Splenic trauma and salvage

The traditional view of the spleen as an expendable organ is no longer tenable. In recent years the importance of the spleen in immunologic processes of bacterial clearance, phagocytosis, and antibody formation has been well established. Post-splenectomy sepsis, once only considered a threat in children, is now recognized in adults. Several techniques have evolved since the early 1930s in dealing with splenic injury. These techniques include observation, prevention of iatrogenic injury, auto transplantation, and suture repair in conjunction with hemostatic agents. A recent review of splenectomies done at our institution showed a salvage rate of 97 per cent in children and 6.3 per cent in adults. The preservation of splenic function should be the principal goal in the isolated injury to the spleen; especially for iatrogenic trauma, conservative surgical management is indicated, particularly in children, but also now in adults.     

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.     

Splenic trauma. Conservative treatment

The spleen performs a wide range of important life functional at an hematological, immunological and hormonal level. The frequency of immediate and late complications following splenectomy suggest that the most conservative treatment possible must be adopted in cases of splenic trauma. The paper reports 180 cases observed during the period from January 1982 to August 1987. Conservative treatment was used to treat 92 patients. The real advantages of this methods are reviewed in relation to the stability of clinical conditions, the absence of associated abdominal lesions, and the availability of diagnostic equipment and intensive therapy units.     

Splenic trauma by ventriculoperitoneal shunt catheter

Ventriculoperitoneal shunt is used as a treatment of hydrocephalus. Although this procedure is usually safe, several abdominal complications have been reported in the literature. However, to our knowledge, a catheter-induced splenic trauma has not been previously described. We report here the case of a patient who presented with a spontaneous splenic trauma, 10 years after ventriculoperitoneal shunt insertion. A conservative treatment with careful monitoring was successful and the patient recovered without surgery.     

Splenic trauma. Choice of management.

The modern era for splenic surgery for injury began in 1892 when Riegner reported a splenectomy in a 14-year-old construction worker who fell from a height and presented with abdominal pain, distension, tachycardia, and oliguria. This report set the stage for routine splenectomy, which was performed for all splenic injury in the next two generations. Despite early reports by Pearce and by Morris and Bullock that splenectomy in animals caused impaired defenses against infection, little challenge to routine splenectomy was made until King and Schumacker in 1952 reported a syndrome of "overwhelming postsplenectomy infection" (OPSI). Many studies have since demonstrated the importance of the spleen in preventing infections, particularly from the encapsulated organisms. Overwhelming postsplenectomy infection occurs in about 0.6% of children and 0.3% of adults. Intraoperative splenic salvage has become more popular and can be achieved safely in most patients by delivering the spleen with the pancreas to the incision, carefully repairing the spleen under direct vision, and using the many adjuncts to suture repair, including hemostatic agents and splenic wrapping. Intraoperative splenic salvage is not indicated in patients actively bleeding from other organs or in the presence of alcoholic cirrhosis. The role of splenic replantation in those patients requiring operative splenectomy needs further study but may provide significant long-term splenic function. Although nonoperative splenic salvage was first suggested more than 100 years ago by Billroth, this modality did not become popular in children until the 1960s or in adults until the latter 1980s. Patients with intrasplenic hematomas or with splenic fractures that do not extend to the hilum as judged by computed tomography usually can be observed successfully without operative intervention and without blood transfusion. Nonoperative splenic salvage is less likely with fractures that involve the splenic hilum and with the severely shattered spleen; these patients usually are treated best by early operative intervention. Following splenectomy for injury, polyvalent pneumococcal vaccine decreases the likelihood of OPSI and should be used routinely. The role of prophylactic penicillin is uncertain but the use of antibiotics for minor infectious problems is indicated after splenectomy.     

Splenic preservation in adults after blunt and penetrating trauma

This study was carried out to evaluate the possibility and safety of splenic preservation in adults subjected to both blunt and penetrating trauma. In an 18 month period there were a total of 36 splenic injuries studied (in 36 patients): 18 due to blunt trauma, 11 due to gunshot wounds, and 7 due to stab wounds. A total of 18 spleens were repaired: 8 (45 percent) in the blunt trauma group, 4 (36 percent) in the gunshot group, and 6 (85 percent) in the stab wound group. There were no deaths in the entire group nor were there any complications associated with splenic salvage. Splenic preservation after both blunt and penetrating trauma is both safe and feasible in the adult population, except in those instances specified herein.     

Splenic trauma in children and techniques of splenic salvage

The increased risk of sepsis after splenectomy applies to any age for any reason. Splenic injuries consequently are now managed when possible by salvage procedures or nonoperative observation. This is not without controversy and in an attempt to define these injuries more appropriately and so predict optimal management, a quantitative and qualitative classification of presence and severity is presented, based on computed tomography. Type I injuries consist of localized capsular disruption or subcapsular hematomas, without significant parenchyma injury. Type II injuries consist of single or multiple capsular disruptions, with parenchymal injury that does not extend into the hilum or involve major vessels, with or without intraparenchymal hematoma. Type III injuries consist of deep fractures, single or multiple, that extend into the hilum and involve major vessels. Type IV injuries are those in which the spleen is completely shattered, fragmented, or separated from its normal blood supply. Added to this is the subclassification A for splenic injuries without associated intra-abdominal injuries; B for splenic injuries with associated intra-abdominal injuries, B₁ for injuries involving a solid viscus, B₂ for injuries involving a hollow viscus; and E for splenic injuries with associated extra-abdominal injuries.Surgical techniques for splenic salvage consist of the application of topical hemostatic agents or omentum with or without simple capsular sutures, direct suturing of capsule and parenchyma, ligation of individual or segmental vessels, partial splenectomy, application of an absorbable net or ladder, and large entire organ through- and-through sutures. These techniques are illustrated and alternatives to salvage are discussed.

