Splenic preservation in adults after blunt and penetrating trauma

Avitene™ Microfibrillar Collagen Hemostat for Adjunctive Hemostasis in Surgical Procedures: A Systematic Literature Review

Adequate hemostasis during surgical procedures is essential for successful patient outcomes and reduced healthcare resource utilization. Topical hemostatic agents can act as catalysts for the clotting cascade or as a scaffold to promote platelet activation or aggregation. Although an ever-increasing number of topical absorbable hemostatic agents are now available for perioperative use, health care providers are disadvantaged by the lack of comparative data on feasibility, clinical effectiveness, advantages, and limitations of each in specific surgical settings. This knowledge is important for appropriate product choice when patient characteristics, type of surgical procedure, type of bleeding, and product availability may differ widely. This manuscript provides the first comprehensive overview of Avitene™ Microfibrillar Collagen Hemostat (MCH), a bovine collagen-based absorbable hemostat that has been widely used for over four decades in the United States and abroad. MCH is indicated as an adjunct to hemostasis across a broad spectrum of surgical specialties and has been shown to achieve hemostasis with positive patient outcomes and a favorable safety profile in many applications, including hepatic, orthopedic, splenic, oral, and otolaryngologic surgery. Although published clinical data regarding the use of MCH in cardiovascular surgery is limited, evidence suggests moderate use in this specialty. The information contained in this systematic review will help health care providers understand the clinical use and effectiveness of the product to determine appropriate use in differing bleeding scenarios across multiple surgical specialties. Future studies may include comparative functional and cost analyses to explore the economic advantages of using absorbable hemostatic agents compared with each other or with conventional techniques of hemostasis, when appropriate.

A new method to approach exact hemoperitoneum volume in a splenic trauma model using ultrasonography

In the trauma setting, the Focused Assessment for the Sonographic examination of the Trauma patient (FAST) accurately detects hemoperitoneum. Currently, only an approximate evaluation of the volume of free intraperitoneal fluid (FIPF) can be done by imaging modalities such as ultrasound (US). The aim of this study was to correlate the thickness of FIPF measured by US in different sites of the peritoneal cavity with the total volume of an experimental post-traumatic hemoperitoneum. An intra-abdominal collection with ongoing bleeding was simulated in eight cadavers with no previous abdominal surgery. Between 200 and 2000 ml of saline solution was instilled into the left hypochondrium of eight non-embalmed cadavers. During the instillation, FIPF thickness was measured every 200 ml by US in six different declivous sites of the peritoneal cavity. The volume of FIPF instilled could be mathematically correlated with fluid thickness in all the sites through the linear equation Y=aX+b, where Y is the volume of FIPF in milliliters, a is 33 (variability coefficient), X is the FIPF thickness in millimeters and b is 470 ml (minimum volume detectable by US). The best correlation between thickness and volume was obtained in the hepatorenal pouch (Morrison pouch). Evaluation of the impact of intraperitoneal hemorrhage on the hemodynamic state of spleen trauma patients is of paramount importance for the surgeon, who has to decide whether to perform a laparotomy for hemostasis or not, specially when intra- and extra-abdominal injuries conjointly exist. After clinical validation, this new method to calculate the exact volume of FIPF could be used in current clinical practice of abdominal trauma to assist in the decision-making regarding non-operative treatment of spleen trauma.

A safe surgical technique for the partial resection of the ruptured spleen. A clinical report

A consecutive series of 11 patients with an acute blunt splenic injury were treated with a 'safe resection' technique. 57% of the injured spleens (range 35-100%) were saved. None of the patients had any signs of secondary bleeding in control CT scan and the mortality was zero. No second-look laparotomies were performed. Follow-up time was at least two months (range 2 month-6 yr). Operation time was in average 120 min. Total mean peroperative bleeding was 1400 ml. Partial resection may offer patient a change for normal function of the injured spleen. However, it is not yet known what is the critical mass of spleen tissue needed for humans. The follow-up time of the present study is still too short to estimate this fact, but further studies may show the benefit of the present method in avoiding serious long term immunological complications of splenectomy. This present study introduces a novel technique for partial resection of injured spleen. Operation can be performed safely and quickly with a complication risk comparable to splenectomy. Resection is applicable even for multi-trauma patients.

