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MINISTRY OF EDUCATION
MINISTRY OF HEALTH
HANOI MEDICAL UNIVERSITY
  

TRAN NGOC DUNG

RESEARCH ON NON-OPERATION
MANANGEMENT OF BLUNT SPLENIC INJURY IN
THE ABDOMINAL TRAUMA AT THE VIET DUC
FRIENDSHIP HOSPITAL

Specialization
Code

: Gastrointestinal surgery
: 62720125

SUMMARY OF DOCTORAL DISSERTATION

HANOI - 2018


THIS STUDY WAS COMPLETED IN:
HANOI MEDICAL UNIVERSITY

Spervisor: 1. Assoc. Prof. MD. NGUYEN DUC TIEN
2. Assoc. Prof. MD. KIM VAN VU

Reviewer 1: ...........................................................
Reviewer 2: ...........................................................

Reviewer 3: ...........................................................

The thesis will be defended before the Examining Board at university
level in Hanoi Medical University
At ................. date .....................

This thesis could be found at
- National Library
- Centre Medical Information Library


1

INTRODUCTION TO THESIS
1. Set the problem
Blunt splenic injury is a common injury in the abdominal trauma. In
many countries in the world as well as in Vietnam, blunt splenic injury is
always a high rate compared with other traumatic organs in the abdomen.
In the United States, about 1200 patients with abdominal traumas have
been reported annually in emergency centers, including 25% of blunt
splenic injuries.
In Vietnam, along with the socio-economic development is the speed
of urbanization, traffic, occupational accidents and many living. These are
favorable conditions for increasing the rate of abdominal trauma in general
and splenic injury in particular. According to statistics from the Viet Duc
hospital from 2001 to 2003, 132 cases of abdominal trauma have surgery
for solid organ damage, blunt splenic injury the most is 31.8%. In Binh
Duong, during the 2006-2007 period, blunt splenic injury accounted for
131/358 cases of abdominal traumas, equivalent to 36.59%.
In the past, all blunt splenic injuries were performed by splenectomy,

even if only a minor injury. However, by the middle of the twentieth
century, the preservation of the spleen by injury was noticed, especially
after King and Shumaker's discovery of the supersonic infection of over 5
splenic children he called The "Overwhelming Post Splenectomy
Infection", followed by further knowledge of the function of the spleen,
especially the immune function and blood purification of the body, the
spleen preservation is systematically set.
In recent decades, the spleen preservation has varied, from spleen
preservation to surgery to non-operation. In 1968, Upadhyaya and
Simpson reported 48 cases with splenic trauma of successful treatment by
non-operation management (NOM) in children. Since then, this method
has become the trend of splenic injury treatment. Today, with the
development of resuscitation and medical imaging, non-operation
management of splenic injury is increasingly widespread and effective,
with successful non-operation management outcomes reaching over 90% .
In Vietnam, the treatment of spleen preservation is set in the 1980s,
with the announcement of two spleen sutures by Nguyen Lung and Doan
Thanh Tung, and later by systematic studies of Tran Binh Giang on spleen
preservation surgery.
In recent years, non-operation management of blunt splenic injury has
also been studied by many authors, applied in some large surgical facilities
and brought about very positive results such as Pham Van Thuyen's
success rate is 98.4%, Tran Ngoc Son is 89.3% or Tran Van Dang is


2
95.78%. However, how can we apply systematically, scientifically and
extensively to this technique in clinical practice, in the face of such
problems? The topic: "Research on non-operation manangement of
blunt splenic injury in the abdominal trauma at the Viet Duc Friendship

Hospital". With aim:
1. Description of clinical and laboratory characteristics of patients
with blunt splenic injury in the abdominal trauma at the Viet Duc
Friendship Hospital.
2. Evaluate the results of non-operation management of blunt splenic
injury of the abdominal trauma and some factors affecting the
outcome.
2. The urgency of the thesis
Blunt splenic injury is a surgical emergency and is a common injury in
the abdominal trauma. The function of the spleen for the body has been
demonstrated by many studies to be very important. And non-operative
management has become a treatment for preservation of blunt splenic
injury. Along with the development of resuscitation and medical imaging,
non-surgical management of blunt splenic injury has also changed, the
indication is extended, the therapeutic effect is enhanced. Therefore, the
study of non-operation management of blunt splenic injuries to apply
modern means, the advances of science in the diagnosis and treatment of
splenic preservation is a current and necessary issue in Vietnam. .
3. The contribution of the thesis
Research conducted at Viet Duc Hospital is one of the major surgical
facilities in Vietnam with a team of well-qualified physicians and
equipment, a large number of patients offering a comprehensive picture of
Diagnosis and non-operation manangement of blunt splenic injury. The
study also demonstrated significant determinants and factors affecting the
effectiveness of non-operative manangement of blunt splenic injury, and
the study showed the role of resuscitation and medical imaging in
improving the diagnostic efficiency and non-operative management of
blunt splenic injury.
4. The composition of the thesis
The thesis has 137 pages, including: Set the problem: 02 pages; Chapter

1 - Overview: 37 pages; Chapter 2- Objectives and Methodology: 16 pages;
Chapter 3 - Research Results: 34 pages; Chapter 4 - Discussion: 45 pages;
Conclusion: 02 pages; Recommendation: 01 page. The thesis results are
presented in 49 tables and 09 graphs. The dissertation uses 129 references
including 23 Vietnamese, 01 French and 105 English.


