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

Evolution of the treatment of splenic injuries: from surgery to non-operative management

The spleen is one of the most frequently injured organs in blunt abdominal trauma. In the past decades, the treatment of patients with blunt splenic injury has shifted from operative to non-operative management. The knowledge of physiology and immunology of the spleen have been the main reasons to develop techniques for splenic salvage. The advances in high-resolution imaging techniques, as well as less invasive procedures, including angiography and angioembolization, have allowed a higher rate of success in the non-operative management. Non-operative management has showed a decrease in overall mortality and morbidity. The aim of this article is to analyze the current management of splenic injury based on a literature review of the last 30 years, from we have identified 63,205 patients. This would enable the surgeons to provide the best care possible in every case.

Role of Vascular and Interventional Radiology in the Diagnosis and Management of Acute Trauma Patients

Vascular and interventional radiology provides an important service in the diagnosis and management of the acute trauma patient. Historically angiography was used primarily as a diagnostic tool for both vascular and solid organ injuries. However, with technological advances, such as the advent of stents, stent grafts, newer embolization materials and sophisticated delivery devices, micro-catheters, and steerable guide wires, vascular and interventional radiology can now offer definitive treatment in selected cases. Transcatheter embolization can effectively treat acute hemorrhage and is useful in locations that are difficult to access surgically, or when surgical disruption of fascial planes, which may eliminate a tamponade effect, is less desirable. Stents and stent grafts have been used to preserve, rather than sacrifice, an injured blood vessel. In splenic, hepatic, and renal trauma, a trend in nonoperative management has been developed by traumatologists. Transcatheter embolization can increase the success rate of nonoperative management in selected injuries. In general, despite the injury grade, if evidence of ongoing hemorrhage is present, angiography and transcatheter embolization should be considered. Peripheral vascular injuries can be treated with transcatheter embolization or stents and stent grafts. Transcatheter embolization in trauma was first applied to bleeding associated with pelvic fractures and dislocations, and continues to be an important treatment option. Carotid and vertebral artery injuries can now be repaired using stents or stent grafts, although the experience of this treatment strategy is somewhat limited. Likewise, acute traumatic aortic injury has been successfully treated with stent grafts in small series. Conventional catheter thoracic aortography is now used as an adjunctive diagnostic test for indeterminate or questionable findings on noninvasive imaging studies, primarily computed tomography scans of the chest. In summary, vascular and interventional radiology maintains an important role in the diagnosis and management of acute vascular and solid organ injury. The following review illustrates its current status in acute trauma.

Blunt Splenic Trauma

The treatment of blunt splenic injury has evolved over time from splenectomy in all patients to nonoperative management in stable patients with operation reserved for failures of NOM. While rates of OPSI remain low in trauma patients, splenic salvage in stable patients should be attempted. However, clinical evidence of ongoing blood loss or instability should be addressed with prompt splenectomy. Careful patient selection is of paramount importance in nonoperative management of blunt splenic injury.

Nonoperative management of splenic injury grade IV is safe using rigid protocol

OBJECTIVE

To demonstrate the protocol and experience of our service in the nonoperative management (NOM) of grade IV blunt splenic injuries.

METHODS

This is a retrospective study based on trauma registry of a university hospital between 1990-2010. Charts of all patients with splenic injury were reviewed and patients with grade IV lesions treated nonoperatively were included in the study.

RESULTS

ninety-four patients with grade IV blunt splenic injury were admitted during this period. Twenty-six (27.6%) met the inclusion criteria for NOM. The average systolic blood pressure on admission was 113.07 ± 22.22 mmHg, RTS 7.66 ± 0.49 and ISS 18.34 ± 3.90. Ten patients (38.5%) required blood transfusion, with a mean of 1.92 ± 1.77 packed red cells per patient. Associated abdominal injuries were present in two patients (7.7%). NOM failed in two patients (7.7%), operated on due to worsening of abdominal pain and hypovolemic shock. No patient developed complications related to the spleen and there were no deaths in this series. Average length of hospital stay was 7.12 ± 1.98 days.

CONCLUSION

Nonoperative treatment of grade IV splenic injuries in blunt abdominal trauma is safe when a rigid protocol is followed.

