Delayed presentation of blunt splenic injury

Nonoperative management of solid abdominal organ injuries: From past to present

BACKGROUND AND AIMS

Today, a significant proportion of solid abdominal organ injuries, whether caused by penetrating or blunt trauma, are managed nonoperatively. However, the controversy over operative versus nonoperative management started more than a hundred years ago. The aim of this review is to highlight some of the key past observations and summarize the current knowledge and guidelines in the management of solid abdominal organ injuries.

MATERIALS AND METHODS

A non-systematic search through historical articles and references on the management practices of abdominal injuries was conducted utilizing early printed volumes of major surgical and medical journals from the late 19th century onwards.

RESULTS

Until the late 19th century, the standard treatment of penetrating abdominal injuries was nonoperative. The first article advocating formal laparotomy for abdominal gunshot wounds was published in 1881 by Sims. After World War I, the policy of mandatory laparotomy became standard practice for penetrating abdominal trauma. During the latter half of the 20th century, the concept of selective nonoperative management, initially for anterior abdominal stab wounds and later also gunshot wounds, was adopted by major trauma centers in South Africa, the United States, and little later in Europe. In blunt solid abdominal organ injuries, the evolution from surgery to nonoperative management in hemodynamically stable patients aided by the development of modern imaging techniques was rapid from 1980s onwards.

CONCLUSION

With the help of modern imaging techniques and adjunctive radiological and endoscopic interventions, a major shift from mandatory to selective surgical approach to solid abdominal organ injuries has occurred during the last 30-50 years.

Laparoscopy reduces iatrogenic splenic injuries during colorectal surgery

BACKGROUND

Splenic injury can occur during colorectal surgery especially in cases, where the splenic flexure is mobilized. The aim of this study was to analyze whether the operative approach (laparoscopic vs. open) was associated with an increased risk for splenic injury during colorectal surgery and to compare the outcomes of different management options.

METHODS

All accidental injuries that occurred during colorectal resections performed in our department between January 2010 and June 2013 were identified from an administrative database. All patients with iatrogenic splenic injuries were classified into two groups according to the operative approach. Only procedures that required splenic flexure mobilization were included. Splenic injury management options and outcomes were compared.

RESULTS

There were 2336 colorectal resections (1520 open, 816 laparoscopic) performed during the study period. There were 25 (1.1%) iatrogenic splenic injuries. 23 out of 25 splenic injuries occurred during open colorectal surgery. Overall, 16 (64%) patients were managed with topical hemostatic methods, 5 (20%) with splenectomy, and 4 (16%) with splenorrhaphy. It was possible to salvage the spleen in both laparoscopic patients. The laparoscopic approach was associated with a lower splenic injury rate (0.25% vs. 1.5%, p = 0.005) and a lower need for splenectomy/splenorrhaphy (p = 0.03).

CONCLUSIONS

Our data suggest that laparoscopic colorectal surgery may be associated with a lower risk of iatrogenic splenic injury, and that most splenic injuries can be managed with spleen-preserving approaches.

Facial trauma evaluation leading to a diagnosis of delayed splenic rupture

A patient presented 48 hours after falling and sustaining facial fractures and was evaluated in an outpatient setting. The patient had been seen at 2 other hospitals, including a level I trauma center, and discharged home. While undergoing evaluation for his facial trauma, the patient became severely hypotensive. The patient was diagnosed with a delayed splenic rupture and underwent splenectomy.

Nonsurgical management of delayed splenic rupture after blunt trauma

BACKGROUND

Delayed splenic rupture (DSR) is a rare manifestation of blunt splenic trauma, and splenectomy remains the primary treatment for patients with DSR. The purpose of this study was to review our experience with nonsurgical management of DSR with the use of splenic artery embolization (SAE) as an adjunct treatment.

METHODS

This retrospective study included patients with DSR treated at our institution from January 2001 to December 2008. Management included initial resuscitation and close observation in the intensive care unit. Further interventions were based on the patient's hemodynamic status and followed a treatment protocol. These interventions included SAE or surgery.

RESULTS

There were 15 patients included in the analysis. Three patients underwent emergent surgery, and 12 patients received nonsurgical management initially. Of these 12 patients, five underwent SAE. One of these five patients subsequently underwent splenectomy because of recurrent bleeding. Of the remaining seven patients who received nonoperative management, one required a splenectomy because of recurrent hemorrhage and hypotension. There were no mortalities; however, two surgery-associated complications occurred. The success rate of nonsurgical therapy was 83%. SAE was used for splenic salvage with a success rate of 80% (4 of 5). The overall failure rate of DSR was 33% (5 of 15).

CONCLUSIONS

Nonsurgical management can safely be used in selected patients with DSR, especially for those with a good response to resuscitation. SAE is as effective for DSR as it is for acute splenic injury. Physicians should consider SAE as an option for the treatment of DSR.

A safe surgical technique for the partial resection of the ruptured spleen. A clinical report

A consecutive series of 11 patients with an acute blunt splenic injury were treated with a 'safe resection' technique. 57% of the injured spleens (range 35-100%) were saved. None of the patients had any signs of secondary bleeding in control CT scan and the mortality was zero. No second-look laparotomies were performed. Follow-up time was at least two months (range 2 month-6 yr). Operation time was in average 120 min. Total mean peroperative bleeding was 1400 ml. Partial resection may offer patient a change for normal function of the injured spleen. However, it is not yet known what is the critical mass of spleen tissue needed for humans. The follow-up time of the present study is still too short to estimate this fact, but further studies may show the benefit of the present method in avoiding serious long term immunological complications of splenectomy. This present study introduces a novel technique for partial resection of injured spleen. Operation can be performed safely and quickly with a complication risk comparable to splenectomy. Resection is applicable even for multi-trauma patients.

