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Imaging and transcatheter arterial embolization for traumatic splenic injuries: Review of the literature
Abstract
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.
... Splenic injury is common affecting up to 32% of patients with blunt abdominal trauma. [1][2][3][4][5] Laparotomy is accepted as the recommended management strategy for blunt splenic injury in hemodynamically unstable patients. [2][3][4][5][6][7][8][9][10][11][12][13][14] In contrast, the efficacy of nonoperative management in hemodynamically stable patients may consist of observation (with or without angiography) or angiography with proximal or selective splenic embolization. ...
... [1][2][3][4][5] Laparotomy is accepted as the recommended management strategy for blunt splenic injury in hemodynamically unstable patients. [2][3][4][5][6][7][8][9][10][11][12][13][14] In contrast, the efficacy of nonoperative management in hemodynamically stable patients may consist of observation (with or without angiography) or angiography with proximal or selective splenic embolization. [1][2][3][4][5] The failure rate of observation alone is high for patients with contrast blush on computed tomography (CT), grade IV injuries (lacerations involving segmental or hilar vessels producing major devascularization greater than 25% of the spleen) or grade V injuries (completely shattered spleens or spleens with hilar vascular injury which devascularizes the spleen), 15 higher injury severity score (ISS), decreasing hemoglobin, and presence of vascular injury or large volume hemoperitoneum. ...
... [2][3][4][5][6][7][8][9][10][11][12][13][14] In contrast, the efficacy of nonoperative management in hemodynamically stable patients may consist of observation (with or without angiography) or angiography with proximal or selective splenic embolization. [1][2][3][4][5] The failure rate of observation alone is high for patients with contrast blush on computed tomography (CT), grade IV injuries (lacerations involving segmental or hilar vessels producing major devascularization greater than 25% of the spleen) or grade V injuries (completely shattered spleens or spleens with hilar vascular injury which devascularizes the spleen), 15 higher injury severity score (ISS), decreasing hemoglobin, and presence of vascular injury or large volume hemoperitoneum. [2][3][4][5][6][8][9][10]12,14 Age as a risk factor for failure of nonoperative management has been evaluated with some evidence showing increased failure rates in older age groups, 3,[16][17][18] but other studies have shown no such association. ...
Introduction:
Laparotomy, embolization, and observation are described for blunt splenic injury management. This study evaluated outcomes of blunt splenic injury management based on baseline factors, splenic injury severity, and associated injuries.
Methods:
A nine-year retrospective review was conducted of adult patients with blunt splenic injury. Collected data included demographics, injury characteristics, treatment modality, complications, and outcomes (mechanical ventilation, days on mechanical ventilation, intensive care unit [ICU] admission and length of stay, hospital length of stay, and in-hospital mortality). Categorical and continuous variables were analyzed using χ2 analysis and one-way analysis of variance for normally distributed variables and a non-parametric test of medians for variables that did not meet the assumption of normality, respectively.
Results:
Splenic injury grade was similar between operative and embolization groups, but severe hemoperitoneum was more common in the operative group. Complications and mortality were highest in the operative group (50.7% and 26.3%, respectively) and lowest in the embolization group (5.3% and 2.6%, respectively). Operative patients required more advanced interventions (ICU admission, mechanical ventilation). There were no differences between those treated with proximal versus distal embolization. Observation carried a failure rate of 11.2%, with no failures of embolization.
Conclusions:
Embolization patients had the lowest rates of complications and mortality, with comparable splenic injury grades to those treated operatively. Further prospective research is warranted to identify patients that may benefit from early embolization and avoidance of major abdominal surgery.
... The proximal approach, with its associated ease and speed of embolic agent deployment, is ideal for patients with high-grade parenchymal injuries or multiple splenic lacerations [16,17]. Proximal splenic artery embolization facilitates hemostasis by reducing intrasplenic blood pressure, resulting in clot formation and healing [18]. Alternatively, the distal technique achieves hemostasis of isolated hemorrhage in terminal branches while maintaining perfusion to the remainder of the spleen [19,20]. ...
... Alternatively, the distal technique achieves hemostasis of isolated hemorrhage in terminal branches while maintaining perfusion to the remainder of the spleen [19,20]. Although this approach partially preserves splenic function, rebleeding may occur when initial vascular injuries go unnoticed because of vasospasm [18]. A recent meta-analysis reviewing splenic artery embolization for blunt injury found that the proximal approach reduced the risk of compilations, including infarction, rebleeding, abscess formation, and contrast-induced nephropathy. ...
... Selection depends on the desired clinical application and outcome, and whether temporary or permanent embolization is preferred [24,25]. The mechanisms and utility of these various agents have been described [18,23,26,27]. In our reported cases, occult hemorrhage could not be excluded via angiographic fluoroscopy. ...
Nonoperative management of traumatic splenic hemorrhage includes the targeted administration of embolic agents. In certain instances where computed tomography angiography cannot exclude a bleed, prophylactic embolization with absorbable gelatin sponge has been used. In this retrospective case series review, we characterized the demographic data and clinical outcomes associated with 4 patients who underwent prophylactic transarterial splenic artery embolization after blunt abdominal trauma. Embolization was employed in cases where computed tomography angiography findings suggested at least a moderate splenic injury, and simultaneously where hemorrhage was not apparent during fluoroscopic angiography. Periprocedural hemodynamic status, technical success, and postoperative complications are discussed. The goal of this report was to discuss the safety and efficacy of prophylactic gelatin sponge embolization for occult splenic hemorrhage. In cases where a hemorrhagic site might be occult, this approach has the potential to minimize bleeding complications and the need for further intervention.
... In this, with the help of co-axial microcatheter system, site specific distal embolization is performed to achieve maximum hemostatic control (Figure 8). Embolization is done by the placement of smaller sized coils, gelfoam pledgets or combination of both [6,23] . Proximal splenic artery embolization in traumatic injuries has a success rate of 90%-95% with low incidence of splenic infarction. ...
... Overall procedural time and radiation exposure is more in proximal than distal embolization. Choosing one technique over the other is solely left to the discretion of interventional radiologist and at times combination of both may be required (Figure 9) [1,[21][22][23] . faster recuperation as compared to surgery. ...
... Technical success rate: Reported success rate of SAE in various series ranges from 73%-100% which has markedly increased the success rate of NOM to over 90%. Several studies suggest that in haemodynamically stable patients, survival rates of angioembolization and splenectomy are comparable [1,23] . In a study by Gaarder et al [25] , it was found that performing angiography with embolization (if needed) in all the cases of high grade splenic injury increased the success rates of NOM from 75%-96% as delayed bleeding was the most important reason for the failure of NOM. ...
Interventional radiology (IR) has become an integral part in the management of traumatic injuries. There is an ever-increasing role of IR in traumatic injuries of solid abdominal organs, pelvic and peripheral arteries to control active bleeding by therapeutic embolization or vascular reconstruction using stent grafts. Traditionally, these endovascular treatments have been offered to hemodynamically stable patients. However, in recent times endovascular approach has become preferable to surgery even in hemodynamically unstable patients with injury of surgically difficult-to-access sites. With shifting trends towards non operative management coupled with availability of the current state-of-the-art equipments, hardware and technical expertise, IR has gained an impeccable role in trauma management. However, due to lack of awareness and widespread acceptance, IR continues to remain an ocean of unexplored potentialities.
... The diagnosis of splenic injury following trauma is most frequently based on computed tomography (CT) scans. Numerous systems based on the extent of injury seen at CT, laparotomy or autopsy have been developed to grade traumatic splenic injuries [4]. ...
... ,4): Angiogram revealed distal curative embolization of post traumatic distal arterial bleeding using a microcatheter. before (3) and after coiling(4). ...
... The diagnosis of splenic injury following trauma is most frequently based on computed tomography (CT) scans. Numerous systems based on the extent of injury seen at CT, laparotomy or autopsy have been developed to grade traumatic splenic injuries [4]. ...
... ,4): Angiogram revealed distal curative embolization of post traumatic distal arterial bleeding using a microcatheter. before (3) and after coiling(4). ...
Background: Management of blunt spleen injuries has evolved from mandatory splenectomy to non-operative management (NOM) allowing for splenic salvage, Splenic artery embolization (SAE) has been shown to be an effective treatment for hemodynamically stable patients with high-grade blunt splenic injury. However, there are no local estimates of how much treatment costs.
... Intravenous contrast extravasation (ICE), arterial pseudoaneurysm (PSA) and AVF require urgent surgical or endovascular management (45). Although, the validity of these CECT findings and their correlation with angiography have been questionable in many studies (46,47). ...
... In hemodynamically unstable patients with an internal iliac artery source, embolization of bilateral internal iliac arteries with gel-foam pledgets or slurry is recommended and is known to be very effective in achieving hemostasis (46). ...
... Nonoperative treatment is the preferred choice, avoiding major surgery and preserving splenic immune function [12,14]. Nonoperative management of splenic injury with fluid resuscitation, bed rest, and hemodynamic monitoring is more likely to succeed in patients with AAST grade I or II injury who are hemodynamically stable, lack peritoneal findings on exam, are younger than 55 years of age, and require little to no transfusion [12,15,16]. ...
... An estimated 85% of patients with blunt splenic injury in the past decade were managed nonoperatively [15]. In patients who fail this initial management and have ongoing bleeding but are hemodynamically stable, splenic artery embolization, which is highly successful in patients in blunt trauma, is the next step [16,17]. The procedure has decreased the failure rate of nonoperative management from 12-13% to 2-3% [15]. ...
Colonoscopy is a commonly performed procedure for diagnosis and treatment of large bowel diseases. Recognized complications include bleeding and perforation. Splenic injury during colonoscopy is a rare complication. We report a case of a 73-year-old woman who presented with left-sided abdominal pain after colonoscopy with finding of splenic injury on CT scan. She was managed conservatively. We discuss the diagnostic and therapeutic approach to colonoscopic splenic injury.
... CECT findings of splenic intravenous contrast extravasation (ICE), pseudoaneurysm (PSA), or arteriovenous fistula (AVF) are risk factors for NOM failure as well as indications for surgical or angiographic management [12]. There is controversy regarding the validity of these predictive findings, however, as several studies have found a low rate of angiographic correlation with CECT findings of splenic vascular injury [13,14]. ...
... Angiographic false positives include bowel and ureteral peristalsis and normal uterine or cavernosal blush. These must be In the hemodynamically unstable patient with hemorrhage from an internal iliac artery source, embolization of the bilateral internal iliac arteries with gelfoam pledgets or slurry should be performed [13]. This can be performed rapidly and is very effective in achieving hemostasis. ...
Trauma is the leading cause of mortality among Americans 1-44 years old and is responsible for 193,000 deaths annually. One third of these patients die from exsanguination. Current practice guidelines emphasizing nonoperative management (NOM) of most hemodynamically stable blunt trauma patients and advances in endovascular equipment and techniques have led to an established role for adjunctive endovascular therapy in the arrest of traumatic hemorrhage.
... Le traitement reste controversé. Chez un patient stable, le scanner est utile dans une approche conservatrice avec le développement de la radiologie interventionnelle de plus en plus pratiquée de nos jours [9,10]. Il n'existe pas de consensus pour la réalisation d'un scanner de contrôle réalisé ici devant l'évolution défavorable. ...
