Traumatic Splenic Injury Research Articles

Randomized clinical trial of ligasure™ versus conventional splenectomy for injured spleen in blunt abdominal trauma

BackgroundSpleen is the most common organ damaged in cases of blunt abdominal trauma and splenectomy and splenorrhaphy are the main surgical procedures that are used in surgical treatment of such cases. In routine open splenectomy cases, after laparotomy, application of sutures in splenic vasculature is the most widely used procedure to cease the bleeding. This clinical trial evaluates the role and benefits of the Ligasure™ system in traumatic splenectomy without using any suture materials and compares the result with conventional method of splenectomy. MethodsAfter making decision for splenectomy secondary to a blunt abdominal trauma, patients in control group (39) underwent splenectomy using conventional method with silk suture ligation of splenic vasculature. In the interventional group (41) a Ligasure™ vascular sealing system was used for ligating of the splenic vein and artery. The results of operation time, volume of intra-operation bleeding and post-operative complications were compared in both groups. ResultsThe mean operation times in control and interventional group were 21 and 12 min respectively (p < 0.05). The average volume of bleeding in control group during open splenectomy was 280 cc, but in the interventional group decreased significantly to 80 ml (p < 0.05) using the Ligasure system. Post-operative complications such as bleeding were non-existent in both groups. ConclusionThe application of Ligasure™ in blunt abdominal trauma for splenectomy not only can decrease the operation time but also can decrease the volume of bleeding during operation without any additional increase in post-operative complications. This method is recommendable in traumatic splenic injuries that require splenectomy in order to control the bleeding as opposed to use of traditional silk sutures.

Delayed splenic vascular injury after nonoperative management of blunt splenic trauma

BackgroundDelayed splenic vascular injury (DSVI) is traditionally considered a rare, often clinically occult, harbinger of splenic rupture in patients with splenic trauma that are managed conservatively. The purpose of our study was to assess the incidence of DSVI and associated features in patients admitted with blunt splenic trauma and managed nonoperatively. Materials and methodsA retrospective analysis was conducted over a 4-y time. Patients admitted with blunt splenic trauma, managed no-operatively and with a follow-up contrast-enhanced computed tomography (CT) scan study during admission were included. The CT scans were reviewed for American Association for the Surgery of Trauma splenic injury score, amount of hemoperitoneum, and presence of DSVI. Logistic regression models were used to investigate the risk factors associated with DSVI. ResultsA total of 100 patients (60 men and 40 women) constituted the study group. Follow-up CT scan demonstrated a 23% incidence of DSVI. Splenic artery angiography validated DSVI in 15% of the total patient population. Most DSVIs were detected only on arterial phase CT scan imaging. The American Association for the Surgery of Trauma splenic injury score (odds ratio = 1.73; P = 0.045) and the amount of hemoperitoneum (odds ratio = 1.90; P = 0.023) on admission CT scan were associated with the development of DSVI on follow-up CT scan. ConclusionsDSVI on follow-up CT scan imaging of patients managed nonoperatively after splenic injury is common and associated with splenic injury score assessed on admission CT scan.

Therapeutic Options in Patients with Traumatic Splenic Injury

Therapeutic Options in Patients with Traumatic Splenic Injury

Splenic Cysts.

Splenic cysts are rare in the United States but more common in regions of the world where Echinococcus is endemic. Cysts are typically classified as true cysts or pseudocysts. True cysts can be parasitic or nonparasitic in origin, whereas most pseudocysts are a result of previous trauma. Recent recognition of features shared by true cysts and pseudocysts suggests the classification system may need to be revised. The prevalence of splenic cysts has increased secondary to the widespread use of abdominal imaging and successful nonoperative management of traumatic splenic injuries. Treatment previously consisted primarily of total splenectomy. However, recognition of the importance of the spleen throughout a patient's life has led to changes in the management of splenic disease. Advances in the testing and preoperative localization of splenic lesions have also led to increased efforts in splenic conservation. [Pediatr Ann. 2016;45(7):e251-e256.].