Traumatic pseudocyst of the spleen

Four patients with pseudocyst of the spleen gave histories of abdominal trauma. In one patient the pseudocyst had ruptured, necessitating emergency splenectomy 34 years after the original injury. In a second patient the pseudocyst was discovered incidentally, and was managed by spleen-preserving excision; and the third and fourth presented with abdominal pain and had splenectomy and spleen-preserving surgery, respectively. All patients with conservatively treated splenic injury are at risk of developing a pseudocyst of the spleen, and the lesion can be detected by computed tomography or ultrasound. When there are no symptoms the natural history is unknown; but if surgery is necessary, splenectomy can sometimes be avoided.

Splenic rupture manifesting two years after diagnosis of injury

The entity of delayed splenic rupture is often challenged. This case report describes a patient who presented with splenic rupture 2 years after a prior splenic injury from blunt trauma. The pathology report confirmed previous splenic injury. Delayed splenic rupture is possible for extended periods following splenic injury managed conservatively.

Patterns of fluid accumulation in splenic trauma: demonstration by CT

Detection of hemoperitoneum in splenic trauma is as important as detection of the visceral injury itself. Observation of a consistent spectrum of fluid accumulation in patients with splenic trauma prompted us to investigate the patterns in more detail. Twenty-three computed tomographic (CT) scans in 20 patients were evaluated with respect to presence of fluid collections in various peritoneal and retroperitoneal compartments. These were correlated with severity of injury and operative and pathologic findings. Hemoperitoneum was detected in the pelvis (65%), paracolic gutters (52%), left subphrenic space (48%), perihepatic space (48%), Morison's pouch (17%) and in the lesser sac (9%). In addition to free fluid, pleural fluid (39%) and retroperitoneal hematoma in the left anterior pararenal space (13%) were also encountered. These ancillary findings may help to substantiate the diagnosis of splenic trauma in equivocal cases, particularly when the spleen itself is obscured by artifacts. Early detection may reduce mortality and morbidity associated with splenic trauma.

Ultrasonography in traumatic splenic rupture

Ultrasound (US) findings and their significance for the clinical outcome were studied in a series of 56 patients hospitalized with a diagnosis of splenic trauma. US was abnormal in 50 cases (89.3%) on admission, revealing intraperitoneal fluid in 41 (73.2%) and a splenic parenchymal injury and/or subcapsular haematoma in 35 (62.5%). US was abnormal in 24/25 patients undergoing urgent surgery, 23/26 undergoing successful non-surgical treatment and 2/5 patients undergoing delayed surgery within 1 to 3 days of a repeat US (abnormal in all five). The presence of intraperitoneal haemorrhage preoperatively was shown accurately by US in 29 cases (96.7%), and the splenic origin of the haemorrhage in 19 (63.3%). Repeat US was of most value for confirming the diagnosis by demonstrating splenic lesions not visible initially. The need for laparotomy could not be predicted on the basis of the US findings alone, however.

Splenic trauma. Choice of management

The modern era for splenic surgery for injury began in 1892 when Riegner reported a splenectomy in a 14-year-old construction worker who fell from a height and presented with abdominal pain, distension, tachycardia, and oliguria. This report set the stage for routine splenectomy, which was performed for all splenic injury in the next two generations. Despite early reports by Pearce and by Morris and Bullock that splenectomy in animals caused impaired defenses against infection, little challenge to routine splenectomy was made until King and Schumacker in 1952 reported a syndrome of "overwhelming postsplenectomy infection" (OPSI). Many studies have since demonstrated the importance of the spleen in preventing infections, particularly from the encapsulated organisms. Overwhelming postsplenectomy infection occurs in about 0.6% of children and 0.3% of adults. Intraoperative splenic salvage has become more popular and can be achieved safely in most patients by delivering the spleen with the pancreas to the incision, carefully repairing the spleen under direct vision, and using the many adjuncts to suture repair, including hemostatic agents and splenic wrapping. Intraoperative splenic salvage is not indicated in patients actively bleeding from other organs or in the presence of alcoholic cirrhosis. The role of splenic replantation in those patients requiring operative splenectomy needs further study but may provide significant long-term splenic function. Although nonoperative splenic salvage was first suggested more than 100 years ago by Billroth, this modality did not become popular in children until the 1960s or in adults until the latter 1980s. Patients with intrasplenic hematomas or with splenic fractures that do not extend to the hilum as judged by computed tomography usually can be observed successfully without operative intervention and without blood transfusion. Nonoperative splenic salvage is less likely with fractures that involve the splenic hilum and with the severely shattered spleen; these patients usually are treated best by early operative intervention. Following splenectomy for injury, polyvalent pneumococcal vaccine decreases the likelihood of OPSI and should be used routinely. The role of prophylactic penicillin is uncertain but the use of antibiotics for minor infectious problems is indicated after splenectomy.

Delayed rupture of the spleen

The concept of delayed splenic rupture is an evolving one. The cases reviewed have led us to reserve the term "delayed splenic rupture" for the situation in which early post-traumatic imaging of the spleen is normal and is followed by the diagnosis of splenic hemorrhage 48 or more hours after the initial insult. Post-traumatic splenic evaluation is indicated when the mechanism of injury is likely to injure the spleen, there is unexplained hypovolemia, or the patient complains of left upper quadrant pain or tenderness. Peritoneal lavage is indicated when hypovolemia is the main manifestation. Radionuclide study is used for screening isolated splenic or hepatic injury when the suspicion is low. Reduced availability of visceral angiogram has resulted in CT scan becoming the main diagnostic modality. When a patient presents with blunt abdominal trauma, awareness of the problem of splenic rupture and active diagnostic approach may help reduce the morbidity and mortality associated with splenic hemorrhage, either immediate or delayed.