Non-operative management of splenic trauma

The risk of overwhelming postsplenectomy infection (OPSI) prompted the evolution toward preservation of the injured spleen. Nonoperative management (NOM) of blunt injury to the spleen in adults has become the standard of care in hemodynamically stable patients. This modality of treatment began in the 1970's in paediatric patients. It is highly successful with overall failures rates from 2% to 31% (average 10.8%)--with the majority of failures occurring in the first 24 hours. Current, NOM of splenic trauma includes splenic artery embolization.However, the criteria for NOM are controversial. In this study we present the current criteria, the evolution and failure rates of this type of management viewed through the general knowledge and, particularly, our experience.

Changing patterns in diagnostic strategies and the treatment of blunt injury to solid abdominal organs

Background

In recent years there has been increasing interest shown in the nonoperative management (NOM) of blunt traumatic injury. The growing use of NOM for blunt abdominal organ injury has been made possible because of the progress made in the quality and availability of the multidetector computed tomography (MDCT) scan and the development of minimally invasive intervention options such as angioembolization.

Aim

The purpose of this review is to describe the changes that have been made over the past decades in the management of blunt trauma to the liver, spleen and kidney.

Results

The management of blunt abdominal injury has changed considerably. Focused assessment with sonography for trauma (FAST) examination has replaced diagnostic peritoneal lavage as diagnostic modality in the primary survey. MDCT scanning with intravenous contrast is now the gold standard diagnostic modality in hemodynamically stable patients with intra-abdominal fluid detected with FAST. One of the current discussions in the literature is whether a whole body MDCT survey should be implemented in the primary survey.

Literature review of the role of ultrasound, computed tomography, and transcatheter arterial embolization for the treatment of traumatic splenic injuries

Introduction

The spleen is the second most frequently injured organ following blunt abdominal trauma. Trends in management have changed over the years. Traditionally, laparotomy and splenectomy was the standard management. Presently, nonoperative management (NOM) of splenic injury is the most common management strategy in hemodynamically stable patients. Splenic injuries can be managed via simple observation (OBS) or with angiography and embolization (AE). Angio-embolization has shown to be a valuable alternative to observational management and has increased the success rate of nonoperative management in many series.

Diagnostics

Improved imaging techniques and advances in interventional radiology have led to a better selection of patients who are amenable to nonoperative management. Despite this, there is still a lot of debate about which patients are prone to NOM.

Angiography and Embolization

The optimal patient selection is still a matter of debate and the role of CT and angio-embolization has not yet fully evolved. We discuss the role of sonography and CT features, such as contrast extravasation, pseudoaneurysms, arteriovenous fistulas, or hemoperitoneum, to determine the optimal patient selection for angiography and embolization. We also review the efficiency, technical considerations (proximal or selective embolization), logistics, and complication rates of AE for blunt traumatic splenic injuries.

Splenic injury during percutaneous nephrolithotomy: a case report with novel management technique

We describe a case of a splenic injury caused by a transsplenic percutaneous nephrostomy tract. The case was completed without incident and the nephrostomy tube was noted to traverse the spleen on routine postoperative imaging. This rare complication was managed by deposition of Gelfoam((R)) pledgets along the transsplenic nephrostomy tract and placement of a ureteral stent. This novel management technique has not been previously described in the literature and was successful in the conservative treatment of the uncommon complication of splenic injury during percutaneous nephrolithotomy.

Computed Tomography Grading Systems Poorly Predict the Need for Intervention after Spleen and Liver Injuries

Computed tomography (CT) grading systems are often used clinically to forecast the need for interventions after abdominal trauma with solid organ injuries. We compared spleen and liver CT grading methods to determine their utility in predicting the need for operative intervention or angiographic embolization. Abdominal CT scans of 300 patients with spleen injuries, liver injuries, or both were evaluated by five trauma faculty members blinded to clinical outcomes. Studies were graded by American Association for the Surgery of Trauma criteria, a novel splenic injury CT grading system, and a novel liver injury grading system. The sensitivity and specificity of each methodology in predicting the need for intervention were calculated. The kappa statistic was used to determine interrater variability. Twenty-one per cent (39/189) of patients with splenic injuries visible on CT scans required interventions, whereas 14 per cent (21/154) of patients with liver injuries visible on CT required interventions. The overall sensitivity of all grading systems in predicting the need for surgery or angioembolization of the spleen or liver was poor; the specificity seemed to be fairly good. When evaluators were compared, the strength of agreement for the various scoring systems was only moderate. Anatomic CT grading systems are ineffective screening tools for excluding the need for operation or embolization after splenic or hepatic trauma. Although insensitive, CT is a good predictor (highly specific) of the need for intervention if certain definitive abnormalities are identified. Considerable inconsistency exists in interpretation of abdominal CT scans after trauma, even among experienced clinicians.

