Results of surgical treatment of patients with closed abdominal trauma and splenic injury in the light of immunological disorders

The dissertation is devoted to evaluating the effectiveness of organ-preserving surgical interventions on the injured spleen in patients with closed abdominal trauma in relation to the immunological status of the patients. The work examines the high frequency of splenic injuries in combined and isolated closed abdominal trauma and the established surgical practice of predominantly performing splenectomy against the background of the significance of the spleen for the antimicrobial and antineoplastic resistance of the organism. The study analyzes immediate treatment results, including the frequency and severity of purulent-septic complications depending on injury severity and patient condition, and conducts a prospective assessment of immunological parameters — cellular and humoral immunity, the cytokine profile, and scintigraphy data — in the long-term postoperative period. Particular attention is paid to the videoendosurgical method of spleen preservation with ligation (clipping) of the splenic artery and its effect on postoperative mortality, the frequency of complications, immunological status, and patients' quality of life.

Relevance of the Problem.

The era of scientific and technological progress and the armed conflicts that have become more frequent in recent years inevitably entail a high level of traumatism. Combined trauma accounts for 60–70% of all injuries [45]. Mortality in combined abdominal injuries remains consistently high, averaging 58.5%, exceeding that in combined craniocerebral trauma (46.7%), chest trauma (32.6%), and pelvic trauma (33.2%), and reaching 90–100% in cases combining thoracoabdominal injuries with craniocerebral trauma and injuries of the musculoskeletal system [25, 29, 40, 43, 45, 47, 57, 81, 102, 109, 225]. The proportion of closed abdominal injuries among combined trauma is approximately 19.6–32.2% [43, 45, 47].

Within the structure of combined trauma, more than 88.3% of surgical interventions are performed for closed abdominal trauma [28]. Splenic injuries are detected in 20–40% of cases [3, 92]. In the surgical treatment of splenic injuries, due to the difficulties of achieving hemostasis and the established stereotype among the majority of surgeons, splenectomy is performed in 99% of cases [92].

At the same time, the significance of splenic function for the antimicrobial and antineoplastic resistance of the organism is extremely great, both in the early postoperative period and throughout subsequent life; therefore, the problem of its preservation remains highly relevant [54, 103, 175].

In this regard, a significant achievement of surgeons in recent decades has been the introduction of a large number of organ-preserving operations on the injured spleen in patients with closed abdominal trauma [6, 12, 18, 21, 24, 30, 37, 39, 58, 91, 104, 122, 141, 167, 193, 236, 238, 278].

The assessment of the effectiveness of these surgical procedures should be based on an analysis of the functions of this organ in comparison with splenectomy, that is, how fully a given method allows preserving or compensating the function of the organ [11, 12, 14, 83].

Undoubtedly, the immunological properties of the spleen after such interventions are largely determined by the filtration capacity of the preserved tissue and the presence of adequate blood circulation in it [9, 95]. Therefore, methods that preserve the main blood supply to splenic tissue are considered more effective than heterotopic transplantation of splenic fragments [12, 83, 143].

At the same time, the literature contains isolated reports on organ-preserving operations on the spleen stating that ligation of the splenic artery makes it possible to expand the possibilities of organ preservation even in severe injuries [91, 139, 194].

The same principle formed the basis for the use of minimally invasive endosurgical technologies for spleen preservation, which made it possible to reduce operative trauma and expand the range of interventions for treating this pathology [4]. However, isolated reports and the absence of long-term results do not currently allow drawing objective conclusions about the effectiveness of such operations.

The question of possible immunological disorders in the body of patients after splenectomy also remains debatable [82, 103, 154, 179, 213].

Given the fact that combined trauma itself leads to immunosuppression [50, 82, 93], it seems expedient to evaluate treatment results depending on the severity of the injury and the severity of the patients' condition.

The need to study immunological disorders and the compensation of the filtration function of the spleen in the long-term period is also indisputable [11, 12, 14, 49, 50, 104].

Thus, many unresolved issues devoted to the problem of spleen preservation in its injury became the basis for choosing this research topic.

Aim of the Study: To determine the effectiveness of organ-preserving operations on the injured spleen in the early and long-term postoperative periods in patients with closed abdominal trauma on the basis of studying immunological status.

