Jebmh.com Original Research Article

Splenic - A Prospective Study from Tertiary Care

Ashish Rathore1, Varun Dogra2, Pranav Sharma3

1Senior Resident, Department of General Surgery, Maharishi Markandeshwar University, Solan, Himachal Pradesh. 2Senior Resident, Department of General Surgery, Government Medical College, Jammu. 3Senior Resident, Department of General Surgery, Government Medical College, Jammu.

ABSTRACT

BACKGROUND is the most frequently injured organ in abdomen. Injury to Corresponding Author: spleen can result in deadly outcomes. Its management spans from conservative Dr. Varun Dogra, Flat No. 704/C, approach to surgical interventions such as . Royal Palm Apartments, Paloura, Jammu-18000 METHODS E-mail: [email protected] This is a prospective study undertaken at Government Medical College, Jammu, DOI: 10.18410/jebmh/2019/646 from 1st November 2017 to 31st October 2018. All patients with blunt splenic trauma, resulting from falls or Road Traffic Accidents, admitted to the Emergency Financial or Other Competing Interests: None. Department of General Surgery, were thoroughly examined with concomitant . After evaluation, they were either operated or managed How to Cite This Article: conservatively. Rathore A, Dogra V, Sharma P. - a prospective study from tertiary RESULTS care. J. Evid. Based Med. Healthc. 2019; Out of fifty patients enrolled in this study, majority was males in the 20-40 years 6(49), 3087-3091. DOI: 10.18410/jebmh/2019/646 age group. They presented mostly with pain and tenderness in upper abdomen.

Other associated were also present in 16 cases. More than half of the Submission 14-11-2019, patients (59.26%) suffered from grade 2 splenic injuries while on 14.81% suffered Peer Review 19-11-2019, from grade 5 splenic injury. 14 patients were managed conservatively, 36 patients Acceptance 27-11-2019, Published 09-12-2019. required operative intervention. Complications were recorded in 20 while there were 3 mortalities.

CONCLUSIONS This study emphasises the use of CT and Ultrasonography in the evaluation and adoption of a conservative approach in managing stable cases of isolated low- grade splenic trauma.

