splenic injury and its management

1. Splenic Injury
Kishore Abuji
M. S. Surgery

2. Background
Trauma leading cause of death – under 45 years
Abdominal trauma – 15% of cases presenting to emergency department
Most commonly injured organ – spleen
Management of splenic injury drastically changed in last 30 years
Changing trend in splenic injury management –
Observation & Expectant
management (Early 1900’s)
Operative management
Non-operative/selective operative
management (currently)
- Poletti PA, Mirvis SE, Shanmuganathan K et al Blunt abdominal trauma patients. J Trauma 2004

3. Management of splenic injury has evolved drastically over the last 30 years
Preservation of spleen undertaken in the 70’s – immunological functions were identified
1980’s – pediatric surgeons provided evidence that the best way to preserve the spleen was to not operate on it
1990’s – progressive adoption in adult patients
Mid 1990’s – angioembolization introduced
Initial non-operative attempts in adults – 30 to 70% failure
In late 90’s NOM have 85% success rate d/t – better patient selection, advanced imaging, greater experience
- Mucha et al. Selective management of blunt splenic trauma. J Trauma. 1986; 26:970-979

4. Brief anatomy of spleen
Weight – 75 – 100 gram
Average blood flow – 300 mL/min
Ligaments – gastrosplenic, splenocolic, splenorenal, phrenocolic
Blood supply – splenic artery, branch of celiac artery (90.6%)
Variation of splenic artery – from abdominal aorta (8.1%), other sights (1.3%)
Course of splenic artery – suprapancreatic (74.1%)
Variation of course – Anteropancreatic (18.5%), intrapancreatic (4.6%), retropancreatic (2.8%)
Branching pattern – magistral and distributive type
- Pandey SK, Bhattacharya S, Mishra RN-anatomical variation of splenic artery. Clin Anat. 2004

5. Mechanism of splenic injury in blunt trauma
Abrupt deceleration – vascular torsion of splenic hilum
Shearing forces at ligamentous fixation points leads to capsular tear, short gastric injury within
gastrosplenic ligament
Splenic trauma evaluation:
Primary survey
Secondary survey
FAST – sensitivity 43 – 93%, specificity 90 – 98%
Contrast enhanced CT

6. Grade – I
Hematoma – subcapsular, <10% surface area
Laceration – capsular tear, <1cm parenchymal depth
Splenic trauma classification - AAST

7. Grade – II
Hematoma – subcapsular, 10-50% surface area; intraparenchymal, <5cm diameter
Laceration – 1-3cm parenchymal depth not involving a parenchymal vessel

8. Grade – III
Hematoma – subcapsular, >50% surface area or expanding; intraparenchymal >5cm
Laceration - >3cm parenchymal depth or involving trabecular vessels

9. Grade – IV
Laceration – laceration of segmental or hilar vessels producing major devascularization
(>25% of spleen)

10. Grade – V
Laceration – completely shatters spleen
Vascular – hilar vascular injury which devascularized spleen

11. Management
Nonoperative management and/or splenic artery embolization
Spleen-preserving surgeries
Splenectomy

12. Nonoperative management
Consists of close observation and splenic artery embolization if needed
Close observation consist of hospitalization, close monitoring, serial abdominal examination
There is no ideal criteria for NOM
In 1987 Johns Hopkins published criteria for NOM
 Rapid hemodynamic stabilization after fluid resuscitation
 Lack of other serious intra-abdominal injury
 Lack of extra-abdominal trauma that requires a prolonged general anesthesia
 Progressive symptomatic improvement early during the hospitalization
- Wiebke EA, Sarr MG, Fishman EK et al. NOM of splenic injuries in adults. Am Surg 1987

13. 2017 – World Society of Emergency Surgery (WSES) give detailed algorithm for management
Based broadly on
 Hemodynamic stability
 Grade of injury
 Availability of intensive care
WSES classification – three classes
1. Minor (WSES class I)
2. Moderate (WSES classes II and III)
3. Severe (WSES class IV)
- Coccolini F, Fugazzola P, Morganti L, et al. WSES spleen trauma classification. World J Emerg Surg

14. WSES AAST Haemodynamic
Minor I I – II Stable
Moderate
II III Stable
III IV – V Stable
Severe IV I – V Unstable

16. Success and failure of NOM
Success of the NOM mainly due to – advanced diagnostic imaging and Splenic artery embolization
- Roy P, Mukherjee R, Parik M. splenic trauma in the twenty-first century. Ann R Coll Surg Engl 2018