---

Resumen El aumento en el riesgo de sepsis observado después de la esplenectomía se aplica a cualquiera edad y a cualquier causa. Por ello las lesiones esplénicas son actualmente manejadas, en lo posible, con procedimientos que preservan el bazo o con observación no operatoria. Tal conducta no está libre de controversia y en un intento por definir en forma más apropiada este tipo de lesiones y con ello poder predecir su manejo óptimo, se presenta una clasificación cuantitativa y cualitativa basada en la tomografía computadorizada. Las lesiones tipo I consisten en rotura capsular localizada o en hematomas subcapsulares, sin daño significativo del parenquima. Las lesiones tipo II consisten en roturas capsulares únicas o múltiples, con daño parenquimatoso que no se extiende hasta el hilio ni afectan vasos mayores, con o sin hematoma intraparenquimatoso. Las lesiones tipo III consisten en fracturas profundas, únicas o múltiples, que se extienden hasta el hilio o que afectan vasos mayores. Las lesiones tipo IV son aquellas en las cuales el bazo está totalmente despedazado, fragmentado o separado de su vascularización normal. A lo anterior se añade la subclasificación A para lesiones esplénicas no asociadas con lesiones intraabdominales; B para lesiones esplénicas asociadas a lesiones intraabdominales, B₁ cuando una viscera mayor está afectada, B₂ cuando está afectada una víscera hueca; y E para lesiones esplénicas asociadas con lesiones extraabdominales.La técnica quirúrgica para preservación esplénica consiste en la aplicación de agentes hemostticos tópicos o de epiplón con o sin suturas capsulares, sutura directa de cápsula y parenquima, ligadura de vasos individuales o segmentarios, esplenectomía parcial, aplicación de una malla o escalera absorbible y suturas grandes a través de todo el órgano (through- and-through). Tales técnicas aparecen ilustradas, y se discuten las diferentes alternativas útiles para el salvamento esplénico.

---

Résumé L'augmentation du risque infectieux après splénectomie s'observe aussi bien chez l'enfant que chez l'adulte et pour les mêmes raisons. Il en résulte que les lésions traumatiques de la rate doivent être traitées par des méthodes nonagressives ou par l'abstention en plaçant le blessé sous un contrôl médical attentif. Cette attitude a prêté à controverse. Pour définir de façon plus précise la blessure splénique, et pour choisir le traitement susceptible de lui être appliqué une classification reposant sur les données de la tomodensitométrie a été établie, classification quantitative et qualitative. Les blessures de type I consistent en la rupture localisée de la capsule ou dans la présence d'un hématome sous-capsulaire en l'absence d'atteinte du parenchyme. Les blessures de type II répondent à une ou à plusieurs ruptures capsulaires associées à une blessure du parenchyme qui n'atteint pas le hile de la rate, qui ne concerne pas des vaisseaux importants, qu'existe ou non un hématome intraparenchymateux. Les lésions de type III répondent à des fractures profondes, fractures uniques ou multiples qui s'étendent jusqu'au hile ou intéressent des vaisseaux importants. Les blessures de type IV répondent aux ruptures complètes de la rate de multiples fragments ou aux cas où la rate est privée de vascularisation. A cette classification principale s'ajoute une sous-classification: le type A représente des blessures spléniques sans lésion intra-abdominale associée. Le type B répond aux lésions spléniques s'accompagnant de lésions traumatiques intra-abdominales. Il est qualifié de B₁ si un viscère plein est intéressé, de B₂ si un viscère creux est en cause. Le type E répond aux lésions traumatiques spléniques associées à des lésions traumatiques extra-abdominales. Le traitement conservateur de la rate consiste à employer des agents hémostatiques locaux ou le grand épiploon en s'aidant ou non de sutures de la capsule, et du parenchyme, de la ligature d'un vaisseau, de l'emploi d'un filet en matériel absorbable ou de sutures de part en part du parenchyme splénique. Ces techniques sont illustrées dans l'article présenté.

     

Splenic trauma following endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) is a safe diagnostic and therapeutic procedure. Splenic injury after ERCP is extremely rare and only two cases have been reported in the English literature. A subscapsular splenic hematoma is reported after ERCP and the mechanism of injury and possible preventive measures are discussed.     

Splenic artery ligation for trauma: An alternative to splenectomy

Splenic artery ligation without splenectomy was successfully used to control hemorrhage after blunt injury to the spleen. A review of experimental and clinical reports on splenic artery ligation reveals that this technique is well tolerated because of fairly extensive collateral blood supply to the spleen. The blood supply to the spleen is described in detail.     

小儿脾外伤55例分析

腹外伤中 ,脾脏是最容易受损伤的器官。近年来 ,随着人们生活水平的提高 ,因坠落伤和交通意外造成的小儿脾外伤发生率逐年增加。本院自 1986年 1月～ 1999年 12月近 14年来共收住外伤性脾损伤 5 5例 ,现总结分析如下。1　临床资料1.1　一般资料　男 41例 ,女 14例 ,年龄 4天～ 14岁 ;入院经 B超检查 40例 ,其中 36例示腹腔积血、脾包膜下血肿或包膜连续性中断、脾实质回声杂乱 ,4例阴性 ;CT检查 2 0例均阳性 ;5 5例均行腹腔穿刺术 ,5 0例抽出不凝血 ;术前伴休克者 2 2例。致伤原因 :高处坠落伤 2 3例 ,车祸伤 19例 ,跌落伤 7例 ,挤压伤 3…