Of the Patients Could Not Afford the Cost of Usage of Such

INTRODUCTION

The spleen is the most commonly injured organ in blunt, and the third in penetrating abdominal injuries1-6. Trauma has been found to be the most common indication for splenic operations (splenectomy, and splenorrhaphy) worldwide. Non operative management in patients with splenic injury is gaining wider acceptance especially in centers with modern diagnostic equipments. Indications for operation on the spleen are commonly encountered in both the young and the old. Surgical procedures performed are usually based on the clinical state of the patient, surgeon’s experience and availability of diagnostic and monitoring gadgets.

Other indications for splenectomy apart from splenic injury include haematological disorders predisposing to hypersplenism. Splenectomy as a component of staging laparotomy is now catching less fancy with the presence of sophisticated diagnostic equipments such as CAT-SCAN which can be used for detailed evaluation of such patients. .Open surgery still remains a standard therapy for splenic trauma or masses in most developing parts of the world where there is dearth of modern diagnostic and therapeutic gadgets and where most

of the patients could not afford the cost of usage of such.

MATERIALS AND METHODS

This is a retrospective review of all operations done on the spleen at LAUTECH Teaching Hospital Osogbo (Nigeria) from August 2001 to July 2005. Information was obtained from the theatre records, clinic notes and the histology laboratory. These included patients’ demographic data, indications for operation, pre-operative resuscitative measures, intra-operative findings, estimated blood loss, number of blood units transfused and post-operative complications. Antibiotic, antimalarial chemopro-phylaxis used and vaccinations taken were noted. Data was analyzed using simple percentage.

RESULTS

Twenty six splenic operations were performed within the period of August 2001 to July 2005. These were done for 18 males and 8 females (M: F 9:4). Age ranged between 2 and 52 years with a mean and median of 24.8 and 26.5 years respectively. Between five to eight patients were in the first four decades of life while only two (7.7%) were above 40 years of age (see table I).

Twenty three (88.4%) of the procedures were done as emergencies. The three elective procedures were done for patients with tropical splenomegally syndrome (TSS), splenomegally in a patient with HbSS (Sickle Cell Haemoglobinopathy) and another one with hypersplenism. Twenty two of the twenty three (95.7%) emergency splenic procedures were for blunt abdominal injuries. The only one penetrating injury was from a stab injury sustained during a fight. Road traffic injury, fall from height, assault, sport and impalement of object accounted for 52.2%, 22%, 8.6%, 8.6%, 8.6% respectively as aetiology of injury. No case of inadvertent iatrogenic splenic injury was recorded.

TABLE I: Age distribution of patients who had operations on the Spleen at LAUTECH Teaching Hosp.Osogbo (August 2001 – July 2005) (n=26).

Age (Year) / No. of Patients
1-10 / 5(19.2%)
11-20 / 5(19.2%)
21-30 / 6(23.1%)
31-40 / 8(30.8%)
41-50 / 1(3.84%)
51 + / 1(3.84%)

There were features of generalized haemo-peritonium confirmed by positive four quadrant tap in 19 (82.6%) of the trauma cases. Abdominal Ultrasound (USS) was carried out in 56% of these trauma cases. Haemoperitoneum, splenic lacerations, splenic haematoma, splenic contusion and capsular irregularity were found in 69%, 38.5%, 23%, 15.5%, 15.5% of all trauma cases scanned. The only case of splenic abscess picked by USS was confirmed at operation. The pre-operative Hb% was between 6 and 10g% in 96% of patients. Thirty percent of patients had pre-operative blood transfusion with one pint of blood. The HbSS patient with splenomegally was operated with a stable Hb of 7g%.

The injury-admission interval was between one hour and one week; only two patients (8.6%) of the

trauma patients presented within 2hours; four patients presented after 48hours. Thirteen trauma patients (56.5%) were operated within 6hours of admission. Only two (8.6%) were operated after 24hours.

Twelve (52%), three (14%) and five (27%) of the splenic injuries were grade II, III and IV respectively while one each had grades I and V injuries. .Associated injuries involving the liver, stomach, pancreas, jejunum and messentary were present in one patient each. Two patients had associated head injury and long bone fractures.

Of the trauma patients, four (17%) had splenic preservation either by partial splenectomy or splenorraphy. All these had grades I - III injuries. All elective cases had splenectomy. Twelve, including the HbSS (46%), nine (34%), four (15%) and one (4%) patient(s) had homologous blood transfusion with one, two, three and four pints respectively. None had autologous blood transfusion.

