Alternatives to splenectomy in adults after trauma: Repair, partial resection, and reimplantation of splenic tissue

doi:10.1016/0002-9610(82)90556-6

The American Journal of Surgery

Volume 144, Issue 6, December 1982, Pages 711-716

https://doi.org/10.1016/0002-9610(82)90556-6 Get rights and content

Abstract

Splenectomy results in a lifelong risk of overwhelming infection in the adult as well as the child. This has prompted our current enthusiasm for splenic salvage in trauma patients. A number of alternatives to total splenectomy exist; however, the complications that result from splenic salvage must not exceed the risk incurred by loss of this organ. Splenorraphy can be performed safely in the majority of patients despite associated intraabdominal injuries. When splenectomy is necessary, reimplantation of splenic tissue is feasible. The efficacy of this technique in preventing postsplenectomy sepsis remains to be established.

References (31)

SH Ein et al.
Nonoperative management of the traumatized injured spleen in children: how and why
J Pediatr Surg
(1978)
JA Church et al.
Antibody responses after splenectomy and splenic autoimplantation in rats
J Surg Res
(1981)
DB Van Wyck et al.
Critical splenic mass for survival from experimental pneumococcemia
J Surg Res
(1980)
M Tavassoli et al.
Studies on regeneration of heterotopic splenic autotransplants
Blood
(1973)
VV Likhite
Evidence of immunological activity in heterotropic autotransplanted splenic tissue in DBA/2 mice
Cell Immunol
(1974)
AD Schwartz et al.
Antibody response to intravenous immunization following splenic tissue autotransplantation in Sprague-Dawley rats
Blood
(1977)
JD Dickerman et al.
The protective effect of intraperitoneal splenic autotransplants in mice exposed to aerosolized suspension of Type III Streptococcus pneumoniae
Blood
(1979)
MD Fasching et al.
Reimmunization and splenic autotransplantation: a long-term study of immunologic response and survival following pneumococcal challenge
J Surg Res
(1980)
JD Dickerman
Traumatic asplenia in adults. A defined hazard
Arch Surg
(1981)
BJ O'Neal et al.
The risk of sepsis in the asplenic adult
Ann Surg
(1981)

CD Robinette et al.

Splenectomy and subsequent mortality in veterans of the 1939–1945 war

Lancet

(1977)

DB Singer

Postsplenectomy sepsis

R Sherman

Perspectives in management of trauma to the spleen

J Trauma

(1981)

J Horton et al.

The importance of splenic blood flow in clearing pneumococcal organisms

Ann Surg

(1982)

G Van Stiegmann et al.

Failure of spleen repair

J Trauma

(1979)

Cited by (91)