3
Chapter 1: OVERVIEW
1.1. General anatomy of the spleen
1.1.1. Location
The spleen lies deep in the left hemisphere, on the left kidney, behind
and to the left of the stomach.
1.1.2. Externality
The classic description of the spleen looks like a coffee bean, a threesided pyramid, a top, a bottom, and a bottom.
1.2. Histological structure
1.2.1. Spleen
- Created by:
* Serous membrane.
- The serous membrane is the peritoneum wrapped around the spleen
except in the spleen and attached to the spleen coat of the spleen.
* Fiber membrane.
- This is a layer of connective tissue that surrounds the spleen.
- From the inside of this layer of fiber, the connective tissue leaves
called the spleen, forming the septum into the spleen, splitting into small
lobes and then gathering in the spleen.
1.2.2. The splenic parenchyma is called splenic marrow.
The splenic marrow is dark red, formed by a sagittal tissue frame
containing blood cells, consisting of two parts: red and white marrow
1.3. Classification of the American Association For The Surgery Of

Trauma in 1994
In 1994, AAST (American Association for the Surgery of Trauma)
proposed splitting the spleen injury to 5 degrees based on lesions of
hematoma or parenchyma, with or without splenic vessel.
Grade I
o Hematoma: subcapsular, <10 percent of surface area
o Laceration: capsular tear <1 cm in depth into the parenchyma
Grade II
o Hematoma: subcapsular, 10 to 50 percent of surface area
o Laceration: capsular tear, 1 to 3 cm in depth, but not involving a
trabecular vessel
Grade III
o Hematoma: subcapsular, >50 percent of surface area OR expanding,
ruptured subcapsular or parenchymal hematoma OR intraparenchymal
hematoma >5 cm or expanding
o Laceration: >3 cm in depth or involving a trabecular vessel


4
Grade IV
o Laceration involving segmental or hilar vessels with major
devascularization (i.e., >25 percent of spleen)
Grade V
o Hematoma: shattered spleen
o Laceration: hilar vascular injury which devascularizes spleen
1.4. Non-operation management of blunt splenic injury
Since King and Schumaker's discovery of post-spontaneous infection
of children after splenectomy and the success of Upadhyaya and Simpon's
non-operation management for 48 patients with splenic injury. The issue
of non-operation management of blunt splenic injury is increasingly being

studied and applied in many parts of the world. In Vietnam, this technique
has been applied in some major surgical facilities in the country such as
Cho Ray Hospital, Viet Duc Hospital, Hue Central Hospital or National
Hospital of Paediatrics
* Initial restoration:
Fluid, blood on the extent of blood loss
* Indication of non-operation management:
- According to many authors, the first indication is that based on the
hemodynamic condition of the patient, hemodynamics should be stable or
rapidly stabilized when positive resuscitation.
- Secondly, the abdominal condition of the disease, excluding the
combined lesions in the abdominal cavity especially the perforation of the
hollow organs, is an indication for an absolute emergency operation.
- Blunt splenic injury is often present in the context of multiple
traumatic injuries, so the diagnosis and assessment of severity of
associated injuries is essential to avoid missed injury, especially when
there is non-operation management of splenic injury.
- In addition, the state of the patient must be in contact. Patients who do
not have coagulopathy or are taking anticoagulants.
* Non-operation management techniques:
- Internal medicine: Patient monitoring
- Internal medicine combined with angioembolization for splenic
vessels injury and/or splenic injury: Grade IV, V.
1.5. The study of splenic injury treatment
1.5.1. On the world
Management of blunt splenic injury was studied very early. However,
the understanding of the anatomy and function of the spleen is limited, so


5

the viewpoint of blunt splenic injury management is changing and
improving according to the progress of science.
Previously, total splenectomy was considered standard in the
management of blunt splenic injury and this was a management viewpoint
for centuries.
In 1881, Billroth noted on the corpse a case of splenomegal healing
spontaneously following injury. In 1927, Hamilton Bailey posed the
question: "Is there any need for splenectomy for splenic injury?" But
perhaps the preservation of the spleen has not been noticed due to limited
knowledge about the spleen. And splenectomy is still a technique that
many authors have studied and applied.
In 1919, Morris and Bullock's study showed a high risk of infection in
splenectomized people. Up until 1952, King and Schumacker discovered
the syndrome of post-sperm infection in children. Conservation of the
spleen has led to more research, beginning with preservation in surgery
such as splenorrhaphy, partial splenectomy, splenic hemorrhage with biomesh to non-operation management.
According to Lucas, the first Wanborough initiating non-operation
management for pediatric patients at Children's Hospital of Toronto 1940.
In 1968, also in Toronto, Upahaya and Simpson, successfully nonopreation management for 48 patients with splenic injury.
In 1971, Douglas and Simpson studied the successful non-operation
management of 25 of 32 pediatric splenic injuries and the authors
commented: Blunt splenic injury are available stop bleeding in almost all
cases of non-operative treatment.
From successes in children, non-operation management is gradually
indicated for adults with the original indication is limited, such as: patients
with hemodynamically stable, alone splenic injury, degree minor injuries
(grade I, II and III), under 55 years old.
In recent decades, along with the development of positive resuscitation
and medical imaging diagnostics, in particular angiography and
embolization, non-surgical treatment of splenic injury has been

increasingly widespread and effective treatment. Resuscitation for both
hemodynamically stable patients, age-limited, combined splenic injury,
can be successfully by non-operation management, especially for severe
(grade IV, V) and vascular lesions can still be successfully treated with
embolization. And many reports give success rates up to 90%.
Today, non-operation management of blunt splenic injury has become
a widespread treatment trend and system in the world.


