Changing patterns in the management of splenic trauma: the impact of nonoperative management

Failure of Observation of Blunt Splenic Injury in Adults: Variability in Practice and Adverse Consequences

BACKGROUND

The Eastern Association for the Surgery of Trauma Multiinstitutional Workgroup reported a failure rate for nonoperative management of blunt splenic injury in adults of 10.8%. Sixty percent of the failures occurred within 24 hours of admission. The purpose of this multiinstitutional study by the Eastern Association for the Surgery of Trauma was to determine common variables in failure of nonoperative management of blunt splenic injury in adults.

STUDY DESIGN

Medical records were reviewed in a blinded fashion on 78 patients in whom nonoperative management failed. Statistical analysis was performed with ANOVA, extended chi-square, and Fisher's exact test; statistical significance was p<0.05.

RESULTS

The 78 patients were categorized based on hemodynamic status. Forty-four percent were stable; 31% had transient hypotension or tachycardia that resolved with fluid infusion (responders); and 25% were unstable. Two-thirds of the unstable patients required laparotomy within 12 hours of admission; all had laparotomy within 72 hours. Mortality was significantly different when comparing the unstable to the stable and responder groups: stable (3%), responders (8%), and unstable (37%), despite similar age and only modest differences in Injury Severity Score. Eight CT scans were misinterpreted initially. Of 26 Focused Abdominal Sonography for Trauma (FAST) studies, 11 (42.3%) were false negative. Abnormal abdominal findings were noted in 67.7% of patients on admission. Ten patients died (12.8%). Sixty percent of the deaths were caused largely by delayed treatment of splenic or other abdominal injuries; one patient died in the responder group and five unstable patients died.

CONCLUSIONS

Thirty percent to 40% of the patients who had unsuccessful nonoperative management in this study were selected inappropriately, with hemodynamic instability or initial misinterpretation of diagnostic studies. As a consequence, the majority of the deaths were from delayed treatment of intraabdominal injuries. This article suggests that written protocols, better adherence to sound clinical judgment, and experienced and timely interpretation of radiologic studies would reduce the incidence of failure of nonoperative management of blunt splenic injury in adults.

Assessment of Nonoperative Management of Blunt Spleen and Liver Trauma

An 8-year analysis of nonoperative management (NOM) of spleen and liver trauma was done in a level 1 trauma center. Spleen and liver trauma was diagnosed in 279 patients: 93 children (<18), 137 younger adults (18–54), and 49 older adults (≥ 55). Nineteen patients who failed resuscitations died within 0–60 minutes of arrival and were excluded from treatment analysis. Operative management (OM) was done in 39 (15%) and NOM in 221 (85%) patients with failure (NOMF) in 11 (5%). NOM and NOMF was 82 per cent and 5.6 per cent in spleen, 74 per cent and 14.3 per cent in combined spleen/liver, and 96 per cent and 1.5 per cent in liver trauma ( P value <0.001). NOM was done in 99 per cent of children, 81 per cent of younger adults, and 68 per cent of older adults with 0 per cent, 8 per cent, and 10 per cent NOMF. Higher grades of splenic trauma and CT fluid had higher OM rate. NOM success rates were 93.8 per cent in grade 3 and 90.3 per cent in higher grades of spleen trauma. There was no NOMF in higher grades of liver trauma. CT fluid grade had no impact on NOMF. Female patients had higher mean injury severity score, age, and mortality compared to cohorts. NOM should be attempted in hemodynamically stable patients. Age over 55, higher grades of injury, and large hemoperitoneum were not predictors of failure of NOM.

Blood transfusion is an independent predictor of increased mortality in nonoperatively managed blunt hepatic and splenic injuries

BACKGROUND

Management strategies for blunt solid viscus injuries often include blood transfusion. However, transfusion has previously been identified as an independent predictor of mortality in unselected trauma admissions. We hypothesized that transfusion would adversely affect mortality and outcome in patients presenting with blunt hepatic and splenic injuries after controlling for injury severity and degree of shock.

METHODS

We retrospectively reviewed records from all adults with blunt hepatic and/or splenic injuries admitted to a Level I trauma center over a 4-year period. Demographics, physiologic variables, injury severity, and amount of blood transfused were analyzed. Univariate and multivariate analysis with logistic and linear regression were used to identify predictors of mortality and outcome.

RESULTS

One hundred forty-three (45%) of 316 patients presenting with blunt hepatic and/or splenic injuries received blood transfusion within the first 24 hours. Two hundred thirty patients (72.8%) were selected for nonoperative management, of whom 75 (33%) required transfusion in the first 24 hours. Transfusion was an independent predictor of mortality in all patients (odds ratio [OR], 4.75; 95% confidence interval [CI], 1.37-16.4; p = 0.014) and in those managed nonoperatively (OR, 8.45; 95% CI, 1.95-36.53; p = 0.0043) after controlling for indices of shock and injury severity. The risk of death increased with each unit of packed red blood cells transfused (OR per unit, 1.16; 95% CI, 1.10-1.24; p < 0.0001). Blood transfusion was also an independent predictor of increased hospital length of stay (coefficient, 5.45; 95% CI, 1.64-9.25; p = 0.005).

CONCLUSION

Blood transfusion is a strong independent predictor of mortality and hospital length of stay in patients with blunt liver and spleen injuries after controlling for indices of shock and injury severity. Transfusion-associated mortality risk was highest in the subset of patients managed nonoperatively. Prospective examination of transfusion practices in treatment algorithms of blunt hepatic and splenic injuries is warranted.

Utilidad de las mallas reabsorbibles en los traumatismos esplénicos

INTRODUCTION

The spleen is not an essential organ for survival but given its important role in immunologic functions its preservation is justified.

