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Websurg, e-Surgery 關於腹腔鏡手術
Clinical Case
CONSERVATIVE MANAGEMENT OF RUPTURED SPLEENF Jamali, MD, E Dutson, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France 1. Summary A case of non-operative management of spontaneous splenic rupture is presented, detailing presentation, therapy, and discussion of indications and requisites for such management. 2. KeywordsSpleen, trauma, hemoperitoneum, malaria 3. Patient47-year-old male 4. Previous historyNot significant 5. History of the present illnessThe patient was born in Africa but had been living in Europe for the last 20 years. He takes yearly trips to Africa, the last one 2 months prior to presentation. Upon presentation the patient was noted to have:
6. Laboratory values- Hgb: 10 g/dL; - platelets: 48 000/mm3; - CRP: 187 (N<10); - LDH: 665 (N<300); - hemagglutination test positive for Plasmodium falciparum. 7. Clinical progressionThe patient was admitted to the medical service for treatment of malaria. Surgical consultation obtained on hospital day 5 for:
8. CT scanAfter initial resuscitation and stabilization, contrasted CT scan demonstrated splenic rupture with hemoperitoneum. Diagnosis of parenchymal rupture of the spleen 9. TreatmentThe patient was admitted to intensive care for continuous monitoring of vital signs, NPO status, and transfusion/IVF resuscitation. With stable measurements of Hgb and blood pressure, diet was gradually advanced. The patient was then moved to a regular hospital bed for several days’ observation. Clinical symptoms disappeared progressively in ten days and the patient was discharged after 3 weeks. 10. DiscussionThe spleen is the intra-abdominal organ most often injured in case of blunt abdominal trauma, but rupture can occur after occult trauma or in the case of several infectious diseases such as malaria. Malaria was the presumptive etiology in this case. The risk of overwhelming post-splenectomy infection (OPSI), which varies with age and indication for splenectomy from 1% in adults to more than 4% in children, points to the importance of respecting the spleen after a trauma. The rate of patients managed non-operatively has recently increased and is, in fact, the most common method of treatment (69%), followed by splenectomy (27%) and splenorrhaphy (4%). Over the last 10 years, the incidence of conservative surgery has declined as observation has been shown to be a safe alternative, with a success rate of at least 90%. This trend presumedly started with comparison to the successes of non-operative management of splenic injury first observed in the pediatric population. The decision to abstain from surgery depends on the hemodynamic stability of the patient (number of packed red cell units transfused) and the lack of other intra-abdominal injury requiring a laparotomy. Additionally, in the case of multiple trauma, any patient who must receive general anesthesia for other operative management (such as orthopedic or cranial procedure) does not qualify for non-operative management of splenic injury because an abdominal examination cannot be followed under these circumstances. Computed tomography signs predictive of recurrent bleeding and the development of arteriography techniques with embolization may further raise the rate of success after abstention from surgery. 11. References
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