|Year : 2020 | Volume
| Issue : 1 | Page : 31-35
Splenic injury 25 years after deceased-donor liver transplantion at National Trauma Center, Abuja, Nigeria
Usman A Gwaram, Kanati D Apollo
National Trauma Center, National Hospital, Abuja, Nigeria
|Date of Submission||20-Jun-2020|
|Date of Acceptance||07-Sep-2020|
|Date of Web Publication||06-May-2021|
Dr. Usman A Gwaram
National Trauma Center, National Hospital, 265 Independence Ave, Central Business District, Abuja
Source of Support: None, Conflict of Interest: None
Trauma surgeons and emergency care physicians in Nigeria would often be required to manage solid organ transplant patients with injuries; this is because of increased transplant activity both locally and from other countries for the citizens.Knowledge of various transplanted organs physiology and anatomy is essential to ensure adequate allograft protection and good outcome. The reported patient had split deceased-donor liver transplantation at infancy 25 years ago for biliary atresia. He presented with blunt abdominal injury following road traffic accident and was evaluated and managed according to the guidelines for managing native solid organ injuries. The injury to the pathologic spleen was managed non-operatively, successfully. Familiarization with transplant process, physiology, and management is recommended for acute care and trauma specialist to enable adequate participation in transplant services establishment, optimal management of transplant patients with emergency conditions for better allograft protection and overall patient outcome.
Keywords: Blunt abdominal trauma, deceased-donor liver transplant, splenic injury
|How to cite this article:|
Gwaram UA, Apollo KD. Splenic injury 25 years after deceased-donor liver transplantion at National Trauma Center, Abuja, Nigeria. Arch Int Surg 2020;10:31-5
|How to cite this URL:|
Gwaram UA, Apollo KD. Splenic injury 25 years after deceased-donor liver transplantion at National Trauma Center, Abuja, Nigeria. Arch Int Surg [serial online] 2020 [cited 2023 Mar 29];10:31-5. Available from: https://www.archintsurg.org/text.asp?2020/10/1/31/315397
| Introduction|| |
There is increasing solid organ transplant activity in Nigeria, especially kidney., In addition, citizens of the country may have other organs transplanted from other countries and the doctors are often involved in the long-term care and other medical conditions of these patients.
Solid organ transplantation provides a survival benefit for patients with end-stage diseases of the kidney, liver, pancreas, small intestine, heart, and lung. Although it is not a procedure that improves survival, certain quality of life improvements are realized with vascular composite allograft and uterus transplantation. An understanding of the anatomy and the physiology of the various transplanted organ is useful to the emergency physician and trauma surgeon in managing patients with solid organ transplant presenting with traumatic injuries.
This is a report of splenic trauma in a patient that had deceased-donor transplant 25 years ago for biliary atresia at infancy. Severity of splenic injury is objectively described by a grading system developed by the American Association for the Surgery of Trauma AAST. This is based on CT scan, operative, or autopsy findings. This classify injuries into 5 grades of increasing severity based on size of splenic laceration, subcapsular hematoma, and hilar vascular injuries.
| Case Report|| |
A 25-year-old gentleman who had cadaver split-liver transplant at infancy for biliary atresia was referred from a General Hospital with 5-h history of abdominal and chest pain following a motor vehicular accident. He was a restrained lone driver of a saloon car at moderate speed that was involved in a T-bone accident; at an intersection, the front of another saloon car crashed into his passenger side. He was veered-off the road and hit a pavement and stopped. Airbags were not deployed and he came out of the vehicle unassisted.
On examination he had clear airways with no nuchal tenderness, fully conscious and alert and not pale. He had a respiratory rate of 24 cycles/min, good air entry in both lung fields without added sounds and no chest compression tenderness, he had a pulse rate of 92/min, regular with good volume, blood pressure of 106/69 mmHg, and SPO2 of 98% at room air. His abdomen was full, moving with respiration with a Chevron incision scar. There was left flank tenderness, normoactive bowel sounds, and digital rectal examination was normal.
