Surgery xxx (2020) 1e7

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Surgery
journal homepage: www.elsevier.com/locate/surg

Increased long-term pneumonia risk for the trauma-related

splenectomized population - a population-based, propensity score
matching study
Hou-Ju Lee, MDa, Chi-Tung Cheng, MDb, Chih-Chi Chen, MDc, Chien-An Liao, MDb,
Shao-Wei Chen, MD, PhDd, Shang-Yu Wang, MDa, Yu-Tung Wu, MDb,
Chi-Hsun Hsieh, MD, PhDb, Chun-Nan Yeh, MDa, Chien-Hung Liao, MD, FACS, FICSb,*
a
Department of General Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
b
Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
c
Departments of Rehabilitation and Physical Medicine, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
d
Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: Background: Splenectomy is the life-saving treatment for high-grade spleen trauma. Splenectomized
Accepted 13 January 2020 patients are at a significant infection risk. However, the trauma-induced splenectomy results in less
Available online xxx incidence of postsplenectomy infection than the hematologic disorder. We conducted a large-scale study
to identify the infection rate and management strategy in trauma-related splenic injuries.
Methods: We included patients with the diagnosis of spleen injury in Taiwan from January 2003 to
December 2013 by using the National Health Insurance Database and divided them into spleen preserved
and splenectomized groups. The demographic factors including age, sex, hospital level, year of injury,
trauma mechanism, associated injuries, whether injury severity score S16, and comorbidities were
extracted. A 1:1 propensity score match was performed, and we analyzed the long-term outcome as the
presence of infection-related disease (septicemia, pneumonia, and meningitis) after spleen trauma. The
multivariate logistic regression analysis was used to identify the risk factor for each outcome.
Results: During the 11 years included in this study, a total of 8,897 patients with spleen trauma were
identified. A total of 3,520 (39.6%) patients were splenectomized, and 5,377 (60.4%) were spleen preserved.
After propensity score matching, 3,099 pairs of patients were enrolled for further analysis. In univariate
analysis, the incidence of pneumonia is significantly higher in the splenectomized group (8.5% vs 7.0%, P ¼
.037). There was no significant difference in septicemia and meningitis between the 2 groups. In multi-
variate analysis, splenectomy is an independent risk factor for pneumonia in long-term follow-up.
Conclusion: Compared with the spleen preserved group, splenectomy is related to an increased likeli-
hood of long-term pneumonia onset but not to an increase in the possibility of other infections.
© 2020 Elsevier Inc. All rights reserved.

Introduction still considered the definite management method for hemostasis

The spleen is one of the viscera that is most commonly injured
as a result of blunt abdominal trauma. The trend of nonoperative
management (NOM) increased at the end of the last century.1e6
However, surgical treatment in the form of a splenectomy was
Hou-Ju Lee and Chi-Tung Cheng contributed equally to this manuscript.
* Reprint requests: Chien-Hung Liao, MD, FACS, FICS, Department of Trauma and
Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung Univer-
sity, Taoyuan, Taiwan.
E-mail address: surgymet@gmail.com (C.-H. Liao).
and for life-saving in cases of massive hemorrhage and patients
with unstable hemodynamics.5e8
The spleen is an immune organ that is essential for the acute
clearance of pathogens from the bloodstream. Splenectomized
patients are at a significant risk of infection because of depressed
phagocytosis, suppressed serum levels of immunoglobulin M, and
environmental changes wherein erythrocytes rid themselves of
solid waste material.9e12 The most common conditions in which
postsplenectomy infection (PSI) takes place are pneumonia and
meningitis.13 The infectious risk varies with the time interval after
splenectomy and the associated comorbidities. The incidence of
infection is highest in the first 2 years after splenectomy (50%e