KEYWORDS

Spleen, Trauma, Road Traffic Accidents

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 49/Dec. 09, 2019 Page 3087

Jebmh.com Original Research Article

BACKGROUND operative management of blunt splenic trauma. In some

series there is increase in the frequency of non-operative 3 Following blunt , spleen is the most management for equivalent injuries from 11 to 71%. frequently injured solid organ and it represents around 31- The strategy for management of blunt splenic injury, 35% and sometimes up to 50% of all abdominal solid organ which may have an impact on mortality, has changed. Blunt injuries.1 Majority of cases with splenic injury is observed in splenic injury has various therapeutic options depending on second and third decade of life. This being the most active the patient’s hemodynamic condition and the accompanying period of life when movements in motor vehicles and injuries of other organs. Surgery remains the gold standard outdoor works result in increased risk of trauma.2 Spleen is for treating patients with splenic injuries with hemodynamic susceptible to injury during trauma to the left lower thorax instability and it has constituted 31-35% or even up to 50% or left upper abdomen. Other injuries that may be of cases. A distinct trend in spleen saving has been observed associated with it include injuries to the rib cage, and increasing numbers of patients with these injuries have diaphragm, pancreas, and bowel.3 been treated non-operatively, including patients with The delayed diagnosis of blunt splenic injury (BSI) abdominal multi-organ injuries. Non-operative treatment might result in poor outcome with a reported high mortality combined with splenic artery angioembolization is among rate, ranging from 7 to 18%. The initial hours of blunt the options for the treatment of hemodynamically stable 7 trauma abdomen are extremely crucial for the patient. patients, regardless of splenic injury severity. When the spleen is injured, blood may be released into the The conservative management of splenic injuries has peritoneal cavity and the amount of bleeding depends on evolved over the past few decades with the realisation of the grade of the splenic injury. Low grade (I & II) injuries the importance of the spleen in immunological defence are usually admitted to the surgical ward and are treated against encapsulated organisms and a better understanding conservatively. While, high grades of blunt splenic injuries of the role of non-operative management of splenic 3 (≥grade III) are admitted to the intensive care unit and their injuries. Non-operative management in adults have management depends on the clinical condition and progress achieved success rates ranging from 68 to 83% and is of the patient condition.1 considered to be the cornerstone of treatment in 8 A hematoma of the spleen does not bleed into the hemodynamically stable patients. Non-operative abdomen at first but may rupture and bleed in the first few management represents the progression of ‘save our spleen’ days after injury. An injured or ruptured spleen can make concept which was initially used for children and later on the abdomen painful and tender. The pain is in the left side extended to adults. The only absolute indication for 9 of the abdomen just below the rib cage. Sometimes the pain emergency laparotomy is hemodynamic instability. is felt in the left shoulder. If enough blood leaks out, blood Hemodynamic instability is the primary reason for pressure falls and people feel light-headed, have blurred surgical management. Salvage procedures including vision and confusion, and lose consciousness.4 splenorrhaphy or partial resection of the spleen are The initial assessment of patients with suspected blunt appropriate in certain situations such as when carried out as abdominal trauma should focus on the abdominal an adjunct to the repair of other abdominal organ injuries. examination (tenderness and abdominal wall ecchymosis), Splenectomy should be avoided as far as possible, because vital signs, and response to resuscitation. In patients with it leads to increased risks of severe infections and clot evidence of shock or overt serious injury, blood should be formation. However, the risks should be balanced against 10 immediately drawn for all laboratory investigations and the risk of re-bleeding after salvage. adequate intravenous (IV) access should be obtained for We wanted to estimate the prevalence, severity and resuscitation. There is considerable variability in the mode of splenic trauma, evaluate the other associated intra- abdominal injuries, evaluate various available investigations definition of hemodynamic instability.5 Clinical examination for detection of splenic injuries and evaluate various alone is inadequate because patients may have altered modalities of treatment and common complications. mental status and other distracting injuries. Initial resuscitation along with focused assessment with solography in trauma (FAST) and computed tomography METHODS (CT) abdomen are very beneficial to detect those splenic injury in patients with minimal and clinically undetectable signs of abdominal injury.6 It was a prospective study which was undertaken at FAST is particularly useful in hemodynamic ally unstable Government Medical College, Jammu in Department of patients to look for free abdominal fluid (sensitivity 98%), Surgery from 1st November 2017 to 31st October 2018. All as it is highly accessible, quick to perform, portable, and patients with blunt splenic trauma, resulting from falls or non-invasive. The technique does however have limitations Road Traffic Accidents, admitted to the Emergency in obese patients as it is operator dependent and intra- Department of General Surgery, being thoroughly examined abdominal injuries may be missed. Computed tomography with concomitant resuscitation. scanning has become the gold standard for imaging in blunt The choice of diagnostic approach depends on the abdominal trauma and in the identification of splenic hemodynamic status of the patients. The most utilized injuries. This has contributed to the development of non- primary modalities are FAST and CT scan. The decision for

