Complex design of surgical instruments as barrier for cleaning effectiveness, favouring biofilm formation.

BACKGROUND: Inadequately reprocessed reusable surgical instruments (RSIs) may harbour infectious agents which may then be transferred to a suitable site for replication. AIM: To determine the cumulative effect of 20 cycles of contamination, cleaning (manual or manual followed by automated) and steam sterilization on high-complex-design RSIs used for orthopaedic surgery. METHODS: New flexible medullary reamers and depth gauges were contaminated by soaking in tryptone soya broth, containing 5% sheep blood and 109 cfu/mL of Staphylococcus aureus (ATCC 25923), for 5 min. To mimic a worse-case scenario, RSIs were dried 7 h and subjected to either (a) rinsing in distilled water, (b) manual cleaning or (c) manual plus automated cleaning (reference standard), and steam sterilization. The contamination, cleaning, and sterilization cycle was repeated 20 times. Adenosine triphosphate (ATP) was measured after cleaning procedures; microbial load and residual protein were measured following the 10th and 20th reprocessing, in triplicate. Scanning electron microscopy (SEM) was used to confirm soil and biofilm presence on the RSIs after the 20th reprocessing. FINDINGS: Manual and manual plus automated cleaning significantly reduced the amount of ATP and protein residues for all RSIs. Viable bacteria were not detected following sterilization. However, SEM detected soil after automated cleaning, and soil, including biofilms, after manual cleaning. CONCLUSION: Soil and/or biofilms were evident on complex-design RSIs following 20 cycles of contamination and reprocessing, even using the reference standard method of cleaning. Although the depth gauges could be disassembled, biological residues and biofilm accumulated in its lumen. The current design of these RSIs prevents removal of all biological soil and this may have an adverse effect on patient outcome.

Effect of disinfectant formulation and organic soil on the efficacy of oxidizing disinfectants against biofilms.

BACKGROUND: Biofilms that develop on dry surfaces in the healthcare environment have increased tolerance to disinfectants. This study compared the activity of formulated oxidizing disinfectants with products containing active ingredients against Staphylococcus aureus dry-surface biofilm (DSB) alone. METHODS: DSB was grown in the CDC bioreactor with alternating cycles of hydration and dehydration. Disinfectant efficacy was tested before and after treatment with neutral detergent for 30 s, and in the presence or absence of standardized soil. Biofilms were treated for 5 min with peracetic acid (Surfex and Proxitane), hydrogen peroxide (Oxivir and 6% H2O2 solution) and chlorine (Chlorclean and sodium dichloroisocyanurate tablets). Residual biofilm viability and mass were determined by plate culture and protein assay, respectively. FINDINGS: Biofilm viability was reduced by 2.8 log10 for the chlorine-based products and by 2 log10 for Proxitane, but these products failed to kill any biofilm in the presence of soil. In contrast, Surfex completely inactivated biofilm (6.3 log10 reduction in titre) in the presence of soil. H2O2 products had little effect against DSB. Biofilm mass removed in the presence and absence of soil was <30% by chlorine and approximately 65% by Surfex. Detergent treatment prior to disinfection had no effect. CONCLUSION: The additives in fully formulated disinfectants can act synergistically with active ingredients, and thus increase biofilm killing whilst decreasing the adverse effect of soil. It is suggested that purchasing officers should seek efficacy testing results, and consider whether efficacy testing has been conducted in the presence of biological soil and/or biofilm.

Breast Implant-Associated Anaplastic Large Cell Lymphoma.

PURPOSE OF REVIEW: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a recently recognised malignancy of T lymphocytes exclusively associated with textured breast implants. This review aims to evaluate existing theories regarding the epidemiology, pathogenesis, clinical evaluation and management of the disease. RECENT FINDINGS: The true incidence of BIA-ALCL is difficult to define. Prevailing pathogenic theories recognise the interplay between textured implants, Gram-negative bacteria, host genetics (e.g. JAK/STAT, p53) and time. Patients typically present with a delayed seroma and less commonly with a capsular mass or systemic disease at an average of 8-10 years after implantation. BIA-ALCL staging has evolved from a "liquid tumour" model to a "solid tumour" classification. For localised disease, surgery involving complete capsulectomy and implant removal is the cornerstone of treatment. For more advanced disease, treatment includes surgery followed by chemotherapy (combination anthracycline-based), radiotherapy and the antibody drug conjugate (brentuximab vedotin). The interplay between the Gram-negative biofilm, implant texturing, genetic mutations and time has been implicated in pathogenesis of BIA-ALCL. The identification of a putative infectious cause is not unique to lymphomagenesis. Future research, investigating BIA-ALCL genetic mutations and immunological modulation with Gram-negative biofilm in BIA-ALCL models is warranted.

