|Year : 2022 | Volume
| Issue : 4 | Page : 327-338
Splenic injuries in native Africans: Presentation, limitations of management, and treatment outcomes in a civilian trauma service in Southeast Nigeria
Aloysius Ugwu-Olisa Ogbuanya1, Uzoamaka Esther Ajuluchuku2, Ugochukwu Uzodimma Nnadozie2, Onyeyirichi Otuu2, Daniel Akuma Umezurike2, Nwanneka Kwento2
1 Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State; Department of Surgery, Bishop Shanahan Specialist Hospital, Nsukka, Enugu State; Department of Surgery, Mater Misericordie Hospital, Afikpo, Ebonyi State; Department of Surgery, Ebonyi State University, Abakaliki, Nigeria
2 Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State; Department of Surgery, Ebonyi State University, Abakaliki, Nigeria
|Date of Submission||08-Mar-2021|
|Date of Decision||28-May-2022|
|Date of Acceptance||07-Jun-2022|
|Date of Web Publication||16-Nov-2022|
Aloysius Ugwu-Olisa Ogbuanya
Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, PMB 102, Abakaliki, Ebonyi State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Splenic trauma has emerged as a major global health burden, especially in developing nations with limited diagnostic and therapeutic facilities. The current trend toward nonoperative management (NOM) and adoption of splenic salvage whenever feasible calls for local evaluation of our current practice. The aim of this study was to document the epidemiology and outcomes of management of splenic injuries in our setting. Patients and Methods: This was a multicenter, prospective study of epidemiology and outcomes of patients with splenic injuries recruited over 10 years in southeast Nigeria. Results: Approximately 66% of all patients with abdominal injuries sustained splenic trauma. A total of 313 patients with splenic trauma were recruited; 226 (72.2%) were managed operatively (OM) and 87 (27.8%) conservatively (NOM). Majority (75.7%) had blunt abdominal trauma (BAT), while 24.3% sustained penetrating injuries. Sonographic grading showed that 46 (14.7%), 58 (18.5%), 79 (25.2%), 106 (33.9%), and 24 (7.7%) patients had grades I, II, III, IV, and V injuries, respectively. Isolated splenic injuries occurred in 172 (55%) patients, and the rest (141, 45%) had associated intra-abdominal injuries. Two-thirds (67.1%) were aged 16–45 years. In the OM group, 178 (78.7%) had total splenectomy, while 48 (21.3%) had splenic salvage. There was a statistically significant difference (P = 0.022) in the rate of postoperative complications between the splenectomy and splenorrhaphy groups. The overall mortality rate was 4.5%. Major predictors of morbidity and mortality were high-grade splenic injuries, total splenectomy, multiple injuries, advanced age, and comorbidities. Conclusion: Splenic injuries complicate approximately two-thirds of all abdominal injuries in our environment and majority of these injuries were due to BAT. In this study, majority had OM and splenic salvage rate was relatively low.
| Abstract in French|| |
Contexte: Le traumatisme splénique est devenu un fardeau mondial majeur de santé, en particulier dans les pays en développement avec des installations diagnostiques et thérapeutiques limitées. La tendance actuelle vers la gestion non opératoire (NOM) et l'adoption du sauvetage splénique chaque fois que cela appelle à l'évaluation locale de notre pratique actuelle. Le but de cette étude était de documenter l'épidémiologie et les résultats de la gestion des blessures spléniques dans notre contexte. Patients et méthodes: Il s'agissait d'une étude prospective multicentrique de l'épidémiologie et des résultats de patients souffrant de blessures spléniques recrutés sur 10 ans dans le sud-est du Nigéria. Résultats: Environ 66% de tous les patients atteints de blessures abdominales ont subi un traumatisme splénique. Au total, 313 patients atteints de traumatisme splénique ont été recrutés; 226 (72,2%) ont été gérés de manière opératoire (OM) et 87 (27,8%) de manière conservatrice (NOM). La majorité (75,7%) avait un traumatisme abdominal émoussé (BAT), tandis que 24,3% ont subi des blessures pénétrantes. Classement échographique ont montré que 46 (14,7%), 58 (18,5%), 79 (25,2%), 106 (33,9%) et 24 (7,7%) avaient respectivement des grades I, II, III, IV et V, respectivement. Des lésions spléniques isolées se sont produites chez 172 (55%) patients, et le reste (141, 45%) avait des lésions intra-abdominales associées. Les deux tiers (67,1%) étaient âgés de 16 à 45 ans. Dans le groupe OM, 178 (78,7%) avaient une splénectomie totale, tandis que 48 (21,3%) avaient un récupération splénique. Il y avait une différence statistiquement significative (p = 0,022) dans le taux de complications postopératoires entre les groupes de splénectomie et de splénorrhaphie. Le taux de mortalité global était de 4,5%. Les principaux prédicteurs de la morbidité et de la mortalité étaient les blessures spléniques de haut niveau, la splénectomie totale, les blessures multiples, l'âge avancé et les comorbidités. Conclusion: Les blessures spléniques compliquent environ les deux tiers de toutes les blessures abdominales dans notre environnement et la majorité de ces blessures étaient dues à BAT. Dans cette étude, la majorité avait le taux de récupération OM et splénique était relativement faible.
