Original Article

Results of non-operative management of splenic trauma and its

complications in children
Ndour Oumar, Forgues Dominique1, Kalfa Nikola1, Guibal Marie Pierre1, Ndoye Mamadou,
Galifer René Benoit1
Department of Pediatric Surgery, Aristide Le Dantec Hospital, Dakar, Sénégal, 1Pediatric Urology and visceral
surgery Pediatric Surgery of Lapeyronie Hospital Montpellier, France

Address for correspondence: Dr. Oumar Ndour, Department of Pediatric Surgery, Aristide Le Dantec Hospital, BP : BP 3001
Dakar – Etoile, Dakar, Sénégal. E-mail: roundrouma@yahoo.fr

ABSTRACT Access this article online

Website: www.jiaps.com
Introduction: Non-operative management (NOM) of splenic trauma in children is DOI: 10.4103/0971-9261.136468
currently the treatment of choice. Purpose: We report a series of 83 cases in order to Quick Response Code:

compare our results with literature data. Patients and Methods: For this, we conducted
a retrospective study of 13 years and collected 83 cases of children with splenic trauma
contusion, managed at Lapeyronie Montpellier Hospital in Visceral Pediatric Surgery
Department. The studied parameters were age, sex, circumstances, the blood pressure
(BP), hematology, imaging, associated injuries, transfusion requirements, treatment,
duration of hospital stay, physical activity restriction and evolution. Results: NOM
was successful in 98.7% of cases. We noted 4 complications including 3 pseudo
aneurysms (PSA) of splenic artery and 1 pseudocyst spleen with a good prognosis.
There was no mortality in our series. Conclusion: NOM is the treatment of choice for
splenic trauma in children with a success rate of over 90%. Complications are rare
and are dominated by the PSA of splenic artery.

KEY WORDS: Contusion, child-non-operative management, complications, fracture,

pseudo aneurysm, spleen

INTRODUCTION have demonstrated good results of this method, with 80

The spleen is the most frequently injured organ in
blunt abdominal trauma. Splenectomy has long
been the standard treatment for the spleen fractures
from the success of the first splenectomy reported
in 1892 by Reinger.[1] In the early 20th century, many
studies, including one of King Shumacker[2] in 1952,
demonstrated the importance of the spleen in immunity
and risk of infection exposed to splenectomized patients.
This has led in recent decades to a more conservative
approach in the management of spleen injuries. NOM
of splenic trauma in children was reported in 1968 by
Upadhyaya,[3] followed by other authors in the 80s that
to 90% of positive change. This non-operative treatment
is currently considered by most centers as the method of
choice for the spleen injuries treatment in children. The
unanimity has been made on the success of this method,
but there is no practical uniform protocol except the one
published by the American Pediatric Surgical Association
(APSA) in 2000.[4] To improve the method, it is necessary
that its results should be regularly evaluated. That is why
we have conducted this retrospective study to provide
results of NOM of splenic trauma at a university hospital
in visceral pediatric surgery department and compare
them with literature data.

Cite this article as: Oumar N, Dominique F, Nikola K, Pierre GM, Mamadou N, Benoit GR. Results of non-operative management of splenic trauma
and its complications in children. J Indian Assoc Pediatr Surg 2014;19:147-50.
Source of Support: Nil, Conflict of Interest: None declared.

Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3 147
 Ndour, et al.: Results of non-operative management of splenic trauma and its complications in children