https://doi.org/10.1016/j.surg.2020.01.006
0039-6060/© 2020 Elsevier Inc. All rights reserved.
2 H.-J. Lee et al. / Surgery xxx (2020) 1e7
75%), with an average interval of 22.6 months, but the risk could
persist throughout life.14 As stated in a previous report, the inci-
dence of PSI is lower in trauma patients than in patients with he-
matologic disorders.10,15 Therefore, trauma-induced splenectomy
should result in fewer PSIs than other etiologies. However, a large-
scale study to identify the infection rate and management strategy
of trauma-related splenic injuries is still required.
In the present study, we used a national health databank to
explore the incidence of PSI and analyzed the risk factors of PSI in
the trauma population.
Materials and methods
Data source
Data for this study were retrieved from the Taiwan National
Health Insurance Research Database (NHIRD). The National Health
Insurance (NHI) program in Taiwan was implemented on March 1,
1995 and covers more than 99% of Taiwan’s residents. All the re-
cords and original claim data for payment purposes at the hospitals
are enrolled in the NHIRD after deidentification and anonymiza-
tion. The database includes all admission records, diagnostic codes,
hospital information, and procedures received by each patient. All
the hospitals and clinics in Taiwan will claim that government
payment depends on the NHI procedure code. To prevent the
improper use of medical resources, there is an independent, peer-
review process to confirm that the procedures’ claim was reason-
able based on medical records. This study was exempt from full
review by the Ethics Institutional Review Board of Chang Gung
Memorial Hospital.
Study population
In this study, all admission records between 1997 and 2013 were
included in the analysis. We identified all patients who were admitted
between January 2003 and December 2011 with a diagnosis of splenic
Fig 1. The flowchart of patient selection and matching.
injury (International Classification of Diseases, Ninth Revision, Clinical
Modification code 865). Patients younger than 18 years or who died
during the index admission period were excluded. All the NHI diag-
nosis codes and procedure codes extracted during the index admission
period were analyzed. The diagnosis codes before and after the index
admission were also analyzed. The definition of the hospital level is
according to the Hospital Accreditation System in Taiwan. The medical
center level is similar to the tertiary trauma center in the United States.
The nonmedical center is a regional hospital which does not fulfill the
criteria of a medical center. Patients who underwent splenectomy
were defined as the splenectomized group; the patients who received
spleen preservation management, including splenorrhaphy, partial
splenectomy, transarterial embolization, and nonoperative treatment
were defined as the spleen-preserved group.
Associated injury, comorbidity, and infectious disease correlations
All major injuries at the index admission were analyzed,
including traumatic brain injury, cardiopulmonary injury, pneu-
mohemothorax, kidney injury, gastrointestinal tract injury, liver
injury, pelvic fracture, femoral fracture, and spine injury. The details
of the injury severity score (ISS) are not recorded in the NHIRD.
However, an ISS greater than 16 is considered a major illness in the
NHI program. Under these circumstances, the patient will be
registered in a catastrophic illness database and provided full
coverage of medical fees related to the episode. The underlying
comorbidity before the index admission was also analyzed,
including diabetes mellitus (DM), coronary artery disease (CAD),
chronic obstructive pulmonary disease (COPD), chronic kidney
disease (CKD), cirrhosis, dialysis, and malignant disease. To evaluate
the susceptibility to infectious disease among postsplenectomy
patients, we evaluated the occurrence of 3 diseases: sepsis, pneu-
monia, and meningitis. The patients admitted owing to any of the
abovementioned diagnoses after 30 days of the index admission
were considered a positive event. The details of the definition for
each diagnosis are listed in Supplementary Table I.
 H.-J. Lee et al. / Surgery xxx (2020) 1e7 3

Table I
Comparison of demographic factors and long-term, infection-related outcomes between splenectomy and spleen-preserving group