6
1.5.2. In Viet Nam
Management of blunt splenic injury in Vietnam also follows the trend
of the world. Previously, all studies on blunt plenic injury were referred to
total splenectomy.
In 1942, Pham Van Hat presented the thesis of splenic rupture. In 1952,
Nguyen Huu described the distribution of blood vessels in a branched
manner, dividing the blood supply into lobes and lobules. Until 1956,
Nguyen Huu performed successfully partially splenectomy on experiment
on dogs, he realized that if passing the boundary between the lobed, the
bleeding is little and can completely stop the bleeding well by the suture U, which is the foundation for conservation spleen surgery. Partial
splenectomy was first reported in Vietnam by Nguyen Lung and Doan
Thanh Tung. Two cases were performed at the Viet Tiep Hospital.
In 1999, Nguyen Xuan Thuy and Tran Binh Giang's study on vessel
distribution and splenic hilus in Vietnamese people contributed a scientific
basis to the preservation of the spleen during surgery.
In 2001, Tran Binh Giang's study of spleen conservative surgery has
established a science and systematic basis for splenic injury management.
In recent years, non-operation management of splenic injury has been
studied by some authors and applied in some large hospitals for good
results:

Research by Pham Van Thuyen in 2008 and Pham Vu Hung in 2011 at
Viet Duc Hospital have resulted in over 95% success.
The study of Tran Ngoc Son and Nguyen Thanh Liem in 2007 included
29 patients with splenic injuries in 98 patients with solid trauma who were
indicated by non-operation management at the National Pediatrics
Hospital.
In 2010, Tran Van Dang did non – operation management for 95
patients with splenic injury at Binh Duong General Hospital for successful
results is 95.78%.
In 2010, research by Phan Dinh Tuan Dung and colleagues at Hue
Hospital for 52 patients with blunt splenic injury has concluded nonoperation management gives good results with the degree of injury from
degree I - III.
In 2014, Tran Binh Giang has researched and introduced a procedure
for non-operation management of splenic injury in the abdominal trauma.


7
Chapter 2: OBJECTIVES AND RESEARCH METHODS
2.1. Research subjects
All patients with splenic injury were diagnosed and indicated for nonoperation management at Viet Duc Hospital from 01 January 2014 to 31
December 2016.
2.1.1. Standard selection
- All ages, regardless of gender.
- Blunt splenic injury alone or combination with and / or outside the
abdominal cavity.
- Diagnosis by clinical and subclinical examination: blood, ultrasound
and CT scans.
- Evaluate splenic injury and intra-abdominal organs by CT scans
according to AAST (1994).
- Hemodynamically stable hospitalization (defined as systolic blood

pressure ≥ 90mmHg) or stable after initial resuscitation for 24 hours
(response to fluid and / or blood: 3000ml of fluid crystal and / or no more
than 4 units of blood in 24 hours).
2.1.2. Exclusion criteria
- Patients with blunt splenic injury alone and / or in combination in the
abdomen designated emergency surgery in the first 24 hours of admission
(not including emergency surgery due to injuries outside the abdomen).
- Patients with splenic disease as: splenic tumour, splenic abscess,
thalassemia ...
- Patients who are taking anticoagulant or have coagulopathy.
2.2. Research Methods
2.2.1. Research design
Study of descriptive method with prospective analysis
2.2.2. Research sample size
The research sample size is calculated according to the relative
reliability formula for a ratio (*) as follows:

n  Z1α/2
2

1 p
2p

Inside:
n: number of patients needed for the study
2
Z1-/2 : The confidence limits coefficient estimates with 95%
confidence (= 1.96)
p: The proportion of splenic injuries with non-operation management is
successful average: 0.9

8
ε: The exactly desired ratio (= 0.05).
Replace the formula above with:

1.962 * (1  0.9)
n
0.052 * 0.9
n = 171
(*) According to S.K. Lwanga and S. Lemeshow: Sample size
determination in health studies, a practice manual. WHO, Geneva, 1991.
2.2.3. Steps study
The patients with blunt abdominal trauma on admission were
diagnosed and treated in accordance with an agreed protocol.
2.2.4. Collecting and processing data
All selected patients have their own medical records with all necessary
parameters
Data collected after cleansing will be entered into computerized
calculations and processed using EPIDATA 3.1 software with "check" file
to minimize errors during data entry.
Data analysis using STATA 14.0 software uses statistical algorithms in
medicine.
Continuous quantitative variables are described in terms of mean,
standard deviation, maximum and minimum values. Comparing the results
of a continuous quantitative variable between two groups using the
Student t-test (standard distribution variable) or the Mann-Whitney test.
Qualitative variables are presented in percentages. Statistical inference
compares the results of variables measured with the p-value test algorithm
2 or fisher's exact test, depending on the expected frequency. The logistic

regression model was used to calculate the odds ratio (OR) and confidence
intervals (95% CI) of the non-operation management results in the blunt
abdominal traumas.
Select the tolerance level α = 0.05, which corresponds to a 95%
confidence interval and the significance level is p <0.05.
2.2.5. Research ethics
The patient's personal information in the record is confidential and only
used for research.
The research protocol is approved by the review council of Hanoi
Medical University and the Ministry of Education and Training. The study
was approved by the Viet Duc Hospital.


9
Chapter 3: RESEARCH RESULTS
3.1. General characteristics
In our study of 185 patients with splenic injury is indicated in nonoperation mamagement accounted for 83.7% of 221 patients with splenic
injuries in Viet Duc Hospital during the period from January 2014 to
December 2016. Of these, 172 patients with non-operation management is
successful, 13 patients failed. Patients with complications during treatment
were 29 patients and 156 patients without complications.
3.1.1. The age
The mean age of the study group was 30.75 ± 15.51, the smallest was 4
years old and the highest was 92 years.
Patients in working age accounted for the largest share in the study,
with 151/185 accounting for 81.6%.
3.1.2. Gender: In the study, 143 males (77.3%) and 42 females (22.7%).
3.2. Diagnose
3.2.1. clinical
- Systolic blood pressure (SBP) on admission:

Table 3.3: systolic blood pressure on admission and treatment outcomes
Non-Operation management
SBP
Total
p(a, b)
(mmHg)
Success (a)
Failure (b)
< 70
0 (0,0)
0 (0,0)
0
70 - < 90
17 (77,3)
5 (22,7)
22
0,010*
≥ 90
155 (95,1)
8 (4,9)
163
Total
172 (93,0)
13 (7,0)
185
*: Fisher's exact test
Remarks: Patients with systolic blood pressure on admission big part of
the study with 163/185 patients accounted for 88.1%.
The successful rate of non-operation management in patients with SBP
was ≥90 mmHg is higher than those with SBP at 70 - <90 mm Hg and the

failure rate is lower with p = 0.01.
The risk of failure of the group SBP on 70 - <90 mmHg is higher than
the group with ≥ 90 mmHg SBP entering the OR (95% CI): 5.70 (1.67 19.39 ) and p = 0.01.
- The level of clinical blood loss:
Table 3.4: Clinical blood loss and outcome
Non-Operation management
Level of
p(a, b)
blood loss
Success (a)
Failure (b)
Total
125 (94,7)
7 (5,3)
132
I
38 (97,4)
1 (2,6)
39
II
0,001*
9 (64,3)
5 (35,7)
14
III
0 (0,0)
0 (0,0)
0
IV
172 (93,0)

13 (7,0)
185
Total
*: Fisher's exact test


10
Remarks: The patients with mild clinical disease (grade I, II) accounted for
the majority with 171/185 patients accounting for 92.4%.
The successful rate of non-operation management in patients with mild
blood loss (level I, II) is higher than blood loss severity (grade III) and the
failure rate is lower with p = 0.001.
The risk of failure of patients with the level III group blood loss
compared with grade I and II with the OR (95% IC) respectively: 9.92
(2.62 - 37.59), p = 0.001 and 0, 47 (0.06-3.94), p = 0.486.
3.2.2. Subclinical:
3.2.2.1. Results of CT scans
- Free abdominal fluid:
In 185 patients, on CT scans 17 (9.2%) patients without free abdominal
fluid, 33 (17.8%) patients had less fluid levels, 134 (72.4%) of the amount
medium level and 1 (0.05%) with high levels of fluid.
- Grading splenic injury:
In 185 patients: Blunt splenic injury level I, II, III, and IV with the corresponding
results are: 6 (3.2%), 63 (34.1%), 90 (48.6%) and 26 (14.1%).
3.2.2.2. Results of angiography
Table 3:20: Morphology vessel damage and treatment outcomes
Non-Operation management
Morphology
Total
p(a,b)

Success (a)
Failure (b)
Contrast
13 (92,9)
1 (7,1)
14 (100,0)
extravasation
1,000
Arterial aneurysm
3 (100,0)
0 (0,00)
3 (100,0)
Total
16 (94,1)
1(5,9)
17
*: Fisher's exact test
Remarks: There was no difference in success rates and failure between
splenic vessel damage forms.
3.2.3. Diagnosis of combined lesions
- Extra-abdominal combined injury:
Table 3.21: Extra-abdominal combined injury and outcome of splenic injury
Non-Operation management
Damage
Success (n=172)
Failure (n=13)
Total
organ
Total
NonNonOperation

Operation
Operation
Operation
Chest
18 (81,8)
4 (18,2)
22
2 (100,0)
0 (0,0)
2
Skull
17 (100,0)
0 (0,0)
17
0 (0,0)
0 (0,0)
0
Bones 14 (100,0)
0 (0,0)
14
2 (100,0)
0 (0,0)
2
Spine
7 (100,0)
0 (0,0)
7
0 (0,0)
0 (0,0)
0

Face
4 (100,0)
0 (0,0)
4
0 (0,0)
0 (0,0)
0
Remarks: Out-of-abdominal combined injury in the study included
closed thoracic tract, skull, bone, spine and facial features. A patient may
have more than one out-of-abdominal combined injury to the spleen.


11
Injury can still be performed when emergency management is indicated
and splenic injury is indicated for non-operative treatment.
- Intra-abdominal combined injury:
Table 3.22: Intra-abdominal combined injury
Operation
Non-Operation
Damage organ
Total
management
Spleen Other organ
Liver
1 (100,0)
0 (0,0)
0
1
Pancreas
4 (100,0)

0 (0,0)
0
4
Kidney
9 (100,0)
0 (0,0)
0
9
Adrenal
2 (100,0)
0 (0,0)
0
2
Hollow viscera
0
0
1(100,0)
1
Total
13
0
1
14
Remarks: Blunt splenic trauma with solid organ trauma can still be
treated without operation. In the study, 14 patients with blunt splenic
injury were co-ordinated with other intra-abdominal organs, including 11
patients in combination with one organ and 3 traumatic patients in
combination with two organs.
In patients with lesions of coordination, 1 patient must transfer surgery
for peritonitis due to rupture of the gallbladder when medical therapy

splenic injury after more than 24 hours in the hospital and only injury was
discovered during surgery.
All patients with blunt splenic injury with solid organ injury were
treated successfully by noo-operation management.
3.3. Method Treatments
Table 3.27: Methods and results of treatment
Medical
Non-Operation
Medical
treatment +
Total
management
treatment
Embolization
172
156 (92,9)
16 (94,1)
Success
(93,0)
11 (6,5)
1 (5,9)
12 (6,5)
Spleen
Failure
1 (0,6)
0 (0,0)
1 (0,5)
Other organ
Total
168 (90,8)

17 (9,2)
185
Remarks: In the 185 patients indicated non-operation management, 168
patients accounted for 90.8% of patients were treated medically and 17
patients accounted for 9.2% of patients treated medically can coordination
with the embolization.