A diagnosis of blunt chest and abdominal injury was made and patient had a Chest X-ray, which showed clear lung fields with slight elevation of the left hemidiaphragm. Abdominal ultrasound scan revealed a grossly enlarged spleen with a span of 202 mm and increased echogenicity, with free fluid at the inferior pole of the spleen. There is also significant free fluid in the peritoneal cavity with floating bowel loops. The liver is normal in size with a span of 161 mm with normal parenchymal echotexture and the intra-hepatic ducts and vasculature were not dilated. Both kidneys were normal in position, outline, and size and they show normal parenchymal echogenicity with good cortico-medullary distinction. The gall bladder and pancreas were within normal limit. The urinary bladder was uniformly filled with a regular outline and normal wall thickness.
Electrolytes, urea, and creatinine: were within normal range. Full Blood Count Hb 7.4 g/dl, PCV 28%, RBC 2.7 × 10/L, hypochromasia, erythrocytopenia, anisocytosis, WBC leukocytopenia, and thrombocytopenia. LFTs were deranged; similar to his previous reports as ALT 103.54 U/L, AST 72.87U/L, ALP 729.8 IU/L Total bil. 24 mg/dl and Direct bil. 0.6 mg/dl.
The scanogram of a chest CT confirms elevation of the left hemi-diaphragm, normal heart in contour and size with the great vessels intact. There was irregular coalescing fibrotic parenchymal consolidations in the left mid and lower zones extending into the pleural surface. The tracheo-bronchial airways are unremarkable and no focal mass is seen within it. The bony thoracic cage and the soft tissue of the chest wall are within normal limits. No obvious rib fracture is seen.
Abdominal CT showed a liver that is normal in size with a span of 13.7 cm. There is a nodular mass with metallic density in the right lobe (self-expanding metal stent for biliary stricture prevention after hepatic transplant). No obvious subcapsular collection seen [Figure 1]. The spleen is markedly enlarged measuring 21.8 cm in its longest length. It is surrounded by hypodense fluid which is also seen within the pelvic cavity, about 200 ml. The gall bladder, pancreas, and both kidneys are within normal limits. No bowel dilatation is seen [Figure 2] The urinary bladder and prostate gland were unremarkable. Conclusion: massive splenomegaly with subcapsular hematoma more than 50% of surface area (OIS Grade III injury).
|Figure 1: Coronal CT scan of the chest and abdomen showing a normal size liver with focal irregular hypodense area in the right medial lobe (segment VIII), and associated marked splenomegaly|
Click here to view
|Figure 2: Transverse abdominal ultrasounds scan showing enlarged spleen with normal left kidney and perisplenic collection|
Click here to view
At birth, he was recognized to have biliary atresia and went to a teaching hospital in Nigeria where at the age of 2 months he had a laparotomy. This confirmed he had biliary atresia but no operation was carried out. Shortly afterwards he went to Britain where after some considerable delay (waiting for a donor), he underwent a split deceased-donor liver transplant; where the donor liver was divided between two recepients. The 6-h surgery was successfully done on 16 April 1995. He had been on immunosuppressant therapy, regular LFT. He had an episode of acute rejection in 1997, following which his immunosuppressants were changed from cyclosporine to tacrolimus, his liver enzymes had been on the steady increase. His LFT 3 months before the accident were similar to the index results. He was managed in May 2016 for a complex empyema with klebsiella pneumonia culture with Video-Assisted Thoracic Surgery and placement of chest drain and antibiotics in ICU.
The patient was admitted for conservative management; initially on NPO, abdominal observation, and close monitoring. He was commenced on graded oral sips after 48 h with resolved abdominal pain, stable vitals, and no abdominal distention, there was no drop in serial Packed Cell Volume (28%) and his electrolytes were within normal limits.
