Traumatic Splenic Injury Research Articles

Spleen autotransplantation. Morphological and functional follow‐up after spleen autotransplantation in mice: A research summary

In 1986, we started the research on spleen surgery aimed at saving the splenic mass after its traumatic injury, with elaboration of special resection and autotransplantation techniques. The researches started on mongrel dogs and were continued on inbred mice and beagle dogs with complex histological, imaging, and laboratory investigations, following-up the function and the regeneration of autotransplanted spleen chips. Performing research on mice provided more immunological methods, such as lymphocyte subsets, immunoglobulin levels, and monitoring the phagocytic functions. Researches showed evidence also on the presence of apoptosis, furthermore, stem cell studies on regeneration and functional restoration of the spleen chips are in progress. Our results contributed to two multidisciplinary guidelines in Hungary: (1) One of them is under preparation and underlines the importance of spleen saving methods after traumatic splenic injury; (2) The second guideline shows that hemorheological changes can be early indicators of the increased sensitivity to postsplenectomy infections.

Nonoperative Management of Traumatic Splenic Injuries: Is There a Role for Proximal Splenic Artery Embolization?

Nonoperative Management of Traumatic Splenic Injuries: Is There a Role for Proximal Splenic Artery Embolization?

Nonoperative Management of Traumatic Splenic Injuries: Is There a Role for Proximal Splenic Artery Embolization?

The objective of our study was to evaluate our experience with transcatheter proximal (i.e., main) splenic artery embolization (TPSAE) in the nonsurgical management of patients with grade III-V splenic injuries, according to the American Association for the Surgery of Trauma (AAST) guidelines, and patients with splenic injuries associated with CT evidence of active contrast extravasation or blush (or cases meeting both criteria). The records of patients with traumatic splenic injuries admitted during a 52-month period were retrospectively reviewed for patient age and sex, mechanism of injury, injury severity score (ISS), RBC transfusion requirements, AAST splenic injury CT grade, presence of active contrast extravasation or blush on CT examination, and amount of hemoperitoneum on CT examination. Demographics, CT findings, transfusion requirements, and outcome were compared using the Student's t test or chi-square test in patients undergoing standard nonoperative management and nonoperative management TPSAE-that is, TPSAE followed by nonoperative management. Of the 79 identified patients with splenic trauma, 67 were managed nonoperatively. Thirty-seven patients (28 men, nine women; mean age, 40 years; mean ISS, 28.8) underwent nonoperative management TPSAE and 30 patients (27 men, three women; mean age, 37 years; mean ISS, 25.1) underwent nonoperative management. Age, sex, and ISS were not significantly different between the two groups. TPSAE was always technically feasible. Splenic injuries were significantly more severe in the nonoperative management TPSAE group than in the nonoperative management group with respect to the mean splenic injury AAST CT grade (3.7 vs 2, respectively; p < 0.0001), active contrast extravasation or blush (38% [14/37] vs 3% [1/30], respectively; p = 0.0005), and hemoperitoneum grade (1.6 vs 0.8, respectively; p = 0.0006). Secondary splenectomy rate was lower in the nonoperative management TPSAE group (2.7% [1/37] vs 10% [3/30]). No procedure-related complications were encountered during early and delayed clinical follow-up. TPSAE is a feasible and safe adjunct to observation in the nonoperative management of severe traumatic splenic injuries. The secondary splenectomy rate using nonoperative management TPSAE (2.7%) is among the lowest reported despite a selection of severe injuries.

