Management and outcome of patients with blunt splenic injury and preexisting liver cirrhosis

Abstract

Prognostic/epidemiologic study, level III.

Cirrhosis increases mortality and splenectomy rates following splenic injury

“…The use of prothrombotic agents or fibrinolysis inhibitors is not specifically addressed in this study; although given the inherent thrombophilia of liver failure patients, the associated thrombotic risk may be much more significant than the general population. 25,26 Although the retrospective nature of this study limits our ability to fully clarify the difference between failed NOM and primary splenectomy, this rate of splenectomy in patients with cirrhosis and BSI is much higher than the 17% failure rate reported in an NTDB study reported by Bugaev et al, but somewhat less than the 92% failure rate reported in a 12 patient series by Fang et al 13,14 The higher than usual splenectomy rate observed in the control population may be an artifact of the 20-year period of the study, or may be an artifact of selecting control patients to match cirrhotic patients with significant splenic injuries. Our case and control populations had a greater than 50% incidence of high-grade splenic injuries, and these patients are presumably at a higher risk of failing NOM than populations that include a lower incidence of high-grade splenic injuries.…”

“…This surrogate has been previously used given the challenges with evaluating the true surgical intent on retrospective review. 14 We found no statistical difference in the frequency of immediate splenectomy between patients with cirrhosis [64% (25/39)] and control patients [47% (43/91), P 5 .88].…”

“…We therefore used time to the operating room as a surrogate for intention to operate immediately, and we defined immediate transfer to the operating room as a splenectomy less than or equal to 6 hours, a time cutoff used by prior studies in this field. 14 We calculated admission MELD scores from laboratory data collected within 24 hours of admission using the accepted formula: [MELD score 5 (.957 ! ln(serum creatinine) 1 .378 !…”

“…[10][11][12] A series of 12 patients demonstrated that 92% of patients with cirrhosis and BSI required a splenectomy, while a recent analysis of the National Trauma Data Bank (NTDB) demonstrated increased risk of failed NOM and mortality in cirrhotic patients with BSI. 13,14 This study has several key limitations. 15 Perhaps most importantly, the NTDB lacks information necessary to calculate a model for end-stage liver disease (MELD) score, an accepted prognostic score in chronic liver disease patients.…”

“…15 Perhaps most importantly, the NTDB lacks information necessary to calculate a model for end-stage liver disease (MELD) score, an accepted prognostic score in chronic liver disease patients. 14 The MELD score may be particularly pertinent in patients with BSI and cirrhosis as the degree of liver dysfunction and subsequent portal hypertension could predispose patients to more severe ongoing bleeding.…”