Patient was discharged on 6th day. Even though abdominal CT was not repeated, high resolution abdominal ultrasound showed no abnormal areas in or around the spleen with no deformation of splenic outline and no presence of hematoma or perisplenic fluid collection. He was seen in the clinic weekly for 3 weeks, then fortnightly for three more visits and adviced to avoid strenous physical activity for 6 months.
| Discussion|| |
The indication for transplant in the patient was biliary atresia; this condition remains the most common cause of chronic liver failure in infancy and childhood. Portoenterostomy (Kasai Procedure) when performed in affected children may partially or fully alleviate the jaundice, but it will not reverse the liver damage that has already occurred or prevent any low-grade ongoing damage. After this procedure patients often recover for some years, but until the age of 10 about 50% of the patients have to be transplanted due to chronic liver failure. Cirrhosis generally occurs despite a successful Kasai procedure.,
Survival after liver transplantation has progressively improved over the decades, from the first effort to replace a human liver was at the University of Colorado on March 1, 1963 in which the patient died, as did four others during the next 7 months. Advances in surgical technique, perioperative and post-transplant intensive care management, and the introduction of better immunosuppressive drugs are responsible for our patient reaching adulthood. The patient had blunt abdominal injury from a Road Traffic Accident. RTA remains the commonest cause of blunt abdominal injury especially in the young adult males who are at the most active phase of their lives., So also, spleen is the commonest solid organ injured in blunt abdominal injury.
Management of trauma in transplant recipients should ideally be multidisplinary involving transplant surgeons, nephrologist/hepatologists, and interventional radiologist as well as trauma surgeons. Close monitoring of the patients and the graft using USS, ideally in a transplant unit is recommended. The American Association for the Surgery of Trauma AAST grading scores is commonly used in solid organ trauma; however, it has not been validated in transplant recipients.
The Focused Abdominal Scan for Trauma FAST done initially for the patient at bedside to detect blood collection in the abdomen was supplanted with a biliary scan as baseline and for future comparison, this showed non-dilated biliary and intrahepatic parenchyma. The fluid collection was however, ambiguous because of ascites detected from his previous checkup scan. Abdominal CT scan done when the patient remained hemodynamically stable similar to diagnostic evaluation for a patient with native liver trauma further provided details of the transplanted liver and yielded the splenic enlargement and injury. This accurate diagnosis from the CT facilitated non-operative management of the patient with close clinical monitoring and transfusion requirement. This management strategy was employed in the patient with success. The technique originated with pediatric surgeons in Toronto, who managed children with splenic injures and observed high rates of success. It was then extrapolated to selected adult patients, and has produced reported success rates consistently from 83 to 95%, Improved imaging studies, ICU monitoring, and resuscitation strategies, led to the application of the NOM concept to the majority of patients.
While non-operative management of blunt splenic injury in the stable patient has become the standard of care, splenectomy is still advocated as the safest management for rupture of the diseased spleen as found from the abdominal CT. The combination of splenectomy and underlying immunosuppression might render this patient particularly susceptible to post-splenectomy infection. However, some studies concluded that the pathologic spleen could heal after parenchymal disruption.,
As part of his management, the patient was placed on prophylactic antibiotics, although Barone et al. identified infectious complications among 12 traumatized transplant patients (seven kidney, five kidney/pancreas) over a 40-month period at the University of Arkansas, However, a retrospective study demonstrated that Transplant Patients did not have a higher incidence of infection than patients without solid-organ transplants and the immune suppression associated with organ transplantation, despite having similar Injury Severity Scores. Transplant patients also had clinical outcomes similar to those of Non-Transplant Patients with respect to hospital length of stay, ventilator days, and ICU length of stay.
In Nigeria, liver transplant is a necessity given the burden of liver diseases, it is more than a good gesture and medical service as recognized by the Madrid Resolution on Organ donation and transplantation. There is increasing number of patients who had solid organs transplanted both from local activity and those that had transplant abroad, therefore its important for practitioners to appreciate the physiology, procedure, and management in transplant patients to protect the allograft and improve outcome in disease conditions of these patients. Furthermore, there should be a national effort at initiating and sustaining liver transplant service given the endemicity of liver disease in the country and the cost-effectiveness of transplant in the patients. The ingredients of a successful liver transplant program include adequate hospital set-up, a well-trained transplant team, cooperation from hospitals, and coordination and retrieval agency, and administrative back up.
