Splenic trauma

This Presentation gives general overview of history of spleen and its trauma, clinical presentation, staging, managaement and OPSI

1. Splenic Rupture/Trauma/Injury (According to Eastern Association for Surgery of Trauma (EAST) 2012 guidelines) Jibran Mohsin Resident, Surgical Unit I SIMS/Services Hospital, Lahore

2. Outline History Etymology Surgical Anatomy Etiology Pathophysiology Types of injuries Associated injuries Clinical Presentation Workup Staging Management OPSI

3. Identification of References of EAST 2012 Recommendations English-language citations between 1996 (the last year of literature used for the previous guideline) and 2010 using the keywords splenic injury and blunt abdominal trauma. The articles were limited to humans, clinical trials, randomized controlled trials, practice guidelines, meta-analyses, and reviews. 223 articles were identified. Case reports and small case series were excluded. The committee chair and members then reviewed the articles for relevance and excluded any reviews and tangential articles. 176 articles were reviewed of which 125 were used to create the nonoperative management of blunt splenic injuries recommendations .

4. History The great ancient Roman physician, surgeon and philosopher Claudius Galen (129-216 AD) described the spleen as “ Plenum mysterii organum ” or “ the organ full of mystery” as he struggled to elucidate its function. The mystery continued for over a millennium, as no one challenged his theory that the spleen functioned to remove the evil humor “black bile” produced by the liver

5. History In 1893, Reigner published the first documented successful splenectomy in the German literature. Operative mortality rates remained high until the 1950s Nonoperative care during this period was predominantly fatal. Prior to the advent of CT scanning, physical examination and diagnostic procedures such as diagnostic peritoneal lavage (DPL) and radioisotope scans were the only diagnostic methods. Minor splenic injury was probably frequently missed while major injury prompting laparotomy for hypotension or physical findings was the norm.

6. History With the widespread availability of computed tomography surgeons began to focus on those needing surgery and those who could be observed safely. Starting with the pediatric population and expanding into the adult population, nonoperative observation became more prevalent for hemodynamically stable patients . Further improvements in CT sensitivity and specificity made vascular extravasation easier to diagnose, and interventional radiology became an integral part of the management of splenic injuries, in some institutions replacing emergency operation as the treatment of choice.

7. Changing Trends in management of Spleen trauma during last century

8. Etymology Ancient Greek ……..σπ λήν  ( splḗn ) idiomatic equivalent of the heart in English, i.e. to be good- spleened means to be good-hearted or compassionate French  " splénétique " refers to a state of pensive sadness or  melancholy*. English employed to characterise the hypochondriacal and hysterical affections during 18 th century In modern English, "to vent one's spleen" means to vent one's anger, e.g. by shouting (BAD TEMPER) ____________________________________________________________________________*derives from Greek " melas kholé " meaning 'black bile', from the belief that an excess of black bile caused depression

9. William Shakespeare , in  Julius Caesar  uses the spleen to describe Cassius' irritable nature Must I observe you? must I stand and crouch Under your testy humour ? By the gods You shall digest the venom of your spleen , Though it do split you; for, from this day forth, I'll use you for my mirth, yea, for my laughter, When you are waspish.

10. Etymology Talmud (central text of rabbinic Judaism) refers to the spleen as the organ of  laughter. In 18 th and 19 th century England, women in bad humor were said to be afflicted by the spleen, or the vapours of the spleen

11. Surgical Anatomy Ovoid/wedge, usually purplish, pulpy mass About size and shape of one’s fist MOST VULNERABLE ABDOMINAL ORGAN Located in left upper quadrant or LHC Protected by lower thoracic cage C ompletely encircled and covered with peritoneum except at hilum

12. 1×3×5×7×9×11 rule Size 1 inch thickness 3 inch wide 5 inch long Weight 7 ounce Related ribs 9-11 (along long axis of 10 th rib)

13. Relations ANTERIOR: Stomach POSTERIOR: Left diaphragm Lung Costodiaphragmatic recess 9-11 ribs INFERIOR: Left colic flexure MEDIAL: Left kidney

14. LIGAMENTS: Gastrosplenic  Short gastric vessels and left gastro- omental vessels Splenorenal ( lienorenal )  splenic vessels and tail of pancreas Phrenicocolic  in contact with lower pole of spleen; at danger during spleenectomy BORDERS: ENDS: SURFACES: Superior(notched) border Posterior end (Medial end) Diaphragmatic Inferior border Anterior end (Anterior border) Visceral Anterior border (anterior end) (3 areas)

15. Blood Supply ORIGIN COURSE END Splenic Artery (blood flow= 300 ml/min) Largest branch of celiac trunk ( OR aorta, SMA) Tortuous course posterior to omental bursa anterior to left kidney along superior border of pancreas bifurcates externally ( in splenorenal ligament), supplying upper and lower poles separately * Splenic Vein Formed by several tributaries that emerge from hilum Joined by IMV Runs posterior to body and tail of pancreas Unites with SMV at 90 posterior to neck of pancreas to form portal vein _____________________________________________________________________ *Lack of anastomsis of arterial vessels  formation of VASCULAR SEGMENTS of spleen: 2 in 84 % spleens and 3 in the others, with relatively avascular planes between them, enabling subtotal splenectomy / splenorraphy

16. Blood Supply Short gastric vessels B ranch from the left gastroepiploic artery. M ay be as short as 1 mm creating a challenge during emergency operative intervention. Notably , the splenic artery and vein may have small branches feeding the body and tail of the pancreas care should be taken in dissecting these vessels away from the splenic hilum.

