CHANGING PATTERNS IN THE MANAGEMENT OF SPLENIC TRAUMA - THE IMPACT OFNONOPERATIVE MANAGEMENT

Objective The recognition that splenectomy renders patients susceptibl e to lifelong risks of septic complications has led to routine attempt s at splenic conservation after trauma. In 1990, the authors reported that over an 11-year study period involving 193 patients, splenorrhaph y was the most common splenic salvage method (66% overall) noted, with nonoperative management employed in only 13% of blunt splenic injurie s. This report describes changing patterns of therapy in 190 consecuti ve patients with splenic injuries seen during a subsequent 6-year peri od (1990 to 1996). An algorithmic approach for patient management and pitfalls to be avoided to ensure safe nonoperative management are deta iled. Methods Nonoperative management criteria included hemodynamic st ability and computed tomographic examination without shattered spleen or other injuries requiring celiotomy. Results Of 190 consecutive pati ents, 102 (54%) were managed non-operatively: 96 (65%) of 147 patients with blunt splenic injuries, which included 15 patients with intrinsi c pathology, and 6 hemodynamically stable patients with isolated stab wounds (24% of all splenic stab wounds). Fifty-six patients underwent splenectomy (29%) and 32 splenorrhaphy (17%). The mean transfusion req uirement was 6 units for splenectomy survivors and 0.8 units for nonop erative therapy (85% received no transfusions). Fifteen of the 16 majo r infectious complications that occurred followed splenectomy, Two pat ients failed nonoperative therapy (2%) and underwent splenectomy, and one patient required splenectomy after partial splenic resection. Ther e no missed enteric injuries in patients managed nonoperatively, The o verall mortality rate was 5.2%, with no deaths following nonoperative management. Conclusions Nonoperative management of blunt splenic injur ies has replaced splenorrhaphy as the most common method of splenic co nservation. The criteria have been extended to include patients previo usly excluded from this form of therapy. As a result, 65% of all blunt splenic injuries and select stab wounds can be managed with minimal t ransfusions, morbidity, or mortality, with a success rate of 98%. Sple nectomy, when necessary, continues to be associated with excessive tra nsfusion and an inordinately high postoperative sepsis rate.