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Journal of Indian Association of Pediatric Surgeons
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ORIGINAL ARTICLE
Year : 2007  |  Volume : 12  |  Issue : 4  |  Page : 209-213
 

Splenic injuries in children: The challenges of non operative management in a developing country


1 Pediatric Surgery Unit, Department of surgery, University of Benin Teaching Hospital, Benin City, Nigeria
2 Orthopedics/Trauma Unit, Department of surgery, University of Benin Teaching Hospital, Benin City, Nigeria

Correspondence Address:
O D Osifo
Pediatric Surgery Unit, Department of Surgery, UBTH, Benin City
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.40837

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   Abstract 

Aim: This is to report the challenges and experience gained with non operative management of splenic injuries in a developing country where sophisticated imaging facilities are either not available or exorbitantly expensive. Materials and Methods: All patients who presented with splenic injury at the University of Benin Teaching Hospital between January, 2000 and December, 2006 were assessed and those who met the criteria were recruited for non operative management. Diagnosis of splenic injury was made by combining clinical assessment and ultrasound findings. Results: A total of 24 children with a mean age 12 ± 0.04 years and male/female ratio 1.7:1 were treated during the period. Road traffic accident, accounting for 50% of the cases was the major cause of trauma followed by falls from heights. Delay in presentation was a major concern as 62.5% of them were not referred until shock supervened. None of the patients could afford CT scan but ultrasound scan was able to confirm diagnosis in all. Basing decision on clinical parameters, non operative management was successfully done in 75% while 25% were operated as they could not meet the criteria. No mortality was recorded in the non operated group while one was recorded in those operated. The average length of hospitalization was two weeks. Conclusion: Non operative management of splenic injuries can be successfully done in a developing country using clinical parameters as a guide. The 75% of patients with splenic injury treated can be improved upon by health awareness campaign/improvement in government policy that will result in early presentation.


Keywords: Children, nonoperative management, splenic injuries


How to cite this article:
Osifo O D, Enemudo R E, Ovueni M E. Splenic injuries in children: The challenges of non operative management in a developing country. J Indian Assoc Pediatr Surg 2007;12:209-13

How to cite this URL:
Osifo O D, Enemudo R E, Ovueni M E. Splenic injuries in children: The challenges of non operative management in a developing country. J Indian Assoc Pediatr Surg [serial online] 2007 [cited 2019 Aug 25];12:209-13. Available from: http://www.jiaps.com/text.asp?2007/12/4/209/40837



   Introduction Top


The spleen is a highly vascular lymphoid organ, located in the left hypochondrium, which plays a major role in providing immunity. The absence of bony protection makes it one of the most frequently injured abdominal viscera. Diseased spleen especially due to malaria fever which is endemic in Africa ruptures even from trivial abdominal trauma. [1] Prior to 1970, particularly during the Nigeria civil war, the only treatment for splenic injury was splenectomy irrespective of the grade of injury and patients' clinical state. [1],[2] The problems of asplenia soon became a major drawback to total splenectomy. Overwhelming post splenectomy sepsis and resistant malaria fever became very fatal more than ever in children. [3],[4]

The recognition, that patients without spleen have an increased risk of death from overwhelming infection, led surgeons to consider methods of splenic preservation. [2],[5] Initially operative repair, splenorrhaphy, was attempted. Subsequently, in North America and Europe, where the majority of abdominal injuries are from blunt trauma, usually road traffic accidents (RTA) and with the introduction of the CT scan, non operative management became popular and now predominant. [2],[5],[6],[7],[8] Today, more than 90% of blunt pediatric splenic injuries and about 60-70% of adult ones are managed non operatively in the West and other developed countries. [2],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] In developing countries, such as Nigeria, however, lack of imaging facilities or inability to afford them even when available make it a great challenge to embark on non operative management. [1],[20],[21],[22],[23],[24],[25] In view of this, laparotomy with splenorrhaphy or splenectomy continued to remain the standard treatment in this centre. [20] Splenorrhaphy in children who reside in regions where malaria is endemic is very difficult as the splenic capsule is attenuated and holds sutures poorly. [1],[21],[22],[23],[24],[25] Asplenic children in developing countries are also more exposed to virulent organisms because of the poor environmental hygiene and as such die more from overwhelming post splenectomy sepsis. [1]