Splenectomy After Trauma More Common at General Than Pediatric Centers

Hemodynamically stable children with traumatic splenic injury can be successfully managed nonoperatively more than 90% of the time. To compare splenectomy rates at general hospitals and children’s hospitals, these …

Utilidad de las mallas reabsorbibles en los traumatismos esplénicos

The spleen is not an essential organ for survival but given its important role in immunologic functions its preservation is justified.To analyze our experience with absorbable meshes applied to treat splenic injuries.We performed an ambispective study. From July 1999 to February 2004, 30 patients were treated for traumatic splenic injuries. Ultrasonography and/or spiral computed tomography scanning was carried out for the initial screening evaluation and grading of splenic injuries. The New Injury Severity Score (NISS) was calculated to quantify the severity of trauma. Operative splenic preservation was performed according to established selection criteria. Splenorrhaphy with prosthetic material was accomplished by means of a bag of polyglycolic acid mesh measuring 18 cm yen 23 cm (Dexon mesh) that was hand tailored and wrapped around the entire surface of the spleen.Thirty patients with splenic traumatic injuries were treated. The mean age was 36.2 +/- 16.6 years. Twenty-three patients (76.6%) required splenectomy, nonoperative management was achieved in 1 patient (3.3%), and splenorrhaphy with prosthetic material was carried out in 6 patients (20%). Grade III injuries were present in 13 patients (43.3%), grade IV in 13 patients (43.3%), and grade V in 4 patients (13.3%). The mean NISS was 18.9 +/- 9.1. No significant differences were detected between the two groups (splenectomy or mesh splenorrhaphy) in NISS (p=.53) or grade of splenic injuries (p=.69). Morbidity was related to the presence of multiple injuries (p=.002) and was greater in the group with mesh splenorrhaphy (p=.002); however, there were no septic complications in this group. A positive correlation was observed between the length of hospital stay and NISS (p=.01). The length of hospital stay was also significantly associated with the presence of multiple injuries (p=.005) and with morbidity (p=.0002), but was not associated with the type of surgery carried out (p=.17). No complications were observed during follow-up (median of 28 months) in patients who underwent splenic salvage procedures.Mesh splenorrhaphy is a suitable therapeutic option for patients with severe trauma, grade IV splenic injuries, or delayed rupture of the spleen. Both morbidity and length of hospital stay were associated with the presence of multiple injuries rather than with the type of surgery carried out. The safety, effectiveness and absence of septic complications related to the use of prosthetic material in splenic trauma salvage surgery were notable.

Nonoperative Management of Blunt Splenic Injury: A 5-Year Experience

The purpose of this study was to examine the success rate of nonoperative management of blunt splenic injury in an institution using splenic embolization. We conducted a retrospective review of all patients admitted to a Level I trauma center with blunt splenic injury. Data review included patient demographics, computed tomographic (CT) scan results, management technique, and patient outcomes. A total of 648 patients with blunt splenic injury were admitted, 280 of whom underwent immediate surgical management. Three hundred sixty-eight underwent planned nonoperative management, and 70 patients were treated with observation, serial abdominal examination, and follow-up abdominal CT scanning. All were hemodynamically stable, with a 100% salvage rate. One hundred sixty-six patients had a negative angiogram, with a nonoperative salvage rate of 94%, and 132 patients underwent embolization, with a nonoperative salvage rate of 90%. Overall salvage rates decreased with increasing injury grade; however, over 80% of grade 4 and 5 injuries were successfully managed nonoperatively. The salvage rate was similar for main coil embolization versus selective or combined embolization techniques. Admission abdominal CT scan correlated with splenic salvage rates. Significant hemoperitoneum, extravasation, and pseudoaneurysm had acceptable salvage rates, whereas arteriovenous fistula had a high failure rate, even after embolization. Splenic embolization is a valuable adjunct to splenic salvage in our experience, allowing for the increased use of nonoperative management and higher salvage rates for American Association for the Surgery of Trauma splenic injury grades when compared with prior studies. Main coil embolization has a similar salvage rate when compared with other angiographic techniques. An arteriovenous fistula as a CT finding was predictive of a 40% nonoperative failure rate.

