SCIENTIFIC PAPERS

Splenic Preservation

Penetrating Trauma

John Barrett, MD, Chicago, Illinois

in Adults After Blunt and

Charles Sheaff, MD, Chicago, Illinois

Sabas Abuabara, MD, Chicago, Illinois

Olga Jonasson, MD, Chicago, Illinois

The dangers of overwhelming postsplenectomy sepsis are well recognized in children who have undergone splenectomy for trauma as well as for hematologic disease [I]. Repair and nonoperative management of splenic injuries is now standard procedure in children. Less accepted is the fact that adults who have undergone splenectomy for trauma are also at increased risk of sepsis [2]. The purpose of the present study was to determine the feasibility and safety of applying the intraoperative techniques of splenic preservation currently in use in children to an adult population subjected to penetrating as well as blunt trauma.

Matkrial and Methods

Patient select&x From July 1980 to December 1981 every trauma patient admitted to the trauma unit at Cook County Hospital was considered for inclusion in this study. All of these patients are 15 years of age or older. Every patient who was found to have a splenic injury at laparot- omy was evaluated, and an attempt to repair the spleen was made unless the patient was unstable, associated injuries were so severe that the additional time necessary for repair was felt to be unwarranted, or the spleen was completely shattered or avulsed from its pedicle.

Technique of splenic preservation: The initial step was to obtain adequate mobilization of the spleen to permit thorough examination and manipulation. This was

From the Trauma Unit and the Department of Swgery. Cook County Hospital, and the Department of Surgery, Abraham Lincoln School of Medicine of the University of Illinois. Chicago, Illinois.

Requests for reprints should be addressed to John Barrett, MD, Trauma Office M-7, Cook County Hospital, 1835 West Harrison Chicago, Illinois 60612.

Volume 145, March 1983

achieved by dividing the attachments of the spleen to the colon, kidney, and diaphragm. The spleen and the tail of the pancreas were then completely mobilized up into the wound. Blood clot and devitalized tissue were removed and the injury assessed.

Classification of injuries: It proved possible to classify the splenic injuries into four types. Type I: Capsular dis- ruption without significant parenchymal injury. Type I injuries were repaired by resuturing the capsule with 3-O absorbable sutures and reinforcing the repair with micro- cystalline collagen (Avitenee, Avicon Inc.) which had been compressed into a flat disc to facilitate application (Figure 1). Type II: Capsular disruption with parenchymal injury which did not extend into the hilum. Deep 3-O absorbable sutures were passed into the splenic substance to reap- proximate the splenic tissue. The repair was then bolstered by a live pedicle of omentum tied in place over the repair (Figure 2). Type III: A deep laceration that extended into the splenic hilum. Partial splenectomy was carried out in this group of patients. The vessels to the injured segment of the spleen were isolated and ligated. A clear line of de- marcation could then be easily identified between the normal and devitalized tissue. Interlocking absorbable sutures on large needles were passed through the edge of the normal splenic tissue at the line of demarcation and tied in position. The devitalized injured portion was then excised with a scalpel or with electrocautery. The small amount of residual oozing from the transected edge was controlled with microcystalline collagen and bolstered with an omental patch (Figure 3). In every case of partial sple- nectomy at least 50 percent of the original amount. of splenic tissue was retained. Type IV: A spleen that was completely shattered or avulsed from its pedicle. No at- tempt was made to preserve these spleens and splenectomy was immediately carried out (Figure 4). No attempts were made to reimplant splenic tissue or induce splenosis. No drains were placed in the splenic fossa.

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Barrett et al

Figure 7. Type I. Capsular dlmpikn wlthotd alpdlkad paren- chymal lnbry. Rqalr by dhof matdurLng.

Results

A total of 36 patients with splenic injuries were evaluated. A splenic preservation procedure was accomplished in 18 patients (50 percent) (Table I). No deaths occurred in this group, nor were there any surgical complications associated with the splenic preservation procedure.

