1. Current Management of Splenic Trauma
No financial disclosures

3. 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

4. Historical Milestones, cont’d
Splenectomy for blunt trauma
Nonoperative Tx associated with mortality of %
Prevalence of “delayed rupture” (15-30%)
Splenorrhaphy, partial splenectomy

5. “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

6. 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

7. 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

8. 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

9. 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
?????

11. Magnitude of Splenic Injury is changing over time

12. Splenic Injury Severity Trends from the National Trauma Data Bank

13. Mortality with Moderately Severe Splenic Injuries

14. Mechanism of Injury is changing over time
MVC
Other
Fall
MCC, Assaults, Peds struck were unchanged

15. 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

16. Nonoperative Management Operative Management
Delay in Tx
Missed Injuries
Risk of operation
OPSI

17. Is this splenic injury actively bleeding?
Operative vs Nonoperative Tx
Is this splenic injury actively bleeding?
(likely to bleed)?

18. Splenic Injury with extravasation of contrast

19. Minor Blunt Splenic Injury

20. Moderately Severe Blunt Splenic Injury

21. 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

22. Grade of Splenic Injury correlates with success of NOM
EAST, J Trauma 2000

23. Quantity of Hemoperitoneum correlates with success of NOM
EAST, J Trauma 2000

24. Magnitude of injury correlates with success of nonoperative management

25. Age impacts Nonoperative Management

26. 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 ?

27. ULH Experience 1/2009-6/2010

28. EAST 25.9%
Smith 23.2%
EAST 4.2%
Smith 8.6%
EAST 16.5%
Smith 8.2%

29. Kentucky Pediatric Experience

30. 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?

31. 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)

32. Splenic Artery Embolization, cont’d
Angiographic technique affects splenic vessel recanalization and splenic function
Proximal vs Distal
Coil vs gelfoam/clot

33. Splenic Artery and Collaterals

34. 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

35. 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

36. 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)

37. 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)

38. UPMC Experience

39. UPMC Experience

40. UPMC Experience

41. Splenic Injury Presenting 3 Days after Fall
Pseudoaneurysm

42. Nonoperative Management Operative Management
Delay in Tx
Missed Injuries
Risk of operation
OPSI

43. 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

44. 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?)

45. 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

48. 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

49. Embolization for Splenic Artery Pseudoaneurysms

50. Natural History of Splenic Artery Pseudoaneurysm ?
Day of Injury

51. Natural History of Splenic Artery Pseudoaneurysm ?
Post Injury Day 4

52. Splenic Artery Embolization, cont’d
Does embolization impair or preserve splenic function ??
Does embolization increase splenic salvage ??
Does angiography/embolization improve overall outcome ??