... Since then, SAE has been widely used in the treatment of blunt splenic injury. [8,9] Although SAE is undertaken for hemodynamically stable lowgrade splenic injuries, some institutions have expanded the application of SAE to Grades IV and V injuries according to the American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) ( Table 1). [9,10] Given the broad acceptance of SAE, this intervention has been considered a safe and INTRODUCTION Non-operative management (NOM) is a widely accepted method for managing hemodynamically stable patients with blunt splenic injury. ...
Background: Splenic artery embolization (SAE) is commonly employed as a non-operative management technique for splenic injury. Nonetheless, information on follow-up duration and methods, and the natural course of splenic infarction after SAE is limited. Thus, this study is aimed to analyze the patterns of complications and recovery of splenic infarction after SAE and to determine the appropriate follow-up duration and method.
Methods: Medical records of 314 patients with blunt splenic injury admitted at the Pusan National University Hospital, Level I Trauma Centre were analyzed to identify patients who underwent SAE between January 2014 and November 2018. Computed tomography (CT) scans that were obtained after SAE in patients who were followed up were compared with all their previous CT scans to identify any changes in the spleen and the occurrence of complications such as sustained bleeding, pseudoaneurysm, splenic infarctions, or abscess formation.
Results: Of the 314 patients, 132 who underwent SAE were included in the study. In total, 30 complications were noted among the 132 patients; of these, 7 (5.30%) required repeat embolization and 9 (6.82%) required splenectomy. Splenic infarction of <50% occurred in 76 patients and that of ≥50% including total and near-total infarctions occurred in 40 patients. Among patients with splenic infarction of ≥50%, 3 (2.27%) patients had abscesses between 16 and 21 days after SAE, and the range of infarctions increased as the AAAST-OIS grade increased. After SAE, repeat abdominal CT scans for >14 days were obtained in 75 patients; among these, 67 pre-sented with recovery of splenic infarction. The median period of recovery was 43 days after SAE.
Conclusion: The present findings suggest that patients with ≥50% infarction may need 3 weeks of closed observation, with or without a follow-up CT scan, to rule out infection after SAE, follow-up CT follow-up at 6 weeks after SAE may be necessary to confirm the recovery of the spleen.
... -AG/AE may be performed in hemodynamically stable and rapid responder patients with moderate and severe lesions and in those with vascular injuries at CT scan (contrast blush, pseudo-aneurysms and arterio-venous fistula) ( The reported success rate of NOM with AG/AE ranges from 86 to 100% with a success rate of AG/AE from 73 to 100% [68][69][70][71][72][73][74][75][76][77][78]. In a large study, Haan et al. suggested that indications to AG/AE were pseudo-aneurysms (PSA) or active bleeding at admission CT scan, significant hemoperitoneum, and high-grade splenic injury [68][69][70]. ...
... Uncontrolled bleeding post-splenic biopsy was reported in literature and this complication could be managed with emergency surgical splenectomy (Civardi et al., 2001;Sammon, Twomey, Crush, Maher, & O'Connor, 2012;Yardeni, Polley, & Coran, 2004). Trans-arterial embolization (TAE) using permanent or temporary embolic agents for traumatic or iatrogenic intra-abdominal and splenic bleeding post trauma is well established and is widely practiced within the medical community (Raikhlin, Baerlocher, Asch, & Myers, 2008). Mortal sepsis has been reported in children post-splenectomy (Yardeni et al., 2004). ...
The aim of this study was to evaluate the safety and effectiveness of computed tomography (CT) and ultrasound (US) imaging-guided percutaneous fine needle aspirations (FNAs) and/or spleen and focal splenic lesion tissue core biopsies in patients with splenomegaly and/or focal splenic focal lesions. The vascular interventional radiology records, clinical charts, laboratory and histopathology results of patients who underwent splenic FNAs and tissue core biopsies between January of 2016 and June of 2019 were retrospectively analyzed. These procedures success rate in making specific diagnoses and the frequency of related complications were documented. After conducting imaging-guided FNAs and tissue core biopsies, the diagnosis reached in 18 (90%) of the 20 (100%) patients. Of the 18 (90%) patients, tumoral and non-tumoral diagnoses were made in 10 (55%) and 8 (45%) patients, respectively. All procedures were achieved without major complications. In conclusion, CT and US imaging-guided percutaneous FNAs and tissue core biopsies are safe and effective for diagnosing the causes of splenomegaly and the nature of focal splenic lesions.
... Surgery is indicated when a patient is hemodynamically unstable and does not respond to transfusion or when associated intraabdominal injuries require surgical management. Possible disadvantages of surgery are postsplenectomy complications, such as sepsis, thrombocytosis, and a lifetime risk of invasive infections (overwhelming postsplenectomy infection) [23,24]. All complications may have a major impact on patients' QOL. ...
Background:
Little is known about the effect of a splenic rupture on the quality of life (QOL) of patients, although the spleen is one of the most frequently injured organs in blunt abdominal trauma. It is essential to obtain more knowledge about QOL after traumatic spleen injury so that this can be taken into account when choosing treatment.
Objective:
The primary objective of the SPLENic Injury and Quality of life (SPLENIQ) study is to determine QOL after treatment for traumatic spleen injury. The secondary objective is to investigate clinical and imaging outcome in relation to QOL.
Methods:
A combination of a retrospective single-center and a prospective multicenter observational cohort study will be conducted. Patients in the retrospective study have had a splenic injury after blunt abdominal trauma and were admitted for treatment to the ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis) in Tilburg between January 2005 and February 2017. Concerning the prospective cohort study, patients with splenic injury admitted to 1 of the 10 participating hospitals between March 2017 and December 2018 will be asked to participate. The follow-up period will be 1 year regarding QOL, clinical symptoms, and imaging. Patients in the retrospective study will complete 2 questionnaires: World Health Organization QOL assessment instrument-Bref (WHOQOL-Bref) and 12-Item Short-Form Health Survey (SF-12). Patients in the prospective study will complete 5 questionnaires at 1 week, 1 month, 3 months, 6 months, and 12 months after treatment: WHOQOL-Bref, SF-12, Euroqol 5-Dimensional 5-Level (EQ-5D-5L) questionnaire, Institute for Medical Technology Assessment (iMTA) Productivity Cost Questionnaire (iPCQ), and iMTA Medical Consumption Questionnaire (iMCQ). In both the retrospective and prospective study, patients treated with splenic artery embolization will undergo magnetic resonance imaging (MRI). The retrospective group will undergo MRI once, and the prospective group will undergo MRI 1 month and 1 year after treatment. Treatment of splenic injury depends on the severity of the splenic injury, the hemodynamic condition of the patient, and the hospital's or doctor's preference. This study is observational in nature without randomization. Concerning the retrospective data, multivariate analysis of covariance will be done. With regard to the prospective data, mixed linear modeling will be performed.
Results:
This project was funded in April 2015 by ZonMw. The results of the retrospective study will be expected in March 2019. With regard to the prospective study, inclusion of patients was completed in December 2018 and data collection will be completed in December 2019. The first results will be expected in 2019.
Conclusions:
To our knowledge, this is the first study that examines QOL in patients with a traumatic spleen injury. The SPLENIQ study responds to the shortage of information about QOL after treatment for traumatic spleen injury and may result in the development of a patient-oriented protocol.
Trial registration:
ClinicalTrials.gov NCT03099798; https://clinicaltrials.gov/ct2/show/NCT03099798 (Archived by WebCite at http://www.webcitation.org/714ZKV6A0).
International registered report identifier (irrid):
DERR1-10.2196/12391.
... 6,7 Embolization can be tried in hemodynamically stable patients with active contrast extravasation noted in CT angiography. 17 Emergent laparotomy with splenectomy should be performed in hemodynamically unstable patients. 7 ...
Apixaban is a direct oral anticoagulant that works by inhibiting factor Xa. It has been associated with adverse bleeding outcomes including atraumatic splenic rupture. We present the case of an 86-year-old man who presented with features of left upper abdominal pain and hemorrhagic shock found to have atraumatic splenic rupture and hemoperitoneum on imaging.
... A taxa de sucesso reportada com o TNO associado a AG/AE varia de 86 a 100% com taxa de sucesso do AG/AE de 73 a 100% [68][69][70][71][72][73][74][75][76][77][78]. Em grande estudo, Haan et al. sugeriram que as indicações para AG/AE fossem: PSA ou sangramento ativo na TC de admissão, grande hemoperitônio e lesões esplênicas de alto grau [68][69][70]. ...
As lesões esplênicas estão entre as mais frequentes relacionadas ao trauma. Atualmente, a classificação leva em conta a anatomia da lesão. A estratégia de tratamento ideal, no entanto, deveria levar em consideração, o perfil hemodinâmico, as alterações anatômicas e as lesões associadas. O tratamento de pacientes com trauma esplênico visa restaurar a homeostasia e a fisiologia dos indivíduos, em especial, considerando os modernos métodos de abordagem do sangramento. Assim, o tratamento do trauma esplênico deve ser, em última instância, multidisciplinar e com base na fisiologia do paciente, na anatomia da lesão e nas lesões associadas. Finalmente, como o tratamento de adultos e crianças deve ser diferenciado, as crianças devem sempre, ser tratadas em centros especializados ao trauma pediátrico. Na verdade, a grande maioria dos pacientes pediátricos com trauma esplênico contusos, pode ser tratada por abordagem não operatória. Este artigo apresenta a classificação da World Society of Emergency Surgery (WSES) do trauma esplênico e as diretrizes do tratamento.
... -AG/AE may be performed in hemodynamically stable and rapid responder patients with moderate and severe lesions and in those with vascular injuries at CT scan (contrast blush, pseudo-aneurysms and arterio-venous fistula) ( The reported success rate of NOM with AG/AE ranges from 86 to 100% with a success rate of AG/AE from 73 to 100% [68][69][70][71][72][73][74][75][76][77][78]. In a large study, Haan et al. suggested that indications to AG/AE were pseudo-aneurysms (PSA) or active bleeding at admission CT scan, significant hemoperitoneum, and high-grade splenic injury [68][69][70]. ...
Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.
... In the past decade, the use of splenic artery embolisation 7,8 (SAE) has contributed to the non-operative management 9,10 of blunt splenic trauma. This technique is performed by interventional radiologists and was first described by Sclafani in 1981. ...
... CT scan is useful in diagnosis and monitoring a patient in whom conservative management of splenic rupture is considered [11] Historically, the treatment of choice for all kinds of splenic rupture used to be splenectomy; however, nowadays it remains subject to debate. Transcatheter splenic artery embolization has a major role in the management of traumatic splenic injuries [12] and can be used in selective cases of non-traumatic rupture. The therapy of choice can vary between patients depending on grade of splenic rupture, hemodynamic instability, availability of endovascular treatment and preference of the treating physician. ...
Introduction:
Blunt abdominal trauma is the most common cause of splenic rupture. Malaria is the most frequent tropical infectious cause of spontaneous splenic rupture. The exact mechanism is not well-defined.
Case report:
We report a case of thirty-year-old male patient known to have malaria who presented with spontaneous splenic rupture. A trial of conservative treatment failed and splenecomy was done to control bleeding.
