Annals of the Royal College of Surgeons of England (1991) vol. 73, 185-188
Early post-splenectomy sepsis after missile in jury in adults Yakub A Ellias
ABGS* FRCSI Consultant General Surgeon
Basrah Teaching Hospital, Iraq
Mazin A Elias MB ChB FCAnaes Consultant Anaesthetist St James's Hospital, Dublin
Thomas F Gorey
MCh FRCSI Consultant General Surgeon
Mater Misericordiae Hospital, Dublin Key words: Early sepsis; Splenectomy; Hepatic injury; Intestinal injury; High-velocity missiles; Gram-negative organisms
Early septic complications were studied in 292 patients operated on for penetrating missile injury of the abdomen with involvement of either the spleen or the liver, at Basrah Teaching Hospital between January 1983 and April 1986. Depending on associated injuries, patients with splenectomy were divided into three groups, the first with isolated splenic injury, the second with splenic and associated extraintestinal organ injury, and the third with splenic and intestinal injuries with or without extra-intestinal organ injury. Patients with hepatic injury were classified similarly. Splenectomy was carried out for any degree of splenic injury. Grade I hepatic injuries were managed by debridement and suturing while major grades II-IV underwent segmentectomy or lobectomy. Patients were considered septic if they had any three of four clinical criteria: temperature higher than 39°C; significant haemodynamic deterioration; respiratory alkalosis, or oliguria.
Of the total, 79 were excluded due to: early transfer 51, incomplete records 8, perioperative death 11, and having combined splenic and hepatic injuries 9 (excluded by definition), leaving 104 (74.8%) patients with splenectomy and 109 (71.1%) with hepatic injury available for study. Sepsis developed in 48 (46.1%) of patients after splenectomy and in 28 (25.7%) with hepatic injury. This difference was significant (P> 0.005). In patients with isolated splenic injury, eight (25.8%) were septic while three (13.6%) of those with isolated hepatic injury developed sepsis. This was not significant (P = 0.32, Fisher's exact test). When either was
Initials stand for diploma of Arab Board in General Surgery Correspondence to: Dr M A Elias, Department of Anaesthetics, St James's Hospital, Dublin 8, Eire *
associated with an injury to an extra-intestinal organ, 15 (50%) of the splenectomy group developed sepsis compared to five (23.8%) of the hepatic injury group. This did not reach significance. When either was associated with intestinal injury, sepsis developed in 25 (58.1%) of the splenectomy patients, in contrast to 20 (30.3%) of patients with hepatic injury. This was significant (P < 0.005). Gram-negative coliforms were the most common organisms isolated comprising 72.5% and 67.8%, in contrast to pneumococci isolated in 5.9% and 3.6% in the splenectomy group and hepatic injury group, respectively. In conclusion, in patients with penetrating missile injuries of the abdomen, the risk of sepsis is increased after splenectomy compared to hepatic injury, only if there was associated bowel injury. This was reflected in the type of causative organism (predominantly enteric flora) despite 'appropriate' antibiotic cover, as well as a fivefold increase in mortality among the splenectomy group. We suggest that splenic salvage, where feasible, is mandatory if associated with intestinal injury.
Sepsis is a significant complication of penetrating abdominal trauma (I) and while blunt injuries are more serious, shotgun wound injuries are associated with a higher rate of sepsis compared to blunt injuries (2,3). High-velocity shotgun wounds of the liver in Vietnam were associated with a high rate of intra-abdominal abscesses (4) and it is well documented that splenectomy predisposes to late septic sequelae (5,6). Hepatic and splenic injuries are common among battlefield casualties, and since the development of sepsis is the most important factor influencing mortality
186
Y A Ellias et al.
(7), and since early sepsis would influence the outcome, this study was aimed at evaluating the rate of early sepsis and possible factors influencing its development in battlefield casualties with splenic and hepatic injuries.
