Original Article Results of non-operative management of splenic trauma and its complications in children Ndour Oumar, Forgues Dominique1, Kalfa Nikola1, Guibal Marie Pierre1, Ndoye Mamadou, Galifer René Benoit1 Department of Pediatric Surgery, Aristide Le Dantec Hospital, Dakar, Sénégal, 1Pediatric Urology and visceral surgery Pediatric Surgery of Lapeyronie Hospital Montpellier, France Address for correspondence: Dr. Oumar Ndour, Department of Pediatric Surgery, Aristide Le Dantec Hospital, BP : BP 3001 Dakar – Etoile, Dakar, Sénégal. E-mail: [email protected]
ABSTRACT Introduction: Non-operative management (NOM) of splenic trauma in children is currently the treatment of choice. Purpose: We report a series of 83 cases in order to compare our results with literature data. Patients and Methods: For this, we conducted a retrospective study of 13 years and collected 83 cases of children with splenic trauma contusion, managed at Lapeyronie Montpellier Hospital in Visceral Pediatric Surgery Department. The studied parameters were age, sex, circumstances, the blood pressure (BP), hematology, imaging, associated injuries, transfusion requirements, treatment, duration of hospital stay, physical activity restriction and evolution. Results: NOM was successful in 98.7% of cases. We noted 4 complications including 3 pseudo aneurysms (PSA) of splenic artery and 1 pseudocyst spleen with a good prognosis. There was no mortality in our series. Conclusion: NOM is the treatment of choice for splenic trauma in children with a success rate of over 90%. Complications are rare and are dominated by the PSA of splenic artery.
Access this article online Website: www.jiaps.com DOI: 10.4103/0971-9261.136468 Quick Response Code:
KEY WORDS: Contusion, child-non-operative management, complications, fracture, pseudo aneurysm, spleen
INTRODUCTION The spleen is the most frequently injured organ in blunt abdominal trauma. Splenectomy has long been the standard treatment for the spleen fractures from the success of the first splenectomy reported in 1892 by Reinger.[1] In the early 20th century, many studies, including one of King Shumacker[2] in 1952, demonstrated the importance of the spleen in immunity and risk of infection exposed to splenectomized patients. This has led in recent decades to a more conservative approach in the management of spleen injuries. NOM of splenic trauma in children was reported in 1968 by Upadhyaya,[3] followed by other authors in the 80s that
have demonstrated good results of this method, with 80 to 90% of positive change. This non-operative treatment is currently considered by most centers as the method of choice for the spleen injuries treatment in children. The unanimity has been made on the success of this method, but there is no practical uniform protocol except the one published by the American Pediatric Surgical Association (APSA) in 2000.[4] To improve the method, it is necessary that its results should be regularly evaluated. That is why we have conducted this retrospective study to provide results of NOM of splenic trauma at a university hospital in visceral pediatric surgery department and compare them with literature data.
Cite this article as: Oumar N, Dominique F, Nikola K, Pierre GM, Mamadou N, Benoit GR. Results of non-operative management of splenic trauma and its complications in children. J Indian Assoc Pediatr Surg 2014;19:147-50. Source of Support: Nil, Conflict of Interest: None declared.
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
147
Ndour, et al.: Results of non-operative management of splenic trauma and its complications in children
MATERIALS AND METHODS This retrospective study was conducted in the Visceral Surgery and Pediatric Urology Department at CHU Montpellier (Lapeyronie Hospital, Prof. RB Galifer). From April 1997 to March 2010, we collected 83 cases of children with splenic blunt trauma due to the abdominal contusion managed in our Department. Eighty-three patients were treated non-operatively and are the cases of our study. The considered parameters were age, sex, mechanism of injury, blood pressure, hematology (hemoglobin), imaging (ultrasound and/or CT-scan), associated injuries, transfusion requirements, treatment and evolution (morbidity and mortality). The splenic trauma diagnosis was confirmed by ultrasonography and/or CT- scan abdomen. All radiological images were reviewed by fellow Pediatric Radiologists (Department of Pediatric Radiology, Dr. Couture) allowing us to distribute patients according to the classification of the American Association for the Surgery of Trauma (AAST).[4] Patients hemodynamically stable or stabilized after blood transfusion (less than 40ml/kg) were managed with NOM. The need for admission in ICU was decided on the basis of hemodynamic stability, the existence or absence of a poly trauma and grade lesion. All these children have been closely monitored by regular clinical evaluations of hemodynamic parameters, checking hemoglobin and ultrasound. The discharged patients are reviewed in consultation: The 15th day following the trauma, after 1 month, 3 months and sometimes beyond depending on evolution. We included in our study patients initially treated and secondarily referred from other departments of surgery. Stab injuries or pathological spleen and/or spontaneous
splenic rupture were excluded from our study. The results were compared with literature data to improve our attitude in managing these patients.