In conclusion, conservative management of pathologic splenic injury from trauma was done successfully in the patient post liver transplant. Background Ascites may cause diagnostic confusion from FAST, which could be resolved with abdominal CT in addition to anatomical description of the injury. Familiarization with transplant process, physiology and management is recommended for acute care and trauma specialist to enable adequate participation in transplant services establishment in the country, optimal management of transplant patients with emergency conditions for better allograft protection and overall patient outcome.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bappa A, Aliyu A, Mahmoud MS, Sani UA, Borodo MM. Three years follow-up of the first renal Transplant in Aminu Kano Teaching Hospital: A case report. Trop J Nephrol 2006;1:29-30.
Umezurike HO. Kidney transplant in Nigeria: A single center experience. Pan Afr Med J 2016;25:112.
Rana A, Gruessner A, Agopian VG, Khalpey Z, Riaz IB, Kaplan B, et al.
Survival benefit of solid-organ transplant in the United States. JAMA Surg 2015;150:252-9.
Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: Spleen and liver (1994 Revision). J Trauma 1995;38:323-4.
Chardot C, Carton M, Spire-Bendelac N, Le Pommelet C, Golmard J, Reding R, et al
. Is the Kasai operation still indicated in children older than 3 months diagnosed with biliary atresia? J Pediatr 2001;138:224-8.
Chardot C, Carton M, Spire-Bendelac N, Le Pommelet C, Golmard JL, Auvert B. Prognosis of biliary atresia in the era of liver transplantation: French national study from 1986 to 1996. Hepatology 1999;30:606-11.
Starzl TE, Marchioro TL, Von Kaulla KN, Hermann G, Brittain RS, Waddell WR. Homotransplantation of the liver in humans. Surg Gynecol Obstet 1963;117:659-76.
Adoga AA, Ozoilo KN. The epidemiology and type of injuries seen at the accident and emergency unit of a Nigerian referral center. J Emerg Trauma Shock 2014;7:77-82.
] [Full text]
Elachi IC, Yongu WT, Odoyoh OO, Mue DD, Ogwuche EI, Ahachi CN, et al
. An epidemiological study of the burden of trauma in Makurdi, Nigeria. Int J Crit Ill Inj Sci 2015;5:99-102.
Asuquo M, Nwagbara V, Umoh M, Ugare G, Agbor C, Japhet E, et al
. Blunt abdominal trauma in a Teaching Hospital, Calabar, Nigeria. Int J Clin Med 2012;3:693-6.
Rajagopal P, Chughtai SA, Khan S, Ali A. Traumatic injury to renal allograft, literature review and case series. Int J Collab Res Intern Med Public Health 2019;11:859-68.
Caddeddu M, Garnett A, Al-Anezi K, Farrokhyar F. Management of spleen injuries in the adult trauma population: A ten year experience. Can J Surg 2006;49:386-90.
Upadhyaya P, Simpson JS. Splenic trauma in children. Surg Gynecol Obstet 1968;126:781-90.
McIntyre LK, Schiff M, Jurkovich GJ. Failure of nonoperative management of splenic injuries. Causes and consequences. Arch Surg 2005;140:563-9.
Barone GW, Sailors DM, Hudec WA, Ketel BL. Trauma management in solid organ transplant recipients. J Emerg Med 1997;15:169-76.
Tessier JM, Sirkin M, Wlofe LG, Duane TM. Trauma after transplant: Hold the antibiotics please. Surg Infect 2013;14:177-80.
Adeleye O, Olatunji O, Afe T, Odusan O, Olaitan A, Soyego G. A study of disease pattern in a tertiary level gastroenterology and hepatology out-patient unit. Ann Health Res 2017;3:92-7.
WHO, Transplantation Society (TTS), Organizatión Nacional de Transplantes (ONT). Third WHO global consultation on organ donation and transplantation: Striving to achieve self-sufficiency, March 23-25, 2010, Madrid, Spain. Transplantation 2011;91(Suppl 11):S11-4.
Al Sebayel M. Starting a liver transplantation program: Experience at King Fahad National Guard Hospital in Riyadh Ann Saudi Med 1998;18:330-2.
[Figure 1], [Figure 2]