Patients and methods As a consequence of the Iraq-Iran war, 292 patients underwent laparotomy for penetrating missile injury of the abdomen at Basrah Teaching Hospital between January 1983 and April 1986. It is hospital policy to explore all patients with penetrating missile injuries of the abdomen and to leave a suction drain in every case. Depending on the associated injuries, patients with splenic injury were classified into three groups, the first with isolated splenic injury, the second with splenic and associated extra-intestinal organ (lung, kidney, pancreas and bladder) injury, and the third with splenic and intestinal (from oesophagus to the rectum) injury, with or without extra-intestinal injuries. Patients with hepatic injuries were classified similarly. Splenectomy was carried out for any degree of splenic injury. The spleen is first mobilised from its bed then the vessels of the pedicle are clamped separately and doubly ligated. With hepatic injury, resection of devitalised tissue and haemostasis was the main objective; for grade I injuries haemostasis and suturing the edges with catgut was carried out, while for the major grades II-IV, debridement of devitalised tissue and haemostasis were carried out, attempts to suture under tension were avoided, resorting most of the time to covering the raw surface with omentum. Debridement was kept to a minimum; segmentectomy or lobectomy were considered only if a major hepatic vein had to be ligated. No attempts to disrupt stable subcapular haematomas or to dissect intrahepatic shrapnel were made. The diagnosis of sepsis depended on clinical criteria, thus it was felt from the start that only patients who completed at least 1 week of postoperative follow-up should be included. That meant excluding 51 transferred to other hospitals as they had milder injuries and were stable, eight with incomplete records, 11 who died within 48 h of surgery, and nine with combined splenic and hepatic injuries (excluded by definition), a total of 79 patients.
Of 139 patients who underwent splenectomy, 19 were transferred before completing 1 week of postoperative follow-up, five had incomplete records, one had splenosis and 10 died within 48 h of surgery. Therefore, 104 (74.8%) patients (103 males and 1 female) were available for study, their ages ranged from 18 to 44 years (mean 26.3 years). Of these, 31 had isolated splenectomy, 30 had splenectomy and an extra-intestinal organ injury, and 43 had splenectomy and associated bowel injury, with or without extra-intestinal injury. During the same period, 153 patients underwent hepatic surgery for missile injuries, 33 were transferred before completing 1 week of follow-up, nine had associated splenectomy, and two died on the day of opera-
tion. Therefore, 109 (71.1%) patients, all male, ranging in age from 19 to 37 years (mean 25.1 years) were available for study. Of these, 22 had isolated hepatic injury, 21 had hepatic and extra-intestinal injuries, and 66 had hepatic and intestinal injuries, with or without extra-intestinal organ injury. Sepsis was diagnosed postoperatively if any three of the following clinical criteria were present: temperature higher than 39°C for 3 days or longer; significant haemodynamic deterioration (blood pressure of less than 100/60 mmHg) for more than 8 consecutive hours; respiratory alkalosis (in non-ventilated patients) or oliguria (urinary output of less than 600 ml/day) (8). Sepsis was clinically assessed while septic foci were localised by the use of plain radiographic screening and ultrasound and cultures were obtained from wounds, sputum, blood and urine. It is hospital policy to cover all patients with gentamicin, 80 mg three times a day and metronidazole 500 mg three times a day preoperatively and continued for at least 3 days postoperatively. In the splenectomy group 15 patients died. Of these, 10 died within 48 h of surgery: three arrested on the table, one went into irreversible shock, two failed to regain spontaneous respiration and went into circulatory failure, and four died of disseminated intravascular coagulation (DIC). Between 1 and 4 weeks postoperatively, five more died, one of DIC and four of overwhelming sepsis. In the hepatic injury group three patients died. Of these, two died on the day of operation, one arresting on the table and the other, a grade IV hepatic injury (9), dying of DIC. The third died of DIC in the second week. All these deaths were included in the
operative mortality. The evacuation time from injury to arrival at the hospital ranged from 10 min to 26 h, the average being just under 3 h. Patients included in the study had followup periods ranging from 7 to 32 days (average 13.1 days) after surgery.
