splenic trauma

Splenic Rupture/Trauma/Injury(According to Eastern Association for Surgery of Trauma (EAST) 2012 guidelines)

Jibran Mohsin

Resident, Surgical Unit I

SIMS/Services Hospital, Lahore

Outline

• History• Etymology• Surgical Anatomy• Etiology• Pathophysiology• Types of injuries• Associated injuries• Clinical Presentation• Workup• Staging• Management• OPSI

Identification of References of EAST 2012 Recommendations

• English-language citations between 1996 (the last year of literature used for the previous guideline) and 2010 using the keywords splenic injury and blunt abdominal trauma.

• The articles were limited to humans, clinical trials, randomized controlled trials, practice guidelines, meta-analyses, and reviews.

• 223 articles were identified.

• Case reports and small case series were excluded.

• The committee chair and members then reviewed the articles for relevance and excluded any reviews and tangential articles.

• 176 articles were reviewed of which 125 were used to create the nonoperativemanagement of blunt splenic injuries recommendations.

History

• The great ancient Roman physician, surgeon and philosopher Claudius Galen (129-216 AD) described the spleen as

“Plenum mysterii organum” or “the organ full of mystery”

as he struggled to elucidate its function.

• The mystery continued for over a millennium, as no one challenged his theory that the spleen functioned to remove the evil humor “black bile” produced by the liver

History

• In 1893, Reigner published the first documented successful splenectomy in the German literature.

• Operative mortality rates remained high until the 1950s– Nonoperative care during this period was predominantly fatal.

• Prior to the advent of CT scanning, – physical examination and diagnostic procedures such as

diagnostic peritoneal lavage (DPL) and radioisotope scans were the only diagnostic methods.

– Minor splenic injury was probably frequently missed– while major injury prompting laparotomy for hypotension or

physical findings was the norm.

History

• With the widespread availability of computed tomography – surgeons began to focus on those needing surgery and – those who could be observed safely.

• Starting with the pediatric population and expanding into the adult population, – nonoperative observation became more prevalent for

hemodynamically stable patients.

• Further improvements in CT sensitivity and specificity – made vascular extravasation easier to diagnose, and – interventional radiology became an integral part of the management

of splenic injuries, in some institutions replacing emergency operation as the treatment of choice.

Changing Trends in management of Spleen trauma during last century

Observation and Expectant management (early 1900’s)

Operative intervention for all injuries

Selective operative and non -operative management (Currently)

Etymology

• Ancient Greek ……..σπλήν (splḗn)– idiomatic equivalent of the heart in English, i.e. to be good-

spleened means to be good-hearted or compassionate

• French– "splénétique" refers to a state of pensive sadness

or melancholy*.

• English– employed to characterise the hypochondriacal and hysterical

affections during 18th century– In modern English, "to vent one's spleen" means to vent

one's anger, e.g. by shouting (BAD TEMPER)

____________________________________________________________________________*derives from Greek "melas kholé" meaning 'black bile', from the belief that an excess of black

bile caused depression

William Shakespeare, in Julius Caesar uses the spleen to describe Cassius' irritable nature

Must I observe you? must I stand and crouch

Under your testy humour? By the gods

You shall digest the venom of your spleen,

Though it do split you; for, from this day forth,

I'll use you for my mirth, yea, for my laughter,

When you are waspish.

Etymology

• Talmud (central text of rabbinic Judaism)

– refers to the spleen as the organ of laughter.

• In 18th and 19th century England,

– women in bad humor were said to be afflicted by the spleen, or the vapours of the spleen

Surgical Anatomy

• Ovoid/wedge, usually purplish, pulpy mass

• About size and shape of one’s fist

• MOST VULNERABLE ABDOMINAL ORGAN

• Located in left upper quadrant or LHC

• Protected by lower thoracic cage

• Completely encircled and covered with peritoneum except at hilum

1×3×5×7×9×11 rule• Size

– 1 inch thickness– 3 inch wide– 5 inch long

• Weight– 7 ounce

• Related ribs– 9-11 (along long axis of 10th rib)

