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Current Management of Splenic Trauma
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Historical Milestones
2nd-12th Cent. Seat of emotions; source of laughter, mirth, anger, malice or bad temper, latent malevolence, melancholy, depression, black bile cleanse the blood First splenectomy for disease Partial splenectomy for trauma Total splenectomy for trauma
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Historical Milestones, cont’d
Splenectomy for blunt trauma Nonoperative Tx associated with mortality of % Prevalence of “delayed rupture” (15-30%) Splenorrhaphy, partial splenectomy
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“Injuries of the spleen demand excision of the gland
“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
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Historical Milestones, cont’d
Increased infection in children after splenectomy Overwhelming Post Splenectomy Infection (OPSI) Nonoperative management of spleen (pediatric patients) 1990’s Nonop management in adults
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Epidemiologic Facts Related to Infections 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
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What is the risk of OPSI after splenectomy?
Therefore …… What is the risk of OPSI after splenectomy? Best guess is < 1% in adults after trauma ( %) More frequently rapidly fatal in adults (less meningitis) Impact of immunization after splenectomy
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Diagnostic Modalities Influence Treatment of Blunt Splenic Injuries
Physical Exam (premodern era) Physical Exam (modern era) DPL Computed tomography ?Ultrasound/CT? No specific treatment Splenectomy Splenorrhaphy Nonoperative management ?????
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Magnitude of Splenic Injury is changing over time
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Splenic Injury Severity Trends from the National Trauma Data Bank
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Mortality with Moderately Severe Splenic Injuries
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Mechanism of Injury is changing over time
MVC Other Fall MCC, Assaults, Peds struck were unchanged
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Nonoperative treatment is the most common form of management for blunt splenic injuries
More frequent use of CT for diagnosis/triage More low magnitude splenic injuries Low velocity accidents Decreased overall number/severity of associated injuries
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Nonoperative Management Operative Management
Delay in Tx Missed Injuries Risk of operation OPSI
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Is this splenic injury actively bleeding?
Operative vs Nonoperative Tx Is this splenic injury actively bleeding? (likely to bleed)?
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Splenic Injury with extravasation of contrast
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Minor Blunt Splenic Injury
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Moderately Severe Blunt Splenic Injury
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Grade of Splenic Injury
I 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
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Grade of Splenic Injury correlates with success of NOM
EAST, J Trauma 2000
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Quantity of Hemoperitoneum correlates with success of NOM
EAST, J Trauma 2000
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Magnitude of injury correlates with success of nonoperative management
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Age impacts Nonoperative Management
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Blunt splenic injury in adults
Selection of adults for treatment of blunt splenic injury hemodynamic stability status severity of injury (ISS) grade of splenic injury quantity of hemoperitoneum Age ? Co-morbidities ?
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ULH Experience 1/2009-6/2010
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EAST 25.9% Smith 23.2% EAST 4.2% Smith 8.6% EAST 16.5% Smith 8.2%
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Kentucky Pediatric Experience
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What should the surgeon do with high grade splenic injuries?
Proportionately less common injuries Some can be managed nonoperatively but which ones? Price associated with failure (morbidity, mortality) is real Problem with using historical controls Impact of patients taken directly to the operating room Does angiography have an impact?
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Splenic Artery Embolization
Angiography 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 19 without extravasation on angio 17 with extravasation embolized 8 underwent laparotomy (no angio)
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Splenic Artery Embolization, cont’d
Angiographic technique affects splenic vessel recanalization and splenic function Proximal vs Distal Coil vs gelfoam/clot
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Splenic Artery and Collaterals
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Does angiography/embolization improve splenic salvage?
Haan et al, J Trauma 2004 Multicenter study, n=155 w/ embolizaton Splenic salvage of 87% reported Failure rate of 14%, infarction rate of 27% ? how many patients had angio without embolization ? Compared to historical controls
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Does angiography/embolization improve splenic salvage?
Dent et al, J Trauma 2004 Report 168 injuries, 13 patients undergoing embo Overall nonop success rate of 98% Did not stratify by injury grade Compared to historical controls 38% required repeat angio/embo
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Does angiography/embolization improve splenic salvage?
Haan et al, J Trauma 2005 Protocolized angio/embo (all patients after CT then only grades 3-5 deemed stable) (? n=298 ?) Nonop success rate of 83-87% for grade 3-5 Not clear how this compared to no angio pts Compared to historical controls (8 yr old data)
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UPMC Experience 570 patients with blunt splenic trauma from 2000-2004
221 patients - immediate operation (39%) 349 patients - attempted nonoperative Tx 46 (13%) underwent angio & 28 embolization Decision of trauma attending (no protocol)
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UPMC Experience
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UPMC Experience
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UPMC Experience
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Splenic Injury Presenting 3 Days after Fall
Pseudoaneurysm
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Nonoperative Management Operative Management
Delay in Tx Missed Injuries Risk of operation OPSI
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Complication Rates after Splenectomy
Fry 1980 Wiseman 2006 Demetriades 2012 U of L 09-10 Isolated Spleen Abd Abcess 11% 9% 6.2% 5% 0% Wound Infection 16% 4% 8.2% 1.0% Pancreatitis Panc Fistula 17% ----- Wound Dehis Hemorrhage Pneumonia 33% 30% 14.4% 23% 6% Sepsis/Bacteremia 8% 19% 12.4% 3.0% UTI 12% 2.1% 6.0% DVT/PE
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Conclusions More splenic injuries are being identified
More frequent use of CT More minor injuries Low velocity mechanisms Number of severe injuries unchanged Careful patient selection for nonoperative manage-ment is essential for severe injuries Morbidity and mortality are increased in patients that ultimately fail nonoperative Tx compared to patients who do not fail (?poor selection or failure-induced morbidity?)
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Conclusions Role of angiography remains to be defined
triage tool vs selective application Splenectomy patients do suffer complications Rate due to splenectomy itself is low Role of associated injuries Patients still die of splenic injuries stop the hemorrhage
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Splenic 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
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Embolization for Splenic Artery Pseudoaneurysms
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Natural History of Splenic Artery Pseudoaneurysm ?
Day of Injury
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Natural History of Splenic Artery Pseudoaneurysm ?
Post Injury Day 4
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Splenic Artery Embolization, cont’d
Does embolization impair or preserve splenic function ?? Does embolization increase splenic salvage ?? Does angiography/embolization improve overall outcome ??
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