Temporal changes in hematologic markers after splenectomy, splenic embolization, and observation for trauma.

The spleen is one of the most commonly injured abdominal solid organs during blunt trauma. Modern management of splenic trauma has evolved to include non-operative therapies, including observation and angioembolization to preclude splenectomy in most cases of blunt splenic injury. Despite the shift in management strategies, relatively little is known about the hematologic changes associated with these various modalities. The aim of this study was to determine if there are significant differences in hematologic characteristics over time based on the treatment modality employed following splenic trauma. We hypothesized that alterations seen in hematologic parameters would vary between observation (OBS), embolization (EMB), and splenectomy (SPL) in the setting of splenic injury. An institutional review board-approved, retrospective study of routine hematologic indices examined data between March 2000 and December 2014 at three academic trauma centers. A convenience sample of patients with splenic trauma and admission lengths of stay >96h was selected for inclusion, resulting in a representative sample of each sub-group (OBS, EMB, and SPL). Basic demographics and injury severity data (ISS) were abstracted. Platelet count, red blood cell (RBC) count and RBC indices, and white blood cell (WBC) count with differential were analyzed between the time of admission and a maximum of 1080h (45days) post-injury. Comparisons between OBS, EMB, and SPL groups were then performed using non-parametric statistical testing, with statistical significance set at p<0.05. Data from 130 patients (40 SPL, 40 EMB, and 50 OBS) were analyzed. The median age was 40years, with 67% males. Median ISS was 21.5 (21 for SPL, 19 for EMB, and 22 for OBS, p=n/s) and median Glasgow Coma Scale (GCS) was 15. Median splenic injury grade varied by interventional modality (grade 4 for SPL, 3 for EMB, and 2 for OBS, p<0.05). Inter-group comparisons demonstrated no significant differences in RBC counts. However, mean corpuscular volume (MCV) and RBC distribution width (RDW) were elevated in the SPL and EMB groups (p<0.01). Similarly, EMB and SPL groups had higher platelet counts than the OBS group (p<0.01). In aggregate, WBC counts were highest following SPL, followed by EMB and OBS (p<0.01). Similar trends were noted in neutrophil and monocyte counts (p<0.01), but not in lymphocyte counts (p=n/s). This study describes important trends and patterns among fundamental hematologic parameters following traumatic splenic injuries managed with SPL, EMB, or OBS. As expected, observed WBC counts were highest following SPL, then EMB, and finally OBS. No differences were noted in RBC count between the three groups, but RDW was significantly greater following SPL compared to EMB and OBS. We also found that MCV was highest following OBS, when compared to EMB or SPL. Finally, our data indicate that platelet counts are similarly elevated for both SPL and EMB, when compared to the OBS group. These results provide an important foundation for further research in this still relatively unexplored area.

致死的多発外傷に対しハイブリッド手術室を活用した治療経験(Treatment experience using hybrid operating room for fatal multiple trauma)

要旨我々は，致死的多発外傷に対しハイブリッド手術室を用いて治療し救命に至った1例を経験したので報告する。症例は日常生活の自立した81歳の女性。歩行中に40km/hr程度の軽トラックと衝突し受傷した。当院搬送時は血圧低下，意識障害を呈しておりtrauma pan scanで右急性硬膜下血腫，外傷性胸部大動脈解離，腹腔内出血を伴う脾損傷，extravasationを伴う骨盤骨折などの損傷を認めた。ハイブリッド手術室でinterventional radiology，開頭手術を行う方針とした。手技は胸部大動脈損傷に対するステントグラフト挿入術から開始し，続いて脾損傷及び骨盤骨折に対する塞栓術，開頭血腫除去術を行った。術後は脾臓仮性動脈瘤など合併症の治療を行った後，療養目的に転院となった。ハイブリッド手術室は近年国内外で広く普及しつつあるが，多発外傷の治療についての報告例は少ない。本症例のような止血術，開頭手術を要する致死的損傷を複数有する症例では，患者搬送のリスクや搬送先の判断に悩むことなく外科手術と血管内治療を同一の部屋で実施できるハイブリッド手術室が治療戦略に与える恩恵は非常に大きい。外傷への応用を想定した準備を行うことで，より迅速な治療の開始や手技完遂が期待でき今後の症例蓄積が期待される。

An Overview of Splenic Embolization.