Results A total of 48 (46.1%) patients with splenectomy developed sepsis, compared to 28 (25.7%) with hepatic injury. This difference was significant (P 0.1
15 (50) 16 (76.2)
25 (58.1) 20 (30.3) P > 0.005
18 (4.19) 46 (69.7)
(25.7) P > 0.005
one thoracic empyema. The pelvic and two subphrenic abscesses occurred after hepatic injury, while the rest occurred after splenectomy. In all but one, surgical drainage led to recovery. One patient with anastomotic leak and splenectomy went on to develop generalised peritonitis and overwhelming sepsis. It is noted that three of the asplenic patients had more than one focus of infection while none with hepatic injury did so (Table II). Gram-negative coliforms were by far the most common isolates, accounting for 72.5% and 67.8% of septic foci after splenectomy and hepatic injury, respec-
tively (Table II). There were 18 deaths, 15 (10.8%) after splenectomy and 3 (2%) after hepatic injury. Of these, 12 died within 48 h of surgery while six died between 1 and 4 weeks postoperatively, five among the splenectomy group (four of overwhelming sepsis and one of DIC) and one died of DIC after hepatic injury.
Discussion Sepsis occurs commonly and is a leading cause of early and late mortality in patients with penetrating missile injuries to the abdomen (1), with associated splenectomy (5,10) and those with associated hepatic injury (4). The Table II. Organisms cultured from septic patients after splenectomy and hepatic injury Patients with
Patients with
splenectomy*
hepatic injury
16 13 7 6 4 3 1 1
12 4 2 5
Escherichia coli Klebsiella aeruginosa Pseudomonas pyocyanea Staphylococcus aureus
Haemophilus influenzae Streptococcus pneumoniae Proteus mirabilis Streptococcus haemolyticus *
Spleniclhepatic
Septic
%2 test
Type of organism cultured
Spleniclhepatic and extra-intestinal injury
Some patients had multiple septic foci
1 1 3
x2 test
x2 test
peritoneal cavity is contaminated from the start by the penetrating missile and debris is introduced. Both the spleen and liver are vascular organs, where injury predisposes to shock and to blood collection in the peritoneal cavity. Blood in the peritoneal cavity may reduce normal tolerance to bacterial contamination and may directly enhance bacterial growth (7). Severe immune dysfunction occurs within 24 h of trauma (11,12). The resulting haemorrhagic shock leads to bacteraemia and toxaemia in such patients (13). Studies show that blood cultures became positive 2-4 h into the shock period; all cultured organisms were normal enteric flora, the gut being a possible source of bacteraemia (14). The role of the gut as a source of infection in hepatic injury is controversial. While some studies implicate associated bowel perforation in increasing the risk of sepsis (1,7) others did not (15). It is suggested in a nonprospective study (16) that perforation of bowel may increase the rate of sepsis in splenectomy. In this study, early sepsis among patients having splenectomy after missile injury was compared with that in patients with hepatic injury. The liver is frequently injured by missiles due to its size; it occupies an anatomical position comparable to the spleen (subdiaphragmatic and protected by the rib cage) and is also equally vascular. Sepsis was significantly higher in patients after splenectomy in contrast to those with hepatic injury. When studying subgroups, however, the rate of sepsis with isolated splenectomy was no higher than with isolated hepatic injury (Table I). Sepsis was not significantly different in patients with splenectomy compared with hepatic injury when either was associated with injury to organs other than bowel (Table I). However, sepsis was significantly higher after splenectomy compared to hepatic injury when both were associated with bowel injury. Other studies report an increased risk of sepsis after splenectomy (5) and suggest that bowel injury may increase that risk (16). Furthermore, Gram-negative coliforms were the most common isolates from blood, wound, sputum and urine cultures of 72.5% septic splenectomy patients and 67.8% of those with hepatic trauma who developed sepsis (17,18).
188
Y A Ellias et al.
Evacuation time is shorter in urban guerrilla warfare compared to battlefield casualties (19). An average evacuation time of 3 h, however, compares favourably with other battlefield studies such as Korea (20) of 8 h and Vietnam 30-60 min (evacuation by helicopter) (21). Despite the arrival at our hospital of seriously injured casualties, those most susceptible to infection, our mortality rate was acceptably low (4,5). In conclusion, in penetrating missile injuries of the abdomen, the risk of early sepsis is increased after splenectomy compared to hepatic injury only when associated with bowel injury. This was reflected in the type of causative organisms (predominantly enteric flora) despite 'appropriate' antibiotic cover as well as a fivefold increase in mortality among the splenectomy group. We suggest that splenic salvage, where feasible, is mandatory if associated with intestinal injury.
