Fragile structure of spleen parenchyma, thin capsule, plenty of blood in spleen and anatomic localisation are the main causes that determine high frequency of spleen injuries during blunt and penetrating abdominal trauma.1 The spleen is the most frequently injured intra-abdominal structure, regardless of injury mechanisms (isolated or multiple organ trauma).2
Literature data shows that splenectomy patients, despite their age and indications for surgical treatment, are very liable to develop fulminant post-splenectomy sepsis - the entity named "Overwhelming Postsplenectomy Sepsis Syndrome - OPSS". Many multicentric studies have showed that splenectomy increases death risk mainly by developing OPPS more than 200 times when compared with healthy persons with intact spleen. Global mortality rate of OPPS is between 50-85% and is significantly higher compared to septic mortality in general population of children 0,01%.5,6,7
A huge multicentric study that involved 2795 splenectomy patients from 14 surgical centres has showed that 4,25% patients developed fulminant sepsis with 59,7% mortality rate. Incidence of sepsis in splenectomy patients is 65 times higher than that of the general population, with 200 times higher mortality rate. It was showed that incidence of OPSS in adults was 58 times higher compared to non-splenectomised patients. Iatrogenic splenectomy during long surgical interventions results in high rate of sepsis, which is at least 86 times more frequent in surgically treated adults compared to unoperated patients.6,7,8
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Duration of vulnerability period especially in the development of fulminant pneumonia after splenectomy is unknown. Average time interval between splenectomy and OPSS appearance vary from several weeks to years and decades. Usually, the risk for life threatening sepsis is not limited and it can be life long.9, 10.
Â Â Â Â Â Â Â Â Â Â Â Â The largest numbers of spleen ruptures are transversely oriented, which seems to be determined by the internal architecture of the spleen, which is arranged in a transversal plane. Such injuries create minimal vascular damage. 9,11
Until recently all spleen injuries, despite grade and clinical presentation, have been routinely surgically treated by splenectomy. New data especially in the field of immune spleen functions and its role in body defence from life threatening systemic infections induced a lean towards surgical treatment favouring injured spleenÂ preservation, not infrequently, and their conservative treatment.Â 10, 11.
Fibrin glue is a useful bio-adhesive for safe and efficient treatment of diffuse parenchimatous spleen haemorrhages. In the last few years, it has become an important for spleen haemostasis and parenchimatous organs treatment especially in preservative surgical approach to spleen injuries.12, 13
Â Â Â Â Â Â Â Â Â Â Â Â Â In order to estimates exact chemostatic adhesive ability of FG, the experimental model is designed which simulates spleen lesions with an incision of the capsule and parenchyma.
Â Â Â Â Â Â Â Â Â Â Â Â Â Â Due to the large bleeding which is caused by the section of trabecular and segmental blood vessels such lesions are difficult to compare with blunt traumatic lesions, in which the blood vessels mentioned are mostly unaffected. FG-use efficiency in the treatment of transcapsular spleen lesions II degree, compared with the suture, as the traditional method, with evaluation: a) the efficiency of primary Haemostasis, b) the appearance of secondary or recidivant bleeding, c) sufficiencyÂ adhesive-suture line, d) tissue vitality e) the process of healing spleen f) mortality and other complications between the two applied techniques.
MATERIAL AND METHODS
Experimental evaluation of an injured spleen surgical preservation is performed in Department of experimental surgery, Medical Faculty of Nis; Clinic of pathology, Clinical Centre Nis and Department of pathology, Military Hospital in Nis. A total number of 40 healthy mixed breed adult dogs weighing 12-16 kg were involved in surgical procedures. Anaesthesia was performed with 5% ketamine hydrochloride (KetalarR) (0,1-0,16 ml/kg). Medial laparotomy and exteriorization of spleen was carried out on all animals. Traumatic spleen rupture grades II were simulated by 1-2 transcapsular incision, 5 cm long and 2 cm deep (Splenic Organ Injury Scale).