Blunt trauma accounted for 18 splenic injuries; 8 of these patients’ spleens (45 percent) were saved (Table II). Splenectomy was performed in the re- maining 10 patients due to type IV (irreparable) in- jury in 8 patients, an associated severe head injury in 1 patient, and a 2 day old injury in 1 patient, thought to be unsuitable for repair. In two patients

+re 3. Trpb Ill, Laceration extending hto Bpknlc hihm Repa& by part/al spkmcfomy.

Fm 2. vpe H. Pamnch~l &@y nd exiemjhg MO the hkm Repak by suture and omental bob&.

with blunt trauma initial attempts at preservation was abandoned because of continued bleeding, and splenectomies were performed instead. Both of these injuries were type II longitudinal lacerations on the diaphragmatic surface of the spleen rather than the more common transverse lacerations.

Penetrating trauma accounted for the remaining 18 splenic injuries; 11 were due to gunshot wounds and 7 to stab wounds. Of the 11 patients with gunshot wound injuries, splenic preservation was accom- plished in 4 (36 percent) (Table II). Splenectomy was performed due to a gunshot wound through the hilum which caused irreparable injury in one patient, and shock and associated injuries in six patients. These patients had an average of four additional organs injured. Of the seven spleens that were injured due to stab wounds, six (85 percent) were preserved

314 The American Journal of Stargary

Splenic Preservation After Trauma

(Table II). The remaining patient in this group un- derwent a splenectomy because of associated injuries to the adrenal gland, left renal vein, pancreas, colon, lung, and diaphragm. More than one third of the patients with gunshot wounds were unstable or in shock (4 of 11 patients) and had an average of four additional organs injured, which accounted for a higher percentage of splenectomy in this group. Only 2 of 18 patients with blunt trauma and 1 of 7 with stab wounds were unstable or in shock, and associ- ated organ injuries were uncommon (Table III). Splenic repair procedures added an average of 30 minutes to the operating time.

Comments

The spleen is now known to be an important component of host defense. It is involved in the clearance of particulate matter and appears to be the preferential organ for the intravascular clearance of pneumococci [3]. In addition, the spleen participates in the development of a normal immune response to blood-borne antigens and reduced levels of immu- noglobulin M have been noted following splenectomy [4]. It is also responsible for the production of tuftsin, an opsonic peptide which facilitates phagocytosis [a.

Postsplenectomy sepsis, most frequently due to pneumococcus, can occur in any patient who has undergone splenectomy, regardless of the reason for splenectomy [2]. This abrupt and catastrophic dis- ease can occur at any time after splenectomy [6]. It is particularly likely to develop in children, and has a mortality rate of 50 percent [2]. King and Schu- macher [7] in 1952 described five children who un-

TABLE I Adult Splenic Trauma: July 1980 to December 1981

Mechanism of

Injury

Blunt Gunshot wounds Stab wounds

Total

Total Spleens Number Preserved Splenectomy

18 8 (45%) 10 (55%) 11 4 (36%) 7 (64%) 7 6 (85%) 1(15%)

36 18 (50%) 18 (50%)

derwent splenectomy before the age of 6 months. Septicemia developed in all five and two died. Sub- sequently in 1962, Horan and Colebatch [I] reported that of 64 pediatric patients who underwent sple- nectomy for trauma, a subsequent serious infection developed in 6.3 percent compared with a 0.7 percent expected incidence in the general population. Singer in 1973 [2] described 688 patients (including adults) who had a splenectomy for trauma. He reported a 1.5 percent sepsis rate in this group with a 0.58 percent death rate, compared with an expected death rate in, the healthy population of 0.01 percent. Therefore, the patient who undergoes a splenectomy for trauma is 58 times more likely to die from sepsis than a healthy individual.