OBJECTIVE

To analyze our experience with absorbable meshes applied to treat splenic injuries.

PATIENTS AND METHOD

We performed an ambispective study. From July 1999 to February 2004, 30 patients were treated for traumatic splenic injuries. Ultrasonography and/or spiral computed tomography scanning was carried out for the initial screening evaluation and grading of splenic injuries. The New Injury Severity Score (NISS) was calculated to quantify the severity of trauma. Operative splenic preservation was performed according to established selection criteria. Splenorrhaphy with prosthetic material was accomplished by means of a bag of polyglycolic acid mesh measuring 18 cm yen 23 cm (Dexon mesh) that was hand tailored and wrapped around the entire surface of the spleen.

RESULTS

Thirty patients with splenic traumatic injuries were treated. The mean age was 36.2 +/- 16.6 years. Twenty-three patients (76.6%) required splenectomy, nonoperative management was achieved in 1 patient (3.3%), and splenorrhaphy with prosthetic material was carried out in 6 patients (20%). Grade III injuries were present in 13 patients (43.3%), grade IV in 13 patients (43.3%), and grade V in 4 patients (13.3%). The mean NISS was 18.9 +/- 9.1. No significant differences were detected between the two groups (splenectomy or mesh splenorrhaphy) in NISS (p=.53) or grade of splenic injuries (p=.69). Morbidity was related to the presence of multiple injuries (p=.002) and was greater in the group with mesh splenorrhaphy (p=.002); however, there were no septic complications in this group. A positive correlation was observed between the length of hospital stay and NISS (p=.01). The length of hospital stay was also significantly associated with the presence of multiple injuries (p=.005) and with morbidity (p=.0002), but was not associated with the type of surgery carried out (p=.17). No complications were observed during follow-up (median of 28 months) in patients who underwent splenic salvage procedures.

CONCLUSIONS

Mesh splenorrhaphy is a suitable therapeutic option for patients with severe trauma, grade IV splenic injuries, or delayed rupture of the spleen. Both morbidity and length of hospital stay were associated with the presence of multiple injuries rather than with the type of surgery carried out. The safety, effectiveness and absence of septic complications related to the use of prosthetic material in splenic trauma salvage surgery were notable.

Isolated blunt splenic injury: do we transfuse more in an attempt to operate less?

OBJECTIVE

To determine if blood transfusion requirements in patients with isolated blunt splenic injury (BSI) are greater if they are managed nonoperatively, we did a retrospective case study of patients with isolated BSI who were seen at a Canadian university teaching hospital over a 10-year period.

METHOD

Data such as number of units of packed erythrocytes transfused and mortality in the 75 patients with isolated BSI seen from 1992 to 2002 were separated into operative and nonoperative management groups.

RESULTS

In the operative management group (n = 10), patients received more transfused erythrocytes (3.0 v. 0.7 units), and a higher proportion of patients were transfused (80% v. 20%). There were no deaths in either group.

CONCLUSION

In the management of isolated BSI, initial nonoperative management does not increase patients' requirements for blood transfusion.

Hospital Factors Associated with Splenectomy for Splenic Injury: A National Perspective

BACKGROUND

The management of patients with splenic injury has shifted from routine splenectomy to attempts at splenic salvage. Using the Healthcare Cost and Utilization Project's National Inpatient Sample (HCUP-NIS), we assessed the patterns of care for splenic trauma. We hypothesized that the processes of care in urban and rural hospitals would differ.

METHODS

Generalized estimating equations were used to identify predictor variables associated with laparotomy and splenectomy from a national, population-based sample of inpatients (HCUP-NIS). Fourteen thousand nine hundred one patients with an International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code of 865 were selected from the 1998 to 2000 HCUP-NIS data. Exclusion criteria included age greater than 80 years. Analyses were compared using all patients and excluding patients who died during the first 2 hospital days.

RESULTS

Eight thousand five hundred fifty-three patients were treated in urban teaching hospitals. Forty percent underwent a laparotomy and 28% underwent a splenectomy at that time. Another 4,461 patients were cared for in urban nonteaching hospitals. Of these, 46% had a laparotomy and 35% underwent a splenectomy. The remaining 1,887 patients were seen in rural hospitals. Forty-six percent had a laparotomy and 36% had a splenectomy. Patients in urban teaching hospitals had lower risk-adjusted odds of splenectomy in multivariate models controlling for confounders including overall injury severity. Overall splenic salvage increased from 1998 to 2000, primarily because of increased salvage rates among urban teaching hospitals.

CONCLUSION

The management of patients with splenic injury differs among urban teaching, urban nonteaching, and rural hospitals. Surgeons at urban teaching hospitals appear more willing to attempt splenic salvage by means of nonoperative management.

Multi-detector row CT imaging of blunt abdominal trauma

CT is the imaging modality of choice to evaluate hemodynamically stable patients suffering blunt abdominal trauma. During the past five years, single-slice helical CT has been replaced by multidetector row CT (MDCT). This development has revolutionized cross-sectional imaging for blunt trauma patients. Volumetric imaging with helical CT has been a major factor supporting the nonoperative management of solid organ injury. Trauma centers in the United States are replacing single-slice helical CT scanners with state-of-the-art MDCT in suites proximate to the patient receiving area and with facilities for monitoring and maintaining physiologic support. The ability to obtain high-resolution images with MDCT during optimal contrast enhancement at unparalleled speed helps detect the presence and define the extent of injuries, and crucially, to diagnose hemorrhage and vascular injuries. This article describes our current imaging protocol with MDCT-16 (i.e., 16 detector MDCT), the spectrum of diagnostic findings seen in blunt abdominal injury, and the role of MDCT in the characterization of hemorrhage and planning injury management.

Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST)

BACKGROUND

Thoracic ultrasound (EFAST) has shown promise in inferring the presence of post-traumatic pneumothoraces (PTXs) and may have a particular value in identifying occult pneumothoraces (OPTXs) missed by the AP supine chest radiograph (CXR). However, the diagnostic utility of hand-held US has not been previously evaluated in this role.

METHODS

Thoracic US examinations were performed during the initial resuscitation of injured patients at a provincial trauma referral center. A high frequency linear transducer and a 2.4 kg US attached to a video-recorder were used. Real-time EFAST examinations for PTXs were blindly compared with the subsequent results of CXRs, a composite standard (CXR, chest and abdominal CT scans, clinical course, and invasive interventions), and a CT gold standard (CT only). Charts were reviewed for in-hospital outcomes and follow-up.

RESULTS

There were 225 eligible patients (207 blunt, 18 penetrating); 17 were excluded from the US examination because of battery failure or a lost probe. Sixty-five (65) PTXs were detected in 52 patients (22% of patients), 41 (63%) being occult to CXR in 33 patients (14.2% whole population, 24.6% of those with a CT). The US and CXR agreed in 186 (89.4%) of patients, EFAST was better in 16 (7.7%), and CXR better in 6 (2.9%). Compared with the composite standard, the sensitivity of EFAST was 58.9% with a likelihood ratio of a positive test (LR+) of 69.7 and a specificity of 99.1%. Comparing EFAST directly to CXR, by looking at each of 266 lung fields with the benefit of the CT gold standard, the EFAST showed higher sensitivity over CXR (48.8% versus 20.9%). Both exams had a very high specificity (99.6% and 98.7%), and very predictive LR+ (46.7 and 36.3).

CONCLUSION

EFAST has comparable specificity to CXR but is more sensitive for the detection of OPTXs after trauma. Positive EFAST findings should be addressed either clinically or with CT depending on hemodynamic stability. CT should be used if detection of all PTXs is desired.

Infectious mononucleosis: return to play

Infectious mononucleosis most commonly affects adolescents and young adults with a febrile illness accompanied by pharyngitis,lymph node enlargement, and transient fatigue. The diagnosis is usually confirmed with demonstration of heterophile antibodies. Typical signs and symptoms are reviewed, along with pitfalls in diagnosis and management. The rare complication of splenic rupture serves to focus recommendations for returning athletes to strenuous physical activities. Because careful prospective studies of infectious mononucleosis in athletes are lacking, review of available literature suggests that clinicians may recommend a return to all sports in those without spleen enlargement 4 weeks after the onset of illness.

Splenic preservation: an additional haemostatic measure during mesh splenorrhaphy

BACKGROUND

Various treatment measures have been described in achieving splenic preservation following splenic injury. We describe an additional measure in achieving haemostasis during mesh splenorrhaphy.

METHODS

Oxycel (BD, Franklin Lakes, NJ, USA) (topical haemostatic agent composed of oxidized cellulose) is sutured onto the inside of Dexon (Sherwood, Davis & Geck, St Louis, MO, USA) (polyglycolic acid) mesh.

RESULTS

Two patients with splenic lacerations were operated on from July 2002 to February 2003 using this technique and both patients did not experience postoperative abdominal complications and were clinically well at follow up 1-2 months later.

CONCLUSIONS

In our experience this technique made the Dexon mesh bulkier and easier to secure as well as more haemostatic.

Resource utilization and its management in splenic trauma

BACKGROUND

This study compared resource utilization and its management for splenic injury at 2 level-I trauma centers and a pediatric referral center with other facilities in a state currently developing a trauma system.

METHODS

Management strategy, length of stay, and total charges for children were compared among the pediatric referral center, trauma centers, and other facilities. Adult management, length of stay, and total charges were compared between trauma centers and other facilities.

RESULTS

Nonoperative management was more frequent in children at the pediatric referral center than trauma centers or other facilities and was more common in adults at trauma centers than at other facilities. Mean length of stay and total charges for children were significantly greater at the pediatric referral center and trauma centers than at other facilities and for adults at trauma centers than at other facilities. Facility type was associated with length of stay and total charges when injury type and severity were controlled.

CONCLUSIONS

Nonoperative management of splenic injury is more common at trauma centers, and splenic trauma management may be more costly at trauma centers.

Pediatric splenic injuries with a contrast blush: successful nonoperative management without angiography and embolization

BACKGROUND

The presence of a contrast blush on computed tomography (CT) in adult splenic trauma is a risk factor for failure of nonoperative management. Arterial embolization is believed to reduce this failure rate. The significance of a blush in pediatric trauma is unknown. The authors evaluated the outcome of children with blunt splenic trauma and contrast extravasation.

METHODS

The trauma registry was queried for all pediatric patients with blunt splenic injuries. Admission CT was reviewed for injury grade and presence of an arterial blush by a radiologist blinded to patient outcome. Hospital and office charts were reviewed for success of nonoperative management, late splenic rupture, and other complications.

RESULTS

One hundred seven children with blunt splenic trauma were identified over a 6-year period. Mean injury grade was 2.9. Six patients required emergency splenectomy. An additional 7 patients met hemodynamic criteria for surgical intervention (3 splenectomies, 4 splenorrhaphies). Admission CT was available in 63 patients. An arterial blush was identified in 5 (9.7%). Four remained stable and were treated conservatively. One underwent splenectomy for hemodynamic instability. There were no cases of delayed splenic rupture, failed nonoperative treatment, or long-term complications.

CONCLUSIONS

Contrast blush in children with blunt splenic trauma is rare, and its presence alone does not appear to predict delayed rupture or failure of nonoperative treatment. Based on this limited series, splenic artery embolization does not have a place in the management of splenic injuries in children.