The need to adopt a non operative protocol that is available and cost effective in our own setting became paramount. This paper reports the challenges and experience with non operative management of splenic injuries in children at the University of Benin Teaching Hospital. An experience we feel may be useful to health provider, especially those working in low socioeconomic setting where sophisticated facilities may not be available.


   Materials and Methods Top


This is a seven year experience with non operative management of splenic injury at the University of Benin Teaching Hospital, Benin City, Edo State, Nigeria, between January, 2000 and December, 2006. The hospital is a tertiary health institution located in the South-south Geopolitical Zone of Nigeria. Patients were referred to our unit from trauma unit of the hospital, other hospitals in the state and by the paramedical health providers. Each patient was evaluated for age, sex, etiology of splenic injury, place of referral, time lag between trauma and presentation to us and clinical state on arrival. Splenic injury was diagnosed by combining clinical assessments, imaging and radiological investigations. Based on clinical evaluations within the first 24 h on presentation, the patients were placed in either of the four categories:

  • A - Those who were hemodynamically stable on arrival and thereafter.
  • B - Those that were unstable but stabilized by administration of crystalloids only.
  • C - Those that were unstable but stabilized by administration of colloids.
  • D - Those who have penetrating abdominal injury and those who remained unstable after resuscitation with 50% of their estimated blood volume within the 24h.


The mode of treatment; operative or non operative was then decided. Category A-C had non operative treatment while category D had operation. Non operative treatment included crystalloids and or colloids, antibiotics and analgesia administration. All the patients had hourly assessment of pulse rate, blood pressure, urinary output, abdominal girth and tenderness, sensorium, temperature and respiratory rate. Daily hematocrit, blood chemistry, radiological monitor and restriction to bed for one to two weeks were the routine but these were, however, adjusted based on the financial status of the patients. In such instances, after the initial ultrasound confirmation of splenic injury, subsequent decisions were based on clinical evaluations. Splenorrhaphy or splenectomy and intraoperative autotransfussion were done for those who had an operation.

Some patients had severe multiple trauma and some were found to have neither clinical nor radiological evidence of splenic injury. These categories were excluded from the study. The data obtained was analyzed using SPSS and presented in tables and figures.


   Results Top


A total of 24 children comprising of 15 males and 9 females with a ratio of 1.7:1 were treated with isolated splenic injury in 19 (79.2%). Their ages ranged between 2-18 years with a mean of 12 ± 0.04 years. [Figure - 1] shows the age distribution of the patients. The age group mainly affected were those between 11-15 years who accounted for 10 (41.7%) and 16-18 years 8 (33.3%). Those in age group 5-10 years 4 (16.7%) and less than 5 years 2 (8.3%) were less commonly affected. Out of the 24 patients, only 9, (37.5%) presented to us directly after the trauma. The remaining 15 (62.5%) were referred from 10 (41.7%) chemist's shops, 4 (16.7%) private clinic and 2 (8.3%) traditional clinics when they had deteriorated [Figure - 2].

Road traffic accidents was a leading cause of splenic injuries as half (50%) of the patients were involved in car, motorcycle or bicycle accidents. Fall from a height was implicated in six (25.0%), domestic accidents three (12.5%), sport injuries two (8.3%) and penetrating gunshot one (4.2%). Only few patients presented within few hours of injuries. The mean time lag for RTA was two days, fall from heights 1.5 days, domestic accident six hours, sport injuries 11 hours and gunshot one hour. All those referred late were hemodynamically unstable. Overall, a total of 16 (66.7%) were in poor clinical state on arrival. Eight from RTA, three fall from a height, two domestic accidents, two sport injuries and 1 penetrating gunshot [Table - 1]. The clinical parameters of the patients, their mean and standard deviation on presentation are depicted in [Table - 2]. Body weight 12-20 kg (26 ± 2.05), haematocrit 6-12.5 mg% (8.5 ± 0.40), core body temperature 35-37.4șc (36 ± 0.12), systolic blood pressure 50-120 mmHg (70 ± 2.80) and pulse rate 80-130/min (98 ± 2.40).

