Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
ORIGINAL ARTICLE  
Year : 2013  |  Volume : 6  |  Issue : 3  |  Page : 186-188
Splenectomy in a Nigerian Teaching Hospital: A comparison of sonographic correlation with intra-operative findings in trauma


1 Department of Surgery, College of Medicine, University of Ibadan; University College Hospital, Ibadan, Nigeria
2 University College Hospital, Ibadan; Department of Radiology, College of Medicine, University of Ibadan, Ibadan, Nigeria
3 Department of Surgery, University College Hospital, Ibadan, Nigeria

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Date of Submission25-Jun-2012
Date of Acceptance10-Sep-2012
Date of Web Publication20-Jul-2013
 

   Abstract 

Background: Missed or inappropriately-treated splenic injury is a significant cause of preventable trauma-related death. Physical examination and abdominal ultrasonography are essential tools for early diagnosis of splenic injury. However, some injuries may not be accurately diagnosed by ultrasonography at initial evaluation. Aim: The aim of this study was to audit indications for splenectomy at the University College Hospital, Ibadan and to compare the intra-operative findings in trauma-related cases with the sonographic findings. Materials and Methods: We retrospectively reviewed all adult (12 years and older) patients' records who had splenectomy between July 2003 and June 2010. The data extracted included patient demographics and indications for splenectomy. In trauma cases, the mode of injury and vital signs at presentation, sonographic findings, and operation findings were recorded. The intervals between injury and sonography and duration to surgery were also noted respectively. Results: Eighty-four patients were reviewed in the 7-year review period. The male to female ratio was approximately 2:1. The ages ranged from 14 to 76 years with a peak incidence in the third decade. Elective indications for splenectomy were 14 (16.6%), while 70 (83.3%) were emergency cases. Forty-four of the trauma-related patients had pre-operative abdominal ultrasound, of which 31 (70%) was reported as sonographically normal prior to surgery, while the rest of the trauma-related cases were considered too ill for ultrasonography. Conclusion: Potentially significant injuries may be missed with screening sonography. For this reason, a physician must maintain a high index of suspicion and consider the patient's clinical status or an alternative imaging modality in excluding a diagnosis of splenic injury.

Keywords: Sonography, spleen, trauma

How to cite this article:
Afuwape O, Ogole G, Ayandipo O. Splenectomy in a Nigerian Teaching Hospital: A comparison of sonographic correlation with intra-operative findings in trauma. J Emerg Trauma Shock 2013;6:186-8

How to cite this URL:
Afuwape O, Ogole G, Ayandipo O. Splenectomy in a Nigerian Teaching Hospital: A comparison of sonographic correlation with intra-operative findings in trauma. J Emerg Trauma Shock [serial online] 2013 [cited 2019 Jun 24];6:186-8. Available from: http://www.onlinejets.org/text.asp?2013/6/3/186/115336



   Introduction Top


Trauma has become a major health problem due to industrialization and transportation, especially in developing countries. [1] Road traffic accidents are the commonest cause of trauma in the civil population in Nigeria. [2] As a result of this, abdominal injuries are one of the common injuries associated with trauma in the emergency department. Blunt injuries are commoner than penetrating injuries. [3] Splenic injury constitutes about 30% of missed blunt abdominal injuries. [4] Splenic injury is one of the causes of preventable mortality when not rapidly diagnosed and treated. This, therefore, makes trauma; one of the commonest indications for splenectomy. [5] Physical examination may not be reliable in the initial phase of evaluating trauma patients, especially when patients are hemodynamicaly unstable, [6] necessitating the use of imaging studies to make early diagnosis of splenic injury.

Ultrasound is a rapid non-invasive and affordable method of diagnosing splenic injuries in blunt trauma. Its sensitivity in diagnosis of hemoperitoneum and distortion of splenic architecture varies with the interval between injury and sonography. [7] A scanning method called Focused Assessment with Sonography for Trauma (FAST) was devised with a primary objective of developing a procedure that could easily detect increased intra-peritoneal fluid. [8] We conducted an audit of splenectomy at the University College Hospital, Ibadan and compared the intra-operative findings in trauma-related cases with the sonographic findings.


