Injury (1992) 23, (I), 5-9
printed in Great Brituin
5
Review
Management of splenic trauma R. H. Wilson and R. J. Moorehead Department
of Surgery, The Queen’s University
of Belfast, UK
This article examinesthe cut-renfmanagement of trauma to the spleen. l%e incidence, mechanism, classi,fiuziion,diagnosis, treatment ana’ camplicalions of splenic trauma are reviewed Modern radiologiral investigations are assessed in view of the recent vogue for non-operative management. The effects of splenectomy and particuhrly of ovenohelming postsplenectomy sepsis are discussed. The role of non-operative management of splenic injuties in chikiren and in adults without associated injuries is emphasized. Means of repaikg and preserving the spleen are detailed. &ompt splenectomy is necessary in seriously traumatized patients, especially those with head or mulfiple injuries.
Table I. Splenic injury scale Grade
I Haematoma Laceration II Haematoma
Laceration III
Haematoma
Incidence and mechanism of injury The spleen is the most commonly injured organ in blunt abdominal trauma. Between two-thirds and three-quarters of all cases of splenic injury arise from such trauma (Milliken et al., 1982; Nallathambi et al., 1988). Splenic damage in children may be due to blunt trauma in up to 97 per cent of cases (King et al., 1981). The commonest causes of blunt trauma responsible for splenic injury are road traffic accidents (Kidd et al., 1987). Penetrating injuries to the spleen account for less than one-third of all cases (Milliken et al., 1982; Nallathambi et al.,
Laceration IV Haematoma Laceration
V Laceration Vascular
Injury description Subcapsular, non-expanding, < 10% surface area Capsular tear, non-bleeding, < 1 cm deep Subcapsular, non-expanding, 1 O-50% surface area lntraparenchymal non-expanding, < 2 cm diameter Capsular tear, active bleeding, 1-3 cm deep, does not involve trabecular vessel Subcapsular, > 50% surface area or expanding. Ruptured subcapsular haematoma with active bleeding lntraparenchymal haematoma. > 2 cm or expanding > 3 cm deep or involving trabecular vessels Ruptured intraparenchymal haematoma with active bleeding Laceration involving segmental or hilar vessels producing major devascularization ( > 25% of spleen) Completely shattered spleen Hilar vascular injury which devascularizes spleen
1988).
While isolated splenic injuries can occur, it is much more common to see associated injuries. Injuries of the head, chest and limbs are frequently seen and reflect the nature of the causative agent, e.g. motor vehicle. The incidence of such associated injuries varies widely, ranging from 16 per cent to 95 per cent (King et al., 1981; Traub and Perry, 1981; Livingston et al., 1982; Bongard and Lim, 1985; Feliciano et al., 1985; Andersson et al., 1986; Flancbaum et aI., 1986; Sortland et al., 1986; Kidd et al., 1987; Splenic Injury Study Group, 1987). Damage to other intra-abdominal viscera is also frequently seen, with reported figures ranging between 26 per cent and 62 per cent (Livingston et aI., 1982; Livingston et al., 1983; Andersson et al., 1986; Flancbaum et al., 1986; Sortland et al., 1986; Kidd et al., 1987; Feliciano et al., 1988). Renal injuries are commonly encountered, but hepatic, diaphragmatic, gastrointestinal, mesenteric and vascular injuries frequently occur (Splenic Injury Study Group, 1987). While the incidence of associated intra-abdominal injuries is high, such injuries are not usually serious. It has been reported that only 17 per cent of such injuries required surgical intervention and that the need for this was evident preoperatively (Kidd et al., 1987). e 1992 Butterworth-Heinemann 002&1383/92/010005-5
Ltd
Penetrating injuries to the spleen are associated with other serious abdominal injuries in up to 94 per cent of instances (Splenic Injury Study Group, 1987).
Classification of injury Many classifications exist to describe splenic injuries. With different classifications, comparisons in diagnostic and management techniques are difficult to make. In an attempt to overcome this problem the American Association for the Surgery of Trauma, Organ Injury Scaling Committee devised a classification in 1987 (TubkI). It was suggested that all trauma surgeons should adopt it (Moore et al., 1989). This classification is useful for making comparisons in the literature and for planning the appropriate management of the patient with splenic trauma.
Diagnosis For many years the diagnosis of splenic injury has been made from a combination of physical signs and peritoneal lavage. In some instances immediate laparotomy has been
6
Jnjury: the British Journal of Accident Surgery (1992) Vol. 23/No. 1
necessary because of the clinical status of the patient or the presence of serious associated injuries. Recently, a changing emphasis in the management of splenic trauma, particularly with increasing enthusiasm for a non-operative approach, has created the need for more accurate diagnostic tests. While certain clinical situations will continue to dictate urgent surgical intervention, several radiological investigations are now widely used in the stable patient.
of little consequence. However, with increased understanding of splenic function, together with recognition of the potential consequences of splenectomy (particularly overwhelming sepsis), this standard has been questioned. A number of options including a non-operative approach are now in vogue. It is useful to consider briefly the structure and function of the spleen together with post-splenectomy sequelae before considering the management options.
Technetium scan Technetium 99mTc sulphur colloid scanning is commonly used to diagnose splenic trauma (King et al., 1981; Mishalany et al., 1982; Morgenstem and Uyeda, 1983; Sekikawa and Shatney, 1983; Chadwick et al., 1985; Andersson et al., 1986; Mucha et al., 1986; Sortland et al., 1986; Weill et al., 1988). The isotope is taken up by the liver and spleen where it is phagocytosed by Kupffer cells. While such scanning is contraindicated in the severely shocked or multiply-injured patient, it is generally considered mandatory in children with suspected splenic injury (Mishalany et al., 1982). Such scans are particularly useful in uncooperative adults and those with local trauma to the left lower thorax (Sekikawa and Shatney, 1983). These scans are accurate, with a specificity of 80 per cent, and are useful for following up injuries, giving an indirect measurement of a return of splenic function (Mishalany et al., 1982; Sekikawa and Shatney, 1983). Such scans are particularly useful if a non-operative approach is contemplated.
Structure and function of the spleen The splenic artery runs along the upper border of the pancreas and divides into superior and inferior branches before entering the splenic substance. These branches feed anatomically distinct segments. Usually there are four segments, but the number varies from three to seven (Pimp1 et al., 1989). The early identification of these segmental vessels during surgery increases the possibility of performing a conservation procedure. The spleen has various haematological and immunological functions -the latter being particularly important. The spleen has a major role in cell-mediated and humoral immunity, but its most important role is in phagocytosis of encapsulated bacteria.
