Splenic Repair Research Articles

Surgical Repair vs Splenectomy in Patients With Severe Traumatic Spleen Injuries

The spleen is often removed in laparotomy after traumatic abdominal injury, with little effort made to preserve the spleen. To explore the association of surgical management (splenic repair vs splenectomy) with outcomes in patients with traumatic splenic injuries undergoing laparotomy and to determine whether splenic repair is associated with lower mortality compared with splenectomy. This is a trauma registry-based cohort study using the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2019. Participants included adult patients with severe splenic injuries (Abbreviated Injury Scale [AIS] grades 3-5) undergoing laparotomy after traumatic injury within 6 hours of admission. Data analysis was performed from April to August 2023. Splenic repair vs splenectomy in patients with severe traumatic splenic injury. The primary outcome was in-hospital mortality. Outcomes were compared using different statistical approaches, including 1:1 exact matching with consecutive conditional logistic regression analysis as the primary analysis and multivariable logistic regression, propensity score matching, and inverse-probability weighting as sensitivity analyses. A total of 11 247 patients (median [IQR] age, 35 [24-52] years; 8179 men [72.7%]) with a severe traumatic splenic injury undergoing laparotomy were identified. Of these, 10 820 patients (96.2%) underwent splenectomy, and 427 (3.8%) underwent splenic repair. Among patients who underwent an initial splenic salvage procedure, 23 (5.3%) required a splenectomy during the subsequent hospital stay; 400 patients with splenic preservation were matched with 400 patients who underwent splenectomy (matched for age, sex, hypotension, trauma mechanism, AIS spleen grade, and AIS groups [0-2, 3, and 4-5] for head, face, neck, thorax, spine, and lower and upper extremity). Mortality was significantly lower in the splenic repair group vs the splenectomy group (26 patients [6.5%] vs 51 patients [12.8%]). The association of splenic repair with lower mortality was subsequently verified by conditional regression analysis (adjusted odds ratio, 0.4; 95% CI, 0.2-0.9; P = .03). Multivariable logistic regression, propensity score matching, and inverse-probability weighting confirmed this association. In this retrospective cohort study, splenic repair was independently associated with lower mortality compared with splenectomy during laparotomy after traumatic splenic injury. These findings suggest that efforts to preserve the spleen might be indicated in selected cases of severe splenic injuries.

Laparotomy for Traumatic Splenic Injury: Should we Increase our Efforts to Preserve the Spleen?

Abstract Background In trauma laparotomy the spleen is removed very liberally, and often little effort is made for splenic preservation. Aims The aim of this study was to assess the effect of surgical management (splenic repair vs. splenectomy) on outcomes in patients undergoing trauma laparotomy. Methods This is a trauma registry (TQIP) study (2013–2019), including adult patients with severe splenic injuries (grades III-V) undergoing trauma laparotomy. Characteristics and outcomes of patients who underwent splenic repair vs. splenectomy within 6 hours of admission were compared using different statistical approaches, i.e. 1:1 exact matching with consecutive conditional logistic regression analysis as primary analysis, multivariable logistic regression, propensity score matching and inverse-probability weighting as sensitivity analyses. The primary outcome was in-hospital mortality. Results A total of 11,247 patients with a severe splenic injury undergoing trauma laparotomy within 6 hours of admission were identified. Of these, 10,820 (96.2%) patients underwent splenectomy and 427 (3.8%) patients splenic repair within 6 hours of admission. Among patients who underwent an initial splenic salvage procedure, 23 (5.3%) patients underwent a splenectomy during the subsequent hospital stay. 400 patients with splenic preservation, were matched with 400 patients who underwent splenectomy (matched for age, sex, hypotension, trauma mechanism as well as AIS spleen grades 3,4,5 and AIS groups (AIS 0-2, AIS 3, AIS 4-5) for head, face, neck, thorax, spine, and lower & upper extremity). The mortality was significantly lower in the group of patients with splenic repair (6.5% vs 12.8%, p=0.002). The mortality benefit was subsequently verified by conditional regression analysis (aOR 0.4, CI 95% 0.2; 0.9). Multivariable logistic regression, propensity score matching, and inverse-probability weighting confirmed the lower mortality in the splenic repair group. Conclusion In trauma laparotomy splenic repair was independently associated with lower mortality compared with splenectomy. Splenectomy was required in approximately 5% of the patients after initial splenic repair. The findings provide evidence that efforts for spleen preservation in trauma laparotomy should be considered in selected cases.