References I Gibson DM, Feliciano DV, Mattox KL et al. Intraabdominal abscess after penetrating abdominal trauma. Am J Surg 1981; 142:699-704. 2 Noyes LD, Doyle DJ, McSwain NE. Septic complication associated with the use of peritoneal drains in liver trauma. J Trauma 1988;28:337-45. 3 Redmond HB, Daly NN, Gorey TF. An approach to selective conservative management of liver injuries. Ir Med 7 1988;81:14-16. 4 Pilcher DB. Penetrating liver injuries in Vietnam. Ann Surg 1969;170:793-800. 5 Ziemski JM, Rudowski WJ, Jaskowisk W et al. Evaluation of early post-splenectomy complications. Surg Gynecol Obstet 1987;165:507-14. 6 Francke EL, New HG. Post-splenectomy infections. Surg Clin North Am 1981;61:133-55. 7 Scott CM, Grasberger RC, Heeran TF et al. Intraabdominal sepsis after hepatic trauma. Am J Surg 1988; 155:284-88.
8 Sekikawa T, Shatney CH. Septic sequelae after splenectomy for trauma in adults. Am J Surg 1983;145:667-73. 9 Flint LM, Mays ET, Aaron WS et al. Selectivity in the management of hepatic trauma. Ann Surg 1977;185:61318. 10 Dicataldo A, Puleo S, LiDestri G et al. Splenic trauma and overwhelming post-splenectomy infection. Br 7 Surg 1987;74:343-5. 11 Baker CC, Miller CL, Trunkey DD. Correlation of traumatic shock with immunocompetence and sepsis. Surg Forum 1979;30:20-21. 12 Howard RJ, Simmons RL. Acquired immunologic deficiencies after trauma and surgical procedures. Surg Gynecol Obstet 1974;139:771-82. 13 Rush BF Jr, Sori AJ, Murphy TF et al. Endotoxaemia and bacteraemia during haemorrhagic shock, the link between trauma and sepsis? Ann Surg 1988;207:549-54. 14 Sori AJ, Rush BF Jr, Lysz TW et al. The gut as source of sepsis after haemorrhagic shock. Am J Surg 1988;155: 18792. 15 Dawidson I, Miller E, Litwin MS. Gunshot wounds of the abdomen. Arch Surg 1976;111:862-5. 16 Blackwood JM, Hurd T, Machicdo GW. Intra-abdominal infection following combined spleen-colon trauma. Am Surg 1988;54:212-16. 17 Cheslyn-Curtis S et al. Effect of splenectomy on Gramnegative bacterial clearance in the presence and absence of sepsis. BrJr Surg 1988;75:177-80. 18 Ohshio G, Tadao M, Takayoshi T et al. The effect of splenectomy on antibody response to lipopolysaccharide (E Coli) immunization. J Trauma 1988;28:379-82. 19 Byrnes DP, Crockard HA, Gordon DJ, Gleadhill CA. Penetrating craniocerebral missile injuries in the civil disturbances in Northern Ireland. Br7 Surg 1974;61: 169-76. 20 Barnett JC, Meirowsky AM. Intracranial haematomas associated with penetrating wounds of the brain. J Neurosurg 1955;12:34-8. 21 Hammon WM. Analysis of 2187 consecutive penetrating wounds of the brain from Vietnam. J Neurosurg 1971;34:127-31.