Conclusion:
Spontaneous splenic rupture should be kept in mind in malaria patients presenting with left upper quadrant pain and signs of hypovolemia. Early diagnosis and treatment is essential.
... To the best of our knowledge, a very limited number of malarial splenic rupture patients have been treated with transcatheter coil embolization [10]. However, splenic artery embolization has been reported to have a high success rate in trauma patients and preferable to splenectomy [11,12]. Despite the associated risks such as radiation exposure and more time-consuming, or technically challenging, angiographic embolization may be an appropriate option for avoiding harmful effects of splenectomy for malaria patients. ...
An enlarged spleen is considered one of the most common signs of malaria, and splenic rupture rarely occurs as an important life-threatening complication. Splenectomy has been recommended as the treatment of choice for hemodynamically unstable patients. However, a very limited number of splenic rupture patients have been treated with transcatheter coil embolization. Here we report a 38-year-old Korean vivax malaria patient with ruptured spleen who was treated successfully by embolization of the splenic artery. The present study showed that angiographic embolization of the splenic artery may be an appropriate option to avoid perioperative harmful effects of splenectomy in malaria patients.
... Splenic artery embolization was first described in the 1970s and has since been used in different clinical settings, including traumatic spleen rupture, portal hypertension-related ascites, immune thrombocytopenic purpura, hemoglobinopathies, and hereditary spherocytosis [1][2][3][4][5]. Use of splenic embolization in patients with autoimmune hemolytic anemia is rarely reported [6]. ...
Assessment of general health status and hematological parameters usually precedes the use of invasive diagnostic and therapeutic procedures in critically ill patients. Angiography can be effective and safe as a substitute for major surgical procedures, or as a bridging therapy in such cases. We present a critically ill patient with hemolytic anemia that underwent splenic artery embolization as a bridging therapy. We aimed to emphasize that minimally invasive approaches and multidisciplinary care can be utilized in the treatment of critically ill patients with accompanying hematological disease.
... In caso di lesioni estese l'embolizzazione può precedere la chirurgia o seguire una resezione chirurgica che non abbia determinato il controllo completo del sanguinamento. Anche la gestione dei traumi della milza è sempre più orientata verso un NOM; l'embolizzazione trans-catetere delle lesioni spleniche aumenta il successo del NOM specialmente nei pazienti con lesioni di grado elevato (successo del trattamento endovascolare del 73-100%, anche nei pazienti OIS III o IV [15]). Il NOM è preferibile anche in molti casi di lesioni traumatiche dei reni, spesso non gravi e autolimitantisi. ...
... 8,9 The merit of follow-up imaging studies in diagnosing delayed splenic rupture has not been proven and multiple studies echo this finding and recommend omission of repeat CT scans in stable patients with Grade I to III blunt splenic injuries because they do not affect management. [10][11][12][13][14] In a recent survey of Eastern Association for the Surgery of Trauma member practices, only 14.5 per cent of the surveyed surgeons would routinely obtain in-hospital follow-up abdominal CT scans. 15 To further address this, Weinberg et al. in 2007 examined the use of serial CT imaging of blunt splenic injury to identify latent formation of splenic artery aneurysms. ...
In the modern era, while the majority of patients presenting with splenic injury are victims of blunt trauma, up to 14% are victims of penetrating trauma. Conversely, for victims of penetrating trauma, the spleen has been reported to be one of the most infrequently injured organs, ranging from 7% to 9%.
One of the current trends in modern surgery is the study of the spleen injuries and diseases, in particular, its traumatic ruptures which are a fairly common pathology, being the most prevalent among all injuries of the abdominal organs. The improvement of hemostasis options and the choice of tactics in the surgical treatment of the spleen pathologies are crucial. Few recent decades have been dominated by the idea that splenectomy is the major surgical option for the spleen damage and diseases. Currently, as reported in Russia and globally, surgical tactics implying the use of organ-preserving surgeries in case of the spleen injury are being widely developed and applied.If compared with organ-preserving operations, there are negative changes in the cellular and humoral links of the immunity after splenectomy. A significant number of proposed spleen preserving options are grouped into: conservative treatment, wound tamponades, splenic sutures, segmental resection, ligation of splenic arteries, wound bonding, infrared contact coagulation, autotransplantation of splenic tissue. Currently, surgeons have quite a lot of experimental and clinically tested techniques in their arsenal that allow successfully performing organ-preserving spleen surgery. However, none of them lacks of drawbacks. These drawbacks are quite diverse, ranging from the inability to provide guaranteed reliable hemostasis to technological and economic aspects of the operation, thus, the search for novel organ-preserving techniques remains promising.
Splenic injuries are among the most frequent trauma-related injuries. The optimal treatment strategy for splenic trauma patients has shifted towards a predominantly nonoperative approach. This has been made possible with close monitoring of the patients and the use of adjuncts such as angioembolization. There is however, still a role for splenectomy in penetrating injuries and in unstable patients. The final management pathway taken, is ultimately based on the physiology of the patient, the anatomy of the injury, and the associated lesions.KeywordsSpleenTraumaSurgeryNonoperativeEmbolizationConservativeSplenectomy
Background:Spleen is commonly injured in blunt abdominal trauma.Eachyear,an average of 25% of admissions are for blunt trauma[1].The incidence is higher in males (M/F:2:1) with a peak between 18 to 34 years old[2].In the last few years the management of blunt splenic injuries both in adults and children has shifted towards a conservative approach[3]. Materials and methods:A hospital based prospective observational study was done in 30 patients presenting with blunt splenic trauma admitted in Jorhat Medical College and Hospital ,Jorhat, from June 2021 to May 2022. Demographic profile, detailed history, physical examination, operative managements and the outcome were noted. Results:A striking male preponderance of 93% was observed.The most common age group affected was those aged 20–39 years.The majority of our study population presented with abdominal pain in 25 cases. Most common sign was abdominal tenderness 25 cases . Non-operative management was adopted in 63.33% patients,operative management was done in 11 cases (36.67%).The most common post-operative complication was respiratory infections(27.27%).The present study showed a mortality of 10% (3 cases). 11 were treated operatively and 19 patients were treated conservatively.
The article analyzes the main aspects of the development of various approaches and methods in the provision of medical care to patients with closed abdominal trauma with damage to the liver and spleen. The most important stages of improving approaches, the impact of scientific and technological progress on the introduction of modern technologies in this area of surgery are described. The modern views of various authors on the existing problem are considered.
We report a rare case of a delayed splenic rupture, presenting five months after a blunt abdominal trauma in a 57 year old man. CT-angiography of the abdomen demonstrated a large intracapsular splenic hematoma with intra-abdominal free fluid, suggesting a rupture of the capsule. After failure of non-operative treatment, successful proximal embolisation of the splenic artery was performed.
Introduction. Until now, there is an ongoing controversy regarding the curative strategy in spleen pseudoaneurysms which are detected by CT imaging.Purpose. To present a diagnostic and curative algorithm for treating spleen injury complicated by multiple pseudoaneurysms in a 13-year-old child.Observation. A 13-year-old boy was injured in a traffic accident (a cyclist hit by a car) and was admitted to the hospital by an ambulance with brain concussion, abrasions and bruises of soft tissues. On the second day after the injury, the child complained of the pain in the left lumbar region. Multiphase spiral computed tomography (MSCT) revealed damage of the lower pole of the spleen with formation of multiple round hyperdense formations in the arterial phase disappearing in the portal phase. Ultrasound examination revealed multiple hypoechoic zones up to 8 mm in diameter in the lower pole of the spleen, in which blood flow was seen at the color Doppler mapping (CDM). Diagnosis: closed trauma of the spleen, Grade 4 (AAST). Multiple pseudoaneurysms of the lower pole of the spleen. Repeated MSCT on the 6th day after the injury registered disappearance of pseudoaneurysms, like it was at the ultrasound examination. In six months after the injury, there were no complaints; spleen structure at ultrasound examination corresponded to age normal parameters.Conclusion. The presented clinical observation demonstrates the success of conservative treatment of spleen injury complicated by the formation of multiple pseudoaneurysms.
Purpose:
An increasing number of polytraumatized patient presenting with active abdominal pelvic bleeding (APB) have been treated by endovascular selective embolization. However, reports on evaluate the efficacy, safety and complications caused by this technique have been limited. The aim of this study was to assess the safety and efficacy of embolization of APB using N-butyl cyanoacrylate glue (NBCA).
Materials and methods:
Single center retrospective study, that included consecutive 47 patients presenting with traumatic APB treated by embolization with NBCA between January 2013 and June 2019. The efficacy endpoint was defined as the absence of contrast extravasation immediately after procedure and clinical stabilization in the following 24 h after procedure. Clinical stabilization was defined as no rebleeding after embolization or the need for a surgical approach until the patient is discharged. Safety endpoint were any technical or clinical complications related to the embolization procedure.
Results:
The mean age of patients was 38.6 years (3-81), with a predominance of males (87.2%). The major causal factor of APB being involvement in a car accident, accounting for 68% of cases. Of the 47 cases, 29.8% presented pelvic trauma and the remaining (70.2%) presented abdominal trauma. The efficacy rate was 100%, while no complications related to the procedure were observed. The mortality rate was 14.8% (7/47) due to neurologic decompensation and other clinical causes.
Conclusion:
Endovascular embolization of traumatic abdominopelvic bleedings appear to be a highly safe and effective treatment, while avoiding emergent exploratory open surgeries.
Objective: To assist health care professionals in selecting the best management strategy and pathway for an adult patient with blunt splenic injury.
Target Level: Trust wide, including the departments of surgery, anaesthesia, radiology and emergency medicine.
Purpose
To evaluate the benefits and risks of splenic artery embolization (SAE) in patients with American Association for the Surgery of Trauma (AAST) grade V blunt spleen injury (BSI)
Materials and Methods
Medical records of 88 patients treated with SAE between April 2013 and May 2017 at a regional trauma care center were reviewed retrospectively. The BSI grade according to the AAST spleen injury scale (revised version 2018) was determined by using computed tomography (CT) images. A total of 42 patients (46.6%) had AAST grade V injury and were included in the analysis. Patient demographics, angiographic findings, embolization techniques, and technical and clinical outcomes, including splenic salvage rate and procedure-related complications, were examined.
Results
SAE was performed within 2 hours after admission for 78.5% of the patients. All patients underwent selective distal embolization (n = 42). Primary clinical success rate was 80.9% (n = 34), and secondary clinical success rate was 88.1% (n = 37). The clinical failure group consisted of 5 patients. Four patients underwent splenectomy, and 1 patient died due to acute respiratory distress syndrome after embolization. The splenic salvage rate was 85.7% (n = 36). No patient had sepsis at follow-up (median, 247.0 days; interquartile range, 92.0–688.0). Clinical success rates (P = .356) and spleen salvage rates (P = .197) of patients who were hemodynamically stable (n = 19) showed no significant differences from those who were unstable (n = 23).
Conclusions
Distal embolization of grade V BSI is a safe and feasible procedure which is effective for successful spleen salvage.