Management of Splenic Injury at B&C Medical College, Teaching Hospital and Research Centre

Background: In all blunt abdominal injuries splenic injury relates to about 40%. Splenectomy is the preferred treatment choice for blunt splenic injury in hemodynamically unstable patients. The low-grade splenic injuries and stable patients are mostly treated by non-operative management (NOM) at today era. Consensuses have not been yet formulated about the management of high-grade splenic injuries in hemodynamically stable patients. So, this study analyzes the treatment of patients with high-grade splenic injuries in our institution. Methods: This study includes all the patients with splenic injuries presented to our hospital during the 5 years period from 2017 to 2022. The datas regarding primary baseline at emergency, complications and mortality were collected from the patient records at medical record section. Based on splenic injury and the treatment they received, they were grouped accordingly. Results: In a total of 38 cases of spleen injuries, the most common mode of injury was a road traffic accident (RTA) 84% followed by fall injury (10%) spontaneous rupture of the spleen and blast injury 3% each. Sixty-six per cent of the cases underwent operative management out of which 96% cases had a splenectomy and 4% cases had a splenic repair. There was 5% mortality and 95% recovery without residual morbidity. Conclusion: Most of the cases with spleen injury were managed with a favorable outcome. The careful patient selection for non-operative management will result in higher splenic salvage with close monitoring in an intensive care unit.

Spleen: Reparative Regeneration and Influence on Liver.

This review considers experimental findings on splenic repair, obtained in two types of small animal (mouse, rat, and rabbit) models: splenic resections and autologous transplantations of splenic tissue. Resection experiments indicate that the spleen is able to regenerate, though not necessarily to the initial volume. The recovery lasts one month and preserves the architecture, albeit with an increase in the relative volume of lymphoid follicles. The renovated tissues, however, exhibit skewed functional profiles; notably, the decreased production of antibodies and the low cytotoxic activity of T cells, consistent with the decline of T-dependent zones and prolonged reduction in T cell numbers. Species–specific differences are evident as well, with the post-repair organ mass deficiency most pronounced in rabbit models. Autotransplantations of splenic material are of particular clinical interest, as the procedure can possibly mitigate the development of post-splenectomy syndrome. Under these conditions, regeneration lasts 1–2 months, depending on the species. The transplants effectively destroy senescent erythrocytes, assist in microbial clearance, and produce antibodies, thus averting sepsis and bacterial pneumonia. Meanwhile, cellular sources of splenic recovery in such models remain obscure, as well as the time required for T and B cell number reconstitution.

Contemporary Management of Pediatric Blunt Splenic Trauma: A National Trauma Databank Analysis

PurposeTo quantify changes in the management of pediatric patients with isolated splenic injury from 2007 to 2015. Materials and MethodsPatients under 18 years old with registered splenic injury in the National Trauma Data Bank (2007–2015) were identified. Splenic injuries were categorized into 5 management types: nonoperative management (NOM), embolization, splenic repair, splenectomy, or a combination therapy. Linear mixed models accounting for confounding variables were used to examine the direct impact of management on length of stay (LOS), intensive care unit (ICU) days, and ventilator days. ResultsOf included patients (n = 24,128), 90.3% (n = 21,789), 5.6% (n = 1,361), and 2.7% (n = 640) had NOM, splenectomy, and embolization, respectively. From 2007 to 2015, the rate of embolization increased from 1.5% to 3.5%, and the rate of splenectomy decreased from 6.9% to 4.4%. Combining injury grades, NOM was associated with the shortest LOS (5.1 days), ICU days (1.9 days), and ventilator days (0.5 day). Moreover, splenectomy was associated with longer LOS (10.1 days), ICU days (4.5 days), and ventilator days (2.1 days) than NOM. The average failure rate of NOM was 1.5% (180 failures/12,378 cases). Average embolization failure was 1.3% (6 failures/456 cases). Splenic artery embolization was associated with lower mortality than splenectomy (OR: 0.10, P <.001). No statistically significant difference was observed in mortality between embolization and NOM (OR: 0.96, P = 1.0). ConclusionsIn pediatric splenic injury, NOM is the most utilized and associated with favorable outcomes, most notably in grades III to V pediatric splenic injury. If intervention is needed, embolization is effective and increasingly utilized most significantly in lower grade injuries.

