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Introduction
Recognition of overwhelming post-splenectomy infection in splenectomized patients led to greater efforts to conserve splenic tissue following blunt trauma. Nonoperative management (NOM) of splenic trauma has emerged as a means to enhance splenic salvage. Accurate assessment of haemodynamic stability and injury severity are prerequisites to safety of such approach. Identification of splenic injuries that require early surgical repair or removal is vital.
Aim
To study the management of traumatic splenic injury at our institution and compare it against published guidelines from SSAT (Society for Surgery of the Alimentary Tract) and AAST (American Association for Surgery in Trauma) in relation to assessment, indications for splenectomy and role of NOM in absence of associated injuries.
Methods
A retrospective database was constructed to include splenic injuries admitted over a 10 year period. Cases were captured by searching the electronic CT scan reports database for those containing the words "splenic injury/rupture/haematoma/laceration" and the surgical database for operations coded as "Splenectomy/Splenorrhaphy". Cases were cross-checked against splenic pathology specimens' reports. Cases not associated with traumatic injury were excluded. A range of parameters were assessed and compared against published guidance from both SSAT and AAST. All index and follow up CT images were re-reviewed and re-graded by a radiologist blinded to the outcome. The neo-CT reports with haemodynamic and haematologic status was compared with actual management and final outcome.
Results:
48 cases of blunt traumatic splenic injury were identified; RTA was the most frequent mechanism of injury. 38 underwent splenectomy while 10 were managed conservatively. CT assessment was performed in all cases bar 4 who were taken straight for resuscitative laparotomy. AAST grading of the severity of splenic injury was reported in 8.3% of cases. Repeat imaging was sought in 60% of those cases initially managed conservatively with 7.8% having subsequent splenectomy. Average duration of observation was 0.8 days (0 - 8) in splenectomy group verses 10.1 days (3 - 23) in the successful conservative management group. There was a single mortality in this cohort due to associated head injury.
Conclusions
CT grading of splenic injury is under-reported and splenectomy is over-represented in this cohort. Protocol-based management and CT grading of all splenic injuries is recommended and will aid in identifying those who may benefit from a safe conservative approach.