12
- Complications and treatment methods:
Table 3:31: The complications during the treatment and treatment methods
Complication/
Laparoto Laparo Laparotomy >
Embolization n
Treatment
my
scopic Laparoscopic
Bleeding continues
4 (100,0) 0 (0,0)
0 (0,0)
0 (0,0)
4
Splenic vessel injury
0 (0,0)
0 (0,0)
1 (5,8)
16 (94,2)
17
Delayed hemorrhage 2 (100,0) 0 (0,0)
0 (0,0)

0 (0,0)
2
Increased intra1 (20,0) 2 (40,0)
2 (40,0)
0 (0,0)
5
abdominal pressure
Peritonitis
0 (0,0)
0 (0,0)
1 (100,0)
0 (0,0)
1
Total
7 (24,2) 2 (6,8)
4 (13,8)
16 (55,2)
29

Remarks: The incidence of complications was 29/185, accounting for 15.7%.
Splenic vessel damage accounted for at most 17 patients, all of them was
performed by embolization but one patient failed to move the operation.
Abdominal pressure increases in 5 patients, all of whom have clinical
symptoms of increased abdominal pain during treatment and transplants
due to suspected hollow viscera injury. Four of five patients was
performed by laparoscopic.
Bleeding continues 4 patients must be operated by the systolic blood
pressure continued to drop despite being intensive care for 24 hours in the
hospital and on CT scans did not see vessel damage.
1 patient must transfer surgery for peritonitis due to rupture of the

gallbladder when medical therapy splenic injury after more than 24 hours
in the hospital and only injury was discovered during surgery.
2 patients with delayed hemorrhage occurred after the 7th day in the
hospital had to switch operation because of systolic blood pressure decreased.
3.4. Early treatment results
- The treatment results for each method:
Treatment results
92.90%

Success
94.10%

7.10%

Medical treatment

Failure

93.00%

7.00%

5.90%

Medical treatment +
Embolization

Non-Operation
management

Remarks: The success rate of medical therapy and medical therapy in
collaboration with the embolization are over 90%, the overall success for
the whole group is 93.0%.


13
- Treatment results according to the degree of splenic injury:
Table 3.34: Treatment results according to the degree of splenic injury
Non-Operation
Success
Failure
Total
p
management
Degree I
5 (83,3)
1 (16,7)
6
Degree II
60 (95,2)
3 (4,8)
63
0,163*
Degree III
85 (94,4)
5 (5,6)
90
Degree IV
22 (84,6)
4 (15,4)

26
Total
172 (93,0)
13 (7,0)
185
* Fisher's exact test
Remarks: Patients with blunt splenic injury who failed to undergo an
operation at all levels of splenic injury.
The successful rate of non-operation treatment at all levels of splenic
injury was 80%.
- Time in hospital:
The length average of hospitalization in our study was 7.03 ± 2.53 days,
the patients were the shortest for 4 days, the longest was 18 days.
Table 3.35: Length of hospitalization by method of treatment
The length average of
Method of treatment
n
p
hospitalization
156
6,78±2,80
Medical treatment
Medical treatment +
16
7,6±3,11
0,0095*
Embolization
13
9,38±3,52
Undergo an operation

Total
185
7,03±2,53
*: test through Kruskal Wallis test
Remarks: The length of stay of patients with medical therapy alone
shortest, followed respectively in patients treated by medical therapy with
embolization and transfer operation. This difference was statistically
significant with p = 0.0095.
3.5. Follow-up results after hospital discharge
- The health status examination after hospital discharge:
Table 3.37: The health status examination after hospital discharge
Outcome far
n
%
Good
112
91,1
Medium
10
8,1
Bad
1
0,8
Tử vong
0
0,0
Total
123
100,0

14
Remarks: After 6 months follow-up: 123/185 (66.5%) had health status
information after hospital discharge, of which 91.1% had good results, 8.1 %
for average results, these patients have to change labor, living as a result of the
combination damage with splenic injuries like broken limbs, spinal injury or
chest trauma and 0.8% for bad results, patients lose the ability to labor after
injury accident because the splenic injury with cervical spine injury led to
complete paralysis, no patient deaths because of the splenic injury.
Chapter 4: DISCUSSION
4.1. General characteristics
4.1.1. The age
Previously, many authors still indicated for under 55 age because the
authors have said that the failure rate and high mortality were related to
patients with splenic trauma advanced age of 55. According to Godley and
colleagues, over 55 years of age are contraindicated for non-operation
management. In the author's study, 91% of patients with blunt splenic injury
who was indicated by non-operation management failured were 55 years or
older. Today, many authors found that, over 55 years old is not a factor
contraindicated for non-operation management. In our study, splenic injury
occurred at various ages ranging from the smallest 4 to the oldest age of 92
years, of which age 15-55 accounted for 82.1% (Figure 3.1).
4.1.2. Gender
Similar to many other studies, in our study, the proportion of male patients
was 77.3% and 22.7% respectively (Figure 3.2). According to a study by
Margherita Cadeddu et al, the proportion of males is higher than females at
66.9% and 33.1%, respectively. According to Tran Binh Giang, splenic injury
is mainly seen in men with 78.66% and female only 26.34%.
4.2. Diagnosis
4.2.1. Clinical

Systemic symptoms
Solid organ injuries in the blunt abdominal trauma in general and in
particular the splenic injury, according to many authors, hemodynamics is
the most important sign to indicate an operation or non-operation
mananemgent. According to Eric H. Bradburn and Heidi L. Frankel, the first
and most important condition in the indication for non-operative
management for blunt splenic injury is that the hemodynamic condition
must be stabilized and the combined intraoperative lesions eliminated. In
our study, all patients were evaluated as to the hemodynamic condition
through the pulse, blood pressure and levels of blood loss classified


