Current Management of Current Management of Splenic TraumaSplenic Trauma

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Historical Milestones2nd-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 Epidemiologic Facts Related to Infections after SplenectomyInfections 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 ……Therefore ……

What is the risk of OPSI after splenectomy?

Best guess is < 1% in adults after trauma (0.02-0.2%)

More frequently rapidly fatal in adults (less meningitis)

Impact of immunization after splenectomy

Diagnostic Modalities Influence Diagnostic Modalities Influence Treatment of Blunt Splenic InjuriesTreatment of Blunt Splenic Injuries

Physical Exam Physical Exam (premodern era) (premodern era)

Physical Exam (modern Physical Exam (modern era)era)

DPLDPL

Computed tomographyComputed tomography

?Ultrasound/CT??Ultrasound/CT?

No specific treatmentNo specific treatment

SplenectomySplenectomy

SplenorrhaphySplenorrhaphy

Nonoperative Nonoperative managementmanagement

??????????

1986 1988 1990 1992 1994 1996 1998 2000 20020

20

40

60

80

100

Per

cent

Dx using CT Dx using US Dx using surgery

1986 1988 1990 1992 1994 1996 1998 2000 2002

14000

16000

18000

20000

22000

24000

Total PTSF patients Patients with splenic injuries

Year

Tot

al P

TS

F P

atie

nts,

#

3

4

5

6

Pat

ient

s w

ith S

plen

ic In

jurie

s,%

Magnitude of Splenic Injury is Magnitude of Splenic Injury is changing over timechanging over time

1986 1988 1990 1992 1994 1996 1998 2000 20020

100

200

300

400

500

600

700

800

900

1000

Nu

mb

er

of P

atie

nts

Year

All Injuries 865.04 865.03 865.02 865.01

Splenic Injury Severity Trends from Splenic Injury Severity Trends from the National Trauma Data Bankthe National Trauma Data Bank

0

1000

2000

3000

4000

5000

# Cases

AIS 2

AIS 3

AIS 4 & 5

Total

Mortality with Moderately Severe Mortality with Moderately Severe Splenic InjuriesSplenic Injuries

1986 1988 1990 1992 1994 1996 1998 2000 20020

5

10

15

20

25

30

35

40M

ort

alit

y, %

Year

All Injuries 865.03 865.02

1986 1988 1990 1992 1994 1996 1998 2000 20020

10

20

Year

Per

cent

40

50

60 MV

C, P

ercent

MVC

Other

Fall

Mechanism of Injury is changing over time

MCC, Assaults, Peds struck were unchanged

Nonoperative treatment is the most Nonoperative treatment is the most common form of management for common form of management for

blunt splenic injuries blunt splenic injuries

More frequent use of CT for diagnosis/triageMore frequent use of CT for diagnosis/triage

More low magnitude splenic injuriesMore low magnitude splenic injuries

Low velocity accidentsLow velocity accidents

Decreased overall number/severity of associated Decreased overall number/severity of associated injuriesinjuries

Delay in Tx

Missed Injuries

Risk of operation

OPSI

Nonoperative Management

Operative Management

Operative vs Nonoperative Tx

Is this splenic injury actively bleeding?(likely to bleed)?

Splenic Injury with extravasation of Splenic Injury with extravasation of contrastcontrast

Minor Blunt Splenic InjuryMinor Blunt Splenic Injury

Moderately Severe Blunt Splenic Moderately Severe Blunt Splenic InjuryInjury

Grade of Splenic InjuryGrade of Splenic InjuryI Hematoma subcapsular, <10%

Laceration < 1cm deep

II Hematoma subcapsular, 10-50%

intraparenchymal, <5 cm

Laceration 1-3 cm deep

III Hematoma >50%, ruptured, >5cm

Laceration >3 cm, + trabecular vessels

IV Laceration segmental or hilar vessel with major devascularization

V Laceration shattered spleen, avulsion

Grade of Splenic Injury Grade of Splenic Injury correlates with success of NOMcorrelates with success of NOM

EAST, J Trauma 2000

Quantity of Hemoperitoneum Quantity of Hemoperitoneum correlates with success of NOMcorrelates with success of NOM

EAST, J Trauma 2000

1 2 310

15

20

25

30

35

40

*p<0.05 vs SNOM#p<0.05 vs FNOM

#****

Failed NOM

Successful NOM

OM

Inju

ry S

ever

ity S

core

Level 1 Level 2

Magnitude of injury correlates with Magnitude of injury correlates with success of nonoperative managementsuccess of nonoperative management

1 2

0

20

40

60

80

@p=.054 vs Age#p<0.05 vs Age

*p<0.05 vs Successful

Unsuccessful Nonop

Successful Nonop

** @,

#

#29.212.3

8.33.6%

of Patients

Age<55 Age>55

Age impacts Nonoperative Management

Blunt splenic injury in adultsBlunt splenic injury in adults

Selection of adults for treatment of blunt splenic Selection of adults for treatment of blunt splenic injuryinjury

– hemodynamic stability statushemodynamic stability status

– severity of injury (ISS)severity of injury (ISS)

– grade of splenic injurygrade of splenic injury

– quantity of hemoperitoneumquantity of hemoperitoneum

– AgeAge

– ? Co-morbidities ?? Co-morbidities ?

0

50

100

150

200#

Pa

tien

ts

Op Success Nonop

Failed Nonop

37%

93.5% 6.5%

ULH Experience 1/2009-6/2010

0

2

4

6

8

10

12

14

Failed Nonop

Success Nonop

Op

Mo

rta

lity,

%15/136

11/216

2/15

EAST 25.9%Smith 23.2%

EAST 4.2%Smith 8.6%

EAST 16.5%Smith 8.2%

Kentucky Pediatric Experience

What should the surgeon do with What should the surgeon do with high grade splenic injuries?high grade splenic injuries?