Spleen preserving n ¼ 5,377 Splenectomized n ¼ 3,520 P value Smd

Male sex (n, %) 3,764 (70.0) 2,542 (72.2) .026 0.049

Age (median [IQR]) 36.60 [23.96e51.53] 37.53 [24.38e52.76] .069 0.045
Tertiary center (n, %) 2,356 (43.8) 1,119 (31.8) <.001 0.25
Blunt insult (n, %) 5,302 (98.6) 3,437 (97.6) .001 0.071
Initial associated injury
Traumatic brain injury (n, %) 814 (15.1) 577 (16.4) .114 0.034
Cardiopulmonary injury (n, %) 297 (5.5) 164 (4.7) .078 0.039
Pneumohemothorax (n, %) 936 (17.4) 576 (16.4) .204 0.028
Kidney injury (n, %) 662 (12.3) 298 (8.5) <.001 0.126
Gastrointestinal injury (n, %) 296 (5.5) 458 (13.0) <.001 0.261
Liver injury (n, %) 617 (11.5) 418 (11.9) .566 0.012
Pelvic fracture (n, %) 229 (4.3) 123 (3.5) .075 0.04
Femoral fracture (n, %) 203 (3.8) 169 (4.8) .02 0.051
Spine fracture (n, %) 231 (4.3) 100 (2.8) <.001 0.079
ISS >16 (n, %) 797 (14.8) 914 (26.0) <.001 0.279
Comorbidities before injury
DM (n, %) 358 (6.7) 210 (6.0) .199 0.028
CAD (n, %) 145 (2.7) 109 (3.1) .269 0.024
COPD (n, %) 92 (1.7) 75 (2.1) .174 0.031
CKD (n, %) 29 (0.5) 12 (0.3) .202 0.03
Cirrhosis (n, %) 173 (3.2) 163 (4.6) .001 0.073
Dialysis (n, %) 19 (0.4) 8 (0.2) .33 0.023
Malignancy (n, %) 102 (1.9) 41 (1.2) .007 0.06
Year of index injury <.001 0.21
2003 471 (8.8) 464 (13.2)
2004 579 (10.8) 481 (13.7)
2005 593 (11.0) 414 (11.8)
2006 585 (10.9) 387 (11.0)
2007 621 (11.5) 369 (10.5)
2008 591 (11.0) 372 (10.6)
2009 601 (11.2) 355 (10.1)
2010 643 (12.0) 360 (10.2)
2011 693 (12.9) 318 (9.0)
Outcomes
PRBC transfusion (unit, median [IQR]) 2.00 [0.00e4.00] 7.00 [4.00e12.00] <.001 0.721
FFP transfusion (unit, median [IQR]) 0.00 [0.00e0.00] 4.00 [0.00e10.00] <.001 0.431
Hospital LOS (d, median [IQR]) 8.00 [6.00e13.00] 12.00 [8.00e18.00] <.001 0.336
ICU LOS (d, median [IQR]) 2.00 [0.00e3.00] 3.00 [1.00e6.00] <.001 0.312
Ventilator d (d, median [IQR]) 0.00 [0.00e0.00] 2.00 [0.00e4.00] <.001 0.154
Follow-up infection-related admissions
Late sepsis episode (%) 64 (1.2) 44 (1.2) .843 0.005
Late pneumonia episode (%) 329 (6.1) 304 (8.6) <.001 0.096
Late meningitis episode (%) 20 (0.4) 17 (0.5) .501 0.017

CKD, chronic kidney disease; FFP, frozen fresh plasma; ICU, intensive care unit; IQR, interquartile range; LOS, length of hospital stay;
PRBC, packed red blood cell; Smd, standardize mean difference.

Statistical analysis underwent splenectomy, and 60.5% of patients received spleen-

All analyses were performed using R (v3.4.1) with the basic li-
brary and the “Matchit,” “finalfit,” and “survminer” packages (R
Foundation for Statistical Computing, Vienna, Austria). Continuous
variables were analyzed by the Kruskal-Wallis rank-sum test, and
categorical variables were analyzed by c2 tests. To balance the
confounding effect of immunity status related to demographic
factors, including age, sex, hospital level, year of injury, trauma
mechanism, associated injuries, ISS 16, and comorbidities, we use
propensity score matching (PSM), including all the above factors, to
create a 1:1 cohort to compare the major outcomes. The standard
mean difference was used to evaluate the quality of the PSM result.
Multivariate logistic regression was used to evaluate the risk factors
for each complication. The cumulative risk for pneumonia was also
evaluated with the Cox proportional hazard model, and P values
<.05 were considered statistically significant.
Results
A total of 8,897 patients suffered from a splenic injury during the
study period in Taiwan, as shown in Fig 1. A total of 39.5% of patients
preserving treatment after spleen injury. Within the spleen-
preserved group, most of the patients received nonoperative
treatment. A total of 6.9% of the patients received splenorrhaphy and
partial splenectomy. The basic demographic data of patients in the
splenectomized and spleen-preserved groups are shown in Table I. We
found a decreasing number of splenectomies by year. Compared with
the spleen-preserved group, we found that splenectomy patients had
a male sex predominance, older age, and received treatment in
nonmedical centers. The rates of kidney disease, gastrointestinal tract
injury, femur fracture, and ISS >16 were higher in the splenectomized
group than in the spleen-preserved group. Underlying liver cirrhosis
and malignancy led to a higher incidence of splenectomy (4.6% vs 3.2%,
P ¼ .001). However, there were no differences in DM, CAD, COPD,
chronic kidney disease, or dialysis between the groups. The splenec-
tomy rate decreased significantly each year. At the index admission,
the splenectomy group had a higher rate of blood transfusion, longer
hospital and intensive care unit stays, and more ventilator days. The
overall survival showed a hazard ratio of 1.14 (0.99e1.31, P ¼ .059) for
splenectomy in the multivariate Cox proportional hazard model. The
median follow-up time was 5.97 years (interquartile range 3.7e8.4
years). During the follow-up, the splenectomy group had a
4 H.-J. Lee et al. / Surgery xxx (2020) 1e7

