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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 11  |  Issue : 3  |  Page : 112-115

The management of blunt splenic injury in adults: The trauma centre experience in Dubai


Department of General Surgery, Rashid Hospital, Dubai, UAE

Date of Web Publication24-Sep-2018

Correspondence Address:
Ali Salem
Department of General Surgery, Rashid Hospital, Dubai
UAE
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HMJ.HMJ_46_18

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  Abstract 


Introduction: The spleen is the most frequently injured solid organ during blunt abdominal trauma. The treatment strategy for managing splenic insults came under review as doctors were increasingly concerned about post-splenectomy sepsis. Nonoperative management (NOM) of blunt splenic injuries (BSIs) became the standard of care for most of the cases where patients are haemodynamically stable, irrespective of injury grade. Methodology: This is a retrospective study where all adult patients with blunt abdominal injuries treated at level-1 trauma centre in Dubai, between January 2011 and October 2013, were reviewed. Data regarding demographics, pre-operative management, intraoperative findings, blood transfusions requirements and length of hospital stay were collected from patients' files. SPSS (version 20, IBM) was used for data analysis. Results: During the study, 153 patients were enrolled. Nearly 82% of patients with splenic injury were between 13 and 44 years of age. Only 12 patients had an isolated splenic injury. Of 153 patients, 106 were managed conservatively; only 6/106 failed the conservative treatment and got operated. Of 6 patients, 2 were operated due to bowel perforation and the rest 4 patients underwent splenectomy due to hemodynamic instability and drop in haemoglobin. Among the living group, 25/30 patients with Grade I injury and 45/50 patients with Grade II injury were managed conservatively. Conclusion: NOM of BSI was successful in 62.1% in our study which is consistent with other studies. Careful selection of patient and resource availability should be taken into consideration while adopting NOM approach.

Keywords: Isolated splenic injury, nonoperative management, splenectomy


How to cite this article:
Alozaibi O, Salem A, Satti R, Kaiyasah H, Badri F, Al Mazrouei A. The management of blunt splenic injury in adults: The trauma centre experience in Dubai. Hamdan Med J 2018;11:112-5

How to cite this URL:
Alozaibi O, Salem A, Satti R, Kaiyasah H, Badri F, Al Mazrouei A. The management of blunt splenic injury in adults: The trauma centre experience in Dubai. Hamdan Med J [serial online] 2018 [cited 2019 Nov 12];11:112-5. Available from: http://www.hamdanjournal.org/text.asp?2018/11/3/112/241547




  Introduction Top


The spleen is most frequently injured solid organ during blunt abdominal trauma. The treatment strategy for managing splenic insults came under review as doctors were increasingly concerned about post-splenectomy sepsis.[1] Nearly 2%–5% of adult splenectomised patients will develop post-splenectomy sepsis with a mortality rate ranging from 50% to 70%.[2],[3] Nonoperative management (NOM) of blunt splenic injuries (BSIs) became the standard of care for most of the cases where patients are haemodynamically stable, irrespective of injury grade. The delayed diagnosis of BSI might result in a poor outcome with a reported high mortality rate, ranging from 7% to 18%.[4] Development in radiological facilities, ultrasound and computed tomography (CT) scanning has greatly improved splenic injury severity scoring which might help identify suitable patient for NOM.

This change towards conservative management of splenic injuries requires careful selection of patients to avoid the risk of life-threatening haemorrhage and possibility of transfusion-related complications.[5],[6],[7]

Since the 1990s, angioembolisation has been used as an alternative to operative management in the treatment of selected cases of blunt abdominal injury. Currently, NOM involving close observation of the patient, supplemented with splenic artery embolisation (SAE) when necessary, has become the standard treatment for haemodynamically stable patients. Recent reports have, however, revealed that there is variation in the treatment of splenic injury.[8],[9],[10],[11] In a study conducted in Dutch trauma centres, 253 traumatised patients were enrolled. They found that observation rates were the same among trauma centres, but there was a clear difference in operative and embolisation rates. This necessitates standardised guidelines for splenic injuries to achieve optimal management of such injuries.[12]

The most used grading scale for BSI has been established by the American Association for the Surgery of Trauma (AAST Spleen Injury Scale), which grades the BSI into five grades according to the extent of haematoma and depth of laceration; low-grade (I and II) injuries are usually admitted to the surgical ward and are treated conservatively. Whereas, higher grades of BSIs (Grades III–V) are admitted to the Intensive Care Unit and their management depends on the clinical condition and progress of the patient's condition.[13]


  Methodology Top


All adult patients with BSI treated at level-1 trauma centres (Rashid Hospital, Dubai), between January 2011 and October 2013, were reviewed retrospectively. Our study is a descriptive type.