Mots-clés: Abdomen, urgence, laparotomie, mortalité, rate, traumatisme
Keywords: Abdomen, emergency, laparotomy, mortality, spleen, trauma
|How to cite this article:|
Ogbuanya AU, Ajuluchuku UE, Nnadozie UU, Otuu O, Umezurike DA, Kwento N. Splenic injuries in native Africans: Presentation, limitations of management, and treatment outcomes in a civilian trauma service in Southeast Nigeria. Ann Afr Med 2022;21:327-38
|How to cite this URL:|
Ogbuanya AU, Ajuluchuku UE, Nnadozie UU, Otuu O, Umezurike DA, Kwento N. Splenic injuries in native Africans: Presentation, limitations of management, and treatment outcomes in a civilian trauma service in Southeast Nigeria. Ann Afr Med [serial online] 2022 [cited 2022 Dec 9];21:327-38. Available from: https://www.annalsafrmed.org/text.asp?2022/21/4/327/361266
| Introduction|| |
It was estimated that by 2020, 8.1 million people will die yearly due to trauma, and road traffic accidents (RTA) will be the third most common cause of morbidities worldwide and the second most common cause in developing nations. Globally, the burden of disease due to RTA has decreased significantly since 1990, but this decline is largely in high-income regions, but in low and middle-income countries (LMICs), the reverse trend has occurred.,
In 2013, over 85% of all deaths and 90% of disability-adjusted life years lost from road traffic injuries occurred in LMICs, which have only 47% of the world's registered vehicles. In civilian practice, blunt abdominal trauma (BAT) from RTA accounts for 80%–90% of all splenic trauma and is especially common in young adults., However, with increasing use of guns, arrows, sharp iron, and spears, the incidence of splenic trauma from penetrating abdominal injuries has continued to rise in the civil setting., The spleen is the most frequently injured organ in blunt abdominal injury and an unrecognized splenic injury is the most common cause of preventable death in trauma patients.,,,,, The common causes of splenic injuries include RTA, fall from height, gunshot, assaults, stab, and recreational and industrial injuries.,, The two mechanisms of splenic injury are blunt and penetrating, but the injury types range from bruises, capsular tear, parenchymal laceration, laceration of trabecular vessels, to hilar avulsion/shattered spleen.,,
Elsewhere, it has been cited that enlarged, pathologic spleens are more vulnerable to traumatic rupture, especially in the setting of blunt injury.,,, This is particularly relevant in Africans where splenomegaly is common due to hemoglobinopathies, chronic pyogenic infections, and chronic parasitic infestations from malaria, visceral leishmaniasis (kala-azar), or schistosomiasis.,, In the past, splenectomy for rapid control of hemorrhage was the traditional approach in the management of splenic injuries, but the increased understanding of the immunological and hemopoietic functions of the spleen and particularly its role in clearing encapsulated organisms from the bloodstream have led to a trend toward nonoperative management (NOM) or splenic salvage., Current clinical data have elucidated the value of postsplenectomy vaccination and use of antimicrobials against encapsulated organisms to prevent overwhelming postsplenectomy infections (OPSIs), but splenic preservation whenever possible has shown to be superior in minimizing the risk of OPSI.,,,,,
Despite improvement in diagnostic facilities and laparoendoscopic services in the high human development index (HDI) countries, many centers in LMICs including Nigeria lack functional imaging facilities such as computed tomography (CT) scan and magnetic resonance imaging (MRI) needed in evaluation and management of patients with solid-organ injuries such as splenic trauma., Moreover, late presentation is very common in our environment, and together with a paucity of diagnostic facilities, and often severe splenic injuries, many patients in our community are still being managed operatively, with a low operative splenic salvage rate.,, Typically, spleen traumatized patients may present in three main patterns. The first is the ultra-urgent injury where hypotension sets in rapidly and the spleen is commonly found to have shattered or become avulsed, leading to devastating, uncontrollable hemorrhage., The second is the classic type where majority of patients are initially normotensive, but shock sets in after a period of an hour or two.,,, Delay in this category means onset of shock before patient reaches the hospital or before prehospital management is commenced., Third, the uncommon “delayed rupture” of spleen represents development of subcapsular hematoma that eventually ruptures within a variable period of 2 weeks to several months.,, From the foregoing, it is clear that a time duration that is too short to rescue a patient with ultra-urgent injury will be adequate to resuscitate, triage and plan treatment in a patient with the classic or delayed form of splenic trauma. Therefore, the general surgeon managing patients with splenic injuries in our setting faces great challenges different from his colleagues in developed nations. The lack of advanced prehospital system for transportation of injured patients coupled with limited work force, poor infrastructure, and extreme poverty precluding affordability of some of the expensive imaging facilities such as CT and MRI even when they are available makes management of these patients a tall challenge.,
There are limited data on splenic injuries in our environment despite the frequent admissions and management of splenic trauma patients. Most documentations on splenic trauma in our environment were performed hurriedly when discussing subjects in the domain of abdominal injuries or trauma pattern in the population. Although the global trend toward NOM and splenic salvage has been emphasized, the current state of the art in our setting has not been reported despite several reports from other regions in Nigeria,,, and Africa., The aim of this study was to document the pattern of presentation, limitations of management, and treatment outcomes of splenic injuries in our setting.
| Patients and Methods|| |
Design and setting
The study was a cross-sectional, analytical study of patients with splenic injuries in three hospitals located in southeast Nigeria from January 2010 to December 2019.
Initially, all adult patients with abdominal injuries were evaluated. However, further analysis involved only adult patients aged 16 years and above with splenic injuries who presented at the emergency units of the selected hospitals. Only patients who gave informed consent were included. Those too ill to give consent and had no next of kin to do so were excluded from the study. Furthermore, those who died before the initial assessment were excluded.
Diagnosis followed by grading of splenic injuries was made through combined preoperative clinical assessment, diagnostic imaging studies (abdominal ultrasonography and CT scan), and intraoperative findings. It must be emphasized that the gold standard investigation for splenic injury worldwide is CT scan, but due to often nonavailability, high cost, or nonfunctioning state of the CT scan in the hospitals where this study was done, combined clinical, plane upper abdominal/chest X-ray and abdominal ultrasound scan were the main preoperative diagnostic instruments. After primary and secondary survey, all recruited patients were initially resuscitated according to the protocol set by the advanced trauma life support principles.,,
The sociodemographic and clinical data such as age, gender, occupation, educational status, mechanism of injury, injury-arrival time, comorbidities, and associated injuries were elicited and recorded in a pro forma. Other variables studied included prehospital care and hemodynamic parameters at admission (systolic blood pressure [SBP], pulse rate, and Glasgow Coma Scale [GCS]). In addition, blood transfusion requirement, estimated blood loss, treatment modalities, early and late complications of treatments, mortality rate, length of hospital stay, and follow-up protocol for splenectomized patients were recorded.
All recruited patients had abdominal ultrasound scan. However, to contain expense, only those billed for NOM were requested to do abdominal CT scan. Other ancillary tests to aid diagnosis included plane abdominal and chest X-rays, abdominal paracentesis, hematological tests, and serum electrolytes. In the preoperative period, sonographic assessment of splenic injuries was performed routinely and injuries graded from I to V using the organ injury scaling of the American Association for the Surgery of Trauma.
