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Management of
Splenic Injury
Dr. Akshay Sarraf
3rd Year Resident
Dept. of General surgery
Introduction
• The spleen, in alternation with the liver, is the first or second most
commonly injured abdominal organ.
• Isolated splenic injury comprises approximately 42% of abdominal
trauma.
• The frequency of these injuries requires the surgeon to possess a sound
understanding of management strategies in splenic injury.
• Splenic rupture should be considered in any case of blunt abdominal
trauma
• Splenic trauma represents a spectrum of diseases, ranging from self-
limitation and observation to immediate splenectomy.
• Iatrogenic injury to the spleen remains a frequent complication of any
surgical procedure.
• In blunt trauma, direct compression of the spleen with parenchymal
fracture is a common pathophysiologic mechanism at the tissue level.
• Injury can also be secondary to rapid deceleration that tears the splenic
capsule and/or parenchyma where it is fixed to the retroperitoneum.
Management of Traumatic Splenic injury.pptx
• Penetrating splenic trauma is less common but is still present in 8.5%
of all penetrating abdominal injuries in the 2012 NTDB.
• Hemorrhage from a splenic injury can be ongoing with instability at
the time of presentation or, more commonly, will have resolved
spontaneously.
• Patients who are nonresponders to resuscitation with intraabdominal
fluid on FAST require exploration.
• Based upon the extent of injury, spleen rupture is classified into five
grades on the basis of CT
https://doi.org/10.1007/978-3-642-00418-6_517
Management
• The management of splenic trauma has changed considerably in the
last few decades especially in favor of non-operative management
(NOM).
• Ranges from observation and monitoring alone to angiography/
angioembolization (AG/AE) with the aim to preserve the spleen and
its function.
• Considering the immunological function of the spleen there is high
risk of immunological impairment in splenectomized patients.
• Splenic injuries can be fatal not only at the admission of the patient to
the Emergency Department (ED), but also due to delayed subcapsular
hematoma rupture or pseudoaneurism (PSA) rupture.
• Overwhelming post-splenectomy infections (OPSI) are a late cause of
complications due to the lack of the immunological function of the
spleen.
• Standardized guidelines in the management of splenic trauma are
necessary.
• The existing classification of splenic trauma considered the anatomical
lesions.
• However, patients’ conditions may lead to an emergent transfer to the
operating room (OR) without the opportunity to define the grade of the
splenic lesions before the surgical exploration.
• The present guidelines and classification reconsider splenic lesions in
the light of the physiopathologic status of the patient.
• World Society of Emergency Surgery (WSES) Classification of
Splenic Trauma and the Management Guidelines.
• Evidence-based, with the grade of recommendation also based on the
evidence.
• Present the diagnostic and therapeutic methods for optimal management
of spleen trauma.
• Suggests plans of care, based on best available evidence and the
consensus of experts.
• Frequently low-grade AAST lesions (i.e., grades I–III) are considered as
minor or moderate and treated with NOM.
• However, hemodynamically stable patients with high-grade lesions could be
successfully treated non-operatively.
• On the other hand, “minor” lesions associated with hemodynamic instability
often must be treated with OM.
• Hence, the classification of spleen injuries into minor and major must
consider both the anatomic AAST-OIS classification and the hemodynamic
status.
• The WSES classification divides spleen injuries into three classes:
• Minor spleen injuries:
– WSES class I includes hemodynamically stable AAST-OIS grade I–II blunt and
penetrating lesions.
• Moderate spleen injuries:
– WSES class II includes hemodynamically stable AAST-OIS grade III blunt and
penetrating lesions.
– WSES class III includes hemodynamically stable AAST-OIS grade IV–V blunt and
penetrating lesions.
• Severe spleen injuries:
– WSES class IV includes hemodynamically unstable AAST-OIS grade I–V blunt and
penetrating lesions.
Management of Traumatic Splenic injury.pptx
Initial Assessment
Hemodynamic Stability Hemodynamic Instability
Constant or an amelioration of blood
pressure after fluids with a blood pressure
> 90 mmHg and heart rate < 100 bpm
Admission systolic blood pressure < 90
mmHg
SBP > 90 mmHg but requiring bolus
infusions/transfusions and/or vasopressor
drugs
Admission base excess (BE) > −5 mmol/l
Shock index > 1
Transfusion requirement of at least 4–6
units of packed red blood cells within the
first 24 h
9th edition of the Advanced Trauma
Life Support (ATLS)
• Blood pressure < 90 mmHg and heart
rate > 120 bpm, with evidence of skin
vasoconstriction (cool, clammy,
decreased capillary refill), altered level
of consciousness and/or shortness of
breath
- American College of Surgeon’s Commitee on Trauma. Advanced Trauma Life
Support® (ATLS®) Student manual 9th ed.ed., American College of Surgeon,
Chicago; 2012.
• In the management of severe bleeding, the early evaluation and
correction of the trauma induced coagulopathy remains a main
cornerstone.
• Physiologic impairment is frequently associated with aggressive
resuscitation and the activation and deactivation of several
procoagulant and anticoagulant factors.
• The application of massive transfusion protocols (MTP) is of
paramount importance.
• Diagnostic Procedures:
– The choice of diagnostic technique at admission must be based on the
hemodynamic status of the patient.