Preservation of all or part of the spleen after injury has recently been advocated for children, and a number of successful series of operative and nonop- erative methods of management have been reported [8,9]. No evidence exists at present to suggest that nonoperative management is applicable to adults,

TABLE II Splenlc Preservation in Adults by Classification and Mechanism of Injury

Mechanism of Injury

Type I (n) Type II (n) Type Ill (n) Type IV (n) Total Preserved Total Preserved Total Preserved Total Preserved

Blunt 1 1 3 Gunshot wounds 1 6

3 6 5 8 0 3 0 1

Stab wounds 0 6 5 1 1 0

Total 2 2 15 10 10 6 9 0

TABLE Ill Indications for Splenectomy in Adults

Mechanism of

Injury Splenectomies

(n)

Indication for Splenectomy (n) Additional Unstable Type IV Associated Organs Patient Injury Injuries Injured (n)

Blunt

Gunshot wounds Stab wounds

Total

l Two day old Injury.

10 1 8 1’ 1.5

7 3 1 3 1 0 0 1 3

18 4 9 5 2.7

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Barrett et al

but over 200 cases of successful operative splenic preservation have been reported since 1970 [JO].

Reluctance to consider splenic preservation in adults has been based on a lack of awareness that adults are also at a small but substantial risk for de- velopment of postsplenectomy sepsis, as well as on anatomic considerations. The muscular capsule of the adult spleen is thinner than a child’s, and it was feared that repair or partial splenectomy would not be technically feasible; however, the overall preser- vation rate of 50 percent and lack of complications encountered in this series demonstrate that attempts to preserve the injured spleen in adults are safe and effective.

Blunt trauma causes injury by explosive or inertial forces, whereas gunshot wounds with civilian weap- ons and stab wounds will simply penetrate the spleen, causing an anatomically defined injury. It is not surprising then that 78 percent (14 of 18) of patients in our series with blunt trauma had type III or IV injuries which required partial or total splenectomy. On the other hand, associated organ injuries or he- modynamic unstability were rarely present in these patients, which permitted the time and extra mobi- lization required to define the area of injury and to attempt partial splenectomy or repair.

Gunshot wounds and stab wounds usually injure the splenic parenchyma (type II injuries), and repair by direct suture techniques, commonly bolstered with omentum, can be readily accomplished. In fact, five of seven penetrating splenic injuries caused by stab wounds were repaired by suturing; partial splenectomy was necessary in only one instance. The high rate of splenectomy (67 percent) in patients with similar injuries caused by gunshot wounds was not due to the type of splenic injury sustained, but rather was due to associated organ injuries and hemody- namic instability. We have previously reported the high rate of organ injuries and the multiplicity of intraabdominal organs injured in 362 patients ad- mitted to the Cook County Hospital Trauma Unit with abdominal gunshot wounds [II]; 97.6 percent of patients with abdominal penetration had signifi- cant organ injuries, and the average number of organs injured per patient was 2.3. A splenic injury was found in 11.8 percent of patients with gunshot wounds to the abdomen. In the current series, the patients with gunshot wounds had an average of four additional organs injured and a high rate of hemo- dynamic u&ability, factors which preclude attempts at splenic preservation. Nonetheless, a third of our patients with gunshot wounds to the spleen were successfully managed without splenectomy, and we now routinely attempt to perform a preservation procedure in all stable patients whose associated injuries are limited.

Functional intraperitoneal splenosis can often be documented following splenectomy for trauma leading to experimental and clinical efforts to reim-

plant splenic tissue [12,13]. With one exception all such efforts have failed to show that the autotran- splanted splenic fragments provide protection against a subsequent intravenous, live pneumococcal challenge [14]. In addition, fatal postsplenectomy sepsis has been reported in patients with splenosis and with accessory spleens [ 151, It has been suggested by Goldthorn et al [16] that the normal supply of blood from the major arteries to the spleen is neces- sary for it to play its protective role. It also appears that at least a third of the splenic mass must be pre- served to afford adequate protection. Therefore, we have not attempted to implant splenic tissue and do not proceed with splenic preservation unless at least 50 percent of the spleen can be saved.

