Conservative Management of Splenic Injuries

Conservative Management of Splenic Injuries *Satyanarayana Rao S. V. 1, Ramkishan 1, Prabakar Rao P. V. 2 Research Article 1. Department of Surgery, Katuri Medical College and Hospital, Guntur-5222019, Andhra Pradesh, India. 2. Department of Pulmonology, Katuri Medical College and Hospital, Guntur-5222019, Andhra Pradesh, India. ABSTRACT Katuri Medical College and Hospital is a tertiary rural medical college catering to the needs of surrounding villages. It is situated in between Guntur and chilakaluripeta on National Highway No 05 and this strip has been identified as a high prone accident zone. Therefore a prospective study of splenic injuries due to road traffic accidents of 50 patients out of 143 cases attended to our hospital was undertaken from May 2010 to October 2013. For each and every patient, serial monitoring of clinical and haematological data with evaluation of focused assessment with sonography in trauma and Contrast Enhanced Computerized Tomography were done. All the 50 subjects selected for conservative management as the first option based on their haemodynamic stability. In our study group of 50 cases, 42 cases were managed conservatively, while 08 cases needed operative intervention (splenectomy). The grade I and grade II splenic injuries were managed with non operative regimen with average hospital stay of 09-12 days and blood transfusion of 02-05 units. The present study focused on the ability to preserve an increasing number of traumatized spleens by non operative management. This has become popular and possible due to increasing experience and expertise in pursuing the non operative approach. It is worth noting that a safe grade of splenic injuries does not exist and even mild injuries can lead to shock and massive haemoperitoneum. The objective of this research study is to purport the benefits of splenic preservation in splenic injuries which has gained worldwide acceptance. Keywords: Blunt abdominal trauma, contrast enhanced computerised tomography, focussed assessment with sonography in trauma, intensive care unit, road traffic accident, ultra sonogram Received 02 July 2014 Received in revised form 09 August 2014 Accepted 16 August 2014 *Address for correspondence: Satyanarayana Rao S. V., Associate Professor, Department of Surgery, Katuri Medical College and Hospital, Guntur-5222019, Andhra Pradesh, India. E-mail: drsatyanarayana1951@gmail.com INTRODUCTION Spleen is a most vulnerable intra abdominal organ during blunt abdominal trauma. It is located in the posterior left upper quadrant of the abdomen at the level between the 8 th and 11 th ribs. In its closed proximity are the fundus of the Stomach, left dome of the diaphragm, splenic flexure of the Colon, the left Kidney and the tail of the Pancreas. It is the largest ductless gland. It is bean shaped organ with variable consistency, highly vascular and of dark purplish in colour. The main functions of the spleen are haemopoetic, immunological and mechanical filtration of senescent RBC and bacteria. Spleen is functionally complex organ weighing 100 to 150 grms and measures 12X7X4 cms in the adult. It is the most vascular organ of the body and approximately 250-300 liters of blood passes through it per day. For this reason splenic injury poses a potentially life threatening situation. This risk is true because the spleen is the organ most commonly injured during thoraco abdominal trauma and splenic injuries represent 25% of all blunt injuries approximately. Trauma is a major worldwide public health problem and one of the leading causes of death and disability in the industrialised and developing countries. Globally injury is the seventh leading cause of death resulting Satyanarayana Rao S V et.al, IJPRR 2014; 3(8) 1

