1
|
Schild-Suhren S, Zygmunt AC, Biggemann L, Hosseini ASA, Ghadimi M, Bösch F. [Treatment recommendation and care in traumatic rupture of the spleen]. CHIRURGIE (HEIDELBERG, GERMANY) 2023:10.1007/s00104-023-01873-2. [PMID: 37115223 DOI: 10.1007/s00104-023-01873-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 04/29/2023]
Abstract
The spleen is the most frequently affected organ in blunt abdominal trauma. Initial diagnostics include the physical examination, laboratory blood controls and ultrasound. Furthermore, a triphasic dynamic contrast-enhanced computed tomography (CT) scan is indicated. Apart from the imaging-based classification of the injury with consideration of vascular alterations and active bleeding, the hemodynamic condition of the patient is a crucial factor. For patients who are hemodynamically stable or can be stabilized, a nonoperative management with a minimum of 24 h of continuous monitoring, regular blood controls of the hemoglobin level as well as ultrasound follow-up should be given precedence. In cases of active bleeding or pathological vascular alterations, a radiological intervention in the sense of an embolization should be initiated. A hemodynamically unstable patient must immediately undergo surgical treatment, during which a spleen-preserving approach via splenorrhaphy should principally be favored over splenectomy. This also applies to patients where the intervention has failed. To prevent severe infections after splenectomy it is advised to vaccinate against Pneumococcus, Haemophilus influenzae type B and Meningococcus as well as the annual seasonal influenza vaccination according to the Standing Committee on Vaccination (STIKO) recommendations.
Collapse
Affiliation(s)
- Stina Schild-Suhren
- Klinik für Allgemein‑, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Anne-Christine Zygmunt
- Klinik für Allgemein‑, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Lorenz Biggemann
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Ali Seif Amir Hosseini
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Michael Ghadimi
- Klinik für Allgemein‑, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Florian Bösch
- Klinik für Allgemein‑, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| |
Collapse
|
2
|
Arvieux C, Frandon J, Tidadini F, Monnin-Bares V, Foote A, Dubuisson V, Lermite E, David JS, Douane F, Tresallet C, Lemoine MC, Rodiere M, Bouzat P, Bosson JL, Vilotitch A, Barbois S, Thony F. Effect of Prophylactic Embolization on Patients With Blunt Trauma at High Risk of Splenectomy: A Randomized Clinical Trial. JAMA Surg 2021; 155:1102-1111. [PMID: 32936242 DOI: 10.1001/jamasurg.2020.3672] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Splenic arterial embolization (SAE) improves the rate of spleen rescue, yet the advantage of prophylactic SAE (pSAE) compared with surveillance and then embolization only if necessary (SURV) for patients at high risk of spleen rupture remains controversial. Objective To determine whether the 1-month spleen salvage rate is better after pSAE or SURV. Design, Setting, and Participants In this randomized clinical trial conducted between February 6, 2014, and September 1, 2017, at 16 institutions in France, 133 patients with splenic trauma at high risk of rupture were randomized to undergo pSAE or SURV. All analyses were performed on a per-protocol basis, as well as an intention-to-treat analysis for specific events. Interventions Prophylactic SAE, preferably using an arterial approach via the femoral artery, or SURV. Main Outcomes and Measures The primary end point was an intact spleen or a spleen with at least 50% vascularized parenchyma detected on an arterial computed tomography scan at 1 month after trauma, assessed by senior radiologists masked to the treatment group. Secondary end points included splenectomy and pseudoaneurysm, secondary SAE after inclusion, complications, length of hospital stay, quality-of-life score, and length of time off work or studies during the 6-month follow-up. Results A total of 140 patients were randomized, and 133 (105 men [78.9%]; median age, 30 years [interquartile range, 23-47 years]) were retained in the study. For the primary end point, data from 117 patients (57 who underwent pSAE and 60 who underwent SURV) could be analyzed. The number of patients with at least a 50% viable spleen detected on a computed tomography scan at month 1 was not significantly different between the pSAE and SURV groups (56 of 57 [98.2%] vs 56 of 60 [93.3%]; difference, 4.9%; 95% CI, -2.4% to 12.1%; P = .37). By the day 5 visit, there were significantly fewer splenic pseudoaneurysms among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 8 of 65 [12.3%]; difference, -10.8%; 95% CI, -19.3% to -2.1%; P = .03), significantly fewer secondary embolizations among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 19 of 65 [29.2%]; difference, -27.7%; 95% CI, -41.0% to -15.9%; P < .001), and no difference in the overall complication rate between the pSAE and SURV groups (19 of 65 [29.2%] vs 27 of 65 [41.5%]; difference, -12.3%; 95% CI, -28.3% to 4.4%; P = .14). Between the day 5 and month 1 visits, the overall complication rate was not significantly different between the pSAE and SURV groups (11 of 59 [18.6%] vs 12 of 63 [19.0%]; difference, -0.4%; 95% CI, -14.4% to 13.6%; P = .96). The median length of hospitalization was significantly shorter for patients in the pSAE group than for those in the SURV group (9 days [interquartile range, 6-14 days] vs 13 days [interquartile range, 9-17 days]; P = .002). Conclusions and Relevance Among patients with splenic trauma at high risk of rupture, the 1-month spleen salvage rate was not statistically different between patients undergoing pSAE compared with those receiving SURV. In view of the high proportion of patients in the SURV group needing SAE, both strategies appear defendable. Trial Registration ClinicalTrials.gov Identifier: NCT02021396.
Collapse
Affiliation(s)
- Catherine Arvieux
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Julien Frandon
- Department of Imaging and Interventional Radiology, Nîmes University Hospital (CHU), Nîmes, France
| | - Fatah Tidadini
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Valérie Monnin-Bares
- Department of Imaging and Interventional Radiology, Montpellier University Hospital (CHU), Montpellier, France
| | - Alison Foote
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Vincent Dubuisson
- Department of Vascular and General Surgery, Bordeaux University Hospital (CHU), Bordeaux, France
| | - Emilie Lermite
- Department of Visceral Surgery, Angers University Hospital (CHU), Angers, France
| | - Jean-Stéphane David
- Department of Anesthesia and Intensive Care, Lyon-Sud University Hospital (CHU), Pierre Bénite, France
| | - Frederic Douane
- Department of Imaging and Interventional Radiology, Nantes University Hospital (CHU), Nantes, France
| | - Christophe Tresallet
- Department of General, Digestive, Oncologic, Bariatric, and Metabolic Surgery, Avicenne University Hospital (CHU), Bobigny, France
| | | | - Mathieu Rodiere
- Department of Imaging and Interventional Radiology, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Pierre Bouzat
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Jean-Luc Bosson
- Department of Medical Information, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Antoine Vilotitch
- Department of Medical Information, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Sandrine Barbois
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Frédéric Thony
- Department of Imaging and Interventional Radiology, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | | |
Collapse
|
3
|
Coccolini F, Kobayashi L, Kluger Y, Moore EE, Ansaloni L, Biffl W, Leppaniemi A, Augustin G, Reva V, Wani I, Kirkpatrick A, Abu-Zidan F, Cicuttin E, Fraga GP, Ordonez C, Pikoulis E, Sibilla MG, Maier R, Matsumura Y, Masiakos PT, Khokha V, Mefire AC, Ivatury R, Favi F, Manchev V, Sartelli M, Machado F, Matsumoto J, Chiarugi M, Arvieux C, Catena F, Coimbra R. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg 2019; 14:56. [PMID: 31867050 PMCID: PMC6907251 DOI: 10.1186/s13017-019-0278-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022] Open
Abstract
Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.
