脾创伤保脾手术术式的选择（附158例分析体会）

目的　探讨脾创伤保脾术的术式选择。方法　对脾创伤采用术中保脾的 15 8例手术方式进行分析 ,其中氩气刀止血 5例 ,ZT生物胶止血 3例 ,单纯脾修补术 2 6例 ,脾部分切除术 77例 ,修补加脾部分切除术 12例 ,脾切除自体脾组织片网膜囊内移植术 35例。结果　全组病例治愈出院。脾切除自体脾组织片网膜囊内移植术组 35例中 ,2例出现粘连性肠梗阻 ,11例出现各类术后感染 ,而其它术中保脾组 12 3例中 ,10例出现术后感染 ,两组总感染数比较 ,P <0 .0 1。结论　脾创伤术中保脾术的术式选择 ,应根据病人个体情况及脾破裂的类型而定 ,必要时采用联合多种术式保脾。对伴有空腔脏器破裂者也可选择性保脾。但应慎重选择脾切除自体脾组织片网膜囊内移植术。     

Factors influencing the risk of early and late serious infection in adults after splenectomy for trauma

We reviewed the clinical course of 245 adults who underwent splenectomy for trauma to assess the risk of both early and late serious infection. Twenty-one patients (9%) had an early serious infection (sepsis) during hospitalization for splenectomy. The mortality rate was 62% in patients with early sepsis, and encapsulated bacteria were isolated from the blood of 43% of patients with sepsis. Only one of 58 patients with isolated splenic injury had sepsis (2%), and the risk of early sepsis increased when three or more concomitant injuries were present (p less than 0.05). Stepwise multiple regression analysis revealed that patients with injuries to the pancreas, colon, or central nervous system or with extremity fractures had an increased risk of sepsis (p less than 0.05). The risk of sepsis was not influenced by age, the type of injury, delay in operation, use of drains, or other individual injuries. Sufficient information was available to assess the risk of late serious infection for 140 surviving patients (63%). Follow-up ranged from 2 to 277 months. Three late infections occurred at 2, 8, and 15 years after splenectomy; two were due to Streptococcus pneumoniae. None of these patients died. There were no identifiable factors influencing the risk of late infection. These results suggest that the risk of early serious infection in adults after splenectomy for trauma is low when isolated splenic injury is present but that this risk is increased by both the degree of injury and the presence of certain associated injuries. Encapsulated bacteria are frequent pathogens in both early and late infections. The mortality rate related to an early septic episode is high, but the risk of late serious infection is low and is not related to identifiable factors that decrease host defenses.     

The influence of trauma to the spleen on postoperative complications and mortality

Although splenectomy has been associated with an increased risk of late sepsis, it is not clear whether splenectomy for trauma increases the incidence of acute infectious complications or deaths during the initial hospital stay. We reviewed the charts of 175 trauma patients who had exploratory laparotomy between July 1977 and June 1983. Eighty patients underwent total splenectomy and 15 patients had splenic salvage operations performed. A group of 80 patients with no splenic trauma (N.S.T.) who had laparotomy for trauma, served as a control group. These N.S.T. patients had injury severity scores (ISS) similar to the patients who had splenectomy. The incidence and types of postoperative complications, mortality rates, and length of hospitalization were similar for both groups, indicating that splenectomy was not associated with an increased risk of postoperative complications or mortality.     

Factors affecting the outcome of patients with splenic trauma

This is a report of 546 consecutive patients with penetrating and blunt splenic trauma seen over a 17 1/2-year period (1980-1997). The etiology of the splenic injuries and the associated mortality rates were: blunt injuries 45 of 298 (15%), gunshot wounds 48 of 199 (24%), and stab wounds four of 49 (8%). The overall mortality rate was 97 of 546 (18%). The most significant risk factors for death were all associated with major blood loss: transfusion requirements > or = 6 units of blood, low initial operating room blood pressure, associated abdominal vascular injuries, and performance of a thoracotomy. The two most important organs injured in conjunction with the spleen that were significant predictors of postoperative infectious complications were colon and pancreas. The need for splenectomy was most significantly correlated with higher grades of splenic injury especially grades IV and V. The evolution in management of blunt splenic trauma has led to a significant improvement in splenic preservation and avoidance of laparotomy for many patients. Operative splenic salvage is reduced in patients subjected to laparotomy who are candidates for nonoperative treatment. Improved results with splenic injury should be obtained by rapid control of bleeding. This may require more liberal criterial in selecting patients with splenic trauma for early operative treatment.     