Imaging and transcatheter arterial embolization for traumatic splenic injuries: review of the literature

The spleen is the most commonly injured visceral organ in blunt abdominal trauma in both adults and children. Nonoperative management is the current standard of practice for patients who are hemodynamically stable. However, simple observation alone has been reported to have a failure rate as high as 34%; the rate is even higher among patients with high-grade splenic injuries (American Association for the Surgery of Trauma [AAST] grade III-V). Over the past decade, angiography with transcatheter splenic artery embolization, an alternative nonoperative treatment for splenic injuries, has increased splenic salvage rates to as high as 97%. With the help of splenic artery embolization, success rates of more than 80% have also been described for high-grade splenic injuries. We discuss the role of computed tomography and transcatheter splenic artery embolization in the diagnosis and treatment of blunt splenic trauma. We review technical considerations, indications, efficacy and complication rates. We also propose an algorithm to guide the use of angiography and splenic embolization in patients with traumatic splenic injury.

Blunt splenic injuries: have we watched long enough?

BACKGROUND

Nonoperative management (NOM) of blunt splenic injuries (BSIs) has been used with increasing frequency in adult patients. There are currently no definitive guidelines established for how long BSI patients should be monitored for failure of NOM after injury.

METHODS

This study was performed to ascertain the length of inpatient observation needed to capture most failures, and to identify factors associated with failure of NOM. We utilized the National Trauma Data Bank to determine time to failure after BSI.

RESULTS

During the 5-year study period, 23,532 patients were identified with BSI, of which 2,366 (10% overall) were taken directly to surgery (within 2 hours of arrival). Of 21,166 patients initially managed nonoperatively, 18,506 were successful (79% of all-comers). Patients with isolated BSI are currently monitored approximately 5 days as inpatients. Of patients failing NOM, 95% failed during the first 72 hours, and monitoring 2 additional days saw only 1.5% more failures. Factors influencing success of NOM included computed tomographic injury grade, severity of patient injury, and American College of Surgeons designation of trauma center. Importantly, patients who failed NOM did not seem to have detrimental outcomes when compared with patients with successful NOM. No statistically significant predictive variables could be identified that would help predict patients who would go on to fail NOM.

CONCLUSIONS

We conclude that at least 80% of BSI can be managed successfully with NOM, and that patients should be monitored as inpatients for failure after BSI for 3 to 5 days.

Improved outcome of adult blunt splenic injury: a cohort analysis

BACKGROUND

The purpose of this study was to review our 15-year experience in the treatment of blunt splenic injury in adults. Our hypothesis was that the implementation of a change in practice, with stress on splenic preservation and splenic artery embolization for the management of splenic injury, would result in improved splenic salvage rates without negatively affecting mortality rates.

METHODS

A retrospective cohort analysis was performed on all consecutive adults with blunt splenic injury who were admitted to a Level One Trauma Center. The cohorts were defined by 2 separate 7.5-year periods (1991-1998 and 1998-2005).

RESULTS

Six hundred twenty-five patients with blunt splenic trauma were identified; 403 patients who were treated from 1998 to 2005 were compared with 222 patients whose cases had been reviewed previously (1991 to 1998). The present cohort differed in age (35 vs 40 years; P < .001) and injury severity score (27 vs 21; P < .0001). Nonoperative treatment was implemented in 136 patients (61%) in the initial cohort and 344 patients (85%) in the present cohort. The frequency of splenic artery embolization increased from 2.7% to 22.6% (P < .001). The success of nonoperative management increased from 77% to 96% (P < .001); the splenic salvage rate for all patients improved from 57% to 88% (P < .0001). Hospital mortality rates decreased from 12% to 6% (P < .001), and the mean hospital length of stay decreased from 15 to 9 days (P < .001).

CONCLUSION

These results demonstrate that the success of nonoperative management and the splenic preservation for blunt injury has improved over time. This improvement correlated with a greater use of splenic artery embolization.

Is anything new in adult blunt splenic trauma?

Several decades ago, a shift occurred in the management of adult splenic injuries. Influenced by the experience in pediatric trauma patients, adult trauma surgeons began turning from mandatory operative treatment of all splenic injuries toward nonoperative management. Nonoperative treatment is now the most common method of management for patients with splenic injuries and is the most common method of splenic salvage. However, controversy exists about how to appropriately select patients for nonoperative treatment since bleeding from splenic injuries can incur significant morbidity and mortality. Recent refinements in the management of adult blunt splenic injuries will be reviewed.