Gunshot Wounds of Abdomen: Evaluation of Stable Patients with Triple-Contrast Helical CT

PURPOSE

To assess helical computed tomography (CT) with contrast material administered intravenously, orally, and rectally (triple contrast helical CT)) in the prospective evaluation of stable patients with abdominal gunshot wounds in whom there is no clinical indication for immediate exploratory laparotomy.

MATERIALS AND METHODS

The study was conducted for 19 months. All patients met the following inclusion criteria: age of 16 years or older, hemodynamic stability, no clinical signs of peritoneal irritation, and signed consent to participate. Patients with obvious indications for laparotomy, such as gastrointestinal bleeding or evisceration, were excluded from the study. Forty-seven patients fulfilled the criteria and underwent abdominal triple-contrast helical CT. CT findings were evaluated by one of four radiologists for evidence of peritoneal penetration and injury to solid organs or hollow viscera. Patients were followed up clinically for 13 weeks. CT findings were compared with those at surgery and/or clinical follow-up.

RESULTS

CT demonstrated abnormalities in 27 (57%) patients. Laparotomy was performed in 11 (23%) patients; 10 procedures were therapeutic and one was nontherapeutic. The remaining 20 patients had a negative CT scan. These patients were treated conservatively. One injury was missed at CT. For prediction of the need for laparotomy, sensitivity of CT was 96%; specificity, 95%; positive predictive value, 96%; negative predictive value, 95%; and accuracy, 96%.

CONCLUSION

In stable patients with gunshot wounds to the abdomen in whom there is no indication for immediate surgery, triple-contrast helical CT can help reduce the number of cases of unnecessary or nontherapeutic laparotomy (negative laparotomy) and can help identify patients with injuries that may be safely treated without surgery.

Liver cirrhosis: an unfavorable factor for nonoperative management of blunt splenic injury

BACKGROUND

Nonoperative management (NOM) of blunt splenic injury (BSI) is currently a well-accepted treatment modality for hemodynamically stable patients. More than 60% of BSI patients can be successfully treated without operation. Old age, high-grade injury, contrast blush, and multiple associated injuries were reported to have a higher failure rate but not to be exclusive of NOM. The purpose of this study was to review the treatment courses and results of a special group of BSI patients with coexistent liver cirrhosis. Factors leading to poor results were analyzed and treatment strategy was proposed accordingly.

METHODS

During a 5-year period, 487 patients with BSI were treated following a standard protocol. Twelve of them had underlying liver cirrhosis. The medical records, radiographic findings, laboratory data, and operative variables were retrospectively reviewed.

RESULTS

Eighty-nine (18%) patients had immediate celiotomy for splenic hemorrhage with unstable hemodynamic status, 59 (12%) had non-spleen-related or nontherapeutic laparotomy, and 339 (70%) patients received NOM initially. Failure of NOM was found in 74 patients (22%). Twelve patients with initial NOM had coexistent liver cirrhosis. The amount of blood transfusion within 72 hours after admission for these 12 patients ranged from 4 to 26 units. Patients with coexistent liver cirrhosis and BSI had a significantly higher NOM failure rate (92% vs. 19%). In NOM failure patients, those with liver cirrhosis had lower Injury Severity Scores, lower splenic injury severity grades, more blood transfusions, and a higher mortality rate. Risk factors for mortality in these patients included a higher Injury Severity Score, a severely elevated prothrombin time (PT), a larger transfusion requirement, and a lower serum albumin level.

CONCLUSION

Liver cirrhosis with subsequent development of portal hypertension, splenomegaly, and coagulopathy makes spontaneous hemostasis of the injured spleen difficult. NOM for BSI patients with coexistent liver cirrhosis carries a high failure and mortality rate. NOM may be successful in only a small group of patients with low-grade single-organ injury and with a normal or mildly elevated PT. Aggressive correction of coagulopathy should be performed in these patients. High-grade splenic injury, multiple associated injuries, and an elevated PT are indicators for early surgery. The mortality rate is high in patients with a severely prolonged PT irrespective of treatment modalities.

Nonoperative Management of Blunt Renal Trauma: A Prospective Study

Despite the abundance of literature on nonoperative management (NOM) of blunt trauma to the liver and spleen there is limited information on NOM of blunt renal injuries. In an effort to evaluate the role of NOM 37 consecutive unselected patients with renal injuries (grade 1, four; grade 2, 12; grade 3, 11; grade 4, six; and grade 5, four) were followed prospectively over 30 months (March 1999 to September 2001). Patients without peritonitis or hemodynamic instability were managed nonoperatively regardless of the appearance of the kidney on CT scan. Six (16%) patients were operated on immediately but only two (5.4%) for the kidney (grades 3 and 5 respectively). Of the remaining 31 patients 26 (84%) were managed successfully without an operation (grade 1 or 2, 12; grades 3–5, 14). Five patients were taken to the operating room after a period of observation (3, 3.5, 9, 36, and 44 hours respectively) but only three for the kidney (grades 4 and 5). The overall failure rate was 16 per cent (5 of 31); the rate of failure specifically related to the renal injury was 9.6 per cent (three of 31). Compared with the patients with successful NOM the five patients with failed NOM were more severely injured (Injury Severity Score ≥15 in 80% vs 27%, P = 0.04), required in the first 6 hours more fluids (4.17 ± 1.72 vs 1.87 ± 1.4 liters, P = 0.003) and blood transfusions (2.40 ± 2 vs 0.42 ± 1.17 units, P = 0.005), and more frequently had a positive trauma ultrasound (80% vs 11.5%, P = 0.005). We conclude that NOM is the prevailing method of treatment after blunt renal trauma. It is successful in the majority of patients without peritonitis or hemodynamic instability and should be considered regardless of the severity of renal injury. Predictors of failure may exist on the basis of injury severity, fluid and blood requirements, and abdominal ultrasonographic findings and need validation by a larger sample size.