– E-FAST is effective and rapid to detect free fluid.
– CT scan with intravenous contrast is the gold standard in hemodynamically
stable or stabilized trauma patients.
– Doppler US and contrast-enhanced US are useful to evaluate splenic
vascularization and in followup.
– Injury grade on CT scan, extent of free fluid, and the presence of PSA do not
predict NOM failure or the need of OM.
• Extended focused assessment sonography for trauma (E-FAST) and
ultrasonography (US) have replaced diagnostic peritoneal lavage (DPL)
management of abdominal trauma.
• Has sensitivity up to 91% and a specificity up to 96% also for a small fluid
amount.
- Doody O, Lyburn D, Geoghegan T, Govender P, Monk PM, Torreggiani WC. Blunt trauma to the spleen: ultrasonographic findings. Clin Radiol. 2005;60:968–76.
• 42% of false-negative have also been reported.
• Contrast-enhanced US (CEUS) increases the visualization of a variety of
splenic injuries and complications.
• Doppler US (DUS) has been reported as safe and effective in evaluating
PSA or blush previously found at CT scan.
• Contrast tomography (CT) scan is considered the gold standard in trauma
with a sensitivity and specificity for splenic injuries near to 96–100%.
• Carr et al. reported that CT scan can underestimate splenic injuries at hilum.
• Must be rapidly available and must be performed only in hemodynamically
stable patients or in those responding to fluid resuscitation.
• Delayed-phase CT helps in differentiating patients with active bleeding
from those with contained vascular injuries.
• Active contrast extravasation is a sign of active hemorrhage.
• Contrast blush occurs in about 17% of cases and has been demonstrated to
be an important predictor of failure of NOM
Non-operative management
– Patients with hemodynamic stability and absence of other abdominal organ
injuries requiring surgery should undergo an initial attempt of NOM irrespective
of injury grade.
– NOM of moderate or severe spleen injuries should be considered only in an
environment that provides capability for patient intensive monitoring, AG/AE,
an immediately available OR and immediate access to blood and blood product
or alternatively in presence of a rapid centralization system and only in patients
with stable or stabilized hemodynamic and absence of other internal injuries
requiring surgery.
– NOM in splenic injuries is contraindicated in the setting of unresponsive
hemodynamic instability or other indicates for laparotomy (peritonitis, hollow
organ injuries, bowel evisceration, impalement).
– In patients being considered for NOM, CT scan with intravenous contrast should
be performed to define the anatomic spleen injury and identify associated injuries.
– AG/AE may be considered the first-line intervention in patients with
hemodynamic stability and arterial blush on CT scan irrespective from injury grade.
– Strong evidence exists that age above 55-years old, high ISS, and moderate to
severe splenic injuries are prognostic factors for NOM failure. These patients require
more intensive monitoring and higher index of suspicion
– Age above 55 years old alone, large hemoperitoneum alone, hypotension before
resuscitation, GCS < 12, and low hematocrit level at the admission, associated
abdominal injuries, blush at CT scan, anticoagulation drugs, HIV disease, drug
addiction, cirrhosis, and need for blood transfusions should be taken into account,
but they are not absolute contraindications for NOM.
– In WSES classes II–III spleen injuries with associated severe traumatic brain injury,
NOM could be considered only if rescue therapy (OR and/or AG/AE) is rapidly
available; otherwise, splenectomy should be performed
• Hemodynamic status at the admission should not be considered an absolute
contraindication for NOM.
• Need for red cell transfusions in ED or during the first 24 h, hemoglobin
and hematocrit levels at admission, HIV disease, cirrhosis, and drug
addiction could affect the outcome after NOM.
- Peitzman AB, Heil B, Rivera L, Federle M, Harbrecht BG, Clancy K, et al. Blunt splenic injury in adults: multi-institutional study of the Eastern
Association for the Surgery of Trauma. J Trauma-Injury Infect Crit Care. 2000;49:177–89.
• ISS values above 15 are significantly associated with the failure of NOM.
• Indication to angiography and angioembolization:
– 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).
– In patients with bleeding vascular injuries and in those with intraperitoneal
blush, AG/AE should be performed as part of NOM only in centers where
AG/AE is rapidly available. In other centers and in case of rapid hemodynamic
deterioration, OM should be considered.
– In case of absence of blush during angiography, if blush was previously seen at
CT scan, proximal angioembolization could be considered.
– AG/AE should be considered in all hemodynamically stable patients
with WSES class III lesions, regardless the presence of CT blush.
- AG/AE could be considered in patients undergone to NOM,
hemodynamically stable with sings of persistent hemorrhage regardless
the presence of CT blush once excluded extra-splenic source of bleeding.
– Hemodynamically stable patients with WSES class II lesions without
blush should not underwent routine AG/AE but may be considered for
prophylactic proximal embolization in presence of risk factors for NOM
failure.
– In performing AG/AE coils should be preferred to temporary agents.
– In presence of a single vascular abnormality (contrast blush, pseudo-
aneurysms and artero-venous fistula) in minor and moderate injuries the
currently available literature is inconclusive regarding whether proximal
or distal embolization should be used. In presence of multiple splenic
vascular abnormalities or in presence of a severe lesion, proximal or
combined AG/AE should be used, after confirming the presence of a
permissive pancreatic vascular anatomy.