Patients were broadly grouped into NOM and operative management (OM) groups. Indications for NOM included hemodynamic stability (SBP >90 mmHg and pulse <100 beats/min), absence of associated intra-abdominal injuries, and limited need for splenic rupture-related transfusion requirements (less than or equal to 2 units of blood). Those scheduled for OM were assessed by the anesthesiologist and grouped according to the American Society of Anesthesiologists (ASA) classification. Prophylactic antibiotic was administered routinely on all OM cases at the induction of anesthesia or 30 min before skin incision was executed. In the OM group, it was continued for a variable period postoperatively. However, parenteral antibiotic therapy was continued in the presumptive sense for another variable period of 5–7 days due to peculiarities of the tropical environment, the presence of laparotomy wound, and the fact that some patients may have other injuries that may necessitate presumptive antibiotic therapy. In patients with surgical site infection or established systemic infection, antibiotic therapy was routinely used in the therapeutic sense. For those managed on the NOM basis, presumptive antibiotic therapy was equally used to forestall the development of established infection in the traumatized organ (s) or general peritoneal cavity or in the extra-abdominal sites.
All patients with evisceration following penetrating injuries and those with high velocity gunshot abdominal wounds or generalized peritonitis received mandatory exploratory laparotomy. Intraoperatively, the type, number, and degree of associated injuries, intraoperative grade of splenic injury, and extent of operative treatment (splenic salvage or total splenectomy) were noted and recorded. For correlation with sonographic grading, intraoperative grading using the American Injury Severity grading system, was employed routinely.
Patients for NOM were admitted and monitored for hemodynamic stability and need for blood transfusion. Pulse rate, blood pressure, hourly urine output, GCS, respiratory rate, temperature, and abdominal girth were monitored closely. Hemoglobin estimation, serum electrolytes, and serial imaging studies (mainly abdominal ultrasound) were done regularly (every 24–48 h). All patients were followed up and complications recorded. Patients were followed up for variable period ranging from 1 month to 5 years.
The data were analyzed using Statistical Package for the Social Sciences (SPSS) software version 22.0 (IBM, Chicago, IL, USA, 2015). The data were presented as mean, standard deviation (SD), percentages, and tables. Confidence interval was calculated at 95% level and significance at 5% probability level (P < 0.05).
The protocol for this study was approved by the Research and Ethics Committee of the three hospitals before commencement of the study.
| Results|| |
During the period under study, a total of 345 (65.8%) out of 524 adult patients who presented with abdominal injuries sustained splenic trauma and were seen. However, only 313 (90.7%) of the spleen-traumatized patients met the inclusion criteria and formed our study population. Majority (267, 85.3%) were male; the rest were female (46; 14.7%), in the ratio of 5.8:1. Their ages ranged from 16 to 68 years with a mean of 36.8 ± SD 15.42. Approximately two-thirds (210; 67.1%) were aged 45 years and below, while only 16 (5.1%) patients were aged 65 years and above. Nearly half (156; 49.8%) were traders; the rest were artisans (58, 18.5%), farmers (37, 11.8%), civil servants (24; 7.7%), unskilled laborers (20; 6.4%), and others (18; 5.8%). Over three-quarter (244; 78%) of the patients were urban and semiurban dwellers, and the remaining 69 (22%) resided in the rural area.
Mechanism of injuries
Approximately three-quarter (237; 75.7%) of the splenic injuries were due to blunt abdominal injuries, and the remaining 76 (24.3%) patients had penetrating injuries, giving blunt to penetrating injury ratio of 3:1. RTA were the most common cause of splenic trauma accounting for approximately half (157, 50.2%) of all the patients, followed by fall from height (73, 23.3%) [Table 1]. Nearly half (156, 49.8%) of the patients were seen in the last three years of this study (2017–2019), and of these, RTA accounted for the greater majority (88, 56.4%). In the RTA group, motor vehicular accident (MVA) was the most frequent cause accounting for 53.5% (84 cases) of all cases of RTA. Other RTA-related causes were due to motorbike (45, 28.7%), tricyclic system, otherwise called “Keke Napepe” (22, 14%), and pedestrian (6, 3.8%) accidents.
Among the 237 patients with BAT, 146 (61.6%), 71 (30%), 12 (5.1), 4 (1.7%), 2 (0.8%), and 2 (0.8%) cases resulted from RTA, fall from height, assaults, industrial accidents, domestic violence, and recreational injuries, respectively. Majority (268, 85.6%) of the patients sustained the injuries in the day time, and the rest (45, 14.4%) occurred in the night. Majority (174, 83.3%) of the 209 patients with severe injuries (grades III-V) had either RTA or gunshot injury.
Clinical presentation and diagnosis
More than half of the patients (170, 54.3%) presented within 12 h of injuries, though a significant proportion (53, 16.9%) delayed beyond 24 h. There were 21 (6.7%) cases of delayed rupture and no cases of ultra-urgent injury; the rest (292, 93.3%) were the classic type. All cases of ultra-urgent injury expired before detailed evaluation. Nearly a third (99, 31.6%) presented in shock. Sonographic grading showed that 46 (14.7%), 58 (18.5%), 79 (25.2%), 106 (33.9%), and 24 (7.7%) patients had grades, II, III, IV, and V splenic injuries, respectively. The mean pulse rate for grades I-II was 89.8 ± SD 12.8 compared to 102.6 ± SD 21.4 for grades III-V (P = 0.058). The mean SPB was 111.5 ± SD 14.8 for grades I-II, but 88.9 ± SD 11. 6 for grades III-V (P = 0.052). The mean hourly urine output for grades I-II was 28.4 ± SD 16.3 and 21.5 ± SD 25.6 for grades III-V (P = 0.077). Similarly, there was a correlation between grades of injury and the percentages of both abdominal distention and fever, but this did not reach statistical significance: abdominal distension (P = 0.066) and fever (P = 0.214). The details of the clinical parameters at presentation are shown in [Table 2]. Prior to presentation, 39 (12.5%) had been admitted in other hospitals before referral to us. Majority (34, 87.2%) of the referred patients presented in shock. More than half (172, 55%) presented with isolated splenic injuries, and the rest (141, 45%) had associated visceral injuries involving the liver, colon, small intestine, omentum, stomach, mesentery, gallbladder, pancreas, kidneys, urinary bladder, and retroperitoneum in various proportions.
|Table 2: Correlation of clinical parameters at admission and sonographic grading|
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Comorbid medical illnesses were present in less than a tenth (26, 8.3%) of the patients, and these ranged from hypertension (11), diabetes mellitus (five), bladder outlet obstruction (four), chronic obstructive pulmonary disease (three), renal disease (two), and HIV/AIDS (one). Of those with comorbidities, 20 were in the OM group and 6 in the NOM group. Preoperatively, clinical assessment showed that only 211 (67.4%) patients had splenic injuries, 62 (19.8%) were suspicious or equivocal of splenic trauma, while in 40 (12.8%) patients, splenic trauma was entirely missed.