Table II
Comparison of demographic factors and long-term, infection-related outcomes between splenectomy and spleen-preserving group
after PSM

Spleen preserving n ¼ 3,099 Splenectomized n ¼ 3,099 P value Smd

Male sex (%) 2,221 (71.7) 2,209 (71.3) .757 0.009

Age (median [IQR]) 37.68 [24.40e51.43] 37.25 [24.22e52.67] .846 0.007
Tertiary center (n, %) 1,059 (34.2) 1,065 (34.4) .894 0.004
Blunt trauma (%) 3,037 (98.0) 3,034 (97.9) .858 0.007
Initial associated injury
Traumatic brain injury (n, %) 484 (15.6) 494 (15.9) .754 0.009
Cardiopulmonary injury (n, %) 154 (5.0) 147 (4.7) .723 0.011
Pneumohemothorax (n, %) 519 (16.7) 509 (16.4) .759 0.009
Kidney injury (n, %) 258 (8.3) 277 (8.9) .416 0.022
GI injury (n, %) 261 (8.4) 274 (8.8) .587 0.015
Liver injury (n, %) 373 (12.0) 359 (11.6) .609 0.014
Pelvic fracture (n, %) 105 (3.4) 109 (3.5) .835 0.007
Femoral fracture (n, %) 147 (4.7) 138 (4.5) .628 0.014
Spine fracture (n, %) 84 (2.7) 95 (3.1) .448 0.021
ISS >16 (%) 641 (20.7) 649 (20.9) .827 0.006
Comorbidities before injury
DM (n, %) 185 (6.0) 190 (6.1) .831 0.007
CAD (n, %) 92 (3.0) 92 (3.0) 1.000 <0.001
COPD (n, %) 60 (1.9) 62 (2.0) .927 0.005
CKD (n, %) 13 (0.4) 12 (0.4) 1.000 0.005
Cirrhosis (n, %) 132 (4.3) 134 (4.3) .950 0.003
Dialysis (n, %) 7 (0.2) 8 (0.3) 1.000 0.007
Cancer (n, %) 43 (1.4) 39 (1.3) .739 0.011
Year of index injury .990 0.033
2003 371 (12.0) 369 (11.9)
2004 418 (13.5) 407 (13.1)
2005 369 (11.9) 362 (11.7)
2006 339 (10.9) 342 (11.0)
2007 339 (10.9) 331 (10.7)
2008 337 (10.9) 339 (10.9)
2009 315 (10.2) 332 (10.7)
2010 304 (9.8) 323 (10.4)
2011 307 (9.9) 294 (9.5)
Outcomes
PRBC transfusion (unit, median [IQR]) 2.00 [0.00e4.00] 6.00 [4.00e12.00] <.001 0.618
FFP transfusion (unit, median [IQR]) 0.00 [0.00e0.00] 4.00 [0.00e10.00] <.001 0.356
Hospital LOS (d, median [IQR]) 9.00 [6.00e14.00] 11.00 [8.00e18.00] <.001 0.252
ICU LOS (d, median [IQR]) 2.00 [0.00e4.00] 3.00 [1.00e6.00] <.001 0.226
Ventilator d (d, median [IQR]) 0.00 [0.00e0.00] 1.00 [0.00e4.00] <.001 0.155
Follow-up infection-related admissions
Late sepsis episode (%) 41 (1.3) 40 (1.3) 1.000 0.003
Late pneumonia episode (%) 218 (7.0) 263 (8.5) .037 0.054
Late meningitis episode (%) 8 (0.3) 16 (0.5) .152 0.042

CKD, chronic kidney disease; FFP, frozen fresh plasma; GI, gastrointestinal; ICU, intensive care unit; IQR, interquartile range; LOS,
length of hospital stay; PRBC, packed red blood cell; Smd, standardize mean difference.