Splenic preservation: an additional haemostatic measure during mesh splenorrhaphy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Nonsurgical management of blunt splenic injury: use of CT criteria to select patients for splenic arteriography and potential endovascular therapy

PURPOSE

To determine if contrast material-enhanced spiral computed tomography (CT) can be used to select patients with blunt splenic injuries to undergo arteriographic embolization.

MATERIALS AND METHODS

During a 15-month period, 78 patients who were hemodynamically stable and required no immediate surgery underwent contrast-enhanced spiral CT followed by splenic arteriography. CT scans were assessed for splenic vascular contrast material extravasation or posttraumatic splenic vascular lesions. Medical records were reviewed for splenic arteriographic results and clinical outcome.

RESULTS

There were 25 grade I, 12 grade II, 27 grade III, 12 grade IV, and two grade V splenic injuries. CT showed active contrast material extravasation in seven patients and splenic vascular lesions in 19 patients. At CT, splenic vascular contrast material extravasation was 100% (seven of seven patients) and a posttraumatic splenic vascular lesion was 83% (10 of 12 patients) sensitive on the basis of arteriographic or surgical outcome in predicting the need for transcatheter embolization or splenic surgery. Overall, CT had a sensitivity of 81% (17 of 21 patients), a specificity of 84% (48 of 57 patients), negative and positive predictive values of 92% (48 of 52 patients) and 65% (17 of 26 patients), respectively, and an accuracy of 83% (65 of 78 patients) in predicting the need for splenic injury treatment.

CONCLUSION

Contrast-enhanced spiral CT plays a valuable role in selecting hemodynamically stable patients with splenic vascular injury who may be treated with transcatheter therapy and potentially improves the success rate of nonsurgical management.

Accuracy of administrative data in trauma: splenic injuries as an example

BACKGROUND

Accurate data are needed to evaluate clinical outcomes, therapeutic modalities, and quality of care in trauma. Administrative data, usually used for billing, have been used to evaluate performance and assess therapy in other medical specialties. This study was performed to determine whether administrative databases are accurate in the recording of information about trauma patients with splenic injuries.

METHODS

Patients who had blunt splenic injuries were identified using a state trauma registry. The medical records of those patients were reviewed. The data collected by chart review were compared with data in the statewide administrative database of patients who had splenic injuries at the same four Level I and II trauma centers in the same 5-year period. Age, sex, admission date, and hospital were matched to assure comparison of the identical cohort. chi2 analysis was used to compare dichotomous data and Student's t test continuous data.

RESULTS

The administrative database identified 641 and the trauma registry identified 529 patients with a diagnosis of splenic injury. A total of 401 patients were found in both databases. Of these, 120 (22.7%) patients were not recorded in the administrative database. Injury Severity Score was underreported by the administrative database (25.74 +/- 14.7 vs. 19.52 +/- 11, p < 0.0001). The administrative database underreported orthopedic, chest, and head injuries (317 vs. 215, 325 vs. 228, and 234 vs. 155, respectively; all p < 0.0001). Use of abdominal computed tomographic scan and diagnostic peritoneal lavage were also underreported (260 vs. 56 and 104 vs.17, both p < 0.0001). The number of operations on the spleen and number of orthopedic procedures were underreported (259 vs. 225, p < 0.014 and 147 vs. 94, p < 0.0001). Complications were markedly underreported by the administrative database (200 vs. 47, p < 0.0001)

CONCLUSION

This study shows that administrative data lack accuracy in the recording of associated injuries, injury severity, diagnostics, procedures, and outcomes data in patients with splenic injuries. Whether these data should be used to evaluate treatment modalities or quality of care in trauma is questionable.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Adult splenic injuries: treatment patterns and predictive indicators

BACKGROUND

With the trend towards conservation in splenic trauma, the ability to identify a group of patients for whom we can safely offer conservative treatment becomes an important factor.

METHODS

Data were reviewed from the trauma register at the Auckland Hospital, Auckland, New Zealand, in an attempt to isolate any predictive factors that may allow more appropriate allocation of treatment modalities in the future. Methods of treatment were determined and the success or failure of conservative management noted. Differences in the demographics, Injury Severity Score (ISS) and computed tomographic (CT) findings were particularly sought.