Anesthetic assessment and treatment
At presentation, the 313 patients were initially triaged into OM (215, 68.7%) and NOM (98, 31.3) groups. However, following failed NOM in 11 cases, the number of OM rose to 226 (72.2%), while the NOM cases reduced to 87 (27.8%). In the OM group, anesthetic assessment showed that 80 (35.4%), 136 (60.2%), and 10 (4.4%) were in ASA III, ASA IV, and ASA V classes, respectively. Of those that had operative treatment, 178 (78.8%) had splenectomy, while the remaining 48 (21.2%) patients had splenic salvage (splenorrhaphy or partial splenectomy). However, intra-abdominal hemorrhage and rebound hypovolemic shock occurred postoperatively in three patients that received splenic salvage; they were reexplored and formal total splenectomy performed, thereby reducing successful salvage rate to 19.9%.
The choice of NOM or OM was predicated on several clinical, pathologic, sociodemographic, and technical parameters as shown in [Table 3]. Intraoperatively, the severity of splenic trauma was assessed using the American Injury Severity grading system, which ranged from grade I to V. Subsequently, the concordance between sonographic and intraoperative gradings was determined [Table 4]a. The 158 missed sonographic diagnoses were correctly typed by the intraoperative method [Table 4]b. The overall intraoperative grading was compared with overall sonographic grading in the OM group [Table 4]c. Additional procedures were performed in a quarter (57, 25.2%) of the OM group. These included intestinal resections with or without stoma (29, 50.9%), intestinal repair (17, 29.8%), simple repair of hepatic laceration (6, 10.5%), repair of gastric injuries (4, 7%), and cholecystectomy (1, 1.8%). Tube drain was inserted in 156 (69%) cases. In the NOM group, serial ultrasonographic and clinical assessments were mandated. Less than a tenth (8, 9.2%) of those managed nonoperatively did CT scan for serial evaluation. Interventional radiology services such as angioembolization were not available in our centers. Of the three hospitals where this study was done, only one (a teaching hospital) has an intensive care unit (ICU) set up that is poorly equipped.
Outcomes of management
Wound infection was the most common complication in both the splenic salvage and total splenectomy groups (19.7% versus 12.5%). Of the 226 patients who had OM, 128 (56.6%) had associated injuries, while 98 (43.4%) had isolated injuries. The vast majority (128, 90.8%) of patients with associated injuries had OM compared to those with isolated splenic injuries (98, 57%). Prophylactic antibiotic was used in all OM cases. In the OM group, therapeutic antibiotic therapy was required in a total of 59 (26.1%) patients: 41 SSI, 9 intra-abdominal abscesses, 7 septic cases, and 2 enterocutaneous fistulae [Table 5]. Of the 59 cases that required therapeutic antibiotics, 46 (78%) patients had associated abdominal injuries, while 13 (12%) had isolated splenic injuries. Overall, mortality rate was 4.5% (14 patients). Mortality rate was 7% in those with associated injuries and 4.1% in isolated splenic trauma cases. Only one death was recorded in the NOM cases. Other complications and length of hospital stay for the patients managed operatively are shown in [Table 5]. About one-third (76, 33.6%) of the patients managed by OM-developed postoperative complications. The major predictors of morbidity and mortality included high grade of splenic injury, associated intra-abdominal injuries, advanced age, and presence of comorbidities [Table 6].
|Table 5: Outcome measures for operative management and nonoperative management|
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|Table 6: Determinants of morbidity and mortality among patients managed operatively|
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The length of follow-up ranged between 1 month and 5 years with a median of 15.4 months. Of the 299 survivors, 181 (60.5%) were available for follow-up at 6 months. Due to high dropout rate, only 12 (4%) patients were followed up for five years. During follow-up, detailed assessment to elicit opportunistic infections by encapsulated organisms was done. No clinical findings consistent with OPSI were encounter. Total splenectomized patients (178, 78.8%) especially younger ones were counseled for vaccinations against the encapsulated organisms, but less than two-third (111, 62.4%) were ultimately vaccinated. Of the 111 patients who received postsplenectomy vaccination, only 25 (22.5%) were completely immunized with meningococcal vaccine, Pneumovax, and Haemophilus influenza type b (Hib) vaccine, while the remaining 88 patients received either one or two vaccine type (s). The vaccines are 1 dose of Pneumococcal 13-valent conjugate vaccine followed by a dose of pneumococcal polysaccharide vaccine 23 after at least 8 weeks; 1 dose of meningococcal ACWY conjugate vaccine (or a series of 2 doses of meningococcal B vaccine at least 1 month apart); and 1 dose of Haemophilus Influenza type B conjugate vaccine (Hib). Patients were counseled to commence vaccination 2 weeks after splenectomy unless where not practicable. Booster dose at 5 years were recommended for both pneumococcal and meningococcal vaccines. The protocol adopted in this study was according to the guideline proposed by the World Society of Emergency Surgery. Majority (90, 81.1%) of the vaccinated patients were aged 30 years and below. Prophylactic antibiotics were advised in patients that underwent common procedures such as dental extraction and abscess drainage during follow-up.
| Discussion|| |
Over the years, discussions on splenic injuries and OM of splenic diseases have become subjects of lively debate worldwide, though the focus and degree of progress vary from region to region.,,,, This research study was set to present our local experience in a West African subregion where inadequate diagnostic and therapeutic facilities, albeit increasing rates of splenic injury cases, have created a gap in the standard of care for trauma patients. Our patient population comprised predominantly young adults, with a preponderance of males who were mostly traders and artisans with vast majority residing in urban or semiurban areas. These observations overlapped with reports from referral hospitals in Nigeria and Tanzania.,, Elsewhere,,,, it has been cited that human movements and civil unrest are more common among younger persons both in war and peace time and these findings may partly explain the observed high proportion of young patients presenting with splenic trauma in this series.
