Pattern and Outcome of Splenic Injury in Children

Kevin Emeka Chukwubuike
Pediatric Surgery Unit, Department of Surgery, Enugu State University Teaching Hospital, Enugu, Nigeria

 

Correspondence to: Dr. Kevin Emeka Chukwubuike; Email: chukwubuikeonline@yahoo.com
 

Received: 8th August 2020; Revised: 8th September 2020; Accepted: 18th December 2020; Available online: 9th March 2021 

Abstract
Background: The spleen is the most frequently injured organ in abdominal trauma. The aim of this study was to evaluate the pattern and management outcome of splenic injury in children in a tertiary hospital. Methods: This was a retrospective study of children treated for splenic trauma at the Pediatric Surgery Unit of Enugu State University Teaching Hospital (ESUTH) Enugu, Nigeria. The medical records of the patients over a 10-year period were evaluated. Results: There were 61 cases of splenic trauma of which 72.1% were male. Their ages ranged from 4 to 14 years with a median of 10 years. Road traffic accident and fracture were the most common mechanism of injury and associated injury respectively. The majority had grade III splenic injury and non-operative management was the predominant modality of treatment. Operative procedures included splenectomy and splenorrhaphy. Mortality occurred in two (3.3%) patients.

Conclusions: Splenic injury can be associated with significant morbidity and mortality. Road traffic accidents are a common cause of splenic injury and non-operative management is an effective modality of treatment.

Keywords: Children, splenic injury, tertiary hospital, outcome.

Ann Afr Surg. 2021 ; 18(3): 150-154

DOI: http://dx.doi.org/10.4314/aas.v18i3.5
Conflicts of Interest: None
Funding: None
© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

Introduction
Injury is regarded as a global health concern and in pediatric trauma patients the spleen is the most commonly injured solid organ which may follow accidental or non-accidental trauma (1, 2). The mechanisms of splenic trauma include: falling from a height, bicycle injuries, child abuse, sports-related injuries, and motor vehicle and pedestrian injuries (2). Traumatic injury to the spleen can be blunt or penetrating with the former being more common than the latter (3). In comparison to adults, children have an elastic rib cage which causes transmission of force into the abdominal compartment (4). Symptomatology of splenic trauma may include left upper quadrant abdominal pain with associated referred left shoulder pain. Patients who present late may be in a state of shock with generalized abdominal pain (1). The evaluation of children with splenic injuries includes the use of ultrasound which is non-invasive and does not make use of radiation (5). The advantage of the use of ultrasound is its affordability and availability. The diagnostic yield of ultrasound is enhanced by Doppler and contrast enhanced ultrasound (6). Contrast-enhanced computed tomography (CT) scan is the gold standard for the evaluation of splenic trauma (7). However, because of the risk of radiation exposure, low-dose protocol (3-6) is preferred in children (1). The grading of splenic injury is usually achieved through a CT scan. Non-operative management of blunt splenic trauma is the mainstay in children and in pediatric trauma centers, splenic preservation approaches 100% (8).  Treatment of penetrating splenic injuries can be challenging: a significant number of penetrating splenic injuries require surgery. However, a certain number of patients may present without hemodynamic instability and non-operative treatment can be offered (9). Management of splenic injury should be multidisciplinary based on the physiology of the patient, anatomy of the injury and associated injuries (10).  Initial evaluation of children with splenic injuries must follow the Advanced Trauma Life Support (ATLS) protocol to ensure that no associated injury is missed. There is paucity of data on splenic injury in Enugu, hence, the need for this study. The aim of this study was to evaluate the pattern and management outcome of splenic injury in children at a pediatric surgery unit of a teaching hospital in Enugu, Nigeria.

 

Materials and methods
This was a retrospective study of children aged 15 years and younger who were managed for splenic injury between January 2008 and December 2018 at the pediatric surgery unit of Enugu State University Teaching Hospital (ESUTH) Enugu, Nigeria. All traumatized pediatric patients, involving an injury to the spleen, were included in the study. Patients with incomplete case records were excluded.  ESUTH is a tertiary hospital located in Enugu, South East Nigeria. The hospital serves the whole of Enugu State, which according to 2016 estimates of the National Population Commission and Nigerian National Bureau of Statistics, has a population of about 4 million people and a population density of 616.0/km2 (11). The hospital also receives referrals from its neighboring states. Information was extracted from the case notes, operation notes, operation register, and admission discharge records. The information extracted included the age, gender, interval between the incident and presentation, indication for surgical intervention, definitive operative procedure performed, complications of treatment, duration of hospital stay and outcome of treatment. The period of follow up was for 12 months. 
Ethical approval was obtained from the Ethics and Research Committee of ESUTH. The Statistical Package for Social Science (SPSS) for Windows version 23 (IBM Corp., Armonk, NY, USA) was used for data entry and analysis.  Data were expressed as percentages, median, mean, and range.  

 

Protocol
On presentation to the hospital, the patients were clinically evaluated and resuscitated using the Advanced Trauma Life Support (ATLS) protocol. Patients in a stable condition were sent for investigations such as urgent hemoglobin estimation and abdominal ultrasound for assessment of the grade of splenic injury and associated injuries. Patients who presented in shock were resuscitated and stabilized using crystalloids, colloids, and blood transfusion. 
The treatment protocol adopted for each patient depended on the hemodynamic status of the patient. Stable patients were put on strict bed rest, serial hemoglobin estimation and ultrasound examination until there was ultrasound evidence of healing of the spleen. The frequency of serial ultrasound scan evaluations was based on the findings on clinical assessment. Patients in shock that failed to respond to blood transfusions underwent emergency splenorrhaphy or a splenectomy. Post operatively, patients who had surgery were placed on parenteral antibiotics and oral intake commenced when bowel function returned. Post splenectomy vaccines were not given to the patients due to its non-availability.   

 

Results
Patients’ demographics
Sixty-three children had splenic injury during the study period but only 61 cases had complete case records and formed the basis of this report. Thirty-one (50.8%) patients were referred from the peripheral hospital and half of these patients were in shock at presentation. There were 44 (72.1%) males and 17 (27.9%) females. The ages of the patients range from 4 years to 14 years with a median age of 10 years. The median interval between the incident and presentation was 3 days with a range of 1─6 days.  Eight (13.1%) patients presented within 24 h, 12 (19.7%) patients present