The purpose of this article is to define the role of splenic embolization in trauma patients and in patients presenting for treatment of thrombocytopenia and portal hypertension. This article reviews the indications, technical considerations, outcomes, and complications of splenic artery embolization. Transcatheter splenic artery embolization has a major role in the management of traumatic splenic injuries and as an adjunctive procedure in the treatment of thrombocytopenia and portal hypertension.

The impact of coagulopathy on traumatic splenic injuries

BackgroundPatients with pre-injury coagulopathy have worse outcomes than those without coagulopathy. This article investigated the risk-adjusted effect of pre-injury coagulopathy on outcomes after splenic injuries. MethodsReview of the National Trauma Data Bank from 2007 to 2010 comparing mortality and complications between splenic injury patients with and without a pre-injury bleeding disorder. ResultsOf 58,896 patients, 2% had a bleeding disorder. Coagulopathic patients had higher odds of mortality (odds ratio, 1.3), sepsis (odds ratio, 2.0), acute respiratory distress syndrome (odds ratio, 2.6), acute renal failure (odds ratio, 1.5), cardiac arrest (odds ratio, 1.5), and overall complications (odds ratio, 2.4). The higher odds of myocardial infarction did not achieve statistical significance (odds ratio, 1.6). ConclusionsPre-injury coagulopathy in patients with splenic injury has a negative impact on cardiac arrest, sepsis, acute respiratory distress syndrome, acute renal failure, and mortality. The higher likelihood of myocardial infarction did not reach statistical significance.

Trends in pediatric spleen management: Do hospital type and ownership still matter?

Nonoperative management of traumatic blunt splenic injury is preferred over splenectomy because of improved outcomes and reduced complications. However, variability in treatment is previously reported with respect to hospital profit types and ownership. Our study objectives were to investigate the past decade's trends in pediatric splenic injury management and to determine whether previously reported disparities by hospital type have changed. We analyzed data from the Kid's Inpatient Database from Healthcare Cost and Utility Project for Years 2000, 2003, 2006, and 2009. Multivariable logistic regression was used to investigate the likelihood of receiving splenectomy in different hospital profit and ownership types. Patients 18 years and younger admitted with blunt splenic injury (DRG International Classification of Diseases-9th Rev.-Clinical Modification code 865) were included. Treatment was dichotomized into nonoperative management, defined as initial attempt at nonoperative management, and operative management, defined as splenectomy within 1 day of admission. Of 17,044 patient records, 11,893 participants were studied. Not-for-profit hospitals demonstrated a higher rate of nonoperative management than for-profit hospitals in 2000 (83.8% vs. 71.0 %). Both not-for-profit and for-profit hospitals increased the use of nonoperative management, with a narrower disparity observed by 2009 (87.5% vs. 84.6%). The use of splenectomy was reduced significantly between 2000 and 2003 (odds ratio, 0.66; weighted 95% confidence interval, 0.54-0.81). The rate of nonoperative management in children's hospitals remained very high across the study period (98.6% in 2009) and continued to be the benchmark for pediatric spleen injury management. Improvement was observed in nonoperative management rates for pediatric spleen injuries in both not-for-profit and for-profit hospitals. However, general hospitals still fail to reach the target of 90% nonoperative management. Further investigations are needed to facilitate optimal management of such children in general hospitals. Epidemiologic and prognostic study, level III.

