|Year : 2011 | Volume
| Issue : 2 | Page : 217-221
|Blunt splenic injury in Sikkimese children and adolescents
Pradip Kumar Mohanta1, Amrita Ghosh2, Ranabir Pal3, Shrayan Pal1
1 Department of Surgery, Calcutta National Medical College, Kolkata, India
2 Department of Biochemistry, Sikkim Manipal Institute of Medical Sciences, Gangtok and Central Referral Hospital, Sikkim, India
3 Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences, Gangtok and Central Referral Hospital, Sikkim, India
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|Date of Submission||01-Dec-2010|
|Date of Acceptance||01-Feb-2011|
|Date of Web Publication||18-Jun-2011|
| Abstract|| |
Background : The contemplation for the salvage operations and the nonoperative treatment for the pediatric splenic injuries had increasingly been suggested as the standard case management. Objectives : The study was carried out to identify the risk factors, the presentations, the severities and outcome of the interventions of blunt splenic injuries in the children and adolescents. Materials and Methods : This retrospective review was carried out in a tertiary care hospital in Sikkim on the children and adolescents admitted with splenic injury from January 2005 to December 2009. Splenic injuries were graded with the American Association for the Surgery of Trauma Splenic Injury Scale followed by the operative and nonoperative managements (NOM). Results : Overall 147 cases with the abdominal trauma were diagnosed with splenic injury. Of them, males reported in higher numbers; three-fourths were adolescents with preponderance above 16 years of age. Majority of the cases [n=91(61.90%)] were due to fall from heights and others from road traffic accidents. Immediate surgical interventions was instituted in the hemodynamically unstable cases (n=87) NOM failed in 27 patients; of them eight cases underwent splenectomy, and 19 underwent surgical salvage; 33 were closely followed up by conservative approach with both clinical and CT criteria. Total number of cases in grade III and above was significantly higher than with lower grades of injury. Conclusions : In total 95(64.63%) of the cases were managed with total splenectomy; 19 cases in the initial nonsurgical group underwent salvage operation and 33 cases received NOM.
Keywords: Splenectomy, splenic injury, nonoperative management
|How to cite this article:|
Mohanta PK, Ghosh A, Pal R, Pal S. Blunt splenic injury in Sikkimese children and adolescents. J Emerg Trauma Shock 2011;4:217-21
| Introduction|| |
Spleen is a vulnerable organ and frequently sustains injury from the abdominal trauma in all age groups. In civilian practice frequency of splenic injury due to blunt trauma far exceeds than that due to penetrating trauma, road traffic accidents, steering wheel injuries and seat belt injuries. Penetrating injuries of the left thorax should also arouse suspicion of splenic injury. ,,[ 3] After blunt injury to the spleen, splenectomy was the preferred method of management till late seventies. Contemplations for the splenic salvage operations and nonoperative treatment for splenic injuries was increasingly been suggested for its invaluable functions. , The drift to the concept of splenic salvage ushered in response to King and Schumacher's report of overwhelming sepsis in children after splenectomy.  The idea of nonoperative treatment of selected pediatric patients with splenic injury was introduced in 1968. Still, it was not until the development of better diagnostic modalities in two subsequent decades that nonoperative management (NOM) became a more common treatment strategy in children. , Currently, the standard of care for a hemodynamically stable child with a splenic injury documented by computed tomography scan is nonoperative treatment with close monitoring by an experienced surgical team. ,, Morbidity and mortality are further compounded by the life-long risk of overwhelming postsplenectomy sepsis that is estimated to occur 85 times the rate of the normal population.  Even in regions with organized trauma systems, a significant number of children are likely managed at the general hospitals.  No previous study has systematically examined the treatment of children with splenic injury at the nontrauma centers in Sikkim. The objectives of our study were to find out the risk factors, the presentations, the severities and the outcomes of the interventions of splenic injuries in the children and adolescents.
| Materials and Methods|| |
A retrospective blinded review was designed of the records of 147 children and adolescents with history of abdominal trauma with splenic injury spanning over a 5-year period from January 2005 to December 2009 admitted in the Department of surgery of a tertiary care teaching hospital in Sikkim.