[Table - 3], Shows the modalities of treatment based on clinical evaluations. There were eight stable and 16 unstable patients on assessment. The eight stable patients (category A) were managed none operatively and hospitalized for between one and two weeks. Of the unstable group, three patients (category B) were stabilized by only crystalloid administration while seven (category C) needed blood transfusion to become stable. These two categories were also successfully managed non operatively and hospitalized for two weeks. The five patients who could not be stabilized even after receiving more than half their estimated blood volume within 24 hours and the one penetrating gunshot injury (category D) had exploratory laparotomy and findings were grade IV-V splenic injuries. The surgical options offered were splenorrhaphy in 4 and splenectomy in 2. On the whole 18 (75%) of the patients were successfully managed without operation while six (25%) were operated. No death was recorded in the non operated group while one death was recorded in those operated giving an overall mortality of 4.2% in this study.


   Discussion Top


Non operative management is feasible in developing countries in spite of the enormous challenges. This study shows that 18 (75.0%) of the 24 children treated over the seven years period were successfully managed without operation. Management protocol based on categorizing the patients using clinical evaluations rather than expensive imaging [7],[8] was found to be affordable and cost effective. Earlier reports [20],[21],[22],[23],[24],[25] from this sub-region were not encouraging perhaps due to the understanding that non operative management is not feasible without sophisticated imaging facilities. The importance of imaging (CT scan) for the diagnosis and follow-up of patients with splenic injuries cannot be overemphasized. [26],[27],[28] Depending on it as the sole determinant and predictor of management outcome have been queried by other workers. [7],[8]

CT scan was not available in this centre until recently and when it was, none of our patients could afford it. Ultrasound scan was good enough in detecting splenic injury and the presence of hemoperitoneum has also been reported. [6] The diagnosis having been confirmed, the subsequent clinical state is a reflection of the rate of bleeding. [6],[7],[8] This to a large extent reflects the severity and grade of splenic injury. Diligent and committed staffs were on ground to detect any variations from the baseline clinical parameters throughout the period of hospitalization as also noted in previous report. [10] This was, however, exerting on the staffs as most monitoring were manual. Understaffed pediatric surgery units in developing countries where there are no CT scan may need to adopt non operative management cautiously.

More males were affected than females with a ratio of 1.7:1 and the age range 11-15 years was the highest group affected. This tallies with reports [1],[21],[22],[23],[24],[25] from other geopolitical zones in Nigeria. Trauma generally, affects more males worldwide particularly during periods of civil unrest and the incidence increases with age, reaching a peak between 20-30years. [1],[22] Some patients above 16 years are managed by adult surgeons [20] and this could explain why the prevalence was lower in the age range 16-20 years than 11-15 years in this series, even though the incidence of trauma is the reverse.

The mortality of 6.3% earlier reported by Ameh [21] in Northern Nigeria is comparable with 4.2% recorded in this study. All his patients were, however, operated due to lack of imaging facilities, 59.4% splenorrhaphy and 40.6% splenectomy. He opined that laparotomy would have been avoided in 51.6%, were imaging facilities available. This is similar to a report [23] from Eastern Nigeria where all 23 cases seen over the past one and half decades were operated, 65.2% splenectomy and 34.8% splenorrhaphy. Adopting this non operative protocol based on clinical evaluations in view of the scarce resources resulted in 75% of our patients being successfully managed non operatively. We could not, however, record up to 90% non operative management as recorded in developed countries [2],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19] due to factors peculiar to our setting.