significantly higher incidence of pneumonia (8.6% vs 6.1%, P .001) but
a similar incidence of sepsis (1.2% vs 1.2%, P ¼ .843) and meningitis
(0.5% vs 0.4%, P ¼ .501) compared with the rates in the spleen-
preserving group.
We use PSM to eliminate the possible confounding factors for long-
term, infection-related complication risks to create a 1:1 PSM cohort.
The matching result and comparison of the outcomes are shown in
Table II. Each group included 3,099 patients, and the characteristics of
the initial severity of injury and comorbidities were balanced after
PSM. For the outcome of index admission of the injury episode, the
rates of blood transfusion, length of hospital stay, length of intensive
care unit stay, and number of ventilator days were significantly higher
in the splenectomized group. The late sepsis rate and meningitis rate
were similar between the 2 groups. However, a higher pneumonia rate
was found in the splenectomized group (8.5% vs 7.0%, P ¼ .037).
pneumonia occurrence after traumatic spleen injury, as shown in
Table III. We discovered that male sex, older age, splenectomy,
traumatic brain injury, DM, CAD, COPD, dialysis, cirrhosis, and
malignancy were significant risk factors for pneumonia in both
univariable and multivariable analyses. Splenectomy could be
recognized as an independent risk factor for late pneumonia after
traumatic spleen injury. The multivariable cumulative risk analysis
showed that the hazard ratio of pneumonia for the 40- to 65-year-
old age group was 2.13 (95% confidence interval [CI], 1.68e2.70,
P < .001), and that of the >65-year-old age group was 7.75 (95% CI,
6.01e9.99, P < .001) compared with the patients who were <40
years old. Among all the associated injuries, only traumatic brain
injury showed an increased hazard ratio for pneumonia (1.56, 95%
CI, 1.25e1.95, P < .001). For splenectomized patients, the hazard
ratio for pneumonia was 1.24 (95% CI, 1.04e1.49, P ¼ .019), and the
adjusted cumulative incidence plot is presented in Fig 2.

Follow-up
We further categorized the matched 6,198 patients into pneu-
monia and pneumonia-free groups according to long-term follow-
up results to determine the possible risk factors for long-term
Discussion
Postsplenectomy infection is always a critical issue in patients
who have undergone splenectomy, whether owing to medical
 H.-J. Lee et al. / Surgery xxx (2020) 1e7 5

Table III
Risk factors of long-term pneumonia occurrence after traumatic spleen injury

Pneumonia n ¼ 481 No pneumonia n ¼ 5,717 OR (univariable) P value OR (multivariable) P value

