The Management of Splenic Trauma in a Trauma System Melinda R. Molin, MD, Steven R. Shackford, MD \s=b\ Large teaching centers have reported splenic salvage rates of 40% to 50% in adults after splenic trauma. It is unknown whether similar salvage rates can be achieved safely in community trauma centers with a lower volume of patients and less experience. Between August 1984 and August 1988,117 patients with splenic injury were treated at a level I center and 311 were treated at four level II centers. Splenectomy was performed in 252 patients (59%), splenorrhaphy was performed in 160 patients (37%), and 16 patients (4%) were observed. While the splenic salvage rate was higher at the level I center (50% vs 38%), selective splenorrhaphy was successful in the level II centers where the volume of splenic injury was lower (15 to 25 cases per year).
(Arch Surg. 1990;125:840-843)
The
treatment of splenic injury has changed over the past decade from prompt splenectomy in all cases to splenic salvage when possible.1 Four factors have most influenced this change: recognition of the risk of overwhelming sepsis after splenectomy for trauma,2,3 delineation of the anatomic basis for splenic repair,4 increasing experience with tech¬ niques of splenorrhaphy,5,6 and advances in organ-specific
imaging technology.7,8 Large series of splenic injuries in adults reported by major trauma centers suggest that splenorrhaphy can be performed in approximately 50% of cases.9"11 Splenic salvage rates of 90% in children using a combination of nonoperative management and splenorrhaphy have also been reported.12"15 Most reports of increased splenic salvage have come from large teaching centers where splenic trauma is generally handled by a small cadre of experienced attending surgeons using uniform tech¬ niques for diagnosis and treatment. Such reported experience may, therefore, reflect the best obtainable results. We sought to determine whether similar rates of splenic salvage could be achieved in community trauma centers with a lower volume of splenic injury, a greater number of surgeons taking trauma call, and a greater percentage ofblunt injury (known to have a lower splenic salvage rate than penetrating injury). PATIENTS AND METHODS
August 1984 and August 1988 all major trauma victims using triage by the San Diego County (California) Trauma System to adult trauma centers were eligible for study.16 Patients who died within 48 hours of unrelated causes (usually head injury) were eliminated from the study. The hospital records and trauma registries were reviewed and the following data were extracted: year Between
sent
of treatment, level of center for treatment, age, sex, mechanism of injury, trauma score,17 injury severity score (ISS),1 probability of survival using the TRIS method,17 method of diagnosis (diagnostic
peritoneal lavage, computed tomography [CT] scan, or physical examination), type of splenic treatment (splenectomy, splenorr¬ haphy, or observation), number of units of blood transfused, whether a pneumococcus vaccine (Pneumovax) was given, need for réopéraAccepted for publication April 4,1990. From the University of California School of Medicine, San Diego (Dr Molin), and the University of Vermont College of Medicine, Burlington (Dr Shackford). Read before the Annual Meeting of the Western Trauma Surgical Association, St Louis, Mo, November 14,1989. Reprint requests to the University of Vermont College of Medicine, Department of Surgery, Given Building D-319, Burlington, VT 05405 (Dr Shackford).
tion, and septic complications. The total number of units of blood transfused was revised by the authors to reflect only the amount of homologous transfusion; autotransfused blood (in applicable cases) was subtracted. Major septic complications included bacteremia, fungemia, pneumonia, and intra-abdominal sepsis. Intra-abdominal sepsis was defined as a focal infection requiring treatment, either operative or CT-directed percutaneous drainage. Minor septic com¬ plications included wound infection, cellulitis, sinusitis, and urinary tract infection. The final decision as to what constituted an infectious complication (either major or minor) was made by the trauma director at each hospital using explicitly defined criteria established prospec-
tively by9 the San Diego County Trauma System Medical Audit Com¬ mittee. Injuries were retrospectively graded by the authors using operative notes and CT scan reports according to the splenic injury scale proposed by the Injury Scaling Committee of the American Association for the Surgery of Trauma (Table l).20 Spleens that were salvageable but removed because of hemodynamic or neurologic instability were classified as grade V. Patients who sustained isolated injury to the spleen were analyzed as a subgroup to more precisely compare splenectomy with splenorrhaphy.