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 49/Dec. 09, 2019 Page 3088

Jebmh.com Original Research Article operative or non-operative management depends on the splenic injury along with associated injury to other intra outcome of the clinical examination and results of diagnostic peritoneal and retro peritoneal structures. In our study, the tests. All hemodynamically unstable patients were relative percentage of various Grades of splenic injury immediately taken to the operating room following an FAST (Table 3) was 0% (Grade-I), 11.11% (Grade-II), 59.26% Scan to undergo an emergency laparotomy, while those (Grade-III), 14.81% (Grade-IV) and 14.81% (Grade-V). who were stable were evaluated by CT) scan of the CECT abdomen besides diagnosing splenic trauma also abdomen and pelvis and x-ray chest and abdomen. diagnosed hepatic injuries in 5 cases (10%) and renal In those patients who were hemodynamically stable, injuries in 4 cases (8%). Hepatic injuries include Grade II splenic injuries were Graded I to V according to the and Grade IV while renal injuries were of Grade I, Grade III American Association for the Surgery of Trauma (AAST) and Grade V. organ injury scale based on the findings of the CT. Those Out of 50 cases of splenic trauma, 14 patients (28%) patients who were taken up for immediate laparotomy were were managed conservatively and 36 patients (72%) graded according to operative findings. Patients who were underwent operative management. Among 14 patients, who managed conservatively were kept on Intravenous Fluids on were selected for non-operative management Grade-II strict bed rest. Enteral nutrition was restricted and vital signs injury was present in 3 cases (21.43%) and Grade-III in 11 (Pulse Rate, Respiratory Rate, Blood Pressure) were cases (78.57%). The success rate in our present study is monitored. Serial abdominal examinations and Monitoring of 100%. Patients who were managed conservatively required Haemoglobin concentration were done daily. Follow up blood transfusion, with fewer units in low grade splenic scans were done after one week and after one month after injury. No complications occurred in patients who injury. Outcomes were compared according to Morbidity and underwent non operative management. Mortality, Postoperative complications, requirement of Out of 36 patients, who required operative intervention mechanical ventilation and Length of hospital stay. splenectomy was performed in 24 patients (66.6%), Splenectomy with hepatorrhaphy in 2 patients (5.56%), Splenectomy with intercostals chest tube (ICCT) in 5

RESULTS patients (13.89%), Splenectomy with gastrointestinal repair

in 3 patients (8.33%), Splenectomy with repair of

mesenteric tear in 1 patient (2.78%) and splenorrhaphy in In our study of 50 patients with blunt trauma abdomen with 1 patient (2.78%). The splenic injuries varied from large splenic injury, the most common age group was found to be subcapsular hematoma, intraparenchymal laceration and between 20 to 40 years with mean age group of 28.80 ± laceration with involvement of hilar vessels to completely 13.88 years accounting for 46% of all the cases. Only 6 shattered spleen (Table 4). Most commonly associated patients were below 10 years of age. Males were affected 7 intra-abdominal solid organ injury was liver in 2 cases (4%), times more common than females. 88% of the patients Gut injuries in 4 cases (8%), Mesenteric tear in 2 cases were males and 12% were females. Road traffic accidents (4%), Omental tear in 1 case (2%) and vascular injury in 1 were the commonest mode of trauma (Table 1) accounting case (2%). Complications were recorded in 20 patients for 62% of cases followed by fall from heights (32%) and (Table 5). Wound related complications were most common least caused by the assaults (6%). and occurred in 11 patients (22%) followed by mechanical Most of the patients admitted in emergency had ventilation in 5 cases (10%), Left sided pleural effusion in 4 (92%) as the most common symptom cases, and left lower lobe consolidation in 1 case (2%). Out (Table 2). Vomiting was present in 15 cases (30%). 9 of 50 patients, 47 patients (94%) recovered and 3 patients patients (18%) were drowsy while 5 (10%) were (6%) expired making the overall mortality rate of 6%. unconscious at the time of presentation. Most of the patients had more than one symptom. Also, tenderness was Age No. of Patients (%) present in 46 patients (92%), guarding in 10 patients (20%) (Years) RTA Fall from Heights Assaults and 13 patients presented with shock. More than one sign ≤10 (n=6) 2 (33.33) 4 (66.67) 0 (0.0) 11-20 (n=11) 6 (54.55) 5 (45.45) 0 (0.0) was present in the same patient. Associated injuries were 21-30 (n=9) 6 (66.67) 2 (22.22) 1 (11.11) present in 16 cases (32%).Thoracic injury was present in 8 31-40 (n=14) 10 (71.43) 4 (28.57) 0 (0.0) >40 (n=10) 7 (70.0) 1 (10.0) 2 (20.0) cases (16%), limb injuries in 4 cases (8%), in 3 Total 31 (M:F = 27:4) 16 (M:F = 14:2) 3 (M:F = 3:0) cases (6%) and 1 patient had burn injury. Table 1. Mode of Injury Chest X-ray showed simply rib fractures in 4 patients (8%), rib fractures with associated Haemothorax in 5 Symptoms/Signs Number of Patients (n=50) % Abdominal pain and 46 92 patients (10%) and in 1 patient (2%). One tenderness patient showed free gas under right dome of diaphragm. Vomiting 15 30 Low GCS 9 18 Ultrasonography was performed in all the patients who were Pallor 17 34 stable and also in patients who were initially unstable after Pulse >100 26 52 BP<90 13 26 adequate resuscitation and stabilization. Hemoperitoneum Guarding 10 20 was detected in all the cases. CECT Abdomen was Crepitus 1 2 Decreased Air Entry 6 12 performed in patients who were hemodynamically stable. It Distension 0 0 was done in 27 patients and helped in accurately diagnosing Table 2. Associated Signs and Symptoms