Proportionately less common injuriesProportionately less common injuries

Some can be managed nonoperatively but which ones?Some can be managed nonoperatively but which ones?

Price associated with failure (morbidity, mortality) is realPrice associated with failure (morbidity, mortality) is real

Problem with using historical controlsProblem with using historical controls

Impact of patients taken directly to the operating roomImpact of patients taken directly to the operating room

Does angiography have an impact?Does angiography have an impact?

Splenic Artery EmbolizationSplenic Artery EmbolizationAngiography 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, Splenic Artery Embolization, cont’dcont’d

Angiographic technique affects splenic vessel recanalization and splenic function

Proximal vs Distal

Coil vs gelfoam/clot

Splenic Artery and Collaterals

Does angiography/embolization Does angiography/embolization improve splenic salvage?improve splenic salvage?

Haan et al, J Trauma 2004Haan et al, J Trauma 2004

Multicenter study, n=155 w/ embolizatonMulticenter study, n=155 w/ embolizaton

Splenic salvage of 87% reportedSplenic salvage of 87% reported

Failure rate of 14%, infarction rate of 27%Failure rate of 14%, infarction rate of 27%

? how many patients had angio without ? how many patients had angio without embolization ?embolization ?

Compared to historical controlsCompared to historical controls

Does angiography/embolization Does angiography/embolization improve splenic salvage?improve splenic salvage?

Dent et al, J Trauma 2004Dent et al, J Trauma 2004Report 168 injuries, 13 patients undergoing Report 168 injuries, 13 patients undergoing

emboembo

Overall nonop success rate of 98%Overall nonop success rate of 98%

Did not stratify by injury gradeDid not stratify by injury grade

Compared to historical controlsCompared to historical controls

38% required repeat angio/embo38% required repeat angio/embo

Does angiography/embolization Does angiography/embolization improve splenic salvage?improve splenic salvage?

Haan et al, J Trauma 2005Haan et al, J Trauma 2005

Protocolized angio/embo (all patients after Protocolized angio/embo (all patients after CT then only grades 3-5 deemed CT then only grades 3-5 deemed stable) (? n=298 ?)stable) (? n=298 ?)

Nonop success rate of 83-87% for grade 3-5Nonop success rate of 83-87% for grade 3-5

Not clear how this compared to no angio ptsNot clear how this compared to no angio pts

Compared to historical controls (8 yr old data)Compared to historical controls (8 yr old data)

UPMC ExperienceUPMC Experience

570 patients with blunt splenic trauma from 2000-570 patients with blunt splenic trauma from 2000-20042004

221 patients - immediate operation (39%)221 patients - immediate operation (39%)

349 patients - attempted nonoperative Tx 349 patients - attempted nonoperative Tx

46 (13%) underwent angio & 28 embolization46 (13%) underwent angio & 28 embolization

Decision of trauma attending (no protocol)Decision of trauma attending (no protocol)

UPMC ExperienceUPMC Experience

2000 2001 2002 2003 20040

10

20

Per

cent

age

unde

rgoi

ng

angi

o

Year

2 3 40

10

20

30

40

*A

ngio

grap

hy, %

Spleen AIS

*

UPMC ExperienceUPMC Experience

UPMC ExperienceUPMC Experience

2 3

0

20

40

60

80

100N

onop

Suc

cess

, %

Spleen AIS

Angio No Angio

2 3-5

Splenic Injury Presenting 3 Days Splenic Injury Presenting 3 Days after Fallafter Fall

Pseudoaneurysm

Delay in Tx

Missed Injuries

Risk of operation

OPSI

Nonoperative Management

Operative Management

Fry 1980

Wiseman 2006

Demetriades 2012

U of L09-10

U of LIsolated Spleen

Abd Abcess 11% 9% 6.2% 5% 0%

Wound Infection 16% 4% 8.2% 1.0% 0%

PancreatitisPanc 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%

Complication Rates after Splenectomy

ConclusionsConclusions

More splenic injuries are being identifiedMore splenic injuries are being identifiedMore frequent use of CTMore frequent use of CTMore minor injuriesMore minor injuriesLow velocity mechanismsLow velocity mechanismsNumber of severe injuries unchangedNumber of severe injuries unchanged

Careful patient selection for nonoperative manage-Careful patient selection for nonoperative manage-ment is essential for severe injuriesment is essential for severe injuries

Morbidity and mortality are increased in Morbidity and mortality are increased in patients that patients that ultimately fail nonoperative Tx compared to patients who do ultimately fail nonoperative Tx compared to patients who do

not fail (?poor selection or failure-induced morbidity?)not fail (?poor selection or failure-induced morbidity?)

ConclusionsConclusions

Role of angiography remains to be definedRole of angiography remains to be definedtriage tool vs selective applicationtriage tool vs selective application

Splenectomy patients do suffer complicationsSplenectomy patients do suffer complicationsRate due to splenectomy itself is lowRate due to splenectomy itself is low

Role of associated injuriesRole of associated injuries

Patients still die of splenic injuriesPatients still die of splenic injuries

stop the hemorrhagestop the hemorrhage

Splenic Function, cont’dSplenic 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 Embolization for Splenic Artery PseudoaneurysmsPseudoaneurysms

Natural History of Splenic Artery Pseudoaneurysm ?

Day of Injury

Natural History of Splenic Artery Pseudoaneurysm ?

Post Injury Day 4

Splenic Artery Embolization, cont’dSplenic Artery Embolization, cont’d

Does embolization impair or preserve splenic function ??

Does embolization increase splenic salvage ??

Does angiography/embolization improve overall outcome ??