Decision analysis in children with blunt splenic trauma: the effects of observation, splenorrhaphy, or splenectomy on quality-adjusted life expectancy.
The management of blunt splenic trauma in children has remained controversial, with different physicians advocating observation, splenorrhaphy, and splenectomy. Proponents for each position have debated the relative importance of rebleeding (delayed splenic rupture), posttransfusion hepatitis with its sequelae, and overwhelming postsplenectomy sepsis. In an attempt to guide the clinician, a decision analysis was performed. Variables evaluated included the incidence of transfusion, postsplenectomy sepsis, posttransfusion hepatitis, chronic active hepatitis, cirrhosis, and rebleeding. The quality-adjusted life expectancies (QALEs) when the average incidence of the variables were used in the decision analysis were 62.69 years for observation, 62.32 years for splenorrhaphy, and 61.14 years for splenectomy. Sensitivity analysis showed that there was very little difference between observation and splenorrhaphy when the transfusion rate and hepatitis rate were varied. But these treatment options produced longer QALEs than splenectomy. Therefore, in appropriately selected patients, observation is a safe and effective therapeutic option. If an operation is necessary, every effort should be made to preserve the spleen. Splenectomy may still be required in those cases of complete devascularization, persistent hemorrhage, or other associated significant injuries.
Velanovich
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Department of Surgery, Madigan Army Medical Center, Tacoma, WA.
Tapper
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D
D001803:Blood Transfusion / Q000706:statistics & numerical data; D002648:Child; D003661:Decision Support Techniques; D003663:Decision Trees; D005355:Fibrosis / Q000453:epidemiology / Q000209:etiology; D006470:Hemorrhage / Q000453:epidemiology / Q000209:etiology; D006505:Hepatitis / Q000453:epidemiology / Q000209:etiology; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D008017:Life Expectancy; D010372:Pediatrics / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D011788:Quality of Life; D016879:Salvage Therapy / Q000523:psychology / Q000592:standards; D018805:Sepsis / Q000453:epidemiology / Q000209:etiology; D013154:Spleen / Q000293:injuries*; D013156:Splenectomy / Q000401:mortality / Q000523:psychology / Q000592:standards*; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000401:mortality / Q000523:psychology / Q000601:surgery*