Â The vascular stalk was clamped with simultaneous digital compression of the wound edge, minimized the bleeding in the area early that fulfil the FB-om with Duploject application system. FG was applied directly on the wound with Double eject application system. Bi-component FG prepared at the Institute of blood transfusion in Nis was used. The first component was blood cryoprecipitate (40-50 g/l fibrinogen, factor XIII and fibronectin) and antifibrinolitic (aprotinin). The second component is CaCl2 (40 mmol/l) and bovine thrombin (TrombostatR) (500 NIH Units/ml).
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A tiny adhesive layer over the spleen wound was made after simultaneous ejection of both components. Digital compression was held until sintering of fibrinous Â»fillingÂ«, and its adhesion to spleen parenchyma. Adhesiveness of FG was checked during spleen reposition in the abdomen.Â If the adhesion of FG with spleen parenchyma and its elasticity was satisfactory and if the filling of wound without haemorrhage was stable during reposition - treatment with FG was considered successful.
The control group consisted of 30 animals in which the injuries (identical features) treated by placement 2-3 Z-suture, (chromic catgut 2-0). In cases of incomplete Haemostasis, the additional reparations by placement 1-2 additional Z-sutures with omentoplasty were performed (Added Z Sutures with omentoplasty - ASO). In cases of such additional reparationsÊ¹ inefficiency, further reparation attempts are cancelled, stitches are removed, lesion areas checked, and then splenectomy is performed consecutively.
Animals were monitored 10 weeks postoperatively, during which they are subjected to clinical control,Â two-stage exploration relaparotomy, morphological and histopathological (PH) review of removed spleen.
Â Â Â Â Â Â Â Â Â Â All operated animals (both groups) were subjected to the first planned exploration after 72 h, which was aimed to check compactness (the absence of partial or total dehiscency) adhesive suture-line assessment and effects of haemostasis. Animals, in which dehiscency was found, traces of haemorrhage, focal necrosis or local infection in the area of reparations, the spleen was then removedÂ andÂ subjected to morphological and PH examination. Dead animals were subjected to autopsy, splenectomy and its morphological examination.
Â Â Â Â Â Â Â Â Â Â All the remaining animals in the control group were, by random elections, divided into 5 subgroups. Every next day, (4 th to 8 th day) one of the subgroups was explored again andÂ splenectomy was performed.
Â Â Â Â Â Â Â Â Â Animals in experimental group (treated with FG), were also randomly divided into 5Â subgroups. Seventh, 15 th, 30 th, 45 th and 70 th days, one of the subgroups was surgically explored and subjected to splenectomy. All explored animals of both groups were maintained until complete recovery, and removed spleens were morphologically and pH examined with special emphasis on the area of reparations ..
A.Â Â Â Â Experimental group
Â Â Â Â Â Â Â Â Â Â Â Â Isolated FG applicationÂ was effective, i.e. allowed the establishment of definitive Haemostasis in 38 (95%) cases (Figure1). Only in two (5%) cases, because of traces of active bleeding, the method of preservation is complemented withÂ fibrin omentoplastic.
Figure.1. Appearance of transcapsular lesionsÂ of the spleen IIÂ° (A). Aspect immediatelyÂ after the treatment of lesions using theÂ isolated FG (B)
Â Â Â Â Â Â Â Â Â Â Â Â Although blood transfusion is not applied in any case, all animals survived the operation, quickly and completely recovered without any local or systemic disorders. In 39 (97.5%) animals during explorative relaparatomy, performed 72 h after primary surgery (Figure 2), the following findings were:
a)Â Â Â Â Â Impeccable lesion filling with FG, with no trace of dechiscency of adhesive lines;
b)Â Â Â Â Â CompleteÂ efficiency of primary haemostasis was estimated with lack of presence coagulated and fresh blood in spleen and peritoneal cavity and the absence of bleeding from the spleen wound filled with FG
c)Â Â Â Â Â PreservedÂ vitality of organs without evidence of necrosis.
Figure. 2. Third postoperative day healing extensive "rupture" of the spleen supervised FG (A). Macroscopical aspect of wound space (formalin preparation), which is completely filled with FG (B).