Introduction
Over the past decades, the treatment for blunt splenic injuries has shifted from operative to non-operative management. Interventional radiology such as splenic arterial embolisation generally increases the success rate of non-operative management. However, the type of intervention, such as the first definitive treatment for haemostasis (interventional radiology or surgery) in blunt splenic injuries is unclear. Therefore, we aim to clarify whether interventional radiology improves mortality in patients with blunt splenic trauma compared with operative management by conducting a systematic review and meta-analysis.
Methods and analysis
We will search the following electronic bibliographic databases to retrieve relevant articles for the literature review: Medline, Embase and the Cochrane Central Register of Controlled Trials. We will include controlled trials and observational studies published until September 2018. We will screen search results, assess the study population, extract data and assess the risk of bias. Two review authors will extract data independently, and discrepancies will be identified and resolved through a discussion with a third author where necessary. Data from eligible studies will be pooled using a random-effects meta-analysis. Statistical heterogeneity will be assessed by using the Mantel-Haenszel χ² test and the I² statistic, and any observed heterogeneity will be quantified using the I² statistic. We will conduct sensitivity analyses according to several factors relevant for the heterogeneity.
Ethics and dissemination
Our study does not require ethical approval as it is based on the findings of previously published articles. This systematic review will provide guidance on selecting a method for haemostasis of splenic injuries and may also identify knowledge gaps that could direct further research in the field. Results will be disseminated through publication in a peer-reviewed journal and presentations at relevant conferences.
PROSPERO registration number
CRD42018108304.
Spontaneous splenic rupture is a rare but often life-threatening condition. However, there is no consensus on appropriate management for this condition, due to its rarity. Here, we report three cases of malignant lymphoma with spontaneous splenic rupture. In each case, progression of splenic bleeding was rapid and complicated by malignant lymphoma. Spontaneous splenic rupture complicated by malignant lymphoma may cause exacerbation of anemia and hypovolemic shock. When splenic rupture is indicated by abdominal pain, tachycardia, or hypotension in a patient with splenomegaly, abdominal examination should be performed immediately, and emergency transcatheter arterial embolization and/or splenectomy should be considered.
This is a unique question‐and‐answer chapter for surgical residents and trainees, concentrating on the injuries of liver and spleen. In a nonoperative patient, angiographic embolization (AE) can be an adjunct in liver injuries that contains an arterio‐venous fistula or have ongoing bleeding. Nonoperative management of blunt liver injuries in patients with normal hemodynamics is recommended with greater than 90% success. Hydatid disease of the liver is uncommon. It is caused by parasitic Echinococcus, which has dogs as its definitive hosts. Patients with high‐grade liver injuries have an increased risk of developing post‐injury biloma as a complication. The accessory spleen is a common anomaly, occurring in up to 20% of the population. However, it can occur in up to 30% of patients with a hematologic disorder. Splenic artery aneurysm is very uncommon, but it is the third most frequent abdominal artery to undergo aneurismal changes.
The spleen is the most commonly injured organ involved in blunt trauma, and the diagnosis of splenic injury may be difficult. The clinical presentation includes left upper quadrant pain or referred pain to the left shoulder. Laboratory test results (e.g., hematocrit) do not always reflect the degree of splenic injury. However, because the spleen is the most vascular organ of the body, peritoneal bleeding from splenic injury can be potentially life-threatening. Ultrasonography (US) and Computed Tomography (CT) have a key role in the management of blunt splenic trauma. US is used first in hemodynamically stable patients with minor trauma, because how quick, noninvasive and easy it is to perform. US is also performed in unstable patient with the aim to detect the presence of hemoperitoneum.
Purpose of Review
This review describes the current role of diagnostic and interventional radiology in the management of solid organ trauma, particularly the role of non-operative endovascular interventions such as angioembolization (AE). We will also provide a brief highlight of interventions available for thoracic trauma.
Recent Findings
There has been a paradigm shift over the past 2 decades in the management of solid organ injuries from surgical management to non-operative management, especially in cases of minor injuries. Many factors, including the advances in multidetector contrast enhanced CT (MD-CECT) imaging, demands of cost-effective healthcare, and innovation of minimally invasive interventions with lower complication rates than surgical laparotomy have all contributed to this shift. Interventional radiology now plays a crucial role in the management of solid organ trauma, focusing on less invasive endovascular therapies. In addition, the grading and triaging of patients with stable solid organ traumatic injuries has become more reliant on MD-CECT findings.
Summary
This review article highlights the common imaging findings, grading systems, and most current management guidelines for solid organ trauma with a brief highlight of thoracic trauma.
Introduction:
The management of blunt splenic injuries (BSI) has evolved toward strategies that avoid splenectomy. There is growing adoption of interventional radiology (IR) techniques in non-operative management of BSI, with evidence suggesting a corresponding reduction in emergency laparotomy requirements and increased splenic preservation rates. Currently there are no UK national guidelines for the management of blunt splenic injury. This may lead to variations in management, despite the reorganisation of trauma services in England in 2012.
Materials and methods:
A survey was distributed through the British Society of Interventional Radiologists to all UK members aiming to identify availability of IR services in England, radiologists' practice, and attitudes toward management of BSI.
Results:
116 responses from respondents working in 23 of the 26 Regional Trauma Networks in England were received. 79% provide a single dedicated IR service but over 50% cover more than one hospital within the network. All offer arterial embolisation for BSI. Only 25% follow guidelines. In haemodynamically stable patients, an increasing trend for embolisation was seen as grade of splenic injury increased from 1 to 4 (12.5%-82.14%, p<0.01). In unstable patients or those with radiological evidence of bleeding, significantly more respondents offer embolisation for grade 1-3 injuries (p<0.01), compared to stable patients. Significantly fewer respondents offer embolisation for grade 5 versus 4 injuries in unstable patients or with evidence of bleeding.
Conclusion:
Splenic embolisation is offered for a variety of injury grades, providing the patient remains stable. Variation in interventional radiology services remain despite the introduction of regional trauma networks.
In the modern era, while the majority of patients presenting with splenic injury are victims of blunt trauma, up to 14 % are victims of penetrating trauma. Conversely, for victims of penetrating trauma, the spleen has been reported to be one of the most infrequently injured organs, ranging from 7 to 9 %.
Partial splenic embolization (PSE) is a non-surgical procedure used to treat hypersplenism in various clinical settings and thus to avoid the disadvantages of splenectomy. PSE can be employed for the treatment of a variety of diseases including hypersplenism, thrombocytopenia, portal hypertension, splenic arterial aneurysms, etc. PSE can effectively relieve the splenic artery steal syndrome which occurred after liver transplantation, and therefore significantly improve the blood perfusion of the recipient liver. Besides, PSE can also be adopted to reduce the bleeding risk in patients with esophageal and gastric varices caused by portal hypertension. PSE is beneficial to the improvement of peripheral hematologic parameters, which helps the patients successfully undergo the high-dose chemotherapy or interferon therapy. In addition, PSE possesses potential curative effect for thrombocytopenia related diseases such as chronic idiopathic thrombocytopenic purpura. This paper aims to make a comprehensive review of the recent progress in the clinical application of partial splenic embolization.
Clinical history Dysphagia and retrosternal pain. HIV-positive. Model answer The barium swallow (Figures 2.1a–2.1c) shows a longitudinally arranged, shaggy serrated appearance of the middle and lower third of the oesophagus with innumerable small filling defects. Multiple tiny erosions and areas of ulceration are present. There is no evidence of obstruction or barium hold-up. No mass lesions identified. No stricture formation. Features are likely to represent candida oesophagitis, particularly given the history of HIV. This is an opportunistic infection of the oesophagus. I would like to examine the patient for evidence of oropharyngeal candidiasis, which is often manifested as white plaques in the mouth. As candida oesophagitis is an AIDS-defining illness in an HIV-positive patient, I would also like to discuss the case urgently with the referring clinician to ensure appropriate clinical management. Fungal cultures from the upper gastrointestinal tract can be obtained for definitive diagnosis. Questions 1. What are the symptoms associated with candida oesophagitis? Symptoms include dysphagia, retrosternal chest pain and odynophagia. Oral thrush may be present. Weight loss is common. There may be associated nausea and vomiting. Fever is not typical of candida oesophagitis and may suggest another cause or fulminant systemic infection. 2. Which patient groups are predisposed to candida oesophagitis? Susceptible patient groups include individuals on inhaled steroid therapy or prolonged antibiotics, those who are HIV-positive, immunocompromised or elderly patients, or patients with delayed oesophageal emptying such as those with scleroderma, achalasia, strictures and post fundoplication.
The management of trauma patients has also evolved in recent decades due to increasing availability of advanced imaging modalities such as computed tomography (CT). Nowdays, CT replace the diagnostic function of angiography. The latter is considered when a therapeutic option is hypothized. Arterial embolization is a life-saving procedure in abdomino-pelvic hemorrhagic patients, reducing relevant mortality rates and ensuring hemodynamic stabilization of the patient. Percutaneous transarterial embolization (TAE) has been shown to be effective for controlling ongoing bleeding for patients with high-grade abdomino-pelvic injuries, thereby reducing the failure rate of nonoperative management, preserving maximal organ function. Surgery is not always the optimal solution for stabilization of a polytrauma patient. Mini-invasivity and repeatability may be considered relevant advantages. We review technical considerations, efficacy and complication rates of hepatic, splenic, renal and pelvic embolization to extrapolate current evidence about TAE in traumatic patients.
Interventional radiology, particularly percutaneous angioembolisation plays an important role in the management of blunt abdominal trauma involving solid organs and pelvic fractures. The traumatic injuries of the central nervous system, heart and great vessels often lead to death at the site of trauma. Though patients with visceral organ injuries can also expire at the site of trauma, these patients often reach the hospital thus giving us an opportunity to treat them with surgical or radiological intervention depending upon the clinical condition of the patient.
Background:
Nonoperative management is the standard of care in hemodynamically stable patients with blunt splenic injury. However, a number of issues regarding the management of these patients are still unresolved. The aim of this study was to reach consensus among experts concerning optimal treatment and follow-up strategies.
Methods:
The Delphi method was used to reach consensus among 30 expert trauma surgeons and interventional radiologists from around the world. An online survey was used in the two study rounds. Consensus was defined as an agreement of 80% or greater.
Results:
Response rates of the first and second rounds were 90% and 80%, respectively. Consensus was reached for 43% of the (sub)questions. The American Association for the Surgery of Trauma organ injury scale for grading splenic injury is used by 93% of the experts. In hemodynamically stable patients, observation or splenic artery embolization (SAE) can be applied in the presence of a small or no hemoperitoneum combined with an intraparenchymal contrast extravasation or no contrast extravasation, regardless of the presence of an arteriovenous (AV) fistula/pseudoaneurysm. Hemodynamic instability is an indication for operative management, irrespective of computed tomographic characteristics and grade of splenic injury (≥82% of the experts). Operative management is also indicated in the presence of associated intra-abdominal injuries and/or the need for five or more packed red blood cell transfusions (22 of 27 experts, 82%). Recommended time span to start SAE in a stable patient with an intraparenchymal contrast extravasation is 60 minutes (19 of 24 experts). Patients should be admitted 1 to 3 days to a monitored setting (27 of 27 experts, 100%). Serial hemoglobin checks are performed by all experts, every 4 to 6 hours in the first 24 hours and once or twice a day after that (21 of 24 experts, 88%), in nonoperative management as well as after SAE. Routine postdischarge imaging is not indicated (21 of 24 experts, 88%).