   Materials and Methods Top


The University College Hospital is the premier teaching hospital in Nigeria. It serves a population of over 5 million people in Oyo state and receives referral from all regions of the country. We retrospectively reviewed all patients who had splenectomy between July 2003 and June 2010. The data extracted included patient demographics and indications for splenectomy. In trauma-related cases, the mode of injury and vital signs at presentation, sonographic findings, operation findings, and the outcome of treatment were also included. The intervals between onset of injury and sonography and duration to surgery were also noted respectively. Patients less than 12 years were excluded from this study because such patients were treated by the pediatric surgical division of the hospital. Three brands of ultrasound machines were used during the period of the study (ALOKA1700, GE Logiq P5, and CHISOM). The standard sonographic procedure focused on detecting intra-peritoneal fluid and parenchymal abnormalities in the spleen. The sonologists were specialist registrars or consultant grade in the radiology department in the hospital. The demographic and clinical data as well as the sonographic findings were analyzed using the Statistical Program for the Social Sciences (SPSS) version 17 (SPSS Inc, IL, USA). Descriptive statistics were presented in sizes and proportions (percentages, means ± standard deviation). The level of statistical significance was set at a P ≤ 0.05


   Results Top


Eighty-four patients underwent splenectomy in the 7-year review period. The male to female ratio was approximately 2:1 with males constituting 63% of all patients. The patients' ages ranged from 14 to 76 years with a peak incidence in the third decade. Elective indications for splenectomy were 14 (14.8%) while 70 (83.3%) were emergency cases. Hematological indications and incidental splenectomy associated with gut resection constituted 9 (10.7%) and 5 (5.9%) cases, respectively. Within the group of patients who had trauma-related splenectomy, 58% had isolated splenic injuries while 42% had other associated organ injuries. Forty-four patients who had trauma-related splenectomy had pre-operative abdominal ultrasound. Thirteen (29.6%) of these patients who had pre-operative ultrasonography were reported to have features suggestive of splenic injury while 31 (70%) were reported as sonographically normal. The duration between the onsets of trauma and sonography ranged from 1 to 36 hours with a mean duration of 5 hours while the mean duration from injury to surgery was 9 hours. A significant percentage of sonographic diagnosis (66.7%) was made more than 6 hours after the injuries were sustained. There was, however, no significant statistical significant difference in the timing of sonography and a positive diagnosis. A significant proportion of the missed injuries (84%) was done by the resident staff (senior registrar) being the first available staff level in the emergency hours. Disparities between sonographic and intra-operative findings are shown in [Table 1]. There was no significant statistical difference.
Table 1: Comparison of sonographic and intra-operative findings in patients with suspected splenic injury

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Serial examination of the trauma-related patients at presentation revealed pallor in 79.6% of the patients, and cardiovascular instability characterized by a significant increase in the pulse rate with a drop in systolic blood pressure to values below 90 mmHg in 61.8%. Splenic conservation was attempted in only one patient who ultimately had splenectomy. The mean follow-up duration was 7 months. Nine patients (11%) had evidence of post-splenectomy immunization.

There were 3 post-operative mortalities. Two of these patients died of respiratory failure from associated chest injury while one patient died from overwhelming sepsis from opportunistic infection a year after splenectomy.


   Discussion Top


Splenectomy is associated with increased susceptibility to opportunistic post-splenectomy infection. Consequently, there is a recognized global shift in the management of splenic injuries from splenectomy to splenic conservation when feasible. This is, however, based on early diagnosis and the availability of support services such as imaging and adequate blood banking services. While this may be the current consensus in many advanced countries, the treatment option still heavily leans towards splenectomy in Ibadan. We recorded 84 patients in the 7-year period under review. Trauma was the commonest indication for splenectomy, thus making pre-operative prophylactic immunization impossible. However, in the less industrialized rural population, trauma is not a leading indication for splenectomy. [9] The incidence of splenectomy peaks similarly with trauma incidence in the second and third decades, which accounts for the peak in the second decade as previously documented. [10]

The clinical diagnosis of splenic injury requires a high index of suspicion during evaluation of a trauma patient. The mechanism of injury, the findings at presentation, and radiological findings should be taken into consideration in making the appropriate diagnosis. Abdominal sonography has been demonstrated by some studies to have a sensitivity and specificity of 89% and 96%, respectively, with a negative predictive value of 95% for sonography in the setting of blunt abdominal trauma. [11] On the other hand, a much lower sensitivity and specificity has been demonstrated in some advanced trauma centers. [12] Our audit demonstrates a relatively poor correlation between radiological findings on ultrasound and intra-operative findings of splenic injuries, consequently rendering ultrasonography a less reliable diagnostic tool in our center. However, there was a better correlation (79.6%) of ultrasound with the pre-operative diagnosis of hemoperitoneum [Table 1]. The reason for a low sonographic correlation may be due to several factors. Some of the major factors that could be considered are the experience and professional cadre of the performing or reporting sonologist, the interval between the onset of injury and the time of sonography, as well as the resolution of the sonographic equipment being used. A consequence of this delay in diagnosing splenic injury is significant hemoperitoneum and cardiovascular instability, thus making attempts at splenic conservation impossible.