In the classic manner of a developing economy, petty traders, farmers, and artisans formed the greater majority (80.1%) of the injured patients akin to reports from central Africa. In native Africans, agricultural produce, household materials, clothing, and an avalanche of general-purpose goods are moved from one region to the other in dilapidated roads with no or minimal observance of driving and traffic laws., In our setting, it is usual for artisans, farmers, traders, and many professionals to scamper daily for means of livelihood, thereby necessitating increased movements, interpersonal disagreement or confrontations, industrial violence, and assaults. In the course of these movements, overloading of poorly serviced vehicles, trucks, motorbikes, tricyclic units (Keke napepe), or even bicycles is common in our setting and contributes to increased RTA. Perhaps, the above pattern may partly explain the preponderance of traders, artisans, and farmers encountered in this study.
Our finding that splenic injuries are common among abdominal trauma patients and that 65.8% of the patients with abdominal injuries in this study had splenic injury overlapped with values of 64% and 62.7% reported by Dogo et al. in Maiduguri, Nigeria, and Hady et al. in Poland, respectively. Mehta et al. in India and Yawe and Inunduh in Markudi, Nigeria, however, recorded comparable, but lower values of 53% and 57.9%, respectively. These lower rates of splenic involvement may be explained by the fact that only blunt abdominal injuries were analyzed in those studies, compared to studies done in Maiduguri and Poland, where both BAT and Penetrating Abdominal Trauma (PAT) were simultaneously evaluated. A South African study by Howes et al. reported a disturbingly lower figure of 15.4% from 65 patients who had emergency laparotomy for BAT. However, critical review of the study revealed that the population of patients with BAT was 926, but the authors analyzed only 65 cases that had laparotomy and this, perhaps, contributed to the low value recorded in that series. In Mauritania, Idriss et al. reported that PAT (68%) surpassed BAT (32%) as a mechanism of abdominal injuries, only 10% of the abdominal trauma patients harbored splenic injury, while majority (24%) sustained intestinal injuries, lending further support that PAT is more frequently associated with bowel than splenic injuries.
In agreement with data from similar prospective studies by Chalya et al. in Tanzania, Agbakwuru et al. in Ekiti and Asuquo et al. in Calabar, both in Nigeria and retrospective studies by Akinkuolie et al. in Ile-Ife and Iribhogbe and Okolo in Benin City, both in Nigeria, we found that RTA represented the most common cause of splenic injuries in our current study. We equally agree with the views of Ogbuanya and Emedike in southeast Nigeria, Chalya et al. in Tanzania, and Agbakwuru et al. in southwest Nigeria, that avoidable risk factors like abuse of alcohol, over speeding, driver fatigue, poor maintenance of vehicles, and noncompliance to road safety rules and principles play major roles in the etiology of these accidents. The proportions of splenic injuries contributed by RTA in Bugando, Tanzania (63.6%), Benin City, Nigeria (78.3%), and southwest Nigeria (75.3%) were higher than the rate of 50.2% recorded in this study probably due to the fact that penetrating injuries from stab wound and gunshot injuries were high in the present study. Fall from heights and injuries from firearms contributed a significant proportion of splenic injuries in this series and ranked the second and third most common causes, respectively.
In southeast Nigeria where this study was done, Chianakwana et al. cited a recent civilian unrest from political, social, and ethnoreligious disharmony, leading to rising incidence in firearm, stab wounds, and other violence-related injuries. The current spate of violence from agitation for the actualization of Biafra by the “Indigenous People of Biafra” and the rise in the incidence of banditry, kidnapping, communal land clashes, political thuggery, farmer-herder clashes, and “accidental discharge” of bullets by law enforcement agents has been previously reported and perhaps contributed to the increase in the rate of PAT in southeast Nigeria. These observations may explain the increased contribution of PAT to splenic injuries in this study and the relatively lower contribution of RTA compared to other studies.,,, In a single-center, hospital-based retrospective descriptive study in lIle-Ife, Nigeria, where analysis was restricted to isolated splenic injuries only, RTA accounted for 95% of the injuries in the third to sixth decades of life, but a relatively low value of 40% in the first two decades of life. The exclusion of associated injuries in the Ile-Ife series systematically eliminated most cases arising from stab and gunshot injuries which were likely to involve the mobile bowel or liver. Previous publications on abdominal injuries by Sheshe and Yakubu in Kano, Nigeria, Adejumo et al. in northeast Nigeria, Dongo et al. in Maiduguri, Nigeria, Idriss et al. in Mauritania, and Hady et al. in Poland showed that PAT from gunshot and stab wounds commonly involve the small intestine.