Computed tomography This is widely used in diagnosing splenic trauma (King et al., 1981; Mishalany et al., 1982; Morgenstem and Uyeda, 1983; Sekikawa and Shatney, 1983; Chadwick et al., 1985; Andersson et al., 1986; Mucha et al., 1986; Sortland et al., 1986; Weill et al., 1988). It is an accurate non-invasive method and can be used with contrast agents to detect the presence of associated injuries. It is particularly useful in patients with multiple injuries (Sekikawa and Shatney, 1983). In expert hands CT scanning can accurately evaluate the extent of splenic injury. Some centres initially suggested that it was useful for differentiating those suitable for non-operative management and those needing operative intervention (Jeffrey et al., 1981; Federle et al., 1987; Buntain et al., 1988; Redmond et al., 1988). More recent reports using CT-based injury severity scores are less forthright (Resciniti et al., 1988; Mirvis et al., 1989). It is an accurate method for identifying and quantifying splenic injury and for monitoring the healing process but cannot reliably predict the outcome, i.e. those who could or could not be managed non-operatively (Mirvis et al., 1989). While a valuable adjunct in management, treatment still needs to be based on haemodynamic status and bedside assessment (Resciniti et al., 1988; Mirvis et al., 1989). Other methods used to investigate suspected splenic trauma include angiography and ultrasound scanning (Traub and Perry, 1982; Morgenstem and Uyeda, 1983; Chadwick et al., 1985; Andersson et al., 1986; Sortland et al., 1986). The former is not commo~y used and ultrasound, while useful for detecting haemoperitoneum (Traub and Perry, 1982), is not as accurate as CT scanning. The latter, if available, is the investigation of choice.
Management For some time the standard treatment for splenic injury has been splenectomy. Removal of the spleen was regarded as
Effects of splenectomy While there is an increase in circulating abnormal red cells and platelet production, immunological changes are of much greater importance. The net immunological effect of splenectomy is a reduced ability to opsonize and phagocytose encapsulated organisms. It is now well-recognized that there is an increased risk of sepsis after splenectomy (Green et al., 1986; Downey et al., 1987). Almost all sepsis seen is due to encapsulated bacteria such as pneumococcus. While minor infections are quite common, occurring in up to 30 per cent of cases (Green et al., 1986), it is the development of Overwhelming Post-splenectomy Sepsis (OPSI) that is of particular significance. Overwhelming post-splenectomy sepsis (OPSI) This can occur immediately or many years after surgery. The clinical picture is of sudden onset of nausea, vomiting and mental confusion. Coma and death can occur within a few hours. Disseminated intravascular coagulation, severe hypoglycaemia, electrolyte imbalance and shock are all frequently seen with OPSI. Although an important development, the risk of OPSI is low. Most series suggest an overall incidence of only 0.27 per cent with a range from O-2.2 per cent (Green et al., 1986; Di Cataldo et al., 1987; Luna and Dellinger, 1987). While established OPSI carries a mortality of between 50 per cent and 75 per cent, it is questionable whether the very low incidence justifies elaborate attempts at splenic conservation in adults (Di Cataldo et al., 1987). The immunological consequences of splenectomy for trauma are less than those after elective procedures. This is thought to be due to splenosis. This results from intraperitoneal implantation of splenic material following trauma. It occurs in 26 per cent to 66 per cent of those who have had splenectomy for trauma (Livingston et al., 1983; Ludtke et al., 1989). While it results in some restoration of splenic function it is probably insufficient to prevent OPSI. Autotransplantation of splenic tissue has been suggested as a means of restoring function (Lanng Nielsen et al., 1982; Livingston et al., 1983; Moore et al., 1984; Chadwick et al., 1985; Di Cataldo et al., 1987; Pickhardt et al., 1989). It is unproven whether this function will prevent the development of OPSI (Ludtke et al., 1989; Mizrahi et al., 1989).
Wilson and Muorehead: Management of splenic trauma Some other prophylactic measures have been suggested to reduce the risk of OPSL With over 50 per cent of cases due to pneumococcus, vaccination has been advocated (Caplan et al., 1983; Ludtke et al., 1989, Pickhardt et al., 1989). However, this does not cover all possible infecting organisms and is ineffective in children under 2 years of age. The role of vaccination in trauma is controversial, though some suggest it is effective and should be administered routinely (Caplan et al., 1983; Pickhardt et al., 1989). Pneumococcal sepsis may be reduced by prophylactic penicillin taken for at least 3 years after splenectomy (Ludtke et al., 1989; Pickhardt et al., 1989). Patient compliance, however, is an obvious difficulty. Non-operative management The injured spleen can heal both spontaneously and after surgical repair. A non-operative approach has been practised in children for almost 20 years. It is only more recently ihat this option has been considered in adults. The reported proportion of injuries that can be managed this way varies from 4.7 per cent to 44 per cent (King et aI., Chadwick et Hebeler et al., 1982; 1981; al., 1985; Mucha et al., 1986; Sortland et al., 1986; Redmond et al., 1988; Long0 et al., 1989). There is broad agreement on the criteria used to select patients suitable for this approach (Morgenstem and Uyeda, 1983; Zucker et al., 1984; Andersson et al., 1986; Mucha et al., 1986;Sortland et al, 1986; Kidd et al., 1987; Cngbill et al., 1989; Elmore et al., 1989). These are: II. The patient must be stable after initial resuscitation b. There should be no serious associated abdominal in&uy. c. There should be no extra-abdominal injuries which could preclude abdominal assessment, e.g. head injuries. Suggestions far the upper liiit of transfused blood range from 2-4 units Qviorgenstem and Uyeda, 1983; Zucker et al., 1984; Mucha et al., 1986; Long0 et al., 1989). Some suggest that a non-operative approach should not be considered in those over 60 years of age (Long0 et al., 1989). Non-operative management requires accurate ClinicaIand radiological assessment of the patient. The possibility of missing associated injures must be remembered (Splenic Injury Study Group, 1987). For this reason the approach is inappropriate for penetrating trauma (Weill et al., 1988). This form of treatment is considered safe and effective in selected patients, with success rates in up to 83 per cent of adult cases (Cogbill et al., 1989). It is important that these patients have continuous assessment and that they should be in hospital for 10-14 days. Strenuous activity should be avoided for 6-S weeks and contact sport for 6 months (King et al., 1981; Andersson et al., 1986). Advocates of this form of management report no morbidity or mortality, nor any cases of delayed rupture (King et al., 1981; Morgenstem and Uyeda, 1983; Elmore et al., 1989). Not all agree that non-operative management in adults is the best way to preserve the spleen. Early laparotomy has been suggested as giving the best chance for salvage (h4aIangon.i et al., 1984ab; Mucha et al., 1986; tuna and Dellinger, 1987). It is claimed that early surgery can preserve almost 50 per cent of spleens, whereas only 25 per cent could be saved after failed non-operative treatment (Mucha et al, 1986). Others disagree with this view (CogbiII et al., 1989) and as a result non-operative management in adults remains controversial.
