Severe Splenic Injuries Research Articles

Delayed Presentation of Splenic Rupture after Colonoscopy

Purpose: A review of delayed presentation of splenic rupture after colonoscopy. Methods: Splenic rupture after a colonoscopy is a rare but potentially fatal complication. Patients typically present with signs of abdominal pain and hemorrhagic shock within minutes to days after the procedure. Results: We present a case of a 59 year-old woman with a past history of Hodgkin's disease and gastric bypass who developed increasing abdominal pain three weeks after a routine colonoscopy and polypectomy. The patient presented with hypotension and underwent aggressive resuscitation with IVF and IV pressors. CT scan demonstrated a large subcapsular hematoma of the spleen. Angiography did not reveal active bleeding. Due to the patient's continued clinical deterioration, she was taken emergently to the operating room for an exploratory laparotomy, which demonstrated a full splenic capsular avulsion and hemorrhage. The patient underwent splenectomy and had an uneventful recovery. Conclusions: Though usually presenting hours to a few days after colonoscopy, severe splenic injury can have an insidious onset weeks from the original insult. This is the most delayed presentation of such an injury after colonoscopy to date.

Trends in Operative Management of Pediatric Splenic Injury in a Regional Trauma System

Selective nonoperative management of pediatric blunt splenic injury became the standard of care in the late 1980s. The extent to which this practice has been adopted in both trauma centers and nontrauma hospitals has been investigated sporadically. Several studies have demonstrated significant variations in practice patterns; however, most published studies capture only a selective population over a relatively short time interval, often without simultaneous adjustment for confounding variables. The objective of this study was to characterize the variation in operative versus nonoperative management of blunt splenic injury in children in nontrauma hospitals and in trauma centers with varying resources for pediatric care within a regionalized trauma system in the past decade. The study population included all children who were younger than 19 years and had a diagnosis of blunt injury to the spleen (International Classification of Diseases code 865.00-865.09) and were admitted to each of the 175 acute care hospitals in Pennsylvania between 1991 and 2000. The proportion of patients who were treated operatively was stratified by trauma-level certification and adjusted for age and splenic injury severity. Multivariable logistic regression models were used to generate probabilities of splenectomy by age, injury severity, and hospital type. From 1991 through 2000 in Pennsylvania, 3245 children sustained blunt splenic injury that required hospitalization; 752 (23.2%) were treated operatively. Generally, as age and splenic injury severity increased, the proportion of patients who were treated operatively increased. Compared with pediatric trauma centers, the relative risk (with associated 95% confidence interval) of splenectomy was 4.4 (3.0-6.3) for level 1 trauma centers with additional qualifications in pediatrics; 6.2 (4.4-8.7) for level 1 trauma centers, 6.3 (5.3-7.4) for level 2 trauma centers, and 5.0 (4.2-5.9) for nontrauma centers. Significant variation in practice pattern was seen among hospital types and over time even after adjustment for age and injury severity. The operative management of splenic injury in children varied significantly by hospital trauma status and over time during the past decade in Pennsylvania. Given the relative benefits of nonoperative treatment for children with blunt splenic injury, these results highlight the need for more widespread and standardized adoption of this treatment, particularly in hospitals without a large volume of pediatric trauma patients.

The significance of contrast blush on computed tomography in children with splenic injuries

Purpose Most children and adults with blunt splenic injuries are treated nonoperatively by well-established management protocols. The “blush sign” is an active pooling of contrast material within or around the spleen seen during intravenous enhanced computed tomography (CT) scan. Adult treatment algorithms often include the “blush sign” as an indication for embolization or surgical intervention. This study was designed to evaluate the implications of the “blush sign” in children with blunt splenic injuries. Methods A review was performed of all children with blunt splenic injuries treated between January 1996 and December 2001 at a level I pediatric trauma center using an established solid organ injury protocol. The demographic, CT imaging, and outcome data were recorded. Treatment was categorized as operative or nonoperative. A single pediatric radiologist retrospectively reviewed all available CT scans to confirm injury grade and the presence or absence of a “blush sign.” Results There were 133 eligible children admitted with blunt splenic trauma, with a mean age of 9.1 years (range, 1 to 15), including 86 children with an abdominal CT available for review. A “blush sign” on initial CT scan was noted in 6 children, all with grade 3 or above splenic injuries, 5 of who were treated nonoperatively. In this series, the single child with a “blush sign” who did not respond to nonoperative treatment had a severe polytrauma requiring urgent splenectomy and left nephrectomy. None of the children died of their splenic injury. Conclusions Although associated with higher grades of injury, the blush sign did not mandate embolization or surgical intervention in children with blunt splenic trauma in this series. Severe splenic injuries with a blush sign on the initial CT scan may be successfully treated nonoperatively when using an established treatment protocol. Management should be based primarily on physiological response to injury rather than the radiologic features of the injury.