Nonoperative Management of Blunt Splenic Injuries: Factors Influencing Success in Age &lt;55 Years

Historically poor success rates of nonoperative management of splenic injuries in elderly patients have led to recommendations for operative intervention in patients more than 55 years of age. Recent studies are in opposition to earlier recommendations revealing equal success rates of nonoperative management of splenic injuries in all age groups. A retrospective chart review was performed to assess factors related to the successful management of splenic injuries in patients over 55 years of age at a Level I trauma center. Thirty-seven patients over 55 presented with blunt splenic injuries during the 5-year study period. Thirteen patients were taken immediately to the operating room on the basis of clinical findings and/or abdomen/pelvis CT results. Nonoperative management was attempted in 24 patients on the basis of CT findings. Nonoperative management was successful in 15 patients (62.5%) and failed in eight patients (33.3%). Patients who failed nonoperative management had significantly higher American Association for the Surgery of Trauma splenic injury grade and associated pelvic free fluid. There were no deaths related to complications from failed nonoperative management. We conclude that nonoperative management of blunt splenic injuries in patients over 55 may be attempted. Patients with higher-grade injuries and pelvic free fluid are at greater risk for failure. Patients with these two findings must be monitored closely. The physicians caring for elderly patients with high-grade splenic injuries and free fluid in the pelvis must use clinical judgment regarding the need and timing of operative management.

Nonoperative Management of Blunt Splenic and Hepatic Trauma in the Pediatric Population: Significant Differences between Adult and Pediatric Surgeons?

Although operative management was the preferred method of treating blunt abdominal trauma in the past, recent literature and practice recommend a nonsurgical approach to most pediatric splenic and hepatic injuries. The majority of data supporting the safety and efficacy of this nonoperative approach are derived from university trauma programs with a pediatric center where care was managed by pediatric surgeons only. To evaluate the applicability of this approach in a regional trauma center where pediatric patients are managed by pediatric and non-pediatric surgeons we reviewed the experience at a Level II community trauma center. Fifty-four children (16 years of age or less) were admitted between April 1992 and April 1998 after sustaining blunt traumatic splenic and/or hepatic injuries. There were 37 (69%) males and 17 (31%) females; the average age was 11 years (range 4 months to 16 years). Of the 54 patients 34 (63%) sustained splenic injuries, 17 (31%) sustained hepatic injuries, and three (6%) sustained both splenic and hepatic injuries. All of these injuries were diagnosed by CT scan or during laparotomy. The average Injury Severity Score was 14.9 with a range from four to 57. Of the 47 patients initially admitted for nonoperative management one patient failed nonoperative management and required operative intervention. In our study 98 per cent (46 of 47 patients) of pediatric patients were successfully managed nonoperatively. Complications of nonoperative management occurred in two patients. Both developed splenic pseudocysts after splenic injury, which required later operative repair. These data are comparable with those from university trauma programs and confirm that nonoperative management is safe in a community trauma center. The majority of children with blunt splenic and hepatic trauma can be successfully treated without surgery, in a regional trauma center treated by nonpediatric trauma surgeons, if the decision is based on careful initial evaluation, aggressive resuscitation, and close observation of their hemodynamic stability.

Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms.

By using abdominal computed tomographic scans in the evaluation of blunt splenic trauma, we previously identified the presence of vascular blush as a predictor of failure, with a failure of nonoperative management of 13% in that series. This finding led to an alteration in our management scheme, which now includes the aggressive identification and embolization of splenic artery pseudoaneurysms. The medical records of 524 consecutive patients with blunt splenic injury managed over a 4.5-year period were reviewed for the following information: age, Injury Severity Score (ISS), American Association for the Surgery of Trauma splenic injury grade (SIG), method and outcome of management. Of the patients, 66% were male with a mean age of 32 +/- 16, and mean ISS of 25 +/- 13. A total of 180 patients (34%) were managed with urgent operation on admission (81% splenectomy (SIG 4.0), 19% splenorrhaphy (SIG 2.6)). The remaining 344 patients (66%) were hemodynamically stable and underwent computed tomographic scan and planned nonoperative management. Of these patients, 322 patients (94%) were successfully managed nonoperatively (61% of total splenic injuries). In 26 patients (8%), a contrast blush identified on computed tomographic scan was confirmed as a parenchymal pseudoaneurysm on arteriography. Twenty patients (SIG, 2.8) were successfully embolized. In six patients, technical failure precluded embolization; all required splenectomy (SIG, 4.0). A total of 22 patients (6%) failed nonoperative management, including the six with unsuccessful embolization attempts. Sixteen patients (SIG, 3.0) who had no evidence of pseudoaneurysm were explored for a falling hematocrit, hemodynamic instability, or a worsening follow-up computed tomography: 13 patients had splenectomy, and three patients had splenorrhaphy. Aggressive surveillance for and embolization of posttraumatic splenic artery pseudoaneurysms improved the rate of successful nonoperative management of blunt splenic trauma to 61%, with a nonoperative failure rate of only 6%. In comparison with our previous work, this reduction in failure of nonoperative management is a significant improvement (p < 0.03).