Collapse
Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Leslie Kobayashi
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital, La Jolla, CA USA
| | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Imitiaz Wani
- Department of Surgery, DHS Hospitals, Srinagar, Kashmir India
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta Canada
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Gustavo Pereira Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Carlos Ordonez
- Trauma and Acute Care Surgery, Fundacion Valle del Lili, Cali, Colombia
| | - Emmanuil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Maria Grazia Sibilla
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Yosuke Matsumura
- Department of Emergency and Critical Care Medicine, Chiba University Hospital, Chiba, Japan
| | - Peter T. Masiakos
- Pediatric Trauma Service, Massachusetts General Hospital, Boston, MA USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mazyr, Belarus
| | - Alain Chichom Mefire
- Department of Surgery and Obstetrics and Gynecology, University of Buea, Buea, Cameroon
| | - Rao Ivatury
- General and Trauma Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Francesco Favi
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Fernando Machado
- General and Emergency Surgery Department, Montevideo Hospital, Montevideo, Uruguay
| | - Junichi Matsumoto
- Department of Emergency and Critical Care Medicine, Saint-Marianna University School of Medicine, Kawasaki, Japan
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Catherine Arvieux
- Clin. Univ. de Chirurgie Digestive et de l’Urgence, CHUGA-CHU Grenoble Alpes, UGA-Université Grenoble Alpes, Grenoble, France
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | - Raul Coimbra
- Department of General Surgery, Riverside University Health System Medical Center, Moreno Valley, CA USA
| |
Collapse
|
4
|
Di Re AM, Adusumilli S, O'Grady G, Lam V. Acute surgical experience of Australian general surgical trainees. ANZ J Surg 2019; 89:1432-1436. [DOI: 10.1111/ans.15388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Angelina M. Di Re
- Department of General Surgery, Westmead Hospital Sydney New South Wales Australia
| | - Sanjay Adusumilli
- Department of General Surgery, Blacktown Hospital Sydney New South Wales Australia
| | - Greg O'Grady
- Department of Colorectal Surgery, Auckland City Hospital Auckland New Zealand
| | - Vincent Lam
- Department of General Surgery, Westmead Hospital Sydney New South Wales Australia
| |
Collapse
|
5
|
Roy P, Mukherjee R, Parik M. Splenic trauma in the twenty-first century: changing trends in management. Ann R Coll Surg Engl 2018; 100:1-7. [PMID: 30112955 PMCID: PMC6204520 DOI: 10.1308/rcsann.2018.0139] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2018] [Indexed: 12/16/2022] Open
Abstract
Over the past three decades, management of blunt splenic trauma has changed radically. Use of improved diagnostic techniques and proper understanding of disease pathology has led to nonoperative management being chosen as the standard of care in patients who are haemodynamically stable. This review was undertaken to assess available literature regarding changing trends of management of blunt splenic trauma, and to identify the existing lacunae in nonoperative management. The PubMed database was searched for studies published between January 1987 and August 2017, using the keywords 'blunt splenic trauma' and 'nonoperative management'. One hundred and fifty-three articles were reviewed, of which 82 free full texts and free abstracts were used in the current review. There is clear evidence in published literature of the greater success of nonoperative over operative management in patients who are haemodynamically stable and the increasing utility of adjunctive therapies like angiography with embolisation. However, the review revealed a lack of universal guidelines for patient selection criteria and diagnostic and grading procedures needed for nonoperative management. Indications for splenic artery embolisation, the current role of splenectomy and spleen-preserving surgeries, together with the place of minimal access surgery in blunt splenic trauma remain grey areas. Moreover, parameters affecting the outcomes of nonoperative management and its failure and management need to be defined. This shows a need for future studies focused on these shortcomings with the ultimate aim being the formulation and implementation of universally accepted guidelines for safe and efficient management of blunt splenic trauma.
Collapse
Affiliation(s)
- P Roy
- RG Kar Medical College and Hospital, General Surgery, Kolkata, India
| | - R Mukherjee
- RG Kar Medical College and Hospital, General Surgery, Kolkata, India
| | - M Parik
- RG Kar Medical College and Hospital, General Surgery, Kolkata, India
| |
Collapse
|
6
|
Jambon E, Hocquelet A, Petitpierre F, Le Bras Y, Marcelin C, Dubuisson V, Grenier N, Cornelis F. Proximal embolization of splenic artery in acute trauma: Comparison between Penumbra occlusion device versus coils or Amplatzer vascular plug. Diagn Interv Imaging 2018; 99:801-808. [PMID: 29910169 DOI: 10.1016/j.diii.2018.05.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 04/14/2018] [Accepted: 05/16/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare intervention duration and fluoroscopy time for proximal embolization of splenic arteries in acute trauma using the Penumbra occlusion device (POD®), coils or Amplatzer™ vascular plug (AVP). MATERIAL AND METHODS A total of 29 patients with splenic injury without vascular injury who were treated by proximal splenic artery embolization using POD® (n=12), coils (n=9) or AVP (n=8) were retrospectively included. There were 25 men and 4 women with a median age of 34 years (range: 10-69 years). To overcome bias in treatment choice, a propensity score was used using inverse probability weighting. Intervention duration and fluoroscopy time, treatment success and complications were compared. RESULTS The median intervention duration was significantly shorter using POD® (30min) or AVP (47min) than using coils (60min) (P=0.0001 and 0.004, respectively). The median fluoroscopy time was significantly lower using POD® (11.5min) than using coils (23.6min) (P=0.0076) or AVP (16.5min) (P=0.049). The primary efficacy rate was 100% with POD® and AVP and 89% with coils (P=0.586). Six complications occurred with a mean follow-up of 12 months for POD®, 32 months for coils and 40 months for AVP, consisting in 2 abscesses treated by anti-biotherapy with POD®, one abscess with AVP, 2 material migrations with coils and 1 coil dismantled without consequence. CONCLUSION POD® and AVP allow proximal embolization of splenic artery in acute trauma with shorter intervention duration by comparison with conventional metallic coils with similar technical success. POD® allows a shorter fluoroscopy time than coils or AVP.