Transfer of dry surface biofilm in the healthcare environment: the role of healthcare workers' hands as vehicles.

BACKGROUND: Dry surface biofilms (DSBs) persist for extended periods in hospital, and may play a significant role in transmission of healthcare-associated infections. AIM: To determine whether DSBs may be transferred from hospital surfaces to healthcare workers' hands. METHOD: Twelve-day Staphylococcus aureus DSB was grown on polycarbonate and glass coupons in a CDC Biofilm Reactor®. A total of 1.8 × 106 and 8.8 × 105 bacteria grew on the polycarbonate and glass coupons respectively. Transmission was tested by lifting the coupon with forefinger and thumb of ungloved hands to a height of 30 cm, then touching horse blood agar (HBA) plates 19 sequential times. Transferred bacterial number was determined by colony-forming units. The effect of DSB wetting on biofilm transfer was tested with 5% neutral detergent treatment for 5 s. FINDINGS: Between 5.5 and 6.6% of the DSB bacteria were transferred to hands with one touch and ∼20% were then transferred to HBA with one touch, giving an overall transfer rate of 1.26% and 1.04% for polycarbonate and glass coupons, respectively. Detergent treatment had little effect on bacterial removal from coupons, but, for biofilm grown on polycarbonate, significantly increased transferral to HBA (P < 0.001) to 5.2%. Large numbers of bacteria were transferred by bare hands to multiple fomites. One-third of polycarbonate coupons transferred >1000 colonies during the first five sequential touches. Sufficient bacteria to cause infection were transmitted up to 19 times following one touch of the DSB. CONCLUSION: DSB bacteria are transferred by hands from one fomite to multiple fomites, suggesting that DSB may serve as a persistent environmental source of pathogens.

Staphylococcus aureus dry-surface biofilms are more resistant to heat treatment than traditional hydrated biofilms.

BACKGROUND: The importance of biofilms to clinical practice is being increasingly realized. Biofilm tolerance to antibiotics is well described but limited work has been conducted on the efficacy of heat disinfection and sterilization against biofilms. AIM: To test the susceptibility of planktonic, hydrated biofilm and dry-surface biofilm forms of Staphylococcus aureus, to dry-heat and wet-heat treatments. METHODS: S. aureus was grown as both hydrated biofilm and dry-surface biofilm in the CDC biofilm generator. Biofilm was subjected to a range of temperatures in a hot-air oven (dry heat), water bath or autoclave (wet heat). FINDINGS: Dry-surface biofilms remained culture positive even when treated with the harshest dry-heat condition of 100°C for 60min. Following autoclaving samples were culture negative but 62-74% of bacteria in dry-surface biofilms remained alive as demonstrated by live/dead staining and confocal microscopy. Dry-surface biofilms subjected to autoclaving at 121°C for up to 30min recovered and released planktonic cells. Recovery did not occur following autoclaving for longer or at 134°C, at least during the time-period tested. Hydrated biofilm recovered following dry-heat treatment up to 100°C for 10min but failed to recover following autoclaving despite the presence of 43-60% live cells as demonstrated by live/dead staining. CONCLUSION: S. aureus dry-surface biofilms are less susceptible to killing by dry heat and steam autoclaving than hydrated biofilms, which are less susceptible to heat treatment than planktonic suspensions.

Determination of bacterial species present in biofilm contaminating the channels of clinical endoscopes.