Conclusion:
Although treatment should always be adjusted to the specific patient, the results of this study may serve as general guidelines.
Objective:
The objective of this article is to familiarize the reader with the most commonly used embolic agents in interventional radiology and discuss an approach for selecting among the different embolic agents. This article reviews their properties and uses a case-based approach to explain how to select one.
Conclusion:
A wide variety of embolic agents are available. Familiarity with the available embolic agents and selection of the most appropriate embolic agent is critical in interventional radiology to achieve optimum therapeutic response and avoid undesired, potentially disastrous complications such as nontarget embolization.
We evaluated the efficacy of nonsurgical management of patients with blunt splenic injury using detailed angiographic examinations and transcatheter arterial embolization.
We prospectively studied 228 patients who had blunt abdominal injury and for whom CT was performed. When splenic injury was revealed by CT, angiography was performed in all patients except those requiring emergency surgery. Transcatheter arterial embolization was performed when patients had the following angiographic criteria: (1) extravasation of contrast material extending beyond or within the splenic parenchyma, (2) arterial disruption or major arteriovenous fistula, or (3) both. Splenic function was subsequently estimated by 99mTc-sulfur colloid scintigraphy and repeat angiography.
Of 228 patients with blunt trauma, 31 patients had CT evidence of splenic injury. In three of these 31 patients, emergency laparotomy was performed before angiography because of an associated injury or unstable circulatory status. In 13 of the 28 remaining patients, transcatheter arterial embolization was not required as these patients did not meet the necessary criteria. They were treated with bed rest. Transcatheter arterial embolization was performed in the remaining 15 patients and was completely successful in 13. Because one of these 13 patients died of a brain contusion, follow-up angiography and scintigraphy were performed in the remaining 12 patients and showed preservation of splenic function. Nonsurgical treatment of splenic injury with angiography was successful in 93% of patients.
Our success rate for nonsurgical management of patients with blunt splenic injury should encourage more extensive evaluation and use of angiography for splenic injury and the subsequent management of splenic injury without surgery.
Using CT to grade blunt splenic injuries frequently does not predict clinical outcome. This retrospective, blinded study evaluated whether revealing a traumatic pseudoaneurysm or frank hemorrhage on an initial CT examination can be used to predict the successful clinical outcome of patients managed without surgery.
The medical and CT records of all patients with blunt splenic injury during a 5-year period were independently reviewed for vascular abnormalities. Also, the grade of injury was reconfirmed. Hemodynamically stable patients with injuries of grades 1-3 were managed without surgery. Clinical failure occurred if a patient required splenectomy or splenorrhaphy after any attempt of nonsurgical management.
Two hundred sixty-three patients were treated for blunt splenic injuries. Eighty-two of these patients underwent emergent surgery on the basis of clinical and peritoneal lavage findings without CT examination. The remaining 181 (69%) patients were initially evaluated with emergent abdominal CT. Of these 181 patients, 72 (40% of those undergoing CT) were treated nonsurgically. Nonsurgical therapy failed in 11 (15%) of these 72 patients. Of these 11 patients, nine (82%) had a defined vascular abnormality of the spleen. Only eight (13%) of the remaining 61 patients who underwent CT and successful nonsurgical management had a vascular abnormality of the spleen.
The failure rate in patients with nonsurgically managed blunt splenic injuries may be markedly reduced if patients with traumatic pseudoaneurysm or active hemorrhage revealed on emergent CT are treated with early surgical or endovascular repair.
Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen were first published by the British Committee for Standards in Haematology in 1996. Key aspects of these guidelines related to anti-infective prophylaxis, immunisation schedules and treatment of proven or suspected infection. A recent review of the guidelines was undertaken, with a view to updating the recommendations where necessary. The guideline review process did not reveal any major change in patient groups considered at risk. Occupational exposure to certain pathogens may, however, be a new risk factor for some infections. The recommendations for anti-infective prophylaxis remain unchanged. New recommendations for vaccination include the use of meningococcal group C vaccine in previously non-immunised hyposplenic patients and a need to consider the use of seven-valent pneumococcal vaccine. Recommendations for treatment of suspected or proven infection have not been significantly amended, but a local protocol should take into account relevant resistance patterns. There is an identified urgent need for further research into the effectiveness of varying vaccination strategies in the hyposplenic patient, and audit of infective episodes in this patient group should continue long term. Key guidelines are summarised below, together with grades of recommendation.
Documentation of overwhelming post-splenectomy sepsis, characterized by infection from encapsulated organisms, has led to development of surgical techniques for preservation of the injured spleen to maintain splenic clearance of encapsulated, opsonized organisms from the circulation. In this study splenic artery ligation (SAL) was performed as an adjunct to seccessful splenorrhaphy in 20 adults suffering blunt splenic injury. There were no deaths and no reoperations. Twenty units of blood were transfused in ten patients. Splenic removal of blood-borne opsonized particles was measured as the clearnce of anti-Rh-antibody-coated 51 Cr-radiolabeled autologous red blood cells from the circulation in five SAL patients and nine normal volunteers. The clearance of opsonized red cells 120 minutes after injection was not different (40 +/- 7% of injected dose in controls, 40 +/- 4% in SAL patients). These results demonstrate that SAL can safely be applied as an adjunct to splenorrhaphy and that SAL does not diminish splenic clearance of opsonized particles from the circulation.
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.
Objectives: By using abdominal computed tomographic scans in the evaluation of blunt splenic trauma, we previously identified the presence of vascular blush as a predictor of failure, with a failure of nonoperative management of 13% in that series. This finding led to an alteration in our management scheme, which now includes the aggressive identification and embolization of splenic artery pseudoaneurysms, Methods: The medical records of 524 consecutive patients with blunt splenic injury managed over a 4.5-year period were reviewed for the following information: age, Injury Severity Score (ISS), American Association for the Surgery of Trauma splenic injury grade (SIG), method and outcome of management, Results: Of the patients, 66% were male with a mean age of 32 +/- 16, and mean ISS of 25 +/- 13, A total of 180 patients (34%) were managed with urgent operation on admission (81% splenectomy (SIG 4.0), 19% splenorrhaphy (SIG 2.6)), The remaining 344 patients (66%) were hemodynamically stable and underwent computed tomographic scan and planned nonoperative management. Of these patients, 322 patients (94%) were successfully managed nonoperatively (61% of total splenic injuries), In 26 patients (8%), a contrast blush identified on computed tomographic scan was confirmed as a parenchymal pseudoaneurysm on arteriography, Twenty patients (SIG, 2.8) were successfully embolized, In six patients, technical failure precluded embolization; all required splenectomy (SIG, 4.0), A total of 22 patients (6%) failed nonoperative management, including the six with unsuccessful embolization attempts, Sixteen patients (SIG, 3.0) who had no evidence of pseudoaneurysm were explored for a falling hematocrit, hemodynamic instability, or a worsening follow-up computed tomography: 13 patients had splenectomy, and three patients had splenorrhaphy. Conclusions: Aggressive surveillance for and embolization of posttraumatic splenic artery pseudoaneurysms improved the rate of successful nonoperative management of blunt splenic trauma to 61%, with a nonoperative failure rate of only 6%. In comparison with our previous work, this reduction in failure of nonoperative management is a significant improvement (p < 0.03).
Objective: To determine the value of follow-up abdominal computed tomography in patients with splenic trauma managed nonoperatively. Design: Retrospective chart review. Materials and Methods: A total of 108 consecutive patients with splenic injuries treated at a single institution from 1990 to 1996 were studied. All admission and follow-up computed tomographic (CT) scans were reviewed by the authors. Results: Initial management was surgical in 35 patients (32%) and intentionally nonoperative in 73 patients (68%). Nonoperative management was successful in 45 of 49 adults (92%) and 21 of 24 children(88%). Sixty-two follow-up abdominal CT scans were obtained in 49 patients. Information that affected management was evident on only one follow-up CT scan performed in the absence of clinical indications. Potential savings in hospital and physician charges for routine follow-up CT scans in this study were $54,302.00. Conclusions: Follow-up abdominal CT scans are not routinely necessary in patients with splenic injuries managed nonoperatively.
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.
Objectives. The purpose of this study was to examine the success rate of nonoperative management of blunt splenic injury in an institution using splenic embolization. Method: We conducted a retrospective review of all patients admitted to a Level I trauma center with blunt splenic injury. Data review included patient demographics, computed tomographic (CT) scan results, management technique, and patient outcomes. Results. A total of 648 patients with blunt splenic injury were admitted, 280 of whom underwent immediate surgical management. Three hundred sixty-eight underwent planned nonoperative management, and 70 patients were treated with observation, serial abdominal examination, and follow-up abdominal CT scanning. All were hemodynamically stable, with a 100% salvage rate. One hundred sixty-six patients had a negative angiogram, with a nonoperative salvage rate of 94%, and 132 patients underwent embolization, with a nonoperative salvage rate of 90%. Overall salvage rates decreased with increasing injury grade; however, over 80% of grade 4 and 5 injuries were successfully managed nonoperatively. The salvage rate was similar for main coil embolization versus selective or combined embolization techniques. Admission abdominal CT scan correlated with splenic salvage rates. Significant hemoperitoneum, extravasation, and pseudoaneurysm had acceptable salvage rates, whereas arteriovenous fistula had a high failure rate, even after embolization. Conclusion. Splenic embolization is a valuable adjunct to splenic salvage in our experience, allowing for the increased use of nonoperative management and higher salvage rates for American Association for the Surgery of Trauma splenic injury grades when compared with prior studies. Main coil embolization has a similar salvage rate when compared with other angiographic techniques. An arteriovenous fistula as a CT finding was predictive of a 40% nonoperative failure rate.
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.
Background : To analyze the use of admission angiography as a nonoperative adjunct for management of blunt splenic injury.
Methods : Retrospective chart review of all blunt splenic injuries to a Level I trauma center from March 1997 through July 1999.
Results : One hundred twenty-six patients underwent angiography for splenic injury. Eighty-six patients (68%) had a negative angiogram and were treated expectantly. Of these, seven patients (8%) required laparotomy, with a splenic salvage rate of 92%. Embolization was performed on 40 patients (32%) for evidence of vascular injury. Of these, three patients (8%) required laparotomy, for a total salvage of 92%. Repeat angiography was performed for suspicion of bleeding in 12 patients (10%), with 50% requiring embolization. Outcome based on CT grade demonstrated an average grade of 2.9, with a salvage rate of greater than 70% for grade IV and V injuries.
Conclusion : Vascular injury increases with splenic injury grade. Embolization improves nonoperative salvage rates to 92%, even with high-grade injuries. Ten percent of patients require additional therapy including second-look angiography. A significant portion of patients with negative screening angiograms (10%) required either embolization or laparotomy to control delayed hemorrhage.
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.
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.
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.
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.
