Management of Splenic Injury Where on the Pendulum Are We Now? Matthew L Davis, MD FACS Trauma Medical Director Texas A&M University Health Science Center Scott & White Hospital

Background Management of splenic injury has evolved drastically over the last 30 years. When the immunologic function of the spleen was identified in the 70’s, efforts to preserve the spleen were undertaken Pediatric surgeons provided evidence that the best way to preserve the spleen was to not operate on it. (1980’s) Progressive adoption in adult patients (1990’s) Angioembolization introduced in mid-90’s

Background Initial non-operative attempts in adults were met with a 30- 70% failure rate 1-4. With greater experience,better patient selection and advanced imaging, NOM became standard of care for adults in the 90’s with success rates of 85% With the addition of angio-embolization (AE), reported failure rates of NOM dropped to 2% 5

Splenic Anatomy Long axis of spleen runs parallel to the 10th rib. Marginal artery branches close to hilum. Diffuse branches away from hilum. Skandalakis et al., The Surgical Anatomy of the Spleen, Surgical Clinics of North America. 73(4): 747-768. 1993

Splenic Anatomy Skandalakis et al., The Surgical Anatomy of the Spleen, Surgical Clinics of North America. 73(4): 747-768. 1993

American Association for the Surgery of Trauma Splenic Injury Scale (1994 Revision) Moore et al., J of Trauma. 2008; 65: 1007-1011.

Grade I

Grade I

Grade 2

American Association for the Surgery of Trauma Splenic Injury Scale (1994 Revision) Moore et al., J of Trauma. 2008; 65: 1007-1011.

Grade 3 Mark Mccoy 24380669 Ex lap for contrast extravasation, splenectomy

Grade 3

Grade 3 Padilla, Luis 24035883 Repair liver injury, spleen left in situ

American Association for the Surgery of Trauma Splenic Injury Scale (1994 Revision) Moore et al., J of Trauma. 2008; 65: 1007-1011.

Grade 4 Gwendolyn Womack 12683843 Ex lap with splenectomy

Grade 4 Hector Perez 23987191 Obs, HD 7 repeat CT revealed large pseudoaneurysm therefore ex lap

Grade 4 Hector Perez 23987191

American Association for the Surgery of Trauma Splenic Injury Scale (1994 Revision) Moore et al., J of Trauma. 2008; 65: 1007-1011.

Grade 5 Salazar, Mario 24427189 abdominal pain, Ex lap with splenectomy

Grade 5 Atondo, Valeria 14344614 - Ex Lap with Splenectomy, severe brain injury

Grade 5 Lopez, Rafael 23626344 Ex lap with splenectomy, left hospital

Management Decisions Driven by several factors – Stability of the patient Result of diagnostic procedures – ie FAST, CT scan, DPL Availability of interventional angiography In general, hemodynamically unstable patients should be triaged immediately to the operating room after FAST is performed.

Non-Operative Management Hemodynamic Stable HR < 130 SBP > 100 Hemodynamic Correctable < 2L of fluid No ongoing need for fluid bolus No Signs of Peritonitis As many as 85% of splenic injuries qualify Admit to Monitored Beds, 24 hr q6 H/H, serial abdominal exams Areas of debate Age >55 > 2u PRBC Missed Hollow Viscus Injury Neurologic Impairment High Grade Injuries Moore et al., J of Trauma. 2008; 65: 1007-1011. Cocanour et al., J of Trauma. 2000; 48: 606-612. Smith et al., Surgery. 1996; 120: 745-751.

When does NOM fail? The following have been identified as predictors of NOM failure: Higher grade of injury Degree of hemoperitoneum + FAST and ongoing need for transfusion Presence of contrast blush Presence of arteriovenous fistulae Presence of combined liver and splenic injuries Advanced age is not a contraindication

When does NOM fail? NOM failure rates per Grade of Injury: Grade I – 4.8% Grade II – 9.5% Grade III – 19.6% Grade IV – 33.3% Grade V – 75% Peitzman et al., J of Trauma. 2000; 49: 177-189.

East Trial: Multi-institutional Study Results: 39% directly to OR (Mortality 26%) 54% Successful NOM (Mortality 4%) 11% Failed NOM (Mortality 16%) Majority of failures in 1st 24 hours. Retrospective Multi- Institutional Study 1993-1997 27 Institutions N = 6,308 Goal: find predictors of failure Peitzman et al., J of Trauma. 2000; 49: 177-189.