Received 13 September 1990
Assessor's comment This is an interesting paper which reports a considerable experience of battlefield casualties who sustained hepatic or splenic injuries. The authors are to be congratulated on their good results. They have clearly shown that in all patients with splenectomy, the postoperative infection rate is twice as high as in patients with hepatic injury only. This difference is present in all groups. The failure to demonstrate statistical significance in patients with isolated splenic or hepatic injuries and those with non-intestinal associated injuries is due to a type II error. It seems to me that the risk of infection is twice as high in all patients with splenic injury as in those with liver injury, irrespective of associated injuries. The authors' comment that splenic
preservation should be attempted wherever possible therefore applies to all splenic injuries, and not only those with associated intestinal injuries. It is also noteworthy that patients with non-intestinal injuries associated with hepatic or splenic injury have a high infection rate (50%), similar to that seen with intestinal injuries. The mechanism for this is unclear but possibly reflects the severity of the injury. Patients with multiple organ injuries constitute a high-risk group for infection, irrespective of whether the bowel is entered. C D JOHNSON MChir FRCS Senior Lecturer Honorary Consultant Surgeon University of Southampton
Early post-splenectomy sepsis after missile in jury in adults Yakub A Ellias
ABGS* FRCSI Consultant General Surgeon
Basrah Teaching Hospital, Iraq
Mazin A Elias MB ChB FCAnaes Consultant Anaesthetist St James's Hospital, Dublin
Thomas F Gorey
MCh FRCSI Consultant General Surgeon
Mater Misericordiae Hospital, Dublin Key words: Early sepsis; Splenectomy; Hepatic injury; Intestinal injury; High-velocity missiles; Gram-negative organisms
Early septic complications were studied in 292 patients operated on for penetrating missile injury of the abdomen with involvement of either the spleen or the liver, at Basrah Teaching Hospital between January 1983 and April 1986. Depending on associated injuries, patients with splenectomy were divided into three groups, the first with isolated splenic injury, the second with splenic and associated extraintestinal organ injury, and the third with splenic and intestinal injuries with or without extra-intestinal organ injury. Patients with hepatic injury were classified similarly. Splenectomy was carried out for any degree of splenic injury. Grade I hepatic injuries were managed by debridement and suturing while major grades II-IV underwent segmentectomy or lobectomy. Patients were considered septic if they had any three of four clinical criteria: temperature higher than 39°C; significant haemodynamic deterioration; respiratory alkalosis, or oliguria.
Of the total, 79 were excluded due to: early transfer 51, incomplete records 8, perioperative death 11, and having combined splenic and hepatic injuries 9 (excluded by definition), leaving 104 (74.8%) patients with splenectomy and 109 (71.1%) with hepatic injury available for study. Sepsis developed in 48 (46.1%) of patients after splenectomy and in 28 (25.7%) with hepatic injury. This difference was significant (P> 0.005). In patients with isolated splenic injury, eight (25.8%) were septic while three (13.6%) of those with isolated hepatic injury developed sepsis. This was not significant (P = 0.32, Fisher's exact test). When either was
Initials stand for diploma of Arab Board in General Surgery Correspondence to: Dr M A Elias, Department of Anaesthetics, St James's Hospital, Dublin 8, Eire *
associated with an injury to an extra-intestinal organ, 15 (50%) of the splenectomy group developed sepsis compared to five (23.8%) of the hepatic injury group. This did not reach significance. When either was associated with intestinal injury, sepsis developed in 25 (58.1%) of the splenectomy patients, in contrast to 20 (30.3%) of patients with hepatic injury. This was significant (P < 0.005). Gram-negative coliforms were the most common organisms isolated comprising 72.5% and 67.8%, in contrast to pneumococci isolated in 5.9% and 3.6% in the splenectomy group and hepatic injury group, respectively. In conclusion, in patients with penetrating missile injuries of the abdomen, the risk of sepsis is increased after splenectomy compared to hepatic injury, only if there was associated bowel injury. This was reflected in the type of causative organism (predominantly enteric flora) despite 'appropriate' antibiotic cover, as well as a fivefold increase in mortality among the splenectomy group. We suggest that splenic salvage, where feasible, is mandatory if associated with intestinal injury.
Sepsis is a significant complication of penetrating abdominal trauma (I) and while blunt injuries are more serious, shotgun wound injuries are associated with a higher rate of sepsis compared to blunt injuries (2,3). High-velocity shotgun wounds of the liver in Vietnam were associated with a high rate of intra-abdominal abscesses (4) and it is well documented that splenectomy predisposes to late septic sequelae (5,6). Hepatic and splenic injuries are common among battlefield casualties, and since the development of sepsis is the most important factor influencing mortality
186
Y A Ellias et al.
(7), and since early sepsis would influence the outcome, this study was aimed at evaluating the rate of early sepsis and possible factors influencing its development in battlefield casualties with splenic and hepatic injuries.