Collapse
Affiliation(s)
- E Jambon
- Department of Radiology, Pellegrin University Hospital Center, place Amélie Raba Léon, 33076 Bordeaux, France.
| | - A Hocquelet
- Department of Radiology, Haut-Leveque University Hospital Center, avenue Magellan, 33600 Pessac, France; Department of Radiology, University Hospital Center, 46, rue du Bugnon, 1011 Lausanne, Switzerland
| | - F Petitpierre
- Department of Radiology, Pellegrin University Hospital Center, place Amélie Raba Léon, 33076 Bordeaux, France
| | - Y Le Bras
- Department of Radiology, Pellegrin University Hospital Center, place Amélie Raba Léon, 33076 Bordeaux, France
| | - C Marcelin
- Department of Radiology, Pellegrin University Hospital Center, place Amélie Raba Léon, 33076 Bordeaux, France
| | - V Dubuisson
- Department of Surgery, Pellegrin Hospital, place Amélie Raba Léon, 33076 Bordeaux, France
| | - N Grenier
- Department of Radiology, Pellegrin University Hospital Center, place Amélie Raba Léon, 33076 Bordeaux, France
| | - F Cornelis
- Department of Radiology, Pellegrin University Hospital Center, place Amélie Raba Léon, 33076 Bordeaux, France; Department of Radiology, Tenon Hospital, AP-HP, 4, rue de la Chine, 75020 Paris, France
| |
Collapse
|
7
|
A comparison of the management of blunt splenic injury in children and young people-A New South Wales, population-based, retrospective study. Injury 2018; 49:42-50. [PMID: 28867641 DOI: 10.1016/j.injury.2017.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/25/2017] [Accepted: 08/11/2017] [Indexed: 02/02/2023]
Abstract
UNLABELLED The importance and safety of non-operative management (NOM) of Blunt Splenic Injury (BSI) has been established in children and adults over recent decades. However, studies have shown higher operation rates in adults. There is international evidence that when children are managed in adult centres, operation rates are higher while adolescents in paediatric centres, are operated on in line with paediatric guidelines. This difference between children and young adults, and the factors responsible, have not been examined in New South Wales (NSW). OBJECTIVE To use NSW hospital and mortality data to compare the characteristics of BSI in patients aged 0-16 to those aged 17-25, and determine factors related to operative management (OM) and splenic salvage in each group. METHODS Patients age 0-25 between July 2000 and December 2011, with a diagnosis of BSI, were identified in the NSW Admitted Patient Data Collection, and linked to deaths data from Registry of Births Deaths and Marriages and Bureau of Statistics. Operation rate was compared between the two groups. Univariable analysis was used to determine factors associated with OM. Multivariable logistic regression with stepwise elimination was then performed to determine likelihood of OM according to age group, adjusting for potential confounders. RESULTS 1986 cases were identified, with 422 (21.2%) managed operatively - 101/907 children (11.1%) and321/1079 (29.7%)young adults(p<0.001). Of these, 59 (58%) children underwent splenectomy compared with 233 (73%) young adults (p<0.001). OM increased significantly after the age of 12 (p=0.03), and the percentage almost tripled in the teenage years, coinciding with a higher proportion admitted to adult centres. OM doubled again in young adults(p<0.001), all of whom were managed away from paediatric centres. On multivariable analysis, factors significantly associated with operation included age over 16 (OR 2.82, 95%CI 2.10-3.81), splenic injury severity, associated thoracic, liver, pancreatic and hollow viscus injury, and blood transfusion. CONCLUSION While Paediatric Surgeons have wholeheartedly adopted non-operative management, away from paediatric centres, it is possible children and young people in NSW are undergoing operation unnecessarily. Further evaluation of the surgeon attitudes and institutional factors involved in the management of injured children and young people within the broad NSW trauma system is required.
Collapse
|
8
|
|
9
|
Bosch N, Renteria AS, Quillen K, Brauneis D, Santilli J, Kim D, Sanchorawala V. Nonoperative Management of Spontaneous Splenic Rupture in a Patient with Light-Chain Amyloidosis: A Case Report. J Vasc Interv Radiol 2015; 26:1578-80. [DOI: 10.1016/j.jvir.2015.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 04/24/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022] Open
|
10
|
|
11
|
Affiliation(s)
- C Arvieux
- Trauma System du Réseau Nord Alpin des Urgences (TRENAU), Université Joseph Fourier, Clinique universitaire de chirurgie digestive et de l'urgence, CHU de Grenoble, BP 217, 38043 Grenoble cedex 9, France.
| |
Collapse
|
12
|
Complications after laparotomy for trauma: a retrospective analysis in a level I trauma centre. Langenbecks Arch Surg 2014; 400:83-90. [PMID: 25534708 DOI: 10.1007/s00423-014-1260-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Laparotomy is a potential life-saving procedure after traumatic abdominal injury. There is limited literature about morbidity and mortality rates after trauma laparotomy. The primary aim of this study is to describe the complications which may occur due to laparotomy for trauma. METHODS Retrospective evaluated single-centre study with data registry up to 1 year after initial laparotomy for trauma was performed in a level 1 trauma centre in The Netherlands. Between January 2000 and January 2011, a total of 2390 severely injured trauma patients (ISS ≥ 16) were transported to the VUMC. Patient demographics; mechanism of injury; injury patterns defined by Abbreviated Injury Scale (AIS), Injury Severity Score (ISS) and Revised Trauma Score (RTS); surgical interventions and findings; and morbidity and mortality were documented. RESULTS A total of 92 trauma patients who underwent a trauma laparotomy met the inclusion criteria. Of these patients, 71 % were male. Median age was 37 years. Median ISS was 27. Mechanisms of injury comprised of car accidents (20 %), fall from height (17 %), motorcycle accidents (12 %), pedestrian/cyclist hit by a vehicle (9 %) and other in three patients (5 %). Penetrating injuries accounted for 37 % of the injuries, consisting of stab wounds (21 %) and gunshot wounds (16 %). Complications classified by the Clavien-Dindo Classification of Surgical Complications showed grade I complications in 21 patients (23 %), grade II in 36 patients (39 %), grade III in 21 patients (23 %), grade IV in 2 patients (2 %) and grade V in 16 patients (17 %). CONCLUSION Laparotomy for trauma has a high complication rate resulting in significant morbidity and mortality. Most events occur in the early postoperative period. Further prospective research needs to be conducted in order to identify possibilities to improve care in the future.
Collapse
|
13
|
Clark R, Hird K, Misur P, Ramsay D, Mendelson R. CT grading scales for splenic injury: why can't we agree? J Med Imaging Radiat Oncol 2011; 55:163-9. [PMID: 21501405 DOI: 10.1111/j.1754-9485.2011.02246.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Computed tomography (CT) has been proven to be able to accurately diagnose splenic injury. Many have published CT splenic injury grading scales to quantify the extent of injury. However, these scales have failed at predicting clinical outcomes and therefore cannot be used to accurately predict the need for intervention. We hypothesised that low interrater reliability is the reason why these scales have failed at predicting clinical outcomes. METHODS AND MATERIALS This is a retrospective study of patients who were admitted to the Royal Perth Hospital with blunt splenic injury as coded in the trauma registry. The abdominal CT images of these patients were reviewed by three consultant radiologists and were graded using the six different splenic injury grading scales. We assessed interrater reliability between each of the scales using generalised kappa and proportion of agreement calculations. RESULTS The images of 64 patients were reviewed. The interrater reliability yielded a generalised kappa score of 0.32-0.60 and proportion of agreement ranging from 34.4% to 65.5%. CONCLUSION The six studied CT splenic injury grading scales did not have a high enough interrater reliability to be adequate for clinical use. The poor interrater reliability is likely to contribute to the failure of the scales at predicting clinical outcomes. Further research to improve the interrater reliability is recommended.