The study conformed to the Helsinki declaration. The Institution Ethics Committee of Sikkim Manipal Institute of Medical Sciences approved this study. The study included all children and adolescents with a diagnosis of blunt injury to the spleen. Adolescent age was defined by World Health Organization as a person between 10 and 19 years of age.  The splenic injuries were graded with the American Association for the Surgery of Trauma Splenic Injury Scale. 
All the cases were evaluated with detail history of the mode of injury, prehospital care, time interval between the incident and arrival in this hospital, hemodynamic stability, routine investigations (hematological: hemoglobin, total leukocyte count, blood grouping and cross match, platelet count; biochemical: BUN, serum creatinine, plasma sugar, serum sodium and potassium; radiological: X-ray chest and abdomen, ultrasound of abdomen, intravenous contrast-enhanced CT scan of abdomen and ultrasound guided diagnostic peritoneal tap.
Overall 147 patients with the abdominal trauma had been diagnosed of splenic injury. Standard clinical criteria allowed triage of patients to immediate surgery or in the initial nonsurgical intervention groups. Eighty-seven cases among 147 enrolled cases were hemodynamically unstable and went directly to surgery without CT evaluation due to hypotension or following Focused Abdominal Sonography for Trauma (USG) criteria. The second group (n= 60) cases underwent CT evaluation with contrast; of them eight cases were decided for splenectomy, 19 cases underwent surgical salvage and 33 were closely observed with a by the conservative approach with both clinical and CT criteria. The clinical criteria included morphological grade of the injury, the hemodynamic instability, the requirement of the transfusion and the abdominal rigidity. CT criteria included the extent of the splenic injury, the active extravasations, and the amount of hemopenitoneum.
The operative managements included total splenectomy and salvage operation (partial splenectomy and splenorraphy). NOM was done with abdominal rigidity and girth measurements, serial CT assessment, hemodynamic status evaluation, etc. Postoperative vaccination was provided to all cases with polyvalent Pneumococcal vaccine 0.5 ml, Hemophilias influenza type b vaccine and quadrivalent meningococcal vaccine (the latter for those ≥2 years of age).
The statistical analysis was done using Graph Pad 3 and the comparison between cases and control was calculated by using Student's t-test. χ2 test and trend was used to compare the outcomes in relation to the ages of the cases. One-way ANOVA and Bonferroni multiple comparison test was applied to compare multiple independent and dependant variables. The difference was considered to be statistically significant at an α-error of 0.05.
| Results|| |
Out of the 147 patients of splenic injury 87 cases were considered for immediate surgical interventions. Other 60 patients underwent CT evaluation of them, active extravasations of blood was identified in 10 patients; all of them underwent surgical interventions (splenectomy in 8, splenornhaphy in two). Fifty cases were earmarked for NOM; 17 cases, with no demonstrated extravasations at CT, underwent salvage surgery for splenic injuries at a later date in accordance with both the clinical and CT criteria, while 33 were closely followed up by the conservative approach.
In the demographic and clinical characteristics of the study population, nearly three-fourths were adolescents; preponderance of cases were above 16 years [57(38.77%)]; 117(79.59%) were male. Mean age of the splenic injury cases was 13.21±0.46.A great majority [91(61.90%)] were due to fall from heights and others were due to road traffic accidents. However, these differences were not statistically significant (P>0.05). Prehospital care i.e., the treatment before shifting from scene of trauma to our center was received by 59(40.14%) cases and a gender bias was observed in favor of males; these differences were statistically significant (P=0.0453). The mean time interval in hours between the incidence and arrival in this hospital was estimated at 7.67 hours as only 31(21.09%) cases reached our center within an hour.