Patients and methods As a consequence of the Iraq-Iran war, 292 patients underwent laparotomy for penetrating missile injury of the abdomen at Basrah Teaching Hospital between January 1983 and April 1986. It is hospital policy to explore all patients with penetrating missile injuries of the abdomen and to leave a suction drain in every case. Depending on the associated injuries, patients with splenic injury were classified into three groups, the first with isolated splenic injury, the second with splenic and associated extra-intestinal organ (lung, kidney, pancreas and bladder) injury, and the third with splenic and intestinal (from oesophagus to the rectum) injury, with or without extra-intestinal injuries. Patients with hepatic injuries were classified similarly. Splenectomy was carried out for any degree of splenic injury. The spleen is first mobilised from its bed then the vessels of the pedicle are clamped separately and doubly ligated. With hepatic injury, resection of devitalised tissue and haemostasis was the main objective; for grade I injuries haemostasis and suturing the edges with catgut was carried out, while for the major grades II-IV, debridement of devitalised tissue and haemostasis were carried out, attempts to suture under tension were avoided, resorting most of the time to covering the raw surface with omentum. Debridement was kept to a minimum; segmentectomy or lobectomy were considered only if a major hepatic vein had to be ligated. No attempts to disrupt stable subcapular haematomas or to dissect intrahepatic shrapnel were made. The diagnosis of sepsis depended on clinical criteria, thus it was felt from the start that only patients who completed at least 1 week of postoperative follow-up should be included. That meant excluding 51 transferred to other hospitals as they had milder injuries and were stable, eight with incomplete records, 11 who died within 48 h of surgery, and nine with combined splenic and hepatic injuries (excluded by definition), a total of 79 patients.
Of 139 patients who underwent splenectomy, 19 were transferred before completing 1 week of postoperative follow-up, five had incomplete records, one had splenosis and 10 died within 48 h of surgery. Therefore, 104 (74.8%) patients (103 males and 1 female) were available for study, their ages ranged from 18 to 44 years (mean 26.3 years). Of these, 31 had isolated splenectomy, 30 had splenectomy and an extra-intestinal organ injury, and 43 had splenectomy and associated bowel injury, with or without extra-intestinal injury. During the same period, 153 patients underwent hepatic surgery for missile injuries, 33 were transferred before completing 1 week of follow-up, nine had associated splenectomy, and two died on the day of opera-
tion. Therefore, 109 (71.1%) patients, all male, ranging in age from 19 to 37 years (mean 25.1 years) were available for study. Of these, 22 had isolated hepatic injury, 21 had hepatic and extra-intestinal injuries, and 66 had hepatic and intestinal injuries, with or without extra-intestinal organ injury. Sepsis was diagnosed postoperatively if any three of the following clinical criteria were present: temperature higher than 39°C for 3 days or longer; significant haemodynamic deterioration (blood pressure of less than 100/60 mmHg) for more than 8 consecutive hours; respiratory alkalosis (in non-ventilated patients) or oliguria (urinary output of less than 600 ml/day) (8). Sepsis was clinically assessed while septic foci were localised by the use of plain radiographic screening and ultrasound and cultures were obtained from wounds, sputum, blood and urine. It is hospital policy to cover all patients with gentamicin, 80 mg three times a day and metronidazole 500 mg three times a day preoperatively and continued for at least 3 days postoperatively. In the splenectomy group 15 patients died. Of these, 10 died within 48 h of surgery: three arrested on the table, one went into irreversible shock, two failed to regain spontaneous respiration and went into circulatory failure, and four died of disseminated intravascular coagulation (DIC). Between 1 and 4 weeks postoperatively, five more died, one of DIC and four of overwhelming sepsis. In the hepatic injury group three patients died. Of these, two died on the day of operation, one arresting on the table and the other, a grade IV hepatic injury (9), dying of DIC. The third died of DIC in the second week. All these deaths were included in the
operative mortality. The evacuation time from injury to arrival at the hospital ranged from 10 min to 26 h, the average being just under 3 h. Patients included in the study had followup periods ranging from 7 to 32 days (average 13.1 days) after surgery.
Results A total of 48 (46.1%) patients with splenectomy developed sepsis, compared to 28 (25.7%) with hepatic injury. This difference was significant (P 0.1
15 (50) 16 (76.2)
25 (58.1) 20 (30.3) P > 0.005
18 (4.19) 46 (69.7)
(25.7) P > 0.005
one thoracic empyema. The pelvic and two subphrenic abscesses occurred after hepatic injury, while the rest occurred after splenectomy. In all but one, surgical drainage led to recovery. One patient with anastomotic leak and splenectomy went on to develop generalised peritonitis and overwhelming sepsis. It is noted that three of the asplenic patients had more than one focus of infection while none with hepatic injury did so (Table II). Gram-negative coliforms were by far the most common isolates, accounting for 72.5% and 67.8% of septic foci after splenectomy and hepatic injury, respec-
tively (Table II). There were 18 deaths, 15 (10.8%) after splenectomy and 3 (2%) after hepatic injury. Of these, 12 died within 48 h of surgery while six died between 1 and 4 weeks postoperatively, five among the splenectomy group (four of overwhelming sepsis and one of DIC) and one died of DIC after hepatic injury.