Relations

ANTERIOR:Stomach

POSTERIOR:Left diaphragmLungCostodiaphragmatic recess9-11 ribs

INFERIOR:Left colic flexure

MEDIAL:Left kidney

LIGAMENTS:Gastrosplenic Short gastric vessels and left gastro-omental vesselsSplenorenal (lienorenal) splenic vessels and tail of pancreasPhrenicocolic in contact with lower pole of spleen; at danger during spleenectomy

BORDERS: ENDS: SURFACES:Superior(notched) border Posterior end (Medial end) DiaphragmaticInferior border Anterior end (Anterior border) VisceralAnterior border (anterior end) (3 areas)

Blood SupplyORIGIN COURSE END

Splenic Artery(blood flow= 300 ml/min)

Largest branch of celiac trunk( OR aorta, SMA)

Tortuous course

• posterior to omental bursa• anterior to left kidney• along superior border of

pancreas

bifurcates externally (in splenorenalligament), supplying upper and lower poles separately*

Splenic Vein Formed by several tributaries that emerge from hilum

Joined by IMV

Runs posterior to body and tail of pancreas

Unites with SMV at 900 posterior to neck of pancreas to formportal vein

_____________________________________________________________________ *Lack of anastomsis of arterial vessels formation of VASCULAR SEGMENTS of spleen:

2 in 84 % spleens and 3 in the others, with relatively avascular planes between them, enabling subtotal splenectomy/splenorraphy

Blood Supply

• Short gastric vessels – Branch from the left gastroepiploic artery.

– May be as short as 1 mm• creating a challenge during emergency operative intervention.

• Notably, the splenic artery and vein may have small branches feeding the body and tail of the pancreas– care should be taken in dissecting these vessels away from

the splenic hilum.

Inspite of size and the many useful and important functions,

Spleen is not a vital organ

( not necessary to sustain life)

Etiology

• Blunt Trauma– rapid deceleration(motor vehicle crashes)– direct blows to the abdomen(domestic violence, or leisure and play

activities such as bicycling)

• Penetrating Trauma

• Combination of above – explosive type injuries– warfare and civilian bombing

• Iatrogenic– Post Colonoscopy (66 patients in literature with 4.5 % mortality rate)

• Spontaneous Rupture– Malaria, infectious mononucleosis

Pathophysiology

• Injury is more common and severe in enlarged spleen, i.e. malaria, tropical splenomegaly, infectious mononucleosis.

_______________________________________Larang (blunt metal object) was used to kill by murderers in far east where malaria was endemic leading to splenomegaly which ruptured more easily: with little in the

way of external marks being left on body.

Types of Injury

• Splenic Hematoma– Subcapsular

– Intraparenchymal

• Lacerated wound

• Clean incised wound

• Hilar/vascualr injuries

Associated Injuries

• Fracture Left lower ribs (30 %)

• Left sided hemothorax

• Left lung and diaphragm injury

• Left lobe liver injury

• Tail of pancreas injury

• Left kidney

• Left colonic injury

• Small bowel injury

Clinical Presentation

• Hilar injury– Rapid development of shock and deteriorates fast

(even death can occur)

• Other injuries– Features of shock (pallor, tachycardia, restlessness, tachypnea, anxiety,

hypotension, decreased capillary refill and decreased pulse pressure)

– Pain, tenderness and abdominal rigidity in LUQ

– Free intraperitoneal blood diffuse abdominal pain, peritoneal irritation, rebound tenderness- abdominal distension


• Kehr’s sign– Clot collected under left diaphragm irritates it and the phrenic

nerve( C3, C4) causing referred pain in left shoulder 15 minutes after foot end elevation

– because the supraclavicular nerves have the same cervical nerves origin as the phrenic nerve, C3 and C4

• Ballance’s sign

K

Hans Kehr (1862-1916)German Surgeon

Charles Alfred Ballance (1856 – 1936)English surgeon

BALLANCE SIGN

Persistent dullness to percussion in the left flank due to coagulated blood

shifting dullness to percussion in the right flank due to fluid blood

Splenosis

• Autotransplantation of fragments of splenic tissue within peritoneal cavity following

rupture of spleen


Delayed Presentation

• Missed splenic injury

• Delayed Splenic Rupture(DSR)

Delayed Splenic Rupture(DSR)

• Latent period of Baudet(1907)

• Incidence (Before advent of CT scan 15-33 %; afterwards 1 %)

• Tends to occur 4-8 days after trauma(days-months)

• Mortality 5-15 % Œ

• Potential mechanisms – ŒExpanding subcapsular hematoma Œ – Clot disruption – Pseudocyst rupture Œ– Pseudoaneurysm/AV fistula rupture

• Treatment: splenectomy

Workup

• Hematological investigations

• Radiological investigations

Hematological investigations

• CBC (Hb; Hct)

– rarely helpful in the initial workup of the suspected splenic injury.