• 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%.
Operative Managment
- Operative management (OM) of splenic injuries should be performed in
non-responder hemodynamic instable patients(high-ISS trauma, in high-grade
lesions, and in patients with associated lesions).
– In patients with hemodynamic instability and/or with associated lesions like
peritonitis or bowel evisceration or impalement requiring surgical
exploration.
– OM should be performed in moderate and severe lesions even in stable
patients in centers where intensive monitoring cannot be performed and/or
when AG/AE is not rapidly available.
– During OM, salvage of at least a part of the spleen is debated and
could not be suggested.
– Laparoscopic splenectomy in early trauma scenario in bleeding
patients could not be recommended.
• The use of splenic autologous transplantation to avoid infective risk
from splenectomy, has been investigated, but no reduction of
morbidity or mortality has been demonstrated
- Pisters PW, Pachter HL. Autologous splenic transplantation for splenic trauma. Ann Surg. 1994;219:225–35.
- The reported overall hospital mortality of splenectomy in trauma is
near 2%, and the incidence of postoperative bleeding after splenectomy,
ranges from 1.6 to 3%, but with mortality near to 20%
- Qu Y, Ren S, Li C, Qian S, Liu P. Management of postoperative complications following splenectomy. Int Surg. 2013;98:55–60.
Splenectomy
• Anatomy
• The normal spleen is about 8 to 10 cm in longest dimension,
weighs about 100 g.
• Lies high up in the left upper quadrant protected by the lower
rib cage.
• The splenic hilum lies within 2 cm of the pancreatic tail and
contains the branching vessels of the splenic artery and splenic
vein.
• The superior branches of these vessels extend superiorly
through the gastrosplenic ligament and attach, as the short
gastric vessels, to the very proximal greater curvature of the
stomach
• Laparotomy in supine position through a midline incision.
• Rapid packing of the left upper quadrant allows one to sequentially identify
any associated injuries that have a greater priority than the splenic injury.
• Splenic flexure of the colon is then mobilized which typicaaly has two short
vessels extending from the colonic mesentery to the inferior pole of the
spleen.
• Control of hemorrhage can be achieved by compressing the splenic hilum
with the fingers and thumb of the left hand while the right hand is used to
continue the anterior and medial mobilization of both the pancreatic body
with tail and the spleen.
• Packs can be placed posteriorly which will hold the spleen anteriorly and
medially.
• One can then approach the branches
of the splenic artery and splenic
vein.
• identified along the posterior aspect
of the splenic hilum and can be
individually divided and ligated.
• Avoid inadvertent clamping of the
tail of the pancreas
• The lesser sac is entered through the
greater omentum outside the arcades
of the gastroepiploic vessels
• There usually are two or three short gastric vessels that are most safely
controlled by ligature.
• The spleen can then be detached from its “avascular” splenophrenic
attachments
• The plane posterior to both the spleen and the body and tail of the pancreas
is then bluntly dissected
• Prior to closing, one needs to check carefully for hemostasis- assess the
splenic flexure, the greater curvature of the stomach, tail of the pancreas and
posterior surface of the diaphragm
• Thrombo-prophylaxis in splenic trauma:
• Trauma patients are at high risk of venous thromboembolism (VTE); the
transition to a hyper-coagulation state occurs within 48 h from injury [117
• Without any prophylaxis, more than 50% may experience deep vein
thrombosis (DVT)which substantially increases the risk of pulmonary
embolism (PE) whose mortality is about 50% [118
• In trauma patients surviving beyond the first 24 h, PE is the third leading cause
of death.
• Even with chemical prophylaxis, DVT can be detected in 15% of patients.
– Mechanical prophylaxis is safe and should be considered in all patients
without absolute contraindication to its use.
– Spleen trauma without ongoing bleeding is not an absolute
contraindication to LMWH-based prophylactic anticoagulation.
– LMWH-based prophylactic anticoagulation should be started as soon as
possible from trauma and may be safe in selected patients with blunt
splenic injury undergone to NOM.
– In patient with oral anticoagulants the risk-benefit balance of reversal
should be individualized.
• Heparin and LMWH can be combined with mechanical prophylaxis;
however, mechanical prophylaxis alone in high-grade lesions seems to
be preferred by surgeons compared with heparin.
• Eberle et al. and Alejandro et al. demonstrated no differences between
VTE prophylaxis administered within and after 72 and 48 h from trauma
respectively, with highest rate of failure in patients with high-grade
splenic injury.
- Eberle BM, Schnüriger B, Inaba K, Cestero R, Kobayashi L, Barmparas G, et al. Thromboembolic prophylaxis with low-molecular-weight heparin in
patients with blunt solid abdominal organ injuries undergoing nonoperative management: current practice and outcomes. J Trauma. 2011;70:141–6. discussion 147
• Rostas et al. show that VTE rates were over fourfold greater when
LMWH was administered after 72 h from admission.
- Rostas JW, Manley J, Gonzalez RP, Brevard SB, Ahmed N, Frotan MA, et al. The safety of low molecular-weight heparin after blunt liver and spleen injuries. Am J Surg. 2015;210:31–4.
Short and long term Follow-up
• Splenic complications after blunt splenic trauma range between 0 and 7.5%
with a mortality of 7–18% in adults.