Collapse
Affiliation(s)
- Rhys Clark
- University of Notre Dame Australia, School of Medicine, Fremantle, Western Australia, Australia.
| | | | | | | | | |
Collapse
|
14
|
McCarthy CJ, O'Brien GC, Kennedy J, Broe PJ. Splenic mass with remote trauma history: a management dilemma. Ir J Med Sci 2011; 180:553-5. [PMID: 21365317 DOI: 10.1007/s11845-010-0612-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2008] [Accepted: 09/17/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Delayed presentation of splenic trauma is a well described entity. METHOD We report two patients who presented with splenic abnormality found incidentally on imaging for other medical problems. A remote history of splenic trauma was elicited during clinical evaluation; 18 months in one patient and 11 years in the second patient. Both patients underwent surgical exploration. CONCLUSIONS Radiological investigations could not reassure us that the splenic abnormalities were benign, and their management was the subject of some debate.
Collapse
Affiliation(s)
- C J McCarthy
- Department of Surgery, Beaumont Hospital and RCSI, Dublin 9, Ireland
| | | | | | | |
Collapse
|
15
|
Heuer M, Taeger G, Kaiser GM, Nast-Kolb D, Kühne CA, Ruchholtz S, Lefering R, Paul A, Lendemans S. No further incidence of sepsis after splenectomy for severe trauma: a multi-institutional experience of The trauma registry of the DGU with 1,630 patients. Eur J Med Res 2010; 15:258-65. [PMID: 20696635 PMCID: PMC3351995 DOI: 10.1186/2047-783x-15-6-258] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective Non-operative management of blunt splenic injury in adults has been applied increasingly at the end of the last century. Therefore, the lifelong risk of overwhelming post-splenectomy infection has been the major impetus for preservation of the spleen. However, the prevalence of posttraumatic infection after splenectomy in contrast to a conservative management is still unknown. Objective was to determine if splenectomy is an independent risk factor for the development of posttraumatic sepsis and multi-organ failure. Methods 13,433 patients from 113 hospitals were prospective collected from 1993 to 2005. Patients with an injury severity score > 16, no isolated head injury, primary admission to a trauma center and splenic injury were included. Data were allocated according to the operative management into 2 groups (splenectomy (I) and conservative managed patients (II)). Results From 1,630 patients with splenic injury 758 patients undergoing splenectomy compared with 872 non-splenectomized patients. 96 (18.3%) of the patients with splenectomy and 102 (18.5%) without splenectomy had apparent infection after operation. Additionally, there was no difference in mortality (24.8% versus 22.2%) in both groups. After massive transfusion of red blood cells (> 10) non-splenectomy patients showed a significant increase of multi-organ failure (46% vs. 40%) and sepsis (38% vs. 25%). Conclusions Non-operative management leads to lower systemic infection rates and mortality in adult patients with moderate blunt splenic injury (grade 1-3) and should therefore be advocated. Patients with grade 4 and 5 injury, patients with massive transfusion of red blood cells and unstable patients should be managed operatively.
Collapse
Affiliation(s)
- M Heuer
- Department of General Surgery, University Hospital Essen, Essen, Germany
| | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Sabe AA, Claridge JA, Rosenblum DI, Lie K, Malangoni MA. The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16-year experience. THE JOURNAL OF TRAUMA 2009; 67:565-72; discussion 571-2. [PMID: 19741401 DOI: 10.1097/ta.0b013e3181b17010] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Nonoperative management (NOM) of blunt splenic injury has become the preferred treatment for hemodynamically stable patients. The application of splenic artery embolization (SAE) in NOM has been controversial. We hypothesized that incorporation of initial use of SAE into a practice protocol for patients at high risk for NOM failure (contrast extravasation or pseudoaneurysm on computed tomography, grade 3 injury with large hemoperitoneum, grade 4 injuries) would improve patient outcomes. METHODS A retrospective analysis of three continuums of practice was performed: group I (January 1991-June 1998), SAE not part of routine NOM; group II (July 1998-December 2001), introduction and discretionary use of SAE; and group III (January 2002-June 2007), standardized use of initial SAE for patients considered at high risk of nonoperative failure. The primary outcome measure was the success of NOM. Failure of NOM was defined as the need for abdominal operation. Secondary outcomes were mortality, length of stay, and splenic salvage. RESULTS Over 16 years, 815 patients with blunt splenic injury were treated at our level 1 trauma center. There were 222 patients in group I, 195 in group II, and 398 in group III. There was an increase in the use of SAE over time with a significant improvement in the utilization of NOM (61% in group I; 82% in group II; 88% in group III; p < 0.05). This was associated with an increase in successful NOM (77%, group I; 94%, group II; 97%, group III; p < 0.0001 group I vs. group II and III). Mortality, length of stay, and splenic salvage were similar in groups II and III but significantly improved when compared with group I. CONCLUSIONS The increased use of initial SAE in high-risk patients expanded the successful use of NOM but was not associated with other incremental improvements.
Collapse
Affiliation(s)
- Ashraf A Sabe
- Department of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
| | | | | | | | | |
Collapse
|
17
|
Davoodi P, Budde C, Minshall CT. Laparoscopic repair of penetrating splenic injury. J Laparoendosc Adv Surg Tech A 2009; 19:795-8. [PMID: 19637964 DOI: 10.1089/lap.2009.0174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Historically, all splenic injuries were treated with splenectomy. In recent decades, however, there has been a trend toward splenic conservation methods in an attempt to preserve immunologic functions. Although cases of splenic conservation in the setting of penetrating injuries exist in the literature, this method of management is more commonly attempted in blunt traumas. When presented with penetrating splenic trauma, surgeons generally still proceed directly to exploratory laparotomy with splenectomy. Splenic injuries are rarely repaired with splenorrhaphy due to surgeon inexperience and concern for reoperation. We conclude from this case that when presented with a penetrating splenic trauma in a hemodynamically stable patient, management by laparoscopic exploration with splenorrhaphy can be safe and effective.