Contrast enhanced vascular three-dimensional ultrasound imaging

In other imaging modalities three-dimensional (3D) data displays are well established; not so in ultrasound. Due to the real-time requirements of ultrasound the time available to compute 3D displays is limited, particularly when flow data is acquired with Doppler techniques. Consequently, it is only recently that improvements in computer processing power have resulted in useful vascular 3D ultrasound scans. Many manufacturers have now implemented free-hand 3D power Doppler capabilities on their scanners. However, to obtain flow signals from smaller vessels associated e.g., with tumor neovascularity, may very well require the introduction of a microbubble based ultrasound contrast agent into the blood stream. Given the up to 30 dB enhancement of Doppler signals produced by the contrast microbubbles quite spectacular vascular 3D images are feasible. Moreover, new contrast imaging techniques, such as harmonic imaging, have now permitted 3D vascular information to be acquired and displayed in grayscale with the associated improvement in resolution. In this paper we will review different aspects of contrast enhanced vascular 3D ultrasound imaging including implementation, contrast specific techniques and in vivo imaging.

Factors Affecting the Outcome of Patients with Splenic Trauma

This is a report of 546 consecutive patients with penetrating and blunt splenic trauma seen over a 17½-year period (1980–1997). The etiology of the splenic injuries and the associated mortality rates were: blunt injuries 45 of 298 (15%), gunshot wounds 48 of 199 (24%), and stab wounds four of 49 (8%). The overall mortality rate was 97 of 546 (18%). The most significant risk factors for death were all associated with major blood loss: transfusion requirements ≤6 units of blood, low initial operating room blood pressure, associated abdominal vascular injuries, and performance of a thoracotomy. The two most important organs injured in conjunction with the spleen that were significant predictors of postoperative infectious complications were colon and pancreas. The need for splenectomy was most significantly correlated with higher grades of splenic injury especially grades IV and V. The evolution in management of blunt splenic trauma has led to a significant improvement in splenic preservation and avoidance of laparotomy for many patients. Operative splenic salvage is reduced in patients subjected to laparotomy who are candidates for nonoperative treatment. Improved results with splenic injury should be obtained by rapid control of bleeding. This may require more liberal criterial in selecting patients with splenic trauma for early operative treatment.

Contrast-enhanced two- and three-dimensional sonography for evaluation of intra-abdominal hemorrhage

OBJECTIVE

To determine whether a contrast agent enhances sonographic detection of bleeding sites in the abdomen and whether contrast-enhanced three-dimensional sonography provides additional information compared with contrast-enhanced two-dimensional sonography.

METHODS

Bleeding sites were created within the livers (n = 3), spleens (n = 5), and kidneys (n = 3) of 3 dogs. A sonographic contrast agent with vascular and parenchymal enhancement capabilities was administered intravenously at a dose of 0.02 mL/kg. Before and after each contrast agent injection, the bleeding sites were imaged with two- and three-dimensional sonography in gray scale harmonic imaging and color flow modes. Sonographic findings were compared with gross pathologic findings.

RESULTS

Noncontrast-enhanced sonography was not able to show the specific location of the active bleeding in any of the organs evaluated. The contrast agent enhanced the sonographic detection of blood flow in normal vessels and extravasated blood from damaged vessels or organs in all cases. Intrasplenic and intrahepatic hematomas were better identified on delayed imaging sequences because there was marked enhancement of the normal parenchyma, whereas the hematomas remained unenhanced. Reconstructed three-dimensional sonography showed spatial relationships of the bleeding sites and surrounding structures. Gross pathologic findings were consistent with the contrast-enhanced sonographic results.

CONCLUSIONS

Contrast-enhanced sonography improves the detection and evaluation of abdominal bleeding sites. Contrast-enhanced three-dimensional sonography appears to provide additional information when compared with two-dimensional sonography.

Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma

BACKGROUND

The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults.

METHODS

Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively.

RESULTS

Fifteen percent of patients were 55 years of age or older. A similar proportion of patients > or = 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients > or = 55 was significantly greater than patients < 55 (43% vs. 23%). Patients > or = 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women > or = 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05).

CONCLUSION

Patients > or = 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > or = 55 had significantly greater mortality and failure of NOM than women < 55.

Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care?

OBJECTIVE

To evaluate the safety of a policy of selective nonoperative management (SNOM) in patients with abdominal gunshot wounds.

SUMMARY BACKGROUND DATA

Selective nonoperative management is practiced extensively in stab wounds and blunt abdominal trauma, but routine laparotomy is still the standard of care in abdominal gunshot wounds.

METHODS

The authors reviewed the medical records of 1,856 patients with abdominal gunshot wounds (1,405 anterior, 451 posterior) admitted during an 8-year period in a busy academic level 1 trauma center and managed by SNOM. According to this policy, patients who did not have peritonitis, were hemodynamically stable, and had a reliable clinical examination were observed.

RESULTS

Initially, 792 (42%) patients (34% of patients with anterior and 68% with posterior abdominal gunshot wounds) were selected for nonoperative management. During observation 80 (4%) patients developed symptoms and required a delayed laparotomy, which revealed organ injuries requiring repair in 57. Five (0.3%) patients suffered complications potentially related to the delay in laparotomy, which were managed successfully. Seven hundred twelve (38%) patients were successfully managed without an operation. The rate of unnecessary laparotomy was 14% among operated patients (or 9% among all patients). If patients were managed by routine laparotomy, the unnecessary laparotomy rate would have been 47% (39% for anterior and 74% for posterior abdominal gunshot wounds). Compared with patients with unnecessary laparotomy, patients managed without surgery had significantly shorter hospital stays and lower hospital charges. By maintaining a policy of SNOM instead of routine laparotomy, a total of 3,560 hospital days and $9,555,752 in hospital charges were saved over the period of the study.