Overwhelming sepsis is splenectomized children may be a real threat to life. As an alternative to splenectomy, ligation of the splenic artery in combination which splenorrhaphy was used successfully in two children with splenic trauma involving major segmental vessels. In both patients the postoperative course was normal. Peripheral blood tests, immunological studies, and scintigraphies disclosed no abnormalities of the spleen after the ligation of the splenic artery. Aortographies showed a collateral arterial network in the spleen. Therewith, 11 and 12 months after the operation, respectively, both cases--the first of our series--are presented and discussed.
Three techniques of transcatheter splenic arterial occlusion were evaluated in dogs. Angiographic, hematologic, and morphologic studies were done up to 9 weeks postocclusion. All animals showed hematologic changes characteristic of depressed splenic function; the degree and duration of these changes depended upon the technique. Alterations in histology including vascular congestion, infarction, and fibrosis, were also dependent upon the method used and the time elapsed after occlusion. Celiac angiography demonstrated the extent of collateral circulation and degree of recanalization of the occluded vessels. Potential clinical applications are discussed.
The management and outcome of blunt splenic injury diagnosed with computed tomography (CT) were studied in 44 consecutive patients who were hemodynamically stable or whose condition stabilized rapidly with resuscitation. Celiac and splenic arteriography was used in the triage of patients for nonsurgical treatment or for hemostasis. Patients without arterial extravasation of contrast material at arteriography were treated with bed rest only (group 1, n = 19); patients who had such extravasation were treated with bed rest after percutaneous transcatheter coil occlusion of the proximal splenic artery (group 2, n = 17). Abdominal exploration without angiography or embolotherapy was begun if the patient or attending surgeon did not agree with the treatment protocol (group 3, n = 8). Treatment with bed rest alone was successful in 18 patients. Clinical control of hemorrhage was accomplished in all patients in group 2 and one patient in group 1. Thus, exploratory laparotomy was avoided in 34 of 36 patients (94%) in whom nonoperative management was attempted; splenic salvage was achieved in 35 of 36 patients (97%).
A collective critical review of the literature on postsplenectomy sepsis from 1952 to 1987 has been undertaken. The reports cover a cohort of 12,514 patients undergoing splenectomy but of these only 5902 reports were sufficiently detailed to allow a useful analysis. The incidence of infection after splenectomy in children under 16 years old was 4.4 per cent with a mortality rate of 2.2 per cent. The corresponding figures for adults were 0.9 per cent and 0.8 per cent respectively. The present analysis of well documented patients has shown that severe infection after splenectomy for benign disease is very uncommon except in infants (infection rate 15.7 per cent) and children below the age of 5 years (infection rate 10.4 per cent). Many of these reported postsplenectomy infections may have been coincidental. It is also apparent that children contract a different type of infection after splenectomy than adults, predominantly a meningitis which is less frequently fatal. Adults, in contrast, appear to develop a septicaemic type of illness associated with a higher mortality rate. This survey has also shown that children are reported to be more susceptible to pneumococcal sepsis than to infection caused by any other organism. Although the removal of the spleen in otherwise normal people does not appear to be associated with an increased frequency of infection, the presence of a coexistent disorder, notably hepatic disease, can increase the risk substantially.
Documentation of overwhelming post-splenectomy sepsis, characterized by infection from encapsulated organisms, has led to development of surgical techniques for preservation of the injured spleen to maintain splenic clearance of encapsulated, opsonized organisms from the circulation. In this study splenic artery ligation (SAL) was performed as an adjunct to successful splenorrhaphy in 20 adults suffering blunt splenic injury. There were no deaths and no reoperations. Twenty units of blood were transfused in ten patients. Splenic removal of blood-borne opsonized particles was measured as the clearance of anti-Rh-antibody-coated 51Cr-radiolabeled autologous red blood cells from the circulation in five SAL patients and nine normal volunteers. The clearance of opsonized red cells 120 minutes after injection was not different (40 +/- 7% of injected dose in controls, 40 +/- 4% in SAL patients). These results demonstrate that SAL can safely be applied as an adjunct to splenorrhaphy and that SAL does not diminish splenic clearance of opsonized particles from the circulation.
Splenic artery ligation (SAL) combined with either splenorrhaphy or partial splenectomy has been used as a spleen saving procedure in the management of massively bleeding splenic injuries. During the last 10 years, 37 children have been submitted to SAL following a selective management schedule. This study was jointly undertaken by two separate Pediatric Surgical Units in two different countries, in order to evaluate some preliminary observations published previously, with regard to; 1) the percentage of splenic injuries requiring ligation of the splenic artery; 2) the effect of this procedure on the arrest of bleeding; 3) the postoperative complications related to dearterialization of the spleen; 4) the immunological status after the operation and; 5) the postoperative imaging of the spleen using radioscintigrams and ultrasonograms. The mean age of the patients was 6.9 years and the follow up period ranged from 1 to 10 years. Thus, SAL was concluded to be an effective mode of treatment for rare cases of splenic injury unable to be treated nonoperatively or by splenorrhaphy alone. No postoperative complications were recorded in this series, while the immunological status remained undisturbed postoperatively and imaging of the spleen revealed intact and functional tissue with adequate healing.
In all, 1490 patients underwent splenectomy in Western Australia between 1971 and 1983, giving 7825 person years exposure. Thirty-three patients developed severe late postsplenectomy infection (septicaemia, meningitis or pneumococcal pneumonia requiring hospitalization) and three developed overwhelming postsplenectomy infection. The incidence and mortality rates of severe late postsplenectomy infection were 0.42 and 0.08 per 100 person years exposure respectively and for overwhelming postsplenectomy infection the incidence and mortality rates were 0.04 per 100 person years exposure. There were 628 splenectomies after trauma, giving 3922 person years exposure. Eight patients developed severe late postsplenectomy infection of whom one had overwhelming postsplenectomy infection. Following trauma, the incidence of severe late postsplenectomy infection was 0.21 per 100 person years exposure, with the incidence and mortality rates of overwhelming postsplenectomy infection being 0.03 per 100 person years exposure. Patients undergoing splenectomy have a 12.6-fold increased risk of developing late septicaemia compared with the general population. Splenectomy following trauma gives an 8.6-fold increased risk of late septicaemia. The majority of severe late postsplenectomy infections did not occur within the first 2 years and 42 per cent of severe late postsplenectomy infections occurred greater than 5 years after splenectomy. The low incidence of severe late postsplenectomy infection and overwhelming postsplenectomy infection makes statistical evaluation of the effectiveness of prophylactic antibiotics, vaccination and splenic repair most difficult.
We reviewed 37 consecutive, hemodynamically stable patients (16 adults, 21 children) who had splenic injuries diagnosed by computed tomography (CT) scan to compare the CT evaluation with operative assessment of injury and eventual treatment. Computed tomographic scans and operative findings were graded by a splenic injury scoring system. Two patients were classified as having grade 1, 21 as grade 2, 11 as grade 3, and 3 as grade 4 splenic injuries. Computed tomography underestimated the degree of injury in 9 of 17 (53%) operated patients (mean CT score, 2.6; mean operative score, 3.3; p less than 0.01). Six of sixteen adults and 19 of 21 children were intentionally treated by observation. There were 5 treatments failures (20%), 3 due to bleeding and 1 each due to pancreatic injury and splenic abscess. The failure rate of observation was lower in children (16%) than in adults (33%), even though children had a higher Splenic Injury Score (2.4 versus 1.8). Patients who underwent an operation received twice as much blood as the observed group. There was no significant difference in Injury Severity Score or total fluid requirements between operated and observed patients. Operations increased in frequency in both adults and children as the injury score increased. This experience suggests that CT scan accurately determines the presence of splenic injury but commonly underestimates its severity. While children with grades 1 through 3 injuries are likely to be treated successfully with observation, adults who have more minor splenic injuries often fail observation and may be treated better by prompt operation.
This review examines the infectious consequences of elective and emergency splenectomy, highlighting the importance of infection with Streptococcus pneumoniae. The influence of splenectomy on the immune system is discussed and the efficacy of vaccines in preventing postsplenectomy sepsis is reviewed. The value of alternative methods of preventing postsplenectomy sepsis is considered.
Overwhelming post-splenectomy infection (OPSI) is a serious condition associated with a high mortality rate. Occurring most often in the first two years after splenectomy, it has also been described up to 47 years after this operation. We report a further occurrence of this syndrome and stress the importance of early detection and aggressive treatment of this type of infection.
Nonsurgical management of blunt splenic injury in children is a well-established method to salvage splenic function; however, nonsurgical management of adult blunt splenic trauma remains controversial. To assess the value of preoperative abdominal CT in predicting the outcome of blunt splenic injury in adults, a CT-based injury-severity score consisting of four grades was devised and applied in 39 adult patients with blunt splenic injury as the sole or predominant intraperitoneal injury detected with preoperative CT. While patients with high grades of splenic injury generally required early surgery, eight (35%) of 23 patients with initial grade 3 or 4 injury were treated successfully without surgery, and four (29%) of 15 patients with grade 1 or 2 injury initially treated nonsurgically required delayed celiotomy (n = 3) or emergency rehospitalization. Results show that while CT remains an accurate method of identifying and quantifying initial splenic injury, as well as documenting progression or healing of critical injury, CT cannot reliably help predict the outcome of blunt splenic injury in adults. Treatment choices should therefore be based on the hemodynamic status of the patient and results of serial laboratory and bedside assessments.
The recognition of overwhelming post-splenectomy infection (OPSI) has led to greater efforts to conserve splenic tissue in patients sustaining blunt torso trauma. Nonoperative management of splenic trauma has emerged as a means to enhance splenic salvage yet criteria to assure the safety of such an approach remain ill defined and controversial. Since severity of injury directly influences outcome, a need exists for identification of splenic injuries that require early operation and repair or removal. Using our recently reported classification of splenic trauma, 46 patients with blunt splenic trauma were evaluated preoperatively with computed tomography (CT). Injuries were graded I through IV and were described as capsular or subcapsular disruptions without parenchymal injury (four); capsular and parenchymal injuries not involving the major vessels or hilum (24); injuries involving major vessels and/or the hilum (17); and fragmentation/devascularizing injuries (one). Additional modifiers were added for associated intra-abdominal and/or extra-abdominal injuries. Sixteen patients had their splenic injuries managed nonoperatively and the remainder underwent operation for the splenic injury or associated injuries. The CT classification was confirmed in all patients and we believe early operation optimized splenic salvage. We conclude that: 1) CT is an accurate technique to determine the extent of splenic injury; 2) CT classification of splenic trauma has a high correlation with anatomic findings and need for operation; 3) early operation in patients with severe class II and all class III injuries affords optimal conditions for splenic salvage; and 4) early definitive management of splenic trauma significantly reduces late splenectomy and shortens hospitalization.