Collapse
Affiliation(s)
- Puya Davoodi
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
| | | | | |
Collapse
|
18
|
Imbert P, Rapp C, Buffet PA. Pathological rupture of the spleen in malaria: analysis of 55 cases (1958-2008). Travel Med Infect Dis 2009; 7:147-59. [PMID: 19411041 DOI: 10.1016/j.tmaid.2009.01.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Accepted: 01/08/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND Splenic rupture during acute malaria is rare but underreported. Because splenic rupture occurs mostly in non-immune adults, ongoing malaria elimination efforts may paradoxically increase the proportion of Plasmodium-infected patients suffering from this life-threatening complication. The pathogenesis and optimal patient management are still debated. METHOD We collected and analysed reports of pathological rupture of the spleen associated with malaria published over the last 50 years in five languages. RESULTS Fifty-five cases were reported, due to Plasmodium falciparum (n=26), Plasmodium vivax (n=23), Plasmodium ovale (n=2), Plasmodium malariae (n=2), or P. vivax-falciparum (n=2), and occurred in travellers (n=24), locals (n=21), expatriates (n=6) or migrants (n=4). Median age was 31.5 years and sex ratio M/F 3.2. Splenic rupture was complete with hemoperitoneum (n=50), or partial (n=5). Death occurred in 12 patients (22%), 8 of whom from early irreversible collapse (n=7) or unexpected death (n=1). Death rate was higher among travellers than in other patients (9/24, 38%, versus 3/31, 10%, p=0.01). Clinical features of P. falciparum- or P. vivax-associated splenic rupture were strikingly similar. Treatment included in-hospital medical observation without surgery (conservative management, n=14), immediate splenectomy (n=29), delayed splenectomy (n=4), or none (patients dying at admission, n=8). The type of treatment, conservative or not, had no influence on prognosis. The median duration of malaria symptoms before diagnosis was longer in our review (5-6 days) than in previous reports on imported malaria (3-4 days), suggesting that early diagnosis and therapy of malaria may reduce the incidence of splenic rupture. CONCLUSIONS Abdominal pain, collapse, or fainting is warning symptoms. Fourteen published observations support conservative management in carefully selected patients. Spleen preservation likely reduces the risk of future severe malaria attacks in patients with potential further exposition to Plasmodium sp., and also that of overwhelming sepsis in all.
Collapse
Affiliation(s)
- Patrick Imbert
- Service des Maladies Infectieuses et Tropicales, Hôpital d'Instruction des Armées Bégin, Saint-Mandé, France.
| | | | | |
Collapse
|
19
|
Pham TN, Heinberg E, Cuschieri J, Bulger EM, O'Keefe GE, Gross JA, Jurkovich GJ. The evolution of the diagnostic work-up for stab wounds to the back and flank. Injury 2009; 40:48-53. [PMID: 19117560 DOI: 10.1016/j.injury.2008.09.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Revised: 09/24/2008] [Accepted: 09/26/2008] [Indexed: 02/02/2023]
Abstract
BACKGROUND Stab wounds to the back and flank infrequently cause injuries requiring operative treatment. Triple-contrast CT scan (3CT) has essentially replaced diagnostic peritoneal lavage (DPL) as the primary means of identifying patients who require operative intervention. This study aims to review the evolution of the diagnostic work-up for stab wounds to the back and flank. METHODS We performed a retrospective review of haemodynamically stable patients with stab wound to the back or flank treated at a single Level 1 trauma centre over a 10-year period. Diagnostic accuracy of DPL and 3CT screening tests were evaluated against the patient's subsequent clinical course. The elapsed time between emergency department (ED) presentation and test results was recorded and compared. RESULTS A total of 177 patients were identified. 76 patients had stab wounds isolated to the back, 90 had stab wounds isolated to the flank and 11 had wounds in both locations. CT ultimately became the predominant initial diagnostic test during the study period. Although less frequently used over time, DPL retained good sensitivity and specificity for injuries requiring operative intervention (92% and 83%, respectively). 3CT identified all injuries requiring laparotomy (100% sensitivity) and had a specificity of 96%. 3CT was a more time-consuming process, with results available at a median of 3:31h after arrival to the ED, as compared to 1:03h for DPL (p<0.01). CONCLUSIONS 3CT diagnosed all injuries requiring operative intervention, and its use was associated with a lower rate of non-therapeutic laparotomies. However, average time to diagnosis by 3CT was prolonged compared to DPL. Although 3CT has become the predominant diagnostic test when evaluating patients with stab wounds to the back and flank at our institution, efforts to further expedite the diagnostic work-up are necessary.
Collapse
Affiliation(s)
- Tam N Pham
- Department of Surgery, University of Washington, Harborview Medical Centre, Seattle, WA 98104, United States.
| | | | | | | | | | | | | |
Collapse
|
20
|
Benissa N, Boufettal R, Kadiri Y, Lefriyekh MR, Kafih M, Fadil A, Zerouali NO. [Non operative management of blunt splenic trauma in adults]. ACTA ACUST UNITED AC 2008; 145:556-60. [PMID: 19106886 DOI: 10.1016/s0021-7697(08)74686-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Nonoperative management of blunt splenic injury allows preservation of the immune function of the spleen while avoiding unnecessary laparotomy. The aim of our study was to evaluate the feasibility and the results of conservative management of adult blunt splenic trauma in the context of a developing country. Nonoperative management was proposed for 52 out of 62 patients with blunt splenic trauma treated at the Casablanca University Hospital, Morocco. Motor vehicle-road accidents (88%) were the most common etiology. Multiple trauma was present in 79% of the cases. 15% of the cases had hemodynamic instability. Ultrasonography was performed in 52 patients; it showed splenic contusion in 45 patients and subcapsular hematoma in 7 patients. CT scan showed splenic contusion in 11 patients. Four cases ultimately required operative management with one death. Of the remaining 48 patients, 45 had an uneventful course with observation, but there were two deaths in the observation group.
Collapse
Affiliation(s)
- N Benissa
- Service des urgences chirurgicales viscérales, pavillon 35, CHU Ibn Rochd - Casablanca, Maroc
| | | | | | | | | | | | | |
Collapse
|
21
|
Gauer JM, Gerber-Paulet S, Seiler C, Schweizer WP. Twenty Years of Splenic Preservation in Trauma: Lower Early Infection Rate Than in Splenectomy. World J Surg 2008; 32:2730-5. [DOI: 10.1007/s00268-008-9733-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
22
|
Impact of a Statewide Quality Improvement Initiative in Improving the Management of Pediatric Splenic Injuries in Washington State. ACTA ACUST UNITED AC 2008; 64:1478-83. [DOI: 10.1097/ta.0b013e3180342920] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
23
|
Sinha S, Raja SVV, Lewis MH. Recent changes in the management of blunt splenic injury: effect on splenic trauma patients and hospital implications. Ann R Coll Surg Engl 2008; 90:109-12. [PMID: 18325207 DOI: 10.1308/003588408x242033] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Management of blunt splenic injury has been controversial with an increasing trend towards splenic conservation. A retrospective study was performed to identify the effect of this changed policy on splenic trauma patients and its implications. PATIENTS AND METHODS Data regarding patient demography, mode of splenic injury, CT grading, blood transfusion requirement, operative findings hospital stay and follow-up were collected. Statistical analysis of the data was performed using nonparametric Mann-Whitney tests RESULTS Over an 8-year period, only 21 patients were admitted with blunt splenic injury. Ten patients were managed operatively and 11 non-operatively. Non-operative management failed in one patient due to continued bleeding. Using Buntain's CT grading, the majority of grades I and II splenic injuries were managed non-operatively and grades III and IV were managed operatively ( P = 0.008). Blood transfusion requirement was significantly higher among the operative group (P = 0.004) but the non-operative group had a significantly longer hospital stay (P = 0.029). Among those managed non-operatively (median age, 24.5 years), a number of patients were followed up with CT scans with significant radiation exposure and unknown longterm consequences. CONCLUSIONS Non-operative management of blunt splenic trauma in adults can be performed with an acceptable outcome. Although CT is classed as the 'gold standard', initial imaging for detection and evaluation of blunt splenic injury, ultrasound can play a major role in follow-up imaging and potentially avoids major radiation exposure.