RESULTS A total of 83 children with splenic trauma due to abdominal contusion were managed non-operatively in the Visceral Surgery and Pediatric Urology Department at CHU Montpellier in a period of thirteen years. NOM was successful in 82 patients (98.7% of cases). One failure was observed. It was a 14 year old boy admitted in ICU for multiple trauma with AAST grade IV spleen fracture. This was associated with a missing image of the left kidney with renal artery wound and fracture of the left iliac wing. Despite transfusion with two units of red blood cells (hemoglobin:8g/dl), forty-eight hours later, the child presented with anuria, a distended abdomen, low blood pressure of 70/50 mmHg and with Hb of 4g/dl. Given the critical clinical state with pH 7, an urgent surgical exploration was indicated. A significant hemoperitoneum, ruptured spleen and left kidney were found avascular. Total splenectomy and left total nephrectomy were performed. He also received the vaccination protocol in case of total splenectomy. The duration of hospitalization was 11 days. The follow-up was favorable after a period of 3 months. With a mean period of 4.72 months, the evolution has been marked in this series by complications’ occurrence in 4 cases (4.8%) represented by three pseudo-aneurysms splenic artery and 1 pseudocyst splenic [Table 1]. There was no mortality in this series.
Table 1: Detail of various complications Complications paramètres 1er case
Pseudo-aneurysm splenic artery 2nd case
3rd case
Age (years) Sexe AAST Hemodynamic Ultrasound
10 F Grade III Instable Rounded fluid image of 7.7 mm × 5.2 mm thin-walled, containing arterial flow associated with thin echoes corresponding to slow flow: Pseudo aneurysm splenic artery during thrombosis?( 5th day) Two thrombosed pseudoaneurysms (15 days after hospitalization)
13 M Grade I Instable Pseudo aneurysm splenic artery (2nd day) Aneurysm thrombosis (8th day)
14 M Grade III Instable Posttraumatic aneurysm with arteriovenous fistula (8th day) Pseudo-aneurysm splenic artery thrombosis (23rd day)
CT-scan Treatment Follow-up
148
Abstention Abstention Stable thrombus in different Favorable (2 months) ultrasounds control (5 months)
Pseudocyst splenic 13 M Grade II Instable Two juxtaposed mid splenic cystic cavities of 17 mm × 7 mm × 7 mm, all surrounded by well-vascularized parenchyma, heterogenous (10th day) Decreased volume with dimensions of 13.5 mm × 4 mm × 3.5 mm (1 month) Complete disappearance of the cyst formation (two months)
Pseudo aneurysm splenic artery (2nd day) Arterial embolization (4th day) Abstention Favorable (6 months) Favorable (3 months)
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
Ndour, et al.: Results of non-operative management of splenic trauma and its complications in children
DISCUSSION NOM of splenic trauma represents a major advancement in the history of pediatric surgery. It initiated the same approach applied to other solid abdominal organs (liver, pancreas, kidney) trauma. Upadhyaya and Simpson[3] reported the first series of splenic trauma in children managed without surgery at Sick Children’s Hospital in Toronto in 1968. From their experience they suggested that under some conditions the trauma of the spleen in children could be correctly managed without surgery. Several centers have subsequently experienced and confirmed the validity of this therapeutic method.[5,6] In our department, this approach has been used since 1980.[7] In the case of blunt spleen trauma, NOM has become, under strict conditions, a universally accepted strategy. According to the literature, the success rates currently exceed 90% [Table 2] with a failure rate often lower than 5%.[7-11] In our study we obtained 98.7% of good results. We had one failure which was linked to severe injury (grade IV) associated in addition to a wound of the left renal artery. Complications of splenic trauma NOM found in the literature are essentially secondary hemorrhage, pseudoaneurysm, pseudo-cysts and splenic abscesses.[8] Their frequency varies between 0 and 7.5% depending on the series.[8,12] In our study we found 4 complications including 3 pseudo-aneurysms and one pseudo-cyst. The pseudoaneurysm splenic artery is a rare but serious complication. Its frequency is estimated from 5 to 13% in patients managed with NOM.[8,13] Its natural history is not clear, but its involvement in re-bleeding occurrence has been demonstrated. [14] Abdominal pain is clinically the most common sign.[13] However, many cases are asymptomatic as we reported in our 3 patients. Currently it is clearly[8,12,15] indicated that the best test for diagnosis is the contrast enhanced CT scan (CECT). Oguz and et al[15] have confirmed the value of Doppler ultrasonography for early diagnosis. In our study, the diagnosis was made by Doppler ultrasound in 2 cases and CECT in the other case. In our study, 2 of the 3 cases had spontaneously evolved in this way. This spontaneous evolution can be explained by a phenomenon of self-tamponade, a high proportion of myoepithelial cells, thickness of the capsule, Table 2: Success of no operative treatment depending on the series Authors
