Early post-splenectomy sepsis after missile injury in adults

Early septic complications were studied in 292 patients operated on for penetrating missile injury of the abdomen with involvement of either the spleen or the liver, at Basrah Teaching Hospital between January 1983 and April 1986. Depending on associated injuries, patients with splenectomy were divided into three groups, the first with isolated splenic injury, the second with splenic and associated extra-intestinal organ injury, and the third with splenic and intestinal injuries with or without extra-intestinal organ injury. Patients with hepatic injury were classified similarly. Splenectomy was carried out for any degree of splenic injury. Grade I hepatic injuries were managed by débridement and suturing while major grades II-IV underwent segmentectomy or lobectomy. Patients were considered septic if they had any three of four clinical criteria: temperature higher than 39 degrees C; significant haemodynamic deterioration; respiratory alkalosis, or oliguria. Of the total, 79 were excluded due to: early transfer 51, incomplete records 8, perioperative death 11, and having combined splenic and hepatic injuries 9 (excluded by definition), leaving 104 (74.8%) patients with splenectomy and 109 (71.1%) with hepatic injury available for study. Sepsis developed in 48 (46.1%) of patients after splenectomy and in 28 (25.7%) with hepatic injury. This difference was significant (P greater than 0.005). In patients with isolated splenic injury, eight (25.8%) were septic while three (13.6%) of those with isolated hepatic injury developed sepsis. This was not significant (P = 0.32, Fisher's exact test). When either was associated with an injury to an extra-intestinal organ, 15 (50%) of the splenectomy group developed sepsis compared to five (23.8%) of the hepatic injury group. This did not reach significance. When either was associated with intestinal injury, sepsis developed in 25 (58.1%) of the splenectomy patients, in contrast to 20 (30.3%) of patients with hepatic injury. This was significant (P < 0.005). Gram-negative coliforms were the most common organisms isolated comprising 72.5% and 67.8%, in contrast to pneumococci isolated in 5.9% and 3.6% in the splenectomy group and hepatic injury group, respectively.In conclusion, in patients with penetrating missile injuries of the abdomen, the risk of sepsis is increased after splenectomy compared to hepatic injury, only if there was associated bowel injury. This was reflected in the type of causative organism (predominantly enteric flora) despite 'appropriate'antibiotic cover, as well as a fivefold increase in mortality among the splenectomy group. We suggest that splenic salvage, where feasible, is mandatory if associated with intestinal injury.