Predictability of splenic salvage by computed tomography

The recognition of overwhelming post-splenectomy infection (OPSI) has led to greater efforts to conserve splenic tissue in patients sustaining blunt torso trauma. Nonoperative management of splenic trauma has emerged as a means to enhance splenic salvage yet criteria to assure the safety of such an approach remain ill defined and controversial. Since severity of injury directly influences outcome, a need exists for identification of splenic injuries that require early operation and repair or removal. Using our recently reported classification of splenic trauma, 46 patients with blunt splenic trauma were evaluated preoperatively with computed tomography (CT). Injuries were graded I through IV and were described as capsular or subcapsular disruptions without parenchymal injury (four); capsular and parenchymal injuries not involving the major vessels or hilum (24); injuries involving major vessels and/or the hilum (17); and fragmentation/devascularizing injuries (one). Additional modifiers were added for associated intra-abdominal and/or extra-abdominal injuries. Sixteen patients had their splenic injuries managed nonoperatively and the remainder underwent operation for the splenic injury or associated injuries. The CT classification was confirmed in all patients and we believe early operation optimized splenic salvage. We conclude that: 1) CT is an accurate technique to determine the extent of splenic injury; 2) CT classification of splenic trauma has a high correlation with anatomic findings and need for operation; 3) early operation in patients with severe class II and all class III injuries affords optimal conditions for splenic salvage; and 4) early definitive management of splenic trauma significantly reduces late splenectomy and shortens hospitalization.     

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.     

Splenectomy versus splenic salvage for spleens ruptured by blunt trauma

Of 339 patients treated in three Charlotte hospitals from January 1960 through March 1983 for splenic rupture caused by blunt trauma, 317 (93.5%) underwent splenectomy, and 22 (6.5%) underwent splenic salvage operations. Perioperative mortality for splenectomized patients was 7.9 per cent, and that for those who received splenic salvage operations was 22.7 per cent. Perioperative sepsis occurred in 4.4 per cent of the splenectomized patients and in 9 per cent of those whose spleens were salvaged. Perioperative deaths and sepsis in both groups were related to associated injuries, not to splenic injuries. Follow-ups from 5 months to 22.4 years (mean, 9.5 years) of the 292 splenectomized patients who survived their injuries show that 252 (86.3%) are living, 22 (7.5%) have died of causes unrelated to splenic injuries, 18 (6.1%) could not be found, and none of the patients traced has died of sepsis. One patient (0.34%) experienced an episode of sepsis i.e., a nonfatal septicemia 7 years postsplenectomy, that may be related to splenectomy. These data suggest that the importance of splenic salvage for prevention of postsplenectomy sepsis has been overemphasized and that expeditious splenectomy remains the procedure of choice for patients with ruptured spleens, especially for those with hypovolemic hypotension, anemia from hemorrhage, or multiple injuries. Data to substantiate these views will be presented.     

Prospective study of the early postoperative course of splenic rupture: spleen preservation versus splenectomy]

The haematological and immunological changes after splenectomy have been the subject of intensive research in recent years. As a consequence there has been a clear trend towards splenic salvage. Due to the availability of improved diagnostic investigations (sonography, CT) nonoperative treatment with close observation has become increasingly important in adults. 75 patients with documented splenic injury were prospectively evaluated over a 45-month period with an emphasis upon splenic preservation. Unstable patients had operative exploration with attempt at splenorrhaphy or partial splenic resection. Stable patients were managed nonoperatively, regardless of the degree of splenic injury as determined by sonography and/or computed tomography. In 38 patients the spleen was preserved by operative preservation in 20 and nonoperative treatment in 18 patients. 37 patients required splenectomy. Four patients were managed initially by nonoperative treatment, but required exploration for secondary rupture at 7, 7, 10 and 13 days. Delayed splenectomy was performed in three patients and one patient was treated by splenorrhaphy 7 days after admission. Bleeding complications occurred in one patient after splenorrhaphy (bleeding from the pancreatic tail) and the bleeding vessel could be transfixed during the same anaesthetic. Four patients required reexploration after splenectomy for hemorrhage (2) and evacuation of infected haematomas. The Injury Severity Score (ISS) of the splenectomy and splenic preservation group was determined. Splenectomised patients showed in the postoperative follow-up a significantly increased infection rate (40%, p less than 0.02) when compared to patients with splenic preservation (10%) or nonoperative treatment (11%), even when they were matched in respect of multiple trauma using the Injury Severity Score (ISS).     

