Current Management of
Splenic Trauma
No financial disclosures
Historical Milestones
2nd-12th Cent.
Seat of emotions; source of
laughter, mirth, anger, malice or
bad temper, latent malevolence,
melancholy, depression, black
bile
cleanse the blood
1549
First splenectomy for disease
1590
Partial splenectomy for trauma
1678
Total splenectomy for trauma
Historical Milestones, cont’d
1892
Splenectomy for blunt trauma
1900
Nonoperative Tx associated with
mortality of 90-100%
Prevalence of “delayed rupture”
(15-30%)
1895-1930
Splenorrhaphy, partial
splenectomy
“Injuries of the spleen demand excision of the gland.
No evil effects follow its removal, while the danger of
hemorrhage is effectually stopped.”
Kocher, 1911
Historical Milestones, cont’d
1952
Increased infection in children
after splenectomy
1969
Overwhelming Post
Splenectomy Infection (OPSI)
1971
Nonoperative management of
spleen (pediatric patients)
1990’s
Nonop management in adults
Epidemiologic Facts Related to
Infections after Splenectomy
Pneumococcal pneumonia is a common
community acquired pneumonia
Post splenectomy cases often poorly
documented
Other risk factors for pneumonia/infection are
often present
Not all infections after splenectomy are OPSI
Therefore ……
What is the risk of OPSI after splenectomy?
Best guess is < 1% in adults after trauma (0.020.2%)
More frequently rapidly fatal in adults (less
meningitis)
Impact of immunization after splenectomy
Diagnostic Modalities Influence
Treatment of Blunt Splenic Injuries
Physical Exam
(premodern era)
Physical Exam
(modern era)
DPL
Computed tomography
?Ultrasound/CT?
No specific treatment
Splenectomy
Splenorrhaphy
Nonoperative
management
?????
100
Percent
80
60
Dx using CT
Dx using US
Dx using surgery
40
Total PTSF Patients,#
0
1986
24000
1988
1990
1992
1994
1996
1998
2000
2002
6
Total PTSF patients
Patients with splenic injuries
22000
5
20000
18000
4
16000
14000
1986
1988
1990
1992
1994
1996
Year
1998
2000
3
2002
Patients with Splenic Injuries,%
20
Magnitude of Splenic Injury is
changing over time
1000
Number of Patients
900
800
700
600
500
All Injuries
865.04
865.03
865.02
865.01
400
300
200
100
0
1986
1988
1990
1992
1994
Year
1996
1998
2000
2002
Splenic Injury Severity Trends from
the National Trauma Data Bank
5000
4000
AIS 2
3000
AIS 3
# Cases
AIS 4 & 5
2000
Total
1000
03
20
02
20
01
20
00
20
99
19
98
19
19
97
0
Mortality with Moderately Severe
Splenic Injuries
40
35
Mortality, %
30
All Injuries
865.03
865.02
25
20
15
10
5
0
1986
1988
1990
1992
1994
Year
1996
1998
2000
2002
Mechanism of Injury is
changing over time
Fall
Percent
Other
20
60
10
50
0
40
1986 1988 1990 1992 1994 1996 1998 2000 2002
Year
MCC, Assaults, Peds struck were unchanged
MVC, Percent
MVC
Nonoperative treatment is the most
common form of management for
blunt splenic injuries
More frequent use of CT for diagnosis/triage
More low magnitude splenic injuries
Low velocity accidents
Decreased overall number/severity of associated
injuries
Nonoperative
Management
Delay in Tx
Missed Injuries
Operative
Management
Risk of operation
OPSI
Operative vs Nonoperative Tx
Is this splenic injury
actively bleeding?
(likely to bleed)?
Splenic Injury with extravasation of
contrast
Minor Blunt Splenic Injury
Moderately Severe Blunt Splenic
Injury
Grade of Splenic Injury
I
II
Hematoma
subcapsular, <10%
Laceration
< 1cm deep
Hematoma
subcapsular, 10-50%
intraparenchymal, <5 cm
Laceration
1-3 cm deep
Hematoma
>50%, ruptured, >5cm
Laceration
>3 cm, + trabecular vessels
IV
Laceration
segmental or hilar vessel
with major devascularization
V
Laceration
shattered spleen, avulsion
III
Grade of Splenic Injury
correlates with success of NOM
EAST, J Trauma 2000
Quantity of Hemoperitoneum
correlates with success of NOM
EAST, J Trauma 2000
Magnitude of injury correlates with
success of nonoperative management
*p<0.05 vs SNOM
#p<0.05 vs FNOM
Injury Severity Score
40
35
*#
*
Level 1
Level 2
*
30
*
25
20
15
10
1
OM
2
Successful
NOM
3
Failed
NOM
Age impacts Nonoperative Management
3.6
#
8.3
*p<0.05 vs Successful
#p<0.05 vs Age
@p=.054 vs Age
% of Patients
80
Age<55
Age>55
60
40
@
,
12.3* 29.2*
#
20
0
1
Successful
Nonop
2
Unsuccessful
Nonop
Blunt splenic injury in adults
Selection of adults for treatment of blunt splenic
injury
– hemodynamic stability status
– severity of injury (ISS)
– grade of splenic injury
– quantity of hemoperitoneum
– Age
– ? Co-morbidities ?