Anatomical and surgical aspects of splenic segmentectomies

Based upon the anatomicosurgical segments of the spleen, suggested by DiDio and demonstrated in cadavers, classified and named by Neder (1958) and Zappalá (1958, 1959, 1963), the normal segmental organization was anatomically and radiologically confirmed in 51 human spleens, after studying corrosion casts and radiograms of intraparenchymal vessels (Christo, 1959 a, b, 1960, 1962, 1963, 1993). From 1958 to 1965, pioneer segmental resections were performed successfully in 34 dogs and in 9 patients to safely remove traumatic injured splenic segments. At the same time, the overwhelming postsplenectomy infection (OPSI) became well identified. Consequently, to save normally functioning splenic parenchyma became the most important issue in the management of splenic injuries. The anatomical basis for partial splenectomy and splenic segmentectomy is discussed. The term "splenorrhaphy" was employed to designate all conservative or parenchyma saving operations of spleen based upon its vascular supply: from topical packings to splenic sutures including "cappings" and partial splenectomies. From analysis of 38 consecutive reports in 20 years, covering 4,076 patients, it was concluded that "splenorrhaphies" had been electively employed in 46% of the injuries and partial splenectomies were identified in 8.6% of these surgical interventions. However, the critical minimal mass of splenic tissue to be preserved after partial splenectomies is still to be defined. Postoperative complications directly related to "splenorrhaphies" are rare. Uncommonly performed after splenectomies, the heterotopical splenic autotransplantation has presented dubious results. Trials with nonoperative management of splenic blunt trauma injuries have been safer among children, whose spleens are predominantly transversally disrupted and have a higher relationship "capsular resistance/parenchymal bulk". Splenectomies have been most frequently the ultimate result of delayed laparotomy and underlying risks of growing blood requirements may surpass the advantages of preventing OPSI.

Use of biodegradable (PGA) fabric for repair of solid organ injury: a combined institution experience

A fabric constructed of biodegradable mesh was used in the operative repair of injured intra-abdominal organs in 60 patients at two Level I Trauma Centres. Splenorrhaphy was performed in 44 patients, hepatorrhaphy in eight, renorrhaphy in five and one combined repair of spleen and liver and one kidney and liver. The age range for the patients was 5 to 61 years. Multiple-organ injury occurred in 21 patients. Mean emergency room systolic BP for the patient series was 120 +/- 24 mmHg (SD), Glasgow Coma Scale 14.3 +/- 1.9, haematocrit 37.2 +/- 6.4 per cent, Injury Severity Score (ISS) 28.1 +/- 16.3, Abdominal Trauma Index (ATI) 15.5 +/- 7.5. Postoperative complications occurred in 36.7 per cent of patients. Time for the operation averaged 165.1 + 72.1 min and preoperative and operative transfusion volume averaged 2248 ml. There were three deaths (5.4 per cent). The mesh organ repair technique is an alternative to conventional surgical procedures used to control bleeding from injured organ surfaces and to close organ parenchymal defects.

Clinical use of the absorbable spleen net in stellate rupture of spleen in children

This paper reports three cases of stellate rupture of the spleen in children treated by wrapping with the omentum, following the use of the absorbable spleen net (ASN), which is made of the ordinary surgical sutures. All patients were cured with spleen preservation. No complications occurred.

Splenic salvage using an absorbable mesh: feasibility, reliability and safety

Forty-nine adults underwent surgery for splenic injury: 17 (group 1) had salvage with a splenic mesh, seven (group 2) underwent other preservation techniques, and 25 (group 3) underwent splenectomy. There were six, zero and 11 hilar lesions in groups 1, 2 and 3, respectively. Seven of 15 associated lesions involved the digestive tract. There was no significant difference in transfusion requirements, length of operation or postoperative complications. One patient died in each of groups 1 and 2, and eight in group 3. Secondary splenectomy was performed once in groups 1 and 2. The duration of hospital stay was shorter in the preservation groups (1 and 2) than in group 3. Splenic preservation was feasible in 24 of 49 adults with splenic injury requiring surgery. The splenic mesh wrap is safe and reliable, and allows splenic salvage even with hilar injury.

