detected with preoperative CT. While patients with high grades of splenic injury generally required early surgery, eight (35%) of 23 patients with initial grade 3 or 4 injury were treated successfully without surgery, and four (29%) of 15 patients with grade 1 or 2 injury initially treated nonsurgically required delayed celiotomy (n = 3) or emergency rehospitalization. Results show that while CT remains an accurate method of identifying and quantifying initial splenic injury, as well as documenting progression or healing of critical injury, CT cannot reliably help predict the outcome of blunt splenic injury in adults. Treatment choices should therefore be based on the hemodynamic status of the patient and results of serial laboratory and bedside assessments.

Nonoperative management of adult blunt splenic trauma. Criteria for successful outcome.

Nonoperative management of blunt splenic trauma in adults is controversial despite numerous reports advocating this mode of therapy. Blunt splenic trauma is frequently managed without operation at our institution and, to define criteria that may predict a successful outcome, a retrospective review (1980 to 1988) of all adult splenic injuries was undertaken. Splenic injuries were documented by scintillation studies, CAT scanning, or at laparotomy. Sixty of 252 (24%) splenic injuries were initially treated without operation, which included bed rest, ICU monitoring, frequent physical exams, nasogastric tube, serial hematocrits, and follow-up splenic imaging. Five patients (5 of 60) failed nonoperative management and required interval laparotomy. Reasons for failure included blood loss greater than four units, enlarging splenic defect, or increasing peritoneal signs. Parameters predicting a successful outcome were localized trauma to the left flank or abdomen, hemodynamic stability, transfusion requirements less than four units, rapid return of GI function, age less than 60 years, and early resolution of splenic defects on imaging studies. No morbidity or deaths resulted from delayed operative intervention. In carefully selected adult patients, blunt splenic trauma may be successfully managed without operation.

SPLENORRHAPHY IN THE MANAGEMENT OF SPLENIC INJURY

A retrospective study of 301 adult splenic injuries presenting to the Princess Alexandra Hospital during a 15 year period, from 1970 to 1984, was conducted. Particular attention was paid to the last 5 years during which 25% of the ruptured spleens were preserved. The details of the preserved spleens are discussed. Respiratory infections were the only complications in this same selected group of patients; the complication rate being higher in the splenectomy group (15.8%) than the splenorrhaphy group (6.25%). None of the cases of splenorrhaphy required re-operation for continued haemorrhage. Twenty-five per cent of all cases of splenic injury had associated intra-abdominal injury which, of its own nature, would require laparotomy. A policy of operative management for splenic injury in adults with major trauma is therefore proposed because of the rate of associated intra-abdominal injuries. When laparotomy is performed, splenorrhaphy should be considered because of the now widely acknowledged risks of diminished immunological competence and overwhelming sepsis in asplenic individuals.

Nonoperative management of adult splenic injury due to blunt trauma: A warning

An analysis of 11 patients with splenic injury initially receiving nonoperative treatment revealed that 73 percent subsequently required surgery for delayed hemorrhage. The influence of age and the anatomic differences between the adult's spleen and child's spleen may account for the increased incidence of delayed bleeding seen in this series. Which patients might avoid surgical intervention cannot be predicted with certainty from the mechanism of injury or the lack of early physical signs and symptoms. The corresponding medical problems that often exist with the older patient may make nonoperative management, with the inherent risk of hypotension and large transfusion requirements, inappropriate. Although not advocating immediate splenectomy, we encourage early operative intervention with splenorrhaphy. Although improved diagnostic techniques will uncover a greater incidence of splenic injury, the inability to identify the nonoperative patient remains a clinical dilemma. The true role of nonoperative management of splenic injuries in the adult and the criteria for selection need to be further defined with larger prospective series. Although this approach may be useful for some patients, its application cannot be universal, and one must be willing to accept the consequences of delayed hemorrhage.