- El-Matbouly M, Jabbour G, El-Menyar A, Peralta R, Abdelrahman H, Zarour A, et al. Blunt splenic trauma: assessment, management and outcomes. Surgeon. 2016;14:52–8.
• The 19% of splenic-delayed ruptures happen within the first 48 h, more
frequently between 4 and 10 days after trauma.
• The risk of splenectomy after discharge ranges between 3 and 146 days after
injury, and the rate of readmission for splenectomy was 1.4%.
- Zarzaur BL, Vashi S, Magnotti LJ, Croce MA, Fabian TC. The real risk of splenectomy after discharge home following nonoperative management of blunt splenic injury.
J Trauma. 2009;66:1531–8.
• Savage et al. found an average of healing in grades I–II of 12.5 days with a
complete healing after 50 days while in grades III–V, 37.2 and 75 days,
respectively.
- S a S, Zarzaur BL, Magnotti LJ, J a W, Maish GO, Bee TK, et al. The evolution of blunt splenic injury: resolution and progression. J Trauma. 2008;64:1085-91-2.
• Activity restriction may be suggested for 4–6 weeks in minor injuries and
up to 2–4 months in moderate and severe injuries.
• In 2–2.5 months, regardless of severity of spleen injury, the 84% of patients
presented a complete healing.
- S a S, Zarzaur BL, Magnotti LJ, J a W, Maish GO, Bee TK, et al. The evolution of blunt splenic injury: resolution and progression. J Trauma. 2008;64:1085-91-2.
• Mortality of late rupture ranges from 5 to 15% compared with 1% mortality
in case of acute rupture.
- Peitzman AB, Heil B, Rivera L, Federle M, Harbrecht BG, Clancy K, et al. Blunt splenic injury in adults: multi-institutional study of the
Eastern Association for the Surgery of Trauma. J Trauma-Injury Infect Crit Care. 2000;49:177–89.
• Radiological follow-up is used, but there are not clear information regarding
the timing and type of imaging (CT vs. US).
• Imaging follow-up is usually based on clinical judgment and has been
widely debated.
- Shapiro MJ, Krausz C, Durham RM, Mazuski JE. Overuse of splenic scoring and computed tomographic scans. J Trauma. 1999;47:651–8.
Complications
• Reactionary haemorrhage.
• Left Basal atelectasis.
• Left sided pleural effusion
• Gastric fistula.
• Pancreatitis.
• Haematemesis.
• Postoperative thrombocytosis.
• OPSI.
• Infection Prophylaxis in Asplenic and Hyposplenic Adult
• OPSI are defined as fulminant sepsis, meningitis, or pneumonia triggered
mainly by Streptococcus pneumoniae (50% of cases) followed by H. influenzae
type B and N. meningitidis.
• The risks of OPSI and associated death are highest in the first year after
splenectomy, at least among young children, but remain elevated for more than
10 years and probably for life.
• The incidence of OPSI is 0.5–2%; the mortality rate is from 30 to 70%, and
most death occurs within the first 24 h.
• Only prompt diagnosis and immediate treatment can reduce mortality.
– Patients should receive immunization against the encapsulated bacteria
(Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria
meningitidis).
– Vaccination programs should be started no sooner than 14 days after
splenectomy or spleen total vascular exclusion.
– In patients discharged before 15 days after splenectomy or
angioembolization, where the risk to miss vaccination is deemed high, the
best choice is to vaccinate before discharge.
– Annual immunization against seasonal flu is recommended for all patients
over 6 months of age.
– Malaria prophylaxis is strongly recommended for travelers.
– Antibiotic therapy should be strongly considered in the event of any sudden
onset of unexplained fever, malaise, chills, or other constitutional symptoms,
especially when medical review is not readily accessible.
– The recommended options for emergency standby in adults include the
following: (a) Amoxycillin, 3 g starting dose followed by 1 g, every 8 h; (b)
Levofloxacin 500 mg every 24 h or Moxifloxacin 400 mg every 24 h (for beta-
lactam allergic patients).
– Primary care providers should be aware of the splenectomy/angioembolization.
References
1. Bailey & Love’s Short Practice of Surgery, 28th Edition.
2. Sabiston Textbook of Surgery, 21st Edition.
3. Schwartz’s Principles of Surgery, 11th Edition.
4. Coccolini, F., Montori, G., Catena, F. et al. Splenic trauma: WSES
classification and guidelines for adult and pediatric patients. World J
Emerg Surg 12, 40 (2017). https://doi.org/10.1186/s13017-017-0151-4
40
THANK YOU
41

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Management of Traumatic Splenic injury.pptx

  • 1. Management of Splenic Injury Dr. Akshay Sarraf 3rd Year Resident Dept. of General surgery
  • 2. Introduction • The spleen, in alternation with the liver, is the first or second most commonly injured abdominal organ. • Isolated splenic injury comprises approximately 42% of abdominal trauma. • The frequency of these injuries requires the surgeon to possess a sound understanding of management strategies in splenic injury. • Splenic rupture should be considered in any case of blunt abdominal trauma
  • 3. • Splenic trauma represents a spectrum of diseases, ranging from self- limitation and observation to immediate splenectomy. • Iatrogenic injury to the spleen remains a frequent complication of any surgical procedure. • In blunt trauma, direct compression of the spleen with parenchymal fracture is a common pathophysiologic mechanism at the tissue level. • Injury can also be secondary to rapid deceleration that tears the splenic capsule and/or parenchyma where it is fixed to the retroperitoneum.