– helpful in providing baseline values and,

– Performed serially, in diagnosing ongoing blood loss or hemodilution due to volume resuscitation.

Radiological Investigations

Focused Assessment with Sonography for Trauma (FAST)

– routine diagnostic adjunct in the initial assessment of blunt trauma victims BUT

– lacks the ability to reliably predict which patients require laparotomy.

– Poor for delineating organ-specific anatomy with any reliability in the emergency setting

• Physiologic data (hemodynamic state) play a major role in decision making regarding the need for emergent laparotomy versus further diagnostic testing or observation.

Huang FAST scoring system

Interpretation

• Score >3 cm

– Indicates 1 liter or more hemoperitoneum

– 96 % probability of laparotomy

• Score < 3 cm

– 37 % probability of laparotomy

SSORTT(Sonographic Scoring for Operating Room Triage in

Trauma)

SSORTT Scoring System


• Multidetector helical CT scan with IV contrast

– In the stable patient, CT scanning provides structural evaluation of the spleen and surrounding organs.

– Active bleeding from the splenic parenchyma can be missed with a noncontrast CT scan.


• Angiography

– rarely the first choice for evaluation of the patient with a splenic injury

– use more frequently for primary therapeutic management of splenic injuries

(angioembolisation)

• after CT scanning images show an arterial contrast blush or active extravasation.


• MRI

– as an option in the patient with renal failure or significant contrast allergy.


• Radioisotope studies

– rarely helpful in this day of rapid, detailed, high-resolution CT scanners.

– These studies should probably be eschewed as a diagnostic option in the trauma patient unless no other confirmatory tests are available.

Other diagnostic Procedure

• Diagnostic peritoneal lavage(DPL)

– MERIT

• fast and inexpensive.

• low complication rate in experienced hands.

• more sensitive or specific than FAST

– Demerit

• Invasive

American Association for the Surgery of Trauma (AAST)Spleen Organ Injury Scale*

(1994 Revision)

GRADE I II III IV V

Subcapsular Hematoma( % of total surface area)

<10% 10-50% >50% or expanding or Ruptured

Capsular laceration (depth)

<1 cm 1-3 cm >3 cm

Intraparencymal Hematoma(Diameter)

<5 cm >5 cm or expanding or Ruptured

Vessels involved in laceration

Notinvolving trabecular

Trabecular Segmental or hilar(>25 % devascularization)

Hilar(Devascularizedshattered )

*used in conjunction with nonoperative assessment (eg, CT scanning, angiography), operative intervention by laparotomy, or postmortem by autopsy

Staging

• CT scanning overestimates the injury by as much as 10%

– However, CT scan findings correlate well with the need for operative intervention.

Management

• Non-operative management of splenic injury (NOMSI)

– Conservative

– Interventional radiology

• Splenic angioembolization

• Operative management

– Splenorraphy

• procedure to preserve spleen done in past, now replaced by NOMSI

– Splenectomy

Why NOMSI?

• Splenic fractures following blunt abdominal trauma are most frequently perpendicular (transverse) on the organ’s long axis

– therefore the risk of segmental vascular damage is quite small(the intersegmental avascular planes)

• Important immunological role of the spleen

– (risk of OPSI)

• Improvement of non-invasive diagnostic methods (especially CT).

Advantages of NOMSI

• lower hospital cost•

• earlier discharge

• avoiding nontherapeutic celiotomies (and their associated cost and morbidity),

• fewer intra-abdominal complications, and

• reduced transfusion rates

_____________________________________________associated with an overall improvement in mortality of these injuries

NOMSI

• 65% of all blunt splenic injuries could be managed nonoperatively with minimal transfusions, morbidity, or

mortality, with a success rate of 98%

EAST 2012 Recommendations

LEVEL 1

• Patients who have diffuse peritonitis or who are hemodynamically unstable(a positive FAST examination result or positive DPL) after blunt abdominal trauma should be taken

urgently for laparotomy.