Variation in the management of pediatric splenic injuries in New England.

Nonoperative management of stable children with splenic injuries is the standard of care but has been variably applied in New England. The influence of surgeon training on this variation was analyzed. A region-wide administrative data set was queried for children with a splenic injury from 1990 through 1998. The influence of a range of patient- and hospital-specific variables, including surgeon pediatric training, on the risk of operation was analyzed. The risk of operation increased with age, severity of splenic injury, and the presence of multiple injuries, but also trauma center status and the presence of a surgical training program. After allowance for these variables, the risk of operation was reduced by half when children with splenic injuries were cared for by a surgeon with pediatric specialty training. The risk of operation for pediatric splenic injury in New England is dependent on several variables, including the surgeon's training.

Functions of the splenic remnant after subtotal splenectomy for treatment of severe splenic injuries

Background To evaluate the clinical and laboratory characteristics of patients submitted to subtotal splenectomy during the immediate and late postoperative period. Methods The study was conducted on 34 patients, 25 of whom were submitted to subtotal splenectomy (group I), and 9 to total splenectomy without preservation of splenic tissue (group II), and on 22 patients with intact spleens (group III, control). The immediate and late postoperative complications were investigated. Hematological examinations were performed during the late postoperative period (red cell count, hemoglobin, platelets, total and segmented leukocytes, lymphocytes, and Howell-Jolly bodies). Immunoglobulins (IgA, IgM, and IgG) and total T lymphocytes (TTL), active T lymphocytes (ATL), and B lymphocytes were also determined. Splenic scintigraphy with 99mTc colloidal sulfur was performed. Results Groups I and III did not presented abnormal blood bodies and their hematological and immunological pattern were normal. None of the groups showed leukocytosis or thrombocytosis. Howell-Jolly bodies were observed only in group II, which also showed reduced IgM levels. Scintigraphy showed filtering splenic tissue in group I. Conclusions We conclude that subtotal splenectomy is a good surgical alternative for serious distal spleen lesion or when the main splenic pedicle is injured.

Nonoperative management for extensive hepatic and splenic injuries with significant hemoperitoneum in adults.

Although several retrospective studies have been published concerning nonoperative management of minor liver and spleen injuries, few studies have prospectively analyzed the results of nonoperative management for higher-grade liver and spleen injuries. Is it possible to manage extensive hepatic or splenic injuries with hemoperitoneum nonoperatively? The current study was conducted to evaluate the safety of nonoperative management of blunt hepatic and splenic trauma with significant hemoperitoneum in hemodynamically stable patients regardless of injury severity. We used the nonoperative methods prospectively to treat consecutive patients with blunt spleen or liver injury during a 35-month period. Patients with unstable conditions underwent emergency laparotomies, and those who were stable underwent abdominal computed tomography for further evaluation. We analyzed the clinical characteristics and the success rate of this method thoroughly. Twenty-four patients with severe hepatic or splenic injuries treated nonoperatively were included in this study. Among these 24 patients, 18 (75%) with hepatic or splenic injuries had grades of III or greater on the Organ Injury Scale. Twenty patients (83.3%) had moderate to large amounts of hemoperitoneum. Four patients (16.7%) failed at observation and underwent emergency celiotomy, two for liver-related and two for spleen-related causes. There were no differences between the nonoperative and operative management groups in terms of mean age, initial systolic blood pressure, initial heart rate, emergency room fluid requirement except emergency blood transfusion, abdominal complications, and hospital length of stay. We suggest that nonoperative management may be undertaken successfully in appropriately designed areas with close observation for the hemodynamic stable patient.