Rashid Hospital and Trauma Centre consists of around 700 beds, and it is the biggest hospital across the United Arab Emirates. It serves citizens and residents from all emirates. All major trauma cases from Dubai and eastern Emirates are referred to our hospital which is a level-I trauma centre. A dedicated polytrauma team involving all concerned specialties (emergency, orthopaedic trauma, anaesthesia and neurosurgery) led by a general surgery senior doctor were established with the aim to deliver best care to polytraumatised patients in a timely manner.

Patients' data were retrieved from the electronic medical records and patient medical files. Data regarding demographics, pre-operative management, intraoperative findings and blood transfusions requirements, length of stay and clinical outcomes were collected. Injury severity score (ISS) was calculated for all patients. Patients <13 years old and penetrating splenic injuries were excluded.

All patients were managed and resuscitated according to the Advanced Trauma Life Support (American College of Surgeons Committee on Trauma). Haemodynamically unstable patients, those who failed to respond to fluid resuscitation and patients with a continued need for blood transfusion had surgery immediately. All stable patients underwent contrast-enhanced CT through which splenic injury were graded between I and V according to the AAST Splenic Injury Grading Scale.

Patients were allocated into two groups: operative and nonoperative group based on initial decision by senior surgeon on call (team leader) during assessment of patients.

Statistical analysis was performed with the help of clinical statistician. SPSS (version 20, IBM, Armonk, NY, USA) used to calculate different statistics for categorical and numerical variables.


  Results Top


During the study from January 2011 to October 2013, 153 patients were included in the study. Nearly 82% of patients with splenic injury were between 13 and 44 years of age. The mean age was 31 years. These cases included isolated splenic injuries as well as polytrauma. As expected, males were predominantly affected, with a male:female ratio of 4.7:1.

Gender, mechanism of injury, initial systolic blood pressure (BP), heart rate, ISS, AAST splenic injury grade and FAST were among the variables included in the datasheet collection.

Nearly 94% of patients with splenic injury had other associated injuries (polytrauma). Only 12 patients had an isolated splenic injury. Among the patients with blunt abdominal trauma, motor vehicle crash was the most common cause in 98 patients, followed by fall from height in 38, heavy object falls in 4, sports injury in 2 and machine-related injury in 1 [Figure 1].
Figure 1: Mechanism of injury

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Most of the patients who suffered blunt splenic trauma were young males of <44 years of age (82%).

Of the 153 patients, 142 underwent CT scan and the rest 11 patients were taken directly to operation theatre (OT) without CT scan due to hemodynamic instability.

Of 153 patients, 106 were managed conservatively; only 6/106 failed the conservative treatment and got operated. Of 6 patients, 2 were operated due to bowel perforation and the rest 4/6 underwent splenectomy due to haemodynamic instability and drop in haemoglobin (Hgb) [Figure 2].
Figure 2: Flowchart

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Ten deaths were reported, 5 in the operative group and another 5 in the conservative group of patients.

Among the living group, 25/30 patients with Grade I injury and 45/50 patients with Grade II injury were managed conservatively. Only 1 patient with Grade V splenic injury was managed nonoperatively. Five patients with Grade I injury who underwent laparotomy with spleen salvage procedure were due to other intra-abdominal injuries [Table 1].
Table 1: Management in correlation to splenic injury grades

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Eleven of 28 patients with Grade III injuries, 18 of 25 patients with Grade IV injuries and 9 of 10 patients with Grade V injuries were managed operatively; hence, the higher the grade of injury, the greater the likelihood of operative management (P < 0.001) [Table 1].

Of 48 patients who were managed operatively, 10 underwent splenorrhaphy (7 with Grades I–II and 3 with Grade III splenic injury). A SAE was not part of our protocol at the time this study was conducted. The rest 38 patients underwent splenectomy.

Among the most significant clinical parameters between both groups (surgical vs. conservative) are the pulse rate on admission and the transfusion requirements [Table 2].
Table 2: Demographic and clinical characteristics of patients with splenic trauma

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Transfusion requirement was 6.3 units in the operative group and 1.6 units in the nonoperative group (P < 0.0001).