Collapse
Affiliation(s)
- S Sinha
- Department of Surgery, Royal Glamorgan Hospital, Ynysmaerdy, Llantrisant, UK.
| | | | | |
Collapse
|
24
|
Brugère C, Arvieux C, Dubuisson V, Guillon F, Sengel C, Bricault I, Regimbeau JM, Pilleul F, Menegaux F, Letoublon C. L’embolisationprécoce dans le traitement non opératoire destraumatismes fermés de la rate. Étude rétrospectivemulticentrique. ACTA ACUST UNITED AC 2008; 145:126-32. [DOI: 10.1016/s0021-7697(08)73721-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
25
|
|
26
|
Theodorou GL, Mouzaki A, Tsiftsis D, Apostolopoulou A, Mougiou A, Theodori E, Vagianos C, Karakantza M. Effect of non-operative management (NOM) of splenic rupture versus splenectomy on the distribution of peripheral blood lymphocyte populations and cytokine production by T cells. Clin Exp Immunol 2007; 150:429-36. [PMID: 17924970 DOI: 10.1111/j.1365-2249.2007.03517.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Post-traumatic splenectomy is associated with increased postoperative morbidity and mortality and long-term impairment of humoral and cellular immunity. Alternatives to surgery have been developed to minimize or avoid the immediate and/or long-term complications of splenectomy. Herein we investigated the long-term effect of non-operative management (NOM) of the traumatic rupture of the spleen on the distribution of peripheral blood (PB) lymphocyte populations and cytokine production by T cells. PB samples were drawn from six NOM patients, 13 age-matched adults who had undergone splenectomy after trauma (SP patients) and 31 age-matched controls. Cellular phenotypes and the intracellular production of interferon (IFN)-gamma, interleukin (IL)-2, IL-4 and IL-10 cytokines in T cells were determined in whole blood +/- mitogens by flow cytometry. NOM patients did not show any changes in the absolute numbers of lymphocytes or the distribution of their subsets, compared to the controls. In contrast, SP patients showed a sustained increase in the percentage and/or absolute numbers of lymphocytes, CD8 T cells, activated CD8 T cells, natural killer (NK) T cells, NK cells and gammadelta T cells, and a reduction in naive CD4 T cells. The constitutive or induced cytokine production by T cells of the NOM group was similar to the control group, whereas SP patients had increased percentages of constitutive IL-2- and IFN-gamma-producing CD8 T cells and IFN-gamma-producing CD4 T cells. Our findings indicate collectively that the healing process in NOM does not affect the architecture of the spleen to such an extent that it would lead to long-term alterations of the proportions of PB lymphocytes or the T cell cytokine profiles.
Collapse
Affiliation(s)
- G L Theodorou
- Division of Hematology, Department of Internal Medicine, Medical School and University Hospital, University of Patras, Patras, Greece
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Brady RRW, Bandari M, Kerssens JJ, Paterson-Brown S, Parks RW. Splenic Trauma in Scotland: Demographics and Outcomes. World J Surg 2007; 31:2111-6. [PMID: 17849160 DOI: 10.1007/s00268-007-9218-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Splenic trauma is a common organ injury following blunt abdominal trauma. In order to establish the contemporary epidemiology of blunt splenic trauma in Scotland and to detect risk factors associated with patient outcomes, analysis of a multi-center database of trauma patients was performed. METHODS The study used data from a prospectively collated multicenter trauma database containing the details of 52,215 trauma patients admitted to participating Scottish hospitals over an 11-year period. RESULTS 672 (1.3%) patients (530 males, 142 females) with splenic trauma were identified; of them, 579 (86.2%) had blunt trauma and 93 (13.8%) had penetrating trauma. The mean age of patients with blunt splenic trauma was 35.7 years (33.8 years for males, 42.0 years for females). Increasing age and female sex was significantly associated with mortality. The most common mechanism for injury was road traffic accidents (71%). In the series, 93.8% of patients had concomitant injuries including head injuries (46.5%), thoracic injuries (37.7%) and liver injuries (30%). A total of 299 (51.6%) patients proceeded to laparotomy, and 256 (44.2%) patients required ICU support. The overall mortality was 33.5%, and the median Injury Severity Score was 48 in patients who died, compared to 22 in those who survived. Increased mortality was associated with concomitant aortic, cardiac, or abdominal injuries. A number of independent risk factors were associated with increased risk of mortality, including concomitant injuries, increased age, and increased Injury Severity Score. CONCLUSIONS The incidence of splenic trauma is low, but it accounts for significant mortality. Outcome in the present study was worse in those with advanced age and associated injuries.
Collapse
Affiliation(s)
- Richard R W Brady
- Academic Coloproctology, 4th Floor MRC Human Genetics Unit, Western General Hospital, Crewe Road, Edinburgh, Scotland EH4 2XU.
| | | | | | | | | |
Collapse
|
28
|
Paran H, Gutman M, Mayo A. The effect of aprotinin in a model of uncontrolled hemorrhagic shock. Am J Surg 2005; 190:463-6. [PMID: 16105537 DOI: 10.1016/j.amjsurg.2005.03.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2004] [Revised: 03/08/2005] [Accepted: 03/08/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Aprotinin has been shown to promote clot formation through its antifibrinolytic activity, by inhibiting the plasmin-induced complement activation and by protecting the platelets adhesive surface receptors. It has been successfully used in cardiac and liver transplantation surgery. OBJECTIVE To evaluate the effect of aprotinin in a model of uncontrolled intra-abdominal bleeding as a basis for its potential use in trauma patients. METHODS Twenty rats were randomly divided into 2 groups. All animals were operated on and bleeding was induced by transecting 1 lobe of the liver. In the treatment group a single dose of 30,000 U/kg of aprotinin was administered 5 minutes after the injury. The animals were monitored for hemodynamic parameters, blood loss volume, and mortality rates. RESULTS At 120 minutes from trauma induction a significant difference in mean blood pressure was observed: 67+/-22 mm Hg in the treatment group versus 53+/-28 mm Hg in the control group (P=.04). This difference remained consistent until the end of the experiment. Treatment with aprotinin also resulted in a tendency to an increased survival rate (P=.05) and increased mean survival time: 175+/-46 minutes as compared to 123+/-48 minutes in the controls (P=.027). CONCLUSIONS Early administration of aprotinin resulted in temporary hemodynamic stabilization and prolonged survival in a model of uncontrolled bleeding. Further studies are needed to establish the possible use of aprotinin in the treatment of trauma patients.