10 year experience of splenic injury: an increasing place for conservative management after blunt trauma

It has been suggested that over 30 per cent of splenic injuries are suitable for conservative management by non-operative treatment and splenorrhaphy; splenic conservation avoids the risk of overwhelming post-splenectomy infection. In this study, injuries of the spleen have been retrospectively analysed for a 10 year period. In the first 5 years the spleen was conserved in only 6 45 (15 per cent) of patients with blunt injury (three non-operative, three splenorrhaphy). In the second 5 years of the study, the spleen was conserved in significantly more patients with blunt trauma, 25 of 61 (41 per cent). This change has been a result of increased non-operative management which has been successful in the majority of cases ( 20 22 ). This has been associated with the increased use of abdominal ultrasound. The rate of splenorrhaphy has not changed significantly, five patients compared with three in the previous 5 years. Non-operative management may be increasingly appropriate as less severe splenic injuries are being detected with an increased use of ultrasound. Splenic injury is not a mandatory indication for laparatomy; non-operative management of splenic injuries should be considered in selected patients who are haemodynamically stable and can be closely monitored.

Cardiac Injury Complicating Traumatic Asphyxia

During a 3-year period (1986-1989), 8 patients were seen at St. Louis University Medical Center exhibiting the stigmata of traumatic asphyxia. Fewer than 200 cases of traumatic asphyxia have been reported and there is only a single report of a cardiac injury. In this series, 3 of 8 (37.5%) patients were found to have an injury to the heart: two cardiac contusions and a ventricular rupture. Five patients were crushed in motor vehicle collisions, one by an elevator counterweight, and two patients by river barges. Injuries associated with these patients include pulmonary contusion, hemopneumothorax, traumatic pneumatocele, traumatic retinopathy, bone fractures, mental confusion, and liver contusion. There was one death in the series, a patient with rupture of the right ventricle and severe splenic and liver injuries. The cardiac status of the patients was evaluated by serial serum cardiac enzyme determinations, electrocardiograms, and echocardiography. This report illustrates the importance of complete cardiac evaluation in patients with traumatic asphyxia.

Splenic trauma: can CT grading systems enable prediction of successful nonsurgical treatment?

The capability of computed tomographic (CT) grading systems to enable prediction of successful nonsurgical treatment of splenic trauma in children and adults was evaluated. Fifty-six patients with documented splenic injury were examined with CT by use of standard trauma protocols. Each CT scan was graded according to two recently proposed grading systems. The charts of these patients were then reviewed, and correlations between the CT grade and clinical outcome were determined with each grading system. Forty patients underwent successful nonsurgical treatment; three of these patients (8%) underwent delayed celiotomy for splenic rupture after failure of nonsurgical treatment. Two of these three had grades that indicated nonsurgical treatment was viable. In each of these three patients, splenectomy was necessary. In the 16 patients who underwent surgery, eight cases (50%) of CT grading errors were documented with surgery. In four cases, the extent of the injury was underscored with CT, and in another four cases the injury was overscored. It is still not clear whether the severity of splenic injury as defined with CT correlates with clinical outcome.

Absorbable Mesh Splenorrhaphy for Severe Splenic Injuries:

Polyglycolic acid mesh has been introduced as a method of controlling hemorrhage in severely damaged spleens. This study examines the effect of splenic wrapping on the immune function of the spleen, and also on its ability to control splenic bleeding in trauma patients. Thirty purebred beagle dogs were divided into three groups and subjected to sham operation (Group 1), splenectomy (Group 2), and splenic wrap (Group 3). Immunologic studies showed no difference between the wrapped group (Group 3) and those with their spleens intact (Group 1) in the induction of specific antibody-producing lymphocytes in splenic tissue after the injection of attenuated Pneumococci. All splenic injuries treated at Cook County Hospital between January 1985 and May 1988 were retrospectively analyzed. Of 60 patients with splenic injuries, 14 underwent mesh splenorrhaphy without mortality or serious complications. This study demonstrates that the immune function of spleen is preserved following mesh splenorrhapy, and that this technique can be used in a clinical setting with safe and efficacious results.

