Vol 39 # 2 June 2007 - Kma.org.kw

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June 2007KUWAIT MEDICAL JOURNAL 147Hebler et al found that splenorrhaphy and NOMpatients had lower mortality and less infectiouscomplications [9] . Morgestern et al in 1983 treated 17patients nonoperatively without failure. In 1984,Zucker et al noted only one failure (4%) in 14 adultsand 10 children with blunt splenic trauma treatednonoperatively [10,11] . Recently the NOM has replacedthe splenic salvage pro c e d u res in hemodynamicallystable patients in most trauma centers.In this study a total of 83 patients with bluntsplenic trauma were reviewed. We treated 48patients (57.8%) non-operatively. The NOM failedin four patients and had a success rate of 91.6%. Theremaining 35 patients underwent exploratoryl a p a ro t o m y. Splenectomy was performed in 25patients and the spleen was preserved in 10patients. The overall splenic salvage rate was 70%.These results are similar to Pachter et al where 65%of patients with splenic trauma were tre a t e dnonoperatively with success rate of 98% and theoverall splenic salvage rate was 71% [16] . However,others have reported only 40% success rates forNOM and a splenic salvage rate of 50% [17] . Cogbill etal showed that NOM has a higher success rate inchildren (failure rates being 17% in adults and only2% for children) [18] . The largest multicentre studyabout NOM was by Hunt et al, where a total of 2258cases with splenic trauma were reviewed over afive year period [19] . They found that the NOM rateincreased with time from 33.9% to 46%. Pachter et alreported increased frequency of NOM from 13%(from 1978-1989) to 54% (from 1990-1996) [16] .NOM is considered method of choice in themanagement of hemodynamically stable patientswith high success rates and low morbidity [16,17,19] .There are, however, some controversies which needto be addressed. It was argued that NOM willre q u i re more blood transfusion than surg i c a l l ytreated patients. Our study shows that all patients(100%) who were treated surgically received bloodtransfusion at the rate of 3.7 units per patient (range= 1-10 units) while only 18 patients (37%) from theNOM group received blood at the rate of 0.8 units /patient. Similar results were reported by Smith [20] .Another critique for NOM has been that thepatients might have missed intra-abdominal injurywhich could need surgical intervention. Cogbill etal treated 112 patients non-operatively and they hadonly one missed injury (0.91%) [ 1 8 ] . We did notobserve any missed intra-abdominal injuries inNOM patients. The major concern for NOM is thatthis treatment is contraindicated in patients withneurological impairment. Archer et al found nosignificant differences in morbidity, mortality andfailure of treatment or missed visceral injuries inpatients with or without neurological injuries [21] . Wehad five patients with Glasgow Coma Score < 9t reated successfully with NOM. Our studysupports NOM for splenic trauma even in patientswith neurologic impairment provided they haveCT abdomen with oral and intravenous contrastsand are closely monitored with frequent clinicalexamination, preferably in a high dependency orintensive care unit initially. The age of patient hasbeen another concern. Godley et al cautioned intheir study that age > 55 years is a contraindicationfor NOM [22] . The authors reported 10 failures ofNOM out of 11 patients aged > 55 years. HoweverPachter et al found no difference or increased failurerate in patients over 55 years [16] . Our study did nothave any patient more than 50 years in the NOMgroup. Therefore we cannot comment on this aspectwhich remains to be elucidated by further studies.The management of the advanced classs ofsplenic injuries is the most controversial issue inNOM. Cogbill et al concluded that class I and II canbe treated safely and class III can be treated withhigh prediction of failure and recommended thatclass IV and V should be treated surg i c a l l y [ 1 8 ] .Powell et al observed that class III, IV and V splenicinjuries are poor prognostic indicators for NOM [23] .Scalfani et al showed that advanced class of splenicinjuries can be treated non-operatively when theytreated 17 patients with class IV splenic traumawith a success rate of 84% [24] . Our study includednine patients with class III injury with one failure(11%) and 11 patients with class IV and V traumawith three failures (27%). We conclude that advanceclass like III, IV and V can be tre a t e dnonoperatively with high prediction of failure.While one reason for increased bloodtransfusion requirements and higher morbidity andmortality in operated patients could be operativeintervention itself and more severe injury class,hemodynamically stable patients or patients whohad been hemodynamically stabilized with initialvolume replacement, obviously need less bloodtransfusion, have shorter hospital stay and lowermorbidity and mortality rates during NOM.In the present study, 33 patients from NOMgroup had an USG follow up and 15 patients hadCT which showed some degree of improvement inall patients. The follow up CT gives the surgeonfeeling that his patient is in the right way andmakes him feel comfortable by observing theradiological improvement of the injury. Actuallysome recent studies showed that routine follow-upCT for patients managed non-operatively isunnecessary if the patient remained clinicallystable [25,26] . Patients should avoid contact sport foreight weeks at least after having NOM with a CTfollow up [16] .
