JHSGRJHSGRManagement of Management of

blunt splenic blunt splenic injuriesinjuries

Dr PT Chan /QEHDr PT Chan /QEH

IntroductionIntroduction

Spleen is the most frequently injured Spleen is the most frequently injured organ in blunt traumaorgan in blunt trauma

Spleen plays an important role in Spleen plays an important role in immune functionimmune function Overwhelming Post splenectomy Overwhelming Post splenectomy

Infection (OPSI) 0.05-2%Infection (OPSI) 0.05-2%

Mortality 50%-70%Mortality 50%-70%Takehiro Okabayashi,.World Journal of Gastroenterology 2008

Change in the approach to splenic Change in the approach to splenic injuryinjury Operative splenic preservation achieved Operative splenic preservation achieved

by splenorrhaphy has progressed to the by splenorrhaphy has progressed to the non-operative management. non-operative management.

Etiology and RisksEtiology and Risks TraumaTrauma

Rapid deceleration Rapid deceleration Road Traffic AccidentsRoad Traffic Accidents

Direct forceDirect force Fell from height/ sportsFell from height/ sports

IatrogenicIatrogenic

Risks: Pre-existing illness Risks: Pre-existing illness Splenomegaly due to haematological disease / Splenomegaly due to haematological disease /

malaria/ Infectious mononucleosismalaria/ Infectious mononucleosis

Clinical presentationClinical presentation

Left upper quadrant abdominal painLeft upper quadrant abdominal pain Left shoulder tenderness (referred Left shoulder tenderness (referred

pain from subdiaphragmatic nerve pain from subdiaphragmatic nerve root irritation)root irritation)

Peritoneal sign Peritoneal sign Signs and symptoms of shockSigns and symptoms of shock

e.g. tachycardia, restlessness, e.g. tachycardia, restlessness, tachypneatachypnea

InvestigationInvestigation

USGUSG FAST :Look for any free peritoneal fluidFAST :Look for any free peritoneal fluid

Sensitivity 55%-91%, specificity 97-100%Sensitivity 55%-91%, specificity 97-100% Splenic injuriesSplenic injuries

sensitivity 41-63%, specificity 99%sensitivity 41-63%, specificity 99% CT scanCT scan

Splenic injuriesSplenic injuries Sensitivity 95% , specificity 100%Sensitivity 95% , specificity 100%

AAST Grading of splenic AAST Grading of splenic injuryinjury

Grade 1Grade 1

Subcapsular Subcapsular hematoma of less hematoma of less than 10% of than 10% of surface area.surface area.

Capsular tear of Capsular tear of less than 1 cm in less than 1 cm in depth.depth.

Grade 2Grade 2 Subcapsular Subcapsular

hematoma 10-50% hematoma 10-50% of surface areaof surface area

Intraparenchyml Intraparenchyml hematoma < 5cm hematoma < 5cm diameterdiameter

Laceration of 1-Laceration of 1-3cm in depth and 3cm in depth and not involving not involving trabecular vesselstrabecular vessels

Grade 3Grade 3 Subcapsular >50% Subcapsular >50%

surface area or surface area or expandingexpanding

Ruptured subcapsular or Ruptured subcapsular or intraparenchymal intraparenchymal hematomahematoma

Intraparenchymal Intraparenchymal haematoma >5 cm or haematoma >5 cm or expandingexpanding

Laceration of greater Laceration of greater than 3 cm in depth or than 3 cm in depth or involving trabecular involving trabecular vesselsvessels

Grade 4Grade 4

Laceration Laceration involving involving segmental or hilar segmental or hilar vessels producing vessels producing major major devascularization devascularization (>25% of spleen)(>25% of spleen)

Grade 5Grade 5

Shattered spleen / Shattered spleen / Hilar vascular Hilar vascular injuryinjury

ManagementManagement

Haemodynamic unstableHaemodynamic unstable Surgical interventionSurgical intervention

LaparotomyLaparotomy 4 quadrants packed4 quadrants packed Assess the extent of splenic injuriesAssess the extent of splenic injuries

Only if feasible, may consider conserving the Only if feasible, may consider conserving the spleenspleen

Otherwise, Splenectomy should be performed Otherwise, Splenectomy should be performed Excluded other injuriesExcluded other injuries SplenorrhaphySplenorrhaphy

Parenchymal suture/Fibrin glue/ABC/ Parenchymal suture/Fibrin glue/ABC/ Laser/omental patch/mesh bag/partial Laser/omental patch/mesh bag/partial splenectomysplenectomy

Haemodynamic stableHaemodynamic stable

Non operative management with Non operative management with close monitoringclose monitoring Vital signs, haemoglobin levels Vital signs, haemoglobin levels

Successful rate 80% ~89.2%Successful rate 80% ~89.2%

Jason Smith. Journal of Trauma 2007

Andrew B. Peitzman,.Journal of Trauma 2000.