MATERIALS AND METHODS
This retrospective study was conducted in the Visceral
Surgery and Pediatric Urology Department at CHU
Montpellier (Lapeyronie Hospital, Prof. RB Galifer).
From April 1997 to March 2010, we collected 83 cases of
children with splenic blunt trauma due to the abdominal
contusion managed in our Department. Eighty-three
patients were treated non-operatively and are the cases
of our study. The considered parameters were age,
sex, mechanism of injury, blood pressure, hematology
(hemoglobin), imaging (ultrasound and/or CT-scan),
associated injuries, transfusion requirements, treatment
and evolution (morbidity and mortality). The splenic
trauma diagnosis was confirmed by ultrasonography
and/or CT- scan abdomen. All radiological images were
reviewed by fellow Pediatric Radiologists (Department
of Pediatric Radiology, Dr. Couture) allowing us to
distribute patients according to the classification of
the American Association for the Surgery of Trauma
(AAST).[4] Patients hemodynamically stable or stabilized
after blood transfusion (less than 40ml/kg) were
managed with NOM. The need for admission in ICU
was decided on the basis of hemodynamic stability,
the existence or absence of a poly trauma and grade
lesion. All these children have been closely monitored
by regular clinical evaluations of hemodynamic
parameters, checking hemoglobin and ultrasound. The
discharged patients are reviewed in consultation: The
15th day following the trauma, after 1 month, 3 months
and sometimes beyond depending on evolution. We
included in our study patients initially treated and
secondarily referred from other departments of surgery.
Stab injuries or pathological spleen and/or spontaneous
splenic rupture were excluded from our study. The
results were compared with literature data to improve
our attitude in managing these patients.
RESULTS
A total of 83 children with splenic trauma due to
abdominal contusion were managed non-operatively in
the Visceral Surgery and Pediatric Urology Department
at CHU Montpellier in a period of thirteen years.
NOM was successful in 82 patients (98.7% of cases). One
failure was observed. It was a 14 year old boy admitted
in ICU for multiple trauma with AAST grade IV spleen
fracture. This was associated with a missing image of the
left kidney with renal artery wound and fracture of the
left iliac wing. Despite transfusion with two units of red
blood cells (hemoglobin:8g/dl), forty-eight hours later,
the child presented with anuria, a distended abdomen,
low blood pressure of 70/50 mmHg and with Hb of 4g/dl.
Given the critical clinical state with pH 7, an urgent surgical
exploration was indicated. A significant hemoperitoneum,
ruptured spleen and left kidney were found avascular. Total
splenectomy and left total nephrectomy were performed.
He also received the vaccination protocol in case of total
splenectomy. The duration of hospitalization was 11 days.
The follow-up was favorable after a period of 3 months.
With a mean period of 4.72 months, the evolution has
been marked in this series by complications’ occurrence
in 4 cases (4.8%) represented by three pseudo-aneurysms
splenic artery and 1 pseudocyst splenic [Table 1].
There was no mortality in this series.

Table 1: Detail of various complications

Complications Pseudo-aneurysm splenic artery Pseudocyst splenic
paramètres 1er case 2nd case 3rd case
Age (years) 14 10 13 13
Sexe M F M M
AAST Grade III Grade III Grade I Grade II
Hemodynamic Instable Instable Instable Instable
Ultrasound Posttraumatic aneurysm with Rounded fluid image of 7.7 mm Pseudo aneurysm splenic Two juxtaposed mid splenic
arteriovenous fistula (8th day) × 5.2 mm thin-walled, containing artery (2nd day) cystic cavities of 17 mm ×
Pseudo-aneurysm splenic arterial flow associated with thin Aneurysm thrombosis (8th day) 7 mm × 7 mm, all surrounded by
artery thrombosis (23rd day) echoes corresponding to slow well-vascularized parenchyma,
flow: Pseudo aneurysm splenic heterogenous (10th day)
artery during thrombosis?( 5th day) Decreased volume with
Two thrombosed pseudo- dimensions of 13.5 mm × 4 mm
aneurysms (15 days after × 3.5 mm (1 month)
hospitalization) Complete disappearance of the
cyst formation (two months)
CT-scan Pseudo aneurysm splenic
artery (2nd day)
Treatment Abstention Abstention Arterial embolization (4th day) Abstention
Follow-up Stable thrombus in different Favorable (2 months) Favorable (6 months) Favorable (3 months)
ultrasounds control (5 months)