The excessive intra-peritoneal blood loss translated to a peri-operative blood transfusion rate of 88.8%. Early diagnosis with ultrasonography reduces the volume of intra-peritoneal hemoperitoneum, consequently reducing the need for blood transfusion in the peri-operative period. A very small fraction of the population had documented evidence of prophylaxis for post-splenectomy infection. Fifty-nine percent of the patients were lost to follow up within a year. Opportunistic post-splenectomy infection was diagnosed in one patient, which is in agreement with the low incidence of 0.23% [9] per year and a life time risk of 5%. [13] The patient presented with a week history of intermittent fever. Twenty-four hours to his demise, he had severe headache, 2 episodes of convulsion, fluctuating serum glycemic levels, and persistent hypotension. This solitary case of opportunistic post-splenectomy infection may be accounted for by the fact that the patients in this study are not in the pediatric age group.


   Conclusion Top


Trauma is the most common indication for splenectomy in the University College Hospital Ibadan. While Ultrasonography may be useful in diagnosing hemoperitoneum, it is less effective in diagnosing specific organ injury, which may alter the initial approach to treatment. Potentially significant injuries may be missed with screening sonography. For this reason, a physician must maintain a high index of suspicion and consider the patient's clinical status or an alternative imaging modality in excluding a diagnosis of splenic injury. Other ancillary investigations such as computerized tomogram in early diagnosis are underutilized due to the cost and availability. Splenic conservation is not routinely practiced. This is a retrospective study, which consequently has its limitations. Given the operator-dependent nature of ultrasound, an objective assessment of the skills of the individual radiologists will increase our confidence in decision-making.

 
   References Top

1.Richard A, Gosselin RA, Spiegel DA, Coughlin R, Zirkle LG. Injuries: The neglected burden in developing countries. Bull World Health Organ 2009;87:246-246a.  Back to cited text no. 1
    
2.Afuwape OO, Alonge TO, Okoje VM. Pattern of the cases seen in the accident and emergency department in a Nigerian Tertiary Hospital over a period of twelve months. Niger Postgrad Med J 2007;14:302-5.  Back to cited text no. 2
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3.Ayoade BA, Salami BA, Tade AO, Musa AA, Olawoye OA. Abdominal injuries in olabisi onabanjo university teaching hospital sagamu nigeria; Pattern and outcome. Nigerian J Orthop Trauma 2006;5:45-9.  Back to cited text no. 3
    
4.Afuwape OO, Okolo CA, Akinyemi OA. Preventable trauma deaths in Ibadan: A comparison of revised trauma score and panel review. West Afr J Med 2011;30:19-23.  Back to cited text no. 4
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5.Akinkuolie AA, Lawal OO, Arowolo OA, Agbakwuru EA, Adesunkanmi AR. Determinants of splenectomy in spleenic injuries following blunt abdominal trauma. S Afr J Surg 2010;48:15-9.  Back to cited text no. 5
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6.Richards JR, Knopf NA, Wang L, Mc Gahan JP. Blunt abdominal trauma in children: Evaluation with emergency US. Radiology 2002;222:749-54.  Back to cited text no. 6
    
7.Richards JR, McGahan JP, Jones CD, Zhan S, Gerscovich EO. Ultrasound detection of blunt spleenic injury. Injury 2001;32:95-103.  Back to cited text no. 7
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8.Scalea TM, Rodriguez A, Chiu WC, Brenneman FD, Fallon WF, Kato K, et al. Focused assessment with sonography for trauma (FAST): Results from an international consensus conference. J Trauma 1999;46:466-72.  Back to cited text no. 8
    
9.Alufohai E, Odusanya OO. Splenectomy in rural surgical practice. Niger J Clin Pract 2006;9:81-3.  Back to cited text no. 9
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10.Osime OC, Ighedosa SU, Oludiran OO, Iribhogbe PE, Ehikhamener E, Elusoji SO. Patterns of trauma deaths in an accident and emergency unit. Prehosp Disaster Med 2007;1:75-9.  Back to cited text no. 10
    
11.Luks FI, Lemire A, St Vil D, DiLorenzo M, Filiatrault D, Duimelt A. Blunt abdominal trauma in children: Practical value of ultrasonography. J Trauma 1993;34:607-10.  Back to cited text no. 11
    
12.Miller MT, Pasquale MD, Bromberg WJ, Wasser TE, Cox J. Not so FAST. J Trauma 2003;54:52-60.  Back to cited text no. 12
[PUBMED]    
13.Ejstrud P, Kristensen B, Hansen JB, Madsen KM, Schonheyder HC, Sorensen HT. Risk and patterns of bacteraemia: A population based study. Scan J Infect Dis 2000;32:521-5.  Back to cited text no. 13
    

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Correspondence Address:
Oludolapo Afuwape
Department of Surgery, College of Medicine, University of Ibadan; University College Hospital, Ibadan
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.115336

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