Management of splenic trauma

This article examines the current management of trauma to the spleen. The incidence, mechanism, classification, diagnosis, treatment and complications of splenic trauma are reviewed. Modern radiological investigations are assessed in view of the recent vogue for non-operative management. The effects of splenectomy and particularly of overwhelming postsplenectomy sepsis are discussed. The role of non-operative management of splenic injuries in children and in adults without associated injuries is emphasized. Means of repairing and preserving the spleen are detailed. Prompt splenectomy is necessary in seriously traumatized patients, especially those with head or multiple injuries.

Non-operative management of blunt splenic trauma: a 10-year experience

There is growing awareness that the majority of traumatic splenic injuries should be managed non-operatively. This review of all traumatic spleen injuries at a large community teaching hospital over a 10-year period (1978-1988) confirms that principle. The study generated selection criteria and principles of non-operative management. Of a total of 91 patients, 23 were initially treated non-operatively. The average age was 27 years and all but two were adults. Splenic injury was confirmed by computed tomography scan in 20 patients (87 per cent) and by liver/spleen scan in three patients (13 per cent). Of the 23 patients, 21 (91 per cent) were successfully treated non-operatively. Of these, 14 had intraparenchymal or subcapsular haematomas and seven had splenic lacerations with haemoperitoneum. Two patients (9 per cent) initially treated non-operatively required splenectomy. Haemodynamically stable adult patients with blunt splenic injuries can be managed non-operatively if monitored in a setting where immediate operative intervention is available. Operative intervention is indicated not only in haemodynamically unstable patients, but also in patients who require more than four units of blood during a 48-h period.

Management of splenic injuries

The structure and function of the spleen are reviewed in the context of providing a rational basis for splenic salvage after trauma. Guidelines for operative and nonoperative management are provided, and the results of treatment from recent large series are summarized.

Splenorrhaphy. The alternative

From 1980 to 1989, 240 adult patients underwent splenorrhaphy at one urban trauma center. This represents 43.4% of all splenic injuries seen during this time interval. Splenic injuries were graded I to V, and splenorrhaphy was attempted except when the spleen was shattered or when multiple injuries with associated hypotension were present. Penetrating wounds, blunt trauma, or iatrogenic/unknown etiologies were present in 54.2%, 41.6%, and 4.2% of patients, respectively. Grade I or II injuries were present in 51.7% of patients, grade III in 34.6%, grade IV or V in 9.6%, and unknown grade in 4.1%. The technique of splenorrhaphy was simple suture (usually chromic) with or without the addition of topical hemostatic agents in 200 patients (83.3%), topical agents alone in 12 (5%), unknown type of repair in 12 (5%), compression, cautery, or nonbleeding injury in 9 (3.8%), and partial or hemisplenectomy in 7 (2.9%). Postoperative rebleeding occurred in three patients (1.3%) with grade II, III, and IV injuries, respectively, and led to splenectomy at reoperation. In another patient who had a hemisplenectomy performed for a grade IV injury, subphrenic abscesses and septic shock led to the death of the patient. Splenorrhaphy can be safely performed in properly selected adult patients after a variety of injuries. The risk of rebleeding is practically nil when the spleen is fully mobilized and visualized during repair.

Evaluation of splenic injury by computed tomography and its impact on treatment

We reviewed 37 consecutive, hemodynamically stable patients (16 adults, 21 children) who had splenic injuries diagnosed by computed tomography (CT) scan to compare the CT evaluation with operative assessment of injury and eventual treatment. Computed tomographic scans and operative findings were graded by a splenic injury scoring system. Two patients were classified as having grade 1, 21 as grade 2, 11 as grade 3, and 3 as grade 4 splenic injuries. Computed tomography underestimated the degree of injury in 9 of 17 (53%) operated patients (mean CT score, 2.6; mean operative score, 3.3; p less than 0.01). Six of sixteen adults and 19 of 21 children were intentionally treated by observation. There were 5 treatments failures (20%), 3 due to bleeding and 1 each due to pancreatic injury and splenic abscess. The failure rate of observation was lower in children (16%) than in adults (33%), even though children had a higher Splenic Injury Score (2.4 versus 1.8). Patients who underwent an operation received twice as much blood as the observed group. There was no significant difference in Injury Severity Score or total fluid requirements between operated and observed patients. Operations increased in frequency in both adults and children as the injury score increased. This experience suggests that CT scan accurately determines the presence of splenic injury but commonly underestimates its severity. While children with grades 1 through 3 injuries are likely to be treated successfully with observation, adults who have more minor splenic injuries often fail observation and may be treated better by prompt operation.