Surgical Management of Solid Organ Injuries
2017, Surgical Clinics of North America
Citation Excerpt :
Management of blunt splenic trauma (BST) has substantially evolved over the past century. More than 100 years ago, evaluation of postmortem findings led Bilroth to suggest that the injured spleen has the ability of self-healing, and may be observed with NOM.48–59 The landmark Eastern Association for the Surgery of Trauma (EAST) trial in 2000 established the failure rates based on grade of injury for BST with little to no intervention.60
Spleen injuries in Spain: At what point are we?
2013, Cirugia Espanola
Aunque el tratamiento del traumatismo esplénico ha cambiado en las últimas décadas, no existen datos de la actitud que los cirujanos españoles adoptamos frente a este tipo de lesión tan frecuente. El propósito de este estudio es determinar el perfil del traumatismo esplénico en los adultos con traumatismo abdominal severo y el tratamiento que se realiza en nuestro medio.
Estudio de datos de registros de trauma de 6 hospitales españoles: Hospital Gregorio Marañón, Hospital de Getafe, Hospital Doce de Octubre, Hospital Virgen de la Vega, Hospital de Torrevieja y Corporació Sanitària Parc Taulí.
Se analizó a 566 pacientes con lesiones esplénicas (448 hombres y 118 mujeres). El tipo de traumatismo fue fundamentalmente cerrado (94%) y el mecanismo lesional más frecuente fue el accidente de tráfico El ISS medio de la serie fue de 25,2. El tratamiento fue inicialmente quirúrgico en el 56,6%, siendo en el 43,4% restante, conservador. De estos, el 6,5% de los pacientes requirió finalmente cirugía y en el 8,8% se realizó angioembolización esplénica. De los pacientes intervenidos al inicio, en el 85,3% de los casos se realizó esplenectomía, y cirugía conservadora de bazo en el 14,7%, de los que el 4,6% fracasaron y requirieron nueva intervención quirúrgica con esplenectomía.
El tratamiento en España para el traumatismo esplénico continúa siendo en su mayoría quirúrgico (fundamentalmente esplenectomía). La angioembolización y el tratamiento conservador continúan teniendo escasa presencia.
Management of spleen trauma has changed over last decades, although there is no data on its treatment in Spain. The aim of this study is to determine the characteristics of spleen injuries in adults with severe abdominal injuries and how we manage them.
A prospective study using the databases of six Spanish hospitals: Gregorio Marañón Hospital, Virgen de la Vega Hospital, Torrevieja Hospital, Getafe Hospital, Doce de Octubre Hospital and Corporació Sanitària Parc Taulí.
A total of 566 patients who had sustained spleen injuries were analyzed (448 males and 118 females), most of them were due to blunt trauma (94%), and the most frequent mechanism of injury was motor vehicle accident. The mean Injury Severity Score (ISS) was 25.2. The initial treatment was surgical in 56.6% of the patients (85.3% total splenectomy and 14.7% other conservative surgical procedures, of which 4.6% finally failed and required total splenectomy). The remaining 43.4% were initially managed conservatively, but 6.5% of them finally required surgical splenectomy, and in 8.8% angio-embolization was performed.
In Spain, management of spleen trauma is mainly surgical (particularly splenectomy). Angio-embolization and conservative surgical procedures are now hardly used.
Age does not affect outcomes of nonoperative management of blunt splenic trauma
2012, Journal of the American College of Surgeons
Citation Excerpt :
The description of overwhelming postsplenectomy sepsis in 1952 led surgeons to look for alternative management strategies for splenic preservation.15 Although adult surgeons developed splenic salvage techniques such as splenorrhaphy and partial splenectomy to address this challenge, pediatric surgeons provided both clinical and animal model evidence to support NOM as a safe alternative.16-18 Adult trauma surgeons, however, were still slow to adopt NOM techniques, given concerns about missing other concomitant intra-abdominal injuries and early reports of 30% to 70% FNOM rate.19,20
The purpose of this study was to examine the effect of age on the outcomes of nonoperative management (NOM) of blunt splenic trauma (BST).
The records of patients with BST, from July 2000 to December 2010 at a level I trauma center, were retrospectively reviewed using NTRACS (National Trauma Registry of the American College of Surgeons). Patients were divided into 2 age groups: 17 to 55 years and greater than 55 years. Stepwise logistic regression analysis was used to identify risk factors associated with failure of nonoperative management (FNOM).
There were 539 hemodynamically stable patients with BST who underwent NOM. Of these, 459 were age 55 or less, and 80 were greater than 55. Overall, there was no significant difference in FNOM rate for patients age 55 or less vs greater than 55 (4% vs 5%, p = 0.73). This also held true when FNOM was analyzed by each grade: I (1% vs 3%, p = 0.38), II (2% vs 0%, p = 1.0), III (4% vs 0%, p = 1.0), IV (8% vs 20%, p = 0.33), and V (21% vs 50%, p = 0.47). The addition of angioembolization (AE) to high grade IV to V injuries significantly lowered the FNOM rate: age 55 or less (6% AE vs 28% NO-AE, p = 0.02); with a trend toward significance for age greater than 55 (0% AE vs 60% NO-AE, p = 0.2). Age was not a statistically significant independent risk factor for FNOM (p = 0.37).
