Læknablaðið - 15.11.1992, Blaðsíða 10

354
LÆKNABLAÐIÐ
Á þremur stórum spítulum til viðbótar var
hún notuð í 24-30% tilvika og mistókst í 8-
40% tilfella (18,20). Á Borgarspítalanum var
meðferð án uppskurðai' notuð í 32% tilfella
en gekk ekki í 35%. Slík meðferð hefur að
sjálfsögðu vissa áhættu í för með sér þar
sem blæðing getur aukist skyndilega. Sé
sjúklingurinn hins vegar hafður á gjörgæslu
eins og hér var gert þar sem fylgst var náið
með klínískum einkennum og blóðrauða, unnt
var að fá nýja ómun eða sneiðmyndatöku ef
þurfa þótti, krossprófað blóð var við hendina
og skurðstofa gat verið tilbúin fyrirvaralítið,
þá er áhættunni haldið í lágmarki. I vel
völdum tilfellum næst þó ágætur árangur
og endurblæðing er sjaldgæf. Margt bendir
til að meðferð án uppskurðar skuli aðeins
notuð í tiltölulega ungum sjúklingum sem
ekki þurfa nema tvær einingar af blóði og
hafa miltisáverka án annarra meiðsla og þar
sem sneiðmyndir sýna aðeins grunna rifu
eða blóðsafn undir miltishýði. Viss mannleg
tilhneiging er þó til að draga uppskurð hjá
mjög fjölslösuðu fólki (samanber sjúkling nr.
5 í töflu VII).
Bólusetning gegn lungnabólgusýklum
(pneumovax) var notuð á Borgarspítalanum
hjá þeim sem misstu miltað á umræddu
tímbili. Bóluefninu, sem var á markaðnum
síðustu árin, var stefnt gegn fleiri tegundum
lungnabólgusýkla en það sem notað var
fyrstu árin. Engin tilraun hefur verið gerð í
þessari rannsókn, hvorki til að rannsaka tíðni
yfirþyrmandi sýkingar né virkni bóluefnisins,
enda örugglega ekki hægt að komast að
neinni niðurstöðu um þau atriði með svo
fáum sjúklingum. Enginn sjúklinganna fékk
yfirþyrmandi sýkingu í legunni.
SUMMARY
Surgeons have gradually changed their view on
splenectomy. Management has changed from
splenectomy to splenorraphy or non-operative
treatment in selected cases. The aim of this study
was to review our experience on closed splenic
rupture at Reykjavík City Hospital.
Forty four cases of blunt splenic trauma treated
at the Reykjavík City Hospital 1979-1989 were
reviewed. There were 23 males and 21 female.
Most of the patients were young with 65% of the
group under 25 years of age.
Two thirds were traffic accidents and additional
injuries were present in 66% of cases. The injury
severity score was 28 mean with a range from
16-75 (median 24). Thirty patients were treated
by early operation with splenectomy in 28 and
splenorraphy in two. Fourteen were initially treated
non-operatively but five had to undergo laparotomy
with splenectomy in four and splenorraphy in one.
Splenorraphy was therefore done in 3 out of 35
cases operated on or 8.6%. The spleen was saved
in altogether 26.3% of the cases. Two patients died
(4.6%). Pneumovax was given as a routine post-
operatively but no attempt was made in this study
to discover the incidence of OPSI nor the efficiency
of the vaccination.
A review of the literature indicates that
splenorraphy should be attempted more often. For
non-operative treatment patients have to be selected
very carefully.
HEIMILDIR
1. Felicano DV, Vicky Spjut-Patrinely RM, Burch JM,
et al. Splenonaphy. The altemative. Am Surg 1990;
211: 569-82.
2. Lucas EC. Splenic trauma. Choice of Management.
Am Surg 1991; 213: 98-112.
3. Mahon PA. Sutton EJ. Nonoperative management of
adult splenic injury due to blunt trauma. A waming:
Am J Surg 1985; 149: 716-9.
4. Rapport W, Mclntyre KE, Carmona R. The
management of splenic trauma in the adult patient
with blunt multiple injuries. Surg Gynecol Obstet
1990; 170: 204-8.
5. Baker SP, O’Neil, Haddon W, Long WB. The injury
severity score. A method describing patients with
multiple injuries and evaluating emergency care. J
Trauma 1974; 14: 187-96.
6. Kolka PVG. Miltisspmnga. Ruptura lienis subcutanea
traumatica. Splenectomia-Sanitation. Læknablaðið
1929, 15: 116-23.
7. King HK, Schumacher HB. Splenic studies.
Susceptibility to infection after splenectomy
performed in infancy. Am Surg 1952; 136: 239-42.
8. Ellison EC, Fabri PJ. Complications of splenectomy.
Etiology, prevention and managment. Surg Clin N
Am 1983; 63: 1313-30.
9. Georg FS, Croom RD, Meyer AA. Thc spleen.
Sabistons Textbook of Surgery. Philadelphia: WB
Saunders, 1991: 1131.
10. Singer DB. Postsplenectomy sepsis. Perspectives in
pediatric pathology. Year Book Med Publ. Chicago,
1973: 285-311.
11. Eraklis AJ, Filler RM. Splenectomy in childhood. A
rewiew of 1413 cases. J Pediatr Surg 1972; 4: 382-8.
12. Jurcovich JG, Carrico CJ. Trauma. Managment
of acute injuries. Sabistons Textbook of Surgery.
Philadelphia: WB Saunders, 1991: 267.
13. Green JB, Shackford SR, Sise MJ, Fridlund P. Late
septic complications in adults following splenectomy
for trauma. A prospective analysis in 144 patients. J
Trauma 1986; 26: 999-1004.
14. Horton J, Odgen ME, Williams S, Coln D. The
importance of splenic blood flow in clearing
pneumococcal organisms. Am Surg 1982; 195: 172-6.
15. Dulchavsky SA, Lucas CE, Ledgerwood AM,
Grabow D. Wound healing of the injured spleen with