All patients who had splenic preservation procedures were transfused with one pint of blood each, none of them had associated intraperitoneal injury. Closed peritoneal drains were inserted in patients with associated intra-abdominal injuries close to the repaired organ. A consultant was the lead surgeon in 96% of the procedures.

Complications including acute gastric dilatation occurred in the patient with Sickle Cell haemo-globinopathy, while wound infection and wound dehiscence occurred in seven (27%) and five (19%) patients respectively. Grades I, II and III wound infection were observed in one, five and one patients respectively while post-operative fever occurred in three patients. .

Fifteen patients attended follow up clinics for periods varying from one month to one year with a mean period of 5.2 months. Two were referred to other Teaching Hospitals near their homes while five never attended any follow-up clinic. Only two patients had anti-malaria prophylaxis (Palludrine) for a varying period of two to four months. None had antibiotic prophylaxis or pneumovax or any other form of vaccinations. There was no record to show that appreciable health education was given to these asplenic patients.

Four patients (3males and 1 female) died giving a mortality rate of 15.4%. These included the patients with splenic abscess, penetrating injury and two blunt abdominal injuries. Their pre-operative Hb ranged from 7 to 9g% (similar ranges with other patients).The latter two sustained grade II or III splenic injuries but each of them had associated

head and stomach injuries respectively. They had splenectomy but died on the operation day while those with penetrating injury and splenic abscess died on the third and fifth post-operative days respectively. The patient with splenic abscess died possibly of massive pulmonary thromboembolism. Autopsy was not performed on any of them. The only patient who was transfused with four pints of blood survived. The 10year old patient who had splenectomy for TSS died 4 months later from recurrent anaemia and persistent low grade fever though she was seronegative for HIV I and II. Overwhelming post-splenectomy infection (OPSI) was not observed in any of our patients.

DISSCUSSION

Aristotle observed that asplenic state was compatible with life; this was confirmed experimentally by Wren and Morgagni in the 17th and 18th centuries respsectively1. Therapeutic splenectomy was performed for hematological and trauma reasons by Adriana Zaccarello and Nicholas Mathias in 1549 and 1678 respectively1. This remains the tradition until the later half of the 20th century when overwhelming post splenectomy infection was recognized. Preservation or Non-operative treatment then becomes a better option especially for children by experienced surgeons in well established centers 1-6.

In our review, children were equally involved as adults, this is in keeping with other studies, as trauma occurs more commonly in the young age group5. Most of the splenic operations were for emergencies secondary to trauma. Trauma remains the most common indication for the operation on the spleen. 6,,7. The change from splenectomy to splenic preserving procedures in patients with traumatic indications for splenectomy has worldwide acceptance even though practitioners in the undeveloped nations still face some dilemma with this procedure.

Management of patients with traumatic rupture of the spleen in the tropic showed trends towards spleen preservation as the incidence of associated injury- continuous haemorrhage or delayed complications requiring laparatomy is low as shown in this study. Adequate facilities for diagnosis, resuscitation, prolong observation and timely interventions are essential for this. Lack of facilities in the undeveloped world may militate against surgery for spleen preservation. About 20-40% of patients with splenic injury could benefit from the

non-operative approach; these usually cardio-vascularly stable patients are better closely monitored in a well equipped intensive care unit. A detailed follow up with restricted activities for a period of 6 – 10 weeks is also required. Non operative management of splenic injury (NOMSI) is likely to fail in patients with high grade splenic injury requiring to be transfused with more than 1 unit of blood. The likelihood of failure rate also increases significantly with the American Association for surgery (AAST) grades of splenic injury7 8. The multi – institutional trial Committee of the Eastern Association for the surgery of trauma also observed that of the patients with planned observation, 10.8% failed and required laparotomy; 82.1% of patients with injury severity score (1SS) < 15 and 46.6% of patients with 1SS>15 were successfully observed. Sixty percent of failures occurred in the first 24 hours) 8 9. Several series also reported 80-90% success rate with NOMSI in adults without significant haemoperitoneum.2`.

Aside trauma, splenectomy could be found necessary in patients with haematological disorders, myeloproliferative diseases, splenomegally with hypersplenism, and also as adjunct to operations like gastrectomy, left colectomy, or when accidentally injured. It could also be required as a non-shunt procedure for portal hypertension and in patient with hydatid disease. Spontaneous splenic rupture is an uncommon clinical entity which may be associated with diseased spleen in leukemia, abscess and chronic malaria as reported by various authors.5, 9,-11...

