The risk of splenorrhaphy.

The main reason for splenorrhaphy is to prevent the occurrence of overwhelming postsplenectomy sepsis. This fear of postsplenectomy sepsis has led to an enthusiasm for splenic salvage to the extent that it may be felt that the injured spleen must be saved at all costs. However, if that is valid, the complications that result from splenic salvage must not exceed the risk incurred by loss of this organ. To assess this, 119 splenic injuries treated by splenorrhaphy were reviewed. These were major splenic injuries that were actively hemorrhaging at laparotomy and, therefore, required specific operative intervention for hemostasis. There were 14 complications in 11 patients (11.8%) directly attributed to the splenorrhaphy. In one patient, the repaired spleen rebled 17 days postoperatively, necessitating splenectomy. Ten patients had persistent or recurrent bleeding, requiring blood transfusions. Three of these underwent reexploration for additional hemostasis. Blood transfusion in association with splenorrhaphy has not previously been considered a complication. However, the literature clearly documents that the risk of blood transfusion heavily outweighs the risk of postsplenectomy sepsis. Therefore, if blood transfusion becomes a necessary adjunct for successful splenorrhaphy, then splenectomy without transfusion is the safer treatment.

Esophageal perforation following external blunt trauma.

Esophageal perforation from external blunt trauma is an exceedingly rare injury. Since 1900, including our five cases, we found 96 reported cases. The most common cause was violent vehicular trauma. The cervical and upper thoracic esophagus was the site of perforation in 82%. In 78% of the cases, there were findings consistent with esophageal injury, but there was a delay in diagnosis in two thirds of these. The diagnostic difficulty was due to lack of a specific symptom complex for esophageal perforation. Often esophageal perforation was not suspected and the symptoms were attributed to the more common injuries, or the diagnostic workup was incomplete. There were 24 (38%) infectious complications directly related to the esophageal perforation. In 21 of these, there was a delay in diagnosis. There were five (9.4%) deaths due to sepsis from the esophageal perforation.