Management of Splenic Trauma in Contemporary Clinical Practice: A National Trauma Data Bank Study

To evaluate the utilization and efficacy of various treatments for management of adult patients with splenic trauma, highlighting the evolving role of splenic artery embolization. The National Trauma Data Bank (NTDB) was queried for patients who sustained splenic trauma between 2007 and 2015, excluding those with death on arrival and selected nonsplenic high-grade injuries. Patients were categorized into (1) nonoperative management (NOM), (2) embolization, (3) splenectomy, (4) splenic repair, and (5) combined treatment groups. Evaluated outcomes included hospital length of stay (LOS), intensive care unit LOS, mortality, and NOM and embolization failures. Overall, 117,743 patients with splenic predominant trauma were included in this study. Over the 9-year study period, 85,793 (72.9%) were treated with NOM, 21,999 (18.9%) with splenectomy, 3895 (3.3%) with embolization, and 2131 (1.8%) with splenic repair. From 2007 to 2015, mortality rates declined from 7.6% to 4.7%. The rate of NOM did not significantly change over time, while embolization increased 369% (1.3%-4.8%). Failure of NOM was 4.4% in 2007 and decreased to 3.4% in 2015. Across all injury grades, NOM had the shortest LOS (8.3 days), followed by splenic repair (12.3), embolization (12.6), and splenectomy (13.8) (p < 0.001). When adjusted for various clinical factors including severity of splenic injury, mortality rates were 7.1% for splenectomy, 3.2% for embolization, and 2.5% for NOM. Most patients with splenic-dominant blunt trauma are managed with NOM. Over time, the use of embolization has increased while open surgery has declined, and mortality has improved for all treatment methods. Compared to splenectomy, embolization is associated with shorter hospital LOS but is still used relatively infrequently.

4:12 PM Abstract No. 372 The role of interventional radiology in the contemporary management of splenic trauma: a national trauma data bank study

To compare utilization and outcomes of splenic artery embolization (SAE) with surgical management or non-operative management (NOM) in patients with blunt splenic trauma. The National Trauma Data Bank was queried for patients who sustained blunt splenic trauma between 2007 and 2015. Patients dead upon arrival and those with an Abbreviated Injury Scale (AIS) grade 4 or 5 traumatic brain or spinal injury, any grade aortic injury, or additional grade 4 or 5 abdominopelvic injury were excluded. Patients were then categorized by treatment group: NOM (defined as close monitoring without surgical or interventional management), SAE, splenectomy, and splenic repair. Outcomes evaluated included hospital length of stay (LOS) days, ICU LOS days, failure of nonoperative management, and mortality. Tukey’s tests were used for pairwise comparisons of different treatment modalities. Between 2007 and 2015, the annual documented cases of splenic trauma increased from 9123 to 15,775. Overall, 85,793 (73.8%) had NOM, 21,999 (18.6%) had splenectomy, 3895 (3.3%) underwent SAE, and 2131 (1.8%) had splenic repair. Mortality rates decreased from 8.2% in 2007 to 4.9% in 2015. The utilization rate of NOM did not significantly change (74% in 2008 and 73% in 2015). Surgical management decreased by 4.5% and SAE increased by 3.5%. Failure of NOM decreased from 4.2% in 2007 to 1.5% in 2015. Combining injury grades, NOM had the shortest LOS days (8.3) vs. 12.6 for SAE vs. 13.8 for splenectomy vs. 12.3 for splenic repair (P <0.001). Similarly, the ICU LOS days was shortest for NOM (5.5), SAE (8.1), splenectomy (8.6), splenic repair (6.5) (P <0.001). For mortality across all injury grades, splenectomy (11.0%) was significantly higher than splenic repair (3.8%), SAE (4.9%), and NOM (3.7%) with P <0.001. In contemporary clinical practice, NOM remains the most common treatment choice for managing splenic trauma irrespective of injury grade. SAE rates are increasing while surgery is decreasing. Compared to splenectomy, SAE demonstrated shorter hospital and ICU LOS and decreased mortality.Tabled 1Summary of Outcomes of Various Treatment OptionsMean LOS (SD)ICU Days (SD)Mortality Rate (%)NOM8.3 (10.6)5.5 (7.6)3053 (3.7)SAE13.8 (15.0)8.6 (10.9)2503 (11.0)Splenectomy12.3 (12.9)7.4 (10.0)81 (3.8)Splenic repair12.5 (14.3)8.1 (10.8)185 (4.9) Open table in a new tab