RESULTS

Over a period of 111 weeks 48 patients were admitted with splenic injuries. Fifteen (31.2%) had immediate splenectomy, 27 (56.2%) were initially treated non-operatively and six (10.1%) died pre-operatively. Of the non-operative group eight (29.6%) failed this management at an average of 4.125 days into their hospital stay. No differences were found in age, mechanism, gender or ISS between the failed and successfully treated group. Using the Buntain classification of CT-graded splenic injury, 13 (87%) who had successful non-operative treatment had a grade II or III compared with six (86%) who failed this management being grade IV.

CONCLUSION

Although these results did not reach statistical significance, by coupling the trends seen together with other work, CT grading of splenic injury is a predictive indicator and does appear to have a role in the early allocation of patients to appropriate treatment plans.

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

OBJECTIVE

The recognition that splenectomy renders patients susceptible to lifelong risks of septic complications has led to routine attempts at splenic conservation after trauma. In 1990, the authors reported that over an 11-year study period involving 193 patients, splenorrhaphy was the most common splenic salvage method (66% overall) noted, with nonoperative management employed in only 13% of blunt splenic injuries. This report describes changing patterns of therapy in 190 consecutive patients with splenic injuries seen during a subsequent 6-year period (1990 to 1996). An algorithmic approach for patient management and pitfalls to be avoided to ensure safe nonoperative management are detailed.

METHODS

Nonoperative management criteria included hemodynamic stability and computed tomographic examination without shattered spleen or other injuries requiring celiotomy.

RESULTS

Of 190 consecutive patients, 102 (54%) were managed nonoperatively: 96 (65%) of 147 patients with blunt splenic injuries, which included 15 patients with intrinsic splenic pathology, and 6 hemodynamically stable patients with isolated stab wounds (24% of all splenic stab wounds). Fifty-six patients underwent splenectomy (29%) and 32 splenorrhaphy (17%). The mean transfusion requirement was 6 units for splenectomy survivors and 0.8 units for nonoperative therapy (85% received no transfusions). Fifteen of the 16 major infectious complications that occurred followed splenectomy. Two patients failed nonoperative therapy (2%) and underwent splenectomy, and one patient required splenectomy after partial splenic resection. There no missed enteric injuries in patients managed nonoperatively. The overall mortality rate was 5.2%, with no deaths following nonoperative management.

CONCLUSIONS

Nonoperative management of blunt splenic injuries has replaced splenorrhaphy as the most common method of splenic conservation. The criteria have been extended to include patients previously excluded from this form of therapy. As a result, 65% of all blunt splenic injuries and select stab wounds can be managed with minimal transfusions, morbidity, or mortality, with a success rate of 98%. Splenectomy, when necessary, continues to be associated with excessive transfusion and an inordinately high postoperative sepsis rate.

Splenic injury: trends in evaluation and management

BACKGROUND

Changing methods of evaluating blunt abdominal trauma and expanding selection criteria for nonoperative management (NOM) of splenic injury can increase the number of patients managed nonoperatively without affecting success rates.

METHODS

The charts of 164 patients with blunt splenic injuries from July 1, 1991, to June 30, 1996, were reviewed. Thirty-eight patients were excluded because of immediate laparotomy without adjunctive tests or expiration in the resuscitative period. Injuries were graded according to the Organ Injury Scale.

RESULTS

Overall, successful NOM occurred in 84% of patients (73 of 87). NOM was successful in 5 of 7 patients > 55 years old and in 14 of 15 patients with Glasgow Coma Scale scores < 13.

CONCLUSION

Use of computed tomography increased NOM of splenic trauma from 11 to 71% during the 5-year period for injuries of equivalent severity. Age > 55 years or abnormal neurologic status should not preclude NOM, because success was related only to injury grade.

Management of blunt splenic trauma: significant differences between adults and children

BACKGROUND

Although highly successful in children, nonoperative management of blunt splenic injury in adults is less defined. The purpose of this study was to determine whether mechanism of injury, grade of splenic injury, associated injuries, and pattern of injury differ between adults and children (younger than 15 years of age).

METHODS

Four hundred eleven patients (293 adults and 118 pediatric patients) with blunt splenic injury were admitted to an affiliated adult/pediatric trauma program from 1989 to 1994. Computed tomography (CT) scans were interpreted in a blinded fashion. Mechanism of injury was significantly different for adults versus children (p < 0.05): motor vehicle crash (66.9% versus 23.7%), motorcycle (8.8% versus 0.8%), sports (2.4% versus 16.9%), falls (8.8% versus 25.4%), pedestrian/automobile (4.4% versus 11.0%), bicycle (1.4% versus 9.3%), and other (7.3% versus 12.7%).