Causes of death among patients surviving at least one year following splenectomy

To assess the mortality (mostly long-term sequelae) of patients undergoing splenectomy, we carried out a population-based study in Sweden. Using the unique personal identification number assigned to each Swedish resident, we linked centralized hospitalization records with nationwide mortality data. After initially assessing risks within the first 12 months after splenectomy, we excluded deaths during the first year and computed standardized mortality ratios (SMRs) for 1,297 patients splenectomized for external trauma and 991 surgically treated for nonmalignant conditions of adjacent organs who were alive at 12 months following surgery. The general Swedish population was used as the comparison. Both men and women undergoing splenectomy for external trauma had a 1.6-fold (SMR = 1.6) significantly elevated mortality risk, due mainly to circulatory diseases (particularly thromboembolism), alcoholism, digestive disorders, and external causes. Men also had a 28-fold increased mortality from septicemia and an excess of liver cirrhosis (mostly alcohol-related). Patients of both genders splenectomized for nonmalignant conditions had small but significantly elevated mortality overall (SMR = 1.4 to 1.5) reflecting excess risks for malignancies, diseases of blood-forming organs, external causes, and circulatory, respiratory, and digestive disorders. In addition, men had increased mortality from thromboembolism and pneumonia while women experienced elevated risks from septicemia. The excess mortality resulted from functional postsplenectomy defects (including sepsis and thromboembolism), behaviors increasing risk of traumatic splenic injury (eg, alcoholism), damage to other organs from the external trauma (eg, traumatic injury to the central nervous system/spinal cord), or the same or recurrent nonmalignant conditions for which surgery was performed (eg, gastric and duodenal ulcers).

Blunt splenic trauma in a 9-year-old boy with Glanzmann's thrombasthenia

This is the first reported association of blunt splenic rupture and Glanzmann's thrombasthenia in a 9-year-old boy. Splenic salvage procedures are currently preferred in the treatment of traumatic splenic injuries in children because of the high risk of overwhelming infection after splenectomy. Despite intensive conservative treatment, our patient remained hemodynamically unstable. We performed a total splenectomy due to difficulty in achieving hemostasis. We believe it is necessary to choose appropriate treatment according to the pathophysiology of the bleeding tendency in children with splenic rupture.

Selective nonoperative management of pediatric blunt splenic trauma: Risk for missed associated injuries

The spleen is the most commonly injured organ in children sustaining blunt abdominal trauma. Although accepted in pediatric patients, nonoperative management of blunt splenic trauma in adults remains controversial. A principal concern of advocates of early operation is the possibility of overlooking a second injury. To evaluate this question in a pediatric population, we reviewed the charts of 120 children who had traumatic splenic injuries and were admitted to Children's Hospital Medical Center in Cincinnati between 1982 and 1990. Splenic injuries were documented by computed tomography scans, liver/spleen scintigraphy, or during laparotomy. One hundred twelve patients (93.3%) were initially managed nonoperatively; this regimen failed in 2 patients (1.8%), in whom a late splenectomy was required for bleeding. Of 8 patients (6.7%) for whom emergency surgery was required, 4 underwent splenectomy (2 had major associated injuries), 2 underwent splenorrhaphy, and 2 required no splenic repair. Fifty-nine patients (49.2%) had associated injuries, 22 of which (18.3%) were intraabdominal. In this study, there were no missed injuries and no morbidity or mortality associated with delayed treatment. These data confirm that the majority of children with blunt splenic injury can be successfully treated without surgery, and demonstrate that selective nonoperative management of splenic injuries in children does not increase the risk of missed associated injuries.