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Â Â Â Only in one (2.5%) animal that was observed after 72 h we found , hemodynamically insignificant, secondary bleeding fromÂ partially dehiscence of adhesive line. Clinically the animals did not show any change in behaviour, and after splenectomyÂ its recovery was safe.
Â Â Â Â Â Â Â Â Â Â Â PH aspect of many sections, made through the entire depth of the wound of removed spleen, 72 hours after primary surgical intervention, showed intimate contact FB withÂ the edges of the woundÂ spleen. Applied FG is completely filling the entire wound area, but at this stage of its evolution we noticed also its initial absorption. In all the sections made, granulation tissue progressively invades wound space; in this phase of repair it is regularly found in fixed preparations (Figure3).
Figure.3. PH aspect of the spleen lesions treated with FG, after 72 hours. A,Â wound space filled with the remains of FG and "marginalized"Â elements of blood (HEx100). B, remains FB-A, the elements of blood and fibrinÂ net (HE x 200). C, wound space filled with granulatedÂ Â tissue, remains FB-and fibrinÂ net (Masson x 100).
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During the planned explorativeÂ relaparotomy 7 th, 15 th, 30 th, 45 th and 70 th days, confirmed the effectiveness of primary haemostasis. This was further confirmed by the absence of fresh or coagulated blood in the peritoneal cavity or spleen lodge .In a region of adhesive lines, in any case, there was no evidence of insufficientÂ haemostasis, dehiscence or delayed rupture (Figure 4A, 5A).
Gradual absorption fibrin bung, it becomes noticeable only in the 7th day (Figure 4A), when we notice the scar is still fresh in the phase of gradual consolidation. Nonspecific granulation tissue and blood elements were regularly found in numerous sections, made through the wound. Marginal fibroblast proliferation was clearly stated on the preparations made, and the inflammatory response was minimal (Figure 4 B and C).
Figure. 4. Seventh postoperative day after treatment FG large lesions of the spleen A, intraoperative aspect. B, wound filled with granulation tissue, remains of FB - and the elements of blood (Masson x 100). C, Granulation tissue, remains of FB and the elements of blood in the wound area. Marginal stated fibroblast proliferation. Vital tissue of the spleen. (HE x 100).
In the absence of traces fibrin bung the 15 Th day is quite evident showing mild depression scar lines, which histologically presents itself with rough bundles of collagen fibres. In the further course of healing the wounds of the spleen, a noticeable scar retraction in the form of a marked reduction in its length and width, with emphasized umbilication, indicated a completely consolidated, small scar. PH images, in this and further stages of healing, shows a definitive aspect of reparations, with progressive cellular loss and a tendency to indicate scar retraction (Figure 5).
Figure. 5. The appearance of scars after treatment of FG rupture of the spleen IIÂ° (70 day). A, intraoperative aspect. B, histological aspect of the narrow space wounds with surrounding vital tissues, represented part of the scar retraction. Furthest stage reparations. (HE x 200).
Â Â Â Â Â Â Â Â Â Â Â Â All animals treated with FG resulted in good condition, survived the entire period of monitoring and without any complications. The survival rate of these animals was 100%, while the mortality rate was zero.
B.Â Â Â Â Control group
Suture of linealÂ IIÂ° lesions with placement of Z stitches, provided successful primary reparation, i.e. complete haemostasis in only 12 (40%), from a total of 30 animals in the control group processed with this technique. In the remaining (18) animals, because of insufficient haemostasis, additional reparations (ASO) were performed, which was effective only in 7 (23%) animals. In such cases, we demontaged stitch line and deconected omental patch, with regularly observed deep and spacious cutting fragile parenchyma and capsule, which resulted in transformation of primary lesions to become more extensive and deeper, producing lesion characteristics of III-IV degree. In such conditions, we discontinued further attempts of suturing and performed the splenectomy. Animals in which splenectomy was performed, after postoperative recovery, were excluded from further follow-up and19 dogs were excluded.