Collapse
Affiliation(s)
- Haim Paran
- Department of Surgery "A," Meir Medical Center, Kfar-Sava, Israel and the Tel-Aviv University Medical School, Tel Aviv, Israel.
| | | | | |
Collapse
|
29
|
Sharma OP, Oswanski MF, Singer D, Raj SS, Daoud YA. Assessment of Nonoperative Management of Blunt Spleen and Liver Trauma. Am Surg 2005. [DOI: 10.1177/000313480507100503] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- Om P. Sharma
- Toledo Hospital & Toledo Children's Hospital, Toledo, Ohio
| | | | - Daniel Singer
- Toledo Hospital & Toledo Children's Hospital, Toledo, Ohio
| | - Shekhar S. Raj
- Toledo Hospital & Toledo Children's Hospital, Toledo, Ohio
| | | |
Collapse
|
30
|
Sharma OP, Oswanski MF, Singer D. Role of Repeat Computerized Tomography in Nonoperative Management of Solid Organ Trauma. Am Surg 2005. [DOI: 10.1177/000313480507100315] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nonoperative management (NOM) of blunt spleen and liver trauma is currently well accepted. CT imaging is helpful in selecting treatment options and to evaluate resolution of solid organ trauma. This 8-year study was undertaken to assess the role of repeat CT scans in NOM by analyzing indications of surgery in NOM failures. NOM was undertaken in 221 patients with spleen/liver trauma. After initial CT scans, 82 (37%) scans were repeated in 65 patients. There was failure of NOM (NOMF) in 11 patients. Follow-up imaging was done prior to delayed surgery in 4 (36%) patients, 4.9 per cent of repeat scans. Two of these patients had hemodynamic instability and, in the other two, there were clinical signs of peritonitis. The remaining seven patients had delayed surgery due to hemodynamic instability. There is a limited role of repeat CT scans in NOM of spleen and liver trauma. Repeat CT should be done more liberally in patients with suspected intestinal and mesenteric trauma, unexplained blood loss, complex hepato-biliary trauma, and in patients with neurological or pharmacological paralysis.
Collapse
Affiliation(s)
- Om P. Sharma
- Department of Trauma Services, The Toledo Hospital & Toledo Children's Hospital, Toledo, Ohio
| | - Michael F. Oswanski
- Department of Trauma Services, The Toledo Hospital & Toledo Children's Hospital, Toledo, Ohio
| | - Daniel Singer
- Department of Trauma Services, The Toledo Hospital & Toledo Children's Hospital, Toledo, Ohio
| |
Collapse
|
31
|
Alejandro KV, Acosta JA, Rodriguez PA. Bleeding Manifestations after Early Use of Low-Molecular-Weight Heparins in Blunt Splenic Injuries. Am Surg 2003. [DOI: 10.1177/000313480306901119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Low-molecular-weight heparins (LMWHs) have emerged as an effective method for deep venous thrombosis (DVT) prophylaxis after major trauma. The early use of LMWH in patients with splenic injuries may result in increased rates of blood transfusions and failure of nonoperative management. A retrospective review of the records of all patients ≥18 years old that sustained blunt splenic injuries from April 2000 to July 2002 was performed. Patients were divided in two groups based on whether they received LMWH during the first 48 hours (early group) or not (late group). A total of 188 patients were evaluated. One hundred fourteen patients had their splenic injuries managed nonoperatively and were included in the study. Fifty patients were assigned to the early group and 64 to the late group. There was no statistical difference between groups regarding basic demographic data, initial laboratory results, and severity of their splenic injuries. In the early group, two (4%) patients failed nonoperative management compared with four (6%) patients in the late group ( P = 0.593). The number of patients requiring blood transfusions within the first 5 days after admission was 25 (50.0%) in the early group and 36 (56.2%) in the late group ( P = 0.507). The average number of blood units given per patient within the first 5 days after admission were 3.2 ± 1.5 in the early group and 3.0 ± 1.8 in the late group ( P = 0.782). This study suggests that the early use of LMWH in trauma patients with splenic injuries is not associated with an increased rate of blood transfusion requirements or an increased rate of failure of non-operative management.
Collapse
Affiliation(s)
- Kathia V. Alejandro
- From the Puerto Rico Trauma Center, Department of Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Jose A. Acosta
- From the Puerto Rico Trauma Center, Department of Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Pablo A. Rodriguez
- From the Puerto Rico Trauma Center, Department of Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| |
Collapse
|
32
|
Hartnett KL, Winchell RJ, Clark DE. Management of Adult Splenic Injury: A 20-Year Perspective. Am Surg 2003. [DOI: 10.1177/000313480306900713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The objective of this study was to identify changes in the management of blunt splenic injury in adults. Hospital discharge abstract data from Maine were used to identify patients ≥16 years old discharged between January 1, 1981 and December 31, 2000 with International Classification of Diseases (9th revision) codes indicating splenic injury. Incidence of operative intervention and outcomes for trauma hospitals and other hospitals were determined. The number of splenic injuries was about 75 per year for the first 15 years increasing to 96 per year in the last 5-year period. The rate of operative intervention declined from 71 to 41 per cent and was lower at the trauma hospitals during the last two 5-year periods (41% vs 53%). The rate of operative intervention >24 hours after admission was 2.2 per cent during the last 10 years of study. The rate of splenorrhaphy remained stable at about 12 per cent throughout the study period. Mortality rates were higher at the trauma hospitals as were the numbers of patients with very severe injuries (Injury Severity Score >25). There has been a marked decrease in rate of operative intervention for splenic injury in adults especially in the last 10 years. Rates of operative intervention were lower at the trauma hospitals despite higher injury severity. Frequency of delayed intervention was low and did not increase with lower operative rate.
Collapse
Affiliation(s)
| | | | - David E. Clark
- From the Department of Surgery, Maine Medical Center, Portland, Maine
| |
Collapse
|
33
|
Meguid AA, Bair HA, Howells GA, Bendick PJ, Kerr HH, Villalba MR. Prospective Evaluation of Criteria for the Nonoperative Management of Blunt Splenic Trauma. Am Surg 2003. [DOI: 10.1177/000313480306900311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Recent reports have shown an increased mortality associated with the nonoperative management of blunt splenic injury. We have prospectively applied criteria developed from our previous 15-year experience for the nonoperative management (NOM) of blunt splenic injury. These criteria consist of 1) hemodynamic stability on admission or after initial resuscitation with up to two liters of crystalloid infusion, 2) no physical findings or any associated injuries necessitating laparotomy, and 3) a transfusion requirement attributable to the splenic injury of 2 units or less. From 1994 through 2000 a total of 99 patients presented with blunt splenic injury. Thirty-one patients (31%) underwent splenectomy secondary to hemodynamic instability. During the observation period eight of the 68 patients (12%) who initially met criteria for NOM developed hemodynamic instability and underwent splenectomy. All NOM failures occurred within 72 hours of admission. There was no mortality associated with splenic injury in the NOM (Group I) or in the group failing NOM (Group II), and no associated morbidities from the splenic injury were seen in either group. No significant differences were seen between Groups I and II in terms of age, gender, mechanism of injury, Injury Severity Score, admitting systolic blood pressure, admitting hemoglobin, transfusion requirements, intensive care unit length of stay, or total hospital length of stay (all P > 0.200). We conclude that established criteria for intervention and careful observation in an intensive care setting for at least 72 hours will minimize morbidity or mortality associated with blunt splenic injury in adults.