17. Predictive parameters for successful and unsuccessful NOM
Parameters Successful Unsuccessful
Haemodynamics Stable/readily stabilized Unstable (SBP <90mmHg
despite adequate resuscitation)
Blood transfusion ≤ 4 units > 4 units
Age (years) ≤ 55 >55
Leucocytosis No Persistent
Other abdominal signs and
symptoms
early resolution of splenic
abnormalities obvious on
imaging
No periods of unconsciousness
or brain injuries
Onset or aggravating signs of
peritoneal irritation
Intra-abdominal compartment
syndrome (>20 cm H2O)
Injuries No associated intra – or
retroperitoneal injuries (on CT)
that would require surgical
intervention
No rebound or guarding
Complete recovery of bowel
movements
Worsening signs of splenic
injury and other injuries
required operative requirement
- Roy P, Mukherjee R, Parik M. splenic trauma in the twenty-first century. Ann R Coll Surg Engl 2018

18. Splenic artery embolization
First angiographic embolization used for haemostatic purpose before splenectomy
Recent NOM protocols was included angiography for
 Diagnostic purpose
 Therapeutic purpose
Splenic artery embolization can be
 Distal (supraselctive)
 Proximal (splenic artery)
 combined

19. Proximal SAE indications
 > 3 distinct peripheral vascular lesion
 > 50% parenchymal injury
Selective SAE
 Limited vascular injuries
 Advantage – proper hemostasis, adequate perfusion to remaining organ
Combined SAE indication
 Multiple vascular injuries

20. Angiography & embolization were recommended as an adjunct to NOM for grade III - V
No artery
embolization
With artery
embolization
p value
Grade IV 23% 3% 0.04
Grade V 63% 9% 0.03
Failure rates of NOM – decrease with Splenic artery embolization
- Bhangu T, Nepogodiev D, Lai N, Bowley DM. Meta analysis of predictive factors and outcome for failure of NOM of blunt splenic trauma. Injury 2012

21. Complications of SAE
Major (19 – 28.5%)
 Bleeding – MC complication
 Infection – splenic abscess, sepsis
 Splenic atrophy
 Iatrogenic arterial damage
 Acute renal failure after contrast administration
 Deep venous thrombosis

22. Minor (23 – 61.9%)
 Migration of embolic material
 Angiographic vascular dissection
 Vascular damage (AV fistula formation)
 Hematoma at puncture site
 Post-embolization syndrome (general discomfort, fever, pain, leukocytosis)
 Thrombocytosis
 Allergic reaction to contrast

23. Advantages of NOM
 Avoids complications of splenectomy
 Avoids complications related to surgery and anaesthesia
 Avoids operation costs
 High success rates, especially in lower injury grades
Disadvantages of NOM
 Only possible if grade of splenic injury identified accurately
 Requires intensive monitoring
 Require 24-hour availability of operating theatre, laboratory and blood transfusion facilitieas
 Require availability of IR with CT facilities
 Risk of missed injuries in polytrauma

24. Complications of NOM
Immediate (up to 7 days)
 Pseudoaneurysm formation, leading to bleeding or rupture
 Peritonitis
Delayed (beyond 7 days)
 Rupture of spleen
 Intestinal obstruction due to peritoneal adhesions
 Splenosis

25. Spleen – preserving surgeries
Partial splenectomy – patient selection and technical skill
Partial splenectomy/splenorrhaphy – at least one-third of viable splenic tissue required
Essential steps for spleen preserving surgery
 Atraumatic mobilization
 Temporary splenic artery occlusion
 Selective ligation of segmental vasculature
 Controlled intrasplenic dissection with ultrasonic aspirators
 Haemostasis by topical agents (oxidized cellulose) or argon plasma

26. Mesh splenorrhaphy – Delivering the spleen through the centre of absorbable mesh and sewing
the opposite edges
It produce tamponade around spleen
Retained spleen observed for colour and bleeding @ adequate SBP

27. Splenic auto-transplantation
1990 studies showed: spleen preserving > splenic auto-transplantation > splenectomy
The technique of auto-transplantation has been described by various authors
Commonly 2 – 4 grams of splenic tissue minced and implanted in greater omental pockets
After 6 months – absence of Howell-Jolly bodies & immunoglobulins were normal
- Roy P, Mukherjee R, Parik M. splenic trauma in the twenty-first century. Ann R Coll Surg Engl 2018

28. New procedures for spleen preservation
 Polyglycolic acid elastic mesh
 RFA to stop bleeding – experimented on animal models and small populations with
favourable outcomes
Splenectomy

29. Conclusion
Management of splenic injury has evolved over past three decades
NOM replacing surgical intervention as the standard of care
Question still remain regarding formulation of definite patient selection criteria for NOM/SAE

30. Thank you