148Outcome of Non-operative Management of Blunt Splenic Trauma June 2007CONCLUSIONNOM for blunt splenic trauma inhemodynamically stable patients is safe, effective,associated with less blood transfusion, shorterhospital stay, low morbidity and no mortality.However, NOM should be practiced in hospitalswhere the facilities of ICU or HDU are available.REFERENCES1. Pearce RM, Krumbhaar EB, Frazier CH. Experimental &clinical studies. Philadelphia, JB Lippincott, 1918; 3-10.2. O’ Donnell FJ. The value of splenectomy in Banti’s disease.Br Med J 1929; 854.3. Malangoni MA. Splenic salvage; current expectations andresults. In: Mauli KI, Cleveland HC, Strauch GO, WolferthCC, editors. Advances in Trauma. Chicago: Mosby-Year-Book, 1990, p123-141.4. Sorkey AJ, Farnell MB, Williams HJ Jr, Mucha P Jr, IlstrupDM. The complementary roles of diagnostic peritoneallavage and computed tomography in the evaluation ofblunt abdominal trauma. Surgery 1989; 106:794-800.5. Upadhyaya P, Simpson JS. Splenic trauma in children. SurgGynecol Obstet 1968; 126:781-792.6. Wesson DE, Filler RM, Ein SH, Shandling B, Simpson JS,Stephens CA. Ruptured spleen - when to operate? JPediatr Surg 1981; 16: 324-326.7. King DR, Lobe TE, Haase GM, Boles ET Jr. Selectivemanagement of injured spleen. Surgery1981; 90:677-682.8. Kakkasseril JS. Changing treatment of pediatric splenictrauma. Arch Surg1982; 117:758-759.9. Hebeler RF, Ward RE, Miller PW, Ben-Menachem Y. Themanagement of splenic injury. J Trauma 1982; 22:492-495.10. Morgenstern L, Uyeda RY. Non-operative management ofinjuries of the spleen in adults. Surg Gynecol Obstet 1983;157:513-518.11. Zucker K, Browns K, Rossman D, Hemingway D, Saik R.Nonoperative management of splenic trauma.Conservative or radical treatment? Arch Surg 1984; 119:400-404.12. Green JB, Shackford SR, Sise MJ, Fridlund P. Late septiccomplications in adults following splenectomy for trauma:a prospective analysis in 144 patients. J Trauma 1986;26:999-1004.13. Di Cataldo A, Puleo S, Li Destri G, et al. Splenic trauma andoverwhelming postsplenectomy infection. Br J Surg 1987;74:343-345.14. Cullingford GL, Watkins DN, Watts ADJ, Mallon DF. Severelate postsplenectomy infection. Br J Surg 1991; 78:716-721.15. Lynch AM, Kapila R. Overwhelming postsplenectomyinfection. Infect Dis Clin North Am 1996; 10:693-707.16. Pachter HL, Guth AA, Hofstetter SR, Spencer FC. Changingpatterns in the management of splenic trauma: The impactof non-operative management. Ann Surg 1998; 227:708-719.17. Clancy TV, Ramshaw DG, Maxwell JG, et al . Managementoutcomes in splenic injury: a statewide trauma centerreview. Ann Surg 1997; 226:17-24.18. Cogbill TH, Moore EE, Jurkovich GJ, et al. Nonoperativemanagement of blunt splenic trauma: A m u l t i c e n t e rexperience. J Trauma 1989; 29:1312-1317.19. Hunt JP, Lentz CW, Cairns BA, et al. Management andoutcome of splenic injury: the results of a 5-year statewidepopulation based study. Am Surg 1996; 62:911- 917.20. Smith JS Jr, Cooney RN, Mucha P J r. Nonoperativemanagement of the ruptured spleen; a revalidation ofcriteria. Surgery 1996; 120:745-750.21. A rcher LP, Rogers FB, Shackford SR. Selective nonoperativemanagement of liver and spleen injuries inneurologically impaired adult patients. Arch Surg 1996;131:309-315.22. Godley CD, Warren RL, Sheridan RL, McCabe CJ. Nonoperativemanagement of blunt splenic injury in adults: ageover 55 years as powerful indicator of failure. J Am CollSurg 1996; 183:133-139.23. Powell M, Courcoulas A, Gardner M, et al. Management ofblunt splenic trauma: significant differences between adultsand children. Surgery 1997; 122:654-660.24. Sclafani SJ, Shaftan GW, Scalea TM, et al. Nonoperativesalvage of computed tomography - diagnosed splenicinjuries: utilization of angiography for triage andembolization for hemostasis. J Trauma 1995; 39:818-827.25. Allins A, Ho T, Nguyen TH, Cohen M, Waxman K, Hiatt JR.Limited value of routine follow up CT scans in nonoperativemanagement of blunt liver and splenic injuries.Am Surg 1996; 62: 883-886.26. Lawson DE, Jacobson JA, Spizarny DL, Pranikoff T. Splenictrauma: Value of follow up CT. Radiology 1995; 194:97-100.
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