CONCLUSION

Selective nonoperative management is a safe method for managing patients with abdominal gunshot wounds in a level 1 trauma center with an in-house trauma team. It reduces significantly the rate of unnecessary laparotomy and hospital charges.

Has Nonoperative Management of Solid Visceral Injuries Adversely Affected Resident Operative Experience?

The purpose of this study was to assess the impact of increased use of nonoperative management of blunt injuries to the spleen or liver on surgical residents’ operative experience with solid visceral injuries. We conducted a 10-year retrospective study of blunt spleen and liver injuries at a state-designated Level I trauma center and a survey of chief residents’ operative experience with splenic and hepatic injuries from blunt trauma during the same time period. From 1990 through 1999, 431 patients were admitted with splenic injuries and 634 patients were admitted with liver injuries; 350 splenic injuries (81%) were due to blunt trauma; 317 liver injuries (50%) were caused by blunt mechanisms. In 1990 100 per cent of patients with splenic injuries and 93 per cent of those with liver injuries underwent surgery for those injuries. These rates were 19 and 28 per cent respectively in 1999. The number of patients with blunt solid visceral injuries increased more than fourfold from 1990 through 1999. The number of operations for splenic and hepatic injuries performed by chief residents did not decline significantly during this time period (5.5 cases per chief resident in 1990; 4.6 cases per chief resident in 1999). The increased numbers of patients with solid visceral injuries were due to two factors: increased proportion of blunt trauma admissions especially from motor vehicle collisions and improved recognition of spleen and liver injuries by expanded use of CT scans. We conclude that nonoperative management of blunt solid visceral injuries does not necessarily lead to a diminution of operations nor jeopardize resident education. However, trauma volumes must be high enough to support adequate operative experience.

Non-operative management of solid organ trauma in children

Trauma is the commonest cause of mortality in infancy and childhood. Injuries from blunt trauma predominate, with multisystem injury, the rule. Blunt abdominal injury represents the third commonest cause of death from injury in this age group.

Initial management of the child combines assessment and resuscitation. If the child’s condition is stable then the injured organ should be definitively identified, usually by computerized tomography. Over 90% of children who are stable at this point can be managed conservatively, with a period of observation on an intensive care unit, followed by bed rest on a general ward. Instability at any point requires further resuscitation, reassessment and if necessary laparotomy. Repeated clinical assessment and radiological investigation are used to guide further management, mobilization and the return to normal activities.

The Role of Follow-up Radiographic Studies in Nonoperative Management of Spleen Trauma

The management of splenic injuries has evolved significantly in recent years from an operative to a nonoperative approach in stable patients with blunt abdominal trauma. The management of these patients with serial radiographic studies before hospital discharge remains controversial. We reviewed the management of 90 patients retrospectively who were admitted to our Level II trauma center with splenic injuries secondary to blunt trauma to determine the value of serial radiographic studies. Forty-seven (52%) patients underwent immediate laparotomy. Forty-three (48%) patients were managed conservatively without surgery. All nonoperative patients had an initial CT of the abdomen to evaluate their abdominal injuries. Among the 43 patients managed without surgery 31 had no follow-up radiographic studies. Twelve patients had follow-up studies before discharge. Two of these 12 patients subsequently underwent splenectomy. Both had developed hypotension, tachycardia, and a decreasing hematocrit, which prompted their repeat radiographic studies. Ten patients had no change in their clinical status and showed no significant change in the radiographic injury pattern to the spleen. One patient who was initially managed nonoperatively became hemodynamically unstable with increasing abdominal pain and subsequently underwent splenectomy without follow-up radiographic studies. The remaining 30 patients who had no follow-up studies had no significant change in their clinical abdominal examinations and had no further complications from their splenic injuries. Routine follow-up radiographic evaluations are not necessary in the nonoperative management of stable patients with splenic injuries.

Significance of minimal or no intraperitoneal fluid visible on CT scan associated with blunt liver and splenic injuries: a multicenter analysis

BACKGROUND

The use of ultrasound (U/S) for the evaluation of patients with blunt abdominal trauma is gaining increasing acceptance. Patients who would have undergone computed tomographic (CT) scan may now be evaluated solely with U/S. Solid organ injuries with minimal or no free fluid may be missed by surgeon sonographers.

OBJECTIVE

The purpose of this study was to describe the incidence and clinical importance of liver and splenic injuries with minimal or no free intraperitoneal fluid visible on CT scan. We hypothesized that these solid organ injuries occur infrequently and are of minor clinical significance.

METHODS

Patient records and CT scans were reviewed for the presence of and outcome associated with blunt liver and splenic injuries with minimal (<250 mL) or no free fluid detected by an attending radiologist. Data were collected from six major trauma centers during a 4-year period before the introduction of U/S and included demographics, grade of injury (American Association for the Surgery of Trauma scale), need for operative intervention, and outcome.

RESULTS

A total of 938 patients with liver and splenic injuries were identified. In this group, 11% of liver injuries and 12% of splenic injuries had no free fluid visible on CT scan and could be missed by diagnostic peritoneal lavage or U/S. Of the 938 patients, 267 (28%) met the inclusion criteria; 161 had injury to the spleen and 125 had injury to the liver. In the 267 patients studied, 97% of the injuries were managed nonoperatively. However, 8 patients (3%) required operative intervention for bleeding. Compared with the liver, the spleen was significantly more likely to bleed (p = 0.01), but the grade of splenic injury was not related to the risk for hemorrhage (p = 0.051).