RESULTS

Higher injury severity scores, lower Glasgow Coma Scales, and higher mortality indicated that the adults were more severely injured than the children. Fifty-nine percent of the adults and 7% of the children required immediate laparotomy for splenic injury. Both CT grade and quantity of blood on CT predicted the need for exploration in adults but not in children. An injury severity score above 15 and high-energy mechanisms correlated with the need for operative intervention.

CONCLUSIONS

Rather than children simply being physically different, they are injured differently than adults, hence the high rate of nonoperative management.

Nonoperative Management of Solid Abdominal Visceral Injury: Part I. Spleen

The relatively recent recognition of the immunological consequences of splenectomy in both children and adults, coupled with an increased use of noninvasive methods of detecting splenic injuries, has resulted in the development of a nonoperative approach to selected patients with blunt splenic trauma. Currently, nonoperative management of pediatric splenic injuries is the treatment of choice, with success rates greater than 90%. Due to the increased severity of injury in adult trauma patients, this method of treatment is applicable in only 50% of older patients with mild to moderate splenic trauma. As experience with nonoperative treatment has accumulated, the need for large blood transfusions, missed intestinal injuries, and delayed splenic rupture have been found to be uncommon events. However, patients selected for nonoperative management must be monitored in a setting where the treating surgeon is readily available for both serial examinations and operative intervention should nonoperative management fail.

Management of upper abdominal solid organ injuries

Solid organ injuries of the upper abdomen consist primarily of injuries to the spleen and liver. Several years ago, these injuries were fairly straightforward to manage. Recently, however, combinations of new diagnostic modalities and the advent of nonsurgical treatments have added complexity to the management of splenic and hepatic injuries. Splenic injuries that require surgical repairs are managed by splenic salvage when feasible and by splenectomy procedures when the injuries are complicated. Hepatic injuries may require a variety of therapeutic modalities, depending on their complexity. This article reviews some of these treatment options for the management of upper abdominal solid organ injuries.

Changing trends in the management of splenic injury

BACKGROUND

A gradual change in the management of splenic injuries has occurred at our institution. This study was therefore undertaken to determine whether changes in management of splenic injury influenced outcomes during the past 30 years.

PATIENTS AND METHODS

A retrospective study of patients admitted with splenic trauma between 1965 and 1994 was performed. Two hundred seven patients were identified and demographic and outcome data were recorded. Patients were then grouped based upon the period in which they received treatment (ie, Period I [1965 to 1974], Period II [1975 to 1984], and Period III [1985 to 1994]), and the type of treatment received (ie, splenectomy, splenorrhaphy, or observation).

RESULTS

More patients were treated in Period III than in the other two periods, and Period III patients had shorter hospital stays. Splenectomy was solely used during Period I; splenorrhaphy and observation were occasionally performed during Period II; and splenectomy, splenorrhaphy, and observation were performed in near-equal numbers during Period III. Mortality was similar for each period, though Injury Severity Scores (ISS) were higher during later years. When compared by treatment modality, patients receiving splenectomy had higher ISS and splenic injury classifications.

CONCLUSION

Patients treated by splenorrhaphy and observation for splenic injury have markedly increased over the past 30 years without adverse outcome.

Nonoperative salvage of computed tomography-diagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis

OBJECTIVES

The aims of this study were to determine if angiographic findings can be used to predict successful nonoperative therapy of splenic injury and to determine if coil embolization of the proximal splenic artery provides effective hemostasis.

METHODS

Splenic injuries detected by diagnostic imaging between 1981 and 1993 at a level I trauma center were prospectively collected and retrospectively reviewed after management by protocol that used diagnostic peritoneal lavage, computed tomography (CT), angiography, transcatheter embolization, and laparotomy. Computed tomography was performed initially or after positive diagnostic peritoneal lavage. Angiography was performed urgently in stabilized patients with CT-diagnosed splenic injuries. Patients without angiographic extravasation were treated by bed rest alone; those with angiographic extravasation underwent coil embolization of the proximal splenic artery followed by bed rest.