in 5.8 million deaths each year. Data from India reported, that blunt trauma of abdomen is more frequent in the Males aged between 21 to 30 years; the majority of the patients sustain automobile accidents. Recent WHO Data also reveals that automobile accidents are most frequent cause of injuries leading to blunt abdominal trauma. In all accident cases, three mortality peaks (categories) are identified. The first mortality peak comprises of trauma deaths within seconds or minutes in 50% of cases. The second mortality peak occurs within hours of injury and accounts for 30% of deaths. Half of these deaths are caused by Haemorrhage and other half due to Central Nervous System injury. The third mortality peak represents deaths that occur 24 hours after injury and include late deaths due to infection and multi organ failure. Traditionally this peak has included 10-20 % of trauma related deaths. Most of these deaths in the second mortality peak and third mortality peak can be averted by instituting appropriate treatment by Advanced Trauma Care Centres in the country. This period is also considered as golden hour of trauma for saving lives. GRADE I GRADE II GRADE III Quite often patients attend our hospital with splenic injuries due to blunt abdominal trauma, since it is in close proximity to the National High Way No-05 which has been identified as accident prone zone. Hence this prospective steady was undertaken from May 2011 to October 2013 on felt need oriented basis to institute and advocate the benefits of conservative management in splenic injuries. MATERIALS AND METHODS This is a prospective study enrolling 50 number of subjects out of 143 cases of blunt abdominal trauma attended at causality department of Katuri medical college and Hospital from May 2010 to October 2013. Out of the 50 cases, 37 were males and 13 were females M: F ratio is 2.8:1. Due clearance from the Institutional Ethics (Human) Committee was obtained for this research study. Inclusion Criteria: I. Patients of all age groups with blunt abdominal trauma with splenic injury and who are haemodynamically stable. II. Only Grade I, Grade II and Grade III (stable cases) are eligible for inclusion. The splenic injuries are classified as under Non expanding sub capsular hematoma < 10% surface area Non bleeding capsular laceration with < 1cm deep parenchymal involvement Non expanding sub capsular hematoma 10-50% surface area Non expanding intraparenchymal hematoma < 2cms in diameter Bleeding capsular tear or parenchmal laceration 1-3 cms deep without trabecular Vessel involvement Expanding sub capsular or intraparenchymal hematoma. Bleeding sub capsular hematoma > 50% surface area. Intraparenchymal hematoma > 2 cm in dia meter. Parenchymal laceration > 3 cms deep involving trabecular vessels. Exclusion criteria: I. Patients of all age groups with blunt abdominal trauma who expired within 02 hours of admission. II. Patients of splenic injury with Grade IV and Grade V category are excluded. III. Patients having other concomitant injuries needing laparotomy IV. Haemodynamically unstable patients with evidence of haemoperitoneum GRADE IV GRADE V Ruptured intra parenchymal hematoma with active bleeding Laceration involving segmental or hilar vessels producing major (>25% splenic volume) Devascularisation Completely shattered or avulsed spleen Hilar laceration which devascularizes the entire spleen Satyanarayana Rao S V et.al, IJPRR 2014; 3(8) 2

After admission a detailed history was taken and a thorough clinical examination was done. Complete blood picture, blood grouping and cross matching, diabetic and renal profile, Viral Markers, chest x ray, serial ultra sonography of abdomen, CECT of abdomen etc were done. The radiological investigations were the guiding criteria for keeping the patient under non operative management. Patients selected for conservative management were admitted in ICU ward and given absolute bed rest, I.V fluids, antibiotics with regular assessment of vitals, clinical evaluation of abdomen and other systems including output and input charts. Blood transfusion was also administered to the deserving cases. Serial sonography and CECT abdomen were done at intervals to assess the progress of the condition. In our series out of 50 cases, 42 cases were managed conservatively with the above regimen and discharged after 10 Table 1: Age Incidence Table 2: Sex Incidence Sex Number of Cases Percentage Male 37 74% Female 13 26% days with the advice for checkups at regular interval. The other 08 cases were unstable. Hence emergency splenectomy was performed. Their postoperative periods was also uneventful and were discharged on 10th day after suture removal with appropriate advice. RESULTS AND DISCUSSION Clinical examination and radiological studies of all 50 cases, revealed splenic injuries of grade I and Grade II and grade III (stable cases), out of which, 74% are males in the age group of 20-39 years. 50% of splenic injury cases are seen in the age group of 20-39 years. 74% of splenic injuries are found in males. Road traffic accidents account for 66% of splenic injuries. 88% of patients are haemodynamically stable at admission. 84% of patients are found to be haemodynamically stable after 06 hours of admission. Table 3: Mode of Injury Mode of Injury Number of Patients Percentage R. T. A. 33 66% Assaults Fall from Heights Sport Injuries Age ( Years) 10-19 05 20-29 11 30-39 15 40-49 05 50-59 04 60-69 04 70-79 02 Total 50 09 07 Number of Patients 18% 14% 01 02% Table 4: General condition at the time of admission General Condition Number of Patients Percentage Stable 44 88% Unstable 06 12% Satyanarayana Rao S V et.al, IJPRR 2014; 3(8) 3