  • 5. • Penetrating splenic trauma is less common but is still present in 8.5% of all penetrating abdominal injuries in the 2012 NTDB. • Hemorrhage from a splenic injury can be ongoing with instability at the time of presentation or, more commonly, will have resolved spontaneously. • Patients who are nonresponders to resuscitation with intraabdominal fluid on FAST require exploration. • Based upon the extent of injury, spleen rupture is classified into five grades on the basis of CT
  • 7. Management • The management of splenic trauma has changed considerably in the last few decades especially in favor of non-operative management (NOM). • Ranges from observation and monitoring alone to angiography/ angioembolization (AG/AE) with the aim to preserve the spleen and its function. • Considering the immunological function of the spleen there is high risk of immunological impairment in splenectomized patients.
  • 8. • Splenic injuries can be fatal not only at the admission of the patient to the Emergency Department (ED), but also due to delayed subcapsular hematoma rupture or pseudoaneurism (PSA) rupture. • Overwhelming post-splenectomy infections (OPSI) are a late cause of complications due to the lack of the immunological function of the spleen. • Standardized guidelines in the management of splenic trauma are necessary.
  • 9. • The existing classification of splenic trauma considered the anatomical lesions. • However, patients’ conditions may lead to an emergent transfer to the operating room (OR) without the opportunity to define the grade of the splenic lesions before the surgical exploration. • The present guidelines and classification reconsider splenic lesions in the light of the physiopathologic status of the patient.
  • 10. • World Society of Emergency Surgery (WSES) Classification of Splenic Trauma and the Management Guidelines. • Evidence-based, with the grade of recommendation also based on the evidence. • Present the diagnostic and therapeutic methods for optimal management of spleen trauma. • Suggests plans of care, based on best available evidence and the consensus of experts.
  • 11. • Frequently low-grade AAST lesions (i.e., grades I–III) are considered as minor or moderate and treated with NOM. • However, hemodynamically stable patients with high-grade lesions could be successfully treated non-operatively. • On the other hand, “minor” lesions associated with hemodynamic instability often must be treated with OM. • Hence, the classification of spleen injuries into minor and major must consider both the anatomic AAST-OIS classification and the hemodynamic status.
  • 12. • The WSES classification divides spleen injuries into three classes: • Minor spleen injuries: – WSES class I includes hemodynamically stable AAST-OIS grade I–II blunt and penetrating lesions. • Moderate spleen injuries: – WSES class II includes hemodynamically stable AAST-OIS grade III blunt and penetrating lesions. – WSES class III includes hemodynamically stable AAST-OIS grade IV–V blunt and penetrating lesions. • Severe spleen injuries: – WSES class IV includes hemodynamically unstable AAST-OIS grade I–V blunt and penetrating lesions.
  • 14. Initial Assessment Hemodynamic Stability Hemodynamic Instability Constant or an amelioration of blood pressure after fluids with a blood pressure > 90 mmHg and heart rate < 100 bpm Admission systolic blood pressure < 90 mmHg SBP > 90 mmHg but requiring bolus infusions/transfusions and/or vasopressor drugs Admission base excess (BE) > −5 mmol/l Shock index > 1 Transfusion requirement of at least 4–6 units of packed red blood cells within the first 24 h 9th edition of the Advanced Trauma Life Support (ATLS) • Blood pressure < 90 mmHg and heart rate > 120 bpm, with evidence of skin vasoconstriction (cool, clammy, decreased capillary refill), altered level of consciousness and/or shortness of breath - American College of Surgeon’s Commitee on Trauma. Advanced Trauma Life Support® (ATLS®) Student manual 9th ed.ed., American College of Surgeon, Chicago; 2012.
  • 15. • In the management of severe bleeding, the early evaluation and correction of the trauma induced coagulopathy remains a main cornerstone. • Physiologic impairment is frequently associated with aggressive resuscitation and the activation and deactivation of several procoagulant and anticoagulant factors. • The application of massive transfusion protocols (MTP) is of paramount importance.
  • 16. • Diagnostic Procedures: – The choice of diagnostic technique at admission must be based on the hemodynamic status of the patient. – E-FAST is effective and rapid to detect free fluid. – CT scan with intravenous contrast is the gold standard in hemodynamically stable or stabilized trauma patients. – Doppler US and contrast-enhanced US are useful to evaluate splenic vascularization and in followup. – Injury grade on CT scan, extent of free fluid, and the presence of PSA do not predict NOM failure or the need of OM.
  • 17. • Extended focused assessment sonography for trauma (E-FAST) and ultrasonography (US) have replaced diagnostic peritoneal lavage (DPL) management of abdominal trauma. • Has sensitivity up to 91% and a specificity up to 96% also for a small fluid amount. - Doody O, Lyburn D, Geoghegan T, Govender P, Monk PM, Torreggiani WC. Blunt trauma to the spleen: ultrasonographic findings. Clin Radiol. 2005;60:968–76. • 42% of false-negative have also been reported. • Contrast-enhanced US (CEUS) increases the visualization of a variety of splenic injuries and complications. • Doppler US (DUS) has been reported as safe and effective in evaluating PSA or blush previously found at CT scan.