The above observation may partly explain the very high proportions of splenic trauma attributed to RTA in those in the third to sixth decades of life in Ile-Ife. For those in the first two decades of life where activities such as jumping, climbing trees, hills, electric poles, and other heights are more common than older persons, the authors noted that fall from height represented 49% of the isolated splenic injuries, thereby reducing the contribution of RTA to 40%. In the current discourse, the significant contribution of fall from height has been highlighted and this undoubtedly reduced the relative percentage of patients with RTA. Published clinical studies indicate that falls at construction sites of high rising buildings and falls from electricity pole, palm trees, and other economic trees are common among artisans/peasants and often lead to splenic injuries.,,,,
Available evidence from published data showed that abdominal visceral injuries (predominantly spleen and liver) from gunshot injuries are in steady increase in sub-Saharan Africa and other LMICs.,,, The reasons adduced included increases in availability of firearms due to rising civil and military unrest as well as dwindling economy with attendant loss of jobs, displacement at homes, and career termination.,, Armed robbery attacks at homes, workplaces, and highways have been reported to be the most common cause of gunshot injuries in the Sub-Saharan Africa, but in developed countries, gunshot injuries are mostly sustained for homicidal and suicidal reasons.,,, In addition, previous investigators have highlighted the increasing role of terrorists insurgence, herdsmen attacks, communal clashes, hunting expeditions, political thuggery, and shots by law enforcement agents as causes of gunshot injuries that can lead to splenic injuries in developing nations.,,,
Although the rising incidence of splenic trauma in the developing nations has not been matched with similar progress in management, advances in diagnostic imaging have allowed accurate delineation of the grades of injury in a manner that allows an informed decision to be taken.,,, This is usually done in the context of combined diagnostic approach with preoperative clinical assessments playing a major role.,, Classically, the clinical presentations of patients mirror the grades of the injuries and the grades correlate with the mechanism of injury.,, In a referral hospital in Ile-Ife, Nigeria, Akinkuolie et al. reported on a series of 55 patients managed for isolated splenic injuries and found that 24 (72.7%) of 33 patients who had MVA had grade III-IV splenic injuries, while grade I and II injuries, respectively, were reported in the two patients who sustained sports injuries. It has been reported that the force and energy transferred at the time of impact determine the extent of splenic injuries and probably explains why MVA led to higher grades of injury compared to sports injury.,, The above findings conform with our observation that 83.3% of patients with grades III-V injuries had either RTA or gunshot injuries, which further highlights the contribution of trauma mechanism to injury severity. Data from Benin City and Ile-Ife both in Nigeria and Qatar (Middle East) support the above findings.,,
In a municipal hospital in Qatar, Jabbour et al. retrospectively reviewed a large series of 191 cases of blunt splenic injuries over a period of three years and found that 70.5% of the entire patients evaluated in their series had RTA, followed by fall from height (19.5%). The authors found the average mean SBP for grades I-III at presentation was 118.3 ± SD 24.1 compared to 101.4 ± SD 31.5 in grades IV-V injuries (P = 0.001). Similarly, severity of injuries and associated injuries was greater in grades IV-V and resulted in higher mean “injury severity score” (ISS) and abdominal “Abbreviated Injury Scale” (AIS) in grades IV-V injuries (P = 0.001 for both ISS and AIS). Patients with grades IV-V injuries were younger, required more frequent blood transfusions, and were more likely to be FAST-positive compared to grades I-III injuries. The treatment guidelines adopted and mortality profile were equally predicated on the grades. Indeed, NOM was successful in 91.1% of grades I-III, but 26.2% in those with grades IV-V injuries. Mortality rate was 6.7% in grades I-III and 14.3% in grades IV-V. From the foregoing, it is a fact of life that splenic injuries sustained in the setting of high-energy impact mechanisms such as RTA, gunshot, and fall from height are frequently accompanied by high-grade (III-V) and associated splenic injuries akin to reports by Chalya et al. in northwestern Tanzania.
Although ultrasonographic grading of splenic injuries plays an important role in the overall management of trauma patients, the decision to intervene or not lies with the hemodynamic state of the patients., It has been found that FAST is an excellent investigation for hemoperitoneum with a sensitivity of 88%.,,, In the setting of shock with positive FAST, an emergency laparotomy is indicated, but in stable patients, serial ultrasound or CT is helpful in assessing splenic bleeding.,,
Hitherto, splenectomy for control of hemorrhage remained the traditional approach for management of splenic injuries.,,, However, with better understanding of immunological functions of the spleen and further elucidation of the concept of OPSI in splenectomized patients, emphasis shifted toward NOM and procedures that accomplish splenic salvage and preserve the organ's immunologic function when operation cannot be avoided.,,,,
In this series, NOM failed in 11 patients who subsequently received OM giving rise to success rate of 88.8%. Iribhogbe and Okolo in Benin City, Nigeria, Chalya et al. in Bugando Medical Centre, Tanzania, and Weledji in Cameroon, cited global figures of successful NOM varying between 80% and 93%, though the critical determinants of successful NOM in adults remain controversial.,, Nevertheless, it is known that the most important factor for success is appropriate patient selection., In a referral hospital in Benin City, Nigeria, 8 (80%) out of 10 patients that qualified for NOM were successfully managed nonoperatively. Similar to observations in this series, the two patients that failed to respond to NOM in Benin City were due to continued bleeding and peritonitis. Comparable results were reported by investigators in Nigeria,, Qatar, and Tanzania.
In the current report, the main factors that predicted OM included mechanism of injury, long injury-arrival interval, high sonographic grade of injury, and presence of associated abdominal visceral injuries [Table 3]. The splenic salvage rate of 21.2% recorded in this study is comparable to rates of 18.2% documented by Akinkuolie et al. in Ile-Ife and 26.7% reported by Iribhogbe and Okolo in Benin City, both in Nigeria., However, these values are higher than figures of 9.1% quoted by Adejumo et al. in Gombe, Nigeria, and 2.9% cited by researchers from Tanzania. In Gombe, Nigeria, 87.9% of the injuries were sustained through high-energy impact forces from RTA, blasts, gunshot, and fall from height, while over two-thirds of patients had grades III-V splenic injuries. In Bugando, Tanzania, the very low splenic salvage rate may be due to the fact that 89% were due to high-energy force, 81.4% were high grades III-V injuries, and 77.1% had estimated blood loss greater than 1 l at presentation. All penetrating abdominal trauma and splenic trauma with associated intra-abdominal injuries were managed by OM due to frequent association of gut perforation and intraperitoneal soilage. Reports from Benin City and Ile-Ife, both in Nigeria, overlapped with the above findings.,
In the group of patients managed by OM, wound infection was the most common postoperative complication in both splenectomized patients and those that received splenic salvage. Overall, there was a statistically significant difference in the rates of postoperative complications (P = 0.022) and mortality (P = 0.004) between the splenectomized and splenic salvage patients. The explanation for the higher morbidity and mortality rates in total splenectomy patients may be partly due to higher associated intra-abdominal and extra-abdominal injuries in this group of patients akin to observation made in Tanzania.
There was no case of OPSI identified in this study for an unclear reason. However, in a recent review study, Bonanni et al. working in Italy cited a global incidence of OPSI between 0.23% and 0.42% with a lifetime risk of 5%. The authors cited that the risk is higher in splenectomies performed for hematological diseases and malignancies. Reports by Weledji from Camerron in a similar review study and Ioascon et al. in Europe overlapped with the above data. The low incidence of OPSI worldwide, poor adherence to follow-up visits by our patients, and the predilection to childhood, hematological and malignancy-related splenectomy may partly explain why no cases of OPSI was recorded in this study. Although OPSI can occur at any age, children less than 16 years are at greater risk of developing the condition, especially those under the age of 2 years. Therefore, noninclusion of patients less than 16 years in this study may have contributed to the apparent nonobservance of this dangerous complication in this study. Moreover, estimates of the incidences and timing of OPSI vary widely in the literature and some authors reported the greatest risk of developing OPSI in the first 2 years after splenectomy., The above observation may further explain our inability to encounter OPSI during the time of this study since the follow-up period for majority (276, 92.3%) of the survivors in this series was under 2 years when the period of manifestation of OPSI has not elapsed. It is of note that only 23 (7.7%) patients were followed up for up to 2 years despite some having splenectomy early in the study; this is due to abrupt loss from follow-up. These findings suggest that OPSI may not be entirely absent in this cohorts, but more probably insufficient period of follow-up and missed cases may represent the true picture.