15
clinically according to ATLS. In our 185 patients, no patients had systolic
blood pressure on admission <70 mmHg because all patients with splenic
injury in this group were indicated emergency to operate. Patients with
systolic blood pressure ≥90 mmHg had the highest rate with 163/185
patients, 22/185 patients with systolic blood pressure on admission from 70
to 90 mmHg. The rate of patients in the systolic blood pressure group from
70 to <90 mmHg was 77.3% which was less successful than in patients with
systolic blood pressure> 90 mmHg was 95.1% %, but in contrast, the rate of
failure of the systolic blood pressure group on admission 70 - 90 mmHg was
higher than that of systolic blood pressure group at 90 mmHg, respectively
22.7% and 4.9% with p = 0.01 (Table 3.3).
At the same time, the risk of failure of the systolic blood pressure on
admission group 70-90 mmHg was higher than that of systolic blood pressure
on admission ≥ 90 mmHg with OR (95% CI): 5, 7 (1.67-19.39), p = 0.01.
The difference in blood pressure between patients with blunt splenic
injury treated with non-operation management failure and success is
proved by research by Maged Rihan et al, the average systolic blood

pressure on admission in patients failing and success is a significant
difference with results were 89.7 mmHg and 110.8 mmHg respectively.
According to the American College of Surgeons Committee on
Trauma, the level of blood loss in trauma is divided into four levels, which
are based on a number of clinical signs that are important. In particular,
the patient's pulse and blood pressure are used to estimate the amount of
blood lost due to trauma.
According Margherita Cadeddu and colleagues, patients with blunt
splenic injury needed an operation had pulse over 100 beats / minute (blood
loss grade III or more) accounted for a higher proportion of patients who did
not have an operation, respectively 50.9% and 28.4% with p = 0.001.
In our study, patients with the highest level of I blood loss with
132/185 (71.4%), grade IV blood loss with no patient. The rate of failure
in the high-grade III patients was highest at 35.7%, followed by low-grade
I and II patients at 5.3% and 2.6%, respectively. The proportion of success
of non-operation management in the mild blood loss group I and II is
higher than the rate of III with 94.2% respectively, 97.4% and 64.3%. This
difference was statistically significant with p = 0.001 (Table 3.4).
The risk of failure to transfer the operation of the level III group blood
loss compared with grade I and II with the OR (95% IC) respectively: 9.92
(2.62 to 37.59), p = 0.001 and 0, 47 (0.06-3.94), p = 0.486.


16
According to World Societly of Emergency Surgery (WSES), patients
with severity splenic injury (WSES level IV) who are patients with splenic
injury from level I to level V as classified AAST that hemodynamically
unstable ( blood pressure on admission <90 mmHg and pulse rate> 100
beats per minute), while hemodynamic stability is classified as WSES
degrees II, II and III. This means that at all levels of blunt splenic injury

according to AAST there are different systolic blood pressure levels at or
above 90 mmHg.
And in our study, patients with splenic injury at different levels
according to the classification of AAST have systolic blood pressure while
on at different levels (Table 3.5).
4.2.2. CT scan results
According WSES, CT scans has been the gold standard in the diagnosis
of splenic injury alone and in combination.
And according to many authors, CT scans helped change treatment
strategies in blunt abdominal injury from 6.4 to 16%.
- Free abdominal fluid:
According to Andrew B Peiztman et al, free fluid in the abdomen is
divided into three levels: low, medium, and more depending on the
amount of intra-abdominal cavity epidemic.
According to many authors, the amount of free fluid in the abdominal
cavity may play a role in predicting surgical indications for splenic injury.
However, there are also authors who say that the free fluid in the
abdomen itself does not predict the patient's need for surgery. According
Bee TK et al, fluid freely abdomen depends on the patient who is at
hospital sooner or later, how is morphological lesions and whether the
amount of peritoneal fluid levels at or just that hemodynamically unstable
(pulse quick, reduced systolic blood pressure), it proves blood continues to
flow, so the hemodynamic determinants of treatment indications.
In our study, 9.2% of CT scans patients had no free abdominal fluid, all
of whom had been successfully treatmented by non-operation
management. On CT scans, 90.8% of patients with free fluid in the
abdominal cavity of different levels. The patients with average levels
accounted at 134/185 (72.4%) patients.
The rate of patients treated successfully in patients with fluid less and
no is higher than patients with fluid medium level while the failure rate is

in contrast with p = 0.207 (Table 3:15 ).
The level of free fluid in the abdomen may be at the varies level of
spleen injury. Themselves level free fluid in the abdominal cavity is not


17
independent factors to decide the indication for blunt splenic injury , but
the level of free abdominal fluid combined with the degree of splenic
injury are two important foctors to help give indications and prognosis the
results of non-operation management for splenic injury.
- Classification of the splenic injury on CT scans according AAST:
The American Association for the Surgery of Trauma based on the
morphology and size of splenic injury on CT scans to split into 5 levels.
Based on the degree of injury on CT, the first time, according to many
authors, the splenic injury should indicate non-operation management for
patients with low levels I, II and III, because the authors suggest that the
degree of injury spleen higher, the failure rate of non-operation
management is high. However, according to McVay et al, the authors
concluded that NOM is a safe method, not dependent on the degree of
splenic injury on CT that depends on the patient's hemodynamics.
In our study, no patient with the degree V , splenic trauma at the level
II and III dominates the results, respectively 63 (34.1%) and 90 (48.6%).
The successful proportion of NOM at the levels of injury are over 80%
and there is no difference in the rate of success and failure (Table 3.18).
Agreeing with many authors, in the study by us, the degree of splenic
injury does not determine indications for treatment which is a factor
contributing to the prognosis for the course of treatment, every degree of
splenic injury can be successful with NOM if ensuring the stability of
hemodynamic. Thus, classified by AAST to help assess the level of splenic
injury during treatment but the prognosis is not evident what degrees are taken

embolization and what degrees are needed an emergency surgery?
According to many authors, severity splenic injury according AAST
(IV and V) that hemodynamic stability can still be treated by NOM,
conversely, if the splenic injury mild (I, II, III) which
have
hemodynamically unstable needs an operation. This is also a disadvantage
of AAST classification. To overcome this shortcoming, the World Society
of Emergency Surgery (WSES) has combined two factors: anatomy
lesions according to AAST and hemodynamic conditions to classify
splenic injury into 3 types: Minor (WSES class I), Moderate (WSES
classes II and III, Severe (WSES class IV).
Minor spleen injuries:
– WSES class I includes hemodynamically stable
AAST-OIS grade I–II blunt and penetrating lesions.
Moderate spleen injuries:
– WSES class II includes hemodynamically stable


