Related Experiment Videos
New insight for management of blunt splenic trauma: significant differences between young and elderly
Kouji Tsugawa1, Nobuhiro Koyanagi, Makoto Hashizume
1Department of Surgery II, Faculty of Medicine, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
Insights
Non-operative management of blunt splenic injury is less successful in elderly patients, who experience higher complication rates and mortality. Aggressive initial surgical intervention is recommended for elderly patients due to their decreased physiologic reserve.
Area of Science:
- Trauma Surgery
- Emergency Medicine
- Geriatric Medicine
Background:
- Non-operative management of blunt splenic injury is established in younger patients.
- Limited data exists on non-operative splenic injury management in the elderly population.
- Understanding injury patterns in elderly vs. young patients is crucial.
Purpose of the Study:
- To investigate the relationship between injury mechanism, splenic injury grade, and associated injuries.
- To compare injury patterns in young (under 60) and elderly (60+) patients with blunt splenic injury.
- To evaluate the efficacy and outcomes of non-operative management in different age groups.
Main Methods:
- Retrospective analysis of 167 blunt splenic injury patients (116 young, 51 elderly) from 1983-1997.
- Blinded interpretation of computed tomography (CT) scans.
- Comparison of Injury Severity Score (ISS), Glasgow Coma Scale (GCS), splenic injury grade, management types, and outcomes between age groups.
Main Results:
- Elderly patients had higher ISS, lower GCS, and increased mortality.
- Non-operative treatment rates were significantly lower in the elderly (32.3%) compared to the young (62.8%).
- Splenectomy rates were higher in the elderly (51.6%) vs. young (29.1%), with increased infectious complications in the elderly.
Conclusions:
- Non-operative management of blunt splenic injury is challenging in the elderly.
- Factors predicting operative intervention include high ISS, high splenic grade, hemoperitoneum, active extravasation on CT, and high-energy mechanisms.
- Aggressive initial surgical management is recommended for elderly patients due to spleen fragility and reduced physiologic reserve.
Background/Aims:
Although highly successful in children and young patients, the non-operative management of blunt splenic injury in the elderly has yet to be clearly studied. The purpose of this study was to determine whether or not a relationship exists among the mechanism of injury, the grade of splenic injury, the associated injuries, and whether patterns of injury differ between the young group (younger than 60 years old) and the elderly group (60 years and older than 60 years).
Methodology:
One hundred and sixty-seven patients (116 young patients including 30 early deaths and 51 elderly patients including 20 early deaths) with blunt splenic injury were admitted to our clinic from 1983 to 1997. Computed tomography scans were interpreted in a blind fashion. In addition, the Injury Severity Score, Glasgow Coma Scale, blunt splenic injury grade, length of hospital stay, length of intensive care unit stay, survival, number of abdominal injuries and number of total diagnoses were investigated in both the young and elderly groups. The different types of management for blunt splenic injury were also studied.
Results:
Higher injury severity scores, lower Glasgow Coma Scales, and higher mortality all indicated that the elderly were more severely injured than the young patients. The rate of non-operative treatment was also significantly greater for young patients than for elderly patients (62.8 vs. 32.3%, P < 0.05) and the rate of a splenectomy was significantly less for the young patients than for the elderly patients (29.1 vs. 51.6%, P < 0.05). Regarding infectious complications, the rates of pneumonia (14.0 vs. 23.1%, P < 0.05), subphrenic abscess (9.3 vs. 23.1%, P < 0.05), and urosepsis (7.0 vs. 23.1%, P < 0.05) was significantly greater for the elderly patients than for the young patients. The overall failure of non-operative management was 5.2% in the young patients and 9.8% in the elderly patients.
Conclusions:
The final selection of splenic management decision was individualized for each patient and based on multiple variables. For persistent hemodynamic instability or unresolved concerns for other individual pathologic conditions, aggressive management is recommended. In the absence of these two important conditions, the variables that predicted a need for operative intervention include an Injury Severity Score above 20 in younger and elderly patients; an American Association for the Surgery of Trauma splenic grade above III in elderly; a large hemoperitoneum on an initial computed tomography scan; the presence of active extravasation on an initial computed tomography scan; and high-energy mechanisms. In conclusion, selecting the optimal non-operative management of blunt splenic injury in elderly patients remains difficult. An aggressive initial operation is thus recommended because the specific fragility of the spleen and the decreased physiologic reserve in elderly patients is difficult to estimate, especially at small hospitals where performing emergency splenic angiography and treating embolisms is difficult.