Management of blunt splenic injury in children: evolution of the nonoperative approach

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Abstract

Background

Nonoperative management of blunt splenic injury (BSI) was first proposed at our institution in 1948. Since that time, treatment of patients with BSI has evolved from routine splenectomy to an aggressive spleen-preserving philosophy. This report summarizes our institutional experience for the last 50 years.

Methods

All children (0-18 years) admitted to our pediatric trauma center with BSI during 4 eras (1956-1965, 1972-1977, 1981-1986, and 1992-2006) were retrospectively reviewed for demographics, injury patterns, management, and complications.

Results

During the 4 eras captured for the last 5 decades, 486 children experienced BSI. The mean age was 10 years with 347 males (71%). Nonoperative management rate increased from 42% to 97% with improvement in splenic salvage rate (42%-99%). Mean length of stay decreased from 17 to 5 days. In patients with isolated splenic injuries (50%), nonoperative management rate increased (36%-100%) and fewer received transfusions (60%-1%). Overall mortality rate improved (19%-6.6%, 8%-0.7% in isolated injuries).

Conclusion

The management of BSI in children has changed dramatically for the last 50 years. This study clearly demonstrates the safety of nonoperative management and documents progressively lower rates of splenectomy and transfusion, shorter hospitalization, and an extremely low risk of mortality.

Section snippets

Methods

The Research Ethics Board of The Hospital for Sick Children (SickKids) in Toronto, Ontario, Canada, granted ethics approval for this study (REB#1000011509). The medical records of all children (younger than 16 years) admitted with documented BSI between January 1, 1992, and December 31, 2006 (14 years), were examined. The Trauma Registry at our level 1 pediatric trauma center was used to collect demographic data (age, weight, and sex,) and injury-specific data (length of stay and Injury

Results

The populations and demographic characteristics of each era are summarized in Table 1. Each era had a significant number of isolated blunt splenic injuries, defined as those occurring in children with no other major torso, head, spine, or extremity injuries. The mean age and proportional sex distribution of patients were similar throughout the 4 eras.

We present the data for each era as both the overall cohort of blunt splenic injuries and those occurring in isolation. Not only has the

Discussion

The management of blunt splenic injuries in children almost universally consisted of splenectomy until the 1960s. In the early 1900s, proponents of operative management cited delayed bleeding, splenic pseudocyst, organizing hematoma, and abdominal splenosis as the possible consequences of nonoperative management [6], [7], [8], [9]. Various surgeons observed that most of the splenic injuries they operated on had stopped bleeding by the time a laparotomy was performed [1], [10]. This was observed

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Presented at the 40th Annual CAPS Meeting, August 21-24, 2008, Toronto, Ontario, Canada.

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