1. 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

2. 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

3. Background
Initial non-operative attempts in adults were met with a % 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

4. 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):

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

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

7. Grade I

8. Grade I

9. Grade 2

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

11. Grade 3
Mark Mccoy Ex lap for contrast extravasation, splenectomy

12. Grade 3

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

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

15. Grade 4
Gwendolyn Womack Ex lap with splenectomy

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

17. Grade 4
Hector Perez

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

19. Grade 5
Salazar, Mario abdominal pain, Ex lap with splenectomy

20. Grade 5
Atondo, Valeria Ex Lap with Splenectomy, severe brain injury

21. Grade 5
Lopez, Rafael Ex lap with splenectomy, left hospital

22. 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.

23. 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 ; 65: Cocanour et al., J of Trauma ; 48: Smith et al., Surgery ; 120:

24. 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

25. 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 ; 49:

26. 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
27 Institutions
N = 6,308
Goal: find predictors of failure
Peitzman et al., J of Trauma ; 49:

27. 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

28. 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

30. Memphis Group
Previous study had NOM success of 87% with majority of failures being pseudoaneurysm
Retrospective, Single Institution
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): ,

31. 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

32. Embolization of Pseudoanuerysm

33. 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

34. 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

35. “Selective” Splenic Embolization, Shock Trauma (Maryland)
Retrospective, Single Institution
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:

36. 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

37. 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:

38. 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

39. 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

40. 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

41. 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.

43. Questions

44. References
1) Malangoni et al. Management of injury to the spleen in adults. Ann Surg. 1994;200:
2) Mahon et al. Nonoperative management of adult splenic injury due to blunt trauma: a warning. Am J Surg. 1985; 149:
3) Mucha et al. Selective management of blunt splenic trauma. J Trauma. 1986; 26:
4) Nallathambi et al. Nonoperative management versus early operation for blunt splenic trauma in adults. Surg Gynecol Obstet. 1988; 166:
5) Moore et al. Western Trauma Association critical decisions in trauma:Management of adult blunt splenic trauma. J Trauma. 2008; 65:
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:
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:
8) Davis et al. Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery aneurysms. J Trauma. 1998; 44:

45. References
9) Haan et al. Splenic embolization revisited: a multicenter review. J Trauma. 2004; 56:
10) Haan et al. Nonoperative management of blunt splenic injury: a 5 year experience. J Trauma. 2005; 58:
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:
12) Miller et al. Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management. J Trauma. 2002; 53:
13) Zarzour et al. The real risk of splenectomy after discharge home following nonoperative management of blunt splenic injury. J Trauma. 2009; 66: