blunt splenic trauma

8/14/2019 Blunt Splenic Trauma

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REVIEW Scandinavian Journal of Surgery 95: 146151, 2006

Blunt splEnIc tRauma

R. m. Foryhe, B. G. Hrbreh, a. B. peiz

Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A.

Key words: Abdominal trauma; spleen; blunt splenic injury; nonoperative management; angioembolization;splenic salvage

Correspondence:Andrew Peitzman, M.D.Department of SurgeryUniversity of PittsburghMedical Center Department of Medicine1218 Scaife Hall3550 Terrace StreetPittsburgh, PA 15213, U.S.A.Email: [email protected]

INTRODUCTION

The spleen is the most commonly injured organ afterblunt trauma. While the spleen is also frequently in-jured in penetrating trauma to the left upper quad-rant, the management of penetrating splenic injury isstraightforward and primarily operative. In contrast,the management of blunt splenic injury has under-gone signicant evolution over the past two decadesand the optimal management remains an area of dis-cussion and debate (119). The overall mortality ratefrom splenic injury has remained 67% or higher inmany series over the past 20 years, while mortalityfrom liver injuries over that time period has decreased(139). This mortality rate is secondary to associatedinjuries; infrequently from the splenic injury itself.

Management has evolved from splenectomy for alltraumatic injuries to splenic salvage and nonopera-tive management in selected patients. The trend to-ward splenic salvage evolved after the identicationof lifelong risk for overwhelming postsplenectomyinfection (OPSI) (21, 22). Nonoperative managementhas now replaced splenorrhaphy as the most com-mon method of splenic salvage. In addition, as onlythe most severe splenic injuries are taken to the oper-ating room, splenectomy is performed far more fre-quently than splenorrhaphy today. Some series sug-gest that nonoperative management (NOM) successrates can be improved with adjuncts such as trans-catheter embolization (TAE) (13, 14). It is importantfor surgeons to identify appropriate patients for non-

operative management, as controversy still exists inpatient selection. In addition, recognition and treat-ment of NOM failures are increasingly important.

HISTORICAL PERSPECTIVE

The spleen was long considered an organ of mys-tery with its function a topic of debate throughouthistory. The spleen was the seat of emotions andpassions: the source of laughter, violent mirth andmerriment. The spleens role in infection was dem-onstrated in 1919 when Morris and Bullock revealedincreased mortality in dogs that had undergone sple-nectomy compared to controls when challenged withrat plague bacillus (40). Splenectomy for injury wasdescribed in the 18th century and the earliest opera-tions on the spleen were associated with severe orpenetrating injuries. As diagnostic modalities at thetime were limited to physical exam, injuries likely to

be identied would have been associated with hemo-

dynamic derangement or obvious abdominal nd-ings. Splenectomy remained the standard of care forall injuries, based on multiple premises: (1) splenec-tomy was without consequence; (2) the spleen wasincapable of healing; and (3) delayed splenic ruptureafter injury was common (41).

In contrast to these traditional views of splenicfunction, the spleen has since been found to partici-pate in the immune response to infection by mechan-ical ltration of particulate antigens and microorgan-isms, production of opsonins and generation of cel-lular antigen responses (6). The risk of overwhelmingpostsplenectomy sepsis (OPSI) is now well character-ized after splenectomy for any cause (21, 22). In ad-dition, while the risk of OPSI varies by age at sple-

nectomy and indication, these patients remain at in-creased risk of infection for life. After removal of thespleen for trauma, the risk of sepsis has been notedto be 1.02.1% with mortality of 0.60.9% (21). Giventhat the overall risk of OPSI is low, a patient with anactively bleeding splenic injury should be managedaccording to his hemodynamic status with OPSI aminor consideration in management. Splenic healingoccurs with nonoperative management; time to heal-ing is longer with higher grade injury (42, 43). Thehistorical view of delayed splenic rupture likelyrepresented delayed recognition of a splenic injuryand bleeding, rather than rupture later in the patients


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147Blunt splenic trauma

course. True delayed rupture of the spleen, with anormal CT scan or diagnostic peritoneal lavage (DPL)on admission, has an incidence of less than 1% (4144).

PRESENTATION, DIAGNOSTIC TESTS AND

INJURY STAGINGBlunt splenic injury may be suspected on the basis ofmechanism of injury and physical examination nd-ings. Patients who are hemodynamically unstablewill frequently have their diagnosis made in the op-erating room at the time of laparotomy. For mostother patients, diagnostic testing is usually requiredfor denitive diagnosis. The majority of blunt splenicinjuries are due to motor vehicle collisions and falls(20). Many patients may have abdominal tenderness

but physical exam is neither sensitive nor specic forsplenic injury, especially in multiply injured patients.Since the force required to injure the spleen is consid-erable, associated injuries are common; especially,

head injury, long bone fractures, spinal column inju-ries, pelvic fractures and rib fractures. Lower left ribfractures (ribs 1012) due to direct trauma to the areaare associated with splenic laceration in 2025% ofadults. Splenic enlargement can occur with infectiousdiseases, such as mononucleosis or malaria, and maydecrease the amount of kinetic energy required toinjure the spleen, resulting in injury to the patho-logically enlarged spleen with relatively minor trau-ma or even spontaneous rupture of the spleen.

Diagnosis of splenic injury has evolved over thelast two decades; no single diagnostic test is appro-priate for all patients. Patients with hemodynamicinstability do not require the diagnosis of specic

organ injury, rather only a decision regarding theneed for immediate laparotomy. This decision can befacilitated with the judicious use of ultrasound anddiagnostic peritoneal lavage (DPL).

ULTRASOUND

Ultrasound is generally used in the diagnosis of bluntabdominal injury as the Focused Abdominal Sono-gram for Trauma (FAST) exam. This exam uses fourviews (subxiphoid, suprapubic, left and right upperquadrants) with a 3.5 mHz probe to detect hemoperi-toneum and/or hemopericardium. Evaluation of theleft upper quadrant can detect hemoperitoneum as-

sociated with possible splenic injury. In the sagittalview, an anechoic (dark black area without echoes)may be seen in the splenorenal recess, indicating he-moperitoneum. With multiple views, the FAST examhas been shown to have 8085% sensitivity for detect-ing hemoperitoneum (33). The false negative ratemay be higher in patients with hematuria, spine frac-tures, or pelvic fracture (33, 34, 45). Since this examcan be done in the trauma evaluation area, by thesurgeon, it acts as an extension of the physical exam.An unstable patient with a positive FAST exam,demonstrating hemoperitoneum, is taken directly tothe operating room without further imaging for lapa-

rotomy. In stable patients who may be candidates fornonoperative management of solid organ injuries,additional imaging provides additional informationregarding severity (grade) of injury to aid in decision-making. The diagnosis of specic injuries generallyfollows with CT scan in the stable patient.

DIAGNOSTIC PERITONEAL LAVAGE

Diagnostic peritoneal lavage (DPL), developed in the1960s, represented a major advance in the care oftrauma patients. DPL is an accurate diagnostic tech-nique to detect hemoperitoneum, although its use islimited today compared with a decade ago with thewidespread adoption of ultrasound. The sensitivityof DPL rapidly identies patients with intraperito-neal bleeding, but gives no information about thespecic organ injured; DPL is sensitive but nonspe-cic. In widespread use in the past, it also identiedpatients with relatively minor injury, who may havealready ceased active hemorrhage. It remains a valu-

able adjunctive test in unstable patients as it is quickto perform and is also performed in the trauma eval-uation area. Current uses include unstable patientswith an equivocal or negative FAST and centers with-out access to ultrasound. DPL is 97% accurate in thediagnosis of hemoperitoneum, but it is not specicfor the organ injured and is an invasive study.

COMPUTED TOMOGRAPHY

In patients with normal hemodynamic status withoutindication for immediate operation for other injuries,CT remains the diagnostic test of choice for blunt

abdominal injury. It is both sensitive and specic forsolid organ injury. Advances in CT technology, in-cluding helical CT and multidetector scanning, havedecreased the time required for scans to be obtained.At the same time, image quality has improved andinformation is rapidly available. CT is performed af-ter the administration of intravenous contrast, whichmust be timed for peak organ enhancement to avoidartifacts created by heterogenous contrast uptake. CTcan determine the grade of injury to the spleen (32)(AAST grades, Table 1) as well as the quantity of he-moperitoneum. The accuracy of CT grading of solidorgan (spleen) injuries when correlated with opera-tive ndings has been debated and interobservervariability does occur (23). However, as CT technol-

ogy continues to improve, CT grading of splenic in-jury continues to improve and has been reported tobe as high as 95%. Increasing grade of injury on CTor large hemoperitoneum (blood in both pericolicgutters and the pelvis) is associated with greater like-lihood of needing immediate operative treatment andhigher failure rates of nonoperative management(NOM) (20, 2627, 44). A recent statewide study inPennsylvania revealed that there has been an overallincrease in the diagnosis of splenic injuries, particu-larly in the number of moderate splenic injury (46).This may be an outcome of increased utilization ofCT as a diagnostic tool in trauma.


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148 R. M. Forsythe, B. G. Harbrecht, A. B. Peitzman

Other signicant CT ndings include the extrava-sation of intravenous contrast (contrast blush) ei-ther within the splenic parenchyma or within theperitoneum. This indicates a splenic pseudoaneurysmor active hemorrhage. This has been shown to cor-relate with higher failure rates of NOM (24). Carefulpatient selection is mandatory when considering non-operative management in the presence of abnormalcontrast enhancement related to splenic injuries.

ANGIOGRAPHY AND TRANSCATHETER

EMBOLIZATIONAngiography and embolization has been reported asuseful adjunct to nonoperative management of theinjured spleen. Its use in selected patients has beenreported to increase the overall splenic salvage rateto 8792% (14) of attempted NOM. However, it iscritical to understand how TAE was utilized in thisstudy. This was a study from 19972002, from fourLevel trauma centers. Although not presented in thepaper directly, based on the probable volume of pa-tients with blunt splenic injury admitted over thistime period (~1500 patients) (47), only 1015% of thetotal group underwent splenic arteriography and em-

bolization. In addition, only 6 patients had grade V

injury in this report. Furthermore, a paper from oneof the study centers from the same period reportedthat 43% of patients with splenic injury went directlyto the operating room (47). As reported in the EASTmulticenter study, the vast majority (> 90%) of gradeV splenic injuries in adults requires immediate oper-ation (20). Lower rates of splenic salvage are seen inhigh grade injuries (14, 20, 27, 28). However, there areno uniformly accepted indications for either angio-graphy or embolization and its use is applied differ-ently across centers. In some centers, angiographywith subsequent embolization is liberally applied asa means to cease active hemorrhage in order to avoid

laparotomy. Most often, angiography is used in stablepatients when CT reveals a contrast blush or highgrade splenic injuries as an adjunct to nonoperativetreatment. In addition, TAE is generally used for docu-mented vascular abnormality at the time of angio-graphy (13, 14).

Additional controversy exists over the preferredmethod of embolization, main splenic artery coilingversus distal (superselective) embolization. Propo-nents of main artery coiling cite a decrease in splenicperfusion pressure, while maintaining splenic bloodow through short gastric vessels and collaterals to

prevent infarcts. Super-selective embolization ad-dresses the vascular injury encountered, but was as-sociated with a higher rate of splenic infarction onfollow up CT. A combination of both techniques may

be employed for higher grade injuries.Use of TAE is not risk free. As reported in the mul-

ticenter series of TAE, 20% of patients developed ma-jor complications: delayed bleeding, missed abdomi-nal injury, and splenic abscess. Two-thirds of thisgroup (19 of 27 patients) required laparotomy (14).There exists a signicant concern in employing TAE,especially in higher grade injuries where active bleed-ing may be occurring. There may be a signicant de -lay in the availability of the angiographic resourcesnecessary to do these complex procedures. Radiology

can be a dangerous location for a multiply-injuredtrauma patient for a prolonged procedure to obtainangiographic control of hemorrhage. The studies thatshow high success rates with high-grade injuriesclearly have dedicated resources to make this a viabletherapeutic pathway.

NONOPERATIVE MANAGEMENT

Following success rates over 90% in treating bluntsplenic injury in children (12, 17), NOM has also be-come accepted treatment in adults. Success in adults

TABLE 1

AAST Spleen injury scale (1994 Revision)

Grade* Injury type Description of injury ICD-9 AIS-90

I Hematoma Subcapsular, < 10% surface area 865-01 2865.11

Laceration Capsular tear, < 1cm parenchymal depth 865.02 2

II Hematoma Subcapsular, 10%50% surface area; intraparenchymal, 50% surface area or expanding; ruptured subcapsular or parecymal 3hematoma; intraparenchymal hematoma > 5 cm or expanding> 3 cm parenchymal depth or involving trabecular vessels 865.03