BACKGROUND: Outbreaks of endoscopy-related Carbapenem-resistant Enterobacteriaceae has highlighted failures in endoscope decontamination resulting in biofilm formation. Biofilms are tolerant to detergents and disinfectants. We evaluated decontaminated endoscope channels for residual bacterial contamination and biofilm presence. METHODS: 64 channels were collected from 12 gastroscopes and 11 colonoscopes. Aerobic bacteria were isolated from inside the endoscope tubing by scrapping, sonication, and aerobic plate culture. Total number of contaminating bacteria was determined by quantitative real-time PCR with 16s rRNA eubacterial universal primers. Microbial diversity was assessed using next generation DNA sequencing. Biofilm presence was visually confirmed by confocal laser scanning and scanning electron microscopy. RESULTS: 47% of channels were culture positive, with α-haemolytic Streptococci from gastroscopes and coliforms from colonoscopes the most frequently isolated species. Sphingomonas spp., Staphylococcus spp., Streptococcus spp., and Pseudomonas aeruginosa were also isolated. An average of 1.2 × 103 bacteria/cm contaminated air-water channels, 2.8 × 102 and 6.6 × 102 bacteria/cm contaminated gastroscope and colonoscope working channels, respectively. Biofilm was on all 39 channels examined and was principally composed of environmental bacteria, although all samples contained potential pathogens. CONCLUSION: Biofilm is present on many endoscope channels obtained from Australian hospitals. Any soil including biofilm can compromise disinfectant action.

Effect of hand hygiene and glove use on cleanliness of reusable surgical instruments.

BACKGROUND: During functionality testing and packaging of reusable surgical instruments (RSI) for sterilization, instruments are frequently touched. There is a lack of standards relating to hand hygiene frequency and use of gloves in the sterilizing service unit packing area. AIM: To determine the effect of hand hygiene and glove use on maintenance of RSI cleanliness. METHODS: Following manual and automated cleaning, Halsted-mosquito forceps were assessed for adenosine triphosphate (ATP), protein and microbial contamination after handling with gloved and ungloved but washed hands using an ATP surface swab test, bicinchoninic acid assay, and standard culture plate/broth, respectively. Gram's stain was used to classify the isolates. RSI contamination was assessed immediately following and 1, 2, and 4 h after washing hands. FINDINGS: Packing instruments with hands that had been unwashed for 2 or 4 h resulted in a significant increase in contaminating ATP when compared with all other treatment groups (P < 0.05). There was a significant correlation between the time since washing hands, the amount of ATP (r = 0.93; P ≤ 0.001), and the microbial load (r = 0.83; P ≤ 0.001) contaminating the forceps, where the longer the time the hands remained unwashed the higher the contamination. Significantly more contaminating protein was found on forceps handled with ungloved hands that had not been washed for 2 or 4 h (P < 0.001). CONCLUSION: Critical RSI inspection, assembling, lubricating and packing should be performed using either gloves or within 1 h of washing hands.

Intensive care unit environmental surfaces are contaminated by multidrug-resistant bacteria in biofilms: combined results of conventional culture, pyrosequencing, scanning electron microscopy, and confocal laser microscopy.

BACKGROUND: Hospital-associated infections cause considerable morbidity and mortality, and are expensive to treat. Organisms causing these infections can be sourced from the inanimate environment around a patient. Could the difficulty in eradicating these organisms from the environment be because they reside in dry surface biofilms? AIM: The intensive care unit (ICU) of a tertiary referral hospital was decommissioned and the opportunity to destructively sample clinical surfaces was taken in order to investigate whether multidrug-resistant organisms (MDROs) had survived the decommissioning process and whether they were present in biofilms. METHODS: The ICU had two 'terminal cleans' with 500 ppm free chlorine solution; items from bedding, surrounds, and furnishings were then sampled with cutting implements. Sections were sonicated in tryptone soya broth and inoculated on to chromogenic plates to demonstrate MDROs, which were confirmed with the Vitek2 system. Genomic DNA was extracted directly from ICU samples, and subjected to polymerase chain reaction (PCR) for femA to detect Staphylococcus aureus and the microbiome by bacterial tag-encoded FLX amplicon pyrosequencing. Confocal laser scanning microscopy (CLSM) and scanning electron microscopy (SEM) were performed on environmental samples. FINDINGS: Multidrug-resistant bacteria were cultured from 52% (23/44) of samples cultured. S. aureus PCR was positive in 50%. Biofilm was demonstrated in 93% (41/44) of samples by CLSM and/or SEM. Pyrosequencing demonstrated that the biofilms were polymicrobial and contained species that had multidrug-resistant strains. CONCLUSION: Dry surface biofilms containing MDROs are found on ICU surfaces despite terminal cleaning with chlorine solution. How these arise and how they might be removed requires further study.

Outcome measurements in wound healing are not inclusive: a way forward.