148 Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
 Ndour, et al.: Results of non-operative management of splenic trauma and its complications in children
DISCUSSION
NOM of splenic trauma represents a major advancement
in the history of pediatric surgery. It initiated the same
approach applied to other solid abdominal organs (liver,
pancreas, kidney) trauma. Upadhyaya and Simpson[3]
reported the first series of splenic trauma in children
managed without surgery at Sick Children’s Hospital in
Toronto in 1968. From their experience they suggested
that under some conditions the trauma of the spleen in
children could be correctly managed without surgery.
Several centers have subsequently experienced and
confirmed the validity of this therapeutic method.[5,6]
In our department, this approach has been used since
1980.[7] In the case of blunt spleen trauma, NOM has
become, under strict conditions, a universally accepted
strategy. According to the literature, the success rates
currently exceed 90% [Table 2] with a failure rate often
lower than 5%.[7-11] In our study we obtained 98.7%
of good results. We had one failure which was linked
to severe injury (grade IV) associated in addition to a
wound of the left renal artery.
Complications of splenic trauma NOM found in the
literature are essentially secondary hemorrhage, pseudo-
aneurysm, pseudo-cysts and splenic abscesses.[8] Their
frequency varies between 0 and 7.5% depending on
the series.[8,12] In our study we found 4 complications
including 3 pseudo-aneurysms and one pseudo-cyst.
The pseudoaneurysm splenic artery is a rare but serious
complication. Its frequency is estimated from 5 to
13% in patients managed with NOM.[8,13] Its natural
history is not clear, but its involvement in re-bleeding
occurrence has been demonstrated. [14] Abdominal
pain is clinically the most common sign.[13] However,
many cases are asymptomatic as we reported in our
3 patients. Currently it is clearly[8,12,15] indicated that
the best test for diagnosis is the contrast enhanced CT
scan (CECT). Oguz and et al[15] have confirmed the value
of Doppler ultrasonography for early diagnosis. In our
study, the diagnosis was made by Doppler ultrasound
in 2 cases and CECT in the other case. In our study,
2 of the 3 cases had spontaneously evolved in this
way. This spontaneous evolution can be explained by
a phenomenon of self-tamponade, a high proportion
of myoepithelial cells, thickness of the capsule,
Table 2: Success of no operative treatment depending
on the series
Authors Size of series Therapeutic success (%)
Frumiento and al(Canada) [7]
n=40 100
Cotte and al (France)[10] n=13 96
Thompson and al (Australie)[8] n=33 100
Veger and al (Pays Bas)[11] n=34 91,2
Lutz and al (USA)[9] n=86 98
Our serie (France) n=83 98,7
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
the elasticity of the parenchyma and the ability of
contraction and retraction of the splenic arterioles.[1]
In the absence of spontaneous thrombosis recovery, the
current treatment adopted by many centers is arterial
embolization. Dobremez and et al[16] reported two
cases of pseudo-aneurysms successfully treated with
selective embolization. This interventional radiology
technique gives good results[13] but many complications
have been described in the literature.[17] Besides the risk
of femoral thrombosis in young children, there may be
recurrence of the aneurysm in 5 to 10% with need for a
new embolization. If this treatment is well established
in adults, it is not yet fully adopted in children because
of its potential morbidity.[9,17]
The splenic pseudocyst caused by trauma is rarely
described in the literature. It is considered as benign
when there is no rapid increase in volume, mass effect
or infection signs. It often occurs after a subcapsular
hematoma. Kristoffersen and et al[18] have found only
one case in a series of 228 patients treated between
1994 and 2005. We report a single case of splenic
pseudocyst in our series. Evolution may lead to the
spontaneous regression as we have observed in the
case of our study. In the experience of Dobremez and
et al[16] on 5 cases, 3 spontaneous regressions and
two others required cystic resection. It seems that
surgery is indicated for symptomatic pseudocysts.
The technical details vary from marsupialization or
resection of the protruding dome with partial or total
splenectomy. [1] This treatment is more successful
by laparoscopy. [17] The secondary hemorrhage is
defined by splenic rupture occurring 48 hours after
the initial trauma.[8] The re-bleeding is reported in 1
to 2% in different series.[14,17] They are related to the
rupture of a subcapsular hematoma, a pseudocyst or
pseudoaneurysm and can be severe. The secondary
trauma occurrence has also been very noted in the
literature,[14] which raises the question of possible
non strict rules of rest that is the central pillar of
NOM. Huebner and Reed[12] in our study concluded
that the risk of occurrence of this complication in
children is negligible. Our study seems to confirm
this. Management depends on the impact of this
re-bleeding on hemodynamic parameters. Without
the need for sophisticated resuscitation, NOM
keeps on all its indications. Therefore, in the case of
uncontrollable active bleeding, there is a choice. On
one hand: Surgical hemostasis whose main risk is
often total splenectomy for vital rescue. On the other
hand, an urgent selective arterial embolization that
now seems increasingly used in this event since the
conditions are compatible with an urgent referral of the
child for a special care.[19] Several cases of successful
embolization in splenectomized children have been
described in the literature.[17] It helps to reduce the
149
 Ndour, et al.: Results of non-operative management of splenic trauma and its complications in children
number of children in splenic trauma but this benefit
must be weighed against the morbidity of arterial
embolization in children.
The splenic abscess is a rare complication of non-operative
management of splenic trauma in children.[17] Frumiento
and et al[7] found one case in 40 patients. It occurred eight
days after the injury. It should be specific to subcapsular
hematoma. The treatment can be percutaneous drainage,
currently guided by ultrasound or CT-scan.[14] We didn’t
find any case in our study. There was no mortality in
our study. The literature reports rare cases of death
due to splenic trauma in children from industrialized
countries.[20] The causes are often bleeding or multiple
trauma[21] in which the spleen is not necessarily directly
responsible of this unfavorable evolution.
CONCLUSION
NOM is the treatment of choice for the spleen blunt
trauma in the child. We have to obey strict rules of
protocol inclusion and monitoring. This is a method
that gives excellent results with over 90% success rate.
Mortality is almost zero in countries with high medical
status. Complications are rare. They are dominated by
the pseudo-aneurysm splenic artery whose evolution
is usually favorable with or without embolization. The
outlook will update the practical guide established
Figure 1: Our practice protocol of management of blunt splenic trauma
in children
150 Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2014 / Vol 19 / Issue 3
by the APSA in 2000 to optimize the conditions for
this strategy. In this context we propose our protocol
management [Figure 1].
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