Nonoperative observation therapy for splenic injuries: a safe therapeutic option?

Combining these reported and estimated incidences of mortality from overwhelming postsplenectomy infection, splenic salvage with nonoperative observation therapy and operative therapy, and the incidence of posttransfusion hepatitis and related mortality provides a conditional probability estimation of the risks of death with nonoperative observation therapy and operative therapy (Figure 4). The combined mortality rates for nonoperative observation and operative therapies are based on the following measured and estimated statistics: The post-transfusion hepatitis death rate per unit of blood transfused is 0.14 percent. Forty percent of children and 20 percent of adults who have successful nonoperative observation therapy receive an average of 2 units of blood. One hundred percent of children and adults in whom nonoperative observation therapy is unsuccessful receive an average of 4 units of blood. Twenty percent of children and adults who undergo operation initially receive an average of 2 units of blood. Ten percent of observed children require laparotomy and 75 percent of these patients then undergo splenectomy. Forty percent of adults who have nonoperative observation initially later require laparotomy, 93 percent of whom also require splenectomy. Ten percent of children and adults treated with initial operation later require splenectomy. Death from overwhelming postsplenectomy infection occurs in 0.026 percent of adults who undergo splenectomy and 0.052 percent of children who undergo splenectomy. Given these assumptions, the conditional probability of death in a child who initially undergoes nonoperative observation therapy is 0.17 percent compared with 0.06 percent for initial operative therapy. In adults, 0.26 percent of the observed patients die compared with 0.06 percent for those operated on initially. As stated, many of the percentages or probabilities listed are estimations based on the best available clinical data. The inability to establish a mortality rate from overwhelming postsplenectomy infection remotely resembling that reported for otherwise healthy patients required an unsubstantiated estimate. However, even when mortality rates from overwhelming postsplenectomy infection of 0.43 percent and 0.6 percent were substituted, early laparotomy still produced lower mortality rates. This continues to be true if one assumes that early laparotomy will result in 50 percent or even 100 percent of patients undergoing splenectomy, although in these cases the statistical differences would be less. We acknowledge that these statistics may exceed or underestimate the true risk of either treatment plan.(ABSTRACT TRUNCATED AT 400 WORDS)