Splenic resection with the Contact Nd:YAG laser system

Splenic resection in the dog was proven to have decreased blood loss (52%), decreased operating time (44%), and decreased surgical manipulation using the SLT Contact Nd:YAG Laser System with the synthetic sapphire probe, as compared with the noncontact CO2 laser. Tissue damage and hematologic changes were minimal and equivalent in both laser systems. The overall ease of use and operating technique was subjectively better with the contact Nd:YAG laser, and the danger of scattered and reflective beam damage was eliminated. The contact Nd:YAG laser with the synthetic sapphire probes offers a significant advantage over the noncontact CO2 laser in the resection of splenic tissue. Future applications in pediatric surgery now need to be evaluated.

Traumatic rupture of the spleen in the rural tropics. A personal experience and suggestions for its management

Five patients with traumatic rupture of the spleen were treated in a rural 67-bed mission hospital during a one-year period. All had symptoms and signs of major intra-abdominal haemorrhage and were subjected to laparotomy. All five had splenectomy performed, as none were considered suitable for splenic preservation. The problems associated with splenic trauma in the tropics are discussed and suggestions made for its management.

[Risk of infection and surgical consequences of splenic loss in childhood]

Among 1882 splenectomized children with a mean follow-up period of more than 5 years the incidence of sepsis was 3.2% with a mortality of 1.4%. As expected the lowest risk (1.6%) was found in case of trauma. Susceptibility to sepsis increases after splenectomy caused by severe disease. It was highest (9.8%) in case of M. Hodgkin, portal hypertension and thalassemia. The younger the patient the higher the risk of PSI. 55% of the affected patients suffered from sepsis within the first two years, 35% after three up to six years. Vaccination and antibiotic prophylaxis are recommended including information about the risk of sepsis. Preservation of orthotopic splenic tissue, if indicated, should be the surgical consequence in childhood.

[Differential indications of conservative and surgical possibilities of treating splenic rupture]

Conservative therapy of splenic trauma in the adult cannot be recommended, since 2/3 of patients with polytrauma will prove to have additional abdominal organ lacerations. The new methods of local haemostasis, suture and partial resection and their application and contraindications according to Barrett's classification of splenic trauma are discussed. Our own salvage rate has been 50% (70/140) in trauma and 77% (116/151) in iatrogenic lacerations during the past 5 years.

Multisystem trauma

Several unique features of childhood anatomy and physiology mandate an approach to evaluation and treatment of multiply injured children that differs from that applied to adults. Details of this approach have been presented, with particular emphasis, on early, aggressive multimodal imaging, nonoperative management of splenic, hepatic, renal, and duodenal injuries, and specific aids in early precise definition of extent of injury (contrast-enhanced CT, serum levels of hepatic enzymes, and diagnostic peritoneal lavage). The outcome of this approach preserves maximum function and minimizes morbidity when performed in an institution having the requisite supportive resources.

Patterns of infection and mortality in thoracic trauma

Tissue infection and systemic sepsis are common causes of morbidity and late mortality after major thoracic trauma. To seek causative mechanisms, prognostic indicators, and areas of possible improvement in therapy, we reviewed 310 consecutive adults admitted with major thoracic trauma. Of these, 56 (18%) died of massive injuries in the first 5 days; the remaining 254 were considered at risk for infectious complications. There were 21 late deaths in this group, and 15 (71%) were caused by systemic sepsis. Eighty-four patients (33%) developed thoracic infections, and 15 (6%) had significant nonthoracic infections. Markers of increased risk of infection included blunt injury, shock and unconsciousness on arrival, and splenectomy. Pulmonary infection was increased significantly following prolonged endotracheal intubation, but was virtually absent following tracheostomy. The risk of infection was increased significantly if prophylactic antibiotics were not used, but no definite correlation could be made to advanced age, pre-existent disease, nor post-traumatic malnutrition. Attention to some of these factors may decrease the risk of infection in thoracic trauma.