CONCLUSION

Data from this study suggest that injuries to the liver or spleen with minimal or no intraperitoneal fluid visible on CT scan occur more frequently than predicted but usually are of minimal clinical significance. However, patients with splenic injuries may be missed by abdominal U/S. We found a 5% associated risk of bleeding. Therefore, abdominal U/S should not be used as the sole diagnostic modality in all stable patients at risk for blunt abdominal injury.

Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma

BACKGROUND

Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The purpose of this multi-institutional study was to determine which factors predict successful observation of blunt splenic injury in adults.

METHODS

A total of 1,488 adults (>15 years of age) with blunt splenic injury from 27 trauma centers in 1997 were studied through the Multi-institutional Trials Committee of the Eastern Association for the Surgery of Trauma. Statistical analysis was performed with analysis of variance and extended chi2 test. Data are expressed as mean +/- SD; a value of p < 0.05 was considered significant.

RESULTS

A total of 38.5 % of patients went directly to the operating room (group I); 61.5% of patients were admitted with planned nonoperative management. Of the patients admitted with planned observation, 10.8% failed and required laparotomy; 82.1% of patients with an Injury Severity Score (ISS) < 15 and 46.6% of patients with ISS > 15 were successfully observed. Frequency of immediate operation correlated with American Association for the Surgery of Trauma (AAST) grades of splenic injury: I (23.9%), II (22.4%), III (38.1%), IV (73.7%), and V (94.9%) (p < 0.05). Of patients initially managed nonoperatively, the failure rate increased significantly by AAST grade of splenic injury: I (4.8%), II (9.5%), III (19.6%), IV (33.3%), and V (75.0%) (p < 0.05). A total of 60.9% of the patients failed nonoperative management within 24 hours of admission; 8% failed 9 days or later after injury. Laparotomy was ultimately performed in 19.9% of patients with small hemoperitoneum, 49.4% of patients with moderate hemoperitoneum, and 72.6% of patients with large hemoperitoneum.

CONCLUSION

In this multicenter study, 38.5% of adults with blunt splenic injury went directly to laparotomy. Ultimately, 54.8% of patients were successfully managed nonoperatively; the failure rate of planned observation was 10.8%, with 60.9% of failures occurring in the first 24 hours. Successful nonoperative management was associated with higher blood pressure and hematocrit, and less severe injury based on ISS, Glasgow Coma Scale, grade of splenic injury, and quantity of hemoperitoneum.

The Incidence of Splenectomy is Decreasing: Lessons Learned from Trauma Experience

Over the past decade, splenic preservation has become a well-reported and accepted principle in trauma management. The reasons for splenic preservation may have influenced nontraumatic surgical management as well. To investigate the changing incidence and indications for splenectomy, we conducted a 10-year review of all splenectomies at our institution. During this time, between January 1, 1986, and December 31, 1995, 896 patients underwent splenectomy. Hospital charts and records were examined to determine the etiology and incidence of splenectomy. Indications were classified as: 1) trauma, i.e., performed for blunt or penetrating injury; 2) hematologic malignancy, i.e., therapy or staging of underlying leukemia, Hodgkin's lymphoma, or non-Hodgkin's lymphoma; 3) cytopenia, i.e., treatment of thrombocytopenia, anemia, or leukopenia; 4) iatrogenic, i.e., injury during another procedure; 5) incidental, i.e., required for adjacent organ resection; 6) portal hypertension, i.e., left-sided portal hypertension or during shunting procedure; 7) diagnostic, i.e., uncertainty excluding hematologic malignancy; or 8) other, i.e., miscellaneous indications. Trauma accounted for 41.5 per cent of all splenectomies during this time period, hematologic malignancy 15.4 per cent, cytopenia 15.6 per cent, incidental 12.3 per cent, iatrogenic 8.1 per cent, portal hypertension 2.3 per cent, diagnostic 2.0 per cent, and other 2.7 per cent. Comparing the first and second 5-year time periods, the following increases/decreases in average annual incidence were noted: splenectomy for all indications, -36.9 per cent; trauma, -32.9 per cent; hematologic malignancy, -51.4 per cent; cytopenia, 35.1 per cent; incidental, -35.9 per cent; iatrogenic, -30.2 per cent; diagnostic, +4.9 per cent, and other, -57 per cent. Traumatic injury to the spleen remains the most common indication for splenectomy, but the incidence has decreased dramatically over the past 10 years. Splenectomies for treatment of hematologic malignancies and cytopenia, as well as incidental and iatrogenic splenectomies, have also decreased significantly. Only the incidence of diagnostic splenectomy has remained stable. Although initiated within the field of trauma, the advantages of splenic preservation now appear to be well recognized beyond that field.

Blunt trauma to the spleen

BACKGROUND

The management of splenic injury resulting from blunt trauma in adults is controversial, with an increasing trend towards non-operative management and conservation of the spleen. A retrospective review was performed on adult patients treated in a single institution for splenic injury resulting from blunt trauma in an attempt to identify factors important in selecting an appropriate management option and predicting the success of that option.

METHODS

Associated injuries (standardized using Injury Severity Scores), clinical signs at presentation, computed tomographic grading of splenic injury, and transfusion requirements were documented. Statistical analysis was performed using non-parametric Mann-Whitney, Chi-squared, Kolmogorov-Smirnov and multivariate logistic regression tests.