Size of series Therapeutic success (%)
Frumiento and al(Canada) Cotte and al (France)[10] Thompson and al (Australie)[8] Veger and al (Pays Bas)[11] Lutz and al (USA)[9] Our serie (France) [7]
n=40 n=13 n=33 n=34 n=86 n=83
100 96 100 91,2 98 98,7
the elasticity of the parenchyma and the ability of contraction and retraction of the splenic arterioles.[1] In the absence of spontaneous thrombosis recovery, the current treatment adopted by many centers is arterial embolization. Dobremez and et al[16] reported two cases of pseudo-aneurysms successfully treated with selective embolization. This interventional radiology technique gives good results[13] but many complications have been described in the literature.[17] Besides the risk of femoral thrombosis in young children, there may be recurrence of the aneurysm in 5 to 10% with need for a new embolization. If this treatment is well established in adults, it is not yet fully adopted in children because of its potential morbidity.[9,17] The splenic pseudocyst caused by trauma is rarely described in the literature. It is considered as benign when there is no rapid increase in volume, mass effect or infection signs. It often occurs after a subcapsular hematoma. Kristoffersen and et al[18] have found only one case in a series of 228 patients treated between 1994 and 2005. We report a single case of splenic pseudocyst in our series. Evolution may lead to the spontaneous regression as we have observed in the case of our study. In the experience of Dobremez and et al[16] on 5 cases, 3 spontaneous regressions and two others required cystic resection. It seems that surgery is indicated for symptomatic pseudocysts. The technical details vary from marsupialization or resection of the protruding dome with partial or total splenectomy. [1] This treatment is more successful by laparoscopy. [17] The secondary hemorrhage is defined by splenic rupture occurring 48 hours after the initial trauma.[8] The re-bleeding is reported in 1 to 2% in different series.[14,17] They are related to the rupture of a subcapsular hematoma, a pseudocyst or pseudoaneurysm and can be severe. The secondary trauma occurrence has also been very noted in the literature,[14] which raises the question of possible non strict rules of rest that is the central pillar of NOM. Huebner and Reed[12] in our study concluded that the risk of occurrence of this complication in children is negligible. Our study seems to confirm this. Management depends on the impact of this re-bleeding on hemodynamic parameters. Without the need for sophisticated resuscitation, NOM keeps on all its indications. Therefore, in the case of uncontrollable active bleeding, there is a choice. On one hand: Surgical hemostasis whose main risk is often total splenectomy for vital rescue. On the other hand, an urgent selective arterial embolization that now seems increasingly used in this event since the conditions are compatible with an urgent referral of the child for a special care.[19] Several cases of successful embolization in splenectomized children have been described in the literature.[17] It helps to reduce the
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
149
Ndour, et al.: Results of non-operative management of splenic trauma and its complications in children
number of children in splenic trauma but this benefit must be weighed against the morbidity of arterial embolization in children.
by the APSA in 2000 to optimize the conditions for this strategy. In this context we propose our protocol management [Figure 1].
The splenic abscess is a rare complication of non-operative management of splenic trauma in children.[17] Frumiento and et al[7] found one case in 40 patients. It occurred eight days after the injury. It should be specific to subcapsular hematoma. The treatment can be percutaneous drainage, currently guided by ultrasound or CT-scan.[14] We didn’t find any case in our study. There was no mortality in our study. The literature reports rare cases of death due to splenic trauma in children from industrialized countries.[20] The causes are often bleeding or multiple trauma[21] in which the spleen is not necessarily directly responsible of this unfavorable evolution.