Table 5: General condition after 06 hrs of admission General Condition Number of Patients Percentage Stable 42 84% Unstable 08 16% The commonest presenting features are abdominal pain with distension and abdominal tenderness with rebound tenderness, in splenic injuries, 56% of splenic injuries attended the casualty between 11-15hrs of injury for emergency medical consultation. In 20% of Grade III splenic injuries, a trail of conservative management was given at the outset. 16% of grade II and Grade III splenic injuries are initially treated with conservative treatment were later converted to operative management since they were detected to be haemodynamically unstable. Table 6: Symptoms and signs elicited during Hospitalisation Symptoms and signs Total Number of patients (50) Abdominal pain 46 Abdominal distension 30 Guarding and rigidity 05 Abdominal tenderness 45 Rebound tenderness 27 Vomiting 05 Haematuria 02 Pulse rate < 100/minute 23 Blood pressure < 90 mmhg 03 Pallor 35 Free fluid 28 Absent bowel sounds 20 Tenderness in the lower chest 05 Table 7: Time interval between trauma and arrival at casualty Hours Number of Patients Percentage 0-5 01 02% 6-10 11-15 16-20 21-24 08 28 01 12 16% 56% 02% 24% Table 8: Grading of splenic injuries (No of cases 50) a) CECT GRADING Grade Number of Patients Percentage Grade I 18 36% Grade II Grade III 22 10 44% 20% b) Conservative management grading Grade Number of Patients Percentage Grade I 18 36% Grade II Grade III 18 06 36% 12% Total 42 84% Satyanarayana Rao S V et.al, IJPRR 2014; 3(8) 4

CECT Photographs Splenic Injuries Grade I Spleenic Injury Sub Capsular Hematoma < 10% of Surface Area Capsular Laceration < 1cm Depth Grade II Splenic Injury Splenic Laceration 01 03 cms Depth not Involving Trabecular Vessels Grade III Splenic Injury Sub Capsular Hematoma Involving > 50% of Surface Area Laceration > 3CMS Depth or Involving Trabecular Vessels In our series, 50 cases of splenic injuries selected for conservative management, the failure rate was 16% which was within the acceptable limits as compared to the published series [1, 4]. In a recent report published it was observed that out of 524 cases of splenic injuries selected for conservative management the success rate found to be 94% [5]. Multi variate analysis also observed the age group of 55 years in grade III to V splenic injuries, with moderate to large amounts of haemoperitoneum, the failure rate to be 30-40% [6, 7]. In another series published recently it was found that out of 558 no of cases of splenic injuries selected for conservative management, the success rate was 92% [8]. Hence the indications for non operative management of splenic injuries were reviewed thoroughly and in detail. The published indications that were reviewed included 55 years of age group, Glasgow coma scale index of 13, systolic blood pressure lower than 100 mm of Hg at admission, major splenic injuries (grade III to V) and large amounts of haemoperiitoneum. The indications for conservative management in splenic injuries include the following. I. Patients to be haemodynamically stable. II. Grade I, Grade II and Grade III (stable cases) of splenic injuries. III. Facilities of an ICU setup for patient monitoring with operation theatre facilities and personal in the event of sudden bleeding that requires splenectomy. IV. Systolic blood pressure >100 mm Hg at admission. In the past, splenic injury had been an absolute indication for splenectomy. However, the newly recognised role of spleen in intravascular antigen clearance, especially for encapsulated organisms has resulted in a change in the recommendations for management. The high incidence of both over whelming post splenectomy infection and late septic morbidity in both children and adults after splenectomy has led experts to develop new techniques for splenic salvage and guide lines for non operative management. The recent trend rests heavily in favour of conservative management of splenic Satyanarayana Rao S V et.al, IJPRR 2014; 3(8) 5