Laceration 865.03 3Laceration involving segmental or hilar vessels producing major devascularization 865.13 4(>25% of spleen)

IV Laceration Completely shattered spleen 4Hilar vascular injury with devascularizes spleen

V Laceration 865.04 5Vascular 865.04 5

* Advance one grade for multiple injuries up to grade III. From Moore et al. (32)


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is lower, with approximately one-third of adults re-quiring immediate operation for bleeding (1, 15, 18,19, 20). Hemodynamic stability is the key factor inconsideration for nonoperative management. The re-mainder are candidates for NOM and are managedwith bed rest, serial hematocrit measurements andphysical examinations. The majority of patients are

observed in an intensive care setting, although lowergrade injuries are occasionally managed in monitoredstep-down units. Features initially thought to pre-clude NOM, including concomitant head injury orage over 55 years, have since been shown to havereasonable rates of success (15, 2527, 48).

FAILURE OF NONOPERATIVE MANAGEMENT

While the reported success rates of NOM are high, animportant consideration remains the identication offailures of this course of therapy, there are denedrisks associated with failed NOM and therefore ap-propriate patient selection is essential. Failure of

NOM is associated with increased hospital length ofstay and, in selected subgroups, increased mortality(EAST) (49). The need for blood transfusion or thedevelopment of hypotension are indicators of failureof NOM (37). Hypotension after ICU admission sig-nicantly increases morbidity and mortality. Hypo-tension is also a risk factor for the development ofmultiple organ dysfunction syndrome (MODS),which is a leading cause of late death in trauma pa-tients. Given these factors, there may be a signicantdownside to inappropriate selection of patients forNOM and the identication and stratication of pa-tients for operative therapy versus observation iscritical. Hemodynamic stability is an ill-dened, but

should be an essential criterion for consideration ofnonoperative management of blunt splenic injury inadults. Despite this statement, 25% of patients whofailed nonoperative management in the EAST multi-center study were hemodynamically unstable on ad-mission to the hospital. Mortality was signicantlydifferent patients classied by hemodynamic status,comparing stable (3%), responders (8%), and unstablepatients (39%), despite minor differences in injuryseverity scores. In these patients who failed nonop-erative management, the mortality was 12.8%. Sixtypercent of the deaths were caused predominantly bydelayed treatment of splenic or other abdominal in-

juries. Thus, the frequency of avoidable deaths washigher than OPSI, the disease we are attempting to

avoid with nonoperative management (49). Surgicaljudgment remains paramount in determining whichpatients are actively hemorrhaging and require im-mediate operation.

OPERATIVE MANAGEMENT

As NOM has become the standard of care in hemo-dynamically stable adults as well as children with

blunt splenic injury, good operative techniques andattempts at splenic salvage for those patients whorequire surgery remain critical. Although splenorra-

phy is used less frequently than in the past, knowl-edge of operative techniques for splenic salvage isessential. The primary indications for operation after

blunt splenic injury are hemodynamic instability orevidence of ongoing blood loss. As in all trauma pa-tients, adequate intravenous access is secured and

blood products must be available for operation.

All patients are prepped from the chin to the mid-thighs and to the edge of the operating table posteri-orly. A midline incision is used to enter the abdomen.After blood and clot are rapidly evacuated, the abdo-men is packed in all four quadrants. Active bleedingis controlled rst with rapid control of gastrointesti-nal contamination the next priority. If the spleen isactively bleeding with severe injury, a rapid splenec-tomy may be required. The key to safely operating onthe injured spleen is complete mobilization. Neitheridentication of injuries nor operative managementtherein can be safely performed without fully mobi-lizing the ligamentous attachments of the spleen.During this mobilization, the left hand of the surgeonis placed posteriorly to the spleen, gradually and gen-

tly rotating the organ anteromedially. The avascularlienorenal and phrenicolienal ligaments can be in-cised sharply. The lienocolic ligament generally con-tains vessels that require ligation. Once free of theseattachments, the spleen is then rotated into the woundwith careful blunt dissection in the plane between thepancreas anteriorly and the kidney posteriorly. Theshort gastric vessels in the gastrolienal ligament aredivided and ligated next. It is important while divid-ing the short gastric vessels to divide as far from thegreater curvature as possible to avoid entrapment ofthe gastric wall.