We reviewed the charts of 87 patients with documented splenic injuries resulting from blunt trauma admitted to a regional trauma referral center during the 32-month period beginning in January 1984. Delayed celiotomy was defined as surgical intervention for splenic injury after a trail of nonoperative management lasting at least 24 hours. Delayed celiotomy was not required in any of the 16 cases in the pediatric age group (age less than or equal to 17 years) who were initially managed nonoperatively. In contrast, of the 27 adults who were initially treated nonoperatively, ten (37%) ultimately required celiotomy. Although splenorrhaphy was successfully performed in 21 of 44 patients undergoing early operation, all ten of the patients requiring celiotomy after an unsuccessful trial of observation underwent splenectomy rather than a spleen-preserving procedure. Of the 27 adults who were initially managed nonoperatively, 24 had abdominal computed tomography (CT) performed during their initial diagnostic evaluation. Twenty-three of these scans were reviewed by one of the authors. A CT scoring system was developed, based on the degree of splenic parenchymal and capsular injury and the amount of fluid in the abdomen and the pelvis. Adult patients who were successfully treated without operation had a significantly (p = 0.011) lower total CT score than did patients who required delayed celiotomy. No adult with a total CT score less than 2.5 required delayed operative intervention. These data support
Fifty-five consecutive cases of surgically proved splenic injuries were evaluated with computed tomography (CT). CT permitted correct identification of 54 splenic injuries, with one false-negative and three false-positive cases. In the single false-negative case and in two of the three false-positive cases, CT scans correctly indicated the presence of a large hemoperitoneum and other abdominal visceral lacerations and so correctly indicated the need for surgery. Of the 55 proved cases, CT demonstrated hemoperitoneum in 54 (98%), perisplenic clot in 47 (85%), splenic laceration in 39 (71%), and subcapsular hematoma in 13 (24%). Perisplenic clot can be distinguished from lysed blood in the peritoneal cavity and is a sensitive and specific sign of splenic trauma, even in the absence of visible splenic laceration. The authors conclude that CT is a highly reliable means of evaluating splenic trauma.
Splenic embolization using steel coils was performed in 28 patients with hypersplenism caused by portal hypertension. The patients were classified according to the site of placement of the steel coils: In group 1 (six patients), it was the proximal splenic artery; in group 2 (10 patients), the distal splenic artery in the hilum of the spleen; in group 3 (12 patients), the intrasplenic branches of the splenic artery. Platelet counts increased in 27 (96%) of 28 patients within 1 month after embolization; the mean platelet counts at 1 year after treatment were higher than before the procedure in all groups. In group 3, excellent increases in platelet counts were obtained both as short- and long-term results of embolization; however, minor complications lasted longer than in the other two groups. No serious complications resulted from this procedure. Splenic embolization using steel coils is a valuable alternative to splenectomy in patients with hypersplenism.
Computed tomography (CT) was used in the evaluation of 100 patients suffering abdominal trauma. The type of trauma was blunt in 78 patients, penetrating in eight, and iatrogenic in 14. Forty per cent of cases had normal CT scans, while 60% showed substantial abdominal or retroperitoneal injuries. Surgery, clinical follow-up, and repeated radiologic examinations confirmed the accuracy of CT, and there were no cases in which medical or surgical management was inappropriately guided by CT. A wide variety of injuries was detected, including 19 splenic, eight hepatic, six pancreatic, 13 renal, 13 retroperitoneal or abdominal wall, and one intraperitoneal. CT has major advantages over plain radiography, radionuclide imaging, and angiography in assessment of trauma-induced injuries.
Ligation of the splenic artery, combined with splenorrhaphy, was used successfully on eight children with splenic trauma involving major segmental vessels. Evaluation of the collateral arterial network and of its adequacy was done by means of arteriography on four out of the eight patients. Aortographies were carried out on the twentieth day, the first month, the third month, and the fourth month following the ligation.
A collateral arterial network, deriving mainly from the short gastric arteries was detected, dyestream disruption and retrograde filling of the artery. No complications after aortography were noted. Findings demonstrate that collateral blood supply develops rapidly and its pattern is rather uniform.
Arteriographic control of hemorrhage was attempted in 4 patients with splenic trauma, using gelatin foam embolization in 2, vasopressin infusion in 1, and a steel-wool coil in 1. Bleeding was controlled and 2 spleens were salvaged. Experimental and clinical evidence suggests that temporary vasoconstriction and occlusion of large vessels can control bleeding and are better suited for splenic salvage than embolization with small particles.
Treatment of splenic trauma by ligating the splenic artery was studied on 28 dogs. Bleeding was arrested, and the animals under experimentation tolerated the ligation of the splenic artery without complications. The histology of the spleen showed no abnormalities 2 mo after the experiment. The traumatized area of the spleen had healed. The platelets and reticulocytes were temporarily increased. The hemotocrit values, WBC counts, and serum immunoglobulin M, remained within normal levels. Bone marrow smears, and scintigrams of the spleen were normal. Ligation of the splenic artery, combined with splenorrhaphy, was also successfully used in children with splenic trauma involving major segmental vessels.
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.
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.
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).
(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.
Computed tomography (CT) is increasingly utilized in evaluation of adult splenic injury (SI). CT correlation with operative findings, CT relationship to successful nonoperative (NO) management, and CT reading reproducibility were examined. Records of patients > or = 15 years old admitted over a 3-year period were reviewed. Computed tomography scans were graded by two radiologists blinded to clinical results. Computed tomography scans were performed on 49 of 77 patients with SI. Eighteen underwent initial operation (OR) and 31 initial NO. Operative patients had higher Injury Severity Scores and Abdominal Abbreviated Injury Scale scores (p < 0.0001). Grade II readings predominated in the NO group (55%). Nonoperative management was successful for 9 grade III and 3 grade IV readings. Computed tomography matched OR grade in 10 readings, underestimated it in 18, and overestimated it in 6. Computed tomography missed SI in five patients. Radiologists disagreed on 9 of 45 (20%) scans. Computed tomography poorly predicted operative findings. Interobserver variability was common. SI management should not be based solely on CT severity.
To determine the value of follow-up computed tomography (CT) after expectant treatment in patients with clinically stable blunt splenic trauma.
Medical records and CT studies for 42 patients were reviewed, and injuries were graded on a scale of 1-6. Patients were divided into three groups: stable patients with no follow-up CT (group 1, n = 14), stable patients with follow-up CT (group 2, n = 22), and symptomatic patients with follow-up (group 3, n = 6). Serial hemoglobin values and clinical findings at follow-up CT were reviewed.
All patients in groups 1 and 2 remained clinically stable with good outcomes. In group 3, follow-up CT scans demonstrated worsening condition in four patients (67%), and three of the four had poor outcomes.
Follow-up CT may be unnecessary in patients with clinically stable splenic trauma.
The authors reviewed their experience with life-threatening blunt injuries in approximately 2900 children (0-14 years) admitted to the designated state pediatric shock trauma unit between 1990 and 1993.
During this time, the authors treated all severely injured children with a prospective, nonoperative protocol if they were hemodynamically stable after less than 40 mL/kg fluid replacement, had proven evidence of solid organ injuries and remained stable in the pediatric intensive care unit under surgical management.
Twenty-eight children had computed tomography (CT) or operatively proven lacerations of the spleen, 25 had lacerations of the liver, 18 had lacerations of the kidney, 7 had lacerations of the pancreas, and 11 had two or more solid organ injuries. Three of the 28 children with injured spleens required laparotomy (two splenectomy, one splenorrhaphy). Two of the 25 children with liver injuries required laparotomy (one suturing, one partial resection). One of the 18 children with kidney injuries required laparotomy (nephrectomy), and 3 of the 7 children with pancreas injuries required laparotomy (two resection, one pseudocyst). There were three deaths after laparotomy (two head, one chest/abdominal). There were no deaths in the children managed nonoperatively, and there were no immediate or long-range complications.
Comparison of the authors' data with the National Pediatric Trauma Registry shows similar results. The authors believe that nonoperative management of solid organ injuries under careful surgical observation in a pediatric intensive care unit is safe and appropriate.
The role of CT grading of blunt splenic injuries is still controversial. We studied the CT scans of adult patients with proved blunt splenic injuries to determine if the findings accurately reflect the extent of the injury. We were specifically interested in establishing if CT findings can be used to determine whether patients require surgery or can be managed conservatively.
The CT scans of 45 patients with blunt splenic injuries were analyzed retrospectively, and the CT findings were correlated with the need for surgery. We used (1) a CT scale (I-V) for splenic parenchymal injuries that also allowed a comparison with the surgical findings in patients who underwent laparotomy, and (2) a CT-based score (1-6) that referred to both the extent of parenchymal injuries and the degree of hemoperitoneum. Early laparotomy was done in nine patients. Conservative treatment was attempted in 36 patients and was successful in 31; five patients needed delayed laparotomy after attempted conservative treatment.
According to the CT scale (I-V), 25 patients had injuries of grade I or II; 20 patients were successfully treated conservatively, whereas five patients needed delayed surgery. Nineteen patients had injuries of grade III, IV, or V; eight patients underwent early laparotomy, and 11 patients were successfully treated conservatively. CT findings were false-negative in one patient who underwent early surgery for diaphragmatic rupture. A comparison of the CT findings with the intraoperative findings according to the CT scale (I-V) revealed identical parenchymal injury grades in four cases, whereas the injuries were underestimated on CT scans in four patients and overestimated on CT scans in six patients. The CT-based score (1-6) was applied to 41 patients; four patients who had peritoneal lavage before CT were excluded. Twelve patients had scores below 2.5; 10 patients were successfully treated conservatively, and two patients needed delayed surgery. Twenty-nine patients had scores of 2.5 or higher; six patients underwent early laparotomy, 20 patients were successfully treated conservatively, and three patients needed delayed surgery. Patients who required delayed surgery had a mean score of 3.0 (SD, +/- 1.0), which was similar to those who did not require surgery (3.1 +/- 1.5; p = .45).
Our results show that CT findings cannot be used to determine reliably which patients require surgery and which patients can be treated conservatively. Even patients with splenic parenchymal injuries of CT grade III, IV, and V and with CT-based scores of 2.5 or higher can be successfully treated conservatively if the clinical situation is appropriate, whereas delayed splenic rupture can still develop in patients with low CT grades or scores. The choice between operative and nonoperative management of splenic trauma should be mainly based on clinical findings rather than CT findings.
Injured children require an organized, properly equipped, team approach to management. The emergency physician must be aware of the anatomic and physiologic differences that predispose the child to certain injuries. Aggressive airway and hemodynamic resuscitation are essential in the critically injured child.
A network of pediatric trauma consultants should be identified in your region for early consultation and referral. Continued research and the ongoing epidemiologic studies from the National Pediatric Trauma Registry will improve our understanding and management of the injured child. It is essential for each of us to become a strong injury prevention advocate in our own community.
The objective was to determine the utility of a second CT scan in nonoperative management of blunt liver and splenic trauma. The design was a retrospective review of consecutive cases over a 2-year period in two trauma centers. Subjects were 152 patients with blunt abdominal trauma and isolated injuries to liver and/or spleen. Thirty patients received immediate laparotomy, whereas 122 patients (80%) underwent CT scanning that showed splenic (n = 64), liver (n = 44), or combined (n = 14) injuries. Nonoperative management was undertaken in 99 of the 122 (81% of the patients who received CT scans; 65% of the overall series) and was ultimately successful in 94 (95%). Second CT scans were used in 26 patients (26%), one of whom received laparotomy for drainage of a bile leak and three for ongoing bleeding. None of the followup scans showed major progression of injury, and scan findings did not influence decisions for operation in any patients. Routine followup CT scanning is not a justifiable component of nonoperative management protocols for blunt liver and splenic injuries.