  • 18. • Contrast tomography (CT) scan is considered the gold standard in trauma with a sensitivity and specificity for splenic injuries near to 96–100%. • Carr et al. reported that CT scan can underestimate splenic injuries at hilum. • Must be rapidly available and must be performed only in hemodynamically stable patients or in those responding to fluid resuscitation. • Delayed-phase CT helps in differentiating patients with active bleeding from those with contained vascular injuries. • Active contrast extravasation is a sign of active hemorrhage. • Contrast blush occurs in about 17% of cases and has been demonstrated to be an important predictor of failure of NOM
  • 19. Non-operative management – Patients with hemodynamic stability and absence of other abdominal organ injuries requiring surgery should undergo an initial attempt of NOM irrespective of injury grade. – NOM of moderate or severe spleen injuries should be considered only in an environment that provides capability for patient intensive monitoring, AG/AE, an immediately available OR and immediate access to blood and blood product or alternatively in presence of a rapid centralization system and only in patients with stable or stabilized hemodynamic and absence of other internal injuries requiring surgery. – NOM in splenic injuries is contraindicated in the setting of unresponsive hemodynamic instability or other indicates for laparotomy (peritonitis, hollow organ injuries, bowel evisceration, impalement).
  • 20. – In patients being considered for NOM, CT scan with intravenous contrast should be performed to define the anatomic spleen injury and identify associated injuries. – AG/AE may be considered the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan irrespective from injury grade. – Strong evidence exists that age above 55-years old, high ISS, and moderate to severe splenic injuries are prognostic factors for NOM failure. These patients require more intensive monitoring and higher index of suspicion – Age above 55 years old alone, large hemoperitoneum alone, hypotension before resuscitation, GCS < 12, and low hematocrit level at the admission, associated abdominal injuries, blush at CT scan, anticoagulation drugs, HIV disease, drug addiction, cirrhosis, and need for blood transfusions should be taken into account, but they are not absolute contraindications for NOM.
  • 21. – In WSES classes II–III spleen injuries with associated severe traumatic brain injury, NOM could be considered only if rescue therapy (OR and/or AG/AE) is rapidly available; otherwise, splenectomy should be performed • Hemodynamic status at the admission should not be considered an absolute contraindication for NOM. • Need for red cell transfusions in ED or during the first 24 h, hemoglobin and hematocrit levels at admission, HIV disease, cirrhosis, and drug addiction could affect the outcome after NOM. - Peitzman AB, Heil B, Rivera L, Federle M, Harbrecht BG, Clancy K, et al. Blunt splenic injury in adults: multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma-Injury Infect Crit Care. 2000;49:177–89. • ISS values above 15 are significantly associated with the failure of NOM.
  • 22. • Indication to angiography and angioembolization: – 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). – In patients with bleeding vascular injuries and in those with intraperitoneal blush, AG/AE should be performed as part of NOM only in centers where AG/AE is rapidly available. In other centers and in case of rapid hemodynamic deterioration, OM should be considered. – In case of absence of blush during angiography, if blush was previously seen at CT scan, proximal angioembolization could be considered.
  • 23. – AG/AE should be considered in all hemodynamically stable patients with WSES class III lesions, regardless the presence of CT blush. - AG/AE could be considered in patients undergone to NOM, hemodynamically stable with sings of persistent hemorrhage regardless the presence of CT blush once excluded extra-splenic source of bleeding. – Hemodynamically stable patients with WSES class II lesions without blush should not underwent routine AG/AE but may be considered for prophylactic proximal embolization in presence of risk factors for NOM failure.
  • 24. – In performing AG/AE coils should be preferred to temporary agents. – In presence of a single vascular abnormality (contrast blush, pseudo- aneurysms and artero-venous fistula) in minor and moderate injuries the currently available literature is inconclusive regarding whether proximal or distal embolization should be used. In presence of multiple splenic vascular abnormalities or in presence of a severe lesion, proximal or combined AG/AE should be used, after confirming the presence of a permissive pancreatic vascular anatomy. • 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%.
  • 25. Operative Managment - Operative management (OM) of splenic injuries should be performed in non-responder hemodynamic instable patients(high-ISS trauma, in high-grade lesions, and in patients with associated lesions). – In patients with hemodynamic instability and/or with associated lesions like peritonitis or bowel evisceration or impalement requiring surgical exploration. – OM should be performed in moderate and severe lesions even in stable patients in centers where intensive monitoring cannot be performed and/or when AG/AE is not rapidly available.
  • 26. – During OM, salvage of at least a part of the spleen is debated and could not be suggested. – Laparoscopic splenectomy in early trauma scenario in bleeding patients could not be recommended. • The use of splenic autologous transplantation to avoid infective risk from splenectomy, has been investigated, but no reduction of morbidity or mortality has been demonstrated - Pisters PW, Pachter HL. Autologous splenic transplantation for splenic trauma. Ann Surg. 1994;219:225–35. - The reported overall hospital mortality of splenectomy in trauma is near 2%, and the incidence of postoperative bleeding after splenectomy, ranges from 1.6 to 3%, but with mortality near to 20% - Qu Y, Ren S, Li C, Qian S, Liu P. Management of postoperative complications following splenectomy. Int Surg. 2013;98:55–60.