Splenic abscess is not uncommon in regions where sickle cell disease and malaria co-exist; it could be as a result of liquefied splenic infarct. Splenic preservation plus drainage of abscess is preferred to splenectomy when feasible but the latter is indicated in AIDS patients with thrombocytopenia1. Drainage by aspiration under USS guidance, augmented with antibiotic therapy was practiced by Jelliffe in Ibadan12

Fewer staging laparotomy for myeloproliferative diseases are done nowadays in view of the improved degree of sophistication in imaging techniques worldwide including even some parts of the developing nations. Splenectomy could also be of value in relieving symptoms in patients with gross splenomegally.

More aggressive attempts are now being directed at intra-operative splenic salvage with the evolving understanding of the role of the spleen in the immune surveillance system. The salvaging

system could be in form of partial splenectomy or simple suture repair of the parenchyma (using buttress technique or with collagen or Teflon or over an omental patch.). Wrapping with the greater omentum or an absorbable mesh, use of haemostatic agent e.g. fibrin glue, and splenic artery ligation in continuity have also been found to be of value.13. The 90mm linear automatic stapler can also be used for splenorraphy when either of the poles are involved.2. Sutured repair and omental wrapping was the method applied by us as many of the others mentioned are not available to us. Major injury involving the hilar vessels or difficulty in repair (suturing) of diseased spleen, continuous bleeding, massive splenic disruption, blood loss > 1000 mls, and coagulopathy may however necessitate splenectomy.14 The grade of injury determines suitability; however it is known that the critical mass required to confer substantial protection from bacterial infection seems to be up to ¼ or 1/3 of the spleen.15. Associated injuries causing significant peritoneal contamination should discourage the surgeon from preservation. Many trauma centers now perform splenorraphy in more than 2/3 of all adults requiring laparotomy for splenic injury.2. Our patients tend to have higher grade of trauma and relatively higher amount of haemoperitoneum hence more splenectomies than repair were done by us as found in the Benin study.5 This is associated with reduced hospital stay and lower morbidity.

Autologous blood transfusion should be regularly practiced in patients managed openly once the haemoperitoneum is uncontaminated as difficulties are commonly encountered in making homologous blood available to patients. This also minimizes the cost and risks of homologous blood transfusion.

No case of overwhelming post splenectomy infection (OPSI) was found in this study, though a child who had splenectomy for gross splenomegally (? TSS) died of gradual immunosupression. The incidence of OPSI is generally low (between 3-4%) though the lifetime risk is 5% 16. It is also known to be less in adults and patients who had splenectomy for non-haematological reasons. Waghorn studied data on 77 patients who developed OPSI all over the United Kingdom and found an overall mortality rate of 50%; the greatest risk was found to be within 2-3 years.17, 18. Deodhar found no case of OPSI in 56 patients studied over a 5 year period,16 hence pre occupation with the specter of OPSI should not

Interfere with exercise of commonsense and good surgical judgment.

However guidelines need to be stipulated in the management of asplenic populace, as little percentage or none of such are being provided with vaccination e.g. pneumo-vax, or even malaria prophylaxis especially in the under developed world. Patient education and counseling at the time of splenectomy is just as important as appropriate vaccination and antibiotics prophylaxis measures, these are included in the guidelines by the British committee for standards on Haematology for prevention of infection.19. Documentation of extra caution to be taken by patients in the wake of infections need to be taught and a splenectomy registry can be kept in the hospital for easy tracking of patients. A protocol sheet can also be kept in the case note for this purpose.

Other complications noted include wound infection, wound dehiscence and post-operative fever at 27%, 19% and 12% respectively. Associated injuries contributed significantly to morbidity and mortality 2,4,6. Regular low dose aspirin can be used in patients with post splenectomy thrombocytosis.

The mean period for follow up was 5 months; this was rather short for any significant post operative assessment. The rather poor economic status of most of the patients and the fact that most live far away from our centre are possible factors for loss to follow-up.

CONCLUSSION/RECOMENDATION

Trauma is the most common indication for operative procedures on the spleen. Most procedures are done as emergencies. . All attempts should be directed to splenic salvage when open procedure is required. Associated injury significantly increases mortality in trauma cases. Though no case of OPSI was seen in this series, drastic improvement is required in the care of asplenic patients in terms of adequate vaccination against pneumococus, H. Influenza etc antimalaria and antibiotic prophylaxis. Writing of adequate discharge summaries, use of splenectomy card or bracelets and opening of splenectomy registry will go a long way in providing adequate information for follow-up care at the surgical out-patient clinic or by the nearby family physician. The role of splenic conservation and adequate follow-up care with health education cannot be overemphasized in the care of patients with surgical splenic disorders.