Discussion Sepsis occurs commonly and is a leading cause of early and late mortality in patients with penetrating missile injuries to the abdomen (1), with associated splenectomy (5,10) and those with associated hepatic injury (4). The Table II. Organisms cultured from septic patients after splenectomy and hepatic injury Patients with
Patients with
splenectomy*
hepatic injury
16 13 7 6 4 3 1 1
12 4 2 5
Escherichia coli Klebsiella aeruginosa Pseudomonas pyocyanea Staphylococcus aureus
Haemophilus influenzae Streptococcus pneumoniae Proteus mirabilis Streptococcus haemolyticus *
Spleniclhepatic
Septic
%2 test
Type of organism cultured
Spleniclhepatic and extra-intestinal injury
Some patients had multiple septic foci
1 1 3
x2 test
x2 test
peritoneal cavity is contaminated from the start by the penetrating missile and debris is introduced. Both the spleen and liver are vascular organs, where injury predisposes to shock and to blood collection in the peritoneal cavity. Blood in the peritoneal cavity may reduce normal tolerance to bacterial contamination and may directly enhance bacterial growth (7). Severe immune dysfunction occurs within 24 h of trauma (11,12). The resulting haemorrhagic shock leads to bacteraemia and toxaemia in such patients (13). Studies show that blood cultures became positive 2-4 h into the shock period; all cultured organisms were normal enteric flora, the gut being a possible source of bacteraemia (14). The role of the gut as a source of infection in hepatic injury is controversial. While some studies implicate associated bowel perforation in increasing the risk of sepsis (1,7) others did not (15). It is suggested in a nonprospective study (16) that perforation of bowel may increase the rate of sepsis in splenectomy. In this study, early sepsis among patients having splenectomy after missile injury was compared with that in patients with hepatic injury. The liver is frequently injured by missiles due to its size; it occupies an anatomical position comparable to the spleen (subdiaphragmatic and protected by the rib cage) and is also equally vascular. Sepsis was significantly higher in patients after splenectomy in contrast to those with hepatic injury. When studying subgroups, however, the rate of sepsis with isolated splenectomy was no higher than with isolated hepatic injury (Table I). Sepsis was not significantly different in patients with splenectomy compared with hepatic injury when either was associated with injury to organs other than bowel (Table I). However, sepsis was significantly higher after splenectomy compared to hepatic injury when both were associated with bowel injury. Other studies report an increased risk of sepsis after splenectomy (5) and suggest that bowel injury may increase that risk (16). Furthermore, Gram-negative coliforms were the most common isolates from blood, wound, sputum and urine cultures of 72.5% septic splenectomy patients and 67.8% of those with hepatic trauma who developed sepsis (17,18).
188
Y A Ellias et al.
Evacuation time is shorter in urban guerrilla warfare compared to battlefield casualties (19). An average evacuation time of 3 h, however, compares favourably with other battlefield studies such as Korea (20) of 8 h and Vietnam 30-60 min (evacuation by helicopter) (21). Despite the arrival at our hospital of seriously injured casualties, those most susceptible to infection, our mortality rate was acceptably low (4,5). In conclusion, in penetrating missile injuries of the abdomen, the risk of early sepsis is increased after splenectomy compared to hepatic injury only when associated with bowel injury. This was reflected in the type of causative organisms (predominantly enteric flora) despite 'appropriate' antibiotic cover as well as a fivefold increase in mortality among the splenectomy group. We suggest that splenic salvage, where feasible, is mandatory if associated with intestinal injury.
