Ruptured spleen in children--15-year evolution in therapeutic concepts

This is a 15-year retrospective study of 64 pediatric surgical patients with traumatic rupture of the spleen from 1976 to 1990. The overall mortality was 14% (9/64). All non-survivors had severe multiple traumata and no fatalities were attributable to splenic injury. During the first 5 years of the study, the traditional surgical approach of immediate laparotomy and splenectomy was employed. During the next 5 years we practised laparotomy with subtotal splenectomy and repair. During the final 5 years conservative management with clinical and ultrasonographic monitoring became predominant (1 splenectomy, 4 repair, 23 conservative treatments). Among the 55 survivors, 11 had splenectomy, 14 had splenic repairs and 30 were treated non-operatively. All survivors had excellent outcomes and there was only one complication: a local abscess following splenic repair. Based on a very strict protocol in conservative management, the total amount of transfused blood could be reduced remarkably during the last period. Splenectomized patients received pneumococcal vaccine and prophylactic antibiotic coverage was prescribed for febrile episodes. None of the splenectomized patients experienced septic episodes or increased rates of infection. Based on our experience, ultrasonographically monitored conservative management is the treatment of choice in most patients with splenic injury in childhood.