Non operative Non operative managementmanagement

How long should be monitored?How long should be monitored? most failure( 95%) occur within 3 most failure( 95%) occur within 3

days(72hrs) of admission.days(72hrs) of admission.

(97% in 5 days, 99 % in 30 days) (97% in 5 days, 99 % in 30 days) Suggested patients to be closely Suggested patients to be closely

monitored for 3-5 days monitored for 3-5 days Highly dependency unit and step down Highly dependency unit and step down

afterwards afterwards Jason Smith. Journal of Trauma 2007

Jason Smith. Journal of Trauma 2007

Successful rate of NOM

Non operative Non operative managementmanagement

Risk factors for failureRisk factors for failure Higher grading of splenic injuriesHigher grading of splenic injuries larger quantity of haemoperitoneumlarger quantity of haemoperitoneum older ageolder age Contrast extravasations in CT Contrast extravasations in CT

Jason Smith.Journal of Trauma 2007

Siriratsivawong K Am Surg 2007

Andrew B. Peitzman. Journal of Trauma 2000.

Non operative Non operative managementmanagement

Andrew B. Peitzman. Journal of Trauma 2000.

Angioembolization Angioembolization

Increased successful rate of non-Increased successful rate of non-operative management in selected operative management in selected policypolicy Increase up to 97%Increase up to 97%

Indications:Indications: Contrast extravasation, Contrast extravasation,

pseudoaneurysm, grade 4 injuriespseudoaneurysm, grade 4 injuries

Ashraf A. Journal of Trauma 2009

Complications of Complications of embolizationembolization

Total splenic infarction (9.5%), Total splenic infarction (9.5%), rebleeding (19%), splenic atrophy rebleeding (19%), splenic atrophy (4.8%), partial infarction (38%), (4.8%), partial infarction (38%), pleural effusion (33%).pleural effusion (33%).

Shih-chi Wu. World journal of surgery 2008

Resolution and Resolution and ProgressionProgression

Time of mobilization?Time of mobilization? No definite guidelines, earlier for low No definite guidelines, earlier for low

grade injuries. grade injuries. 77% mobilization within 72hrs after 77% mobilization within 72hrs after

admissionadmission Day of mobilization was not associated Day of mobilization was not associated

with delayed splenic rupture. with delayed splenic rupture.

London JA.Arch Surg. 2008.

% of patients remained unhealed over time (days)

Stephanie A.Journal of Trauma. 2008

Activity Restriction-Activity Restriction-AthletesAthletes

No consensus on return to play after No consensus on return to play after splenic injurysplenic injury

Acceptable to engage in light Acceptable to engage in light activity for the first 3 months and activity for the first 3 months and then gradually return to full activitythen gradually return to full activity

Elizabeth H.American College of Sports Medicine.2010.

Follow up Follow up

No evidence that routine follow up No evidence that routine follow up serial CT scans without clinical serial CT scans without clinical indications influenced the outcome indications influenced the outcome or management.or management.

Imaging maybe considered if patient Imaging maybe considered if patient has a high grade of injury/ still has a high grade of injury/ still experiencing symptomsexperiencing symptoms

Thaemert BC. Journal of Trauma 1997

Prevention of InfectionPrevention of Infection

VaccinationVaccination Pneumococcal , then booster after 5 Pneumococcal , then booster after 5

yearsyears Hamemophilus influenza BHamemophilus influenza B Meningococcal every 3 -5 yearsMeningococcal every 3 -5 years Two weeks after emergency Two weeks after emergency

splenectomysplenectomy EducationEducation Bracelet/CardBracelet/Card

Guidelines from the Centers for Disease Control and Prevention

Shatz DV .Journal of trauma 2002, 1998

Antibiotic prophylaxisAntibiotic prophylaxis No clinical trials in adultsNo clinical trials in adults ““StandbyStandby”” antibiotics antibiotics Some suggest 2-5 years prophylaxisSome suggest 2-5 years prophylaxis Long term prophylaxis not generally Long term prophylaxis not generally

recommendedrecommended

DC. The Netherlands Journal of Medicine 2004

SummarySummary Operation if haemodynamic unstableOperation if haemodynamic unstable Only stable patient are admitted for observation for Only stable patient are admitted for observation for

