|Year : 2016 | Volume
| Issue : 1 | Page : 7-12
A profile of splenic trauma cases managed at a tertiary care center
Jayasree Kasula1, Kodandapani Yerroju2, Syed Viquaruddin Masood1, Chalam Venkata Pindicura1, Syed Sajjad Saifullah Quadri3
1 Department of General Surgery, Gandhi Medical College, Secunderabad, Hyderabad, Telangana, India
2 Department of Peadiatrics, Niloufer Hospital, Osmania Medical College, Hyderabad, Telangana, India
3 Department of Pathology, Gandhi Medical College, Secunderabad, Hyderabad, Telangana, India
|Date of Web Publication||18-Mar-2016|
6-1-116, C-502 Natarajan Residency, Padma Rao Nagar, Secunderabad - 500 025, Telangana
Source of Support: None, Conflict of Interest: None
Context: Missed splenic injury is the most common cause of preventable death after abdominal trauma. As clinical presentation varies widely awareness of spectrum of presentations and their relative importance is vital for diagnosing and managing splenic injuries successfully.
Aim: To study various clinical presentations, modes of management and analyse outcomes of splenic trauma.
Setting and design: Retrospective observational study conducted at a tertiary care teaching hospital.
Methods and Material: 154 cases of adult splenic trauma presented to our teaching hospital between 2006 and 2014 diagnosed by FAST or CT scan or per operatively were enrolled retrospectively. Hemodynamically stable patients with grade 1 and 2 injuries with no other injuries necessitating laparotomy were chosen for NOM. Rest underwent splenectomy.
Statistical Analysis Used: Descriptive statistics were used for analysis of data and results were expressed as percentages.
Results: Highest number (44.15%) of victims were aged between 31-40 years. RTAs constituted 69.48%. 13.63% patients were asymptomatic initially. 58.94% were Grade-III injuries. Fracture ribs (90.25%) and hemo or pneumothorax (72.72%) were the most common associations. Number of cases selected for NOM were only 13.64%.
Conclusions: Grade I and II isolated splenic injuries can be safely managed by NOM however under close monitoring. Absence of abdominal signs and symptoms do not exclude splenic trauma.
Keywords: Splenic trauma, associated injuries, NOM
|How to cite this article:|
Kasula J, Yerroju K, Masood SV, Pindicura CV, Quadri SS. A profile of splenic trauma cases managed at a tertiary care center. J NTR Univ Health Sci 2016;5:7-12
|How to cite this URL:|
Kasula J, Yerroju K, Masood SV, Pindicura CV, Quadri SS. A profile of splenic trauma cases managed at a tertiary care center. J NTR Univ Health Sci [serial online] 2016 [cited 2020 Mar 31];5:7-12. Available from: http://www.jdrntruhs.org/text.asp?2016/5/1/7/178947
| Background|| |
The prevalence of abdominal organ injuries is approximately 13% of cases of abdominal trauma reporting to emergency department. Splenic injuries are seen in 60% of these cases.  Missed splenic injury is the most common cause of preventable death after abdominal trauma.  Clinical presentation of splenic trauma varies widely from asymptomatic to fatal hypovolemic shock. Hence, awareness of this spectrum of presentations and their relative importance is vital for diagnosing and managing splenic injuries successfully.
Owing to the recognition of the spleen's immunological importance and the observation that more than 95% of blunt abdominal injuries may be managed nonoperatively with morbidity similar to or even lower than operative management, the management of blunt splenic trauma has shifted toward nonoperative management (NOM).  Studies show that the success rate of NOM is improved with interventional angio-embolism; however, several studies documented a high rate of complications following angio-embolism. ,
Often treating surgeon faces dilemma regarding the choice of management. In this background, 154 cases of splenic trauma presented to the emergency department of our tertiary care center were analyzed retrospectively.
To study various clinical presentations and modes of management and to analyze outcomes of different modes of management of splenic trauma.
| Materials and methods|| |
The present study is done at a tertiary care teaching hospital that has has round the clock trauma care facilities with availability of all super specialists and investigations like USG and CT scan. Trauma cases report directly as well as from primary and secondary referral centers from district hospitals.
This is a retrospective observational study.
All cases of splenic trauma diagnosed by Focussed Abdominal Sonography in Trauma (FAST) or CT scan or per operatively, presented to our hospital between June 2006 and May 2014, were enrolled.
Data were collected from the patient's records.