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 49/Dec. 09, 2019 Page 3089

Jebmh.com Original Research Article

Grade No. of Patients (n=27) % along with associated injury to other intra peritoneal and Grade I 0 0.0 Grade II 3 11.11 retro peritoneal structures. In our study, the relative Grade III 16 59.26 percentage of various Grades of splenic injury are 0% Grade IV 4 14.81 Grade V 4 14.81 (Grade-I), 11.11% (Grade-II), 59.26% (Grade-III), 14.81% Total 27 100.0 (Grade-IV) and 14.81% (Grade-V). Federle MP et al18 Table 3. Grades of Splenic Injury reported 99% of accuracy of CT scan in 200 patients of blunt

abdominal trauma. Sutyak JP et al,19 stated CT in 49 Type of Surgery No. of Patients (n=36) % Splenectomy 24 66.67 patients with 43 splenic injuries correlated surgically with CT Splenectomy with 2 5.56 findings. In our study CECT abdomen besides diagnosing Hepatorrhaphy Splenectomy with ICCT 5 13.89 splenic trauma also diagnosed hepatic injuries in 5 cases Splenectomy with 3 8.33 (10%) and renal injuries in 4 cases (8%). Most of the splenic Gastrointestinal repair Splenectomy with repair of injuries were of grade III, hepatic injuries include Grade II 1 2.78 Mesenteric tear and Grade IV while Renal injuries were of Grade I, Grade III Splenorrhaphy 1 2.78 Table 4. Management of Splenic Injuries and Grade V. Another advantage of CT scanning over other diagnostic modalities is its ability to evaluate the Complications No. of Patients % retroperitoneal structures. Wound infection 11 22.0 In our study, out of 50 cases of splenic trauma, 14 were Lt. Pleural Effusion 4 8.0 Lt. Consolidation 1 2.0 managed conservatively (28%) and 36 patients underwent Mechanical ventilation and Others 5 10.0 operative management (72%). Among the 14 patients who OPSI 0 0.0 DVT 0 0.0 were selected for non-operative management Grade-II-3 Pancreatic fistula 0 0.0 (21.43%), Grade-III - 11(78.57%). The success rate in our Table 5. Associated Complications 20 present study is 100%. Studies by Dharap S et al, Davis 21 22 23 KA et al, Rajani RR et al. Tan KK et al also found a high

success rate of conservative management in low grades of DISCUSSION splenic injury. In our study, all the patients who were