Road traffic accident is a leading cause of splenic injury in developed cities [2] but the delay in presentation with a mean of two days in this study is alarming. This could be due to the poor transportation system and non availability of rescue team. Financial constraint and lack of awareness made those rescued from injury scene (62.5%) initially sought help from cheaper sources such as chemist's shops. They were sent to us when they continued to deteriorate. Unlike Western countries were patients present within few hours of injury and in relatively stable clinical state [13],[14],[15],[16],[17],[18],[19],[20] our patients (66.7%) presented in poor clinical state. This could partly explain while 25.0% of our cases were offered operation. The patient who sustained splenic avulsion from penetrating gunshot, though presented early did not meet the criteria for non operative treatment. Control of bleeding and resuscitation was very difficult and his death within few hours after total splenectomy from irreversible shock was not unexpected as there were no facilities for angiography embolization. [29]

Non operative management of splenic injury is not hundred percent successful even in the most sophisticated centres. [30],[31] Not all patients and all grades of trauma can be treated as seen in our series and reports from centres with modern facilities. [12],[14],[31] Some patients who met the criteria for selection have been lost during management and delay rupture with life-threatening bleeding has been reported several days after splenic trauma. [1],[31] There is, therefore, a need for follow-up long after the most stable patient has been discharged.

In conclusion, developing countries are far behind in acquiring modern facilities available currently for management of splenic injury in developed countries. Transporting such knowledge without taking into account the socioeconomic status of the people will result in poorer outcome as these facilities are not on hand and inexorably expensive. Adequate clinical assessment, vigorous resuscitation, committed monitoring and cooperation between nursing staffs and patients give good results when non operative treatment is adopted using clinical parameters as a guide.