3-5 days3-5 days CT for assessing degree of injuriesCT for assessing degree of injuries

Grade 5 injuries need operationGrade 5 injuries need operation Majority of grade 4 splenic injuries are unstable and likely Majority of grade 4 splenic injuries are unstable and likely

need to be operatedneed to be operated Angio/embolization can be considered for stable Angio/embolization can be considered for stable

patients with contrast extravasation or patients with contrast extravasation or pseudoaneurysmpseudoaneurysm

Advise activity restriction according to the grade of Advise activity restriction according to the grade of injuriesinjuries

Vaccination /education for infection prophylaxis Vaccination /education for infection prophylaxis Follow up CT scan should be considered in selected Follow up CT scan should be considered in selected

patientspatients

ManagementManagement

Thank YouThank You

Latent pseudoaneurysm may present Latent pseudoaneurysm may present ~ 24-48 hrs after injury (2.2%) ~ 24-48 hrs after injury (2.2%)

Computed Tomography Identification of Latent Pseudoaneurysm after blunt splenic injury : Pathology or Technology

Hunter B.Long-Term Follow up of Children with nonoperative management of blunt spenic trauma. Journal of Trauma 2010.

SplenorraphySplenorraphy

Grade 1: haemostatic agentGrade 1: haemostatic agent

Grade 2 : 43% + suture/meshGrade 2 : 43% + suture/mesh

Grade 3 : 100% + suturing /parenchymal Grade 3 : 100% + suturing /parenchymal suturesuture

Grade 4: anatomical resectionGrade 4: anatomical resection

Grade 5: splenectomyGrade 5: splenectomy

PickhardtB, Operative splenic salvage in adults: a decade perspectives. Journal of Trauma 1989

Paediatric patientsPaediatric patients Mechanism of injury:Mechanism of injury:

More fall or sports than RTAMore fall or sports than RTA Elastic ribs readily change contour and cause rapid flexion of Elastic ribs readily change contour and cause rapid flexion of

organs along its axis -> lacertions are more oriented to the organs along its axis -> lacertions are more oriented to the larger segmental vesselslarger segmental vessels

Thicker and more fibrous splenic capsuleThicker and more fibrous splenic capsule Tolerate higher grade of injuries with non operative Tolerate higher grade of injuries with non operative

managementmanagement ComplicationsComplications

Very low incidenceVery low incidence For delayed splenic rupture (0 case in one metaanalysis 1083 For delayed splenic rupture (0 case in one metaanalysis 1083

patient vs 5-6% in adult)patient vs 5-6% in adult) Most pseudoaneurysm will spontaneously resolve or self Most pseudoaneurysm will spontaneously resolve or self

tamponadetamponade

Non-operative management is the standard for all grades of Non-operative management is the standard for all grades of splenic injuries in all haemodynamic stable patients (75-93% splenic injuries in all haemodynamic stable patients (75-93% successful rate)successful rate)

Peditric blunt splenic trauma: a comprehensive review

Pediatr Radiol (2009)39:904-916

Andrew B. Peitzman, Blunt Splenic Injury in Adults: Multi-institutional Study of the Eastern Association for the surgery of Trauma. Journal of Trauma 2000.

Activity RestrictionActivity Restriction

Light activityLight activity Light housework, office work, low Light housework, office work, low

impact aerobic activityimpact aerobic activity Strenuous activityStrenuous activity

Running, lifting over twenty pounds, Running, lifting over twenty pounds, cosntruction work, manual laborcosntruction work, manual labor

Full activity (contact sport)Full activity (contact sport)

Fata P.A survey of EAST member practices in blunt splenic injury; a description of current trends and opportunities for improvement. Journal of Trauma 2005

Late complication of Late complication of splenic injuriessplenic injuries

Non operative Non operative Delayed rupture spleen 1%Delayed rupture spleen 1% Splenic Pseudocyst Splenic Pseudocyst Splenic necrosis/abscessSplenic necrosis/abscess

SplenectomySplenectomy Overwhelming postsplenectomy Overwhelming postsplenectomy

Infection (OPSI)Infection (OPSI)