Adult splenic injuries: treatment patterns and predictive indicators

Partial Splenectomy and Splenic Wrapping for a High-Grade Splenic Injury: A Case Report

The spleen is one of the most commonly injured organs in blunt abdominal trauma, accounting for a vast portion of solid organ injuries, and may lead to rapid haemodynamic instability, requiring urgent operative intervention. Total splenectomies result in relative immunocompromise, with a risk of overwhelming post-splenectomy infection (OPSI) post splenectomy. This case reports the surgical management of a 20-year-old male with a grade IV splenic laceration after a motor vehicle accident. The patient underwent a trauma laparotomy with a partial splenectomy because of early take-off of the upper-lobar branch of his splenic artery, with an absorbable mesh wrap to tamponade the spleen. The patient avoided the need for a total splenectomy and was discharged after six days in the hospital with an uncomplicated recovery.

Octogenarians with blunt splenic injury: not all geriatrics are the same

Geriatric trauma patients (GTP) (age ≥ 65 years) with blunt splenic injury (BSI) have up to a 6% failure rate of non-operative management (NOM). GTPs failing NOM have a similar mortality rate compared to GTPs managed successfully with NOM. However, it is unclear if this remains true in octogenarians (aged 80–89 years). We hypothesized that the failure rate for NOM in octogenarians would be similar to their younger geriatric cohort, patients aged 65–79 years; however risk of mortality in octogenarians who fail NOM would be higher than that of octogenarians managed successfully with NOM. The Trauma Quality Improvement Program (2010–2016) was queried for patients with BSI. Those undergoing splenectomy within 6 h were excluded to select for patients undergoing NOM. Patients aged 65–79 years (young GTPs) were compared to octogenarians. A multivariable logistic regression model was used to determine the risk for failed NOM and mortality. From 43,041 BSI patients undergoing NOM, 3660 (8.5%) were aged 65–79 years and 1236 (2.9%) were octogenarians. Both groups had a similar median Injury Severity Score (ISS) (p = 0.10) and failure rate of NOM (6.6% young GTPs vs. 6.8% octogenarians p = 0.82). From those failing NOM, octogenarians had similar units of blood products transfused (p > 0.05) and a higher mortality rate (40.5% vs. 18.2%, p < 0.001), compared to young GTPs. Independent risk factors for failing NOM in octogenarians included ≥ 1 unit of packed red blood cells (PRBC) (p = 0.039) within 24 h of admission. Octogenarians who failed NOM had a higher mortality rate compared to octogenarians managed successfully with NOM (40.5% vs 23.6% p = 0.001), which persisted in a multivariable logistic regression analysis (OR 2.25, CI 1.37–3.70, p < 0.001). Late failure of NOM ≥ 24 h (vs. early failure) was not associated with increased risk of mortality (p = 0.88), but ≥ 1 unit of PRBC transfused had higher risk (OR 1.88, CI 1.20–2.95, p = 0.006). Compared to young GTPs with BSI, octogenarians have a similar rate of failed NOM. Octogenarians with BSI who fail NOM have over a twofold higher risk of mortality compared to those managed successfully with NOM. PRBC transfusion increases risk for mortality. Therefore, clinicians should consider failure of NOM earlier in the octogenarian population to mitigate the risk of increased mortality.

Role of contrast-enhanced ultrasound (CEUS) in the diagnosis and management of traumatic splenic injuries

Splenic injuries are common emergencies in the setting of abdominal trauma, as the spleen is the second most frequently injured abdominal organ after the liver. The treatment of splenic injuries underwent a severe shift from operative to non-operative due to an increased awareness of the double physiological function, both immunological and hematological, of the spleen. This, in turn, led to an increased application of splenic preservation techniques. The non-operative approach has been strengthened through radiological imaging and interventional radiology. While multidetector computed tomography is mandatory in the evaluation of hemodynamically stable patients after high-energy trauma, one ultrasound (US) can be used as a first-line technique to examine patients in cases of low-energy trauma. Unfortunately, baseline US has low sensitivity in the detection of traumatic injuries. With the introduction of contrast-enhanced ultrasound (CEUS) as a reliable alternative to baseline ultrasound for low-grade abdominal trauma, the sensitivity of the US technique in recognizing traumatic abdominal lesions has strongly increased, reaching levels of accuracy similar to those of the CT. It has also been strongly recommended for use with children, as it allows for the performance of imaging techniques with the lowest dose of radiation possible. In this review, the authors aim to present the typical appearance of traumatic splenic injuries, using enhanced CEUS capability to overcome baseline US limits, and to describe the different techniques applied according to the hemodynamic stability of the patient.