References I Gibson DM, Feliciano DV, Mattox KL et al. Intraabdominal abscess after penetrating abdominal trauma. Am J Surg 1981; 142:699-704. 2 Noyes LD, Doyle DJ, McSwain NE. Septic complication associated with the use of peritoneal drains in liver trauma. J Trauma 1988;28:337-45. 3 Redmond HB, Daly NN, Gorey TF. An approach to selective conservative management of liver injuries. Ir Med 7 1988;81:14-16. 4 Pilcher DB. Penetrating liver injuries in Vietnam. Ann Surg 1969;170:793-800. 5 Ziemski JM, Rudowski WJ, Jaskowisk W et al. Evaluation of early post-splenectomy complications. Surg Gynecol Obstet 1987;165:507-14. 6 Francke EL, New HG. Post-splenectomy infections. Surg Clin North Am 1981;61:133-55. 7 Scott CM, Grasberger RC, Heeran TF et al. Intraabdominal sepsis after hepatic trauma. Am J Surg 1988; 155:284-88.
8 Sekikawa T, Shatney CH. Septic sequelae after splenectomy for trauma in adults. Am J Surg 1983;145:667-73. 9 Flint LM, Mays ET, Aaron WS et al. Selectivity in the management of hepatic trauma. Ann Surg 1977;185:61318. 10 Dicataldo A, Puleo S, LiDestri G et al. Splenic trauma and overwhelming post-splenectomy infection. Br 7 Surg 1987;74:343-5. 11 Baker CC, Miller CL, Trunkey DD. Correlation of traumatic shock with immunocompetence and sepsis. Surg Forum 1979;30:20-21. 12 Howard RJ, Simmons RL. Acquired immunologic deficiencies after trauma and surgical procedures. Surg Gynecol Obstet 1974;139:771-82. 13 Rush BF Jr, Sori AJ, Murphy TF et al. Endotoxaemia and bacteraemia during haemorrhagic shock, the link between trauma and sepsis? Ann Surg 1988;207:549-54. 14 Sori AJ, Rush BF Jr, Lysz TW et al. The gut as source of sepsis after haemorrhagic shock. Am J Surg 1988;155: 18792. 15 Dawidson I, Miller E, Litwin MS. Gunshot wounds of the abdomen. Arch Surg 1976;111:862-5. 16 Blackwood JM, Hurd T, Machicdo GW. Intra-abdominal infection following combined spleen-colon trauma. Am Surg 1988;54:212-16. 17 Cheslyn-Curtis S et al. Effect of splenectomy on Gramnegative bacterial clearance in the presence and absence of sepsis. BrJr Surg 1988;75:177-80. 18 Ohshio G, Tadao M, Takayoshi T et al. The effect of splenectomy on antibody response to lipopolysaccharide (E Coli) immunization. J Trauma 1988;28:379-82. 19 Byrnes DP, Crockard HA, Gordon DJ, Gleadhill CA. Penetrating craniocerebral missile injuries in the civil disturbances in Northern Ireland. Br7 Surg 1974;61: 169-76. 20 Barnett JC, Meirowsky AM. Intracranial haematomas associated with penetrating wounds of the brain. J Neurosurg 1955;12:34-8. 21 Hammon WM. Analysis of 2187 consecutive penetrating wounds of the brain from Vietnam. J Neurosurg 1971;34:127-31.
Received 13 September 1990
Assessor's comment This is an interesting paper which reports a considerable experience of battlefield casualties who sustained hepatic or splenic injuries. The authors are to be congratulated on their good results. They have clearly shown that in all patients with splenectomy, the postoperative infection rate is twice as high as in patients with hepatic injury only. This difference is present in all groups. The failure to demonstrate statistical significance in patients with isolated splenic or hepatic injuries and those with non-intestinal associated injuries is due to a type II error. It seems to me that the risk of infection is twice as high in all patients with splenic injury as in those with liver injury, irrespective of associated injuries. The authors' comment that splenic
preservation should be attempted wherever possible therefore applies to all splenic injuries, and not only those with associated intestinal injuries. It is also noteworthy that patients with non-intestinal injuries associated with hepatic or splenic injury have a high infection rate (50%), similar to that seen with intestinal injuries. The mechanism for this is unclear but possibly reflects the severity of the injury. Patients with multiple organ injuries constitute a high-risk group for infection, irrespective of whether the bowel is entered. C D JOHNSON MChir FRCS Senior Lecturer Honorary Consultant Surgeon University of Southampton