Sclafani et al., J of Trauma. 1995; 39(5): 818-827. First to report on AE as an adjunct to NOM. 172 patients 22 pts (13%) direct to OR 2 Mortalities 150 pts (87%) NOM 87 of 90 NOM no SAE 56 of 60 NOM with SAE 1 Mortality 97% success with NOM Angiography performed on every spleen

Pseudoaneurysm/contrast blush More recent studies have touted the benefits of AE in the setting of contrast extravasation and pseudoaneurysm in patients who are otherwise NOM candidates. With treatment of contrast blush and pseudoaneurysm by AE, Davis et al. showed a decrease in failure rate from 13% to 6%. 8

Memphis Group Previous study had NOM success of 87% with majority of failures being pseudoaneurysm Retrospective, Single Institution 1993-1997 N = 524 34% (n=180) Emergent operation Mortality 17% (n=33) 66% (n=344) NOM All NOM had repeat CT 94% success (n=322) 20 pts had blush and were embolized (6 failures went for splenectomy) 22 pts failed NOM Mortality 20% (n=4) Davis, Fabian, et al., J of Trauma. 1997; 44(6): 1008 - 1015,

Influence of AE on failure rate Haan published a multi-institutional trial looking at 155 patients who were treated with AE.9 Overall splenic salvage rate of 87% 83% of stable Grade IV and V injuries managed successfully. Haan went on to publish a single institution experience with AE which showed splenic salvage rate of 94%; over 80% of GradeIV and V injuries salvaged10

Embolization of Pseudoanuerysm

Utility of Protocol-Driven AE Sabe, et al. examined the influence of a standardized protocol on the management of splenic injuries.11 Grade I,II and III underwent NOM – no AE Indications for initial AE: Grade III with blush, pseudoaneurysm or large degree of hemoperitoneum Grade IV injuries Grade V injuries – managed operatively

Utility of Protocol-Driven AE Use of this protocol achieved a 97% splenic salvage rate in patients undergoing NOM In this review, the use of AE increased success of NOM, decreased mortality and resulted in a shorter LOS

“Selective” Splenic Embolization, Shock Trauma (Maryland) Retrospective, Single Institution 1997-2002 n = 648 Emergent Operation n= 280 HD unstable < 100 SBP Transfusion NOM with Angio (n=368) 168 negative Angio 94% success 132 with SAE 90% success 70 CT only + obs Grade 1 & 2 Repeat CT at 48 – 72hrs 100% success Haan, Scalea,et al., J of Trauma. 2005; 58: 492-498.

Where to coil: main vs selective? Main – reduces bleeding by decreasing pressure head, but may not prevent late pseudoaneurysm persistence or formation and rupture Selective – stops blood flow in polar arteries, but can lead to ischemia/necrosis/abcess formation. Choice should be made based upon expertise and resources available

Complications of NOM/AE Majority of complications include bleeding, infarction, abscess formation and contrast-induced nephropathy Missed associated injury has also been sited as a complication – as high as 3% (4/140) in one series10, but Miller, et al noted a missed injury rate of 0% (0/345) in another12. Haan et al., J of Trauma. 2004; 56: 542-547

Follow-up Despite a Japanese study showing loss of splenic immune function after splenic AE, more recent studies have shown immune competence after embolization. The benefit of mandatory repeat CT scanning prior to discharge has been questioned, but Davis, et al. showed that 74% of pseudoaneurysms were not seen on admission CT8

Follow-up Patients should be watched closely until HGB levels stabilize and then may be discharged home. Fabian, et al. showed a 180-day risk of readmission for splenectomy at 1.4% for persons discharged home – majority of these were within 8 days. 13

Take-Home Frank instability or even transient responders should probably go straight to the OR. Key to NOM is patient selection, bearing in mind the predictors of failure – Grade of injury, degree of hemoperitoneum, presence of blush or pseudoaneurysm. AE can significantly reduce the failure rate in cases undergoing NOM when used as an adjunct to NOM

Take-Home My 2 cents is that, after stability, the degree of hemoperitoneum is likely the most important variable when weighing treatment options. In blunt trauma, the spleen tends to fracture in avascular planes. Thus, even deep parenchymal fractures may have little associate blood loss. The presence of larger amounts of blood signifies a more meaningful injury.

Questions

References 1) Malangoni et al. Management of injury to the spleen in adults. Ann Surg. 1994;200:702-705 2) Mahon et al. Nonoperative management of adult splenic injury due to blunt trauma: a warning. Am J Surg. 1985; 149:716-721 3) Mucha et al. Selective management of blunt splenic trauma. J Trauma. 1986; 26:970-979 4) Nallathambi et al. Nonoperative management versus early operation for blunt splenic trauma in adults. Surg Gynecol Obstet. 1988; 166:252-258 5) Moore et al. Western Trauma Association critical decisions in trauma:Management of adult blunt splenic trauma. J Trauma. 2008; 65: 1007-1011 6) Peitzman et al. Blunt Splenic Injury in Adults: Multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma. 2000; 49:177-189 7) Scalfani, et al. Nonoperative salvage of computer tomography-diagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis. J Trauma. 1995; 39: 818-827 8) Davis et al. Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery aneurysms. J Trauma. 1998; 44:1008-1015

References 9) Haan et al. Splenic embolization revisited: a multicenter review. J Trauma. 2004; 56:542-547 10) Haan et al. Nonoperative management of blunt splenic injury: a 5 year experience. J Trauma. 2005; 58:492-498 11) Sabe et al. The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16 year experience. J Trauma. 2009; 67:565-572 12) Miller et al. Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management. J Trauma. 2002; 53:238- 244 13) Zarzour et al. The real risk of splenectomy after discharge home following nonoperative management of blunt splenic injury. J Trauma. 2009; 66:1531-1538