Is non-operative management safe and effective for all splenic blunt trauma? A systematic review

Introduction

The goal of non-operative management (NOM) for blunt splenic trauma (BST) is to preserve the spleen. The advantages of NOM for minor splenic trauma have been extensively reported, whereas its value for the more severe splenic injuries is still debated. The aim of this systematic review was to evaluate the available published evidence on NOM in patients with splenic trauma and to compare it with the operative management (OM) in terms of mortality, morbidity and duration of hospital stay.

Methods

For this systematic review we followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" statement. A systematic search was performed on PubMed for studies published from January 2000 to December 2011, without language restrictions, which compared NOM vs. OM for splenic trauma injuries and which at least 10 patients with BST.

Results

We identified 21 non randomized studies: 1 Clinical Controlled Trial and 20 retrospective cohort studies analyzing a total of 16,940 patients with BST. NOM represents the gold standard treatment for minor splenic trauma and is associated with decreased mortality in severe splenic trauma (4.78% vs. 13.5% in NOM and OM, respectively), according to the literature. Of note, in BST treated operatively, concurrent injuries accounted for the higher mortality. In addition, it was not possible to determine post-treatment morbidity in major splenic trauma. The definition of hemodynamic stability varied greatly in the literature depending on the surgeon and the trauma team, representing a further bias. Moreover, data on the remaining analyzed outcomes (hospital stay, number of blood transfusions, abdominal abscesses, overwhelming post-splenectomy infection) were not reported in all included studies or were not comparable, precluding the possibility to perform a meaningful cumulative analysis and comparison.

Conclusions

NOM of BST, preserving the spleen, is the treatment of choice for the American Association for the Surgery of Trauma grades I and II. Conclusions are more difficult to outline for higher grades of splenic injury, because of the substantial heterogeneity of expertise among different hospitals, and potentially inappropriate comparison groups.

Conservative management of splenic injury in the tropics

We undertook this study in order to determine whether the conservative management of splenic injuries is a safe practice in a low-volume tropical hospital. We evaluated 69 consecutive patients with splenic injury prospectively. The outcome measures were morbidity and mortality rates, overall hospital stay and blood transfusion requirements. Spleen preservation was achieved in 85% (59) of cases. Of the 16 patients who underwent splenic surgery, six had splenorraphy (38%). The overall mortality was 4.3% (3) and the deaths were not related to the conservative management. Our findings suggest that not only is the conservative management of splenic injuries safe, but also that the repair of an enlarged spleen (splenorrhaphy) is safe and feasible in tropical hospital settings. The findings in this study provide further evidence that the conservative management of splenic injury in a tropical hospital without computed tomography scan is a safe practice.

Recent changes in the management of blunt splenic injury: effect on splenic trauma patients and hospital implications

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.

Assessment of Nonoperative Management of Blunt Spleen and Liver Trauma

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

Sonographic patterns of intraperitoneal hemorrhage associated with blunt splenic injury

OBJECTIVE

To determine the correlation between sonographic detection of free fluid in the left upper quadrant and blunt splenic injury.

METHODS

A retrospective review was conducted of all consecutive emergency blunt trauma sonograms obtained at a level I trauma center from January 1995 to January 2001. Data were collected on demographics, free fluid location, and patient outcome. Injuries were determined from computed tomography, diagnostic peritoneal lavage, laparotomy, or a combination thereof.

RESULTS

A total of 4320 blunt trauma sonograms were obtained, and 596 patients (14%) had intra-abdominal injuries. The mean age was 33.7 +/- 19.1 years (range, 1-95 years), with 294 (49%) male and 302 (51%) female. There was no statistical difference between age, sex, or mechanism for all subgroups. There were 409 true-positive, 187 false-negative, 88 false-positive, and 3636 true-negative findings. Sensitivity of sonography for detecting all intra-abdominal injuries was 68%, and specificity was 97.6%; sensitivity for detecting isolated splenic injuries was 73.8%. Locations of free fluid in patients with nonsplenic injuries were compared with those in patients with splenic injuries. Isolated left upper quadrant free fluid was significantly associated with splenic injury (odds ratio = 3.0; P = .002), followed by diffuse free fluid (odds ratio = 2.1; P = .005). A subanalysis of isolated splenic injuries also revealed a significant association with left upper quadrant free fluid (odds ratio = 3.1; P = .007) and diffuse free fluid (odds ratio = 2.7; P = .0007).

CONCLUSIONS

Free fluid in the left upper quadrant is significantly associated with splenic injury. This finding should triage patients more rapidly to computed tomography, angiography, embolization, and laparotomy.