7 Despite this controversy, non-operative treatment may be reasonable in carefully selected patients. Operative management Splenic preservation is desirable, but not at all costs. Prompt splenectomy remains a safe and appropriate treatment, particularly in the severely injured or multiply-injured patient. Where possible, salvage should be considered. The mean success rate for splenic repair is around 45 per cent (range 15-78 per cent) (Giuliano and Lim, 1981; King et al., 1981; Traub and Perry, 1981; MiUiken et al., 1982; Barrett et al., 1983; Moore et al., 1984; Bongard and Lii, 1985; Chadwick et al., 1985; Feliciano et al., 1985; Flancbaum et al., 1986; Mucha et al., 1986; Sortland et al., 1986; Nallathambi et al., 1988). Repair is generally considered a safe and worthwhile procedure. However, it is contraindicated in patients with instability due to associated injuries, splenic avulsion or fragmentation, extensive hilar injuries* failure to achieve haemostasis, peritoneal contamination due to gastrointestinal injuries and rupture of diseased spleens (Giuliano and Lim, 1981; King et al., 1981; Traub and Perry, 1981; Livingston et al., 1982: Barrett et al., 1983; Moore et al, 1984; Feliciano et al., 1985; Flancbaum et al., 1986; Sortland et al., 1986; Ghosh et al, 1988; Nallathambi et al., 1988). Few problems are encountered with splenic salvage though there is a small risk of rebleeding and abscess formation. There are a number of ways to repair and preserve the spleen: a. Topical haemostatic agents may be applied with good effect in minor injuries. Fibrin glue may be useful in more serious injuries (Kram et al., 1990). Suture repair is suitable for minor lacerations and, if necessary, omentum may be incorporated into the repair_ Suturing .is the most commonly performed procedure in splenic salvage (fipres IA, B). Absorbable mesh, such as polyglycolic acid, can be wrapped around the spleen to control bleeding by producing a tamponade effect. This can produce a salvage rate of up to 67 per cent (Lange et al., 1989) (&0-e IC). Partial splenectomy may be possible because of the segmental blood supply. This is particularly appr+ priate in major injuries of one or other pole. Reported rates for partial resection range from 3 per cent to I3 per cent (So&and et al., 1986; Nalllathambi et al., 1988) Fi&re ZLJ). Splenic artery ligation may permit conservation but its role is controversial. It is not clear whether this will protect against OPSI as there is some evidence that pneumococcal clearance is impaired by arterial ligation. With all but the simplest injuries, a proper assessment of the spleen is necessary. This requires adequate mobilization and thorough examination (Livingston et al., 1982; Ghosh et al., I988).
Morbidity and mortality of splenic trauma Isolated splenic injuries, if properly treated rarely result in death (Sortland et al., 1986; Splenic Injury Study Group, 1987). Any deaths that do occur are usually the result of associated injuries (Milliken et al., I982; Malangoni et al., 1984% S&and et al., 1984; Spknic Injury Study Group, 1987; NaUathambi et al., 19S8). The mean mortality figure for splenic trauma is just under 14 per cent (range 3-23 per cent) (Traub and Perry, 1981; MiUiken et al, 1982; Moore et
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No.
8
1
al., 1984a; Splenic Injury Study Group, 1987). The reported incidence of this disorder ranges from 1 per cent to 13 per et al., 1982; cent (Hebeler et al., 1982; Livingston Morgenstem and Uyeda, 1983; Moore et al., 1984). Although such abscesses are more common after splenectomy, it is difficult to know whether the treatment or the associated injuries are responsible (Traub and Perry, 1981; Hebeler et al., 1982). It appears that postoperative drainage has no bearing on the outcome (Livingston et al., 1982; Chadwick et al., 1985; Ludtke et al., 1989).
a
b
General sepsis Intra-abdominal sepsis and wound sepsis are more common after splenectomy, but, again, the contribution of associated injuries must be considered. Postoperative haemorrhage This is uncommon and occurs equally in splenectomy salvage groups.
C
d
Figure 1. A, Suture of minor laceration. B, Omentum incorpor-
ated by the suture. C, Absorbable mesh wrapped around spleen. D, Partial splenectomy.
al., 1984; Chadwick et al., 1985; Feliciano et al., 1985; Flancbaum et al., 1986; Splenic Injury Study Group, 1987; Nallathambi et al., 1988; Scatamacchia et al., 1989). Apart from the nature of associated injuries, important factors accounting for this wide variation are the patient’s age, type of injury and presence of hypotension on presentation (Splenic Injury Study Group, 1987). Blunt trauma is associated with a higher mortality than penetrating injuries. This probably reflects the mode of injury, e.g. road traffic accident, and the resulting associated injuries. With patients over 65 years of age, the mortality climbs rapidly to 60 per cent (Splenic Injury Study Group, 1987). Comparisons in mortality rates between those undergoing splenectomy or some form of salvage procedure are difficult and probably misleading. While some report big differences in mortality between splenectomy and salvage, 23.4 per cent against 4.9 per cent (Traub and Perry, 1981) it must be remembered that those requiring splenectomy usually have serious associated injuries and these may account for any differences seen. Apart from the small risk of OPSI, there are a number of complications that can arise after splenic trauma. Pulmonary complications These are common. Pneumonia, collapse and effusions are encountered in up to 38 per cent of cases, irrespective of the mode of treatment (Traub and Perry, 1981; Livingston et al., 1982; Milliken et al., 1982; Bongard and Lim, 1985; Chadwick et al., 1985; Splenic Injury Study Group, 1987; Nallathambi et al., 1988). Subphrenic abscess This is rarely seen after isolated splenic trauma, but the risk increases with associated abdominal injuries (Malangoni et
and
Delayed rupture Rupture of the spleen may be delayed for hours or weeks. Bleeding after 2 weeks is rare (Sortland et al., 1986). The true incidence of this problem is unknown, with many cases of delay probably being delay in diagnosis. Delayed rupture results from either a subcapsular haematoma or a posttraumatic cyst which gives way later. Those advocating non-operative management claim this does not occur (Sortland et al., 1986; Kidd et al., 1987). Late complications Whether the increased incidence of early sepsis is due to splenectomy or associated injuries is debatable. Late septic problems, however, are more common in post-splenectomy patients. Apart from OPSI, the rate of late sepsis is around 2.5 per cent (Malangoni et al., 1984a; Scatamacchia et al., 1989). Recent reports suggest that those with a previous splenectomy have twice the incidence of pneumonia-related death, three times the incidence of purulent pyelonephritis and four times the incidence of pulmonary embolism (Pickhardt et al., 1989). The group reporting these figures concluded that splenectomy generates a life-long risk of infection and thromboembolism. Others, however, still consider splenectomy to be a good procedure because the risk of these late problems, including OPSI, is very low (Malangoni et al., 1984). In view of its important immunological functions it is certainly worth attempting splenic preservation where possible. In the seriously injured patient, however, splenectomy remains a safe and appropriate procedure.
References Andersson R., Alwmark A., Gullstrand P. et al. (1986) Nonoperative treatment of blunt trauma to liver and spleen. Ada Chir. sand. 152, 739. Barrett J., Sheaff C., Abuabara S. et al. (1983) Splenic preservation in adults after blunt and penetrating trauma. Am. 1. Swg. 145, 313. Bongard F. S. and Lim R. C. Jr. (1985) Surgery of the traumatized spleen. WorM 1. Surg. 9, 391. Buntain W. L., Gould H. R. and Maull K. I. (1988) Predictability of splenic salvage by computed tomography. J. Trauma 28,~. Caplan E. S., Boltansky H., Snyder M. J. et al. (1983) Response of traumatized splenectomized patients to immediate vaccination with polyvalent pneumococcal vaccine. J. Trauma 23, 801.