18
AAST-OIS grade III blunt and penetrating lesions.
– WSES class III includes hemodynamically stable
AAST-OIS grade IV–V blunt and penetrating lesions.
Severe spleen injuries:
– WSES class IV includes hemodynamically unstable
AAST-OIS grade I–V blunt and penetrating lesions.
Based on this classification, WSES IV spleen is indicated for operation,
while WSES I, II and III are indicative of NOM.
4.3. Treatment
4.3.1. Method treatments
NOM of splenic injury alone and in combination including internal and

internal medical therapy combined with embolization.
4.3.1.1. Medical treatment:
The first indication for NOM is that the hemodynamic condition must
be stable or stable after resuscitation.
According to Nicole A. Stassen et al, NOM for splenic injury is
indicated for patients with splenic injury with hemodynamic stability,
irrespective of the degree of injury, regardless of age and/or combine the
other organs injured. According to the author too, blunt splenic injury
should be treated at the facility and the surgeon has the ability to monitor
and accurately assess the clinical condition of the patient, and can perform
an emergency operation when it’s necessary.
In our study, 163/185 (88.1%) patients with stable hemodynamic on
admission and 22/185 (11.9%) patients with hemodynamic instability on
admission have been active resuscitation and indicated for NOM (Table
3.3). All of these patients are treated at Viet Duc Hospital, Vietnam's
largest surgical hospital, with adequate facilities and human resources for
treatment of blunt splenic injury.
The second condition is to exclude other organs in the abdominal cavity
for surgery, especially the hollow organ. Thus, patients should be closely
monitored clinical status as well as the clinical tests as needed. Among
patients who have to perform an operation, 1 patient had ruptured the
gallbladder and was found only during operation when there was peritonitis
following a blunt abdominal trauma more than 24 hours after admission.
In addition, the patients with splenic conditions such as the splenic tumor,
splenic abscess… and patients with coagulopathy should be excluded.
4.3.1.2. Medical treatment + Embolization
Blunt splenic injury has many different forms in which splenic vessel
damage is the morphology which many authors have high failure rates when

19
NOM is indicated. Some authors announce the results also said that if the
injured spleen only treated by medical treatment, the failure rate is up to 34%,
and this percentage is even higher in patients with splenic injury at grade III,
IV, V according to AAST.
Nicole A. Stassen et al, angiography and embolization are both the
diagnostic and supportive treament for patients with splenic injury with a
high risk of late bleeding, as well as vascular lesions.
The efficacy of angiography and embolization has been well documented in
many studies, but this approach has been shown to have complications and,
according to some studies, the rate of complications is 6-20%. And
complications may be encountered as recurrent bleeding - continues bleeding,
splenic abscess, moving coil position, fever or pleural effusion ...
In 17 patients undergoing angiography and angioembolization in our study,
we encountered one patient with postangioembolization bleeding.
The overall success rate of angioembolization therapy ranged from 73% to
97%. The success rate of angioembolization in our study was 94.1%.
Thus, angiography and angioembolization provide many benefits for
NOM of splenic injury, but inappropriate and inappropriate misuse will
result in failure of NOM.
4.3.1.3. Combination spleen injury
Spleen injury may be alone or in combination with the organ in and / or
outside the abdomen. In the context of emergency treatment, the goal is to
preserve the patient's life and the second to the functional problem.
- Intra-abdominal combined injury:
According to many authors, splenic trauma can still be treated by NOM
with other solid organ injuries and if hemodynamic conditions are stable.
According to Tran Ngoc Son and colleagues, NOM is feasible and safe for
cases of solid organ injury in the trauma abdomen with stable hemodynamics,
with a success rate of over 90% both conditions of Vietnam.

In our study, 14 patients with splenic injury were co-ordinated with
other intra-abdominal organs, in which 13 patients with combined lesions
were solid organs including: grade II liver trauma, kidney trauma with
grade II and III, pancreatitis trauma with grade II and contusion adrenal
glands are treated successfully by NOM, and 1 patient with the gallbladder
ruptured causing peritonitis must transfer surgery for cholecystectomy and
total splenectomy.
- Extra-abdominal combined injury:
Most previous studies have not indicated NOM for splenic trauma as
eliminating the extra-abdominal combined injury, especially brain trauma.


20
According to W. Rappaport and his colleagues, studying 160 patients with
multiple trauma with splenic injury has concluded: only NOM of splenic
injury is indicated without other combination trauma.
In contrast, according to Archer and Corburn's study, the MC found
that the extra-abdominal combined injury did not affect the failure rate of
NOM for splenic trauma. In our study, the extra-abdominal combined
injury with splenic trauma included chest trauma, cerebral cortex, spine,
broken limb, broken pelvis.
- Chest trauma:
The chest trauma combining the spleen injury can only treatment or
emergency surgery, while the spleen injury can still successful with NOM.
In the study of our 24 patients with chest trauma, while 4 patients had
emergency drainage of pleural due to spill blood, pneumothorax , all 4
patients were treated successfully by NOM for splenic injury.
Thus, splenic trauma with chest trauma can be successfully treated by
NOM despite chest trauma can be operated if the patient is ensured
hemodynamic stability.

- Brain trauma, spine trauma:
According to Keller et al., the brain trauma affects the behavior of blunt
abdominal trauma in general and splenic injury in particular due to decreased
perception. Therefore, the authors recommend that NOM should not be
performed for liver and / or spleen injury in combination brain trauma.
However, according to many authors, splenic trauma combined with
brain trauma can be treated by NOM. According to the authors, the patiens
with brain trauma performed a laparotomy can be worse progression,
because of secondary brain damage, these are the patients who have
benefited from the preservation of the liver and / or spleen injury.
In our study, 17 patients with brain trauma combined with splenic
injury were treated with NOM success.
With spinal trauma, clinical examination will also be difficult when
patients with spinal paralysis, loss of sensation, paralysis. Therefore,
according to some authors, if clinical status is suspicion or unclear,
laparoscopy should be performed for exploration.
In research we have 7 patients with spinal injuries in the group of
patients treated by NOM success, no patients of this group has to be
operated emergency, however, 1 patient with the spine injury was loss of
ability to work.