Standardized outcome measurement in wound healing has been an elusive goal. Whilst research into wound healing science and technology continues to progress rapidly, the lack of a uniform outcome assessment is making comparative analysis of results difficult. This paper seeks to outline the reported clinical, physiological, and histological outcomes that have been utilized in the literature. A minimal data set base for wound outcome evaluation is also established to be validated by future multivariate analysis of patient data.

The management of life-threatening haemorrhage following blunt facial trauma.

Life-threatening bleeding is uncommon following blunt facial trauma. There have been few reports in the literature describing its optimal management and a clear approach to treatment is yet to be defined. Reported strategies for control of facial haemorrhage include oro-nasal packing, external carotid artery ligation, transantral ligation of the internal maxillary artery, maxillary reduction and angiographic embolisation. Advances in angiography and selective vessel embolisation have made this the treatment of choice in cases of bleeding following penetrating facial injury. Its use in the management of bleeding following blunt facial trauma is unclear. The combined experience of the facial trauma teams at Harborview Hospital, Seattle, USA and Liverpool Hospital, Sydney, Australia yielded four cases of severe life-threatening haemorrhage following blunt trauma that underwent angiography. The roles of various management strategies were evaluated to generate a preferred management pathway in treating severe bleeding following blunt facial trauma.

Long term follow-up of composite non-vascularized toe phalanx transfers for aphalangia.

The results of 21 non-vascularized toe phalanx transfers in 13 patients were reviewed radiologically with respect to function, physeal patency, growth and donor site morbidity at a mean follow-up of 7.4 (range 2.9-13.6) years. Physeal patency was maintained in 4 of 18 surviving transfers. The length of the transferred phalanx averaged 75% of the contralateral comparable toe phalanx and 44% of the contralateral digit proximal phalanx. Most patients had good or simple use of the hand with active joint motion. There was universal shortening of the donor toe with hypoplasia of the middle and distal phalanges. This review suggests that transfer of a non-vascularized toe phalanx provides a reliable but limited means for increasing length of a digit, stabilizing soft tissue "nubbins" and improving function. Longer follow-up has shown more modest gains in growth than in some previous reports.

The role of biofilm formation in percutaneous Kirschner-wire fixation of radial fractures.

This study examines the formation of bacterial biofilms on percutaneous wires used for fracture fixation. Twelve control (clinically uninfected) wires and ten infected wires were collected and examined using broth culture and scanning electron microscopy. Three of the 12 control wires grew Staphylococcus spp. with very low bacterial counts in their percutaneous portions. In the clinically infected wires, six wires in four subjects had positive cultures in their percutaneous portions and four of these also had positive cultures in their deep portions with much higher bacterial counts than the controls. In two patients (four wires) treated with antibiotics, cultures were negative except for the percutaneous portion of one wire. Scanning electron microscopy did not reveal bacterial biofilm formation, but biological deposit without bacteria was noted on most wires. During the 6 weeks of fracture fixation, some bacterial colonization of wires occurred, but bacteria did not form biofilms which may increase bacterial resistance to systemic antibiotics, cause implant loosening and act as a source of late infection.

Topical negative pressure in wound management.

OBJECTIVE: To investigate the role of topical negative pressure (TNP) therapy in the management of difficult wounds. DESIGN: Prospective consecutive patient series. PATIENTS AND SETTING: 30 patients referred to our tertiary plastic and reconstructive surgical service with wounds deemed unsuitable for reconstructive surgery were treated between November 1997 and the end of December 1998. The mean pretreatment duration of the wounds was 418 days (range, 8-1650 days). All wounds were at least Grade III pressure sores. INTERVENTION: Topical negative pressure therapy (TNP) using the VAC device (KCI Medical, San Antonio, USA). Suction (75-125 mmHg) was continuous for the first 48 hours, then intermittent (2 min on, 5 min off). MAIN OUTCOME MEASURES: Achievement of wound healing endpoints: (1) complete healing of the wound; (2) obliteration of the wound cavity to allow surface dressings; or (3) closure of the wound by suture or skin graft. RESULTS: TNP was successful in 26 out of 30 patients with mean therapy time of 35 days (range, 3-124 days). Healing was more rapid in acute (less than six weeks old) wounds. A reduction in the number of bacterial species and colonies was also observed during therapy. CONCLUSION: TNP can, in some circumstances, promote rapid secondary wound healing. A further randomised trial of TNP versus more traditional wound management modalities is justified.