ULH Experience 1/2009-6/2010
93.5%
6.5%
# Patients
200
150
37%
100
50
0
Op
Success
Nonop
Failed
Nonop
14
Mortality, %
12
2/15
15/136
10
8
6
11/216
4
2
EAST 25.9%
Smith 23.2%
EAST 4.2%
Smith 8.6%
EAST 16.5%
Smith 8.2%
0
Op
Success
Nonop
Failed
Nonop
Kentucky Pediatric Experience
What should the surgeon do with
high grade splenic injuries?
Proportionately less common injuries
Some can be managed nonoperatively but which ones?
Price associated with failure (morbidity, mortality) is real
Problem with using historical controls
Impact of patients taken directly to the operating room
Does angiography have an impact?
Splenic Artery Embolization
Angiography for diagnosis reported in 1957
Angiography for hemostasis reported in 1981
(gelfoam-2, coil-1, vasopressin-1)
Angiography as a triage tool reported in 1991
44 stable patients 1984-87
19 without extravasation on angio
17 with extravasation embolized
8 underwent laparotomy (no angio)
Splenic Artery Embolization,
cont’d
Angiographic technique affects splenic
vessel recanalization and splenic function
Proximal vs Distal
Coil vs gelfoam/clot
Splenic Artery and Collaterals
Does angiography/embolization
improve splenic salvage?
Haan et al, J Trauma 2004
Multicenter study, n=155 w/ embolizaton
Splenic salvage of 87% reported
Failure rate of 14%, infarction rate of 27%
? how many patients had angio without
embolization ?
Compared to historical controls
Does angiography/embolization
improve splenic salvage?
Dent et al, J Trauma 2004
Report 168 injuries, 13 patients undergoing embo
Overall nonop success rate of 98%
Did not stratify by injury grade
Compared to historical controls
38% required repeat angio/embo
Does angiography/embolization
improve splenic salvage?
Haan et al, J Trauma 2005
Protocolized angio/embo (all patients after
CT then only grades 3-5 deemed
stable) (? n=298 ?)
Nonop success rate of 83-87% for grade 3-5
Not clear how this compared to no angio pts
Compared to historical controls (8 yr old data)
UPMC Experience
570 patients with blunt splenic trauma from 20002004
221 patients - immediate operation (39%)
349 patients - attempted nonoperative Tx
46 (13%) underwent angio & 28 embolization
Decision of trauma attending (no protocol)
Percentage undergoing angio
UPMC Experience
20
10
0
2000
2001
2002
Year
2003
2004
UPMC Experience
Angiography, %
40
*
30
*
20
10
0
2
3
Spleen AIS
4
UPMC Experience
Angio
No Angio
Nonop Success, %
100
80
60
40
20
0
2
2
3-5
Spleen AIS
3
Splenic Injury Presenting 3 Days
after Fall
Pseudoaneurysm
Nonoperative
Management
Delay in Tx
Missed Injuries
Operative
Management
Risk of operation
OPSI
Complication Rates
after Splenectomy
Fry
1980
Wiseman
2006
Demetriades
2012
U of L
09-10
U of L
Isolated
Spleen
Abd Abcess
11%
9%
6.2%
5%
0%
Wound Infection
16%
4%
8.2%
1.0%
0%
Pancreatitis
Panc Fistula
17%
-----
-----
1.0%
0%
Wound Dehis
5%
-----
-----
0%
0%
Hemorrhage
-----
-----
-----
1.0%
0%
Pneumonia
33%
30%
14.4%
23%
6%
Sepsis/Bacteremia
8%
19%
12.4%
3.0%
0%
UTI
-----
12%
2.1%
6.0%
6%
DVT/PE
-----
-----
-----
12%
0%
Conclusions
More splenic injuries are being identified
More frequent use of CT
More minor injuries
Low velocity mechanisms
Number of severe injuries unchanged
Careful patient selection for nonoperative management is essential for severe injuries
Morbidity and mortality are increased in patients that
ultimately fail nonoperative Tx compared to patients who do
not fail (?poor selection or failure-induced morbidity?)
Conclusions
Role of angiography remains to be defined
triage tool vs selective application
Splenectomy patients do suffer complications
Rate due to splenectomy itself is low
Role of associated injuries
Patients still die of splenic injuries
stop the hemorrhage
Splenic Function, cont’d
Immune Surveillance
White pulp (25% spleen volume)= lymphoid
compartment
Bind Ag & differentiate into Ab-secreting cells
Initial site of IgM after bacterial challenge
Removal of opsonized particles
Embolization for Splenic Artery
Pseudoaneurysms
Natural History of Splenic Artery
Pseudoaneurysm ?
Day of Injury
Natural History of Splenic Artery
Pseudoaneurysm ?
Post Injury Day 4
Splenic Artery Embolization, cont’d
Does embolization impair or preserve
splenic function ??
Does embolization increase splenic
salvage ??
Does angiography/embolization improve
overall outcome ??