________________________________________________________________________LEVEL 1: Recommendation is convincingly justifiable based on the available scientific

information alone


LEVEL 2

1. A routine laparotomy is not indicated in the hemodynamically stable patient without peritonitis

presenting with an isolated splenic injury.

_________________________________________________________________________LEVEL 2: Recommendation is reasonably justifiable by available scientific evidence and

strongly supported by expert opinion


LEVEL 2

• 2. Following parameters are NO LONGER contraindications to a trial of nonoperative management in a hemodynamically stable patient

– The severity of splenic injury (as suggested by CT grade or degree of hemoperitoneum),

– neurologic status,(ASOC, head injury)– age >55 – Number of tranfusions– Blush on CT and/or – the presence of associated injuries.

_________________________________________________________________________LEVEL 2: Recommendation is reasonably justifiable by available scientific evidence and



LEVEL 2

3. In the hemodynamically normal blunt abdominal trauma patient without peritonitis, an abdominal CT scan with IV

contrast should be performed to identify and assess the severity of injury to the spleen

__________________________________________________________________________LEVEL 2: Recommendation is reasonably justifiable by available scientific evidence and



LEVEL 2

4. Angiography should be considered for patients with

– AAST grade > III injuries,

– presence of a contrast blush,

– moderate hemoperitoneum, or

– evidence of ongoing splenic bleeding

_____________________________________________________________________________LEVEL 2: Recommendation is reasonably justifiable by available scientific evidence and strongly

supported by expert opinion


LEVEL 2

5. Nonoperative management of splenic injuries should only be considered in an environment that provides

• capabilities for monitoring,

• serial clinical evaluations, and

• an operating room available for urgent laparotomy.

____________________________________________________________________________LEVEL 2: Recommendation is reasonably justifiable by available scientific evidence and



LEVEL 3

1. After blunt splenic injury, clinical factors such as a

– persistent systemic inflammatory response,

– increasing/persistent abdominal pain, or

– an otherwise unexplained drop in hemoglobin

should dictate the frequency of and need for follow-up imaging for a patient with blunt splenic injury.

_______________________________________________________________________The recommendation is supported by available data, but adequate scientific evidence is

lacking


LEVEL 3

2.Contrast blush on CT scan alone is not an absolute indication for an operation or angiographic intervention.

Factors such as • patient age,

• grade of injury, and • presence of hypotension

need to be considered in the clinical management of these patients.

________________________________________________________________________The recommendation is supported by available data, but adequate scientific evidence is

lacking


LEVEL 3

3. Angiography may be used

• either as an adjunct to nonoperative management for patients who are thought to be at high risk for delayed

bleeding

• or as an investigative tool to identify vascular abnormalities such as pseudoaneurysms that pose a

risk for delayed hemorrhage.


lacking


4. Pharmacologic prophylaxis to prevent venous thromboembolism can be used for patients with isolated blunt splenic injuries without

increasing the failure rate of nonoperative management, although the optimal timing of safe initiation has not been determined


lacking

Unanswered Queries

• According to EAST 2012 guidelines, there was not enough literature available to make recommendations regarding the following:

1. Frequency of hemoglobin measurements

2. Frequency of abdominal examinations

3. Intensity and duration of monitoring

4. Is there a true transfusion threshold after which operation or angiography should be considered?

5.Optimal time to reinitiating oral intake

Unanswered Queries

6. The duration and intensity of restricted activity (both in-hospital and after discharge)

7. Optimum length of stay for both the intensive care unit (ICU) and hospital

8. Necessity of repeated imaging

9. Timing of initiating chemical deep venous thrombosis (DVT) prophylaxis after a splenic injury

10. Necessity of postsplenectomy vaccination for patients with severe injuries/or embolized injuries

11. Is there an immunologic deficiency after splenic embolization?

12. What exactly constitutes a ‘‘failure’’ of nonoperative management?

splenic trauma

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