Experience with splenic trauma in Ayub Teaching Hospital, Abbottabad

J Ayub Med Coll Abbottabad 2007; 19(3) EXPERIENCE WITH SPLENIC TRAUMA IN AYUB TEACHING HOSPITAL, ABBOTTABAD Tariq Saeed Mufti, Ismail Akbar, Sajjad Ahmed Department of Surgery, Ayub Teaching Hospital, Abbottabad Background: This study was carried out to estimate the prevalence, severity and mode of splenic trauma and management technique from amongst the abdominal trauma cases admitted in Ayub Teaching Hospital Methods: The study was carried out at Surgery units of Ayub Teaching Hospital, Abbottabad, the only referral hospital for major trauma cases, from July 2001 to Dec. 2002. One hundred consecutive abdominal trauma patients admitted to all surgical units which were followed up through complete documentation were included in the study. Their injuries were classified, treatment strategies outlined and complications were documented. Results: Out of the 100 patients presenting in emergency, 25% presented with blunt and 75% with penetrating trauma. 97 patients underwent laparotomy and 03 treated conservatively. Mean age was 27.26 (range 19-49) years. Out of these cases 19 patients had splenic injury, 6 (31.57%) with Type-I & II while 13 (68.42%) with Type-III & IV. 11(57.89%) of the splenic injuries were due to blunt abdominal trauma and 8 (42.10%) due to penetrating abdominal injuries. 14 (83.6%) of the patients with splenic injury underwent splenectomy and 5(26.3%) splenorrhaphy. Conclusion: The commonest cause of splenic injury was blunt abdominal trauma; Assessment of the severity of splenic injuries at the time of laparotomy resulted in splenic salvage procedures in some cases. Splenorraphy was associated with fewer complications. Keywords: Spleen; Trauma; Splenic Salvage INTRODUCTION Although protected under the bony ribcage, the spleen remains amongst the vulnerable organ sustaining injury from amongst the abdominal trauma cases in all age groups. It is a friable and highly vascular organ holding 25% of the body’s lymphoid tissue and has both haematological and immunological functions.1,2 The ancients used to remove the spleen from athletes to improve their wind.3 The first total splenectomy for disease is attributed to Adriano Zacarillo in 1549.1,2,4 Nicolas Mathias is mentioned to do the first total splenectomy for trauma in 1678 and the patient reported to have survived for at least 6 years.1,5 In civilian community practice frequency of splenic rupture due to blunt trauma far exceeds than that of penetrating trauma. Road traffic accidents, steering wheel injuries and seat belt are the common implicating causes.5,6 Penetrating injuries of the left thorax should arouse suspicion of splenic injury. In such cases the frequency of associated intra -abdominal injuries is high.7 The splenic salvage operations and non operative treatment for splenic injuries have increasingly been practiced recently. The objective of this study was to estimate the prevalence, severity and mode of splenic trauma and management technique used from amongst the abdominal trauma admitted in Ayub Teaching Hospital, Abbottabad. MATERIAL AND METHODS This study period was from July 2001 to December 2002 at Department of Surgery, Ayub Teaching Hospital, Abbottabad, which has three surgical units each containing 50 beds. One hundred consecutive patients admitted with abdominal trauma were included in this study. A pre-designed proforma was filled for all the identified information on patient in the study. All patients were received through casualty department where they were assessed and received initial management if their condition was haemodynamically unstable. Routine Investigations included hematological (hemoglobin, Total Leucocyte count, blood grouping & platelet count), biochemical (urea, sugar, serum electrolytes) and radiological (X-ray chest & abdomen) while abdominal ultrasound and CT scan was done on request of the admitting surgical team and subject to their avalability. In some cases where specialized radiological investigation could not be carried out diagnostic peritoneal lavage was carried out. The patients were assessed for a decision to conduct laparotomy. All the patients were given antibiotic cover. At laparotomy the splenic injury encountered was assessed for the extent of injury according to the standard grading system for splenic injury.4 Cases where splenic salvage was feasible the following strategy was adopted. For Grade I tear, Spongestone gelatin sponge was applied with or without suture on the surface of the wound as a haemostatic agent, for Grade II and III tears deep mattress sutures with chromic 0 or 1 were applied over omentum pach to provide buttress to the splenic tissue. For grade IV and V injury the organ was assessed for splenectomy. 3 J Ayub Med Coll Abbottabad 2007; 19(3) Other injuries were also searched and dealt with accordingly. The patients were discharged with postsplenectomy instructions. The data was collected and analyzed by SPSS 10 version of the statistic software. Table 3. Comparison of post operative complications between Splenectomies and splenorrhaphies RESULTS 100 abdominal trauma patients were followed up in this study. Eighty four patients were male and 16 females (5.5:1). Mean age of abdominal injury cases was 27.26 years (range 19 – 55 years). Out of these 97 patients underwent exploratory laparotomy while 3(03%) were treated conservatively. 