Briefly, mortality rates of OPSI range from 50 to 70% despite aggressive therapy, but the most critical action in the treatment is the immediate use of broad-spectrum intravenous antibiotics., In consideration of the foregoing, we offered postvaccination health education in the course of follow-up to all the splenectomized patients (both vaccinated and nonvaccinated) with respect to the risk involved, the need for regular follow-up, the value of early diagnosis and prompt treatment of infection, and the need for compliance with antibiotic and malaria prophylaxis. The need to carry an “identification card” was equally emphasized. In general, postsplenectomy vaccination against encapsulated organisms is highly recommended for all splenectomized patients for trauma; it is administered at least 2 weeks postsplenectomy and revaccination every 5–10 years and additional antibiotic prophylaxis to compensate for the documented occasional vaccination failure.,, However, due to poor adherence to follow-up and vaccine hesitancy demonstrated by some of the patients, time of initiation of immunization and number of vaccines administered in this study varied from one patient to another.
The predictors of morbidity and mortality in OM patients in this study were mostly related to advanced age, comorbidities, associated injuries, and grade III-V splenic injuries, consistent with reports by previous workers.,,,,,, In a referral hospital in Southwest Nigeria, Agbakwuru et al. found that all 8 (11%) patients that died among the 73 patients managed for splenic injuries had associated injuries and that 50.7% of the entire patients presented with grade IV and V splenic injuries. The authors agreed that high degree of associated injuries demands multidisciplinary care and that coordination of facilitated consultation among disciplines will eliminate duplication of theater time and reduce morbidity and mortality rates.
A striking observation is the frequent association between selected clinicopathological parameters (pulse rate, SBP, hourly urine output, abdominal distension, and fever) and grades/severity of splenic injuries. As the grade increases from I to V, there was steady rise in the mean pulse rate, but the rise did not reach statistically significant value (P = 0.058). Similarly, there was a steady increase in the percentages of patients with progressive abdominal distension and fever, but there was no statistically significant difference (P = 0.066 for abdominal distension and P = 0.214 for fever). These observations may be explained by the fact that the ultrasound grading of the splenic injuries missed some injuries and categorized some high-grade (III-V) injuries as low grade and vice versa. Furthermore, this may explain why pulse rate as high as >120b/min was recorded for some cases of grade I-II and rates <90 b/min recorded in some grades IV-V injuries. We made similar observation for SPB and hourly urine output, and in agreement with our colleagues in Ibadan, Nigeria (Afuwape et al.), it is probably the poor performance of ultrasound as a preoperative diagnostic tool that led to the nonuniform pattern of the clinical variables. Nevertheless, we have not dismissed the possibilities of patients with low-grade injuries presenting with life-threatening hypovolemia, especially in those with long injury-arrival time or a setting where patients with grades IV-V injuries are hemodynamically stable probably because a bleeding vessel is sealed by initial clot or temporary localization by omentum. The published clinical data from WSES consensus statement (Coccolini et al.) and Qatar (Jabbour et al.) indicate that the degree of acute hemorrhage and resultant cardiovascular responses are mostly predicated on the grade and severity of splenic injuries, which ranges from parenchymal laceration, through trabecular vessel involvement to hilar avulsion injuries. In summary, we share the views of our colleagues from Benin City (Iribhogbe and Okolo) and Ile-Ife (Akinkuolie et al.), both in Nigeria, Qatar (Jabbour et al.), and Tanzania (Chalya et al.) that hemodynamic instability at admission does not exclusively predict high-grade splenic rupture, but may be prominent in low-grade (I-II) injuries.
Rising pulse rates and decreasing hourly urine output are therefore compensatory efforts to maintain internal hemostasis and raise the diminishing SBP. In an abdominal trauma patient, progressive abdominal distension and appearance of peritonitis are ominous signs that should not be neglected as they often point to entities such as significant hemoperitoneum, secondary peritonitis (from gross intraperitoneal fecal or urinary contamination), pneumoperitoneum, or in extreme cases, abdominal compartment syndrome (ACS) from a retinue of causes including overzealous fluid therapy. In principle and practice, hemodynamic instability and peritonitis constitute the trigger for emergency laparotomy regardless of the grade of the splenic injury.,,,,, Nevertheless, in settings where interventional radiology services are readily available, selected cases of isolated splenic injuries with hemodynamic instability can be managed by angioembolization or argon laser coagulation., However, in our environment with no interventional radiology, we adopted the protocol of mandatory exploratory laparotomy in hemodynamically unstable patients, consistent with reports by Iribhogbe and Okolo in Benin City, Nigeria, and Chalya et al. in Tanzania.
Ultrasound grading of splenic injuries was grossly deficient in this study. We found that undergrading was more common with high grade (III-V) than low-grade (I-II) splenic injuries. Similarly, overgrading was more common with low-grade (I-II) injuries [Table 4]b. In general, hemoperitoneum is not specific to splenic injuries, and life-threatening visceral bleeding from liver, mesenteric, renal, and vascular injuries of the abdomen has been reported by Dongo et al. and Sheshe and Yakubu, both in northern Nigeria. The high false positive and negative diagnoses created by the use of ultrasound in this study are clinically worrisome due to costly clinical errors that may arise if major clinical decisions were made in the context of sonological assessments alone. Perhaps, false positive diagnoses were high with sonographic assessment due to more differential diagnoses of hemoperitoneum and left upper abdominal mass shadows. Common causes of these false positive diagnoses were bleeding from other solid organs (or mesenteric/vascular injuries) and trauma of contiguous organs (liver, diaphragm, pancreas, stomach, and left colon), leading to perisplenic hematoma. The crux of the matter with high false positive diagnoses include overtreatment in the form of OM in patients who otherwise will have successful NOM or application of invasive diagnostic or therapeutic procedures like angioembolization or diagnostic peritoneal lavage in patients that do not deserve them.