Sex
Male 365 (75.9) 4,065 (71.1) - -
Female 116 (24.1) 1,652 (28.9) 0.78 (0.63e0.97) .026 0.63 (0.49e0.79) <.001
Age
40 122 (25.4) 3,257 (57.0) - -
41e65 175 (36.4) 1,997 (34.9) 2.34 (1.85e2.97) <.001 2.10 (1.64e2.69) <.001
>65 184 (38.3) 463 (8.1) 10.61 (8.29e13.63) <.001 8.43 (6.40e11.15) <.001
Hospital level (%)
Tertiary center 157 (32.6) 1,967 (34.4) - -
Nonmedical center 324 (67.4) 3,750 (65.6) 1.08 (0.89e1.32) .433 1.01(0.81e1.25) .957
Splenectomy 263 (54.7) 2,836 (49.6) 1.23 (1.02e1.48) .033 1.23(1.01e1.50) .043
Initial associated injury
Traumatic brain injury (%) 106 (22.0) 872 (15.3) 1.57 (1.25e1.96) <.001 1.70 (1.32e2.17) <.001
Cardiopulmonary injury (%) 17 (3.5) 284 (5.0) 0.70 (0.41e1.12) .162 0.72 (0.41e1.19) .225
Pneumohemothorax (%) 72 (15.0) 956 (16.7) 0.88 (0.67e1.13) .321 0.77 (0.58e1.03) .083
Kidney injury (%) 26 (5.4) 509 (8.9) 0.58 (0.38e0.86) .009 0.77 (0.49e1.15) .217
GI tract injury (%) 40 (8.3) 495 (8.7) 0.96 (0.67e1.32) .797 0.92 (0.63e1.31) .658
Liver injury (%) 49 (10.2) 683 (11.9) 0.84 (0.61e1.12) .251 1.03 (0.73e1.41) .874
Pelvic fracture (%) 10 (2.1) 204 (3.6) 0.57 (0.28e1.03) .090 0.58 (0.27e1.10) .120
Femur fracture (%) 18 (3.7) 267 (4.7) 0.79 (0.47e1.25) .352 1.00 (0.58e1.64) .986
Spine fracture (%) 14 (2.9) 165 (2.9) 1.01 (0.55e1.69) .975 1.12 (0.59e1.96) .717
ISS >16 (%) 103 (21.4) 1,187 (20.8) 1.04 (0.83e1.30) .736 1.14 (0.87e1.49) .340
Comorbidities before injury
DM (%) 82 (17.0) 293 (5.1) 3.80 (2.90e4.94) <.001 1.54 (1.13e2.08) .005
CAD (%) 54 (11.2) 130 (2.3) 5.44 (3.87e7.53) <.001 1.57 (1.06e2.29) .023
COPD (%) 38 (7.9) 84 (1.5) 5.75 (3.84e8.48) <.001 1.64 (1.04e2.53) .030
CKD (%) 11 (2.3) 14 (0.2) 9.53 (4.21e21.07) <.001 2.24 (0.77e6.14) .124
Cirrhosis (%) 51 (10.6) 215 (3.8) 3.04 (2.18e4.15) <.001 2.00 (1.39e2.83) <.001
Dialysis (%) 8 (1.7) 7 (0.1) 13.80 (4.93e39.51) <.001 4.28 (1.15e16.25) .029
Malignancy (%) 24 (5.0) 58 (1.0) 5.12 (3.10e8.22) <.001 1.83 (1.05e3.10) .029

CKD, chronic kidney disease; GI, gastrointestinal; IQR, interquartile range; OR, odds’ ratio.

diseases or trauma.12,15,16 Even increasing the application of NOM,
splenectomy continues to be the most common way to manage
hemodynamically unstable patients with splenic injury.5e8,17 In this
cohort, we still had almost 40% of splenic trauma patients who
required salvage splenectomy. Compared with the spleen-
preservation patients, the incidence of long-term pneumonia was
significantly higher in the patients who underwent splenectomy.
Unlike other studies, 4,15,17 we found that splenectomized patients
did not have a higher occurrence rate of long-term meningitis and
sepsis. A previous cohort study paired trauma-related splenectomy
patients with patients receiving laparotomy without splenectomy
and demonstrated more early postoperative infections in the
splenectomized group, and most of the infections were pneu-
monia.18 We found a comparable result in our study.
Pneumonia after severe trauma is a common early complication,
especially in ventilated patients.12,16,17 Multiorgan injury will
induce systemic inflammation responses, and lung contusion will
become a risk factor for further secondary infection.19 In addition,
the neuronal deficits after a related brain injury, including altered
mental status, dysphagia, inability to clear secretion, and impaired
cough function, could also be risk factors that induce pneumonia
after a trauma event.20 In our data, we identified age, male sex,
underlying immunocompromised status (DM, cirrhosis, and ma-
lignancy), accompanying brain injury, and splenectomy as risk
factors for postsplenectomy pneumonia. Although those risk fac-
tors might occur at the same time, splenectomy is still an inde-
pendent factor for long-term pneumonia. Compared with previous
studies, the incidence of PSI in our study was lower than that in
other studies. This finding might be related to the etiology of
splenectomy. Splenectomy performed for a hematological disease
appears to carry a higher risk than splenectomy performed as a
result of trauma.13,15,21 Unlike patients with other etiologies,
trauma-related patients might have better immunity and
decreased comorbidity; therefore, a lower PSI rate was noted.13
Because our patient cohort was trauma-based, the lower PSI in
our study could be expected. Some authors advocated that emer-
gency splenectomy is associated with an excessive risk of acute
infection during the early postoperative period compared with that
associated with emergency laparotomy without splenectomy or
elective splenectomy.22 In our data, we did not focus on early,
infection-related complications postsplenectomy, but we believe
that trauma-related splenectomy results in fewer infection epi-
sodes. It is well accepted that PSI mostly occurs within the first 2
years after the operation, but up to a third of PSIs may occur at least
5 years later,23 regardless of the indication for splenectomy.18 There
was 1 fulminating infection case reported more than 20 years after
splenectomy.23 To compare with other studies, we identified that
the risk of PSI decreased after the improvement of antibiotics and
the knowledge of the immune function of the spleen. Furthermore,
the trend toward NOM and increasing application of transcatheter
arterial embolization (TAE) with greater preservation of spleen
function also reduces the possibility of PSI and overwhelming PSI in
the current trauma setting.
Another issue that has been raised is that TAE may have some
undesirable complications, such as rebleeding, abscess formation,
splenic infarction, and coil migration. The complication rate is re-
ported to be as high as 32%, but it does not appear to affect the
overall salvage rate. Among the complications, significant splenic
infarction after TAE is quite common. Most of these infarctions
were asymptomatic, but they could potentially increase the risk of
PSI.24 We did not have evidence to support this point, but there is
no apparent trend found to indicate that TAE will increase PSI in our
data. It is well known that splenectomized patients have an
increased risk of infections with gram-positive encapsulated bac-
teria, including Streptococcus pneumoniae, Neisseria meningitides,
and Haemophilus influenza type B. Currently, there are already
6 H.-J. Lee et al. / Surgery xxx (2020) 1e7