Intraoperative splenic injury as a complication of the laparoscopic excision of uterine myoma

The incidence of iatrogenic splenic injury during gynecological laparoscopic surgery is rare or probably underreported. The spleen is situated principally in the left hypochondrium, connected to the colon, the omentum majus and the lateral abdominal wall. The estimated prevalence of iatrogenic trauma after the more common operative procedures is considered relatively low, however, immediate identification and management either by splenic repair or splenectomy should result in avoiding any potential complications. We presented a case of uterine myoma enucleation of the anterior wall of the uterus with an accidental injury of the spleen that implicated splenectomy. Constant awareness of the prevalence of this operative complication and the mechanisms by which it may arise should enable its early identification and prevention of any potential sequelae.

Splenic injury: a prospective multicentre study on non-operative and operative treatment. The Splenic Injury Study Group.

One hundred and forty-seven patients with splenic injury admitted to 18 different hospitals were included in a prospective multicentre study. The spleen was saved in 64 per cent. Out of the total series, 43 per cent of patients were not operated upon, 5 per cent had exploratory laparotomy only, and in 16 per cent splenic repair was performed. Treatment is discussed with reference to the nature of the splenic lesion, concomitant injuries, amount of blood transfusion given, and age of the patient. No deaths were definitely related to the splenic injury. The frequency of serious recurrent bleeding was not higher in the splenic salvage group when compared with the splenectomy group. Delayed bleeding was detected in 4 per cent of the patients. The mode of treatment varied considerably in different hospitals in that conservative treatment was performed in 14, splenic repair in 10 and splenectomy in 12 hospitals. Splenic salvage seems safe in most patients with a splenic injury. However, meticulous surveillance of the patient is mandatory.

Severe late postsplenectomy infection

In all, 1490 patients underwent splenectomy in Western Australia between 1971 and 1983, giving 7825 person years exposure. Thirty-three patients developed severe late postsplenectomy infection (septicaemia, meningitis or pneumococcal pneumonia requiring hospitalization) and three developed overwhelming postsplenectomy infection. The incidence and mortality rates of severe late postsplenectomy infection were 0.42 and 0.08 per 100 person years exposure respectively and for overwhelming postsplenectomy infection the incidence and mortality rates were 0.04 per 100 person years exposure. There were 628 splenectomies after trauma, giving 3922 person years exposure. Eight patients developed severe late postsplenectomy infection of whom one had overwhelming postsplenectomy infection. Following trauma, the incidence of severe late postsplenectomy infection was 0.21 per 100 person years exposure, with the incidence and mortality rates of overwhelming postsplenectomy infection being 0.03 per 100 person years exposure. Patients undergoing splenectomy have a 12.6-fold increased risk of developing late septicaemia compared with the general population. Splenectomy following trauma gives an 8.6-fold increased risk of late septicaemia. The majority of severe late postsplenectomy infections did not occur within the first 2 years and 42 per cent of severe late postsplenectomy infections occurred greater than 5 years after splenectomy. The low incidence of severe late postsplenectomy infection and overwhelming postsplenectomy infection makes statistical evaluation of the effectiveness of prophylactic antibiotics, vaccination and splenic repair most difficult.

Splenic repair for trauma.

The risks of overwhelming post-splenectomy infection (OPSI) are now well documented both in children and adults. Although the incidence of OPSI is comparatively low following splenectomy for trauma, it has a high mortality. Splenectomy is no longer the treatment of choice for splenic injury and splenic salvage is recommended whenever feasible. Since 1982, in the Isle of Wight hospitals, 13 cases of splenic injury following trauma have been treated applying various salvage procedures and are reported here.

