Splenic injuries in children: The challenges of non operative management in a developing country

Abstract

Aim: This is to report the challenges and experience gained with non operative management of splenic injuries in a developing country where sophisticated imaging facilities are either not available or exorbitantly expensive. Materials and Methods: All patients who presented with splenic injury at the University of Benin Teaching Hospital between January, 2000 and December, 2006 were assessed and those who met the criteria were recruited for non operative management. Diagnosis of splenic injury was made by combining clinical assessment and ultrasound findings. Results: A total of 24 children with a mean age 12 ± 0.04 years and male/female ratio 1.7:1 were treated during the period. Road traffic accident, accounting for 50% of the cases was the major cause of trauma followed by falls from heights. Delay in presentation was a major concern as 62.5% of them were not referred until shock supervened. None of the patients could afford CT scan but ultrasound scan was able to confirm diagnosis in all. Basing decision on clinical parameters, non operative management was successfully done in 75% while 25% were operated as they could not meet the criteria. No mortality was recorded in the non operated group while one was recorded in those operated. The average length of hospitalization was two weeks. Conclusion: Non operative management of splenic injuries can be successfully done in a developing country using clinical parameters as a guide. The 75% of patients with splenic injury treated can be improved upon by health awareness campaign/improvement in government policy that will result in early presentation.

Splenic injuries at Bugando Medical Centre in northwestern Tanzania: a tertiary hospital experience

“…Splenic injuries are commonly associated with other injuries and these may complicate the management and affect the outcome [17]. The pattern of complications in the present study is similar to what was reported by others [13,17].…”

“…The high incidence of blunt splenic injuries in this study can be explained by the fact that those patients who had blunt splenic injuries were mostly involved in road traffic crash, a common feature of increased motorization in this environment. Road traffic accidents have been reported to be the commonest cause of blunt splenic injuries in most studies as supported by the present study [ 7 , 11 , 13 , 15 , 17 ]. In contrast to our findings, one study reported fall from height as the most common cause of splenic injuries [ 21 ].…”

“…High incidence of splenectomy in our study is attributed to the large number of patients with higher grades of splenic injury and low rate of splenorrhaphy in our study may be attributed to the lack of technical material, like fibrin glue or dexon mesh, which makes splenorrhaphy more successful. Also, unlike in western countries where patients present within few hours of injury and in relatively stable clinical state [15,17,23,26], most of our patients presented to the A & E department in poor clinical state necessitating emergency laparotomy. The developing nature of our health system and haemodynamic instability of these patients on presentation makes operative management inevitable.…”

“…Today, 90% of blunt pediatric splenic injuries and about 60-70% of adult ones are managed non-operatively in the West and other developed countries [15,17,23]. Criteria used to select patients for non-operative management of splenic injuries described in the literature include hemodynamic stability on admission, grade of splenic injury, amount of haemoperitoneum seen on CT scan, age less than 55 years, ability to elicit reliable physical signs on serial physical examination, limited blood transfusion requirements, and exclusion of other injuries that may require laparotomy [26].…”

“…In developing countries such as Tanzania, however, the majority of patients with splenic injuries from blunt abdominal trauma are still being managed operatively, with a low operative splenic salvage rate [ 5 , 15 , 16 ]. The lack of advanced pre-hospital and ineffective ambulance system for transportation of patients to hospital care coupled with lack of modern diagnostic imaging or inability to afford them even when available make it a great challenge to embark on non-operative management [ 17 ]. There is therefore a need to develop management protocols specific to developing countries based on categorizing the patient using clinical evaluation rather than expensive imaging if non-operative treatment is to be adopted in this region.…”