Blunt splenic trauma.

The treatment of blunt splenic injury has evolved over time from splenectomy in all patients to nonoperative management in stable patients with operation reserved for failures of NOM. While rates of OPSI remain low in trauma patients, splenic salvage in stable patients should be attempted. However, clinical evidence of ongoing blood loss or instability should be addressed with prompt splenectomy. Careful patient selection is of paramount importance in nonoperative management of blunt splenic injury.     

Twenty Years of Splenic Preservation in Trauma: Lower Early Infection Rate Than in Splenectomy

BACKGROUND: Retrospective studies concerning the operative preservation and nonoperative management of splenic injuries in patients with splenic trauma have been published; however, few studies have analyzed prospectively the results and early complication rates of a defined management in splenic injury. METHODS: From 1986 to 2006, adult patients with blunt splenic injuries were evaluated prospectively with the intent of splenic preservation. Hemodynamically unstable patients underwent laparotomy. Stable patients were treated conservatively regardless of the grade of splenic injury determined by ultrasound and/or CT scan. RESULTS: During a 20-year period, 155 patients were prospectively evaluated. In 98 patients (63%), the spleen could be preserved by nonoperative (64 patients, 65%) or operative (34 patients, 35%) treatment and 57 patients (37%) needed splenectomy. There were no differences in age, sex, or trauma score between the groups, but a higher early infection rate in patients with splenectomy compared with patients with splenic preservation (p < 0.005) was observed, even if the patients were matched with respect to multiple trauma using the Injury Severity Score (p < 0.01). CONCLUSIONS: Splenic preservation in patients with blunt splenic injury by operative or nonoperative treatment leads to lower early infection rates in adults and, therefore, should be advocated.     

Late septic complications in adults following splenectomy for trauma: a prospective analysis in 144 patients

One hundred forty-four patients were prospectively followed through our Asplenic Registry for the development of late septic complications following splenectomy for trauma. There were 114 males and 30 females with a mean age of 28.6 years. The total time of followup was 8,810 patient months with a mean followup of 61 months (range, 12-144 months). Indications for splenectomy were blunt trauma, 111 patients; penetrating trauma, six patients; and intra-operative injury, 27 patients. During the followup to date, 15 late major septic complications requiring hospitalization have occurred in 13 patients (9%). Fulminant pneumococcal sepsis resulted in the death of a 27-year-old male, 3 years after splenectomy. Septicemia occurred in four patients, pneumonia in five, abscess in two, infection of a prosthetic heart valve in one, meningitis in one, and fever of unknown origin in one. All but two of these infections were due to encapsulated organisms. Minor septic complications occurred in 44 patients (30%), and consisted of infections which required outpatient medical care. Major late septic complications occurred more frequently following incidental splenectomy than following splenectomy for blunt or penetrating trauma (18.5% and 5.9% respectively; p less than 0.05). The mortality from major septic complications in this series (7%) is lower than previously reported by other investigators (30-80%). Our data suggest that adults undergoing splenectomy for trauma are at an increased risk of developing late major septic complications. This risk is significant enough to warrant attempts at splenic salvage, especially when injury is incidental to an elective operative procedure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Early post-splenectomy sepsis after missile injury in adults

Early septic complications were studied in 292 patients operated on for penetrating missile injury of the abdomen with involvement of either the spleen or the liver, at Basrah Teaching Hospital between January 1983 and April 1986. Depending on associated injuries, patients with splenectomy were divided into three groups, the first with isolated splenic injury, the second with splenic and associated extra-intestinal organ injury, and the third with splenic and intestinal injuries with or without extra-intestinal organ injury. Patients with hepatic injury were classified similarly. Splenectomy was carried out for any degree of splenic injury. Grade I hepatic injuries were managed by débridement and suturing while major grades II-IV underwent segmentectomy or lobectomy. Patients were considered septic if they had any three of four clinical criteria: temperature higher than 39 degrees C; significant haemodynamic deterioration; respiratory alkalosis, or oliguria. Of the total, 79 were excluded due to: early transfer 51, incomplete records 8, perioperative death 11, and having combined splenic and hepatic injuries 9 (excluded by definition), leaving 104 (74.8%) patients with splenectomy and 109 (71.1%) with hepatic injury available for study. Sepsis developed in 48 (46.1%) of patients after splenectomy and in 28 (25.7%) with hepatic injury. This difference was significant (P greater than 0.005). In patients with isolated splenic injury, eight (25.8%) were septic while three (13.6%) of those with isolated hepatic injury developed sepsis. This was not significant (P = 0.32, Fisher's exact test). When either was associated with an injury to an extra-intestinal organ, 15 (50%) of the splenectomy group developed sepsis compared to five (23.8%) of the hepatic injury group.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of iatrogenic splenectomy during open and laparoscopic colon resection

