Conclusions of nonoperative management in blunt splenic injuries

USMF “N. Testemiţanu”, Clinica Chirurgie Nr.1 “N. Anestiadi”, Clinica ATI „V. Ghereg”, Chişinău, Republica Moldova, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Material şi metode: Studiul prospectiv(2008-2011) – 60 traumatizați cu Leziuni Lienale(LL ) închise; B:F/2:1, vârsta medie 39.97±20,35ani; RTS=7,66±0,5; ISS=19,06±8,95. S-a efectuat: USG(100%) de primă intenție în diagnosticarea hemoperitoneului, TC(80%), laparoscopia(20,27%). În 21(35%) cazuri LL a fost izolată, în 39(65%) – asociată. Rezultate: 13(21,66%) pacienți cu PAs≤80mmHg – 11 politraumatizați cu LL: gr.II(7) și III(5) şi fracturi pelviene, 2 pacienți cu LL izolată s-au stabilizat prin repleție volemică fără suport vasotensiv. Trei politraumatizați cu Glasgow ≤12p. şi LL gr.II(2), gr.III(1), (în 2 cazuri instabili hemodinamic) au fost soluționați nonoperator. Severitatea LL(AAST): gr.I-9(15%), gr.II-24(40%), gr.III-25(41,67%), gr.IV-2(3,33%), cele severe constituind 45%. Hemoperitoneul în LL gr.III a constituit 581,25±158,88ml (400-1000ml), în gr.II – 67,65±113,11ml (p<0,001). Volumul hemotransfuziei în LL gr.III asociate cu locomotor şi/sau torace a fost semnificativ mai mare vs pacienții cu gr.III izolat (648,67±49ml vs 283,33±51ml; p<0,001), iar în gr.II asociat valoarea hemotransfuziei a fost 452,5±379ml în raport cu 0 transfuzii în cele izolate (p<0,05). Eşec s-a înregistrat în 6(10%) cazuri: în 5(8,3%) din cauza LL cu hemoperitoneu 1400±200ml (gr.III(2) cu ruptură în doi timpi, gr.IV(2) izolată cu hemoragie prelungită, gr.II(1) cu pseudoanevrism lienal) şi una(1,66%) din cauza perforației jejunului, splina fiind păstrată. Concluzii: LL de gr.I-III izolate, cât şi asociate pot fi rezolvate cu succes, cele de gr.IV necesită o monitorizare complexă riguroasă. Scăderea hematocritului şi hemotransfuziile prelungite la politraumatizați nu pot prezice nereuşita MNO. Volumul şi extinderea hemoperitoneului poate fi un criteriu orientativ de prognostic al eşecului MNO, însă la volume mai mari de 500ml. Lipsa conştiinței nu este un criteriu de evitare a MNO, laparoscopia în aceste condiții ar putea concretiza reuşita opțiunii.Material and methods: Prospective study(2008-2011) on 60 patients with blunt Splenic Injuries(SI): M:F/2:1, mean age 39,27±20,35 years, 21(35%)-isolated SI, 39(65%)- associated, RTS=7,66±0,5; ISS=19,06±8,95. Diagnostic tools: USG in 100%, CT in 48(80%), laparoscopy in 16(20,27%); Results: 13(21,66%) patients with SBP≤80mmHg: 11 polytrauma patients–IInd degree 7, IIIrd dgr.–5 (SI with pelvic trauma), 2 patients with isolated SI, all were stabilized by fluid perfusions, without vasoactive support. 3 polytrauma patients: II nd dgr.-2, III rd dgr.-1, with GCS≤12p. were successfully treated nonoperatively. The severity of SI(AAST) revealed: Istdgr.-9(15%), IInddgr.- 24(40%), IIIrddgr.-25(41,67%), IVthdgr.-2(3.33%), IIIrd degree prevailed, severe injuries being determined in 45%. Hemoperitoneum volume in IIIrd dgr. SI was 581,25±158,88(400-1000ml), in IInddgr.- 67,65±113,11ml (p<0,001). The blood transfusion volume in IIIrddgr. associated SI with thorax or musculo-skeletal trauma was significantly higher vs isolated SI (648,67±49ml vs 283,33±51ml, p<0,001), while in IInddgr. associated SI the average volume of blood transfusion was 452,5±379ml in contrast to 0 transfusions in isolated SI(p<0,05). NOM failure reported in 6(10%) cases: in 5(8,3%) because of SI with hemoperitoneum 1400±200ml (IIIrddgr. (2)-delayed splenic rupture, IVthdgr.(2)-isolated SI with prolonged bleeding, IInddgr.(1)-lienal pseudoaneurism) and 1(1,66%) failure case caused by jejunal rupture, the spleen being preserved.Conclusions: Both isolated and associated Ist-IIIrddgr. SI can be treated nonoperatively, IVthdgr. SI requiring close and complex monitoring. Reduction of haematocrit and expanded blood transfusions in polytrauma patients could not predict NOM failure. The volume and extent of hemoperitoneum could serve as a failure index of NOM when it exceeds 500ml. Lack of awareness is not a criterion to avoid NOM, laparoscopy reflecting the success of the option

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