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Splenic Injury Management: Evolving Practices and Outcomes

Explore the evolution and current status of splenic injury management, including non-operative approaches and predictors of failure. Learn about the impact of angioembolization and patient outcomes.

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Splenic Injury Management: Evolving Practices and Outcomes

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  1. Management of Splenic InjuryWhere on the Pendulum Are We Now? Matthew L Davis, MD FACS Trauma Medical Director Texas A&M University Health Science Center Scott & White Hospital

  2. Background • Management of splenic injury has evolved drastically over the last 30 years. • When the immunologic function of the spleen was identified in the 70’s, efforts to preserve the spleen were undertaken • Pediatric surgeons provided evidence that the best way to preserve the spleen was to not operate on it. (1980’s) • Progressive adoption in adult patients (1990’s) • Angioembolization introduced in mid-90’s

  3. Background • Initial non-operative attempts in adults were met with a 30-70% failure rate 1-4. • With greater experience,better patient selection and advanced imaging, NOM became standard of care for adults in the 90’s with success rates of 85% • With the addition of angio-embolization (AE), reported failure rates of NOM dropped to 2% 5

  4. Splenic Anatomy Skandalakis et al., The Surgical Anatomy of the Spleen, Surgical Clinics of North America. 73(4): 747-768. 1993

  5. Splenic Anatomy Skandalakis et al., The Surgical Anatomy of the Spleen, Surgical Clinics of North America. 73(4): 747-768. 1993

  6. American Association for the Surgery of Trauma Splenic Injury Scale (1994 Revision) Moore et al., J of Trauma. 2008; 65: 1007-1011.

  7. Grade I

  8. Grade I

  9. Grade 2

  10. American Association for the Surgery of Trauma Splenic Injury Scale (1994 Revision) Moore et al., J of Trauma. 2008; 65: 1007-1011.

  11. Grade 3

  12. Grade 3

  13. Grade 3

  14. American Association for the Surgery of Trauma Splenic Injury Scale (1994 Revision) Moore et al., J of Trauma. 2008; 65: 1007-1011.

  15. Grade 4

  16. Grade 4

  17. Grade 4

  18. American Association for the Surgery of Trauma Splenic Injury Scale (1994 Revision) Moore et al., J of Trauma. 2008; 65: 1007-1011.

  19. Grade 5

  20. Grade 5

  21. Grade 5

  22. Management Decisions • Driven by several factors – • Stability of the patient • Result of diagnostic procedures – ie FAST, CT scan, DPL • Availability of interventional angiography • In general, hemodynamically unstable patients should be triaged immediately to the operating room after FAST is performed.

  23. Non-Operative Management • Hemodynamic Stable • HR < 130 • SBP > 100 • Hemodynamic Correctable • < 2L of fluid • No ongoing need for fluid bolus • No Signs of Peritonitis • As many as 85% of splenic injuries qualify • Admit to Monitored Beds, 24 hr q6 H/H, serial abdominal exams • Areas of debate • Age >55 • > 2u PRBC • Missed Hollow Viscus Injury • Neurologic Impairment • High Grade Injuries Moore et al., J of Trauma. 2008; 65: 1007-1011. Cocanouret al., J of Trauma. 2000; 48: 606-612. Smith et al., Surgery. 1996; 120: 745-751.

  24. When does NOM fail? • The following have been identified as predictors of NOM failure: • Higher grade of injury • Degree of hemoperitoneum • + FAST and ongoing need for transfusion • Presence of contrast blush • Presence of arteriovenous fistulae • Presence of combined liver and splenic injuries • Advanced age is not a contraindication

  25. When does NOM fail? • NOM failure rates per Grade of Injury: • Grade I – 4.8% • Grade II – 9.5% • Grade III – 19.6% • Grade IV – 33.3% • Grade V – 75% Peitzman et al., J of Trauma. 2000; 49: 177-189.

  26. East Trial: Multi-institutional Study • Retrospective Multi-Institutional Study • 1993-1997 • 27 Institutions • N = 6,308 • Goal: find predictors of failure • Results: • 39% directly to OR • (Mortality 26%) • 54% Successful NOM • (Mortality 4%) • 11% Failed NOM • (Mortality 16%) • Majority of failures in 1st 24 hours. Peitzman et al., J of Trauma. 2000; 49: 177-189.

  27. Sclafani et al., J of Trauma. 1995; 39(5): 818-827. • First to report on AE as an adjunct to NOM. • 172 patients • 22 pts (13%) direct to OR • 2 Mortalities • 150 pts (87%) NOM • 87 of 90 NOM no SAE • 56 of 60 NOM with SAE • 1 Mortality • 97% success with NOM • Angiography performed on every spleen

  28. Pseudoaneurysm/contrast blush • More recent studies have touted the benefits of AE in the setting of contrast extravasation and pseudoaneurysm in patients who are otherwise NOM candidates. • With treatment of contrast blush and pseudoaneurysm by AE, Davis et al. showed a decrease in failure rate from 13% to 6%. 8

