Splenic Trauma
	Date: Wed, 08 May 96 14:15:00 From: Carlos Previdi [carlos.previdi@mpc.com.br] Revising patient data of whom have been assisted by Trauma Surgery Discipline, at Campinas State University Hospital, from 1990 up to 1994. Looking up for spleen trauma and its complications, we have selected data from 104 patients. Our doubt concerns about high splenectomy incidence in grade III spleen trauma. At those patients, we have discovered a 92.8 % splenectomy rate. Putting aside the ones who have associated lesions, or hipovolemic shock; splenectomy is still high - 57 %. I would like to compare data from another services. For all patients we have calculated TRISS, APACHE II, GLASGOW scores.
	Date: Wed, 8 May 1996 17:02:26 From: John A. Aucar, M.D. [jaucar@bcm.tmc.edu] I do not have accurate comparative data with regards to splenic grading, trauma scoring and salvage rates at our institution for recent years. But, I can make a general comment. Our splenectomy rate is also high for potentially salvageable spleens. Some of the reasons for this may be institution dependant. We under utilize CT scanning for pre-operative evaluation due to cost constraints and a high trauma volume making DPL more valuable for evaluation of the ambiguous abdomen. This , of course leads to a high rate of negative and non-therapeutic laparotomies. We are not as adept at Ultrasound as we would like to be. When a low grade splenic injury is encountered, aggressive manipulation and mobilization often leads to extension of the injury (can I blame the resident?) When a borderline case is encountered, our residents find it easier to justify taking the spleen out than to explain the occasional need to go back or give blood. Thus there are multiple selection biases against the poor defenseless spleen. You may wish to examine your data for trends related to selection and technique.
	Date: Thu, 9 May 1996 14:08:50 From: Bryan Garber [garber@zeus.med.uottawa.ca] We currently reviewed our four year experience at a Canadian lead trauma hospital and found that 50% of multiple injured patients with splenic injuries had their spleens salvaged and 86% of these were by observation alone with a success rate of 90%. When we compared the successful observation to splenectomy group we found that the strongest factor associated with successful observation was diagnosis by CT scan which was performed in over half the patients. while CT scan was not PREDICTIVE of successful observation; the decision to scan was based on a variety of clinical factors such as hemodynamic stability etc. The bottom line was that if yor spleen injury was diagnosed by CT scan you had a good chance of salvage whereas if it was by DPL, your injury was likely more severe and it probably came out. We did very few splenorrhaphies and I suspect that centres which do alot of these diagnose their injuries alot by DPL because of trauma volume.
	Date: Fri, 10 May 1996 07:13:21 From: Dave Adams [dcrad@ihug.co.nz] At Middlemore we don't have a huge throughput of trauma (n=26 splenic injuries per 3 years), almost all due to blunt injury. As with your experience Laparotomy tends to equal spleen in the bucket, so we've tried to get a decent protocol underway, allowing conservative management of solid viscus/abdominal injuries. Essentially it's : Stable, concious => observe Stable or unstable, unconcious => DPL Unstable, concious, abdo equivocal => DPL Unstable, definite abdo signs => Laparotomy. However, +ve DPL does not mandate laparotomy, it merely indicates a need to make the diagnosis, so the next part of the algorithm is: DPL -ve, patient stable => observe DPL -ve, patient unstable => look elsewhere ie CT retroperitoneum DPL +ve, patient stable => no laparotomy, CT to see what we're sitting on DPL +ve, patient unstable => laparotomy. We've used this approach for the past three years. Our laparotomy rate for splenic injury runs around 30%. We haven't opened a belly for liver (n=21/3yrs) or renal injury (n=41/3yrs) over that time, and have not had any complications from conservative management.