21
- Bones injury, pelvis injury and face injury:
According to some authors, injured liver and / or spleen damage
combinted the limb bones injury, the jaw-face injury may be emergency
operated or delayed when NOM for liver and / or spleen injury is stable.
Pelvic fractures, which are stable hemodynamic, can also be treated with
NON for splenic injury.
In our study, the group of patients with spleen trauma is successful

with NOM, 14 patients of this group are fracture of length limbs and / or
pelvis, no patients had an emergency operation, the patients with fracture
of bone and/or pelvis are operated when the spleen injury is stabilized.
Thus, blunt splenic injury coordinating the external abdominal injury can
be treated by NOM when the external abdominal injury needed emergency
surgery if it’s ensuring stability on hemodynamic and eliminate the other
intra-abdominal injuries need to operate, especially hollow organs.
4.3.1.4. Treatment of complications
During treatment for spleen trauma, early diagnosis and management
of complications increase the success rate of NOM. Complications can be
seen at levels of spleen injury, however, according to many authors, the
incidence of complications, particularly vascular lesions and late bleeding,
is common in splenic injury levels of IV and V, to over 40%. In our study,
patients with grade IV splenic injury, the rate of complication is 46.2%
higher than the level of injury I, II and III with p <0.0001 (Table 3:32).
NOM of splenic injury in the blunt abdominal trauma can have many
complications, including splenic injury and the other organ damage. It is
important to monitor the patient closely both in clinical and subclinical to
detect early complications and promptly avoid any serious consequences
for the patient.
4.3.2. Treatment results
- Success rate:
Our research includes medical therapy alone and medical combined
with angioembolization, over 185 patients were indicated for NOM, 168
patients with medical therapy alone success is 156 patients accounted for
92.9% and 17 patients treated with combination angioembolization is
successfully with 16 patients accounted for 94.1%, the successful result of
our research is 172 patients accounted for 93, 0% (Table 3.27).
According to Aman Baneree et al., 1255 patients with splenic injury
were indicated NOM 97 (7.7%) patients co-ordinated with

angioembolization and the success rate of 82%. Medical therapy with


22
angioembolization resulted in 92% of NOM success in Van der Vlies’s
research.
- Time in hospital:
Hospitalization time average of the team are: 7.03 ± 2.53 days, the
patient is shorter than 4 days, the longest is 18 days.
According Margherita Cadeddu and colleagues, the average length of
hospital stay of patients with splenic trauma surgery longer than patients
without surgery had a statistically significant (p <0.001) with time,
respectively 21 days (11- 45 days) and 14 (7- 31.5 days).
This result is similar in our research, the average length of hospital stay
of patients failed is significantly longer than the patients with NOM
success (Table 3:35).
4.3.3. Follow-up results after hospital discharge
- The benefits of NOM:
There have been many studies demonstrate that, after splenectomy
patients may develop serious complications affecting the quality of life, as
depth venous thrombosis and especially syndrome bacterial infections
after splenectomy. Consequently, preservation of the spleen helps the
patient to avoid such complications.
NOM of splenic injury is not only changes the therapeutic strategy for the
patient's health, but also provides other economic and social benefits.
According Fromiento C Sartorelli KH et al, NOM of spleen trauma
bring more value as the cost of treatment is low, patients are discharged
early, to avoid laparotomy is not needed, to avoid sugery complications
and reduce the amount of blood transfused in the treatment process as well
as reduce rates of injury mortality rate.

- Follow up after discharge:
In the study: 123/185 (66.5%) patients with information about the
health status after discharge , including 91.1% for better results, 8.1% for
the average results and 0.8% for bad results, patient lost ability for labor
due to cervical spine injury combined and no patient deaths due to splenic
injury.
Thus, if only the spleen injury with NOM success, patients can return
to working life, normal activities, leaving no sequelae or complications.
This has proven the effective and the benefits of NOM with spleen trauma.


23
CONCLUSION
A study of 185 splenic traumatic patients was indicated for NOM in a
total of 221 patients with spleen trauma (83.7%) hospitalized between
January 2014 and December 2016 at the Viet Duc hospital obtained the
results as follows:
1. The clinical and subclinical characteristics of patients with splenic
injury in blunt abdominal trauma:
- General characteristics:
The most common age for spleen injury was from 16 to 55, accounting
for 81.6%, with an average of 30.75 ± 15.51.
The proportion of men more than women with the corresponding
results are: 77.3% and 22.7%.
- Systemic symptoms:
The majority of patients on admission have ≥ 90mmHg systolic blood
pressure accounted for 88.1%.
Class I of blood loss was the most common with 71.4%.
- Functional symptoms :
Patients with abdominal pain in the area of spleen with 166 patients,

respectively 89.7%.
- Entity symptoms:
There were 97 patients (52.4%) without abdominal wall injury.
The proportion of patients without bloating accounted for 56.2%.
Most patients have no signs of the abdominal wall with 90.3%.
- The tests of blood:
- Ultrasound:
The mean amount of free fluid was 58.9%.
- CT scan:
Morphological lesions most commonly spleen contusion, hematoma
parenchyma with 62.7% and broken lines with 55.1%.
Splenic trauma level II and III accounted for the majority of study with
the proportion respectively: 34.1% and 48.6%.
- Angiography:
There are two forms of vessel damage seen in the study including:
blush in the parenchyma and aneurysms with 7.6% and 1.6%, respectively.
- Combined injuries:
Extra-abdomen: Chest injury and brain injury is the common
percentage with 12.9%, and 9.2%, respectively.
Intra-abdomen: Kidney injury was the highest rate with 9 patients,
accounting for 4.8%.