Nonpalpable peripheral pulse and a nonrecordable systolic blood pressure were noted in 53(36.06%) cases. The hemoglobin level of more than 10 gm% was noted in 23(15.65%) cases. In our series the diagnostic accuracy of ultrasound imaging was in 80.27%, while in computerized tomography the comparable data was 98.33% [Table 1].
|Table 1: Clinicopathological correlates of splenic injury in children and adolescent population in Sikkim (n=147) |
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In our study we noted that 37(25.17%) cases had grade-III, followed by 35(23.81%) with grade-II, 31(21.09%) with grade-I, 25(17.01%) in grade IV and 19(12.92%) in grade V splenic injuries. We observed that total number of cases in grade III and above was significantly higher than with lower grades of injuries (P=0.0038). In males, a significant linear trend was noted when we compared cases with grade III and above with lower grades of splenic injury (P<0.0001). However, linear trend could not be delineated in females. In total, 95(64.63%) cases were managed with total splenectomy; while 19(12.93%) cases in the initial nonsurgical group underwent salvage operation (Partial splenectomy and Splenorraphy) and 33(22.45%) cases had received NOM in surgical intensive critical care unit. We sought for the enhanced understanding on the risk and the outcome of splenic injury in children. So we compared total splenectomy and salvage operation with NOM in children below the age of 10 years with those in the adolescents. Overall it was noted that children recovered in significantly higher number with NOM (P=0.0349). Blood transfusion was needed in all cases; more than 5 U were provided to 89(60.54%) cases. In comparison, the recipients of more than 5 U of blood transfusion were significantly higher than those receiving less (P<0.0001). But when the transfusion analysis was compared we did not note any significant difference between NOM and operative management (OM) (P=0.067). Postoperative complications were observed in 98(66.67%) cases though we could not find any significant difference in age groups in relation to infection, shock, atelectasis or anemia (P>0.05). From the analysis of the records of this review, no mortality was noted [Table 2].
| Discussion|| |
Sikkim is a hilly state in the Himalayan range in the north-eastern part of India; a bit of plane land or a valley is a rare scene in the whole state. So, fall from the height is the commonest risk factor. Further, Sikkim is a peaceful state in India with rare documented cases of violence.
We observed 147 cases of splenic injury; majority was due to fall from heights and others from road traffic accidents. Blunt trauma is the second commonest mode of abdominal trauma and spleen is the most commonly injured organ after blunt trauma. The overall mortality rate from splenic injury was reported as 6-7% or high in many series and this mortality rate is secondary to associated injuries. ,,,, Researchers noted that the most common cause of splenic injury was blunt abdominal trauma. Most of the blunt abdominal traumas were secondary to falls from heights and road traffic accidents. Our results are similar with world literature. ,,
In our series the diagnostic accuracy of ultrasound imaging was in 80.27% in splenic injury cases, while in computerized tomography the comparable data was 98.33%. In a comparable study, patients with hyperattenuating foci were much more likely to need laparotomy or splenic artery embolization than were patients without hyperattenuating foci. Among the patients with hyperattenuating foci, a significant difference in the type of management was also shown on the basis of whether the hyperattenuating foci represented active splenic hemorrhage or contained injury based on dual-phase CT findings. Patients with active splenic hemorrhage were more likely than patients with contained injuries to undergo splenectomy.  Intravenous contrast-enhanced CT has been shown to be accurate in the evaluation of splenic injuries resulting from blunt trauma. ,,[ 26] There is a general trend toward nonsurgical management of abdominal traumatic injuries as well as the confidence our surgeons have in our ability to accurately "stage" splenic injuries, including evidence of active bleeding, and to exclude with confidence other visceral injuries that would necessitate surgery. , Others also reported in that Grade III splenic injury was the most frequent that corroborated our findings. ,
In our series we had performed total splenectomy in 64.63% patients. Other similar study also concluded that the need for splenectomy was most significantly correlated with higher grades of splenic injury. ,,, A study was conducted on the children and adolescents were admitted to all acute care hospitals in Pennsylvania and had a diagnosis of blunt injury to the spleen. Researcher in this field reported that, 23.2% of children with blunt splenic injury in their study were treated operatively. Of the 752 patients who were treated operatively, 56(7.4%) were characterized as having had a partial splenectomy, 208(27.7%) as a repair/plastic operation of the spleen, 484(64.4%) as a total splenectomy and 4(0.5%) as other operations on the spleen.  In our study, postoperative complications were observed in 66.67% cases. Postoperative complication was less than other studies.  From the records of this review, no mortality was noted in our study. The success rates in treating blunt splenic injury in children had been reported to be over 90%. ,
In the Nigerian study, 23 cases were managed for splenic injuries that consisted of 21(91.3%) males and two (8.7%) females within the age range of 16-58 years. The risk factors were blunt injury in 21 cases and penetrating in two cases with motor vehicle accident being the most commonest. The mean injury arrival time was 25.2±26.5 hours. Fifteen undergone surgical intervention while eight cases were on NOM. Splenectomy was the most frequently performed procedure. Challenges identified in the management of patients with splenic injuries in Nigeria include delayed presentation, underutilization of CT, unavailability of interventional radiology, inadequate ICUs, limited vaccination, discharge against medical advice and poor follow-up. 