Transfusion Significantly Increases the Risk for Infection After Splenic Injury

To determine if splenectomy results in an increased risk for perioperative infection when analyzed against splenic repair and to identify factors associated with perioperative infection, respiratory complication, and admission to the intensive care unit following surgery for splenic trauma. Data were collected retrospectively from hospital records and analyzed using stepwise multiple logistic regression. San Francisco (Calif) General Hospital, an urban level 1 trauma center. All patients (n = 252) undergoing operation for traumatic splenic injury at San Francisco General Hospital from 1984 through 1990. Patients who died within 24 hours of presentation were excluded from the study. Perioperative infection, respiratory complications, and admission to the intensive care unit. Infection rates and the types of organisms yielded in cultures were similar between patients who underwent splenectomy and repair. Gram-negative and gram-positive organisms were found in equal numbers, and in no group did encapsulated organisms predominate. Splenectomy had no independent impact on any of the three outcome measures. Total blood transfusion was found to be the only independently significant variable associated with perioperative infection and respiratory complication. Total blood transfusion of more than 2 U and Injury Severity Score of greater than 25 were independently significantly associated with admission to the intensive care unit. The choice between splenectomy and splenic repair does not affect the risk for perioperative infection following injury, whereas blood transfusion significantly increases the risk for perioperative infection, respiratory complication, and admission to the intensive care unit.

NON-OPERATIVE MANAGEMENT FOR DELAYED RUPTURE OF THE SPLEEN -REPORT OF A CASE-

During the past one decade splenic salvage procedures rather than splenectomy have been increasinglyconsidered the preferred treatment for traumatic splenic injurices. A case of delayed rupture of the spleen, which occurred 12 days after intentional non-operative management for the ruptured spleen due to a trauma, is reported with a review of the literature. A 19-year-old man got a bruise on the abdomen due to a traffic accident. CT and ultrasonography revealed hematoma in the spleen and intraperitoneal bleeding. The patient was diagnosed as splenic rupture and underwent non-operative management by keeping at rest in bed for 11 days. On the 12th day when he was permitted to walk, he suddenly complained of abdominal pain. A delayed rupture of the spleen was diagnosed, and intentional nonoperative management was performed once again. Thereafter, his clinical course was quite uneventful. Forty days after the trauma, he was discharged with two splenic cysts due to the traumatic splenic injury. In selected cases of delayed rupture of the spleen, non-operative management should be also an acceptable alternative.

Non-operative management of blunt splenic trauma: a 10-year experience

There is growing awareness that the majority of traumatic splenic injuries should be managed non-operatively. This review of all traumatic spleen injuries at a large community teaching hospital over a 10-year period (1978–1988) confirms that principle. The study generated selection criteria and principles of non-operative management. Of a total of 91 patients, 23 were initially treated non-operatively. The average age was 27 years and all but two were adults. Splenic injury was confirmed by computed tomography scan in 20 patients (87 per cent) and by liver/spleen scan in three patients (13 per cent). Of the 23 patients, 21 (91 per cent) were successfully treated non-operatively. Of these, 14 had intraparenchymal or subcapsular haematomas and seven had splenic lacerations with haemoperitoneum. Two patients (9 per cent) initially treated non-operatively required splenectomy. Haemodynamically stable adult patients with blunt splenic injuries can be managed non-operatively if monitored in a setting where immediate operative intervention is available. Operative intervention is indicated not only in haemodynamically unstable patients, but also in patients who require more than four units of blood during a 48-h period.