Research Objectives:

1. To analyze the frequency and severity of purulent-septic complications depending on the severity of the injury and the severity of the condition of patients with splenic injury.

2. To study the influence of the initial severity of the patients' condition after splenectomy and organ-preserving surgery on quantitative and qualitative changes in blood cell levels in the immediate postoperative period, depending on the development of purulent-septic complications.

3. To study the dynamics of blood cells and changes in the populations and subpopulations of lymphocytes, as well as their ratios, in the long-term postoperative period in patients with removed and preserved spleen.

4. On the basis of immunological status tests, to study the levels of immunoglobulins A, G, and M, cytokines — interleukins 1, 2, and 6, and tumor necrosis factor in the long-term postoperative period in patients with removed and preserved spleen.

Scientific Novelty.

For the first time, the effectiveness of the videoendosurgical method of spleen preservation in closed abdominal trauma has been confirmed, envisaging ligation (clipping) of the splenic artery as the main stage.

Based on the analysis of purulent-septic complications and the study of blood cell parameters in the postoperative period, it was revealed that the level of immunosuppression increases with the worsening of the severity of the patient's condition and is more pronounced and prolonged in patients after splenectomy.

Based on a scientific comparison of changes in immunological parameters in the long-term period after splenectomy, a statistically significant manifestation of immunosuppression has been obtained. It has been established that after spleen preservation the immunological parameters correspond to the physiological norm, which pathogenetically substantiates the expediency of organ-preserving surgery on the spleen with ligation of the splenic artery. The prophylactic role of the proposed variant of spleen preservation in the development of post-splenectomy hyposplenism has been proved. For the first time, an immunological criterion for the presence of residual splenic tissue after splenectomy has been determined.

Practical Significance of the Work.

Spleen preservation makes it possible to reduce both postoperative mortality and the number of postoperative purulent-septic complications, thereby improving the immediate results of treatment of patients with closed abdominal trauma and splenic injury.

Performing organ-preserving surgery with ligation (clipping) of the splenic artery does not impair organ function, as it allows providing an adequate immunological status corresponding to the physiological norm and does not impair the quality of life of patients in the long-term postoperative period.

Implementation into Practice

The results of the dissertation research are used in the educational process at the Department of Surgery with a Course in Endoscopy of the Faculty of Advanced Training of Physicians of the Russian State Medical University of the Federal Agency for Health Care and Social Development.

The method of spleen preservation by ligation (clipping) of the splenic artery substantiated in the dissertation has been implemented in the clinical practice of City Clinical Hospitals No. 36 and No. 54 in Moscow and the Ramenskoye Central District Hospital.

Approval of the Dissertation Work.

The work was approved at a joint meeting of the Academic Council of Clinical Hospital No. 54 in Moscow and the Department of Surgery with a Course in Endoscopy of the Faculty of Advanced Training of Physicians of the Russian State Medical University of the Federal Agency for Health Care and Social Development.

The main provisions of this study were reported at:

• The International Surgical Congress "New Technologies in Medicine" (Rostov-on-Don, October 5–7, 2005). Report: "Laparoscopic Algorithm as the Basis of Surgical Tactics for the Treatment of Combined and Isolated Abdominal Trauma."

• The All-Russian Conference of Surgeons Dedicated to the 85th Anniversary of Corresponding Member of the USSR Academy of Medical Sciences, Honored Scientist of the Russian Federation, Prof. R.P. Askerkhanov. Makhachkala, October 27–28, 2005 (2 reports): "Errors, Hazards, and Complications in Diagnosis and Optimization of Endosurgical Treatment of Closed Abdominal Injuries in Combined and Isolated Trauma" and "Organ-Preserving Operations in Splenic Rupture in Patients with Combined and Isolated Abdominal Trauma from the Perspective of Endosurgery."

Publications.

Based on the materials of the dissertation, 4 articles have been published in central medical journals and 11 works in scientific collections of various conferences, congresses, and symposia.

Structure and Scope of the Work.

The dissertation consists of an introduction, a literature review, a chapter on materials and research methods, a chapter on the assessment and discussion of immediate results, a chapter on the assessment and discussion of long-term results, a conclusion, conclusions, practical recommendations, and a bibliography.