Fig 2. (A) The cumulative pneumonia risk curve regarding age groups adjusted by sex. (B) The cumulative pneumonia risk curve regarding initial traumatic brain injury adjusted by
sex and age. (C) The unadjusted cumulative pneumonia risk curve regarding spleen condition. (D) The cumulative pneumonia risk curve regarding initial traumatic brain injury
adjusted by sex, age, associated injuries, and comorbidities. TBI, traumatic brain injury.

many protocols of standard care for postsplenectomy immuniza-
tion and prophylactic antibiotic treatment.25
Although our study is a national cohort that presented a
noticeable increase in NOM for spleen injuries, there are still lim-
itations associated with studies using nationwide International
Classification of Diseases, Ninth Revision databases. First, we could
not obtain some detailed information from the database that would
be needed for a thorough analysis. For example, several articles
described that the utilization of TAE increased the success rate of
NOM after spleen injury. However, TAEs applied for all anatomical
sites share the same procedure code, so we cannot analyze pre-
cisely the trend of interventional angiography for splenic injuries in
our article. Second, we could not obtain information on splenic
injury severity from our NHIRD database, and it could not be pre-
dicted by anatomic injury score or ISS score. Therefore, we could
not identify the relationship between grades of spleen injury and
postsplenectomy pneumonia occurrence. Third, there are no or-
ganism results included in the national health data registration, so
we could not identify the common organisms that induce post-
splencetomy pneumonia or sepsis. Fourth, we could not identify
the medication used or the number of vaccinations administered
after splenectomy. The immunization status is a major limitation
owing to the characteristics of the NHIRD database. Because the
splenectomy status is not included in the indication for pneumo-
coccal vaccination in Taiwan National Health Insurance, patients
had to pay by commercial insurance or out of pocket. Consequently,
 H.-J. Lee et al. / Surgery xxx (2020) 1e7
those vaccination records are not included in this database.
Although the guidelines from the Centers for Disease Control and
Prevention and trauma academic society advised that all patients
who received splenectomy be vaccinated, the trauma patients had
poor adherence to vaccination, especially when the insurance did
not cover the vaccination. Tristan et al showed that trauma sur-
geons tended to immunize their patients after splenectomy. How-
ever, a wide range of adaption to the Centers for Disease Control
and Prevention guidelines was also noted.26 Therefore, we are not
able to compare the effect of vaccination on PSI in the study.
Despite these limitations, the strengths of our study provide a
significant contribution to the analysis of PSI outcomes in trauma-
related splenectomy in modern medical society.
In conclusion, our study found a decreasing trend of splenec-
tomy as the treatment for splenic trauma and a decreasing
incidence of PSI. Splenectomy is related to an increased likelihood
of long-term postsplenectomy pneumonia but no increases in the
rates of sepsis or meningitis or effects on final prognosis.
Funding/Support
No funding was received for this work.
Conflict of interest/Disclosure
None.
Acknowledgments
The authors thank Chang Gung Memorial Hospital, Linkou,
Taiwan (grant number CMRPG3J0631) for support of the system of
data storage and distribution.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at https://doi.org/10.1016/j.surg.2020.
01.006.
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