Evaluation of disinfection and sterilization of reusable angioscopes with the duck hepatitis B model.

PURPOSE: Nosocomial transmission of viral hepatitis and retrovirus infection has been reported. The expected risk is greatest for the hepatitis B virus (HBV). The duck HBV (DHBV) has similar biologic and structural characteristics to HBV and has been adopted as a suitable model for disinfectant testing. METHODS: Angioscopic examination of the external jugular vein was performed on DHBV-infected ducks. After use, the instrument was air dried for 3 minutes. Samples were obtained by flushing the channel with 5 mL of phosphate buffered saline solution. The samples were collected immediately after drying (control), after flushing with 5 mL of water, after glutaraldehyde disinfection for 5, 10, and 20 minutes, and after ethylene oxide gas sterilization. Angioscopes were either precleaned or uncleaned before disinfection/sterilization. Residual infectivity was assessed with inoculation of samples into the peritoneal cavity of day-old ducks (n = 231). RESULTS: DNA analysis results of liver samples showed that all 38 control ducks became infected. The frequency of DHBV infection was reduced to 93% (14 of 15) by flushing the angioscope with 5 mL of sterile water. No transmission occurred after the use of any of the properly precleaned and disinfected/sterilized angioscopes. However, after the use of the uncleaned angioscopes, the transmission rate was 90% (9 of 10) and 70% (7 of 10) after 5 and 10 minutes of contact time, respectively, in 2% glutaraldehyde. Even after the recommended 20 minutes of contact time, there was still 6% (2 of 35) transmission. After ethylene oxide sterilization, two of the recipient ducklings (2 of 35) were infected with DHBV. CONCLUSION: There was no disease transmission after reuse of disposable angioscopes adequately cleaned before disinfection or sterilization. However, if the angioscopes are inadequately cleaned, DHBV can survive despite glutaraldehyde disinfection or ethylene oxide sterilization. This contrasts with previous in vitro and in vivo data with solid surgical instruments. It is postulated that the presence of a narrow lumen or residual protein shielding within the lumen may compromise effective inactivation of hepadnaviruses on angioscopes, with the potential risk for patient-to-patient transmission.

Inactivation of duck hepatitis B virus by a hydrogen peroxide gas plasma sterilization system: laboratory and 'in use' testing.

Human hepatitis B virus (HBV) is an important cause of nosocomial infections and can be transmitted by contaminated instruments. However, tests of the efficacy of sterilization of materials and equipment contaminated by HBV are difficult to perform because the virus cannot be cultured in the laboratory. In this study, we aimed to evaluate the capability of a low temperature, hydrogen peroxide gas plasma sterilizer (Sterrad, Advanced Sterilization Products, Irvine California,) to inactivate duck hepatitis B virus (DHBV). In laboratory efficacy studies using DHBV dried on to glass filter carriers and exposed to one-half of the hydrogen peroxide gas plasma sterilization process, there was a 10(7) or greater decrease in the viral titer, with no infectivity detected on the carriers after treatment. In-use studies were performed using a laparoscope that was experimentally contaminated with DHBV to mimic the possible transmission of infection between successive patients. Following exposure to the hydrogen peroxide gas plasma sterilization process no transmission of DHBV infection from the laparoscope occurred despite obvious visual soiling with blood (N = 8) while the transmission rate for the unprocessed laparoscope (positive control) was 100% (26/26), and that for instruments after a water wash was 63% (7/11). In conclusion the hydrogen gas plasma sterilization process completely inactivates DHBV a representative of the hepadna group of viruses.

Silicone in nasal augmentation rhinoplasty: a decade of clinical experience.