Iatrogenic splenic injury requiring splenectomy is a well-recognized and potentially serious complication of colon resection. Iatrogenic splenectomy is associated with significant morbidity and mortality, including bleeding and the postsplenectomy sepsis syndrome. Our study aims to compare the incidence of iatrogenic splenectomy in laparoscopic colon resection with that of open colon resection over an 11-year-period at Mount Sinai. A retrospective chart review of all patients undergoing colon resection at Mount Sinai Medical Center during the last 11 years was performed to identify patient demographics, procedure, indication, and outcome. There was a significant difference (P=0.03) in the incidence of iatrogenic splenectomy during open colectomy (13/5477, 0.24%) versus laparoscopic colectomy (0/1911, 0%). All cases complicated by iatrogenic splenectomy involved splenic flexure mobilization. Laparoscopy has many recognized advantages over open procedures, including shorter recovery and length of stay. This retrospective review of our experience at Mount Sinai presents another potential benefit of the laparoscopic approach to colon resection.     

Hospital factors associated with splenectomy for splenic injury: a national perspective

BACKGROUND: The management of patients with splenic injury has shifted from routine splenectomy to attempts at splenic salvage. Using the Healthcare Cost and Utilization Project's National Inpatient Sample (HCUP-NIS), we assessed the patterns of care for splenic trauma. We hypothesized that the processes of care in urban and rural hospitals would differ. METHODS: Generalized estimating equations were used to identify predictor variables associated with laparotomy and splenectomy from a national, population-based sample of inpatients (HCUP-NIS). Fourteen thousand nine hundred one patients with an International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code of 865 were selected from the 1998 to 2000 HCUP-NIS data. Exclusion criteria included age greater than 80 years. Analyses were compared using all patients and excluding patients who died during the first 2 hospital days. RESULTS: Eight thousand five hundred fifty-three patients were treated in urban teaching hospitals. Forty percent underwent a laparotomy and 28% underwent a splenectomy at that time. Another 4,461 patients were cared for in urban nonteaching hospitals. Of these, 46% had a laparotomy and 35% underwent a splenectomy. The remaining 1,887 patients were seen in rural hospitals. Forty-six percent had a laparotomy and 36% had a splenectomy. Patients in urban teaching hospitals had lower risk-adjusted odds of splenectomy in multivariate models controlling for confounders including overall injury severity. Overall splenic salvage increased from 1998 to 2000, primarily because of increased salvage rates among urban teaching hospitals. CONCLUSION: The management of patients with splenic injury differs among urban teaching, urban nonteaching, and rural hospitals. Surgeons at urban teaching hospitals appear more willing to attempt splenic salvage by means of nonoperative management.     

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.     