RESULTS

Patients (172) with blunt splenic injury are the subject of this study. Twenty-two patients were initially managed operatively because of associated injuries or disease (11 patients) or because the surgeon was unwilling to attempt nonoperative therapy (11 patients) and underwent splenectomy (17 patients) or splenorrhaphy (5 patients). One hundred fifty of 172 consecutive patients (87%) with CT-diagnosed splenic injury were stable enough to be considered for nonoperative management. Eighty-seven of the 90 patients managed by bed rest alone, and 56 of 60 patients treated by splenic artery occlusion and bed rest had a successful outcome. Overall splenic salvage was 88%. It was 97% among those managed nonoperatively, including 61 grade III and grade IV splenic injuries. Sixty percent of patients received no blood transfusions. Three of 150 patients treated nonoperatively underwent delayed splenectomy for infarction (one patient) or splenic infection (two patients).

CONCLUSIONS

(1) Hemodynamically stable patients with splenic injuries of all grades and no other indications for laparotomy can often be managed nonoperatively, especially when the injury is further characterized by arteriography. (2) The absence of contrast extravasation on splenic arteriography seems to be a reliable predictor of successful nonoperative management. We suggest its use to triage CT-diagnosed splenic injuries to bed rest or intervention. (3) Coil embolization of the proximal splenic artery is an effective method of hemostasis in stabilized patients with splenic injury. It expands the number of patients who can be managed nonoperatively.

Current concepts in splenic trauma

Despite its protected location inside the rib cage, the spleen remains the most commonly injured organ after blunt abdominal trauma. The clinical decision-making process of splenic injury management continues to evolve due to improvements in surgical technique and noninvasive assessment. Splenic preservation techniques and splenic injury grading systems using computerized tomography were developed due to an increased understanding of the spleen's importance in the body's immunological defense system and awareness of the spleen's resiliency after injury. The concept of splenic salvage using splenorrhaphy and nonoperative management was initially applied to the pediatric population during the 1970s, with great success. Application of splenic salvage to hemodynamically stable adult patients with known or unknown splenic injury has demonstrated that adults can be less predictable in their clinical course. Despite the rigorous attention splenic trauma has received, it remains a controversial subject in the surgical and the radiological literature.

Blunt hepatic and splenic trauma in children: correlation of a CT injury severity scale with clinical outcome

The purpose of this report is to compare a computed tomography (CT) injury severity scale for hepatic and splenic injury with the following outcome measures: requirement for surgical hemostasis, requirement for blood transfusion and late complications. Sixty-nine children with isolated hepatic injury and 53 with isolated splenic injury were prospectively classified at CT according to extent of parenchymal involvement. Clinical records were reviewed to determine clinical outcome. Ninety-seven children (80%) were managed non-operatively without transfusion. One child with hepatic injury required surgical hemostasis, and 17 (25%) required transfusion of blood. Increasing severity of hepatic injury at CT was associated with progressively greater frequency of transfusion (P = 0.002 by chi 2-test). One child with splenic injury underwent surgery and eight (15%) required transfusion of blood. Splenic injury grade at CT did not correlate with frequency (P = 0.41 by chi 2-test) or amount (P = 0.35 by factorial analysis of variance) of transfusion. There was one late complication in the nonsurgical group. A majority of children with hepatic and splenic injury were managed non-operatively without requiring blood transfusion. The severity of injury by CT scan did not correlate with need for surgery. Increasing grade of hepatic injury at CT was associated with increasing frequency of blood transfusion. CT staging was not discriminatory in predicting transfusion requirement in splenic injury.

Is early discharge following isolated splenic injury in the hemodynamically stable child possible?

Nonoperative treatment of splenic injury is well accepted. Two questions have not been answered. (1) What is the intensity of monitoring required in the hemodynamically stable patient? (2) How long do patients need to be hospitalized? Ninety-one patients having computed tomography (CT) or surgically proven splenic injury were treated between September 1986 and September 1991. Excluded from the study were 16 patients requiring operation and 22 patients having multiple system injuries. All operations occurred within 24 hours of admission. No transfusions were required later than 48 hours following admission. The remaining 53 patients (58%) constitute the study group. CT classification of Buntain indicated 6 class I, 21 class II, 24 class III, and 2 class IV injuries. The mean Injury Severity Score (ISS) for the group was 6.98 +/- 3.43. Serial hematocrits for the patients treated without transfusions were followed until three consecutive determinations showed no change. The lowest average hematocrit for the nontransfused group was 30.96% +/- 4.47% and occurred on day 2.06 +/- 0.76. Eleven patients (23%) had left-sided pleural effusions that resolved without intervention. One patient had an ileus for 3 days. CT or ultrasound examination was obtained on day 5 to 7 to document healing before the patient was allowed out of bed and discharged. The average hospital stay was 7.06 +/- 2.24 days. Twenty-two patients were initially observed in the intensive care unit (ICU). Clearly the interval between hematocrit stability (average, 2.06 days) and discharge (average, 7.06 days) constitutes a time of minimal nursing care while utilizing bed space and health care dollars.(ABSTRACT TRUNCATED AT 250 WORDS)