REFERENCES
CONCLUSION NOM is the treatment of choice for the spleen blunt trauma in the child. We have to obey strict rules of protocol inclusion and monitoring. This is a method that gives excellent results with over 90% success rate. Mortality is almost zero in countries with high medical status. Complications are rare. They are dominated by the pseudo-aneurysm splenic artery whose evolution is usually favorable with or without embolization. The outlook will update the practical guide established
Figure 1: Our practice protocol of management of blunt splenic trauma in children 150
1. Upadhyaya P. Conservative management of splenic trauma: History and current trends. Pediatr Surg Int 2003;19:617-27. 2. King H, Shumacker HB Jr. Splenic studies I. Susceptibility to infection after splenectomy performed in infancy. Ann Surg 1952;136:239-42. 3. Upadhyaya P, Simpson JS. Splenic trauma in children. Surg Gynecol Obstet 1968;126:781-90. 4. Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Committee. J Pediatr Surg 2000;35:164-9. 5. Gandhi RR, Keller MS, Schwab CW, Stafford PW. Pediatric splenic injury: Pathway to play? J Pediatr Surg 1999;34:55-9. 6. Pranikoff T, Hirschl RB, Schlesinger AE, Polley TZ, Coran AG. Resolution of splenic injury after nonoperative management. J Pediatr Surg 1994;29:1366-9. 7. Galifer RB, Luciani JL, Allal H, Polliotto SD. Nouvelles stratégies face aux traumatismes spléniques chez l’enfant. Rev Franç Dommage Corp 1995;1:9-16. 8. Frumiento C, Sartorelli K, Vane D. Complication of splenic injuries: Expansion of the nonoperative theorem. J Pediatr Surg 2000;35:788-91. 9. Thompson SR, Holland AJ. Current management of blunt splenic trauma in children. ANZ J Surg 2006;76:48-52. 10. Cotte A, Guye E, Diraduryan N, Tardieu D, Varlet F. Prise en charge des traumatismes fermés de l’abdomen chez l’enfant. Arch Pediatr 2004;11:327-34. 11. Veger HT, Jukema GN, Bode PJ. Pediatric splenic injury: Nonoperative management first!. Eur J Trauma Emerg Surg 2008;34:267-72. 12. 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. 13. Yardeni D, Polley TZ Jr, Coran AG. Splenic artery embolization for post-traumatic splenic artery pseudoaneurysm in children. J Trauma 2004;57:404-7. 14. Lynn KN, Werder GM, Callaghan RM, Sullivan AN, Jafri ZH, Bloom DA. Pediatric blunt splenic trauma: A comprehensive review. Ped Radiol 2009;39:904-16. 15. Dobremez E, Lefevre Y, Harper L, Rebouissoux L, Lavrand F, Bondonny JM, et al. Complications occuring during conservative management of splenic trauma in children. Eur J Pediatr Surg 2006;16:166-70. 16. Oguz B, Cil B, Ekinci S, Karnak I, Akata D, Haliloglu M. Posttraumatic splenic pseudoaneurysm and arteriovenous fistula: Diagnostic by computed tomography angiography and treatment by transcatheter embolization. J Pediatr Surg 2005;40:E43-6. 17. Arvieux C, Nunez-Villega J, Brunot A, Badic B, Reche F, Broux C, et al. Les limites du traitement non operatoire des traumatismes abdominaux fermés. E memoires de l’Academie Nationale de Chirurgie 2009;8:13-21. 18. Kristoffersen KW, Mooney DP. Long-term outcome of nonoperative pediatric splenic injury management. J Pediatr Surg 2007;42:1038-41. 19. Maurer SV, Denys A, Lutz N. Successful embolization of a delayed splenic rupture following trauma in a child. J Pediatr Surg 2009;44:1-4. 20. Davies DA, Pearl RH, Ein SH, Langer JC, Wales PW. Management of blunt splenic injury in children: Evolution of the nonoperative approach. J Pediatr Surg 2009;44:1005-8. 21. Al-Shanafey S, Giacomantonio M, Jackson R. Splenic injuries in children: Correlation between imaging and clinical management. Pediatr Surg Int 2001;17:365-8.