injuries with the availability of sophisticated and highly accurate non invasive imaging tools at the trauma care centre. At present 70-90% of children with splenic injuries are successfully treated without operation and 40-50% of adults are managed nonoperatively in advanced trauma care centers. The lower percentage of non operatively of splenic injury in children compared to adults has always been a source of speculation. The Grade I and Grade II splenic injuries can be managed non operatively, these account for about 62-70% of cases [09]. However the feasibility and safety of such an approach is limited to only few trauma care centres where facilities of ICU setup and advanced imaging and interventional techniques etc are available. Trauma is the leading cause of death in persons under 45 years of age with 10% of the fatalities attributable to abdominal injuries. Indian statistics reveal a disproportionate index of younger age group of 15-25 years. According to the experts at the National Transportation Planning and Research Centre (NTPRC) the no of road accidents in India is 3 times higher than that prevailing in developed countries. The Indian fatality rate for trauma is 20 times more than that of developed countries. About 30% of such deaths are preventable with prompt recognition of injuries and appropriate treatment. The goal of modern trauma care centres focus on these aspects to reduce morbidity and mortality. Blunt abdominal trauma is a challenge to the surgeon due to the multitude of its problems and manifestations. This prospective study was undertaken to evaluate the pattern and grade of splenic injuries arising out of blunt abdominal trauma with special emphasis on benefits of conservative management and its outcome in our study group. Table 9: Comparison of Results of Non Operative Management of Blunt Splenic Injuries (from published series) Study splenic Injuries (Nos) Conservatively Managed cases (%) Success rate (%) Failure rate (%) Shack ford and molin 1866 13 69 31 1990 Schurr et al, 1955 309 25 87 13 Smith et al, 1996 166 47 97 03 Godley et al, 1996 135 18 52 48 Davies et al, 1998 524 61 94 06 Myers et al, 1999 204 68 93 07 Cocanour et al, 1999 368 57 86 14 Bee et al, 2001 558 77 92 08 CONCLUSION This is a prospective study of 50 cases of splenic injuries selected from 143 cases of blunt abdominal trauma patients who attended our hospital from May-2010 to October 2013. I. Road traffic accidents are the most common cause of splenic injuries (66%), II. Splenic injuries are mostly seen in the age group of 20-39 years (50%) which represents the young and economically productive group. Males are predominantly affected (74%). III. In our series it is found that most of the splenic injuries are due to blunt abdominal traumas which were managed effectively by conservative treatment (84%). IV. A thorough and repeated clinical evaluation, appropriate diagnostic radiological investigations with facilities of ICU setup, all contribute to the successful treatment in these patients V. Conservative management in splenic injuries has a worldwide acceptance and is also successful in our series. VI. In our study group, 42 out 50 cases (84%) came under grade I&II splenic injuries which were successfully managed conservatively. Only 08 cases (16%) needed operative intervention. Satyanarayana Rao S V et.al, IJPRR 2014; 3(8) 6

VII. The Grade I &II splenic injuries can be managed conservatively providing immense benefits of splenic preservation to the patients. VIII. In splenic injuries the mandatory laparotomy with splenorraphy or splenectomy once practised can be avoided by conservative management with good results, as observed in our study group. IX. It is also concluded here that patients with severe splenic injuries, Grade III and even higher can also be managed conservatively with a better traumacare setup and additional sophisticated imaging facilities. ACKNOWLEDGEMENTS We express our gratitude to the management and participants in this protocol. REEFERENCES 1. Shackford S R, Mlin M. Management of splenic injuries. Sur Clin North Am 1990, 70: 595. 2. Schurr M J, Fabian T C D, Gavant M et al. Management of blunt splenic trauma: computed tomographic contrast blush predicts failure of non operative management. J Trauma. 1995, sep 39(3), 5017-12. 3. Smith J S Jr, Cooney R N, Mucha P Jr. Non operative management of ruptured spleen. A revalidation of criteria. J trauma. sur 1996, Oct, 120(4) 745-50. 4. Godley C D, Waren R l, Sheridan R L, McCabe. C J. Non operative management of splenic injury in adults: age over 55 years as a powerful indicator for failure. Jour American College of surg 1996, Aug 183(2), 133-9. 5. Davis K A, Fabian T C, Croce M A, et al. Improved success in non operative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms. J Trauma, 1998; Jun 44(6), 1008-13. 6. Meyers J G, Dent, D L Stewart R M. Non operative management of blunt splenic injuries: dedicated trauma surgeons can achieve a high rate of success in patient of all ages, J Trauma 1999, 220(47). 7. Cocanour C S, Moore F A, Artega B S. Age should not be a consideration for Non operative management of blunt splenic injury J Trauma 1999, 220(47). 8. Bee T K, Croce M A, Miller P R, et al. Failure of splenic Non operative management: is the glass half empty or half full? J Trauma 2001, 50; 230-236. 9. Umlas S L, Cronan J J. Splenic Truma: can CT grading system enable prediction of successful Non surgical treatment? Radiology 1991, Feb 178(2),481-7. Satyanarayana Rao S V et.al, IJPRR 2014; 3(8) 7