Wilson and Moorehead: Management of splenic trauma
Chadwick S. J., Huizinga W. K. and Baker L. W. (1985) Management of splenic trauma: the Durban experience. Br. 1, Surg. 72, 634. Cogbill T. H., Moore E. E., Jurkovich G. J. et al. (1989) Nonoperative management of blunt splenic trauma: a multicenter experience. 1, Truuma 29, 1312. Di Cataldo A., Puleo S., Li De&i G. et al. (1987) Splenic trauma and overwhelming postsplenectomy infection. Br. 1. Surg. 74, 343. Downey E. C.. Shackford S. R., Fridlund P. H. et al. (1987) Long-term depressed immune function in patients splenectomized for trauma. J Truuma 27, 661. Elmore J. R., Clark D. E., Isler R. J. et al. (1989) Selective nonoperative management of blunt splenic trauma in adults. Arch. Surg. 124, 581. Feliciano D. V., Bitondo C. G., Mattox K. L. et al. (1985) A four-year experience with splenectomy versus splenorrhaphy. Ann. Surg. 201,568. Federle M. P., Griffiths B., Minagi H. et al. (1987) Splenic trauma: evaluation with CT. Radiology 162, 69. Flancbaum L., Dauterive A. and Cox E. F. (1986) Splenic conservation after multiple trauma in adults. Surg. Gynecol. Obstet. 162, 469. Ghosh S., Symes J. M. and Walsh T. H. (1988) Splenic repair for trauma. Br. 1. Surg 75, 1139. Giuliano A. E. and Lim R. C. Jr. (1981) Is splenic salvage safe in the traumatized patient? Arch. Surg. 116, 651. Green J. B., Shackford S. R., Sise M. J. et al. (1986) Late septic complications in adults following splenectomy for trauma: a prospective analysis in 144 patients. 1. Trauma 26, 999. Hebeler R. F., Ward R. E., Miller P. W. et al. (1982) The management of splenic injury. 1. Truum 22, 492. Jeffrey R. B., Laing F. C., Federle M. P. et al. (1981) Computed tomography of splenic trauma. Radiology 141, 729. Kidd W. T., Lui R. C., Khoo R. et al. (1987) The management of blunt splenic trauma. 1, Truzma 27, 977. King D. R., Lobe T. E., Haase G. M. et al. (1981) Selective management of injured spleen. Surgery 90,677. Kram H. B., de1 Junco T., Clark S. R. et al. (1990)Techniques of splenic preservation using fibrin glue. I. Trauma 30, 97. Lange D. A.. Zaret P., Merlotti G. J. et al. (1988) The use of absorbable mesh in splenic trauma. 1. Trauma 28, 269. Lanng Nielsen J., Hanberg Sorensen F., Saks0 P. et al. (1982) Implantation of autologous splenic tissue after splenectomy for trauma. Br. 1. Surg. 69, 529. Livingston C. D., Sirinek K. R., Levine B. A. et al. (1982) Traumatic splenic injury: its management in a patient population with a high incidence of associated injury. Arch. Surg. 117, 670. Livingston C. D., Levine B. A., Lecklitner M. L. et al. (1983) Incidence and function of residual splenic tissue following splenectomy for trauma in adults. Arch. Surg. 118, 617. Longo W. E., Baker C. C., McMillen M. A. et al. (1989) Nonoperative management of adult blunt splenic trauma. Criteria for successful outcome. Ann. Surg. 210, 626. Ludtke F. E., Mack S. E., Schuff-Werner P. et al. (1989) Splenic function after splenectomy for trauma. Role of auto-transplantation and splenosis. Acfa Ckir. Stand. 155, 533. Luna G. K. and Dellinger E. P. (1987) Nonoperative observation therapy for splenic injuries: a safe therapeutic option? Am. J. Surg. 153, 462. Malangoni M. A., Dillon L. D., Kl&mer T. W. et al. (1984a) Factors influencing the risk of early and late serious infection in adults after splenectomy for trauma. Surgery 96, 775. Malangoni M. A., Levine A. W., Droege E. A. et al. (1984b) Management of injury to the spleen in adults. Results of early operation and observation. Ann. Surg. 200, 702.
9
Milliken J. S., Moore E. E., Moore G. E. et al. (1982) Alternatives to splenectomy in adults after trauma. Repair, partial resection, and reimplantation of splenic tissue. Am. 1. Surg. 144, 711. Mirvis S. E., Whitley N. 0. and Gens D. R. (1989) Blunt splenic trauma in adults: CT based classification and correlation with prognosis and treatment. Radiology 171, 33. Mishalany H. G., Miller J. H. and Woolley M. M. (1982) Radioisotope spleen scan in patients with splenic injury. Arch. Surg. 117, 1147. Mizrahi S., Bickel A., Haj M. et al. (1989) Posttraumatic autotransplantation of spleen tissue. Arch. Surg. 124, 863. Moore F. A., Moore E. E., Moore G. E. et al. (1984) Risk of splenic salvage after trauma. Analysis of 200 adults. Am. 1, Surg. 148, 800. Moore E. E., Shackford S. R., Pachter H. L. et al. (1989) Organ injury scaling: spleen, liver and kidney. 1. Trauma 29, 1664. Morgenstem L. and Uyeda R. Y. (1983) Nonoperative management of injuries of the spleen in adults. Surg. Gynecof. Obslet. 157,513. Mucha P. Jr, Daly R. C. and Fame11 M. B. (1986) Selective management of blunt splenic trauma. 1. Tractma 26, 970. Nallathambi M. N., Ivatury R. R., Wapnir I. et al. (1988) Nonoperative management versus early operation for blunt splenic trauma in adults. Surg. Gynecol. Obstet. 166, 252. Pickhardt B., Moore E. E., Moore F. A. et al. (1989) Operative splenic salvage in adults: a decade perspective. 1. Truuma 29, 1386. Pimp1 W., Dapunt O., Kaindl H. et al. (1989). Incidence of septic and thromboembolic-related deaths after splenectomy in adults. Br. 1. Surg. 76, 5 17. Redmond H. P., Redmond J. M., Rooney B. P. et al. (1988) Surgical anatomy of the human spleen. Br. 1. Surg. 76, 198. Resciniti A., Fink M. P., Raptopoulos V. et al. (1988) Nonoperative treatment of adult splenic trauma: development of a computed tomographic scoring system that detects appropriate candidates for expectant management. J. Truztma 28, 828. Scatamacchia S. A., Raptopoulos V., Fink M. P. et al. (1989) Splenic trauma in adults: impact of CT grading on management. Radiology 171, 725. Sekikawa T. and Shatney C. H. (1983) Septic sequelae after splenectomy for trauma in adults. Am. J. Surg. 145,667. Sortland O., Nerdrum H. J. and Solheim K. (1986) Computed tomography and scintigraphy in the diagnosis of splenic injury. Acta Ckir. Stand. 152, 453. The Splenic Injury Study Group. (1987) Splenic injury: a prospective multicentre study on non-operative and operative treatment. Br. 1. Surg. 74, 310. Traub A. C. and Perry J. F. Jr (1981) Injuries associated with splenic trauma. ]. Trauma 2 I, 840. Traub A. C. and Perry J. F. Jr. (1982) Splenic preservation following splenic trauma. 1. Trmma 22, 496. Weill F., Rohmer P., Didier D. et al. (1988) Ultrasound of the traumatized spleen: left butterfly sign in lesions masked by echogenic blood clots. GnsLroinfesL Radial. 13, 169. Zucker K., Browns K., Rossman D. et al. (1984) Nonoperative management of splenic trauma. Conservative or radical treatment? Arck. Surg. 119, 400.
Paper accepted
28 March
1991.