74 cases were due to penetrating injury while 25% sustained blunt injuries. 10 cases out of blunt trauma (40% )due to falls from heights and 9 (36%)due to road traffic accidents. Splenic injury was noted in 19 (19%) patients. Amongst splenic injuries 12 (63.15%) were males and 7 (36.85%) females. Frequency of type of injuries is given in Table 1. Table 1. Frequency of Injuries amongst Abdominal Trauma Type of Injury Over all Splenic frequency Injury Penetrating Injury Firearm 55 (55%) 06(6%) Stab wound 19 (19%) 02 (2%) Blunt Trauma 25 (25%) 11(11%) Blast 1(%) - Blunt abdominal injury Penetrating Injury Splenectomy cases Splenorrhap hy cases Table 2. Comparative mode of injury in cases operated for splenic injury Mode of Injury Total 09 02 11 (5.8%) 05 03 08 (4.2%) Figure 1: Type of Splenic Injury Type IV, 6, 31.6% Type 1, 3, 15.8% Type II, 3, 15.8% Type III, 7, 36.8% Table 2 presents the mode of injury in splenic trauma cases. Splenectomy was carried out in 14 patients, 13 for type III & IV and 1 for type II 4 injury. In 5 (26.31%) patients splenorraphy was performed for type I , II & III injuries (Figure 1). Comparative post operative complications are given in Table 3. Complications Splenecomy Splenorrhaphy Intra abdominal bleed/ collection High grade fever Wound sepsis ( Gross) Entero- cutaneous fistula Total 02 (14.3%) Nil 02 (14.3%) 03(21.4%) 01 (20%) Nil 01(7.1%) Nil 08 (57.8%) 01(20%) The complications were markedly high in splenectomy cases. Table 4 details the evaluation of treatment in splenorrhaphy cases. Table 4. Evaluation of Splenic salvage techniques Salvage Severity No.of Outcome procedure on Type of cases spleen injury Simple I 1 Uneventful repair with (20%) recovery suture Repair with II 1 Uneventful sutures over (20%) recovery spongiston Repair with III 2 One patient sutures over (40%) developed omental intrapatch abdominal infected collection Partial IV 1 Uneventful splenectomy (20%) recovery and omental patch DISCUSSION Abdominal trauma is the leading cause of mortality and morbidity during first four decades of life and is the third commonest reported cause of death overall.8 Same observations are noted in the present study where the mean age of patients with abdominal trauma was 27.26 years. Ahmad noted 50% of patients in his study belonging to age group of 12 40 years.9 In the present study out of hundred patients the male to female ratio was 5.5:1. while the ratio of splenic injury in male to female was 1.7:1. Qureshi et al noted a male to female ratio of 9:1 5. J Ayub Med Coll Abbottabad 2007; 19(3) Almost similar observations were made by Memon et al,4 Zafar et al,10 Ahmad9 and Khan 7 . Blunt trauma is the second commonest mode of abdominal trauma and spleen is the most common intra-abdominal organ injured in blunt abdominal trauma.1,11-14 Ayub also concluded that blunt abdominal trauma is a common emergency.6 In the present study blunt abdominal trauma accounted for 25%. A total of 19 patients (19%) were noted with splenic injury and the most common cause of splenic injury was blunt abdominal trauma i.e 57.89%.Most of the blunt abdominal traumas were secondary to falls from heights (40%) and road traffic accidents (36%). These results are also comparable with those of Arikan,15 Manoher16 and Powell.17 In the present study type III splenic injury was most frequent i.e 7 patients(36.84% ), type IV accounted for 6 patients(31.57%). Type I & II injuries were noticed for 3 patients(15.78%). Almost similar results were observed by Wasvary 18 and Goan19 where type III was documented as the most frequent one. Carlin 20 concluded that the need for splenectomy was most significantly correlated with higher grades of splenic injury i.e Grade IV. Javed5 , Rathore 21 and Zafar10 did not attempt splenorraphy even in a single patient due to extensive injuries. While Memon4 and Kamel 3 stressed upon splenic conservation in stable patients. This study attempts to follow their guidelines to some extent. In recent years the policy of spleen’s conservation at operation has been established due to its important role in cellular and humoral immunity and the danger of overwhelming sepsis in asplenic patients.3, 4, 12 Consequently operative techniques for splenic preservation have been developed and concept for non-operative management of selected splenic injuries is evolving.22-25 CONCLUSION In this study the commonest cause of splenic injury was blunt abdominal trauma and most of the splenic injuries were Grade III & IV. Splenectomy was performed in majority of the cases. Results of splenorraphy were encouraging. Splenorraphy should be considered in all the splenic injury cases at the time of laparotomy.. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. REFERENCES 1. 2. 3. Cooper MJ. Williamson RCN. Splenectomy: indications hazards and alternatives. Br J Surg 1984;71:173-80. Muhammad G, Ahmad S. Splenectomy indications hazards and alternatives. 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Barone JE, Burns G, Svehlak SA, Tucker JB, Bell T, Korwin S, et al. Management of splenic trauma in patients older than 55 years. Southern Connecticut Regional Trauma Quality Assurance Committee. J Trauma 1999; 46: 87-90. _______________________________________________________________________________________________ Address For Correspondence: Dr. Ismail Akbar, Surgical “A” unit, Ayub Teaching Hospital, Abbottabad Email: drismailakbar@yahoo.com 5