Preservation of the injured spleen

Experience with suture repair of splenic lacerations in 14 children and 8 adults is reported. The youngest patient was 3 days old and the oldest 60 years. Adequate healing was confirmed by postoperative splenic scans with or without arteriography. The 2 deaths in this series were not related to the splenic repair and were due to associated major injuries. The course of illness in the remaining 20 survivors did not reveal a failure of this technique or a complication related to the use of this conservative approach. It is expected that salvage of the traumatized spleen will eliminate the risk of fulminant postoperative infections that may be fatal.

Innovative minimally invasive pediatric surgery is of therapeutic value for splenic injury

Background/Purpose: Until now, minimally invasive surgery (MIS) has not had any therapeutic status for operable splenic trauma, because reliable sealing of larger defects is not possible with general techniques. Methods: Fleece-bound sealing allows rapid, large-area sealing of erosions and defects, so that with the aid of an MIS applicator system (AMISA), this method of tissue management can be transferred to MIS. Results: An in vitro evaluation showed that liquid fibrin sealing (FS) exhibits incomplete selective leak closure and low adhesive strength (4.1 hPa) and is not suitable for challenging surfaces. Fleece-bound sealing (ready-to-use v. prepare-to-use) showed reliable sealing and higher adhesive strength for collagen fleeces that are ready coated with fibrinogen-based sealant (TachoComb H; Nycomed, Linz, Austria) compared with various carrier systems that had to be impregnated on the spot (prepare-to-use; 50.2 v 23 hPa; P <.0001). Between October 1993 and October 2001, 19 of 87 children with splenic rupture were treated with the AMISA system (AMISA + TachoComb H) (21.8%), and 3 of these children had multiple trauma. The operation was indicated because of circulatory instability despite adequate volume replacement therapy. Splenic repair always was possible with the AMISA system, a changeover and splenectomy was not necessary, and the postoperative course was complication free. The mean stay in the hospital was 9.2 days. Conclusions: The AMISA system efficiently expands the indications for emergency laparoscopy and can be used successfully in emergency laparoscopy for splenic rupture management. J Pediatr Surg 37:1146-1150. Copyright 2002, Elsevier Science (USA). All rights reserved.

Management of Blunt Abdominal Trauma in Children

Surgery| July 01 2002 Management of Blunt Abdominal Trauma in Children AAP Grand Rounds (2002) 8 (1): 8–9. https://doi.org/10.1542/gr.8-1-8-a Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Management of Blunt Abdominal Trauma in Children. AAP Grand Rounds July 2002; 8 (1): 8–9. https://doi.org/10.1542/gr.8-1-8-a Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: blunt abdominal injuries, splenectomy, spleen injuries Sources: (1) Potoka DA, Schall LC, Ford HR. Risk factors for splenectomy in children with blunt splenic trauma. J Pediatr Surg. 2002;37:294–299. (2) Hackam DJ, Potoka D, Meza M, et al. Utility of radiographic hepatic injury grade in predicting outcome for children after blunt abdominal trauma. J Pediatr Surg. 2002;37:386–389. Two articles by investigators at the University of Pittsburgh and Children’s Hospital of Pittsburgh, Pennsylvania, examine issues related to blunt abdominal trauma in children. The first study reports a retrospective review of 754 children (ages 0–16) who received care for blunt splenic trauma between 1993–1997 at 1 of 2 pediatric and 24 adult trauma centers and were identified through the Pennsylvania Trauma Outcome Study registry. Factors associated with increased frequency of splenectomy were identified using multivariate logistic regression. Of the 754 children with splenic injury, 15% underwent splenectomy, 7% were managed with operative splenic repair (splenorrhaphy), and 78% of children were managed non-operatively. Factors associated with splenectomy included increased grade of splenic injury, presence of severe, nonsplenic abdominal injuries, Glasgow Coma Scale of 3–8, and age range of 15–16 years. Children treated at designated pediatric trauma centers had significantly fewer splenectomies than those treated at adult trauma centers (7.8% versus 15.7%, P<.05). Authors of the second article retrospectively reviewed 152 children with blunt hepatic injury treated from 1995–2000 at Children’s Hospital of Pittsburgh and graded liver injury severity based upon CT scan evaluation using the American Association for the Surgery of Trauma (AAST) grading system (Grades I–V). They found that AAST injury grade did not correlate with mortality, hospital length of stay or intensive care unit (ICU) length of stay. The authors conclude that the AAST radiographic liver grading system does not accurately predict outcome in the pediatric population. Both of these studies serve to underscore unique aspects of pediatric trauma management with respect to blunt abdominal injury. The nonoperative management of solid visceral injury has become increasingly accepted in the treatment of the pediatric population and is becoming more so in adult trauma management. Nonetheless, indications for operative intervention are still under refinement, as both of these articles indicate. A 15% splenectomy rate is excessive. A recent article from the American Pediatric Surgical Association Liver/Spleen Trauma Study Group found early operation (for hemorrhage) in only 1.3% of the 316 patients studied.1 While it is generally conceded that operation for solid viscus injury alone (usually identified by CT scanning) is indicated for ongoing, severe hemorrhage, the comfort level of surgeons managing children with any degree of hemorrhage varies greatly. Based on the results in the first article, children treated outside of a designated pediatric trauma center, presumably by non-pediatric surgeons, had far higher rates of splenectomy than those who were in designated pediatric trauma centers. Unfortunately, the second article does not identify a grading system for liver injuries that correlates with severity of injury and thus might serve as a safe triage tool. Based on these studies, the... You do not currently have access to this content.