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
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ABSTRACT Introduction: Non-operative management (NOM) of splenic trauma in children is currently the treatment of choice. Purpose: We report a series of 83 cases in order to compare our results with literature data. Patients and Methods: For this, we conducted a retrospective study of 13 years and collected 83 cases of children with splenic trauma contusion, managed at Lapeyronie Montpellier Hospital in Visceral Pediatric Surgery Department. The studied parameters were age, sex, circumstances, the blood pressure (BP), hematology, imaging, associated injuries, transfusion requirements, treatment, duration of hospital stay, physical activity restriction and evolution. Results: NOM was successful in 98.7% of cases. We noted 4 complications including 3 pseudo aneurysms (PSA) of splenic artery and 1 pseudocyst spleen with a good prognosis. There was no mortality in our series. Conclusion: NOM is the treatment of choice for splenic trauma in children with a success rate of over 90%. Complications are rare and are dominated by the PSA of splenic artery.
Access this article online Website: www.jiaps.com DOI: 10.4103/0971-9261.136468 Quick Response Code:
KEY WORDS: Contusion, child-non-operative management, complications, fracture, pseudo aneurysm, spleen
INTRODUCTION The spleen is the most frequently injured organ in blunt abdominal trauma. Splenectomy has long been the standard treatment for the spleen fractures from the success of the first splenectomy reported in 1892 by Reinger.[1] In the early 20th century, many studies, including one of King Shumacker[2] in 1952, demonstrated the importance of the spleen in immunity and risk of infection exposed to splenectomized patients. This has led in recent decades to a more conservative approach in the management of spleen injuries. NOM of splenic trauma in children was reported in 1968 by Upadhyaya,[3] followed by other authors in the 80s that
have demonstrated good results of this method, with 80 to 90% of positive change. This non-operative treatment is currently considered by most centers as the method of choice for the spleen injuries treatment in children. The unanimity has been made on the success of this method, but there is no practical uniform protocol except the one published by the American Pediatric Surgical Association (APSA) in 2000.[4] To improve the method, it is necessary that its results should be regularly evaluated. That is why we have conducted this retrospective study to provide results of NOM of splenic trauma at a university hospital in visceral pediatric surgery department and compare them with literature data.
Cite this article as: Oumar N, Dominique F, Nikola K, Pierre GM, Mamadou N, Benoit GR. Results of non-operative management of splenic trauma and its complications in children. J Indian Assoc Pediatr Surg 2014;19:147-50. Source of Support: Nil, Conflict of Interest: None declared.
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
147
Ndour, et al.: Results of non-operative management of splenic trauma and its complications in children
MATERIALS AND METHODS This retrospective study was conducted in the Visceral Surgery and Pediatric Urology Department at CHU Montpellier (Lapeyronie Hospital, Prof. RB Galifer). From April 1997 to March 2010, we collected 83 cases of children with splenic blunt trauma due to the abdominal contusion managed in our Department. Eighty-three patients were treated non-operatively and are the cases of our study. The considered parameters were age, sex, mechanism of injury, blood pressure, hematology (hemoglobin), imaging (ultrasound and/or CT-scan), associated injuries, transfusion requirements, treatment and evolution (morbidity and mortality). The splenic trauma diagnosis was confirmed by ultrasonography and/or CT- scan abdomen. All radiological images were reviewed by fellow Pediatric Radiologists (Department of Pediatric Radiology, Dr. Couture) allowing us to distribute patients according to the classification of the American Association for the Surgery of Trauma (AAST).[4] Patients hemodynamically stable or stabilized after blood transfusion (less than 40ml/kg) were managed with NOM. The need for admission in ICU was decided on the basis of hemodynamic stability, the existence or absence of a poly trauma and grade lesion. All these children have been closely monitored by regular clinical evaluations of hemodynamic parameters, checking hemoglobin and ultrasound. The discharged patients are reviewed in consultation: The 15th day following the trauma, after 1 month, 3 months and sometimes beyond depending on evolution. We included in our study patients initially treated and secondarily referred from other departments of surgery. Stab injuries or pathological spleen and/or spontaneous
splenic rupture were excluded from our study. The results were compared with literature data to improve our attitude in managing these patients.