Collapse
Affiliation(s)
- Ahmed A. Meguid
- Division of Trauma Surgery, Department of Surgery, Royal Oak, Michigan
| | - Holly A. Bair
- Division of Trauma Surgery, Department of Surgery, Royal Oak, Michigan
| | - Greg A. Howells
- Division of Trauma Surgery, Department of Surgery, Royal Oak, Michigan
| | | | - Hugh H. Kerr
- Division of Trauma Surgery, Department of Surgery, Royal Oak, Michigan
| | - Mario R. Villalba
- Department of Radiology, William Beaumont Hospital, Royal Oak, Michigan
| |
Collapse
|
34
|
Arisawa F, Kogure K, Tsuzuki Y, Ando T, Sekihara M, Kori T, Ide M, Koitabashi H, Kuwano H. Snowboarding splenic injury: four case reports. Injury 2002; 33:173-7. [PMID: 11890921 DOI: 10.1016/s0020-1383(01)00143-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
With the rapidly increasing number of snowboarders, the incidence of injuries has recently become higher. From 1994 to 1995, we encountered four snowboarders with splenic injuries in one season. In three of the four patients the splenic injuries were caused by striking the abdomen with their own elbow when falling by themselves, of which emergent splenectomy was required in two patients. In the other one the collision with another snowboarder caused the splenic injury and splenorrhaphy was performed. Because snowboarders have both feet fixed on a board and do not have poles, they are prone to fall on the left upper limb in the proceeding direction, resulting in the striking of the left upper abdomen. Because in snowboarders splenic injury is caused mostly by a blow from their own left elbow at the time of falling, informing the mechanisms of splenic injuries will serve a speedy correct diagnosis for the doctors.
Collapse
Affiliation(s)
- Fumio Arisawa
- Department of Surgery 1, Gunma University School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Rose AT, Newman MI, Debelak J, Pinson CW, Morris JA, Harley DD, Chapman WC. The Incidence of Splenectomy is Decreasing: Lessons Learned from Trauma Experience. Am Surg 2000. [DOI: 10.1177/000313480006600511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
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.
Collapse
Affiliation(s)
- Amy T. Rose
- Department of Surgery, Vanderbilt University Medical Center and Nashville Veterans Affairs Medical Center, Nashville, Tennessee
| | - Martin I. Newman
- Department of Surgery, Vanderbilt University Medical Center and Nashville Veterans Affairs Medical Center, Nashville, Tennessee
| | - Jacob Debelak
- Department of Surgery, Vanderbilt University Medical Center and Nashville Veterans Affairs Medical Center, Nashville, Tennessee
| | - C. Wright Pinson
- Department of Surgery, Vanderbilt University Medical Center and Nashville Veterans Affairs Medical Center, Nashville, Tennessee
| | - John A. Morris
- Department of Surgery, Vanderbilt University Medical Center and Nashville Veterans Affairs Medical Center, Nashville, Tennessee
| | - David D. Harley
- Department of Surgery, Vanderbilt University Medical Center and Nashville Veterans Affairs Medical Center, Nashville, Tennessee
| | - William C. Chapman
- Department of Surgery, Vanderbilt University Medical Center and Nashville Veterans Affairs Medical Center, Nashville, Tennessee
| |
Collapse
|
36
|
Duverger V, Muller L, Szymszyczyn P, Vergos M. [Surgical abstention in closed injuries of the spleen]. ANNALES DE CHIRURGIE 2000; 125:380-4. [PMID: 10900742 DOI: 10.1016/s0003-3944(00)00211-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Splenic conservation avoids the overwhelming postsplenectomy infection. The high percentage of patients treated by noninvasive procedures would be due to the simple clinical course of splenic trauma and precision of diagnosis, using CT scan. Only clinical evaluation could provide further information on the indications for surgical treatment, as there is no available score regarding the value of CT scan for choosing the therapeutical option. Non-operative management of splenic ruptures should be considered in selected patients in whom hemodynamics is stable and closely monitored.
Collapse
Affiliation(s)
- V Duverger
- Service de chirurgie viscérale et vasculaire, HIA Bégin, Saint-Mandé, France
| | | | | | | |
Collapse
|
37
|
|
38
|
|
39
|
Falcone RA, Luchette FA, Choe K, Tiao G, Ottaway M, Davis K, Hurst JM, Johannigman JA, Frame SB. Zone I retroperitoneal hematoma identified by computed tomography scan as an indicator of significant abdominal injury. Surgery 1999. [DOI: 10.1016/s0039-6060(99)70112-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
40
|
Konstantakos AK, Barnoski AL, Plaisier BR, Yowler CJ, Fallon WF, Malangoni MA. Optimizing the management of blunt splenic injury in adults and children. Surgery 1999. [DOI: 10.1016/s0039-6060(99)70139-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
41
|
Kluger Y, Rabau M, Rub R, Weinbroum A, Chaushu G, Ben-Avraham R, Dayan D. Comparative study of splenic wound healing in young and adult rats. THE JOURNAL OF TRAUMA 1999; 47:261-4. [PMID: 10452459 DOI: 10.1097/00005373-199908000-00007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nonoperative management (NOM) of splenic injuries is a common practice in stable trauma patients. Nevertheless, age-related differences in the success rate of NOM have prompted inclusion of age among the criteria of patient selection. Elucidation of the cellular mechanism of splenic wound healing in the young versus that of adults may explain why age can be related to the success of NOM in splenic injuries. METHODS A laceration was made in the splenic antihilar surface of 40 young and 40 adult male rats. Postoperatively, at specified intervals extending until day 21, spleens were removed, fixed, and examined by routine histopathology. In addition, sections were stained histochemically for collagen fibers and immunohistochemically for myofibroblast histomorphometry. RESULTS The intense local hemorrhage was resorbed within 48 hours in the young rats, and within 7 days in the adults. Disappearance of germinal centers and other splenic alterations started on the first day in both groups, but regeneration of splenic parenchyma was accomplished after 14 days in the young, whereas in the adults, on day 21 it was still incomplete. Maximal myofibroblast accumulation at the laceration site was seen after two days in the young, whereas in adults only on day 4 (p < 0.0001). Collagen scars were not present in either group. Thickening of the damaged capsule, composed of collagen fibers with yellowish-green polarization colors, was observed only in adult rats. CONCLUSION Splenic wounds heal by regeneration and not by collagen scarring. In the young, myofibroblasts accumulate in the site of injury faster than in adults. These cells may enhance contraction and increase the rate of wound healing until parenchymatic regeneration is completed. Our results may indirectly explain the higher success rate of NOM of splenic injury in young patients.
Collapse
Affiliation(s)
- Y Kluger
- Rabin Trauma Center, Department of Surgery, Tel-Aviv Medical Center, Israel
| | | | | | | | | | | | | |
Collapse
|