The mean hospital stay in the operative group was 32.6 days and in the nonoperative group was 25.5 days.

The mean ISS of the operative group was 30.4, higher than in the nonoperative group with a mean ISS of 19.7 (P = 0.4).


  Discussion Top


Managing cases of BSI nonoperatively can be a safe and successful option. As observed in our study, NOM was adopted in 69.3% (106 patients) of all BSIs and was successful in 62.1% (95 patients). Saurabh et al. have shown in their study a comparable rate of NOM of about 63%.[14]

The success rate of NOM (among the 106 patients treated nonoperatively) was 89.6%. Other studies have reported similar success rates of 89.9%–98%.[15] Careful selection of cases for NOM is a major indicator of the success of this treatment. Many studies have looked into factors that favour success of NOM and other factors associated with failure of NOM. In our study, those who failed NOM were too small to conclude any statistically significant factors for failure of NOM.

Renzulli et al. introduced SAE during their study and showed a significant decrease in operative management rates from 33.3% to 11.9% (P < 0.001), but showed no significant difference in the success rate of NOM.[15] This technology was not part of our protocol in managing splenic injury at the time this study was conducted.

In our study, from the 106 patients kept on NOM, 6 patients required operative intervention after a period of conservative management and 5 patients died, and thus the rate of failure was 10.3% (11 patients). Other studies like Garber et al. and Cogbill et al. have reported comparable rates of failure of NOM up to 11%.[16],[17] Chastan et al. and Cadeddu et al. have shown lower rates of failure of NOM of 7% and 6.8%, respectively.[18],[19]

Of the 6 cases requiring consequent operative intervention, 2 had laparotomies for bowel perforations and the other 4 underwent splenectomy for drop-in Hgb or haemodynamic instability. Most of cases were taken to OT after 2 days of observation and conservative treatment.

Among 153 cases of splenic injury treated in our institute, we have 10 cases of mortality and majority of them were due to severe unsalvageable traumatic brain injury.

The only factors found significant in determining success of NOM were the grade of splenic injury (P < 0.001) and the pulse rate. The mean pulse rate in the NOM group was 98.6 bpm, while in the operative group, it was 106.4 bpm (P < 0.001). Other factors such as systolic BP, ISS and age did not have a significant impact on the outcome.

Saurabh et al. showed that grade of splenic injury was also significantly higher in their operative group. Other significant factors leading to operative management in their study were higher ISS and low systolic BP.[14]

In the study by Renzulli et al., the significant factors associated with operative management were age >55 years, transfusion of 5 or more units of packed red blood cells and Glasgow coma scale of 11 or less. The only factor in their study related to failure of NOM was age of 40 years or more.[15]

The mean length of hospital stay in our study showed no significant difference between the operative and nonoperative groups, with a mean of 32.6 days versus 25.5 days, respectively. The mean length of stay in other studies were 12.8–17 days in splenectomy group and 8.3–12 days in the nonoperative group.[14],[18] Longer length of stay could be related to the associated injuries, as the majority (94%) of our patients had other associated injuries with their spleen injury. Patients with isolated spleen injuries had a mean hospital stay of only 6.3 days. Patients with other associated injuries, especially those with extra-abdominal injuries (mainly fractures), had a significantly longer mean hospital stay of up to 31 days.

Blood transfusion rates were significantly higher in the operative group, with a mean of 6.3 units, while in the nonoperative group, the mean was 1.6 units, with a P < 0.001.


  Conclusion Top


NOM of BSI was successful in 62.1% in our study which is consistent with other studies. The only factors found significant in determining success of NOM in our study were the grade of splenic injury (P < 0.001) and the pulse rate. NOM has become the gold standard approach for BSIs. Careful selection of patient and resource availability should be taken into consideration while adopting NOM approach. We recommend strongly that our study to be reproduced with SAE as part of protocol which might have an impact on outcome as shown in some studies.