  29. Memphis Group • Previous study had NOM success of 87% with majority of failures being pseudoaneurysm • Retrospective, Single Institution • 1993-1997 • N = 524 • 34% (n=180) Emergent operation • Mortality 17% (n=33) • 66% (n=344) NOM • All NOM had repeat CT • 94% success (n=322) • 20 pts had blush and were embolized (6 failures went for splenectomy) • 22 pts failed NOM • Mortality 20% (n=4) Davis, Fabian, et al., J of Trauma. 1997; 44(6): 1008 - 1015,

  30. Influence of AE on failure rate • Haan published a multi-institutional trial looking at 155 patients who were treated with AE.9 • Overall splenic salvage rate of 87% • 83% of stable Grade IV and V injuries managed successfully. • Haan went on to publish a single institution experience with AE which showed splenic salvage rate of 94%; over 80% of GradeIV and V injuries salvaged10

  31. Embolization of Pseudoanuerysm

  32. Utility of Protocol-Driven AE • Sabe, et al. examined the influence of a standardized protocol on the management of splenic injuries.11 • Grade I,II and III underwent NOM – no AE • Indications for initial AE: • Grade III with blush, pseudoaneurysm or large degree of hemoperitoneum • Grade IV injuries • Grade V injuries – managed operatively

  33. Utility of Protocol-Driven AE • Use of this protocol achieved a 97% splenic salvage rate in patients undergoing NOM • In this review, the use of AE increased success of NOM, decreased mortality and resulted in a shorter LOS

  34. “Selective” Splenic Embolization,Shock Trauma (Maryland) • Retrospective, Single Institution • 1997-2002 • n = 648 • Emergent Operation • n= 280 • HD unstable • < 100 SBP • Transfusion • NOM with Angio (n=368) • 168 negative Angio • 94% success • 132 with SAE • 90% success • 70 CT only + obs • Grade 1 & 2 • Repeat CT at 48 – 72hrs • 100% success Haan, Scalea,et al., J of Trauma.2005; 58: 492-498.

  35. Where to coil: main vs selective? • Main – reduces bleeding by decreasing pressure head, but may not prevent late pseudoaneurysm persistence or formation and rupture • Selective – stops blood flow in polar arteries, but can lead to ischemia/necrosis/abcess formation. • Choice should be made based upon expertise and resources available

  36. Complications of NOM/AE • Majority of complications include bleeding, infarction, abscess formation and contrast-induced nephropathy • Missed associated injury has also been sited as a complication – as high as 3% (4/140) in one series10, but Miller, et al noted a missed injury rate of 0% (0/345) in another12. Haan et al., J of Trauma.2004; 56: 542-547

  37. Follow-up • Despite a Japanese study showing loss of splenic immune function after splenic AE, more recent studies have shown immune competence after embolization. • The benefit of mandatory repeat CT scanning prior to discharge has been questioned, but Davis, et al. showed that 74% of pseudoaneurysms were not seen on admission CT8

  38. Follow-up • Patients should be watched closely until HGB levels stabilize and then may be discharged home. • Fabian, et al. showed a 180-day risk of readmission for splenectomy at 1.4% for persons discharged home – majority of these were within 8 days. 13

  39. Take-Home • Frank instability or even transient responders should probably go straight to the OR. • Key to NOM is patient selection, bearing in mind the predictors of failure – Grade of injury, degree of hemoperitoneum, presence of blush or pseudoaneurysm. • AE can significantly reduce the failure rate in cases undergoing NOM when used as an adjunct to NOM

  40. Take-Home • My 2 cents is that, after stability, the degree of hemoperitoneum is likely the most important variable when weighing treatment options. • In blunt trauma, the spleen tends to fracture in avascular planes. • Thus, even deep parenchymal fractures may have little associate blood loss. • The presence of larger amounts of blood signifies a more meaningful injury.

  41. Questions

  42. References • 1) Malangoni et al. Management of injury to the spleen in adults. Ann Surg. 1994;200:702-705 • 2) Mahon et al. Nonoperative management of adult splenic injury due to blunt trauma: a warning. Am J Surg. 1985; 149:716-721 • 3) Mucha et al. Selective management of blunt splenic trauma. J Trauma. 1986; 26:970-979 • 4) Nallathambi et al. Nonoperative management versus early operation for blunt splenic trauma in adults. Surg Gynecol Obstet. 1988; 166:252-258 • 5) Moore et al. Western Trauma Association critical decisions in trauma:Management of adult blunt splenic trauma. J Trauma. 2008; 65: 1007-1011 • 6) Peitzman et al. Blunt Splenic Injury in Adults: Multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma. 2000; 49:177-189 • 7) Scalfani, et al. Nonoperative salvage of computer tomography-diagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis. J Trauma. 1995; 39: 818-827 • 8) Davis et al. Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery aneurysms. J Trauma. 1998; 44:1008-1015

  43. References • 9) Haan et al. Splenic embolization revisited: a multicenter review. J Trauma. 2004; 56:542-547 • 10) Haan et al. Nonoperative management of blunt splenic injury: a 5 year experience. J Trauma. 2005; 58:492-498 • 11) Sabe et al. The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16 year experience. J Trauma. 2009; 67:565-572 • 12) Miller et al. Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management. J Trauma. 2002; 53:238-244 • 13) Zarzour et al. The real risk of splenectomy after discharge home following nonoperative management of blunt splenic injury. J Trauma. 2009; 66:1531-1538

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