In the hemodynamically stable blunt splenic injury, nonsurgical management has become the customary care in children and adolescents. Nevertheless opinion is divergent on outcome and prognosis. Researchers noted significant difference in mean time of healing among all grades when followed up to US-documented complete injury healing on nonsurgical management on children and adolescents with splenic injuries grade 1-3. There was a clear relationship between the severity of blunt splenic injury and adolescents and the time course. ,
In a recent extensive review for the Ptolemy monthly reviews in Canada, Iribhogbe summarised that NOM of blunt splenic injuries has become the norm in the developed countries for children. In the absence of RCTs, NOM has shown itself superior to laparotomy, through practice, in terms of mortality rates, blood transfused and splenic preservation. The management protocols used abdominal CT scanning to diagnose the degree of splenic injury and to rule out associated abdominal injuries requiring surgery. However, the sole indication of need for surgery was clinical-hemodynamic instability. 
The strength of the study was that there was no report of management of splenic injury from this part of India on children and adolescents. Further, the reasons for surgical intervention in the nonoperative group varied within the surgical panel responsible for the decisions that included both clinical and CT criteria. We had several limitations. Firstly, in our resource poor setting, we are yet to establish a specialized pediatric and adolescent trauma care unit. Hence even with our best efforts we had to compromise 27 patients from NOM group to surgical salvage. Secondly, intravenous contrast used for the CT diagnosis could not be done in hemodynamically unstable patients. Globally researchers have shown that hemodynamic stability is the key factor for consideration of NOM and injury severity score is optimally related with the outcome. Of the CT criteria, active extravasations usually correlated best with the need for splenic surgery. Yet management had evolved from splenectomy to splenic salvage and NOM in selective patients for preserving the valuable functions of spleen. NOM had replaced splenorrhaphy as the most common method of splenic salvage and the main goal of salvage, preservation of 35-50% of spleen is required. Future researches has to be directed to solve several important unanswered questions dealing with the diagnosis and the treatment of the splenic trauma in growing ages on the degree of splenic injury of prognostic importance by assessing clinical outcome, determination of active hemorrhage by CT, clinical and CT criteria to predict optimum NOM and many more. The management strategies such as the NOM of blunt splenic injury are more likely to be adopted and sustained in pediatric trauma care centers with high volume of experience. Results of this study suggest the need for regionalized trauma care systems to implement evidence-based guidelines and to identify resources that are required to optimize care of the injured child across all types of hospitals. 
To sum up, the practice of the interventions of splenic injury in children and adolescents differ broadly in spite of the well-documented benefits of NOM. CT criteria especially in the absence of active extravasations can help predict successful NOM of splenic injuries. It is important for the dedicated trauma management groups to identify the appropriate patients for NOM as controversy still exist in the selection of the cases in the prediction of failure of NOM. The relative advantages of NOM for children and adolescents with blunt splenic injury necessitated for widespread and standardized adoption of this intervention.
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Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences, Gangtok and Central Referral Hospital, Sikkim
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]
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