managed conservatively required blood transfusion, with In the present study of 50 patients with blunt trauma less units in low grade splenic injury. No complications abdomen with splenic injury, the most common age group occurred in patients who underwent non operative was found to be between 20 to 40 yrs. with mean age group management. of 28.80 ± 13.88 yrs. accounting for 46% of all the cases. In the present study, 36 patients (72%) underwent Road traffic accidents were the commonest mode of trauma operative management. Out of 36 patients, splenectomy accounting for 62% of cases followed by fall from heights was performed in Grade III, Grade IV and Grade V injuries (32%) and least caused by the assaults (6%). The most and splenorrhaphy in Grade II injury. Midline incision was common presentation was abdominal pain and tenderness used most commonly. On laparotomy blood in peritoneal (92%) followed by vomiting present in 15 (30%) of patients cavity was found in all cases. The splenic injuries varied which was similar to the results of studies by Tripathi et al.11 from large subcapsular hematoma, intraparenchymal Lone GN et al.12 and Patel C et al.13 Griswold et al.14 in their laceration and laceration with involvement of hilar vessels studies reported that splenic injury was always associated to completely shattered spleen. with vertigo, nausea and vomiting. Out of 36 patients, splenectomy was performed in 24 In our present study, rib fractures were commonly patients (66.6%). Splenectomy with hepatorrhaphy in 2 associated injuries accounting for 16% of all extra patients (5.56%), Splenectomy with ICCT in 5 patients abdominal associated injuries. Limb injuries were present in (13.89%), Splenectomy with gastrointestinal repair in 3 8% of the cases and head injury in 6% of all cases similar patients (8.33%), Splenectomy with repair of mesenteric to studies of Mclellan et al 15 and Patel C et al.13 tear in 1 patient (2.78%) and splenorrhaphy in 1 patient Ultrasonography was performed in all the cases, free (2.78%). In the present study, the most commonly fluid in abdomen was present in all the cases within 15 to associated intra-abdominal solid organ to be injury was liver 20 minutes. 1 patient had scout film of abdomen and chest in 2 cases (4%), Gut injuries in 4 cases (8%), Mesenteric who had associated bowel perforation. Our current tear in 2 cases (4%), Omental tear in 1 case (2%), vascular algorithm for the evaluation of blunt abdominal trauma injury in 1 case (2%). included FAST in both stable and unstable patients as the Post-operative complications were recorded in 20 initial screening tool which yielded a high sensitivity as in patients. Wound related complication was most common other studies by Rozycki GS et al,16 Feyzi A et al,17 and and occurred in 22% of all cases followed by mechanical Pinjala N et al.4 ventilation in 5 cases (10%), left sided pleural effusion in 4 CT scan was performed in limited number of patients cases and left lower lobe consolidation in (2%). All the post- who were hemodynamically stable. It was done in 27 operative patients were administered pneumococcal vaccine patients and helped in accurately diagnosing splenic injury as early as possible.

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 49/Dec. 09, 2019 Page 3090

Jebmh.com Original Research Article

CONCLUSIONS splenic injury: impact of splenic artery embolization.