A review of non-operative treatment of splenic trauma.

From January 1984 to June 1992, a period of 8.5 years, 60 patients with splenic trauma were treated in Lacor Hospital. the spleen trauma was managed conservatively in 47 (78%) of the patients. Of these, 36 of the patients (60%) were not operated upon. Eleven (18%) were operated upon but nine (15%) patients had exploratory laparotomy only without spleen manipulation and in two (3%) splenic repair was performed. Thirteen (22%) patients had splenectomy. In the non-operative group, recurrent or rebleeding was detected in one patient (2%) and delayed bleeding occurred in five patients (8%). Overall mortality rate was five (8%); two (3%) occurring in splenic salvage and three (5%) in splenectomized patients. It is concluded that with availability of facilities and personnel, in selected cases of blunt splenic trauma, splenic conservation is safe but requires close monitoring.

Reoperation for complications of the Angelchik antireflux prosthesis

The Angelchik antireflux prosthesis is associated with complications that require reoperation in 5% to 15% of patients. To determine the morbidity and success of reoperation for these complications, we conducted a retrospective study of 15 patients. Time to reoperation ranged from 3 weeks to 113 months with a mean of 31 months. Indications for reoperation included dysphagia (8 patients), recurrent reflux (6 patients), and prosthesis migration (1 patient). Ten patients underwent prosthesis removal and fundoplication, 4 had prosthesis removal without fundoplication, and 1 patient had the prosthesis repositioned. latrogenic splenic injury occurred in 2 patients (13%); one splencctomy and one splenic repair were done. Four patients (27%) required intraoperative blood transfusion. There were no operative deaths. Removal of the prosthesis without fundoplication resulted in a significantly higher incidence of recurrent reflux (75%) than prosthesis removal and fundoplication (10%) (p < 0.04). Although reoperation for complications of the Angelchik antireflux prosthesis can be technically difficult, morbidity and mortality are acceptable. An antireflux procedure should be done at the time of prosthesis removal.

Selective nonoperative management of pediatric blunt splenic trauma: Risk for missed associated injuries

The spleen is the most commonly injured organ in children sustaining blunt abdominal trauma. Although accepted in pediatric patients, nonoperative management of blunt splenic trauma in adults remains controversial. A principal concern of advocates of early operation is the possibility of overlooking a second injury. To evaluate this question in a pediatric population, we reviewed the charts of 120 children who had traumatic splenic injuries and were admitted to Children's Hospital Medical Center in Cincinnati between 1982 and 1990. Splenic injuries were documented by computed tomography scans, liver/spleen scintigraphy, or during laparotomy. One hundred twelve patients (93.3%) were initially managed nonoperatively; this regimen failed in 2 patients (1.8%), in whom a late splenectomy was required for bleeding. Of 8 patients (6.7%) for whom emergency surgery was required, 4 underwent splenectomy (2 had major associated injuries), 2 underwent splenorrhaphy, and 2 required no splenic repair. Fifty-nine patients (49.2%) had associated injuries, 22 of which (18.3%) were intraabdominal. In this study, there were no missed injuries and no morbidity or mortality associated with delayed treatment. These data confirm that the majority of children with blunt splenic injury can be successfully treated without surgery, and demonstrate that selective nonoperative management of splenic injuries in children does not increase the risk of missed associated injuries.