CT scan in blunt abdominal trauma

CT scan has been used in blunt abdominal trauma with increasing popularity during the last decade. The sensitivity, specificity and accuracy of CT scan in blunt abdominal trauma have been reported to be very high. CT scan has been shown to eliminate the disadvantages of diagnostic peritoneal lavage (DPL) in the diagnosis of retroperitoneal organ injuries and when there are associated major pelvic fractures. This study describes the results of CT scan in 50 blunt abdominal trauma patients at the Chulalongkorn Hospital, Bangkok, Thailand. All patients had stable vital signs at the time of CT scanning although 36 per cent were in shock on arrival. In all, 34 per cent had associated pelvic fractures. Retroperitoneal organ injuries were suspected in 80 per cent. Of the patients, 34 per cent underwent exploratory laparotomies because of positive CT scan with three unnecessary operations. The sensitivity of CT scan to predict the necessity of operation is 100 per cent, specificity 92 per cent, accuracy 94 per cent, positive predictive value 82 per cent and negative predictive value 100 per cent. We conclude that CT scan is highly reliable in the management of blunt abdominal trauma, especially when retroperitoneal organ injuries are suspected or when there are associated major pelvic fractures. CT scan is also an invaluable tool in selected cases of non-operative management of hepatic trauma.

A prospective analysis of diagnostic laparoscopy in trauma

OBJECTIVE

This study was performed to assess current and potential future application for laparoscopy (DL) in the diagnosis of penetrating and blunt injuries. Efficacy, safety, and cost analyses were performed.

SUMMARY BACKGROUND DATA

Diagnostic peritoneal lavage (DPL) and computed tomography (CT) have been the mainstays in recent years for diagnosis of equivocal nontherapeutic laparotomy, whereas CT is not helpful for the vast majority of penetrating wounds. DL may be a useful adjunct to fill in these gaps.

METHODS

Hemodynamically stable patients with equivocal evidence of intraabdominal injury were prospectively entered into the protocol. DL was performed under general anesthesia; patients with wounds penetrating the peritoneum or blunt injury with significant organ injury underwent laparotomy.

RESULTS

Over 19 months, 182 patients (55% stab, 36% GSW, 9% blunt) were studied. No peritoneal penetration was found at DL in 55% of penetrating wounds with 66% of the remainder having therapeutic laparotomy, 17% nontherapeutic laparotomy, and 17% negative laparotomy. Therapeutic laparotomy was performed in 53% of blunt injuries after DL. Tension pneumothorax occurred in one patient and one had an iatrogenic small bowel injury. Charges for DL were $3,325 per patient compared with $3,320 for a similar group undergoing negative laparotomy before this protocol.

CONCLUSIONS

DL is a safe modality for trauma. With current technology, DL is most efficacious for evaluation of equivocal penetrating wounds. Significant cost savings would be gained by performance under local anesthesia. Development of miniaturized optics, bowel clamps, retractors, and stapling devices will reduce overall costs and permit some therapeutic applications for laparoscopy in trauma management.

Management of splenic trauma: a new CT-guided splenic injury grading system

The aim of this study was to assess a newly developed computerized tomography (CT)-based splenic injury index in predicting the outcome of splenic injury. Twelve patients with isolated splenic injuries were studied. Splenic parenchymal injury was graded from 1 to 4 based on CT. The splenic injury index was obtained by multiplying the parenchymal score by the volume haemoperitoneum, which was measured on the CT scanner. The 12 patients with CT-proven splenic injuries had a mean injury index of 193.5 +/- 191 (mean +/- s.d.). The 3 patients who failed conservative management had a mean index of 475 +/- 50, compared with an index of 99.5 +/- 100 in the nine managed non-operatively (P less than 0.001). This new CT-based splenic injury index allows morphological assessment of splenic injury and may predict the outcome of splenic trauma.