Wideochir Inne Tech Maloinwazyjne 2014;9(3):309-

Splenic Injury following blunt trauma abdomen is mostly 314. seen in the age group of 20-40 yrs., which form the young [8] Matsou A, Valsamidis K, Vrakas G, et al. Management and economically productive group. Males were of splenic injuries following blunt abdominal trauma: predominantly affected. Road traffic accidents are the most our experience. Hellenic J Surgery 2011;83:87. common cause of splenic injuries. A careful examination is [9] Beuran M, Gheju I, Venter MD, et al. Non-operative the key to diagnosis. Investigations are complementary to management of splenic trauma. J Med Life physical findings. FAST is helpful in detecting free fluid 2012;5(1):47-58. collection and gives an idea about solid organ injury. It is a [10] Mitsusada M, Nakajima Y. Protocol for splenic salvage useful tool in the rapid assessment and evaluation of blunt procedures in this era of non-operative management. trauma patients. CT scan is useful in hemodynamically Acute Med Surg 2014;1(4):200-206. stable patients to assess grade of injury, to detect [11] Tripathi MD, Srivastava RD. Blunt abdominal trauma associated intra-abdominal injury and to guide further with special reference to early detection of visceral management. The most common associated solid organ injuries. Int J Surg 1991;53(5):179-184. injury in our study was liver. Most common associated extra- [12] Lone GN, Peer GQ, Warn KA, et al. An experience with abdominal injury in the present study was left hemithorax abdominal trauma in adults in Kashmir. JK Practitioner rib fractures (16%). Scout abdominal film is a useful 2001;8(4):225-230. investigation in cases of hollow viscus injury. Small bowel is [13] Patel CN, Patel IK, Dave DN. A prospective study of the commonly injured hollow viscus in our study. conservative management in cases of hemoperitoneum Conservative management is successful in selected patients. in solid organ injuries at tertiary care hospital in Close monitoring of patients undergoing conservative western India. Int J Med Sci Public Health treatment and the availability of urgent surgical intervention 2013;2(3):670-674. if required is of paramount importance for successful [14] Griswold RA, Collier HS. Collective review: blunt management of patients with splenic injury. Operative abdominal trauma. Surg Gynecol Obstet 1961;112:309- intervention was needed in unstable patients and in patients 329. requiring exploration for other injuries. Complications were [15] McLellan BA, Hanna SS, Montoya DR, et al. Analysis of commonly seen in surgically managed patients with wound peritoneal parameters in blunt abdominal trauma. J related complications being most common. Mortality in Trauma 1985;25(5):393-399. present study is low (6%). Associated injuries play a [16] Rozycki GS, Ochsner MG, Feliciano DV, et al. Early significant role in increasing the mortality. In our study, detection of hemoperitoneum by ultrasound most of the splenic injuries following blunt abdominal examination of the right upper quadrant: a multicenter trauma were managed operatively. study. J Trauma 1998;45(5):878-883. [17] Feyzi A, Rad MP, Ahanchi N, et al. Diagnostic accuracy

of ultrasonography in detection of blunt abdominal REFERENCES trauma and comparison of early and late

ultrasonography 24 hours after trauma. Pak J Med Sci [1] El-Matbouly M, Jabbour G, El-Menyar A, et al. Blunt 2015;31(4):980-983. splenic trauma: assessment, management and [18] Federle MP, Griffiths B, Minagi H, et al. Splenic trauma: outcomes. Surgeon 2016;14(1):52-58. evaluation with CT. Radiology 1987;162(1 Pt 1):69-71. [2] Ahmed H, Pegu N, Rajkhowa K, et al. Splenic injury: a [19] Sutyak JP, D'Amelio LF, Chiu W, et al. Economic impact clinical study and management in a tertiary care and clinical predictors of successful non-operative hospital. Inter Surg J 2015;2(4):652-659. treatment of adult splenic injury. J Trauma [3] Hildebrand DR, Ben-Sassi AN, Ross P, et al. Modern 1994;36(1):158. management of splenic trauma. BMJ 2014;348:g1864. [20] Dharap S, Changlani TT. Splenic trauma: an Indian [4] Pinjala N, Rao NN, Reddy MM. Evaluation and experience. Recent advances in surgery 1996;5:235- management of splenic injury in blunt abdominal 254. trauma. IOSR Journal of Dental and Medical Sciences [21] Davis KA, Fabian TC, Croce MA, et al. Improved success 2016;15(4):1-19. in non-operative management of blunt splenic injuries: [5] Moore FA, Davis JW, Moore EE, et al. Western Trauma embolization of splenic artery pseudoaneurysm. J Association (WAT) critical decisions in trauma: Trauma 1998;44(6):1008-1013. management of adult blunt splenic trauma. J Trauma [22] Rajani RR, Claridge JA, Yowler CJ, et al. Improved 2008;65(5):1007-1011. outcome of adult blunt splenic injury: a cohort analysis. [6] Mehta N, Babu S, Venugopal K. An experience with Surgery 2006;140(4):625-631. blunt abdominal trauma: evaluation, management and [23] Tan KK, Chiu MT, Vijayan A. Management of isolated outcome. Clin Pract 2014;4(2):599. splenic injuries after blunt trauma: an institution's [7] Sosada K, Wiewióra M, Piecuch J. Literature review of experience over 6 years. Med J Malaysia non-operative management of patients with blunt 2010;65(4):304-306.

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 49/Dec. 09, 2019 Page 3091