Data were entered into an IBM-PC-AT (International Business Machines Corp, Boca Raton, Fla) utilizing a computerized database (dBase III Plus, Ashton-Tate, Torrance, Calif). Data were analyzed using statistical analysis software (MRTOD, Retriever Data Sys¬ tems, Seattle, Wash). Data were compared using x2 square analysis with Yates correction, analysis of variance, and Student's t test with a significance of P
(Arch Surg. 1990;125:840-843)
The
treatment of splenic injury has changed over the past decade from prompt splenectomy in all cases to splenic salvage when possible.1 Four factors have most influenced this change: recognition of the risk of overwhelming sepsis after splenectomy for trauma,2,3 delineation of the anatomic basis for splenic repair,4 increasing experience with tech¬ niques of splenorrhaphy,5,6 and advances in organ-specific
imaging technology.7,8 Large series of splenic injuries in adults reported by major trauma centers suggest that splenorrhaphy can be performed in approximately 50% of cases.9"11 Splenic salvage rates of 90% in children using a combination of nonoperative management and splenorrhaphy have also been reported.12"15 Most reports of increased splenic salvage have come from large teaching centers where splenic trauma is generally handled by a small cadre of experienced attending surgeons using uniform tech¬ niques for diagnosis and treatment. Such reported experience may, therefore, reflect the best obtainable results. We sought to determine whether similar rates of splenic salvage could be achieved in community trauma centers with a lower volume of splenic injury, a greater number of surgeons taking trauma call, and a greater percentage ofblunt injury (known to have a lower splenic salvage rate than penetrating injury). PATIENTS AND METHODS
August 1984 and August 1988 all major trauma victims using triage by the San Diego County (California) Trauma System to adult trauma centers were eligible for study.16 Patients who died within 48 hours of unrelated causes (usually head injury) were eliminated from the study. The hospital records and trauma registries were reviewed and the following data were extracted: year Between
sent
of treatment, level of center for treatment, age, sex, mechanism of injury, trauma score,17 injury severity score (ISS),1 probability of survival using the TRIS method,17 method of diagnosis (diagnostic
peritoneal lavage, computed tomography [CT] scan, or physical examination), type of splenic treatment (splenectomy, splenorr¬ haphy, or observation), number of units of blood transfused, whether a pneumococcus vaccine (Pneumovax) was given, need for réopéraAccepted for publication April 4,1990. From the University of California School of Medicine, San Diego (Dr Molin), and the University of Vermont College of Medicine, Burlington (Dr Shackford). Read before the Annual Meeting of the Western Trauma Surgical Association, St Louis, Mo, November 14,1989. Reprint requests to the University of Vermont College of Medicine, Department of Surgery, Given Building D-319, Burlington, VT 05405 (Dr Shackford).
tion, and septic complications. The total number of units of blood transfused was revised by the authors to reflect only the amount of homologous transfusion; autotransfused blood (in applicable cases) was subtracted. Major septic complications included bacteremia, fungemia, pneumonia, and intra-abdominal sepsis. Intra-abdominal sepsis was defined as a focal infection requiring treatment, either operative or CT-directed percutaneous drainage. Minor septic com¬ plications included wound infection, cellulitis, sinusitis, and urinary tract infection. The final decision as to what constituted an infectious complication (either major or minor) was made by the trauma director at each hospital using explicitly defined criteria established prospec-
tively by9 the San Diego County Trauma System Medical Audit Com¬ mittee. Injuries were retrospectively graded by the authors using operative notes and CT scan reports according to the splenic injury scale proposed by the Injury Scaling Committee of the American Association for the Surgery of Trauma (Table l).20 Spleens that were salvageable but removed because of hemodynamic or neurologic instability were classified as grade V. Patients who sustained isolated injury to the spleen were analyzed as a subgroup to more precisely compare splenectomy with splenorrhaphy.
Data were entered into an IBM-PC-AT (International Business Machines Corp, Boca Raton, Fla) utilizing a computerized database (dBase III Plus, Ashton-Tate, Torrance, Calif). Data were analyzed using statistical analysis software (MRTOD, Retriever Data Sys¬ tems, Seattle, Wash). Data were compared using x2 square analysis with Yates correction, analysis of variance, and Student's t test with a significance of P