RESULTS A total of 83 children with splenic trauma due to abdominal contusion were managed non-operatively in the Visceral Surgery and Pediatric Urology Department at CHU Montpellier in a period of thirteen years. NOM was successful in 82 patients (98.7% of cases). One failure was observed. It was a 14 year old boy admitted in ICU for multiple trauma with AAST grade IV spleen fracture. This was associated with a missing image of the left kidney with renal artery wound and fracture of the left iliac wing. Despite transfusion with two units of red blood cells (hemoglobin:8g/dl), forty-eight hours later, the child presented with anuria, a distended abdomen, low blood pressure of 70/50 mmHg and with Hb of 4g/dl. Given the critical clinical state with pH 7, an urgent surgical exploration was indicated. A significant hemoperitoneum, ruptured spleen and left kidney were found avascular. Total splenectomy and left total nephrectomy were performed. He also received the vaccination protocol in case of total splenectomy. The duration of hospitalization was 11 days. The follow-up was favorable after a period of 3 months. With a mean period of 4.72 months, the evolution has been marked in this series by complications’ occurrence in 4 cases (4.8%) represented by three pseudo-aneurysms splenic artery and 1 pseudocyst splenic [Table 1]. There was no mortality in this series.
Table 1: Detail of various complications Complications paramètres 1er case
Pseudo-aneurysm splenic artery 2nd case
3rd case
Age (years) Sexe AAST Hemodynamic Ultrasound
10 F Grade III Instable Rounded fluid image of 7.7 mm × 5.2 mm thin-walled, containing arterial flow associated with thin echoes corresponding to slow flow: Pseudo aneurysm splenic artery during thrombosis?( 5th day) Two thrombosed pseudoaneurysms (15 days after hospitalization)
13 M Grade I Instable Pseudo aneurysm splenic artery (2nd day) Aneurysm thrombosis (8th day)
14 M Grade III Instable Posttraumatic aneurysm with arteriovenous fistula (8th day) Pseudo-aneurysm splenic artery thrombosis (23rd day)
CT-scan Treatment Follow-up
148
Abstention Abstention Stable thrombus in different Favorable (2 months) ultrasounds control (5 months)
Pseudocyst splenic 13 M Grade II Instable Two juxtaposed mid splenic cystic cavities of 17 mm × 7 mm × 7 mm, all surrounded by well-vascularized parenchyma, heterogenous (10th day) Decreased volume with dimensions of 13.5 mm × 4 mm × 3.5 mm (1 month) Complete disappearance of the cyst formation (two months)
Pseudo aneurysm splenic artery (2nd day) Arterial embolization (4th day) Abstention Favorable (6 months) Favorable (3 months)
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
Ndour, et al.: Results of non-operative management of splenic trauma and its complications in children
DISCUSSION NOM of splenic trauma represents a major advancement in the history of pediatric surgery. It initiated the same approach applied to other solid abdominal organs (liver, pancreas, kidney) trauma. Upadhyaya and Simpson[3] reported the first series of splenic trauma in children managed without surgery at Sick Children’s Hospital in Toronto in 1968. From their experience they suggested that under some conditions the trauma of the spleen in children could be correctly managed without surgery. Several centers have subsequently experienced and confirmed the validity of this therapeutic method.[5,6] In our department, this approach has been used since 1980.[7] In the case of blunt spleen trauma, NOM has become, under strict conditions, a universally accepted strategy. According to the literature, the success rates currently exceed 90% [Table 2] with a failure rate often lower than 5%.[7-11] In our study we obtained 98.7% of good results. We had one failure which was linked to severe injury (grade IV) associated in addition to a wound of the left renal artery. Complications of splenic trauma NOM found in the literature are essentially secondary hemorrhage, pseudoaneurysm, pseudo-cysts and splenic abscesses.[8] Their frequency varies between 0 and 7.5% depending on the series.[8,12] In our study we found 4 complications including 3 pseudo-aneurysms and one pseudo-cyst. The pseudoaneurysm splenic artery is a rare but serious complication. Its frequency is estimated from 5 to 13% in patients managed with NOM.[8,13] Its natural history is not clear, but its involvement in re-bleeding occurrence has been demonstrated. [14] Abdominal pain is clinically the most common sign.[13] However, many cases are asymptomatic as we reported in our 3 patients. Currently it is clearly[8,12,15] indicated that the best test for diagnosis is the contrast enhanced CT scan (CECT). Oguz and et al[15] have confirmed the value of Doppler ultrasonography for early diagnosis. In our study, the diagnosis was made by Doppler ultrasound in 2 cases and CECT in the other case. In our study, 2 of the 3 cases had spontaneously evolved in this way. This spontaneous evolution can be explained by a phenomenon of self-tamponade, a high proportion of myoepithelial cells, thickness of the capsule, Table 2: Success of no operative treatment depending on the series Authors