Emergency splenectomy for traumatic splenic injury following colonoscopy

Trauma comes in many forms, and injuries inflicted by medical investigation and treatment should not be forgotten. A 69-year-old man underwent a well-tolerated day case colonoscopy for iron deficiency anaemia; adequate views with no abnormalities were obtained to the ileocaecal valve with intermittent Entonox used for analgesia. Following routine postprocedure observations, the patient was discharged home. The following morning he was admitted via the Emergency Department with severe abdominal pain; on arrival he was peritonitic, tachycardic and hypotensive. After initial fluid resuscitation, a computed tomography (CT) scan was performed to exclude colonic perforation. Instead, it demonstrated a large peri-splenic haematoma and haemoperitoneum (Figure 1). He underwent emergency laparotomy which showed a 2-l haemoperitoneum and a large haematoma surrounding the spleen with near complete capsular avulsion (Figure 2). Standard splenectomy was performed, and all other intraoperative findings were normal, including the splenic flexure of the colon. Postoperative recovery was uncomplicated, and he was discharged on day 14 with pneumococcal antibiotic prophylaxis. Splenic injury is a rare but recognized complication of colonoscopy causing significant morbidity and a mortality rate of approximately 5%. Around 100 cases have been reported and most present with left upper quadrant pain within 24 h of colonoscopy. Neither polypectomy nor previous abdominal surgery has been identified as a risk factor for splenic injury. Figure 1. CT showing peri-splenic haematoma and haemperitoneum. Figure 2. Posterior aspect of spleen illustrating near complete capsular avulsion injury.

Laparoscopic splenctomy in isolated blunt traumatic splenic injury

CONCLUSIONS: Our results support the use of skin grafting and fibrin glue as a successful method of treating enterocutaneous fistulas. VAC use has reduced but not eliminated the need for split-thickness skin grafts or mesh. The use of a dermal matrix and fibrin glue prevents contamination from the enteric fluid from the fistula. Additionally this method prevents the bowel from desiccation and touching surrounding dressings. Our results indicate that the acellular dermal matrix is able to be incorporated into the wound and the fibrin glue secures it and closes the fistula.

Active Hemorrhage and Vascular Injuries in Splenic Trauma: Utility of the Arterial Phase in Multidetector CT

To determine whether the addition of arterial phase computed tomography (CT) to the standard combination of portal venous and delayed phase imaging increases sensitivity in the diagnosis of active hemorrhage and/or contained vascular injuries in patients with splenic trauma. The institutional review board approved this HIPAA-compliant retrospective study; the requirement to obtain informed consent was waived. The study included all patients aged 15 years and older who sustained a splenic injury from blunt or penetrating trauma and who underwent CT in the arterial and portal venous phases of image acquisition during a 74-month period (September 2005 to November 2011). CT scans were reviewed by three radiologists, and a consensus interpretation was made to classify the splenic injuries according to the American Association for the Surgery of Trauma splenic injury scale. One radiologist independently recorded the presence of contained vascular injuries or active hemorrhage and the phase or phases at which these lesions were seen. Clinical outcome was assessed by reviewing medical records. The relationship between imaging findings and clinical management was assessed with the Fisher exact test. One hundred forty-seven patients met the inclusion criteria; 32 patients (22%) had active hemorrhage and 22 (15%) had several contained vascular injuries. In 13 of the 22 patients with contained injuries, the vascular lesion was visualized only at the arterial phase of image acquisition; the other nine contained vascular injuries were seen at all phases. Surgery or embolization was performed in 11 of the 22 patients with contained vascular injury. The arterial phase of image acquisition improves detection of traumatic contained splenic vascular injuries and should be considered to optimize detection of splenic injuries in trauma with CT.

Active Hemorrhage and Vascular Injuries in Splenic Trauma: Utility of the Arterial Phase in Multidetector CT

Purpose To determine whether the addition of arterial phase computed tomography (CT) to the standard combination of portal venous and delayed phase imaging increases sensitivity in the diagnosis of active hemorrhage and/or contained vascular injuries in patients with splenic trauma. Materials and Methods The institutional review board approved this HIPAA-compliant retrospective study; the requirement to obtain informed consent was waived. The study included all patients aged 15 years and older who sustained a splenic injury from blunt or penetrating trauma and who underwent CT in the arterial and portal venous phases of image acquisition during a 74-month period (September 2005 to November 2011). CT scans were reviewed by three radiologists, and a consensus interpretation was made to classify the splenic injuries according to the American Association for the Surgery of Trauma splenic injury scale. One radiologist independently recorded the presence of contained vascular injuries or active hemorrhage and the phase or phases at which these lesions were seen. Clinical outcome was assessed by reviewing medical records. The relationship between imaging findings and clinical management was assessed with the Fisher exact test. Results One hundred forty-seven patients met the inclusion criteria; 32 patients (22%) had active hemorrhage and 22 (15%) had several contained vascular injuries. In 13 of the 22 patients with contained injuries, the vascular lesion was visualized only at the arterial phase of image acquisition; the other nine contained vascular injuries were seen at all phases. Surgery or embolization was performed in 11 of the 22 patients with contained vascular injury. Conclusion The arterial phase of image acquisition improves detection of traumatic contained splenic vascular injuries and should be considered to optimize detection of splenic injuries in trauma with CT. ©RSNA, 2013

Mo2132 Accurate Haemodynamic and Image Based Assessment of Blunt Traumatic Splenic Injury May Identify Those WHO Will Benefit From a Conservative Approach

Mo2132 Accurate Haemodynamic and Image Based Assessment of Blunt Traumatic Splenic Injury May Identify Those WHO Will Benefit From a Conservative Approach

Abstract No. 301 - Distal embolization for blunt traumatic splenic injuries: efficacy and complications

Purpose The role of angiography and embolization for traumatic splenic injuries has been shown, however, the particular techniques of proximal versus distal embolization remain controversial. Based on case reports and series, there is suspected increased risk of focal splenic infarction and/or abscess formation following distal embolization for traumatic splenic injuries, however, there have been no large studies to evaluate the efficacy and complication rates of distal embolization for traumatic splenic injuries. Materials and Methods Retrospective review of traumatic splenic injuries from the trauma registry at a level 1 trauma center was performed for the period between 2005-2011. 23 patients had penetrating splenic injuries and were excluded from the study. 243 patients had documented blunt splenic injuries based on CT imaging, operative findings or autopsy results. Data abstracted included patient demographics, injury severity score (ISS), splenic injury grade, management of splenic injury including surgical, non-surgical, and type of embolization, and outcomes for those cases that underwent angioembolization. Results Of the 243 patients, 30 (12.3%) expired prior to intervention, 55 (22.6%) underwent splenectomy, 2 (0.8%) underwent splenorrhaphy, 25 (10.3%) underwent angioembolization, and 131 (53.9%) had non-operative management. All cases of angioembolization underwent distal embolization using large particles, Gelfoam pledgets, microcoils or a combination of materials. In two cases, there was distal splenic infarction not requiring splenectomy or further intervention. In one additional case, there was focal splenic abscess which was drained percutaneously. There were no cases of rebleeding or major complications requiring delayed splenectomy. Conclusion Distal embolization for blunt traumatic splenic injuries is efficacious with no cases of rebleeding or delayed splenectomy in our series. Distal splenic infarction without clinical significance and focal splenic abscess requiring percutaneous drainage were noted in a minority of cases. However, the overall success rate in our series supports consideration of distal embolization for blunt traumatic splenic injuries.