A four-year experience with splenectomy versus splenorrhaphy

From 1980 to 1984, 326 patients requiring splenectomy or splenorrhaphy were treated at one urban trauma center. Splenic injuries were graded in severity from one to five at the time of celiotomy. Splenorrhaphy was attempted in all patients, except when the spleen was shattered or avulsed or when multiple injuries were present. The mechanisms of injury were: penetrating wounds in 51.2%, blunt trauma in 46%, and iatrogenic mishaps in 2.8% of patients. Grade 1 or 2 injuries were present in 23.9%, Grade 3, 4, or 5 injuries were present in 59.8%. Spleens removed or repaired with unknown grading or removed as part of distal pancreatectomies accounted for 16.3% of patients. Excluding uninjured spleens removed with pancreatectomies, 55.4% (169) of injured spleens required splenectomy and 44.6% (136) had a splenorrhaphy performed. Splenorrhaphy was most commonly performed with chronic suture with or without the addition of topical agents. Grade 1 and 2 injuries were repaired in 88.5%; Grade 3 injuries were repaired in 61.5%; and Grade 4 and 5 injuries were repaired in 7.7% of patients. Splenectomy is generally performed in patients with multiple associated intraabdominal injuries and the more severe grades of splenic injury, and has a mortality rate 13.5 times as great as that for patients undergoing splenorrhaphy. Splenorrhaphy can be performed in approximately 50% of patients with injured spleens and has practically no risk of rebleeding.

Changing trends in the diagnosis and management of rupture of the spleen

In this series of 80 consecutive patients with injured spleens scintigraphy was the diagnostic mainstay and was performed in 63 patients. Fifty-five patients were initially managed without operation. Two of them, however, underwent laparotomy respectively 1 and 2 days after admission because of increasing symptoms and signs. Twenty-seven patients underwent laparotomy, with successful conservative surgery in 8 and splenectomy in 19. However, in at least five of these it was thought in retrospect that repair of the spleen might have been possible. There were no deaths or serious morbidity from the injury to the spleen. It is concluded that no operation or operative repair of the spleen is the treatment of choice in the majority of patients with blunt injuries. In order to avoid loss of life as well as loss of the spleen, strict adherence to an aggressive, exact diagnostic process, using non-invasive diagnostic imaging and close clinical observation, as well as experienced, painstaking surgical techniques, is necessary.

Management of injury to the spleen in adults. Results of early operation and observation

Seventy-seven adults with splenic trauma were treated at a Level I Trauma Center during a 4-year period. Sixty-seven patients had early operation (55 splenectomy, nine splenorrhaphy, three partial splenectomy). Ten adults with stable vital signs were initially managed by observation without operation. Patients who had other intra-abdominal injuries were more likely to have an early operation and splenectomy. Patients who had a lesser transfusion requirement were more likely to have initial nonoperative management. Only three of the 10 patients who were managed initially by observation avoided eventual operation. Six of the seven patients who failed observation management required splenectomy. Patients with isolated splenic injuries had a significantly shorter hospital stay after an early operation than after observation without operation (p less than 0.05). We recommend early operation for the management of splenic injury in adults. Observation of isolated splenic injuries frequently is unsuccessful in adults and unnecessarily prolongs hospital stay.

Risk of splenic salvage after trauma. Analysis of 200 adults

This review was undertaken to analyze critically the complications resulting from operative splenic salvage. Over a 6 year period, 200 adults who sustained splenic trauma underwent laparotomy. The mechanism of injury was blunt in 138 patients (69 percent), a stab wound in 32 patients (16 percent), and a gunshot wound in 30 patients (15 percent). Splenorrhaphy was accomplished in 85 patients (42 percent). Methods of repair included cautery and hemostatic agents in 24 patients (28 percent), debridement and suturing in 42 patients (50 percent), and partial resection in 19 patients (22 percent). Six patients died, four from head trauma and two from multiple organ failure. Postoperative complications occurred in 14 patients. Four were intraabdominal. Three patients required reoperation for splenic hemorrhage; one (2 percent) after suture repair and two (11 percent) after partial resection. A left subphrenic abscess developed in another patient. Splenic reimplantation was performed in 43 patients (22 percent). Five deaths occurred. One was due to head trauma, three to multiple organ failure, and one to overwhelming pneumococcal infection. Eleven postoperative complications occurred, but none was related to splenic autotransplantation. Despite the enthusiasm for splenic salvage, the number of patients suitable for splenorrhaphy plateaued at 56 percent. Complications of splenorrhaphy are infrequent, and the risk increases with more complex salvage attempts. We believe that splenic reimplantation remains a safe procedure.