Size of series Therapeutic success (%)
Frumiento and al(Canada) Cotte and al (France)[10] Thompson and al (Australie)[8] Veger and al (Pays Bas)[11] Lutz and al (USA)[9] Our serie (France) [7]
n=40 n=13 n=33 n=34 n=86 n=83
100 96 100 91,2 98 98,7
the elasticity of the parenchyma and the ability of contraction and retraction of the splenic arterioles.[1] In the absence of spontaneous thrombosis recovery, the current treatment adopted by many centers is arterial embolization. Dobremez and et al[16] reported two cases of pseudo-aneurysms successfully treated with selective embolization. This interventional radiology technique gives good results[13] but many complications have been described in the literature.[17] Besides the risk of femoral thrombosis in young children, there may be recurrence of the aneurysm in 5 to 10% with need for a new embolization. If this treatment is well established in adults, it is not yet fully adopted in children because of its potential morbidity.[9,17] The splenic pseudocyst caused by trauma is rarely described in the literature. It is considered as benign when there is no rapid increase in volume, mass effect or infection signs. It often occurs after a subcapsular hematoma. Kristoffersen and et al[18] have found only one case in a series of 228 patients treated between 1994 and 2005. We report a single case of splenic pseudocyst in our series. Evolution may lead to the spontaneous regression as we have observed in the case of our study. In the experience of Dobremez and et al[16] on 5 cases, 3 spontaneous regressions and two others required cystic resection. It seems that surgery is indicated for symptomatic pseudocysts. The technical details vary from marsupialization or resection of the protruding dome with partial or total splenectomy. [1] This treatment is more successful by laparoscopy. [17] The secondary hemorrhage is defined by splenic rupture occurring 48 hours after the initial trauma.[8] The re-bleeding is reported in 1 to 2% in different series.[14,17] They are related to the rupture of a subcapsular hematoma, a pseudocyst or pseudoaneurysm and can be severe. The secondary trauma occurrence has also been very noted in the literature,[14] which raises the question of possible non strict rules of rest that is the central pillar of NOM. Huebner and Reed[12] in our study concluded that the risk of occurrence of this complication in children is negligible. Our study seems to confirm this. Management depends on the impact of this re-bleeding on hemodynamic parameters. Without the need for sophisticated resuscitation, NOM keeps on all its indications. Therefore, in the case of uncontrollable active bleeding, there is a choice. On one hand: Surgical hemostasis whose main risk is often total splenectomy for vital rescue. On the other hand, an urgent selective arterial embolization that now seems increasingly used in this event since the conditions are compatible with an urgent referral of the child for a special care.[19] Several cases of successful embolization in splenectomized children have been described in the literature.[17] It helps to reduce the
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
149
Ndour, et al.: Results of non-operative management of splenic trauma and its complications in children
number of children in splenic trauma but this benefit must be weighed against the morbidity of arterial embolization in children.
by the APSA in 2000 to optimize the conditions for this strategy. In this context we propose our protocol management [Figure 1].
The splenic abscess is a rare complication of non-operative management of splenic trauma in children.[17] Frumiento and et al[7] found one case in 40 patients. It occurred eight days after the injury. It should be specific to subcapsular hematoma. The treatment can be percutaneous drainage, currently guided by ultrasound or CT-scan.[14] We didn’t find any case in our study. There was no mortality in our study. The literature reports rare cases of death due to splenic trauma in children from industrialized countries.[20] The causes are often bleeding or multiple trauma[21] in which the spleen is not necessarily directly responsible of this unfavorable evolution.
REFERENCES
CONCLUSION NOM is the treatment of choice for the spleen blunt trauma in the child. We have to obey strict rules of protocol inclusion and monitoring. This is a method that gives excellent results with over 90% success rate. Mortality is almost zero in countries with high medical status. Complications are rare. They are dominated by the pseudo-aneurysm splenic artery whose evolution is usually favorable with or without embolization. The outlook will update the practical guide established
Figure 1: Our practice protocol of management of blunt splenic trauma in children 150
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Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
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