RESULTS

Eighty-five patients were identified. Non-operative management was used on 39 patients, splenic conservation on 14 patients, and splenectomy on 32 patients. The mean Injury Severity Score was significantly lower in the non-operative group. Computed tomographic grading of the splenic injury was not found to correlate well with intraoperative findings. Transfusion requirements were lower in the non-operative group. Non-operative management failed in four patients; two had continued splenic bleeding, and two required surgery for other intra-abdominal injuries. Overall mortality was 7%. There was one death in the splenic conservation group, unrelated to the splenic injury, and two patients required a second laparotomy and splenectomy for persistent splenic bleeding. There were five deaths in the splenectomy group, only one of which was related to the splenic surgery.

CONCLUSION

Management of blunt splenic injury remains controversial. The decision to pursue non-operative management rather than splenic conservation or splenectomy depends on the individual merits of each case. There is an increasing trend towards splenic conservation, particularly in younger, stable patients with single organ injury.

Age should not be a consideration for nonoperative management of blunt splenic injury

BACKGROUND

Operative management of blunt splenic injury is recommended for adults > or = 55 years. Because this is not our practice, we did a retrospective review to compare outcomes of patients > or = 55 years old versus patients < 55 years old.

METHODS

During a 5-year period ending in July of 1998, 461 patients (3%) admitted to our Level I trauma center had a blunt splenic injury. Eighty-six patients (19%) died within 24 hours of massive injuries, leaving 375 patients for evaluation. Data were obtained from our trauma registry and medical records.

RESULTS

A total of 29 patients (8%) were > or = 55 years old (mean age, 67 +/- 2 years; mean injury severity score [ISS] 25 +/- 2). Of these, 18 patients (62%) underwent nonoperative management (NOM). A total of 346 patients (92%) were < 55 years old (mean age, 28 +/- 0.6; mean ISS, 20 +/- 1). Of these, 198 patients (57%) underwent NOM. The failure rate was not different between the two age groups (17% vs. 14%). However, the ISS and mortality rate were significantly higher in the older age group that failed (ISS, 29.3 +/- 2.6 vs. 19.5 +/- 2.1; mortality: 67% vs. 4%). None of the deaths could be attributed to splenic injury.

CONCLUSION

Adults > or = 55 years old with blunt splenic injury are successfully treated by NOM. Although older adults had significantly greater injuries, they had similar failure rates of NOM when compared with younger adults. Older adults had significantly higher mortality, but this was not a result of their splenic injury. Therefore, age should not be a criteria for NOM of blunt splenic injury.

Nonoperative management of solid organ injuries. Past, present, and future

All patients with injuries to the solid organs of the abdomen and who are hemodynamically stable should be considered candidates for nonoperative management after their injuries have been staged by abdominal CT scanning, but because the CT stage of the injury does not always predict which patients require laparotomy, these patients must remain under the care of experienced trauma surgeons who can not only recognize the presence of an associated hollow viscus injury in need of repair but also will be readily available to operate if the nonoperative approach fails. Until continued bleeding can be safely ruled out, a period of close monitoring in an ICU-like setting seems warranted. Although delayed bleeding from the liver seems extremely rare, delayed rupture of the spleen and continued hemorrhage into the retroperitoneum from an injured kidney are not unusual, so patients with splenic and renal injuries should be considered candidates for repeat imaging procedures before discharge. Others likely to benefit from a second look at their injuries include patients with subcapsular hematomas, patients with recognized extravasation on the initial scan, and athletes anxious to return to contact sports. Experience from major trauma centers suggests that the incidence of missed intestinal injuries is low in adults and children managed nonoperatively, but surgeons must be diligent in monitoring for increasing abdominal pain, abdominal distention, vomiting, and signs of inflammation, which may be delayed manifestations of intestinal disruption. Patients with vascular injuries (grade V injuries to the spleen, liver, or kidney) may be candidates for radiologic procedures, such as angioembolization or stenting, but some of these patients are best served by immediate laparotomy. Selected patients with penetrating injuries may also be candidates for the nonoperative approach, but further research in this area is needed before this approach can be widely embraced. As we approach the year 2000, the nonoperative approach to hepatic, splenic, and renal injuries will continue to have a major role in the treatment of trauma patients. Currently, the morbidity and mortality rates of nonoperative management are acceptably low, but surgeons still must monitor their results carefully as they apply these methods more liberally among injured patients.

[Videolaparoscopic treatment of splenic injuries. A study of 5 cases]

BACKGROUND

When splenic trauma does not require an emergency splenectomy in order to achieve hemostasis, the current policy is either observation under close surveillance, with transfusions if necessary, or conservative surgical procedure through laparotomy. Videolaparoscopic approach has the advantage of achieving in the same procedure, complete evacuation of the hemoperitoneum, full investigation of the abdominal cavity and repair of the damaged spleen.

PATIENTS AND METHODS

Over a 4-year period, five patients aged 27.3 years on average, with severe splenic trauma but no major hemodynamic disturbance, were operated on by emergency laparoscopy. The diagnosis of splenic lesion had been confirmed preoperatively by ultrasonography. The procedure performed by open laparoscopy included evacuation of the hemoperitoneum and blood clots and splenic hemostasis which was achieved by the use of electrocoagulation and biological glue, associated in three cases with omentoplasty. Drains were inserted systematically.

RESULTS

The average length of operation was 75 min. There were no cases of conversion, nor mortality, no morbidity. The average duration of hospitalization was 10 days. No blood transfusions were required. A CT-scan was performed immediately in the postoperative course and served as the baseline for comparison during the follow-up. There were no reinterventions. The longest follow-up was 4 years and the mean follow-up 2.5 years. Laboratory tests or isotopic imaging did not detect any change in splenic function.

CONCLUSION

In specific defined circumstances, videolaparoscopic repair of splenic trauma is justified provided that careful attention is paid to the patient's condition.