All polytrauma patients presented to the emergency department suspected to have intra-abdominal injury on initial assessment and were subjected to FAST after initiating resuscitation. Hemodynamically stable patients were subjected to contrast enhanced CT (CECT) scan to grade the splenic injury and identify other visceral injuries. Those who had moderate hemoperitoneum as per FAST and were hemodynamically unstable despite resuscitation and those with clear signs of hollow viscus perforation were taken up for exploratory laparotomy without subjecting them to CECT scan. Grading of splenic injury was done according to the injury description given by the American Association for the Surgery of Trauma splenic Injury Scale (1994 revision). 
Hemodynamically stable patients with grade 1 and 2 splenic injuries with no other intra-abdominal injuries necessitating exploratory laparotomy were chosen for the NOM. Others were subjected to exploratory laparotomy and splenectomy. The NOM patients were monitored clinically and with USG of abdomen every day for a period of 2 weeks. Those patients while on NOM who subsequently developed internal bleed underwent splenectomy. All Splenectomy patients were given polyvalent pneumococcal vaccine within 24 h of surgery. Postoperative patients with no complications were discharged on the eighth postoperative (PO) day. Those who developed complications were discharged after complete recovery.
Data with regard to age, gender, mode of injury, clinical presentation at admission, grade of splenic injury, associated injuries, mode of management were recorded.
The primary outcome parameter is the outcome of different modes of management done for splenic trauma at our center such as NOM and splenectomy.
The secondary outcome parameter included postoperative complications and death.
Descriptive statistics were used for the analysis of data and results that were expressed as percentages.
| Results|| |
Out of all the trauma cases presented to our emergency department during the study period, 154 were proven to have splenic trauma. Males were 125 (81.16%) and females were 29 (18.84%). Maximum number patients i.e. 68 (44.15%) were from the age group of 31-40 years [Table 1].
The mode of injury is predominantly blunt injury due to road traffic accidents (69.48%) this is followed by blunt injuries due to other causes such as fall from height, and assaults (20.14%) and penetrating wounds accounted for only 10.38% [Table 2].
Out of 21 patients who had no signs and symptoms of abdominal injury at presentation, 1 patient developed signs after 20 h and another after 3 days. Abdominal tenderness (85.06%), guarding, rigidity (78.57%), and distension (42.2%) were the commonest signs [Table 3].
Maximum were Grade III injuries 89 (58.94%) [Table 4].
The commonest associated injury was chest injury with rib fractures in 139 patients (90.26%) and hemo/pneumothorax in 112 patients (72.73%). Multiple injuries were also noted in the same patients [Table 5].
In the NOM group, 90% had uneventful hospital stay and 10% developed complications, and there were no mortalities. In the splenectomy group, 46.62% had uneventful hospital stay, 53.38% developed complications, and the rate of mortality was 4.51% [Table 6].
Three patients died during resuscitation after diagnosing splenic trauma by FAST. Out of six deaths that occurred in the patients who were given specific management for splenic trauma all belonged to the splenectomy group and there were no case of death in the NOM group. One patient had developed pulmonary thromboembolism (PTE) and succumbed to death on the eighth PO day. All patients who died except the one with PTE had severe associated injuries and perioperative shock and died in immediate postoperative period [Table 7].
| Discussion|| |
Spleen is the most commonly injured organ in blunt trauma to abdomen.  The male-to-female ratio in our study is similar to that in Mousami Singh et al. who reported 55 cases of blunt injury abdomen in 2007-2008 from Lucknow.  An even higher ratio (6.4:1) was found by Chalya et al. in Tanzania in 2009-2011.  This is probably because of regional sociocultural practices where men are more exposed to trauma than women by virtue of their preponderance of outdoor activities including driving, travelling, assaults, and falls from heights.
We have observed that the highest incidence of splenic injury is in the age group of 31-40 years. This was followed by the age group of 21-30 years. But many other researchers found third decade to be the most affected age group. ,, This shift may be due to economic and cultural development leading to increased availability of automobiles at a younger age since majority of blunt abdominal injuries were a result of road traffic accidents.
Most patients in our study sustained splenic injury due to blunt trauma that is comparable to other studies. ,, However, several authors from Nigeria observed (between 2009 and 2012) penetrating trauma (bullet and stab wounds) as the predominant cause of splenic injury. This observation is attributable to an increase in militant and criminal activities within the Niger Delta subregion (Port Harcourt, in particular) as per authors.  Moreover, the age group was limited to 15-45 years only and the total subjects studied were small in number (45).
Interestingly, Arpit Bansal et al. reported penetrating wounds as the most common type of injury (77.7%) in India too.  They studied 130 patients consecutively admitted into their hospital in Allahabad (northern India) over a period of 17 months (2014-2015) with abdominal trauma. The difference in pattern indicates heavy crime rate overriding road traffic accidents locally.