Because of the risks of postsplenectomy sepsis, even in adults, splenic repair and preservation should be carried out whenever possible. This study has demonstrated that simple techniques of repair or segmental resection can be used to preserve adult spleens subjected to blunt as well as penetrating trauma. The techniques are both feasible and safe, and are not difficult provided the spleen is ade- quately mobilized. Splenic preservation should not be attempted if the patient is unstable, associated injuries are severe, or if the spleen is completely shattered or avulsed.

Summary

This study was carried out to evaluate the possi- bility and safety of splenic preservation in adults subjected to both blunt and penetrating trauma. In an 18 month period there were a total of 36 splenic injuries studied (in 36 patients): 18 due to blunt trauma, 11 due to gunshot wounds, and 7 due to stab wounds. A total of 18 spleens were repaired: 8 (45 percent) in the blunt trauma group, 4 (36 percent) in the gunshot group, and 6 (85 percent) in the stab wound group. There were no deaths in the entire group nor were there any complications associated with splenic salvage. Splenic preservation after both blunt and penetrating trauma is both safe and fea- sible in the adult population, except in those in- stances specified herein.

References

1. Horan M, Colebatch JH. Relation between splenectomy and subsequent infection. A clinical study. Arch Dis Child 1962;37:398-414.

2. Singer DB. Post-splenectomy sepsis. In: Rosenberg HS. So- lander RP, eds. Perspectives in pediatric pathology. Vol. 1. Chicago: Year Book~Medical, 1973:285-311. --

3. Schulkind MD, Ellis EF. Smith RT. Effect of antibodv uoon clearance of 1-125 la&led pneumococcibythespleen’and liver. Pediatr Res 1967;1:178-84.

4. Claret I, Morales L, Montaner A. Immunological studies in the post-splenectomy syndrome. J Pediatr Swg 1975; 10:59- 64.

5. Najjar VA, Nishiokak. “Tuftsin”: a physiological phagocytosis

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Splenic Preservation After Trauma

stimulating peptide. Nature 1970;228:672-3. 6. Gopa V, Bisno AL, Fuiminant pneumococcal infections in

“normal” asplenic host. Arch Intern Med 1977;137: 1526-30.

7. King H, Schumacker HB Jr. Splenic studies: 1. susceptibility to infection after spienectomy performed in infancy. Ann

Surg 1952; 136:239-42. 8. Ratner MH, Garrow E, Valda V, Shashikumar VL, Somers L.

Surgical repair of the injured spleen. J Pediatr Surg 1977; 12:1019-25.

9. Ein SH, Shandling B, Simpson-JS, Stephens CA. Nonoperative management of traumatized spleen in children: now and why. J Pediatr Surg 1978;13:117-9.

10. Sherman R. Perspectives in management of trauma to the spleen: 1979 presidential address, American Association for the Surgery of Trauma. J Trauma 1980;20:1-13.

11. Lowe RJ, Saletta JD, Read DR, Radhakrishnan J, Moss GS.

Should iaparotomy be mandatory or selective in gunshot wounds of the abdomen? J Trauma 1977;17:903-7.

12. Church JA, Mahour GH, Lipsey Al. Antibody responses after spienectomy and spienic autoimpfantation in rats. J Surg Res 1981;31:343-6.

13. Aigner K, Dobroschke J, Weber GE, et al. Successful reim- pfantation of spienic tissue after neonatal abdominal trauma. Lancet 1980;1:360-1.

14. Likhite VV, Protection against fulminant sepsis in spienecto- mized mice by implantation autochthonous splenic tissue. Exper Hematoi 1978;6:433-9.

15. Rice HM, James PD. Ectopic spienic tissue failed to prevent pneumococcal septicaemia after splenectomy for trauma. Lancet 1980;1:565-6.

16. Goldthorn JF, Schwartz AD, Swift AJ, Winkelstein JA. Protective effect of residual spienic tissue after subtotal splenectomy. J Pediatr Surg 1978;13:586-90.

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