MINISTRY OF EDUCATION MINISTRY OF HEALTH HANOI MEDICAL UNIVERSITY    TRAN NGOC DUNG RESEARCH ON NON-OPERATION MANANGEMENT OF BLUNT SPLENIC INJURY IN THE ABDOMINAL TRAUMA AT THE VIET DUC FRIENDSHIP HOSPITAL Specialization Code : Gastrointestinal surgery : 62720125 SUMMARY OF DOCTORAL DISSERTATION HANOI - 2018 THIS STUDY WAS COMPLETED IN: HANOI MEDICAL UNIVERSITY Spervisor: Assoc Prof MD NGUYEN DUC TIEN Assoc Prof MD KIM VAN VU Reviewer 1: Reviewer 2: Reviewer 3: The thesis will be defended before the Examining Board at university level in Hanoi Medical University At date This thesis could be found at - National Library - Centre Medical Information Library INTRODUCTION TO THESIS Set the problem Blunt splenic injury is a common injury in the abdominal trauma In many countries in the world as well as in Vietnam, blunt splenic injury is always a high rate compared with other traumatic organs in the abdomen In the United States, about 1200 patients with abdominal traumas have been reported annually in emergency centers, including 25% of blunt splenic injuries In Vietnam, along with the socio-economic development is the speed of urbanization, traffic, occupational accidents and many living These are favorable conditions for increasing the rate of abdominal trauma in general and splenic injury in particular According to statistics from the Viet Duc hospital from 2001 to 2003, 132 cases of abdominal trauma have surgery for solid organ damage, blunt splenic injury the most is 31.8% In Binh Duong, during the 2006-2007 period, blunt splenic injury accounted for 131/358 cases of abdominal traumas, equivalent to 36.59% In the past, all blunt splenic injuries were performed by splenectomy, even if only a minor injury However, by the middle of the twentieth century, the preservation of the spleen by injury was noticed, especially after King and Shumaker's discovery of the supersonic infection of over splenic children he called The "Overwhelming Post Splenectomy Infection", followed by further knowledge of the function of the spleen, especially the immune function and blood purification of the body, the spleen preservation is systematically set In recent decades, the spleen preservation has varied, from spleen preservation to surgery to non-operation In 1968, Upadhyaya and Simpson reported 48 cases with splenic trauma of successful treatment by non-operation management (NOM) in children Since then, this method has become the trend of splenic injury treatment Today, with the development of resuscitation and medical imaging, non-operation management of splenic injury is increasingly widespread and effective, with successful non-operation management outcomes reaching over 90% In Vietnam, the treatment of spleen preservation is set in the 1980s, with the announcement of two spleen sutures by Nguyen Lung and Doan Thanh Tung, and later by systematic studies of Tran Binh Giang on spleen preservation surgery In recent years, non-operation management of blunt splenic injury has also been studied by many authors, applied in some large surgical facilities and brought about very positive results such as Pham Van Thuyen's success rate is 98.4%, Tran Ngoc Son is 89.3% or Tran Van Dang is 95.78% However, how can we apply systematically, scientifically and extensively to this technique in clinical practice, in the face of such problems? The topic: "Research on non-operation manangement of blunt splenic injury in the abdominal trauma at the Viet Duc Friendship Hospital" With aim: Description of clinical and laboratory characteristics of patients with blunt splenic injury in the abdominal trauma at the Viet Duc Friendship Hospital Evaluate the results of non-operation management of blunt splenic injury of the abdominal trauma and some factors affecting the outcome The urgency of the thesis Blunt splenic injury is a surgical emergency and is a common injury in the abdominal trauma The function of the spleen for the body has been demonstrated by many studies to be very important And non-operative management has become a treatment for preservation of blunt splenic injury Along with the development of resuscitation and medical imaging, non-surgical management of blunt splenic injury has also changed, the indication is extended, the therapeutic effect is enhanced Therefore, the study of non-operation management of blunt splenic injuries to apply modern means, the advances of science in the diagnosis and treatment of splenic preservation is a current and necessary issue in Vietnam The contribution of the thesis Research conducted at Viet Duc Hospital is one of the major surgical facilities in Vietnam with a team of well-qualified physicians and equipment, a large number of patients offering a comprehensive picture of Diagnosis and non-operation manangement of blunt splenic injury The study also demonstrated significant determinants and factors affecting the effectiveness of non-operative manangement of blunt splenic injury, and the study showed the role of resuscitation and medical imaging in improving the diagnostic efficiency and non-operative management of blunt splenic injury The composition of the thesis The thesis has 137 pages, including: Set the problem: 02 pages; Chapter - Overview: 37 pages; Chapter 2- Objectives and Methodology: 16 pages; Chapter - Research Results: 34 pages; Chapter - Discussion: 45 pages; Conclusion: 02 pages; Recommendation: 01 page The thesis results are presented in 49 tables and 09 graphs The dissertation uses 129 references including 23 Vietnamese, 01 French and 105 English Chapter 1: OVERVIEW 1.1 General anatomy of the spleen 1.1.1 Location The spleen lies deep in the left hemisphere, on the left kidney, behind and to the left of the stomach 1.1.2 Externality The classic description of the spleen looks like a coffee bean, a threesided pyramid, a top, a bottom, and a bottom 1.2 Histological structure 1.2.1 Spleen - Created by: * Serous membrane - The serous membrane is the peritoneum wrapped around the spleen except in the spleen and attached to the spleen coat of the spleen * Fiber membrane - This is a layer of connective tissue that surrounds the spleen - From the inside of this layer of fiber, the connective tissue leaves called the spleen, forming the septum into the spleen, splitting into small lobes and then gathering in the spleen 1.2.2 The splenic parenchyma is called splenic marrow The splenic marrow is dark red, formed by a sagittal tissue frame containing blood cells, consisting of two parts: red and white marrow 1.3 Classification of the American Association For The Surgery Of Trauma in 1994 In 1994, AAST (American Association for the Surgery of Trauma) proposed splitting the spleen injury to degrees based on lesions of hematoma or parenchyma, with or without splenic vessel Grade I o Hematoma: subcapsular, 5 cm or expanding o Laceration: >3 cm in depth or involving a trabecular vessel Grade IV o Laceration involving segmental or hilar vessels with major devascularization (i.e., >25 percent of spleen) Grade V o Hematoma: shattered spleen o Laceration: hilar vascular injury which devascularizes spleen 1.4 Non-operation management of blunt splenic injury Since King and Schumaker's discovery of post-spontaneous infection of children after splenectomy and the success of Upadhyaya and Simpon's non-operation management for 48 patients with splenic injury The issue of non-operation management of blunt splenic injury is increasingly being studied and applied in many parts of the world In Vietnam, this technique has been applied in some major surgical facilities in the country such as Cho Ray Hospital, Viet Duc Hospital, Hue Central Hospital or National Hospital of Paediatrics * Initial restoration: Fluid, blood on the extent of blood loss * Indication of non-operation management: - According to many authors, the first indication is that based on the hemodynamic condition of the patient, hemodynamics should be stable or rapidly stabilized when positive resuscitation - Secondly, the abdominal condition of the disease, excluding the combined lesions in the abdominal cavity especially the perforation of the hollow organs, is an indication for an absolute emergency operation - Blunt splenic injury is often present in the context of multiple traumatic injuries, so the diagnosis and assessment of severity of associated injuries is essential to avoid missed injury, especially when there is non-operation management of splenic injury - In addition, the state of the patient must be in contact Patients who not have coagulopathy or are taking anticoagulants * Non-operation management techniques: - Internal medicine: Patient monitoring - Internal medicine combined with angioembolization for splenic vessels injury and/or splenic injury: Grade IV, V 1.5 The study of splenic injury treatment 1.5.1 On the world Management of blunt splenic injury was studied very early However, the understanding of the anatomy and function of the spleen is limited, so the viewpoint of blunt splenic injury management is changing and improving according to the progress of science Previously, total splenectomy was considered standard in the management of blunt splenic injury and this was a management viewpoint for centuries In 1881, Billroth noted on the corpse a case of splenomegal healing spontaneously following injury In 1927, Hamilton Bailey posed the question: "Is there any need for splenectomy for splenic injury?" But perhaps the preservation of the spleen has not been noticed due to limited knowledge about the spleen And splenectomy is still a technique that many authors have studied and applied In 1919, Morris and Bullock's study showed a high risk of infection in splenectomized people Up until 1952, King and Schumacker discovered the syndrome of post-sperm infection in children Conservation of the spleen has led to more research, beginning with preservation in surgery such as splenorrhaphy, partial splenectomy, splenic hemorrhage with biomesh to non-operation management According to Lucas, the first Wanborough initiating non-operation management for pediatric patients at Children's Hospital of Toronto 1940 In 1968, also in Toronto, Upahaya and Simpson, successfully nonopreation management for 48 patients with splenic injury In 1971, Douglas and Simpson studied the successful non-operation management of 25 of 32 pediatric splenic injuries and the authors commented: Blunt splenic injury are available stop bleeding in almost all cases of non-operative treatment From successes in children, non-operation management is gradually indicated for adults with the original indication is limited, such as: patients with hemodynamically stable, alone splenic injury, degree minor injuries (grade I, II and III), under 55 years old In recent decades, along with the development of positive resuscitation and medical imaging diagnostics, in particular angiography and embolization, non-surgical treatment of splenic injury has been increasingly widespread and effective treatment Resuscitation for both hemodynamically stable patients, age-limited, combined splenic injury, can be successfully by non-operation