Requests for reprints should be addressen to: Mr R. J. Moorehead, Senior Lecturer, The Queen’s University of Belfast, Department of Surgery, Institute of Clinical Science, Grosvenor Road, Belfast BT12 681, N. Ireland.
printed in Great Brituin
5
Review
Management of splenic trauma R. H. Wilson and R. J. Moorehead Department
of Surgery, The Queen’s University
of Belfast, UK
This article examinesthe cut-renfmanagement of trauma to the spleen. l%e incidence, mechanism, classi,fiuziion,diagnosis, treatment ana’ camplicalions of splenic trauma are reviewed Modern radiologiral investigations are assessed in view of the recent vogue for non-operative management. The effects of splenectomy and particuhrly of ovenohelming postsplenectomy sepsis are discussed. The role of non-operative management of splenic injuties in chikiren and in adults without associated injuries is emphasized. Means of repaikg and preserving the spleen are detailed. &ompt splenectomy is necessary in seriously traumatized patients, especially those with head or mulfiple injuries.
Table I. Splenic injury scale Grade
I Haematoma Laceration II Haematoma
Laceration III
Haematoma
Incidence and mechanism of injury The spleen is the most commonly injured organ in blunt abdominal trauma. Between two-thirds and three-quarters of all cases of splenic injury arise from such trauma (Milliken et al., 1982; Nallathambi et al., 1988). Splenic damage in children may be due to blunt trauma in up to 97 per cent of cases (King et al., 1981). The commonest causes of blunt trauma responsible for splenic injury are road traffic accidents (Kidd et al., 1987). Penetrating injuries to the spleen account for less than one-third of all cases (Milliken et al., 1982; Nallathambi et al.,
Laceration IV Haematoma Laceration
V Laceration Vascular
Injury description Subcapsular, non-expanding, < 10% surface area Capsular tear, non-bleeding, < 1 cm deep Subcapsular, non-expanding, 1 O-50% surface area lntraparenchymal non-expanding, < 2 cm diameter Capsular tear, active bleeding, 1-3 cm deep, does not involve trabecular vessel Subcapsular, > 50% surface area or expanding. Ruptured subcapsular haematoma with active bleeding lntraparenchymal haematoma. > 2 cm or expanding > 3 cm deep or involving trabecular vessels Ruptured intraparenchymal haematoma with active bleeding Laceration involving segmental or hilar vessels producing major devascularization ( > 25% of spleen) Completely shattered spleen Hilar vascular injury which devascularizes spleen
1988).
While isolated splenic injuries can occur, it is much more common to see associated injuries. Injuries of the head, chest and limbs are frequently seen and reflect the nature of the causative agent, e.g. motor vehicle. The incidence of such associated injuries varies widely, ranging from 16 per cent to 95 per cent (King et al., 1981; Traub and Perry, 1981; Livingston et al., 1982; Bongard and Lim, 1985; Feliciano et al., 1985; Andersson et al., 1986; Flancbaum et aI., 1986; Sortland et al., 1986; Kidd et al., 1987; Splenic Injury Study Group, 1987). Damage to other intra-abdominal viscera is also frequently seen, with reported figures ranging between 26 per cent and 62 per cent (Livingston et aI., 1982; Livingston et al., 1983; Andersson et al., 1986; Flancbaum et al., 1986; Sortland et al., 1986; Kidd et al., 1987; Feliciano et al., 1988). Renal injuries are commonly encountered, but hepatic, diaphragmatic, gastrointestinal, mesenteric and vascular injuries frequently occur (Splenic Injury Study Group, 1987). While the incidence of associated intra-abdominal injuries is high, such injuries are not usually serious. It has been reported that only 17 per cent of such injuries required surgical intervention and that the need for this was evident preoperatively (Kidd et al., 1987). e 1992 Butterworth-Heinemann 002&1383/92/010005-5
Ltd
Penetrating injuries to the spleen are associated with other serious abdominal injuries in up to 94 per cent of instances (Splenic Injury Study Group, 1987).
Classification of injury Many classifications exist to describe splenic injuries. With different classifications, comparisons in diagnostic and management techniques are difficult to make. In an attempt to overcome this problem the American Association for the Surgery of Trauma, Organ Injury Scaling Committee devised a classification in 1987 (TubkI). It was suggested that all trauma surgeons should adopt it (Moore et al., 1989). This classification is useful for making comparisons in the literature and for planning the appropriate management of the patient with splenic trauma.
Diagnosis For many years the diagnosis of splenic injury has been made from a combination of physical signs and peritoneal lavage. In some instances immediate laparotomy has been
6
Jnjury: the British Journal of Accident Surgery (1992) Vol. 23/No. 1
necessary because of the clinical status of the patient or the presence of serious associated injuries. Recently, a changing emphasis in the management of splenic trauma, particularly with increasing enthusiasm for a non-operative approach, has created the need for more accurate diagnostic tests. While certain clinical situations will continue to dictate urgent surgical intervention, several radiological investigations are now widely used in the stable patient.
of little consequence. However, with increased understanding of splenic function, together with recognition of the potential consequences of splenectomy (particularly overwhelming sepsis), this standard has been questioned. A number of options including a non-operative approach are now in vogue. It is useful to consider briefly the structure and function of the spleen together with post-splenectomy sequelae before considering the management options.
Technetium scan Technetium 99mTc sulphur colloid scanning is commonly used to diagnose splenic trauma (King et al., 1981; Mishalany et al., 1982; Morgenstem and Uyeda, 1983; Sekikawa and Shatney, 1983; Chadwick et al., 1985; Andersson et al., 1986; Mucha et al., 1986; Sortland et al., 1986; Weill et al., 1988). The isotope is taken up by the liver and spleen where it is phagocytosed by Kupffer cells. While such scanning is contraindicated in the severely shocked or multiply-injured patient, it is generally considered mandatory in children with suspected splenic injury (Mishalany et al., 1982). Such scans are particularly useful in uncooperative adults and those with local trauma to the left lower thorax (Sekikawa and Shatney, 1983). These scans are accurate, with a specificity of 80 per cent, and are useful for following up injuries, giving an indirect measurement of a return of splenic function (Mishalany et al., 1982; Sekikawa and Shatney, 1983). Such scans are particularly useful if a non-operative approach is contemplated.
Structure and function of the spleen The splenic artery runs along the upper border of the pancreas and divides into superior and inferior branches before entering the splenic substance. These branches feed anatomically distinct segments. Usually there are four segments, but the number varies from three to seven (Pimp1 et al., 1989). The early identification of these segmental vessels during surgery increases the possibility of performing a conservation procedure. The spleen has various haematological and immunological functions -the latter being particularly important. The spleen has a major role in cell-mediated and humoral immunity, but its most important role is in phagocytosis of encapsulated bacteria.