Experience with Selective Operative and Nonoperative Treatment of Splenic Injuries in 193 Patients

During the past decade splenic salvage procedures rather than splenectomy have been considered the preferred treatment for traumatic splenic injuries. Splenic preservation has been most often accomplished by splenorrhaphy and more recently by a controversial nonoperative approach. This report delineates indications, contraindications, and results with splenectomy, splenorrhaphy, and nonoperative treatment based on an 11-year experience (1978 to 1989) in which 193 consecutive adult patients with splenic injuries were treated. One hundred sixty-seven patients (86.5%) underwent urgent operation. Of these, 111 (66%) were treated by splenorrhaphy or partial splenectomy and 56 (34%) were treated by splenectomy. During the last 4 years, 26 additional patients (13.5%) were managed without operation. Patients considered for nonoperative treatment were alert, hemodynamically stable with computed tomographic evidence of isolated grades I to III splenic injuries. Overall 24% of the injuries resulted from penetrating trauma, whereas 76% of the patients sustained blunt injuries. Complications were rare, with two patients in the splenorrhaphy group experiencing re-bleeding (1.8%) and one patient (4%) failing nonoperative treatment. The mortality rate for the entire group was 4%. This report documents that splenorrhaphy can safely be performed in 65% to 75% of splenic injuries. Splenectomy is indicated for more extensive injuries or when patients are hemodynamically unstable in the presence of life-threatening injuries. Nonoperative therapy can be accomplished safely in a small select group (15% to 20%), with a success rate of nearly 90% if strict criteria for selection are met.

A Clinical Analysis of 31 Cases of Splenectomy

The author reviewed 31 cases of splenectomy between January 1975 and June 1984, at the department of surgery, college of medicine, Ewha womans'university. The results of analysis are summerized as follow; 1) The highest incidences of age range were 3rd and 4th decades, and male to female ratio was 1.6:1. 2) The causes of traumatic splenic injury were traffic accident(58.33%), violence (25%) and falling down(16.67%) in order of frequency. 3) The traumatic injury was composed of mutiple injury(58.33%) and single splenic injury (41.67%). The most common associated injury was intraabdominal bleeding(58.33%) and rib fracture was 16.67% as extraabdominal injury. 4) The hematologic findings on admission were as follow; 1. The value of hemoglobin was below 10mg/dl in 66.67%. 2. The hematocrit level was below 35% in 33.33%. 3. The leukocyte count was above 15000/mm3 in 50%. 5) The abdominal paracentesis were performed in 10 cases and 7 cases(70%) showed the positive findings. 6) The time interval between injury and operation was within 8 hours in 8 cases(66.67%). 7) The incidence of postoperative complication was 16.13%, and the rate of wound infection, atelectasis and intestinal obstruction was 0.65% in each. 8) The seasonal distribution suggested that spletic injury was more prevalent in summer(58.33%). 9) The motality was 1 case(3.23%) but this was not associated with traumatic injury.

Fibrin gluing of traumatic and intraoperative splenic injuries

The Journal of Trauma: Injury, Infection, and Critical Care: July 1982 - Volume 22 - Issue 7 - p 601

Traumatic splenic injury: its management in a patient population with a high incidence of associated injury.

Nonoperative management of splenic trauma is receiving increasing support following delineation of the spleen's role in infection. Controversy regarding the proper management of this injury led us to study retrospectively 236 consecutive patients with splenic trauma. Blunt trauma occurred in the majority (161); the remainder suffered penetrating abdominal injury secondary to gunshot or stab wounds. Diagnostic peritoneal lavage was accurate in establishing splenic injury in blunt trauma (no false-positive, but three false-negative findings). Associated intra-abdominal injury occurred in 48% and 92% of patients with blunt and penetrating trauma, respectively. Diagnostic peritoneal lavage is an accurate method for establishing an intra-abdominal injury and the need for abdominal exploration in patients with blunt abdominal trauma. Because of the high rate of associated intra-abdominal injury in splenic trauma, nonoperative management can be expected to result in a disturbing incidence of missed intra-abdominal injury in patients with abnormal peritoneal lavage findings.

Selective angiography in splenic trauma

The increasing use of angiography in patients suspected of having traumatic splenic injury has made possible the identification of minor splenic injuries in patients with equivocal findings. Arteriograms, the clinical course, and the appearance of the spleen at laparotomy were compared in forty-one patients. Six patients thought to have minor injuries on arteriography were successfully treated nonoperatively.