Traumatic Splenic Injuries in Khartoum, Sudan

Background: Spleen injuries are most commonly associated with blunt abdominal trauma and represent a potentially life-threatening condition. Objectives: To study the pattern of splenic injuries of the patient, management instituted and its outcome at Khartoum. Patients and Methods: This is a prospective, analytic and hospital-based multicenteric study, conducted at the three main Teaching hospitals at Khartoum. The study was carried over a period from April 2012 to February 2013. It includes all patients, diagnosed as traumatic splenic injury. Excluded were patients with history of splenic disease, iatrogenic injury or spontaneous rupture. Results: The study included 47 patients: their mean age was 26.4 years (SD ± 14.5). Most of them 41 (87.2%) were in the first four decades of life. Males were predominant 41 (87.2%), with a male to female ratio of 6.8:1. The majority of our patients had blunt abdominal trauma 39 (83%), of whom, road traffic accident accounted for 51.1% and none reported cases of gunshot. Isolated splenic injury was found in 23 (48.9%), and Haemodynamic stability was seen in 27 (57.4%) on presentation. The initial haemoglobin assessment revealed <9 gram/dl in 53.2%. CT scan was performed to 24 (51.1%), of whom 66 patients were Grade I and II and none of our patients were diagnosed as Grade V. Blood transfusion was required in 42 (89.4%). Operative treatment was adopted in 66% (61.7% total splenectomy and 4.3% splenorrhaphy), while selective non-operative management was successful in 16 (34%) of the patients. Higher intra-operative grade of splenic injury was found to be significantly associated with blunt abdominal trauma, haemodynamic instability and associated intra-abdominal injuries. 44 patients (93.6%) were discharged home in a general good condition. The morbidity and mortality were seen in 8.5% and 6.4% respectively. Conclusion: Splenic injuries usually follow blunt abdominal trauma, particularly after road traffic accidents. It is common during the first four decades of life with males being frequently affected. The great success rate of adopting selective non-operative management is worthwhile.

CT of Splenosis: Patterns and Pitfalls

After traumatic splenic injury or splenectomy, small isolated spleens may develop. These implants are not limited to the left upper quadrant, and splenosis in other locations can mimic other pathologic entities. This pictorial essay presents the range of appearances of intraabdominal and pelvic splenosis. Radiologists can suggest or establish the correct diagnosis of splenosis in the appropriate clinical setting, particularly in less typical cases, to avert unnecessary tissue sampling.

Management of Splenic Injury

Traumatic splenic injury is a potentially life-threatening complication of both blunt and penetrating trauma to the abdomen and thorax. The spleen is susceptible to injury in the presence or absence...

Splenocolonic fistula following non-operative management of splenic rupture

Non-operative management has become the preferred treatment for splenic trauma in the absence of haemodynamic instability. The reported complications of non-operative management of splenic trauma may include pseudoaneurysm formation, delayed splenic rupture and splenic abscess formation. Splenocolonic fistula is a finding that has only previously been described in association with Crohn’s disease, pancreatitis, malignancy and haematological disorders. We present the case of a 16-year-old male who suffered a blunt traumatic injury to the spleen, was haemodynamically stable and successfully managed non-operatively. He represented 1 month later following a single episode of per-rectum bleeding. A CT scan of his abdomen revealed a pseudoaneurysm within the spleen, a splenic abscess and a splenocolonic fistula. He proceeded to emergency laparotomy for splenectomy and colonic resection and had an uneventful recovery. The history of management of blunt traumatic splenic injury is discussed, along with the associated risks of operative and conservative management. Methods predicting the success of non-operative management are explored, along with their application and relevance to this particular case.

Tonsillar carcinoma metastatic to the spleen presenting as trauma: A case report

Cancers of the head and neck rarely metastasize to the spleen. To the best of our knowledge, there is no reported case of a tonsillar carcinoma metastasizing to the spleen. This patient had a splenic capsular rupture likely related to his metastases that presented as a traumatic splenic injury. The patient had received neoadjuvant chemotherapy followed by concurrent chemoradiotherapy. Two months after completion of radiotherapy, he fell out of bed. The next day he had acute abdominal pain and hypotension. CT findings were consistent with splenic rupture, and he underwent splenectomy. Pathologic assessment of the specimen showed metastatic SCC. New splemic lesions in patients with head and neck cancer should be investigated.