Acknowledgement

We would like to thank Dr. Nazik Nurelhuda for her help with the statistical analysis and her persistent support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Mikocka-Walus A, Beevor HC, Gabbe B, Gruen RL, Winnett J, Cameron P, et al. Management of spleen injuries: The current profile. ANZ J Surg 2010;80:157-61.  Back to cited text no. 1
    
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Davidson RN, Wall RA. Prevention and management of infections in patients without a spleen. Clin Microbiol Infect 2001;7:657-60.  Back to cited text no. 2
    
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Ramachandra J, Bond A, Ranaboldo C, Cullis J. An audit of post-splenectomy prophylaxis – Are we following the guidelines? Ann R Coll Surg Engl 2003;85:252-5.  Back to cited text no. 3
    
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Costa G, Tierno SM, Tomassini F, Venturini L, Frezza B, Cancrini G, et al. The epidemiology and clinical evaluation of abdominal trauma. An analysis of a multidisciplinary trauma registry. Ann Ital Chir 2010;81:95-102.  Back to cited text no. 4
    
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Lo A, Matheson AM, Adams D. Impact of concomitant trauma in the management of blunt splenic injuries. N Z Med J 2004;117:U1052.  Back to cited text no. 5
    
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Shanmuganathan K, Mirvis SE, Boyd-Kranis R, Takada T, Scalea TM. Nonsurgical management of blunt splenic injury: Use of CT criteria to select patients for splenic arteriography and potential endovascular therapy. Radiology 2000;217:75-82.  Back to cited text no. 6
    
7.
Weinberg JA, Magnotti LJ, Croce MA, Edwards NM, Fabian TC. The utility of serial computed tomography imaging of blunt splenic injury: Still worth a second look? J Trauma 2007;62:1143-7.  Back to cited text no. 7
    
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Hamlat CA, Arbabi S, Koepsell TD, Maier RV, Jurkovich GJ, Rivara FP, et al. National variation in outcomes and costs for splenic injury and the impact of trauma systems: A population-based cohort study. Ann Surg 2012;255:165-70.  Back to cited text no. 8
    
9.
Zarzaur BL, Croce MA, Fabian TC. Variation in the use of urgent splenectomy after blunt splenic injury in adults. J Trauma 2011;71:1333-9.  Back to cited text no. 9
    
10.
Jeremitsky E, Smith RS, Ong AW. Starting the clock: Defining nonoperative management of blunt splenic injury by time. Am J Surg 2013;205:298-301.  Back to cited text no. 10
    
11.
Moore FA, Davis JW, Moore EE Jr., Cocanour CS, West MA, McIntyre RC Jr., et al. Western Trauma association (WTA) critical decisions in trauma: Management of adult blunt splenic trauma. J Trauma 2008;65:1007-11.  Back to cited text no. 11
    
12.
Olthof DC, Luitse JS, de Rooij PP, Leenen LP, Wendt KW, Bloemers FW, et al. Variation in treatment of blunt splenic injury in Dutch academic trauma centers. J Surg Res 2015;194:233-8.  Back to cited text no. 12
    
13.
El-Matbouly M, Jabbour G, El-Menyar A, Peralta R, Abdelrahman H, Zarour A, et al. Blunt splenic trauma: Assessment, management and outcomes. Surgeon 2016;14:52-8.  Back to cited text no. 13
    
14.
Saurabh G, Kumar S, Gupta A, Mishra B, Sagar S, Singhal M, et al. Splenic trauma – Our experience at a level I trauma center. Ulus Travma Acil Cerrahi Derg 2011;17:238-42.  Back to cited text no. 14
    
15.
Renzulli P, Gross T, Schnüriger B, Schoepfer AM, Inderbitzin D, Exadaktylos AK, et al. Management of blunt injuries to the spleen. Br J Surg 2010;97:1696-703.  Back to cited text no. 15
    
16.
Garber BG, Yelle JD, Fairfull-Smith R, Lorimer JW, Carson C. Management of splenic injuries in a Canadian trauma centre. Can J Surg 1996;39:474-80.  Back to cited text no. 16
    
17.
Cogbill TH, Moore EE, Jurkovich GJ, Morris JA, Mucha PJr., Shackford SR, et al. Nonoperative management of blunt splenic trauma: A multicenter experience. J Trauma 1989;29:1312-7.  Back to cited text no. 17
    
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Chastang L, Bège T, Prudhomme M, Simonnet AC, Herrero A, Guillon F, et al. Is non-operative management of severe blunt splenic injury safer than embolization or surgery? Results from a French prospective multicenter study. J Visc Surg 2015;152:85-91.  Back to cited text no. 18
    
19.
Cadeddu M, Garnett A, Al-Anezi K, Farrokhyar F. Management of spleen injuries in the adult trauma population: A ten-year experience. Can J Surg 2006;49:386-90.  Back to cited text no. 19
    


    Figures

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    Tables

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