  • 27. Splenectomy • Anatomy • The normal spleen is about 8 to 10 cm in longest dimension, weighs about 100 g. • Lies high up in the left upper quadrant protected by the lower rib cage. • The splenic hilum lies within 2 cm of the pancreatic tail and contains the branching vessels of the splenic artery and splenic vein. • The superior branches of these vessels extend superiorly through the gastrosplenic ligament and attach, as the short gastric vessels, to the very proximal greater curvature of the stomach
  • 28. • Laparotomy in supine position through a midline incision. • Rapid packing of the left upper quadrant allows one to sequentially identify any associated injuries that have a greater priority than the splenic injury. • Splenic flexure of the colon is then mobilized which typicaaly has two short vessels extending from the colonic mesentery to the inferior pole of the spleen. • Control of hemorrhage can be achieved by compressing the splenic hilum with the fingers and thumb of the left hand while the right hand is used to continue the anterior and medial mobilization of both the pancreatic body with tail and the spleen. • Packs can be placed posteriorly which will hold the spleen anteriorly and medially.
  • 29. • One can then approach the branches of the splenic artery and splenic vein. • identified along the posterior aspect of the splenic hilum and can be individually divided and ligated. • Avoid inadvertent clamping of the tail of the pancreas • The lesser sac is entered through the greater omentum outside the arcades of the gastroepiploic vessels
  • 30. • There usually are two or three short gastric vessels that are most safely controlled by ligature. • The spleen can then be detached from its “avascular” splenophrenic attachments • The plane posterior to both the spleen and the body and tail of the pancreas is then bluntly dissected • Prior to closing, one needs to check carefully for hemostasis- assess the splenic flexure, the greater curvature of the stomach, tail of the pancreas and posterior surface of the diaphragm
  • 31. • Thrombo-prophylaxis in splenic trauma: • Trauma patients are at high risk of venous thromboembolism (VTE); the transition to a hyper-coagulation state occurs within 48 h from injury [117 • Without any prophylaxis, more than 50% may experience deep vein thrombosis (DVT)which substantially increases the risk of pulmonary embolism (PE) whose mortality is about 50% [118 • In trauma patients surviving beyond the first 24 h, PE is the third leading cause of death. • Even with chemical prophylaxis, DVT can be detected in 15% of patients.
  • 32. – Mechanical prophylaxis is safe and should be considered in all patients without absolute contraindication to its use. – Spleen trauma without ongoing bleeding is not an absolute contraindication to LMWH-based prophylactic anticoagulation. – LMWH-based prophylactic anticoagulation should be started as soon as possible from trauma and may be safe in selected patients with blunt splenic injury undergone to NOM. – In patient with oral anticoagulants the risk-benefit balance of reversal should be individualized.
  • 33. • Heparin and LMWH can be combined with mechanical prophylaxis; however, mechanical prophylaxis alone in high-grade lesions seems to be preferred by surgeons compared with heparin. • Eberle et al. and Alejandro et al. demonstrated no differences between VTE prophylaxis administered within and after 72 and 48 h from trauma respectively, with highest rate of failure in patients with high-grade splenic injury. - Eberle BM, Schnüriger B, Inaba K, Cestero R, Kobayashi L, Barmparas G, et al. Thromboembolic prophylaxis with low-molecular-weight heparin in patients with blunt solid abdominal organ injuries undergoing nonoperative management: current practice and outcomes. J Trauma. 2011;70:141–6. discussion 147 • Rostas et al. show that VTE rates were over fourfold greater when LMWH was administered after 72 h from admission. - Rostas JW, Manley J, Gonzalez RP, Brevard SB, Ahmed N, Frotan MA, et al. The safety of low molecular-weight heparin after blunt liver and spleen injuries. Am J Surg. 2015;210:31–4.
  • 34. Short and long term Follow-up • Splenic complications after blunt splenic trauma range between 0 and 7.5% with a mortality of 7–18% in adults. - El-Matbouly M, Jabbour G, El-Menyar A, Peralta R, Abdelrahman H, Zarour A, et al. Blunt splenic trauma: assessment, management and outcomes. Surgeon. 2016;14:52–8. • The 19% of splenic-delayed ruptures happen within the first 48 h, more frequently between 4 and 10 days after trauma. • The risk of splenectomy after discharge ranges between 3 and 146 days after injury, and the rate of readmission for splenectomy was 1.4%. - Zarzaur BL, Vashi S, Magnotti LJ, Croce MA, Fabian TC. The real risk of splenectomy after discharge home following nonoperative management of blunt splenic injury. J Trauma. 2009;66:1531–8. • Savage et al. found an average of healing in grades I–II of 12.5 days with a complete healing after 50 days while in grades III–V, 37.2 and 75 days, respectively. - S a S, Zarzaur BL, Magnotti LJ, J a W, Maish GO, Bee TK, et al. The evolution of blunt splenic injury: resolution and progression. J Trauma. 2008;64:1085-91-2.
  • 35. • Activity restriction may be suggested for 4–6 weeks in minor injuries and up to 2–4 months in moderate and severe injuries. • In 2–2.5 months, regardless of severity of spleen injury, the 84% of patients presented a complete healing. - S a S, Zarzaur BL, Magnotti LJ, J a W, Maish GO, Bee TK, et al. The evolution of blunt splenic injury: resolution and progression. J Trauma. 2008;64:1085-91-2. • Mortality of late rupture ranges from 5 to 15% compared with 1% mortality in case of acute rupture. - Peitzman AB, Heil B, Rivera L, Federle M, Harbrecht BG, Clancy K, et al. Blunt splenic injury in adults: multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma-Injury Infect Crit Care. 2000;49:177–89. • Radiological follow-up is used, but there are not clear information regarding the timing and type of imaging (CT vs. US). • Imaging follow-up is usually based on clinical judgment and has been widely debated. - Shapiro MJ, Krausz C, Durham RM, Mazuski JE. Overuse of splenic scoring and computed tomographic scans. J Trauma. 1999;47:651–8.
  • 36. Complications • Reactionary haemorrhage. • Left Basal atelectasis. • Left sided pleural effusion • Gastric fistula. • Pancreatitis. • Haematemesis. • Postoperative thrombocytosis. • OPSI.
  • 37. • Infection Prophylaxis in Asplenic and Hyposplenic Adult • OPSI are defined as fulminant sepsis, meningitis, or pneumonia triggered mainly by Streptococcus pneumoniae (50% of cases) followed by H. influenzae type B and N. meningitidis. • The risks of OPSI and associated death are highest in the first year after splenectomy, at least among young children, but remain elevated for more than 10 years and probably for life. • The incidence of OPSI is 0.5–2%; the mortality rate is from 30 to 70%, and most death occurs within the first 24 h. • Only prompt diagnosis and immediate treatment can reduce mortality.
  • 38. – Patients should receive immunization against the encapsulated bacteria (Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis). – Vaccination programs should be started no sooner than 14 days after splenectomy or spleen total vascular exclusion. – In patients discharged before 15 days after splenectomy or angioembolization, where the risk to miss vaccination is deemed high, the best choice is to vaccinate before discharge. – Annual immunization against seasonal flu is recommended for all patients over 6 months of age.
  • 39. – Malaria prophylaxis is strongly recommended for travelers. – Antibiotic therapy should be strongly considered in the event of any sudden onset of unexplained fever, malaise, chills, or other constitutional symptoms, especially when medical review is not readily accessible. – The recommended options for emergency standby in adults include the following: (a) Amoxycillin, 3 g starting dose followed by 1 g, every 8 h; (b) Levofloxacin 500 mg every 24 h or Moxifloxacin 400 mg every 24 h (for beta- lactam allergic patients). – Primary care providers should be aware of the splenectomy/angioembolization.
  • 40. References 1. Bailey & Love’s Short Practice of Surgery, 28th Edition. 2. Sabiston Textbook of Surgery, 21st Edition. 3. Schwartz’s Principles of Surgery, 11th Edition. 4. Coccolini, F., Montori, G., Catena, F. et al. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg 12, 40 (2017). https://doi.org/10.1186/s13017-017-0151-4 40

Editor's Notes

  1. Particularly if the injury occurs to the left upper quadrant of the abdomen. 
  2. splenectomy in the setting of hemodynamic instability particularly those in the left upper quadrant when adhesions are present
  3. This mechanism can create a subcapsular hematoma
  4. associated with the anatomic grade of injury and the other associated lesions
  5. They should not be used to compel adherence to a given method of medical management, which method should be finally determined after taking account of the conditions at the relevant medical institution (staff levels, experience, equipment, etc.) and the characteristics of the individual patient.
  6. especially exploiting the more advanced tools for bleeding management.
  7. Moreover, transient responder patients (those showing an initial response to adequate fluid resuscitation and then signs of ongoing loss and perfusion deficits) and, more in general, those responding to therapy but not amenable of sufficient stabilization to be undergone to interventional radiology treatments, are to be considered a unstable patients.
  8. contributes to the insurgence of trauma-induced coagulopathy
  9. This might be due to the 20% of cases in which no significant extravasation of blood is present in splenic trauma or in injuries near the diaphragm
  10. (more than 60% of patients with blush failed NOM)
  11. (i.e., voluntarily leaving pieces of spleen inside the abdomen),
  12. Other ligamentous attachments include the superior and posterior splenophrenic ligament, thei nferior splenocolic ligament, and the posterior splenonephric ligament
  13. avulsed from the splenic capsule when too much anterior and medial tension is placed on the omentum during gastric mobilization for truncal vagotomy.
  14. , which may result in subsequent pancreatitis or a pancreaticocutaneous fistula. Proximal dissection exposes short gastric vessels near the apical fat pad of the stomach, whereas lateral dissection exposes the splenic hilar vessels.
  15. Patients with portal hypertension may have extensive collaterals in this “avascular” plane, necessitating suture ligation posteriorly, where one might injure the adrenal vessels or renal vessels.
  16. resulting from a slipped ligature  from damage to the greater curvature of the stomach during ligation of the short gastric vessels. Damage to the tail of the pancreas during ligation of the splenic vessels at the hilum  from gastric mucosal damage and gastric dilatation are uncommon  if the blood platelet count exceeds 1 × 106/mL, prophylactic aspirin is recommended. 
  17. OPSI is a medical emergency.