At this point, the spleen is completely mobile andcan be adequately assessed for injury and an opera-

tive plan determined. Any active bleeding can be con-trolled by the surgeon with direct compression of thevessels of the splenic hilum between the thumb andforenger. Splenectomy is performed at this time inpatients who have been unstable or with competinglife or limb threatening injuries. To complete the sple-nectomy, the splenic artery and vein are ligated sepa-rately at the hilum. Care is taken to avoid injury tothe tail of the pancreas. Full mobilization and visual-ization of the tail of the pancreas is vital to avoidiatrogenic injury. If there is any suspicion of injury tothe tail of the pancreas, a closed suction drain should

be left in the splenic bed. Otherwise, drainage is notnecessary.

Since splenorraphy prolongs operative time, sple-

nectomy should be considered in patients with co-agulopathy, hypothermia or signicant pre-existingmedical disease. Knowledge of splenic vascular anat-omy and an assessment of the severity of the injuryto the spleen are important in the decision for possi-

ble splenorraphy. Grade I and II splenic injuries cangenerally be controlled with electrocautery, argon

beam coagulation or absorbable suture in a continu-ous or running fashion. Topical hemostatic agentssuch as absorbable gelatin sponge (Gelfoam, UpjohnCompany), microbrillar collagen (Avitene) or oxi-dized regenerated cellulose (Surgicel, Johnson &

Johnson) may be used as well. Fibrin sealants may


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150 R. M. Forsythe, B. G. Harbrecht, A. B. Peitzman

also be useful in repair. Grade III injuries involvedeeper injuries to the parenchyma and require sutur-ing, often with a buttress of omentum or vicryl mesh.Grade IV injuries require ligation of segmental ves-sels, debridement of devitalized tissue and through-and-through sutures for hemostasis. A hemisplenec-tomy may be required. Sutures may be buttressed

with Teon or absorbable material. The spleen mayalso be wrapped with an absorbable mesh in highgrade injuries. In general, to maintain immunocom-petence (the goal of salvage), preservation of 3550%is required. A grade V, shattered or avulsed spleen,should be removed.

POSTOPERATIVE ISSUES

Postoperative complications are common after sple-nectomy often due to the associated injuries or over-all severity of injury. The most dreaded spleen-relatedcomplication remains overwhelming postsplenect-omy sepsis (OPSI) which remains a rare event in

trauma patients. Common complications include at-electasis, pneumonia, and left pleural effusion. Therate of intra-abdominal abscess is 313% with higherrate in patients with drains in place or concomitantcontamination from intestinal tract injuries. All com-plications are increased in patients with multisystemtrauma compared to single system injury. Pancreaticstulae are uncommon, occurring in 1.5%. Thrombo-cytosis occurs in as many as 50% of patients between210 days after splenectomy. Although data is scant,there does not appear to be an indication for anti-platelet agents until a level of greater than 1000 x109/L is reached (50,51).

Patient education is essential after splenectomy.

From 11% to 50% of postsplenectomy patients areunaware of the increased risk of infection or the pre-cautions that should be taken. All patients must havea thorough discussion regarding the risk of infectionand should be advised to wear a Medic-Alert brace-let. All splenectomy patients should be immunizedwith the polyvalent pneumococcal, H. infuenzatypeB and meningococcal vaccines. The current pneumo-coccal vaccine contains puried capsular polysaccha-ride from the 23 most prevalent serotypes. The pneu-mococcal vaccine is 70% effective in adults, but reim-munization is recommended every 510 years. Intrauma patients, the antibody response is maximized

by delay vaccination for 14 days, but not improvedwith further delay. However, sporadic follow up in

some trauma populations make vaccination at thetime of discharge favorable to ensure vaccination.Requirements for reimmunization in the other vac-cines are not clear. In addition, asplenic patientsshould be advised to be immunized against inuenzayearly.

SUMMARY

The treatment of blunt splenic injury has evolvedover time from splenectomy in all patients to nonop-erative management in stable patients with operation

reserved for failures of NOM. While rates of OPSIremain low in trauma patients, splenic salvage instable patients should be attempted. However, clini-cal evidence of ongoing blood loss or instabilityshould be addressed with prompt splenectomy. Care-ful patient selection is of paramount importance innonoperative management of blunt splenic injury.

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Received: July 5, 2006

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