 
   References Top

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2.Brian O. Is splenic preservation after blunt splenic injury possible in Africa? Surgery in Africa- Monthly Review; July 2007. p. 1-3.  Back to cited text no. 2    
3.Hansen K, Singer DB. Asplenic-hyposplenic overwhelming sepsis: Post splenectomy sepsis revisited. Pediatr Dev Pathol 2001;4:105-21.  Back to cited text no. 3    
4.Boone KE, Watters DA, Morris J. The incidence of Malaria after splenectomy in Papua New Guinea. Br Med J 1995;311:1273-6.  Back to cited text no. 4    
5.Upadhyaya P. Conservative management of splenic trauma: History and current trends. Pediatr Surg Int 2003;19:617-27.  Back to cited text no. 5    
6.Richards JR, McGahan JP, Jones DC, Zhan S, Gerscovich EO. Ultrasound detection of blunt splenic injury. Injury 2001;32:95-103.  Back to cited text no. 6    
7.Huebner S, Reed MH. Analysis of the value of imaging as part of the follow-up of splenic injury in children. Pediatr Radiol 2001;31:852-5.  Back to cited text no. 7    
8.Lyass S, Sela T, Lebensart PD, Muggia-Sullam M. Follow-up imaging studies of blunt splenic injury: Do they influence management? Isr Med Assoc J 2001;3:731-3.  Back to cited text no. 8    
9.Goan YG, Huang MS, Lin JM. Non-operative management for extensive hepatic and splenic injuries with significant haemoperitoneum in adults. J Trauma 1998;45:360-5.  Back to cited text no. 9    
10.Myers JG, Dent DL, Stewart RM. Blunt splenic injuries: Dedicated trauma surgeons can achieve a high rate of non operative success in patients of all ages. J Trauma 2000;48:801-6.  Back to cited text no. 10    
11.Keller MS, Vane DW. Management of pediatric splenic injury: Comparison of pediatric and adult trauma surgeons. J Pediatr Surg 1995;30:221-4.  Back to cited text no. 11    
12.Falimirski ME, Provost D. Non surgical management of solid abdominal organ injury in patients over 55 years of age. Am Surg 2000;66:631-5.  Back to cited text no. 12    
13.Meguid AA, Bair HA, Howell GA, Benedick JP, Kerr HH, Villalba MR. Prospective evaluation of criteria for non operative management of blunt splenic trauma. Am Surg 2003;69:238-43.  Back to cited text no. 13    
14.Carlin AM, Tyburski PG, Wilson RF, Steffes C. Factors affecting the outcome of patients with splenic trauma. Am Surg 2002;68:232-9.  Back to cited text no. 14    
15.Schwab CW. Selection of non operative management candidates. World J Surg 2001;25:1389-92.  Back to cited text no. 15    
16.Stylianos S. Compliance with evidence-based guidelines in children with isolated spleen or liver injury:a prospective study. J Pediatr Surg 2002;37:453-6.  Back to cited text no. 16    
17.Stylianos S. Evidence based guild lines for resource utilization in children with isolated spleen or liver injury. J Pediatr Surg 2000;35:164-9.  Back to cited text no. 17    
18.Davis DH, Localio R, Stafford P, Helfaer MA, Durbin DR. Trends in operative management of pediatric splenic injury in a regional trauma system. Pediatr 2005;115:89-94.  Back to cited text no. 18    
19.Keller MS, Sartorelli KH, Vane DW. Associated head injury should not prevent non operative management of spleen or liver injury in children. J Trauma 1996;41:471-5.  Back to cited text no. 19    
20.Ohanaka EC, Osime U, Okonkwo CE. A five year review of splenic injuries in the University of Benin Teaching Hospital, Benin City, Nigeria. West Afr J Med 2001;20:48-51.  Back to cited text no. 20    
21.Ameh EA. Management of paediatric blunt splenic injury in Zaria, Nigeria. Injury 1999;30:399-401.  Back to cited text no. 21    
22.Ameh EA, Chirdan LB, Nmadu PT. Blunt abdominal trauma in children: Epidemiology, management and management problems in a developing country. Pediatr Surg Int 2000;16:505-9.  Back to cited text no. 22    
23.Osuigwe AN, Ihekwoba CH. Splenic conservation in children with splenic injury at Nnewi- South Eastern Nigeria: A ten year audit. Trop J Med Res 2005;9:14-6.  Back to cited text no. 23    
24.Edino ST. Pattern of abdominal injuries in Aminu Kano Teaching Hospital, Kano. Niger Postgrad Med J 2003;10:56-9.  Back to cited text no. 24    
25.Chirdan LB, Uba AF, Yiltok SJ, Ramyil VM. Paediatric blunt abdominal trauma: Challenges of management in a developing country. Eur J Pediatr Surg 2007;17:90-5.  Back to cited text no. 25    
26.Ruess L, Sivit CJ, Eichlberger MR, Taylor GA, Bond SJ. Blunt hepatic and splenic trauma in children: Correlation of a CT injury severity scale with clinical outcome. Pediatr Radiol 1995;25:321-5.  Back to cited text no. 26    
27.Brick SH, Taylor GA, Potter BM, Eichlberger MR. Hepatic and splenic injury in children: Role of CT in the decision for laparotomy. Radiology 1987;165:643-6.  Back to cited text no. 27    
28.Nwomeh BC, Nadler EP, Meza MP, Bron K, Gaines BA, Ford HR. Contrast extravasation predicts the need for operative intervention in children with blunt splenic trauma. J Trauma 2004;56:537-41.  Back to cited text no. 28    
29.Wahl WL, Ahrns KS, Chen S, Hommila MR, Rowe SA, Arbabi S. Blunt splenic injury: Operation versus angiographic embolization. Surgery 2004;136:891-9.  Back to cited text no. 29    
30.Ochsner MG. Factors of failure for non operative management of blunt liver and splenic injuries. World J Surg 2001;25:1393-6.  Back to cited text no. 30    
31.McIntyre LK, Schiff M, Jurkovich GJ. Failure of non operative management of splenic injuries- causes and consequences. Arch Surg 2005;140:563-9.  Back to cited text no. 31    


    Figures

  [Figure - 1], [Figure - 2]
 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3]


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