In relation to the isolated application of FG, which was primarily effective in 38 (95%) cases, the suture, as the primary preservationÂ procedure, showed a significantly lower success rate (40%), with the necessity of additional reparations in an attempt to control insufficient haemostasis. Insulated FG application in only 2 (5%) cases required further bonding and great omentum flap coverage. In this group there were cases of unsuccessful preservation. In the group of animals treated by suture, despite the ASO, 11 (37%) cases of unsuccessful preservation were recorded, where the differences were highly significant (tab.1).
Three dogs, treated with suture repair and additional?????????? died 32-48h after surgery. Their autopsy showed heavy bleeding in the abdominal cavity andÂ spleen lodge originating from the rough damaged capsule and parenchyma, which was damaged with sutures. The treated lesion area resembled the "area of explosion". Identical findings were recorded in the autopsy of the first animal which died 72 hours after "successfully" derived primary suture repair, with no additional suture and omentoplastic. Secondary haemorrhage with laceration necrotic parenchyma and the capsule is still recorded in 2 animals treated with suture 4th i.e. 5th day, during planned explorations. Bleedings thatÂ were noted did not have any hemodynamic importance and obvious clinical signs of internal bleeding. After splenectomy, 2 animals recovered. Extensive focal necrosis in the area of placed suture, with no signs of secondary bleeding and infection was recordedÂ in 2 animals, treated with suture, which were scheduled for explorative laparatomy 6 and 7 days after primary surgery. After splenectomy the animal recovery was unremarkable. Fifth and seventh day in a subgroup of animals treated with suture and ASO purulent formations size ofÂ "green walnuts" were detected in the area of reparation. (Tab. 2)
Â Â Â Â Â Â Â Â Â Â Â In the subgroup of animals treated by suture ASO compared with the subgroup treated by primary suture this showed an insignificantly higher incidence of focal necrosis (43:42%), secondary haemorrhage (43:25%), localized purulentÂ infectionsÂ (29:0%) and fatalities (43:8%) (Tab. 2).
Â Â Â Â Â Â Â Â Â Â Â Â Â Looking at the entire group of animals treated with suture, i.e. suture and the ASO, the appearance of focal necrosis in 42% of cases was notable, occurrence of secondary haemorrhage in 32%, localized purulent infection in 11% and fatal outcome in 21% of cases. In the group of animals treated with FG significantly better results were registered in terms of absence of focal necrosis, localized infections, mortality and incidence of secondary haemorrhage is negligible compared with the group treated suture (Table 3)
Â Â Â Â Â Â Â Â Â Â Â Â The application of FG allowsÂ the spleen rupture of II degree in all cases repaired. FG provides a significantly higher rate of successful repair and minimizes the occurrence of complications in relation to the technique of suture and repeated omentoplasty (Table 4).
ÂÂÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â In 9 of the remaining animals treated with suture, during the planned exploration there was no evidence of signs of haemorrhage, laceration, or areas of necrosis of the spleen.
Â Â Â Â Â Â Â Â Â Â Â Many surgical procedures of the spleen have been described in previous literature (application of haemostatic agents, segmental resection, mesh-splenorrhaphy, stapler resection and auto-transplantation) up to this day (14-17).
Â Â Â Â Â Â Â Â Â Â Â FG, under various commercial names (Beriplast, Tissucol etc.), isÂ used in reparation of parenchymal organs (spleen, liver, pancreas, kidneys and lungs). It is proven that the application of FG on the cut surface of internal organs stops bleeding and fistulisation, and that FG is more effective in drier areas, and that large blood vessels must be sealed.
Â Â Â Â Â Â Â Â Â Â Â Â Â Development of a biological adhesive system opens a great epoch of their application in various fields of surgery of parenchymal organs (18-20).
Â Â Â Â Â Â Â Â Â Â Â Â Â FG is the optimal alternative to parenchimal suture, which is burdened by many risks. Unlike other haemostatic agents, such as gelatin sponge, oxidized cellulose and microfibrillar collagen, FG can be effectively used in a deep laceration of the spleen, without increasing the risk of continuing intrasplenic bleeding, formed subcapsular hematoma or delayed rupture of the spleen. In this study, FB was recognized as the supreme procedure of preservation rupture of the spleen in second degree trauma, allowing a definite haemostasis and perfect bonding of 97.5% transcapsular lesions, and only one (2.5%) recorded case with dehiscence of adhesive lines. Condition of preserved organs, its appearance, volume and vitality, remains fully preserved in all of the cases when we used FG, and without any extensive necrosis case recorded.