Computed tomography This is widely used in diagnosing splenic trauma (King et al., 1981; Mishalany et al., 1982; Morgenstem and Uyeda, 1983; Sekikawa and Shatney, 1983; Chadwick et al., 1985; Andersson et al., 1986; Mucha et al., 1986; Sortland et al., 1986; Weill et al., 1988). It is an accurate non-invasive method and can be used with contrast agents to detect the presence of associated injuries. It is particularly useful in patients with multiple injuries (Sekikawa and Shatney, 1983). In expert hands CT scanning can accurately evaluate the extent of splenic injury. Some centres initially suggested that it was useful for differentiating those suitable for non-operative management and those needing operative intervention (Jeffrey et al., 1981; Federle et al., 1987; Buntain et al., 1988; Redmond et al., 1988). More recent reports using CT-based injury severity scores are less forthright (Resciniti et al., 1988; Mirvis et al., 1989). It is an accurate method for identifying and quantifying splenic injury and for monitoring the healing process but cannot reliably predict the outcome, i.e. those who could or could not be managed non-operatively (Mirvis et al., 1989). While a valuable adjunct in management, treatment still needs to be based on haemodynamic status and bedside assessment (Resciniti et al., 1988; Mirvis et al., 1989). Other methods used to investigate suspected splenic trauma include angiography and ultrasound scanning (Traub and Perry, 1982; Morgenstem and Uyeda, 1983; Chadwick et al., 1985; Andersson et al., 1986; Sortland et al., 1986). The former is not commo~y used and ultrasound, while useful for detecting haemoperitoneum (Traub and Perry, 1982), is not as accurate as CT scanning. The latter, if available, is the investigation of choice.
Management For some time the standard treatment for splenic injury has been splenectomy. Removal of the spleen was regarded as
Effects of splenectomy While there is an increase in circulating abnormal red cells and platelet production, immunological changes are of much greater importance. The net immunological effect of splenectomy is a reduced ability to opsonize and phagocytose encapsulated organisms. It is now well-recognized that there is an increased risk of sepsis after splenectomy (Green et al., 1986; Downey et al., 1987). Almost all sepsis seen is due to encapsulated bacteria such as pneumococcus. While minor infections are quite common, occurring in up to 30 per cent of cases (Green et al., 1986), it is the development of Overwhelming Post-splenectomy Sepsis (OPSI) that is of particular significance. Overwhelming post-splenectomy sepsis (OPSI) This can occur immediately or many years after surgery. The clinical picture is of sudden onset of nausea, vomiting and mental confusion. Coma and death can occur within a few hours. Disseminated intravascular coagulation, severe hypoglycaemia, electrolyte imbalance and shock are all frequently seen with OPSI. Although an important development, the risk of OPSI is low. Most series suggest an overall incidence of only 0.27 per cent with a range from O-2.2 per cent (Green et al., 1986; Di Cataldo et al., 1987; Luna and Dellinger, 1987). While established OPSI carries a mortality of between 50 per cent and 75 per cent, it is questionable whether the very low incidence justifies elaborate attempts at splenic conservation in adults (Di Cataldo et al., 1987). The immunological consequences of splenectomy for trauma are less than those after elective procedures. This is thought to be due to splenosis. This results from intraperitoneal implantation of splenic material following trauma. It occurs in 26 per cent to 66 per cent of those who have had splenectomy for trauma (Livingston et al., 1983; Ludtke et al., 1989). While it results in some restoration of splenic function it is probably insufficient to prevent OPSI. Autotransplantation of splenic tissue has been suggested as a means of restoring function (Lanng Nielsen et al., 1982; Livingston et al., 1983; Moore et al., 1984; Chadwick et al., 1985; Di Cataldo et al., 1987; Pickhardt et al., 1989). It is unproven whether this function will prevent the development of OPSI (Ludtke et al., 1989; Mizrahi et al., 1989).
Wilson and Muorehead: Management of splenic trauma Some other prophylactic measures have been suggested to reduce the risk of OPSL With over 50 per cent of cases due to pneumococcus, vaccination has been advocated (Caplan et al., 1983; Ludtke et al., 1989, Pickhardt et al., 1989). However, this does not cover all possible infecting organisms and is ineffective in children under 2 years of age. The role of vaccination in trauma is controversial, though some suggest it is effective and should be administered routinely (Caplan et al., 1983; Pickhardt et al., 1989). Pneumococcal sepsis may be reduced by prophylactic penicillin taken for at least 3 years after splenectomy (Ludtke et al., 1989; Pickhardt et al., 1989). Patient compliance, however, is an obvious difficulty. Non-operative management The injured spleen can heal both spontaneously and after surgical repair. A non-operative approach has been practised in children for almost 20 years. It is only more recently ihat this option has been considered in adults. The reported proportion of injuries that can be managed this way varies from 4.7 per cent to 44 per cent (King et aI., Chadwick et Hebeler et al., 1982; 1981; al., 1985; Mucha et al., 1986; Sortland et al., 1986; Redmond et al., 1988; Long0 et al., 1989). There is broad agreement on the criteria used to select patients suitable for this approach (Morgenstem and Uyeda, 1983; Zucker et al., 1984; Andersson et al., 1986; Mucha et al., 1986;Sortland et al, 1986; Kidd et al., 1987; Cngbill et al., 1989; Elmore et al., 1989). These are: II. The patient must be stable after initial resuscitation b. There should be no serious associated abdominal in&uy. c. There should be no extra-abdominal injuries which could preclude abdominal assessment, e.g. head injuries. Suggestions far the upper liiit of transfused blood range from 2-4 units Qviorgenstem and Uyeda, 1983; Zucker et al., 1984; Mucha et al., 1986; Long0 et al., 1989). Some suggest that a non-operative approach should not be considered in those over 60 years of age (Long0 et al., 1989). Non-operative management requires accurate ClinicaIand radiological assessment of the patient. The possibility of missing associated injures must be remembered (Splenic Injury Study Group, 1987). For this reason the approach is inappropriate for penetrating trauma (Weill et al., 1988). This form of treatment is considered safe and effective in selected patients, with success rates in up to 83 per cent of adult cases (Cogbill et al., 1989). It is important that these patients have continuous assessment and that they should be in hospital for 10-14 days. Strenuous activity should be avoided for 6-S weeks and contact sport for 6 months (King et al., 1981; Andersson et al., 1986). Advocates of this form of management report no morbidity or mortality, nor any cases of delayed rupture (King et al., 1981; Morgenstem and Uyeda, 1983; Elmore et al., 1989). Not all agree that non-operative management in adults is the best way to preserve the spleen. Early laparotomy has been suggested as giving the best chance for salvage (h4aIangon.i et al., 1984ab; Mucha et al., 1986; tuna and Dellinger, 1987). It is claimed that early surgery can preserve almost 50 per cent of spleens, whereas only 25 per cent could be saved after failed non-operative treatment (Mucha et al, 1986). Others disagree with this view (CogbiII et al., 1989) and as a result non-operative management in adults remains controversial.
