Review of traumatic splenic injuries 중앙대학교 흉부외과 인턴 한대훈

Introduction Spleen SKILL Most frequently injured intra-abdominal organ in blunt trauma SKILL Kidney Intestine Liver Large bowel

Functions of the spleen Immunoglobulins 생산 Cellular immune response Asplenic pt. : phagocytosis, Ag-Ab response 손상 Immune response to bacterial capsular type II polysaccharide antigens of encapsulated bacteria 감소 S. pneumoniae H. influenzae N. meningitidis Sepsis에 대한 susceptibility 증가

Post splenectomy syndrome 1952년 Congenital hemolytic anemia의 생후 6개월 미만 환아 5명에서 splenectomy 4명에서 심각한 meningitis, sepsis발생 1969년 Overwhelming postsplectomy infection 용어 사용

Postsplenectomy infection incidence Children 0.6% Adult 0.3%

Rapid & fulminating course Fever Nausea & vomiting Headache Overwhelming postsplenectomy infection syndrome Vs Septicemia under the normal immune system Rapid & fulminating course 12~18시간 지속 Fever Nausea & vomiting Headache Altered mental status Overall mortality rate : 50~80%

Prevention of the overwhelming postsplenectomy infection syndrome Polyvalent pneumococcal vaccine Pneumovax 23, Merck Pnu-immune Lederle Prophylactic antibiotics controversial

Management of the splenic injuries Hemodynamically stable 하다면, U/S : free fluid(+)면, abd. CT 시행 Bleeing source 찾기 Contrast agent의 extravasation 찾기 Bleeding을 의미 : prompt OP Vs angiographic embolization 후 nonOP manage Other intra-abdominal injuries 찾기 Splenic injury의 severity & grade 파악

Spleen Injury Scale (1994 Revision) - Organ injury scaling : Spleen and liver (1994 revision). J. Trauma 38:323-324, 1995

Classic criteria of nonoperative manage Hemodynamically stable Negative abdominal examination CT에서 contrast extravasation이 없는 경우 다른 exploratory laparotomy의 명확한 indication이 없는 경우 Surgical intervention이 필요한 다른 장기 손상이 없는 경우 Bleeding risk 증가시키는 health condition이 없는 경우 Coagulopathy, hepatic failure, anticoagulation, specific coagulation factor deficiency Grade 1~3

Management of the splenic injuries ICU 입원 ABR & NG tube 48~72hr. Abdominal exam, Hct. F/U 48~72hr. 후 stable 하면 일반병실, 중중환자실로 이실 후 walking, eating 시작 Hct 감소, hypotension, persistent ileus 시 CT F/U 3개월 동안 intense physical activity, contact sports는 피하라고 교육 Nonoperative manage 성공률 > 90%

Surgical treatments Laparotomy 동안 spleen에 active bleeding 있는 지 확인 Active bleeding 있으면, total splenectomy or splenic salvage procedure 여부 결정 Segmental splenic resection 환자가 stable하고 다른 장기 손상 없이 splenic parenchymal의 50% 이하의 major laceration hilum까지 손상되지 않은 경우 Splenectomy Spleen의 central portion or hilum 손상

Alternative procedures Autotransplantation Dexon or Vicryl mesh wrapping, argon beam coagulator, fibrin glue cf. splenic salvage procedures의 성공률 : 40~60%(nonOP mange 포함시 90%)

Complications Bleeding(inadequate hemostasis, massive transfusion, coagulation) Transient thrombocytosis Pancreatits Intra-abdominal abscess