Introduction of a Simple Technique for Partial Splenectomy in Multiple Trauma Patients

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Abstract

Background:

The spleen is the most commonly injured intraperitoneal organ in multiple trauma patients. Total splenectomy results in immunodeficiency and predisposes patients to certain infections.

Objectives:

Performing partial splenectomy with a safe, simple, and definite technique in trauma patients with hemodynamic instability and accompanying intra-abdominal injury could play an important role in the preservation of immune function and reducing morbidity.

Patients and Methods:

From 2006 to 2009, a total of 20 patients underwent partial splenectomy, at Mobasher and Be’sat hospitals. Patients with splenic injuries of up to stage IV and grade 3 shocks underwent partial splenectomy. The operations were performed without vascular isolation and by wedge resection of the injured splenic tissue and repair with chromic 2/0 sutures in two rows. Three months later, patients were evaluated by a Tc99 liver-spleen scan, complete blood count, and blood smear.

Results:

There were 16 male and four female patients with an age range of 4 to 54 years old. Ten patients had additional intra and extra abdominal injuries. The salvaged spleen tissue was approximately 30% in nine patients, 40 to 50% in two, and more than 50% in another nine patients. The operation time was less than three hours and hospital stay was 3 to 15 days for 90% of the patients. No complications occurred after the surgery or during the follow up. For all patients, the complete blood count, peripheral smear, and liver-spleen scan were normal after six months.

Conclusions:

Partial splenectomy with preserving at least 30% of the splenic tissue can be performed for trauma patients using wedge resection of the injured splenic tissue and repair by chromic 2/0 sutures in two rows. Using this technique, there is no need for vascular isolation or hemostatic materials. Splenic function is presented and associated intra and extra abdominal injuries are not contraindications for partial splenectomy.

Related collections

Most cited references 28

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Prevention and management of infections in patients without a spleen.

R.N. Davidson, R.A. Wall (2001)

Patients who lack a functioning spleen become vulnerable to sepsis caused by bacteria and, occasionally, protozoa. The risk is higher in children and in those who have had immunosuppressive treatment, and the risk remains lifelong. Overwhelming post-splenectomy infection (OPSI) occurs at an estimated incidence of 0.23-0.42% per year, with a lifetime risk of 5%. Episodes of OPSI are emergencies, requiring immediate parental antibiotics and intensive care; intravenous immunoglobulins may be useful. OPSI carries a mortality of 38-69%. Streptococcus pneumoniae is the commonest infecting organism, accounting for 50-90% of isolates from blood cultures in reported series; it is particularly common in children with sickle cell disease. Less commonly, the infecting organisms are other bacteria, Babesia or Ehrlichia. OPSI may be, to some extent, preventable by several interventions. These are surgical conservation of the spleen; immunization against S. pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis; prophylactic antibiotics; stand-by antibiotics; patient information sheets; and a medical alert bracelet. Asplenic patients living in malaria-endemic areas require optimal prophylaxis. The initial step in prevention of OPSI is the creation of an asplenia register, as many patients are not covered by these simple measures.

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Pediatric blunt abdominal injury: age is irrelevant and delayed operation is not detrimental.

Sean D. Mooney, James Holmes, Jonathan I Groner … (2007)

During the past 40 years, management of solid organ injury in pediatric trauma patients has shifted to highly successful nonoperative management. Our purpose was to characterize children requiring operative intervention. We hypothesized that older children would be more likely to require operative intervention. In particular, we wanted to examine potential outcome disparities between children who were operated upon immediately and those in whom attempted nonoperative management failed. Additionally, we asked whether attempted nonoperative management, when failed, put children at higher risk for mortality or morbidities such as increased blood product transfusions or lengths of stays. Retrospective cohorts from seven Level I pediatric trauma centers were identified. Blunt splenic, hepatic, renal, or pancreatic injuries were documented in 2,944 children 3 hours after arrival (n = 59; 42%). Comparing the two cohorts, no age differences were found. Compared with F-NOM, IO had significantly worse hemodynamics, Injury Severity Score, and Glasgow Coma Scale score and was associated with liver injuries. Pancreatic injuries were significantly associated with F-NOM. While controlling for injury severity to compare IO versus F-NOM, linear regression revealed equivalent blood transfusions, ICU LOS, hospital LOS, and mortality rates. IO and F-NOM are rare events and independent of age. When operated upon for appropriate physiology, the timing of operation in pediatric solid organ injury is irrelevant and not detrimental with respect to blood transfusion, mortality, ICU and hospital LOS, and resource utilization.

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Pediatric blunt splenic trauma: a comprehensive review.

N Scott Lynn, Rabab Jafri, Michelle N. Sullivan … (2009)

Abdominal trauma is a leading cause of death in children older than 1 year of age. The spleen is the most common organ injured following blunt abdominal trauma. Pediatric trauma patients present unique clinical challenges as compared to adults, including different mechanisms of injury, physiologic responses, and indications for operative versus nonoperative management. Splenic salvage techniques and nonoperative approaches are preferred to splenectomy in order to decrease perioperative risks, transfusion needs, duration/cost of hospitalization, and risk of overwhelming postsplenectomy infection. Early and accurate detection of splenic injury is critical in both adults and children; however, while imaging findings guide management in adults, hemodynamic stability is the primary determinant in pediatric patients. After initial diagnosis, the primary role of imaging in pediatric patients is to determine the level and duration of care. We present a comprehensive literature review regarding the mechanism of injury, imaging, management, and complications of traumatic splenic injury in pediatric patients. Multiple patients are presented with an emphasis on the American Association for the Surgery of Trauma organ injury grading system. Clinical practice guidelines from the American Pediatric Surgical Association are discussed and compared with our experience at a large community hospital, with recommendations for future practice guidelines.

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Author and article information

Journal

Journal ID (nlm-ta): Iran Red Crescent Med J

Journal ID (iso-abbrev): Iran Red Crescent Med J

Journal ID (doi): 10.5812/ircmj

Journal ID (publisher-id): Kowsar

Title: Iranian Red Crescent Medical Journal

Publisher: Kowsar

ISSN (Print): 2074-1804

ISSN (Electronic): 2074-1812

Publication date (Electronic): 05 December 2013

Publication date (Print): December 2013

Volume: 15

Issue: 12

Electronic Location Identifier: e9072

Affiliations

[1 ]Department of Surgery, Hamedan University of Medical Sciences, Hamedan, IR Iran

Author notes

[* ]Corresponding Author: Amir Derakhshanfar, Department of Surgery, Hamedan University of Medical Sciences, Hamedan, IR Iran. Tel: +98-9181111499, E-mail: eskandarlou.m@ 123456umsha.ac.ir

Article

DOI: 10.5812/ircmj.9072

PMC ID: 3955528

SO-VID: c0f81371-5252-47a4-80b0-1765ddf8cc0b

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 13 November 2012

Date revision received : 12 October 2013

Date accepted : 29 October 2013

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