A number of materials, both biologic and alloplastic, have been used for nasal augmentation. Although biologic bone and cartilage grafts are associated with lower infection rates, they are also associated with long-term resorption and donor-site morbidity. Alloplastic materials, in particular silicone, have been associated in the literature with extrusion and infection but have the advantages of being affordable and easy to reshape with no requirement for harvesting autografts. A 10-year experience with silicone nasal augmentation documenting clinical experience, acute and long-term complications, and patient satisfaction was reviewed. All patients undergoing silicone augmentation rhinoplasty between July of 1985 and December of 1995 were reviewed. Preoperative nasal phenotype, operative data, and postoperative outcome were recorded. Long-term follow-up was undertaken using a telephone survey. There were 422 patients who underwent silicone nasal augmentation from July of 1985 to December of 1995. Only nine were men. The indications were for aesthetic nasal augmentation in 98 percent, and the majority (98 percent) were of South East Asian origin. Mean age was 26 (range 17 to 36), and 41 of the 422 patients had had previous nasal augmentation performed before presentation. Twenty-three patients (5.5 percent) had complications requiring removal of the implant within 30 days of surgery. These included displacement, prominence, hemorrhage, and excessive pressure in addition to obvious supratip deformity. On late follow-up, a further 18 patients (4.3 percent) had subsequent removal of the prosthesis. The most common reason for this was either displacement or over-prominence, more often judged by the surgeon than the patient. There were only two patients (0.5 percent) who had extrusion of the prosthesis. A total of 266 patients (63 percent) were contacted for a telephone interview. The majority of patients (84.2 percent) were satisfied with their nasal shape. Of the 42 patients (15.8 percent) who were not satisfied, 21 patients still wanted further augmentation of their nose. Photographic analysis of 198 patients showed a mean augmentation of 16.5 percent (range 4.0 to 27.5). Amount of augmentation correlated with preoperative nasal phenotype. Silicone nasal augmentation is a safe and effective procedure when used for moderate increases in nasal height. Contrary to previous reports, this series showed no associated infection. If the implant is shaped appropriately to the patient's nasal phenotype, the risk of extrusion may be reduced.

Detection of persistent vegetative bacteria and amplified viral nucleic acid from in-use testing of gastrointestinal endoscopes.

Hospital-acquired infection attributed to inadequate decontamination of gastrointestinal endoscopes prompted an in use evaluation of recommended procedures. Specimens were obtained from the internal channels of 123 endoscopes before, during and after decontamination by flushing with saline and brushing with a sterile brush, and examined for vegetative bacteria by broth and plate culture. Four endoscopy units were tested; the chemical disinfectants used were: 2% glutaraldehyde in Centres 1 and 2 (automated) and Centre 3 (manual); peracetic acid in Centre 4 (automated). Samples from patients in Centre 1 with known chronic hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV-1) infection were also examined for viral nucleic acid by ultracentrifugation, nucleic acid extraction, reverse transcription (for RNA) and polymerase chain reaction (PCR). No persistent vegetative bacteria were found following standard manual cleaning and disinfection for 20 min in 2% glutaraldehyde in Centres 2 and 3 (N = 37). At Centre 1, while plate culture yielded no growth, 34% of samples (10/29) grew vegetative bacteria in broth culture after cleaning and disinfection for 20 min in 2% glutaraldehyde. Investigation revealed an error in manual cleaning; no bacteria were detected in 37 samples taken after this was corrected. At Centre 4, despite the use of peracetic acid as a sterilant, three out of 20 (15%) of post decontamination samples grew bacteria; one contained persistent bacteria. HBV and HCV PCR analysis detected viral nucleic acid in three out of four and four out of six samples from viraemic patients undergoing endoscopy in Centre 1 during the period of improper manual washing. After proper cleaning was instituted, samples from nine out of nine HCV viraemic patients were negative. HIV RNA was detected in five of 14 samples taken from endoscopes after use on HIV positive patients but all post decontamination samples were negative. Detection of bacteria in washes from endoscope channels is a useful warning of a breakdown in decontamination practice. Inadequate brushing of internal channels may result in persistent HCV and HBV viral nucleic acid, the significance of which is not clear. These results reinforce the importance of adequate manual cleaning of endoscopes before chemical disinfection.

Postpartum avulsion of the terminal ileal wall in Crohn's disease.

A case of acute perforation of the terminal ileum induced by avulsion of the bowel wall in a segment of acutely inflamed Crohn's disease is presented. This case is unusual in that the avulsion developed after delivery following the rapid retraction of the uterus which had been compressing a small localized perforation and abscess. A review of the literature has failed to demonstrate a similar case report.

Delayed rupture of the spleen 5 1/2 years after conservative management of traumatic splenic injury.

A patient in whom spontaneous rupture of the spleen occurred 5 1/2 years following conservative management of splenic trauma is reported. The problem of late splenic rupture following splenic conservation therapy is discussed.