Iatrogenic splenic injury

BACKGROUND: Iatrogenic injury to the spleen is a recognised complication of abdominal surgery but the extent of the problem is often under-estimated. This may be due to failure to report splenic injury on the operation note or inaccurate recording of the indication for splenectomy. In this review article we have tried to estimate the incidence of iatrogenic splenic injury during abdominal surgery, the morbidity and mortality associated with splenic injury and the risk factors for injury to the spleen. We have also identified the common types and mechanisms of injury to the spleen and have made suggestions as to how splenic injury can be avoided and, when it occurs, how it should be managed. METHODS: A Medline literature search was performed to identify articles relating to "incidental splenectomy", "iatrogenic splenic injury", "iatrogenic splenectomy" and "splenectomy as a complication of common abdominal procedures". The relevant articles from the reference lists were also obtained. RESULTS: Up to 40% of all splenectomies are performed for iatrogenic injury. The risk of splenic injury is highest during left hemicolectomy (1-8%), open anti-reflux procedures (3-20%), left nephrectomy (4-13%) and during exposure and reconstruction of the proximal abdominal aorta and its branches (21-60%). Splenic injury results in prolonged operating time, increased blood loss and longer hospital stay. It is also associated with a two to ten-fold increase in infection rate and up to a doubling of morbidity rates. Mortality is also reported to be higher in patients undergoing splenectomy for iatrogenic injury. The risk of injury to the spleen is higher in patients who have previously undergone abdominal surgery, in the elderly and in obese patients. A transperitoneal approach significantly increases the risk of splenic injury during left nephrectomy compared with an extraperitoneal approach and the risk is even higher if the indication for surgery is malignancy. Excessive traction, injudicious use of retractors and direct trauma are the commonest mechanisms of injury. CONCLUSIONS: The incidence of iatrogenic splenic injury is underestimated because of poor documentation. Splenic injury during abdominal surgery can be reduced by achieving good exposure and adequate visualisation, avoiding undue traction and by early careful division of splenic ligaments and adhesions. When the spleen is injured splenic preservation is desirable and often feasible, but this should not be at the expense of excessive blood loss     

Plasma gamma globulin levels after splenectomy and spleen salvage

A series of plasma globulin studies was carried out on 108 patients who were operated on for splenic trauma during the last 3 years. The reasons for splenectomy or spleen salvage were; gunshot wounds in 22 patients (20.3%); stab injuries in 10 patients (9.2%) and blunt abdominal trauma in 76 patients (70.3%). Plasma gamma globulin determinations were made on the 8th postoperative day and at 3 months. In the splenectomy group; plasma gamma globulin determinations demonstrated a significant reduction in serum IgM levels (p less than 0.001) but no significant changes in IgA and IgG levels (p greater than 0.05). No changes were detected in IgA, IgG and IgM levels in the spleen salvage group (p greater than 0.05). We believe that the preservation of the traumatized spleen should be the prime aim of surgeons.     

Postsplenectomy complications

Postsplenectomy complications were reviewed among 420 patients with simple splenic injury, splenic plus multisystem trauma, elective splenectomy, incidental or accidental splenectomy, and those having splenectomy prior to renal transplantation. Complications not specifically related to splenectomy occurred postoperatively in 52 per cent and 41 per cent, respectively, in the complex trauma and incidental-accidental splenectomy groups. Nonfatal complications specifically related to splenectomy occurred in 15 per cent of patients with multi-organ injury and in 18 per cent of patients with incidental-accidental splenic removal. Morbidity was infrequent when simple splenic trauma prompted splenectomy or in elective splenectomy. Mortality related to splenectomy occurred most often following renal transplantation, but also appeared high when the spleen was removed for multiple trauma or incidental to other surgery. The latter category is at risk for morbidity and mortality when splenectomy is incidental to a planned procedure (e.g., radical gastrectomy) or accidental as when injured by the surgeon. These splenectomies and those planned prior to transplantation may be unnecessary in many instances. The postsplenectomy sepsis syndrome was encountered late only once in this entire series; nonetheless, sound indications for splenectomy must prevail before splenic removal since significant early morbidity and mortality follows splenectomy.     

Techniques of splenic preservation using fibrin glue

Fibrin glue (FG) was used to achieve hemostasis of 16 splenic injuries in 14 patients. The etiologies of injury included five gunshot wounds, two stab wounds, four iatrogenic injuries, and five patients with blunt splenic trauma. The intraoperative blood loss averaged 1.8 +/- 2.4 (SD) liters and patients were transfused 3 +/- 2 units of blood perioperatively. The amount of FG required to achieve splenic hemostasis averaged 11 +/- 8 ml and varied directly with the grade of injury. One patient with a splenic hilar vascular injury (Grade V) underwent splenectomy following failure to achieve complete hemostasis despite the use of 25 ml of FG. All other splenic injuries were successfully managed using less than 25 ml of FG. Postoperative computerized tomographic (CT) scanning, performed in ten patients, was negative for rebleeding or abscess formation. The overall splenic salvage rate was 86%. FG was effective in achieving hemostasis of both superficial and deep splenic injuries. Its use as an adjunct in trauma surgery should result in increased splenic salvage rates compared with that obtained using conventional surgical techniques.