Absorbable Mesh Splenorrhaphy for Severe Splenic Injuries:

Absorbable Mesh Splenorrhaphy for Severe Splenic Injuries:

Sutureless hemisplenectomy

Splenic salvage following blunt injury can fail when parenchymal bleeding is uncontrollable. To define the usefulness of an argon beam coagulator for hemostasis, we used the instrument in a laboratory trial of partial splenic resection. New Zealand white rabbits, weighing 4 to 5 kg, had sharp excision of the lower half of the spleen. No sutures were used to control hemorrhage from the cut splenic surface or the hilar vessels. Hemostasis was achieved with 2 to 4 seconds of electrocoagulation delivered by a beam of argon gas. All animals survived the procedure and were in good health when killed between the fourth and sixth week following the procedure. At necropsy, the spleen was viable in all animals with no abscess or hematoma. Minimal adhesions from the treated splenic surface to the omentum were found. The scar at the cut surface was 1 mm in depth, and the histology of the remainder of the spleen was normal. In this simulated splenic injury model, argon beam coagulation was uniformly successful in achieving hemostasis. Minimal tissue destruction and lack of infection were noted. The argon beam coagulator may be useful in patients with severe splenic injuries and other situations requiring partial splenectomy.

Trend toward nonoperative management of splenic injuries

Treatment of splenic injuries has evolved over the past decade to reflect more effort to conserve function of the spleen. Records of 169 patients admitted over a 6-year period were identified as documenting the treatment of splenic injuries. We collected data regarding patient age, gender, degree of hemodynamic stability, number of units of blood required, severity of splenic injury, Injury Severity Score, and results of treatment. There were 143 adults (age greater than 16 years) and 26 pediatric patients (age less than 17 years), with mean age in the 2 groups of 31.6 and 11.4 years, respectively. Males comprised 72% of the group, and blunt injury occurred in 154 of the 169 patients. In the adults, splenectomy, splenorrhaphy, laparotomy without operative treatment of the spleen, and nonoperative management were observed 48%, 30%, 14%, and 8% of the time and in the pediatric group 31%, 27%, 19%, and 23% of the time, respectively. By using operative splenic repair techniques and increased use of nonoperative management, the splenic salvage rate has increased in the last 6 years from 41% to 61% without an increase in morbidity and mortality. Incidence of spleen salvage correlated with severity of spleen and overall injury and cardiovascular stability.

Histopathological and ultrastructural changes in liver tissue from burned patients

Histopathological studies were made on samples of liver and spleen tissue taken post mortem from 59 patients with severe burns. Samples from 8 patients were also studied using the transmission electron microscope. The main pathological findings were degeneration and necrosis of hepatic cells and proliferation of Kupffer cells showing active phagocytosis. Their causes in relation to the time of death after burning and severity of injury have been discussed. The proliferation of Kupffer cells may be a compensatory reaction to the severe splenic injury seen in the patients.

Evaluation of Splenorrhaphy

Since April 1977, we have used splenorrhaphy as the procedure of choice for splenic trauma. To evaluate the efficacy of this procedure, we graded splenic injury based upon the extent of splenic repair in 77 patients with blunt abdominal trauma. This grading system is as follows: Grade 1-capsular treatment (five patients); Grade 2-capsular or parenchymal injuries requiring topical hemostatic agents (13 patients); Grade 3-parenchymal injuries requiring suture repair (nine patients); Grade 4-parenchymal injuries requiring partial splenic resection (seven patients); Grade 5-total splenic devascularization or uncontrollable bleeding from the splenic pedicle requiring splenectomy (43 patients). Twenty-nine patients had associated orthopedic injuries, and 42 patients had associated intra-abdominal or thoracic injuries. Mean operative time was 130 +/- 10 minutes. Operative time increased with severity of associated intra-abdominal injuries. Mean operative transfusion requirement was 500 +/- 100 cc of packed red blood cells. Transfusion requirements were not related to the severity of splenic injury. Twenty-three patients developed complications. Pancreatitis occurred in three patients, atelectasis of pneumonitis in eight patients, ten developed wound infections, and two patients required reoperation for small-bowel obstruction. Complication rates were not related to the degree of splenic injury. The grading system described herein provides a framework for sound clinical judgment and comparison of results in the management of splenic injuries.

Splenosis. A disease or a beneficial condition?

Most of the 70 reported cases of splenosis were found at incidental laparotomy months or years after severe splenic injury. Typically, there were multiple reddish implants from 1 to 3 cm in size, widely scattered throughout the peritoneal cavity. The implants lacked a hilum and their capsules lacked muscle and elastic fibers. In most reports there was no proof of function by the implants. Review of the literature failed to support labelling splenosis a disease. Possible beneficial effects of splenosis might include avoidance of the asplenic state with preservation of a normal blood smear and response to infection. Prospective study of cases of splenectomy for trauma is suggested to differentiate between those cases with and without residual splenic tissue.