The utilization of ultrasound in preoperative assessment of abdominal trauma patients in this study equally led to high false negative diagnoses. These were contributed by slowly leaking low-grade splenic injuries and missed diagnosis due to predominant features of other solid-organ injuries that overshadowed the ultrasound features of splenic injuries. Unfortunately, false negative diagnosis for splenic trauma especially in hemodynamically unstable patients may lead to delay in operative treatments and subsequent increase in mortality. Indeed, the danger lies with the delay rather than in the operation especially in those with fecal peritonitis and ongoing hemorrhage. Consistent with our experience in this study, investigators from Ile-Ife (Akinkuolie et al.), Benin City (Iribhogbe and Okolo), Gombe (Adejumo et al.), and Ibadan (Afuwape et al.) all in Nigeria expressed concern over deplorable health facilities in their centers and reported that avoidable deaths from delayed treatment and negative laparotomy from overzealous OM have continued to be high due to lack of modern diagnostic imaging studies such as CT scan and MRI. Aside avoiding unnecessary OM, accurate preoperative diagnosis and classification of splenic injury enables splenic preservation in properly selected patients.
The poor performance of ultrasound in this study renders it less reliable when considered alone and this observation mandates combined diagnostic approach in all cases of suspected splenic trauma. These results overlapped with reports by Afuwape et al. from a referral hospital in Ibadan and Adejumo et al. in Gombe, both in Nigeria. Nevertheless, the role of ultrasound in preoperative evaluation of patients with splenic trauma is still relevant in patients with abdominal trauma, especially in rural communities, considering the high cost, often unavailability, and higher radiation dose of CT scan. Moreover, Jabbour et al. in Qatar and Coccolini et al. in WSES publication reported that ultrasound is an important investigative tool in early assessment of both hemodynamically stable and unstable patients due to its portability and ease of execution. In our setting with poor health infrastructure and low HDI, there is a need to improve clinical expertise of surgeons and other clinicians involved in trauma management, especially for the health personnel practicing in district/rural areas.
Aside late presentation and poor performance of ultrasound as a preoperative diagnostic tool, we observed several other impediments to adequate care of the patients in this study. First, the high cost and often unavailability of functional CT services in the hospitals where this study was done limited the accuracy of preoperative assessment of the patients and utilization of NOM. Current updates from a prospective study by Jabbour et al. in Qatar and World Society of Emergency Surgery publication by Coccolini et al. on splenic trauma classification and guidelines for management showed that contrast-enhanced CT scan of the abdomen is the modality of choice for diagnosis and evaluation of splenic injuries in patients that are hemodynamically stable. The published data from many series have reported superior validity test results for CT compared to ultrasound in preoperative assessment of patients with splenic injuries or BAT.,, Second, the unavailability of interventional radiology services in our centers allowed many cases that would have been successfully managed by angioembolization to be treated operatively. Jabbour et al. in Qatar successfully used angioembolization to treat three patients who developed delayed pseudoaneurysm in their series. The authors agree with their colleagues from the World Society of Emergency Surgery that though NOM is usually reserved for low-grade splenic injuries, angioembolization could be considered in hemodynamically stable patients with high-grade (IV-V) splenic injuries in the absence of blush to increase the success rate of NOM., Third, the irregularity in availability of vaccines at the hospitals where this study was done and the bureaucratic bottlenecks needed to vaccinate the patients when vaccines are available hampered the utilization of the postsplenectomy vaccine protocol in this study. It must be emphasized that only 62.4% of the total splenectomized patients were immunized postoperatively mainly due to irregularity in the supply chain of relevant vaccines and drop out from follow-up. Comparable rate (66.7%) of postoperative vaccination against encapsulated organisms was reported by Iribhogbe and Okolo in a single-center study in Benin City, Nigeria. Fourth, the unavailability of functional ICU in two of the hospitals involved in this study and presence of poorly equipped ICU unit in the remaining hospital negatively impacted the overall care of the patients and outcome. Fifth, in our environment, there is no dedicated trauma center and the early measures adopted in the prehospital management protocol and advanced ICU monitoring were all missed in this study. Sixth, poor adherence to follow-up protocol was very prominent in this study. As noted earlier, patients were available for follow-up for a variable period of 1 month to 5 years. Important data on mortality, late complications, and postsplenectomy vaccination records were lost in the group of patients lost to follow-up within few months of follow-up.
Nonavailability of functional CT scan to evaluate majority of the patients posed serious limitation, especially for the NOM cases. A CT scan with intravenous contrast is the single most useful investigation in the hemodynamically stable patient as it can assess for intraperitoneal fluid, solid-organ injury, and retroperitoneal hematoma.
The fact that majority of the patients were followed up for <2 years might have led to missed OPSI and other complications such as incisional hernia or death from infection caused by encapsulated organisms.
Training and retraining of trainee and board-certified surgeon on ultrasound scan is salutary, especially for surgeons practicing in rural setting. A wider coverage of the National Health Insurance Scheme in Nigeria by government and nongovernmental health agencies should be adopted. Increase in national health budget to aid establishment of dedicated trauma centers and provision of CT scan, MRI, vaccines, and interventional radiology facilities cannot be overemphasized.
| Conclusion|| |
BAT remained the most common cause of splenic injuries in our environment and majority of the BAT arose from RTA and fall from heights. Majority had long injury-arrival interval, high-grade splenic injuries, and presented with hemodynamic instability. The incidence of associated injuries was high (45%), and in the group treated by OM, the rate of splenic salvage was relatively low (21.2%). The major limitations of care were from challenges of CT underutilization, poor performance of abdominal ultrasound scan as a preoperative diagnostic tool, unavailability of interventional radiology services, poorly equipped ICU, poor adherence to follow-up programs, and limited vaccination. The mortality rate was more among splenectomized patients compared to splenic salvage and NOM groups. The main predictors of mortality were presence of associated injuries, high-grade splenic injuries, presence of comorbidities, and age above 45 years.
We express our gratitude to the board of consultants, general surgery section of our institution for their understanding, and cooperation throughout the period of this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]