Â Â Â Â Â Â Â Â Â Â Â Some studies have emphasized the unacceptably high incidence of unsuccessful primary suture, due to insufficiency of primary haemostasis and extreme damage of the capsule and parenchyma of the spleen. Suture of spleen lesions, as the simplest way ofÂ preservation, is burdened with the possibility of secondary bleeding due to rupture, i.e. dehiscence of suture line (whose incidence varies from 0.3% to over 15% of cases), and the possibility of necrosis. Deep suture significantly compressed blood vessels and caused the creation of spacious tissue compartment prone to necrosis. Suture of the spleen may be an effective method, but only in combination with otherÂ Â preservation methods, such as the use of FG or mesh splenorrhaphy.
Â Â Â Â Â Â Â Â Â Â Â Treatment of second degree spleen lesions with suture in this experiment showed significantly worse results compared to using a FG. Related to the isolated application of FG, which was primarily effective in 95%, and with fibrin omentoplasty of 100% of all cases, the suture, as the primary preservation procedures, showed significantly lower success rate (40%), with the necessity of additional repair in an attempt to control incomplete haemostasis. Related to the group treated with FG, where there was no cases of impracticability primary preservation, with the group of animals treated with suture, despite the additional suture and omentoplasty, 37% cases of unsuccessful preservation where registered, where the differences were highly significant. Autopsy findings showed heavy deferred bleeding to abdominal cavity and spleen lodge, in cases of "successful" derived primary suture repair, and apparently effective haemostasis, that clearly suggests the absence of any safe criterion for assessing performance, reliability and efficiency of this method.
Insignificantly lower incidence of necrosis, secondary haemorrhage, local infection and fatalities in the subgroup treated only with 2-3 Z stitches, shows that the absence of additional stitches does not eradicate the substantial risk of necrosis in comparison with the technique of additional haemostatic stitches and omentoplasty. Higher mortality in the subgroup treated with suture and additional repair, may be explained with the higher risk of secondary bleeding from the additional stitches of devitalized and lacerated parenchyma. Morphological and PH evaluation of the healing lesion of the spleen treated by FG indicates that this method allows optimal reintegration, and thus the functionality of this organ. The reaction of tissue to applied FG is successful and treated parenchyma heals almost with unnoticeable scarring. Any scar, which is formed, shows a complete compact. FG does not act even as the foreign body and the vitality of tissues in all cases remains fully preserved.
Â Â Â Â Â Â Â Â Â Â If the surgeon controls FG application technique, especially with the modalities and details of the application, the success rate reaches 90% in traumatic injuries. In this experimental study an even higher rate of application performance FG was reached, of 97.5%.
Â Â Â Â Â Â Â Â Â Â Â It turned out that the percentage of a primary or forced splenectomy is greatly influenced by the version of a surgeon to a preservation method, or lack of technical details about FG application, i.e. lack of skills and experience. If the surgeon is familiar with this simple and effective method, the rate of saving should exceed 90%, at accidental injury, i.e. 80%, when it comes to traumatic injuries of the spleen. The results of this experimental study suggest the possibility of achieving absolute success, and there is no rational alternative to the FG when it comes to treatment of injuries of the spleen of I and II degree.
Â Â Â Â Â Â Â Â Â Â Â Comparative analysis of the applied methods in terms of feasibility of primary repair, the efficiency of primary Haemostasis, appearance of secondary haemorrhage, mortality rates, sufficiency of adhesive suture-line, assessment of tissue vitality and the process of healing injuries, has undoubtedly shown the superiority of the method of application FG in relation to the suture of the spleen, when reviewing aspects of surgical treatment and preservation in I and II degree spleen rupture.