7 Despite this controversy, non-operative treatment may be reasonable in carefully selected patients. Operative management Splenic preservation is desirable, but not at all costs. Prompt splenectomy remains a safe and appropriate treatment, particularly in the severely injured or multiply-injured patient. Where possible, salvage should be considered. The mean success rate for splenic repair is around 45 per cent (range 15-78 per cent) (Giuliano and Lim, 1981; King et al., 1981; Traub and Perry, 1981; MiUiken et al., 1982; Barrett et al., 1983; Moore et al., 1984; Bongard and Lii, 1985; Chadwick et al., 1985; Feliciano et al., 1985; Flancbaum et al., 1986; Mucha et al., 1986; Sortland et al., 1986; Nallathambi et al., 1988). Repair is generally considered a safe and worthwhile procedure. However, it is contraindicated in patients with instability due to associated injuries, splenic avulsion or fragmentation, extensive hilar injuries* failure to achieve haemostasis, peritoneal contamination due to gastrointestinal injuries and rupture of diseased spleens (Giuliano and Lim, 1981; King et al., 1981; Traub and Perry, 1981; Livingston et al., 1982: Barrett et al., 1983; Moore et al, 1984; Feliciano et al., 1985; Flancbaum et al., 1986; Sortland et al., 1986; Ghosh et al, 1988; Nallathambi et al., 1988). Few problems are encountered with splenic salvage though there is a small risk of rebleeding and abscess formation. There are a number of ways to repair and preserve the spleen: a. Topical haemostatic agents may be applied with good effect in minor injuries. Fibrin glue may be useful in more serious injuries (Kram et al., 1990). Suture repair is suitable for minor lacerations and, if necessary, omentum may be incorporated into the repair_ Suturing .is the most commonly performed procedure in splenic salvage (fipres IA, B). Absorbable mesh, such as polyglycolic acid, can be wrapped around the spleen to control bleeding by producing a tamponade effect. This can produce a salvage rate of up to 67 per cent (Lange et al., 1989) (&0-e IC). Partial splenectomy may be possible because of the segmental blood supply. This is particularly appr+ priate in major injuries of one or other pole. Reported rates for partial resection range from 3 per cent to I3 per cent (So&and et al., 1986; Nalllathambi et al., 1988) Fi&re ZLJ). Splenic artery ligation may permit conservation but its role is controversial. It is not clear whether this will protect against OPSI as there is some evidence that pneumococcal clearance is impaired by arterial ligation. With all but the simplest injuries, a proper assessment of the spleen is necessary. This requires adequate mobilization and thorough examination (Livingston et al., 1982; Ghosh et al., I988).
Morbidity and mortality of splenic trauma Isolated splenic injuries, if properly treated rarely result in death (Sortland et al., 1986; Splenic Injury Study Group, 1987). Any deaths that do occur are usually the result of associated injuries (Milliken et al., I982; Malangoni et al., 1984% S&and et al., 1984; Spknic Injury Study Group, 1987; NaUathambi et al., 19S8). The mean mortality figure for splenic trauma is just under 14 per cent (range 3-23 per cent) (Traub and Perry, 1981; MiUiken et al, 1982; Moore et
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No.
8
1
al., 1984a; Splenic Injury Study Group, 1987). The reported incidence of this disorder ranges from 1 per cent to 13 per et al., 1982; cent (Hebeler et al., 1982; Livingston Morgenstem and Uyeda, 1983; Moore et al., 1984). Although such abscesses are more common after splenectomy, it is difficult to know whether the treatment or the associated injuries are responsible (Traub and Perry, 1981; Hebeler et al., 1982). It appears that postoperative drainage has no bearing on the outcome (Livingston et al., 1982; Chadwick et al., 1985; Ludtke et al., 1989).
a
b
General sepsis Intra-abdominal sepsis and wound sepsis are more common after splenectomy, but, again, the contribution of associated injuries must be considered. Postoperative haemorrhage This is uncommon and occurs equally in splenectomy salvage groups.
C
d
Figure 1. A, Suture of minor laceration. B, Omentum incorpor-
ated by the suture. C, Absorbable mesh wrapped around spleen. D, Partial splenectomy.
al., 1984; Chadwick et al., 1985; Feliciano et al., 1985; Flancbaum et al., 1986; Splenic Injury Study Group, 1987; Nallathambi et al., 1988; Scatamacchia et al., 1989). Apart from the nature of associated injuries, important factors accounting for this wide variation are the patient’s age, type of injury and presence of hypotension on presentation (Splenic Injury Study Group, 1987). Blunt trauma is associated with a higher mortality than penetrating injuries. This probably reflects the mode of injury, e.g. road traffic accident, and the resulting associated injuries. With patients over 65 years of age, the mortality climbs rapidly to 60 per cent (Splenic Injury Study Group, 1987). Comparisons in mortality rates between those undergoing splenectomy or some form of salvage procedure are difficult and probably misleading. While some report big differences in mortality between splenectomy and salvage, 23.4 per cent against 4.9 per cent (Traub and Perry, 1981) it must be remembered that those requiring splenectomy usually have serious associated injuries and these may account for any differences seen. Apart from the small risk of OPSI, there are a number of complications that can arise after splenic trauma. Pulmonary complications These are common. Pneumonia, collapse and effusions are encountered in up to 38 per cent of cases, irrespective of the mode of treatment (Traub and Perry, 1981; Livingston et al., 1982; Milliken et al., 1982; Bongard and Lim, 1985; Chadwick et al., 1985; Splenic Injury Study Group, 1987; Nallathambi et al., 1988). Subphrenic abscess This is rarely seen after isolated splenic trauma, but the risk increases with associated abdominal injuries (Malangoni et
and
Delayed rupture Rupture of the spleen may be delayed for hours or weeks. Bleeding after 2 weeks is rare (Sortland et al., 1986). The true incidence of this problem is unknown, with many cases of delay probably being delay in diagnosis. Delayed rupture results from either a subcapsular haematoma or a posttraumatic cyst which gives way later. Those advocating non-operative management claim this does not occur (Sortland et al., 1986; Kidd et al., 1987). Late complications Whether the increased incidence of early sepsis is due to splenectomy or associated injuries is debatable. Late septic problems, however, are more common in post-splenectomy patients. Apart from OPSI, the rate of late sepsis is around 2.5 per cent (Malangoni et al., 1984a; Scatamacchia et al., 1989). Recent reports suggest that those with a previous splenectomy have twice the incidence of pneumonia-related death, three times the incidence of purulent pyelonephritis and four times the incidence of pulmonary embolism (Pickhardt et al., 1989). The group reporting these figures concluded that splenectomy generates a life-long risk of infection and thromboembolism. Others, however, still consider splenectomy to be a good procedure because the risk of these late problems, including OPSI, is very low (Malangoni et al., 1984). In view of its important immunological functions it is certainly worth attempting splenic preservation where possible. In the seriously injured patient, however, splenectomy remains a safe and appropriate procedure.
References Andersson R., Alwmark A., Gullstrand P. et al. (1986) Nonoperative treatment of blunt trauma to liver and spleen. Ada Chir. sand. 152, 739. Barrett J., Sheaff C., Abuabara S. et al. (1983) Splenic preservation in adults after blunt and penetrating trauma. Am. 1. Swg. 145, 313. Bongard F. S. and Lim R. C. Jr. (1985) Surgery of the traumatized spleen. WorM 1. Surg. 9, 391. Buntain W. L., Gould H. R. and Maull K. I. (1988) Predictability of splenic salvage by computed tomography. J. Trauma 28,~. Caplan E. S., Boltansky H., Snyder M. J. et al. (1983) Response of traumatized splenectomized patients to immediate vaccination with polyvalent pneumococcal vaccine. J. Trauma 23, 801.
