NONOPERATIVE MANAGEMENT OF ADULT BLUNT SPLENIC TRAUMA - A 15-YEAR EXPERIENCE

From January 1989 to December 1993, 40 consecutive adult patients with ruptured spleen from blunt trauma were examined. Fourteen patients (3 5%) were taken to the operating room initially because of hemodynamic instability acid generalized peritoneal signs. Twenty-six patients (65 %) were hemodynamically stabilized al admission and treated by nonoper ative management which included strict bed rest, intensive care unit m onitoring, frequent physical examinations, and serial hematocrits. Fou r patients failed nonsurgical management and required a splenectomy, t hree because of clinical deteri- oration within I to 3 days of admissi on; the fourth patient had recurrent bleeding 7 days after injury. The patients in the operative group had a greater severity of injury with a mean Injury severity score of 26.6, four deaths, and mean transfusi on requirements of 3.7 to 4.0 units of blood, compared to a mean injur y severity score of 14.6, one late death from cardiac causes, and aver age blood requirement of 0.4 to 0.7 units, Splenic injury grading aver aged 3.2 in the surgical group (grade ?, one patient; grade 2, four pa tients; grade 3, eight patients; grade 4, no patients; and grade 5, on e patient) and differed significantly from that of the nonoperative gr oup (mean = 2.4; grade 1, 12 patients; grade 2, seven patients; grade 3, six patients; grade 4, two patients; and grade 5, no patients). Rec ent ultrasound analysis oi select grades I to IV has shown excellent r esolution or repair of these injuries. This report esl ends our series from 1978 to 1993 and includes 144 adult patients sustaining blunt sp lenic ruptures. Seventy-nine (55%) of these patients were treated nons urgically, Seven patients (of 80) failed nonoperative management and r equired interval laparotomy, representing a 91 per cent success rate, Follow-up on more than 90 per cent of the patients has shown no sequel ae from their splenic injuries. We conclude that adult patients wit-fi splenic injuries from blunt trauma who are hemodynamically stable and are without abdominal findings requiring celiotomy can be safely mana ged by a nonoperative approach.