Age does not affect outcomes of NOM of BST. High grade (IV to V) injuries are not a contraindication to NOM for patients older than 55. As experience with AE grows in patients with high grade injury and age greater than 55, it may prove to be a valuable adjunct to NOM in this group of patients.
Controversies in the management of splenic trauma
2012, Injury
Citation Excerpt :
The main focus of treatment was hemorrhage control, and splenectomy was the treatment for virtually all splenic injuries, regardless of how minor. In the 1980s, increased awareness of the immunologic importance of the spleen, prompted efforts towards splenic salvage and led to the development of techniques such as splenorraphy and partial resection [15,21]. Expanding on the groundbreaking approaches of paediatric trauma surgeons, it became clear that non-operative management of splenic injuries was also a therapeutic option [6,14].
The technologic innovations of the last three decades, coupled with a deeper understanding of the immunologic role of the spleen, have significantly shifted the management of splenic injuries towards non-operative approaches. However, there continuous to be a wide range of practice patterns related to the non-operative management of splenic injuries, from which the authors infer a gap between the best available evidence and its translation into practice. We sought to explore ongoing areas of controversy in the non-operative management of splenic trauma with the aim of further elucidating why these controversies continue to exist.
We explored areas of ongoing controversy in the management of splenic injury though a series of iterative surveys. We invited 70 experts in trauma care from ten countries around the world to participate. Areas of controversy explored included: indications and frequency for in-hospital and follow-up imaging, definitions of failure of non-operative management, indications for angioembolisation and non-operative management in special populations (i.e. elderly, concomitant traumatic brain injury, penetrating trauma).
A 49% response rate was obtained. Even though a wide range of practice patterns were identified, no controversies were identified in areas that do not involve the adoption of new technologies. In areas where practice pattern variation was observed, the strong influence of the local environment was constantly identified as an impediment to changes in practice.
We have identified that barriers present within local practice environments are the major driving forces behind controversies in the non-operative management of splenic injuries.
Bacterial clearance after total splenectomy and splenic autotransplantation in rats
2002, Applied Radiation and Isotopes
Wistar rats submitted to isolated total splenectomy or total splenectomy combined with splenic autotransplantation were inoculated with ^99mtechnetium-labeled Escherichia coli. Measurement of isotope uptake in the organs of the mononuclear phagocytic system showed a greater bacterial bloodstream clearance in rats with splenic autotransplantation. Although uptake of bacteria in the spleen was higher in the control group, the number of bacteria remaining in the bloodstream did not differ between groups. These results indicate that splenic autotransplantation preserves the phagocytic function of the spleen.
Injury to the spleen
2001, Current Problems in Surgery
Citation Excerpt :
Moore and colleagues41 reported the case of a patient who died of OPSI after splenectomy plus autotransplantation, with a postoperative radionuclide scan that showed splenic uptake. Other studies of patients who underwent splenic autotransplantation after splenectomy have demonstrated normalization of immunoglobulin and complement factor (C3) levels, disappearance of Howell-Jolly bodies (which suggests normal hematologic function), and the presence of reticuloendothelial function, as shown by the appearance of splenic tissue on technetium sulfur colloid scans.86,93,164 In an important study, Traub and colleagues63 compared various treatment options (including splenorrhaphy, partial splenectomy, and total splenectomy with or without splenic autotransplantation) in 51 patients with spleen injury after abdominal trauma.

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^☆: Presented at the 34th Annual Meeting of the Southwestern Surgical Congress, April 29, 1982, Coronado, California, April 26–29, 1982.

¹: From the Departments of Surgery, University of Colorado Health Sciences Center and Denver General Hospital, Denver, Colorado.

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Scientific paperAlternatives to splenectomy in adults after trauma: Repair, partial resection, and reimplantation of splenic tissue☆

Abstract

J Pediatr Surg

J Surg Res

J Surg Res

Blood

Cell Immunol

Blood

Blood

J Surg Res

Traumatic asplenia in adults. A defined hazard

Arch Surg

The risk of sepsis in the asplenic adult

Ann Surg

Splenectomy and subsequent mortality in veterans of the 1939–1945 war

Lancet

Postsplenectomy sepsis

Perspectives in management of trauma to the spleen

J Trauma

The importance of splenic blood flow in clearing pneumococcal organisms

Ann Surg

Failure of spleen repair

J Trauma

Scientific paper
Alternatives to splenectomy in adults after trauma: Repair, partial resection, and reimplantation of splenic tissue☆