management, especially for severe (grade IV, V) and vascular lesions can still be successfully treated with embolization And many reports give success rates up to 90% Today, non-operation management of blunt splenic injury has become a widespread treatment trend and system in the world 1.5.2 In Viet Nam Management of blunt splenic injury in Vietnam also follows the trend of the world Previously, all studies on blunt plenic injury were referred to total splenectomy In 1942, Pham Van Hat presented the thesis of splenic rupture In 1952, Nguyen Huu described the distribution of blood vessels in a branched manner, dividing the blood supply into lobes and lobules Until 1956, Nguyen Huu performed successfully partially splenectomy on experiment on dogs, he realized that if passing the boundary between the lobed, the bleeding is little and can completely stop the bleeding well by the suture U, which is the foundation for conservation spleen surgery Partial splenectomy was first reported in Vietnam by Nguyen Lung and Doan Thanh Tung Two cases were performed at the Viet Tiep Hospital In 1999, Nguyen Xuan Thuy and Tran Binh Giang's study on vessel distribution and splenic hilus in Vietnamese people contributed a scientific basis to the preservation of the spleen during surgery In 2001, Tran Binh Giang's study of spleen conservative surgery has established a science and systematic basis for splenic injury management In recent years, non-operation management of splenic injury has been studied by some authors and applied in some large hospitals for good results: Research by Pham Van Thuyen in 2008 and Pham Vu Hung in 2011 at Viet Duc Hospital have resulted in over 95% success The study of Tran Ngoc Son and Nguyen Thanh Liem in 2007 included 29 patients with splenic injuries in 98 patients with solid trauma who were indicated by non-operation management at the National Pediatrics Hospital In 2010, Tran Van Dang did non – operation management for 95 patients with splenic injury at Binh Duong General Hospital for successful results is 95.78% In 2010, research by Phan Dinh Tuan Dung and colleagues at Hue Hospital for 52 patients with blunt splenic injury has concluded nonoperation management gives good results with the degree of injury from degree I - III In 2014, Tran Binh Giang has researched and introduced a procedure for non-operation management of splenic injury in the abdominal trauma Chapter 2: OBJECTIVES AND RESEARCH METHODS 2.1 Research subjects All patients with splenic injury were diagnosed and indicated for nonoperation management at Viet Duc Hospital from 01 January 2014 to 31 December 2016 2.1.1 Standard selection - All ages, regardless of gender - Blunt splenic injury alone or combination with and / or outside the abdominal cavity - Diagnosis by clinical and subclinical examination: blood, ultrasound and CT scans - Evaluate splenic injury and intra-abdominal organs by CT scans according to AAST (1994) - Hemodynamically stable hospitalization (defined as systolic blood pressure ≥ 90mmHg) or stable after initial resuscitation for 24 hours (response to fluid and / or blood: 3000ml of fluid crystal and / or no more than units of blood in 24 hours) 2.1.2 Exclusion criteria - Patients with blunt splenic injury alone and / or in combination in the abdomen designated emergency surgery in the first 24 hours of admission (not including emergency surgery due to injuries outside the abdomen) - Patients with splenic disease as: splenic tumour, splenic abscess, thalassemia - Patients who are taking anticoagulant or have coagulopathy 2.2 Research Methods 2.2.1 Research design Study of descriptive method with prospective analysis 2.2.2 Research sample size The research sample size is calculated according to the relative reliability formula for a ratio (*) as follows: n  Z1α/2 1 p 2p Inside: n: number of patients needed for the study Z1-/2 : The confidence limits coefficient estimates with 95% confidence (= 1.96) p: The proportion of splenic injuries with non-operation management is successful average: 0.9 ε: The exactly desired ratio (= 0.05) Replace the formula above with: 1.962 * (1  0.9) n 0.052 * 0.9 n = 171 (*) According to S.K Lwanga and S Lemeshow: Sample size determination in health studies, a practice manual WHO, Geneva, 1991 2.2.3 Steps study The patients with blunt abdominal trauma on admission were diagnosed and treated in accordance with an agreed protocol 2.2.4 Collecting and processing data All selected patients have their own medical records with all necessary parameters Data collected after cleansing will be entered into computerized calculations and processed using EPIDATA 3.1 software with "check" file to minimize errors during data entry Data analysis using STATA 14.0 software uses statistical algorithms in medicine Continuous quantitative variables are described in terms of mean, standard deviation, maximum and minimum values Comparing the results of a continuous quantitative variable between two groups using the Student t-test (standard distribution variable) or the Mann-Whitney test Qualitative variables are presented in percentages Statistical inference compares the results of variables measured with the p-value test algorithm 2 or fisher's exact test, depending on the expected frequency The logistic regression model was used to calculate the odds ratio (OR) and confidence intervals (95% CI) of the non-operation management results in the blunt abdominal traumas Select the tolerance level α = 0.05, which corresponds to a 95% confidence interval and the significance level is p