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Blunt splenic injury in adults: a decision analysis comparing options for treatment
1General Surgery Service, Ireland Army Community Hospital, Fort Knox, Kentucky, USA.
Objective:
To evaluate factors which influence surgeons in their decision to treat blunt splenic injuries in adults by observation, splenorrhaphy or splenectomy.
Design:
Decision analysis.
Setting:
Army hospital, USA.
Material:
56 Selected papers on the treatment of splenic trauma published between 1983 and 1993.
Intervention:
Variables evaluated included the incidence of transfusion, postsplenectomy sepsis, posttransfusion hepatitis, chronic active hepatitis, cirrhosis, and rebleeding.
Main Outcome Measures:
Quality adjusted life expectancies (QALE) after each procedure.
Results:
QALEs when the mean incidence of each variable was used in the decision analysis were 39.68 years for observation, 39.56 years for splenorrhaphy, and 38.94 years for splenectomy. Sensitivity analysis showed that when the incidence of transfusion was controlled, splenorrhaphy was superior, and both splenorrhaphy and observation were superior to splenectomy. Once a patient had been given blood products the advantages of non-operative management were lost.
Conclusions:
Only patients with minor splenic injuries who did not require blood transfusion should be treated by observation. Patients who require blood transfusion should be explored with the object of salvaging the spleen. Some patients with severe, devitalising injuries will require splenectomy despite the best attempts to salvage the organ.