Transfusion Significantly Increases the Risk for Infection After Splenic Injury

To determine if splenectomy results in an increased risk for perioperative infection when analyzed against splenic repair and to identify factors associated with perioperative infection, respiratory complication, and admission to the intensive care unit following surgery for splenic trauma. Data were collected retrospectively from hospital records and analyzed using stepwise multiple logistic regression. San Francisco (Calif) General Hospital, an urban level 1 trauma center. All patients (n = 252) undergoing operation for traumatic splenic injury at San Francisco General Hospital from 1984 through 1990. Patients who died within 24 hours of presentation were excluded from the study. Perioperative infection, respiratory complications, and admission to the intensive care unit. Infection rates and the types of organisms yielded in cultures were similar between patients who underwent splenectomy and repair. Gram-negative and gram-positive organisms were found in equal numbers, and in no group did encapsulated organisms predominate. Splenectomy had no independent impact on any of the three outcome measures. Total blood transfusion was found to be the only independently significant variable associated with perioperative infection and respiratory complication. Total blood transfusion of more than 2 U and Injury Severity Score of greater than 25 were independently significantly associated with admission to the intensive care unit. The choice between splenectomy and splenic repair does not affect the risk for perioperative infection following injury, whereas blood transfusion significantly increases the risk for perioperative infection, respiratory complication, and admission to the intensive care unit.

Complications of antireflux surgery

In order to determine the in-hospital morbidity and mortality rates of antireflux surgery in a community hospital setting, a retrospective 10-year review of 355 antireflux procedures was conducted. A modified Nissen fundoplication, with an incomplete fundal wrap, was the most common operation performed. Concomitant procedures, usually biliary or gastric, were undertaken in 93 patients. Thirty-nine patients had previously undergone an operation involving hiatal dissection. Overall morbidity was 17%, and mortality was 1% (three deaths). Patients with previous hiatal surgery had higher morbidity (44%, p < 0.0001) and mortality rates (3%, p < 0.21). Wound infection occurred in 5% of patients and wound dehiscence in 1%. Splenic repair or splenectomy for iatrogenic injury was required in 2%. Postoperative gastroesophageal leaks occurred in six patients (2%). Patients with previous hiatal surgery had a higher incidence of gastroesophageal leaks (8%, p < 0.002). Three of six patients had contained leaks that resolved with antibiotics, cessation of oral intake, and nutritional support. Two of three patients with noncontained leaks died despite surgical intervention.

Ruptured spleen in children--15-year evolution in therapeutic concepts.

This is a 15-year retrospective study of 64 pediatric surgical patients with traumatic rupture of the spleen from 1976 to 1990. The overall mortality was 14% (9/64). All non-survivors had severe multiple traumata and no fatalities were attributable to splenic injury. During the first 5 years of the study, the traditional surgical approach of immediate laparotomy and splenectomy was employed. During the next 5 years we practised laparotomy with subtotal splenectomy and repair. During the final 5 years conservative management with clinical and ultrasonographic monitoring became predominant (1 splenectomy, 4 repair, 23 conservative treatments). Among the 55 survivors, 11 had splenectomy, 14 had splenic repairs and 30 were treated non-operatively. All survivors had excellent outcomes and there was only one complication: a local abscess following splenic repair. Based on a very strict protocol in conservative management, the total amount of transfused blood could be reduced remarkably during the last period. Splenectomized patients received pneumococcal vaccine and prophylactic antibiotic coverage was prescribed for febrile episodes. None of the splenectomized patients experienced septic episodes or increased rates of infection. Based on our experience, ultrasonographically monitored conservative management is the treatment of choice in most patients with splenic injury in childhood.