In order to determine antibody levels against Streptococcus pneumoniae (pneumococcus) and Haemophilus influenzae type b (Hib) in a population of splenectomized subjects, 561 persons in a Danish county, splenectomized between 1984 and 1993 were identified. Two hundred and thirty-five were alive and 149 participated in the study. Each person donated a blood sample for antibody determination by ELISA. Though vaccine coverage among the 149 persons was 91% only 52% had 'protective' levels of pneumococcal antibodies. Despite recommendations for regular follow-up on pneumococcal antibody levels this had only been carried out in 4% of the subjects. Splenectomized subjects who needed pneumococcal revaccination were significantly more likely to have received their initial vaccination less than 14 days before or after splenectomy, as recommended, than those not requiring revaccination. Therefore, the timing of initial pneumococcal vaccination in relation to splenectomy seems to be important. All persons had Hib antibody levels higher than 0.15 microgram/ml and 60% had levels higher than 1 microgram/ml, which are the levels thought to provide short term and long term protection, respectively. In total, 37% of the 149 persons tested had pneumococcal and Hib antibody levels thought to correlate with protection from serious infections.
To determine the value of follow-up abdominal computed tomography in patients with splenic trauma managed nonoperatively.
Retrospective chart review.
A total of 108 consecutive patients with splenic injuries treated at a single institution from 1990 to 1996 were studied. All admission and follow-up computed tomographic (CT) scans were reviewed by the authors.
Initial management was surgical in 35 patients (32%) and intentionally nonoperative in 73 patients (68%). Nonoperative management was successful in 45 of 49 adults (92%) and 21 of 24 children(88%). Sixty-two follow-up abdominal CT scans were obtained in 49 patients. Information that affected management was evident on only one follow-up CT scan performed in the absence of clinical indications. Potential savings in hospital and physician charges for routine follow-up CT scans in this study were $54,302.00.
Follow-up abdominal CT scans are not routinely necessary in patients with splenic injuries managed nonoperatively.
To evaluate and determine the relevance of clinical and computed tomographic (CT) criteria, particularly extravasation, for prediction of clinical outcome in adults with splenic injuries.
Retrospective blinded review was performed of the records of 270 patients with splenic injury during a 5-year period. Of these, 120 died or underwent surgery without CT and 150 underwent dynamic bolus-enhanced CT. Fifty of the latter underwent immediate surgery and 100 initially were treated without surgery, according to CT and clinical criteria: morphologic grade of injury, amount of hemoperitoneum, active extravasation, and injury severity score (a clinical measure of multiorgan trauma).
Of the clinical criteria, injury severity score had the best correlation with outcome. Of the CT criteria, active extravasation correlated best with the need for splenic surgery. Of 96 patients selected for nonsurgical treatment and who did not have active extravasation, 83 recovered without surgery or other intervention. Nonsurgical therapy failed in 15 of the 100 patients. The splenic salvage rate was 59.3% overall and was 92% among the 100 patients with initial nonsurgical management.
Standard clinical criteria allow triage of patients into immediate surgery or initial nonsurgical groups. CT criteria, especially absence of active extravasation, can help predict successful nonsurgical management of splenic injuries.
Computed tomography is now widely used in the initial diagnostic workup of adult trauma victims with suspected intra-abdominal injuries. We review the role of CT in the detection and management of blunt visceral injuries in two parts. In the first part we discuss general aspects of performing CT in the setting of abdominal trauma and the diagnostic findings of intra-abdominal hemorrhage and blunt hepatic and splenic injuries. Hepatic and splenic injuries can be detected by means of CT with a high accuracy. The vast majority of hepatic injuries can be successfully managed conservatively, even when CT demonstrates parenchymal damage of more than three segments and major hemoperitoneum. Delayed complications, e. g., formation of biloma or a false aneurysm, can be readily detected on repeat CT studies, although they are quite uncommon. The outcome of conservative treatment of splenic injuries remains unpredictable because delayed splenic rupture may occur even when initial CT shows only minor parenchymal lesions and little or no intraperitoneal hemorrhage.
Pneumococcal polysaccharide vaccine is given after emergency splenectomy for trauma to lessen the risk of overwhelming postsplenectomy sepsis. This study was undertaken to determine optimal timing of vaccine administration as determined by serum type-specific polysaccharide antibody concentration titer and functional activity of the resulting antibodies.
Fifty-nine consecutive patients undergoing splenectomy after trauma were randomized to receive pneumococcal vaccine postoperatively at 1, 7, or 14 days. Immunoglobulin G serum antibody concentrations against serogroup 4 and serotypes 6B, 19F, and 23F were measured before vaccination and 4 weeks postvaccination. Antibody concentrations were determined by enzyme-linked immunosorbent assay, and functional antibody by opsonophagocytosis. Results were compared with a normal adult control group (n = 12).
Postvaccination enzyme-linked immunosorbent assay immunoglobulin G antibody concentrations for all serogroups and serotypes studied were not significantly different in splenectomized patients and control subjects. Postvaccination functional antibody activity was significantly reduced in early vaccination groups (serotype 6B excepted). However, with the exception of 19F, all titers for the 14-day group approached those of the control subjects (p > 0.05). Fold-increases of opsonophagocytic titers for serogroup 4 and serotypes 6B and 19F showed progressive increases with delay in vaccination. Except for serotype 23F, the number of postsplenectomy patients with opsonophagocytic titers <64 significantly decreased with a delay in vaccination (14 days).
Postvaccination immunoglobulin G serum antibody concentrations were not significantly different from normal control subjects regardless of the time of vaccination (1, 7, or 14 days). Although concentrations approach normal, functional antibody activity was significantly lower. Better functional antibody responses against the serogroup and serotypes studied seemed to occur with delayed (14-day) vaccination.
By using abdominal computed tomographic scans in the evaluation of blunt splenic trauma, we previously identified the presence of vascular blush as a predictor of failure, with a failure of nonoperative management of 13% in that series. This finding led to an alteration in our management scheme, which now includes the aggressive identification and embolization of splenic artery pseudoaneurysms.
The medical records of 524 consecutive patients with blunt splenic injury managed over a 4.5-year period were reviewed for the following information: age, Injury Severity Score (ISS), American Association for the Surgery of Trauma splenic injury grade (SIG), method and outcome of management.
Of the patients, 66% were male with a mean age of 32 +/- 16, and mean ISS of 25 +/- 13. A total of 180 patients (34%) were managed with urgent operation on admission (81% splenectomy (SIG 4.0), 19% splenorrhaphy (SIG 2.6)). The remaining 344 patients (66%) were hemodynamically stable and underwent computed tomographic scan and planned nonoperative management. Of these patients, 322 patients (94%) were successfully managed nonoperatively (61% of total splenic injuries). In 26 patients (8%), a contrast blush identified on computed tomographic scan was confirmed as a parenchymal pseudoaneurysm on arteriography. Twenty patients (SIG, 2.8) were successfully embolized. In six patients, technical failure precluded embolization; all required splenectomy (SIG, 4.0). A total of 22 patients (6%) failed nonoperative management, including the six with unsuccessful embolization attempts. Sixteen patients (SIG, 3.0) who had no evidence of pseudoaneurysm were explored for a falling hematocrit, hemodynamic instability, or a worsening follow-up computed tomography: 13 patients had splenectomy, and three patients had splenorrhaphy.
Aggressive surveillance for and embolization of posttraumatic splenic artery pseudoaneurysms improved the rate of successful nonoperative management of blunt splenic trauma to 61%, with a nonoperative failure rate of only 6%. In comparison with our previous work, this reduction in failure of nonoperative management is a significant improvement (p < 0.03).
Although nonoperative management of blunt splenic injury (NMBSI) has an established role in the overall management of adult patients with blunt splenic injury, the criteria by which patients are selected continue to be debated. The purpose of this study is to establish the effectiveness of a defined set of criteria that includes CT grading for the selection of patients for NMBSI by examining the outcomes of patients managed in this manner 1 year before with those 1 year after the implementation of this specific set of selection criteria. All patients hospitalized at St. Joseph Mercy Hospital over the time period April 1994 through July 1996 with blunt splenic injury were included. Patients who died in the Emergency Department were excluded. Patients admitted from April 1994 through April 1995 composed Group I, those treated before the specific selection criteria, whereas those admitted from July 1995 through July 1996 composed Group II, those treated after the implementation of selection criteria. The two groups were compared with respect to demographic parameters, Injury Severity Score, mechanism of injury and length of stay. Outcomes were compared between these two groups. Those patients successfully managed without operation were further compared with those for whom NMBSI was unsuccessful. A total of 57 patients met the criteria for study entry, 28 from Group I and 29 from Group II. There were no significant differences between these two groups with respect to age, sex, mechanism of injury, Injury Severity Score, or length of stay. Nine of 27 in Group I required immediate operation; 19 were initially managed nonoperatively. Four of 19 required delayed laparotomy for bleeding, and all required splenectomy. Between patients successfully managed nonoperatively and those requiring delayed operation, the only significant difference was CT grade (1.47 vs 3.5; P = 0.0001). In Group II, after the implementation of selection criteria that included CT grade, no patient required delayed operation. Eleven underwent immediate operation, whereas 18 were successfully managed nonoperatively. We conclude that, in the hemodynamically stable patient without clinical indication for laparotomy, CT grading of the splenic injury is a reliable criterion by which patients may be selected for nonoperative management.
The treatment for splenic injury is evolving to an increased use of nonoperative management. We studied patients with blunt injury to the spleen to determine the overall success with splenic salvage and the reason that adults and children have different outcomes.
Patient records were reviewed retrospectively for information and parameters that may influence outcome. Patients were categorized by age and type of management.
Two hundred sixty-seven patients (222 adults; 45 children < 16 years old) with blunt splenic trauma were treated over a 7.5-year period. Adults had a significantly higher injury severity score (ISS; 27.2 +/- 0.9 vs 19.9 +/- 2.0; P < .05), splenic injury score (SIS; 2.8 +/- 0.1 vs 2.3 +/- 0.1; P < .01), and mortality rate (11.7% vs 2.2%; P < .05) compared with children. Eighty-six adults and 3 children had emergent operation; 23 patients had splenorrhaphy. Nonoperative management was selected initially in 178 patients; 83% (105 adults and 42 children) were treated successfully. The ISS and SIS of patients in whom nonoperative management failed were different from those patients in whom treatment was successful (ISS, 27.5 +/- 2.1 vs 20.6 +/- 1.0; SIS, 3.6 +/- 0.2 vs 2.1 +/- 0.1; P < .05) but were similar to those patients who needed initial emergent operation. Adults and children who had successful nonoperative management had similar ISSs (21.4 +/- 1.1 vs 18.4 +/- 2.0) and SISs (2.0 +/- 0.1 vs 2.3 +/- 0.1). Overall splenic salvage was achieved in 64% of patients (57% of adults and 96 % of children). Salvage increased from 50% to 85% during the study period.
Splenic preservation is possible in most adults and children with blunt injury with the appropriate use of both operative salvage and nonoperative treatment. The higher salvage rate and decreased need for operation in children is due to their lower severity of overall injury and splenic injury. Operative salvage has become less common in adults because more patients are selected for nonoperative management.