Twenty-one patients did not have any signs and symptoms of abdominal injury at presentation, but they had documented splenic injury on FAST. Such patients are likely to be missed if not subjected to FAST at time of admission. This occurs more often when the patients have associated fractures or head injury, as the focus of attention goes to those extra-abdominal injuries. In our case, one of these asymptomatic patients developed signs and symptoms after 20 h and another after 3 days of injury and required laparotomy. Hence, close monitoring of all cases that are kept for NOM is mandatory for at least 1 week.
There are great variations in the incidence of degrees of injuries in different studies. These variations can be explained by the fact that ratios of blunt injuries to penetrating injuries are not similar in the studies compared, which can have a bearing on the severity and grading of splenic injury. Some authors analyzed only a small number of patients. However, our study showed significantly higher number of grade-III injuries and relatively lower number of grade-IV and grade-V injuries. It is questionable whether it is due to interobserver variation among the radiologists and surgeons who graded radiologically and per-operatively [Table 8].
The primary outcome parameter is the outcome of the management of splenic trauma patients by various modes at our center. We had no mortality in the NOM group, as only lower grade injuries were selected for NOM, number of cases selected for NOM were only 13.64% (21 out of 154 cases) of which 2 cases subsequently underwent splenectomy (9.52%). However, of these, two patients subsequently required laparotomy. The facility for splenic artery embolization could have facilitated NOM in more number of patients to be recruited for NOM with even higher grades of splenic injury.
The present trend in advanced centers is to go for NOM for obvious reason of salvaging the spleen and reduce operative complications and mortality. This can be seen in the examples quoted in [Table 9]. Weinberg et al.  of the University of Texas Memphis and Harbrecht et al.  of the University of Pittsburgh had a very high rate NOM with minimal failure rates and mortality. Both of them are advanced centers with facilities such as quick referral system and good patient:doctor:nurse ratios for effective monitoring and management. But Chalya et al., in Tanzania, had low rates of NOM with higher rates of failure. Our center also has lower NOM rates due to the nonavailability of facility and expertise for procedures such as selective splenic artery embolization that would bring down the failure rate of NOM significantly.  This in part may also be due to a conservative outlook of the treating surgeons that may need a review.
The secondary outcome parameters are postoperative complications and death. The presence of associated injuries is an important determinant of outcome.  Left lower lobe atelectasis (LLLA) is a known complication of surgery. It is due to the prolonged compression of LLL during surgery and can be prevented by active chest physiotherapy after the operation, which is often neglected. Lower respiratory tract infections (LRTI) followed LLLA in our series but all of them recovered fully.
The commonest cause of death was postoperative shock in five cases, followed by one case of PTE due to which the patient died on the eighth PO day. High number of grade III splenic injuries and emergency nature of surgery may account for this mortality due to perioperative shock. Postsplenectomy thrombocythemia with inadequate fluid management in the immediate postoperative period could be the cause of thrombus formation and death due to PTE on the eighth PO day. Perioperative fluid management and initiation of active chest physiotherapy in immediate postoperative period are very important to reduce postoperative complications.
There were no deaths in the NOM group and 90% had uneventful hospital stay. However it is not comparable as the number of NOM (13.64%) to operative cases is not equi-distributed.
What this study adds
NOM is being increasingly accepted as a preferred mode of management in developed countries but is not adapted adequately in centers like ours. This may be due to the lack of adequate facilities and expertise for the procedures, such as selective angioembolization of splenic artery, and human resources for close intensive monitoring of patients kept for NOM should they require operative intervention.
Strengths and limitations of this study
Number of cases of splenic trauma studied is reasonably large and this being a retrospective study, there is no scope for any type of bias. However, as different surgeons have different degrees of experience the outcomes of different cases that they diagnosed and managed especially that of the surgically managed cases may not be uniform.
| Conclusions|| |
The most affected age group is fourth decade with gross male preponderance. Blunt trauma due to RTAs far exceeded other causes. Rib fractures or hemo/pneumothorax should raise strong suspicion of splenic injury. Absence of signs and symptoms of abdominal trauma like guarding, rigidity, tenderness and distention does not exclude splenic trauma in poly trauma cases. Grade I and II splenic injuries that do not have other abdominal injuries necessitating laparotomy can be safely managed by NOM. Severe associated injuries had high impact on outcome.
| Recommendations|| |
Financial support and sponsorship
- Close monitoring round the clock by trained staff and facility for doing emergency surgery should the need arise are required for the cases kept under NOM.
- Establishment of more number of well-organized trauma care centers with adequate infrastructure and man power is recommended.
- Facilities and expertise for selective splenic artery embolization need to be developed.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]