Wilson and Moorehead: Management of splenic trauma
Chadwick S. J., Huizinga W. K. and Baker L. W. (1985) Management of splenic trauma: the Durban experience. Br. 1, Surg. 72, 634. Cogbill T. H., Moore E. E., Jurkovich G. J. et al. (1989) Nonoperative management of blunt splenic trauma: a multicenter experience. 1, Truuma 29, 1312. Di Cataldo A., Puleo S., Li De&i G. et al. (1987) Splenic trauma and overwhelming postsplenectomy infection. Br. 1. Surg. 74, 343. Downey E. C.. Shackford S. R., Fridlund P. H. et al. (1987) Long-term depressed immune function in patients splenectomized for trauma. J Truuma 27, 661. Elmore J. R., Clark D. E., Isler R. J. et al. (1989) Selective nonoperative management of blunt splenic trauma in adults. Arch. Surg. 124, 581. Feliciano D. V., Bitondo C. G., Mattox K. L. et al. (1985) A four-year experience with splenectomy versus splenorrhaphy. Ann. Surg. 201,568. Federle M. P., Griffiths B., Minagi H. et al. (1987) Splenic trauma: evaluation with CT. Radiology 162, 69. Flancbaum L., Dauterive A. and Cox E. F. (1986) Splenic conservation after multiple trauma in adults. Surg. Gynecol. Obstet. 162, 469. Ghosh S., Symes J. M. and Walsh T. H. (1988) Splenic repair for trauma. Br. 1. Surg 75, 1139. Giuliano A. E. and Lim R. C. Jr. (1981) Is splenic salvage safe in the traumatized patient? Arch. Surg. 116, 651. Green J. B., Shackford S. R., Sise M. J. et al. (1986) Late septic complications in adults following splenectomy for trauma: a prospective analysis in 144 patients. 1. Trauma 26, 999. Hebeler R. F., Ward R. E., Miller P. W. et al. (1982) The management of splenic injury. 1. Truum 22, 492. Jeffrey R. B., Laing F. C., Federle M. P. et al. (1981) Computed tomography of splenic trauma. Radiology 141, 729. Kidd W. T., Lui R. C., Khoo R. et al. (1987) The management of blunt splenic trauma. 1, Truzma 27, 977. King D. R., Lobe T. E., Haase G. M. et al. (1981) Selective management of injured spleen. Surgery 90,677. Kram H. B., de1 Junco T., Clark S. R. et al. (1990)Techniques of splenic preservation using fibrin glue. I. Trauma 30, 97. Lange D. A.. Zaret P., Merlotti G. J. et al. (1988) The use of absorbable mesh in splenic trauma. 1. Trauma 28, 269. Lanng Nielsen J., Hanberg Sorensen F., Saks0 P. et al. (1982) Implantation of autologous splenic tissue after splenectomy for trauma. Br. 1. Surg. 69, 529. Livingston C. D., Sirinek K. R., Levine B. A. et al. (1982) Traumatic splenic injury: its management in a patient population with a high incidence of associated injury. Arch. Surg. 117, 670. Livingston C. D., Levine B. A., Lecklitner M. L. et al. (1983) Incidence and function of residual splenic tissue following splenectomy for trauma in adults. Arch. Surg. 118, 617. Longo W. E., Baker C. C., McMillen M. A. et al. (1989) Nonoperative management of adult blunt splenic trauma. Criteria for successful outcome. Ann. Surg. 210, 626. Ludtke F. E., Mack S. E., Schuff-Werner P. et al. (1989) Splenic function after splenectomy for trauma. Role of auto-transplantation and splenosis. Acfa Ckir. Stand. 155, 533. Luna G. K. and Dellinger E. P. (1987) Nonoperative observation therapy for splenic injuries: a safe therapeutic option? Am. J. Surg. 153, 462. Malangoni M. A., Dillon L. D., Kl&mer T. W. et al. (1984a) Factors influencing the risk of early and late serious infection in adults after splenectomy for trauma. Surgery 96, 775. Malangoni M. A., Levine A. W., Droege E. A. et al. (1984b) Management of injury to the spleen in adults. Results of early operation and observation. Ann. Surg. 200, 702.
9
Milliken J. S., Moore E. E., Moore G. E. et al. (1982) Alternatives to splenectomy in adults after trauma. Repair, partial resection, and reimplantation of splenic tissue. Am. 1. Surg. 144, 711. Mirvis S. E., Whitley N. 0. and Gens D. R. (1989) Blunt splenic trauma in adults: CT based classification and correlation with prognosis and treatment. Radiology 171, 33. Mishalany H. G., Miller J. H. and Woolley M. M. (1982) Radioisotope spleen scan in patients with splenic injury. Arch. Surg. 117, 1147. Mizrahi S., Bickel A., Haj M. et al. (1989) Posttraumatic autotransplantation of spleen tissue. Arch. Surg. 124, 863. Moore F. A., Moore E. E., Moore G. E. et al. (1984) Risk of splenic salvage after trauma. Analysis of 200 adults. Am. 1, Surg. 148, 800. Moore E. E., Shackford S. R., Pachter H. L. et al. (1989) Organ injury scaling: spleen, liver and kidney. 1. Trauma 29, 1664. Morgenstem L. and Uyeda R. Y. (1983) Nonoperative management of injuries of the spleen in adults. Surg. Gynecof. Obslet. 157,513. Mucha P. Jr, Daly R. C. and Fame11 M. B. (1986) Selective management of blunt splenic trauma. 1. Tractma 26, 970. Nallathambi M. N., Ivatury R. R., Wapnir I. et al. (1988) Nonoperative management versus early operation for blunt splenic trauma in adults. Surg. Gynecol. Obstet. 166, 252. Pickhardt B., Moore E. E., Moore F. A. et al. (1989) Operative splenic salvage in adults: a decade perspective. 1. Truuma 29, 1386. Pimp1 W., Dapunt O., Kaindl H. et al. (1989). Incidence of septic and thromboembolic-related deaths after splenectomy in adults. Br. 1. Surg. 76, 5 17. Redmond H. P., Redmond J. M., Rooney B. P. et al. (1988) Surgical anatomy of the human spleen. Br. 1. Surg. 76, 198. Resciniti A., Fink M. P., Raptopoulos V. et al. (1988) Nonoperative treatment of adult splenic trauma: development of a computed tomographic scoring system that detects appropriate candidates for expectant management. J. Truztma 28, 828. Scatamacchia S. A., Raptopoulos V., Fink M. P. et al. (1989) Splenic trauma in adults: impact of CT grading on management. Radiology 171, 725. Sekikawa T. and Shatney C. H. (1983) Septic sequelae after splenectomy for trauma in adults. Am. J. Surg. 145,667. Sortland O., Nerdrum H. J. and Solheim K. (1986) Computed tomography and scintigraphy in the diagnosis of splenic injury. Acta Ckir. Stand. 152, 453. The Splenic Injury Study Group. (1987) Splenic injury: a prospective multicentre study on non-operative and operative treatment. Br. 1. Surg. 74, 310. Traub A. C. and Perry J. F. Jr (1981) Injuries associated with splenic trauma. ]. Trauma 2 I, 840. Traub A. C. and Perry J. F. Jr. (1982) Splenic preservation following splenic trauma. 1. Trmma 22, 496. Weill F., Rohmer P., Didier D. et al. (1988) Ultrasound of the traumatized spleen: left butterfly sign in lesions masked by echogenic blood clots. GnsLroinfesL Radial. 13, 169. Zucker K., Browns K., Rossman D. et al. (1984) Nonoperative management of splenic trauma. Conservative or radical treatment? Arck. Surg. 119, 400.
Paper accepted
28 March
1991.
Requests for reprints should be addressen to: Mr R. J. Moorehead, Senior Lecturer, The Queen’s University of Belfast, Department of Surgery, Institute of Clinical Science, Grosvenor Road, Belfast BT12 681, N. Ireland.