17. Etiology Blunt Trauma rapid deceleration(motor vehicle crashes) direct blows to the abdomen(domestic violence, or leisure and play activities such as bicycling) Penetrating Trauma Combination of above explosive type injuries warfare and civilian bombing Iatrogenic Post Colonoscopy (66 patients in literature with 4.5 % mortality rate) Spontaneous Rupture Malaria, infectious mononucleosis

18. Pathophysiology Injury is more common and severe in enlarged spleen, i.e. malaria, tropical splenomegaly, infectious mononucleosis. _______________________________________ Larang (blunt metal object) was used to kill by murderers in far east where malaria was endemic leading to splenomegaly which ruptured more easily: with little in the way of external marks being left on body.

19. Types of Injury Splenic Hematoma Subcapsular Intraparenchymal Lacerated wound Clean incised wound Hilar / vascualr injuries

20. Associated Injuries Fracture Left lower ribs (30 %) Left sided hemothorax Left lung and diaphragm injury Left lobe liver injury Tail of pancreas injury Left kidney Left colonic injury Small bowel injury

21. Clinical Presentation Hilar injury Rapid development of shock and deteriorates fast (even death can occur) Other injuries Features of shock (pallor, tachycardia, restlessness, tachypnea, anxiety, hypotension, decreased capillary refill and decreased pulse pressure) P ain, tenderness and abdominal rigidity in LUQ F ree intraperitoneal blood  diffuse abdominal pain, peritoneal irritation, rebound tenderness-  abdominal distension

22. Clinical Presentation Kehr’s sign Clot collected under left diaphragm irritates it and the phrenic nerve( C3, C4) causing referred pain in left shoulder 15 minutes after foot end elevation because the supraclavicular nerves have the same cervical nerves origin as the phrenic nerve, C3 and C4 Ballance’s sign K Hans Kehr ( 1862-1916) German Surgeon Charles Alfred Ballance   ( 1856 – 1936) English  surgeon BALLANCE SIGN Persistent dullness to percussion in the left flank due to coagulated blood shifting dullness to percussion in the right flank due to fluid blood

23. Splenosis Autotransplantation of fragments of splenic tissue within peritoneal cavity following rupture of spleen

24. Clinical Presentation Delayed Presentation Missed splenic injury Delayed Splenic Rupture(DSR)

25. Delayed Splenic Rupture(DSR) Latent period of Baudet (1907) Incidence (Before advent of CT scan 15-33 %; afterwards 1 %) Tends to occur 4-8 days after trauma(days-months) Mortality 5-15 % Œ Potential mechanisms ŒExpanding subcapsular hematoma Œ Clot disruption Pseudocyst rupture Œ Pseudoaneurysm /AV fistula rupture Treatment: splenectomy

26. Workup Hematological investigations Radiological investigations

27. Hematological investigations CBC ( Hb ; Hct )   rarely helpful in the initial workup of the suspected splenic injury . helpful in providing baseline values and, P erformed serially, in diagnosing ongoing blood loss or hemodilution due to volume resuscitation .

28. Radiological Investigations Focused Assessment with Sonography for Trauma (FAST ) routine diagnostic adjunct in the initial assessment of blunt trauma victims BUT lacks the ability to reliably predict which patients require laparotomy . Poor for delineating organ-specific anatomy with any reliability in the emergency setting Physiologic data (hemodynamic state) play a major role in decision making regarding the need for emergent laparotomy versus further diagnostic testing or observation.

29. Huang FAST scoring system

30. Interpretation Score >3 cm Indicates 1 liter or more hemoperitoneum 96 % probability of laparotomy Score < 3 cm 37 % probability of laparotomy

31. SSORTT ( S onographic S coring for O perating R oom T riage in T rauma)

32. SSORTT Scoring System

33. Radiological Investigations Multidetector helical CT scan with IV contrast In the stable patient, CT scanning provides structural evaluation of the spleen and surrounding organs. Active bleeding from the splenic parenchyma can be missed with a noncontrast CT scan.

34. Radiological Investigations Angiography rarely the first choice for evaluation of the patient with a splenic injury use more frequently for primary therapeutic management of splenic injuries ( angioembolisation ) after CT scanning images show an arterial contrast blush or active extravasation.

35. Radiological Investigations MRI as an option in the patient with renal failure or significant contrast allergy.

36. Radiological Investigations Radioisotope studies rarely helpful in this day of rapid, detailed, high-resolution CT scanners. These studies should probably be eschewed as a diagnostic option in the trauma patient unless no other confirmatory tests are available.

37. Other diagnostic Procedure Diagnostic peritoneal lavage(DPL) MERIT fast and inexpensive . l ow complication rate in experienced hands. more sensitive or specific than FAST Demerit Invasive

38. American Association for the Surgery of Trauma (AAST)  Spleen Organ Injury Scale* (1994 Revision) GRADE I II III IV V Subcapsular Hematoma ( % of total surface area) <10% 10-50% >50% or expanding or Ruptured Capsular laceration (depth) <1 cm 1-3 cm >3 cm Intraparencymal Hematoma (Diameter) <5 cm >5 cm or expanding or Ruptured Vessels involved in laceration Not involving trabecular Trabecular Segmental or hilar (>25 % devascularization ) Hilar ( Devascularized shattered )  *used in conjunction with nonoperative assessment ( eg , CT scanning, angiography), operative intervention by laparotomy, or postmortem by autopsy

39. Staging CT scanning overestimates the injury by as much as 10 % However , CT scan findings correlate well with the need for operative intervention.

40. Management Non-operative management of splenic injury (NOMSI) Conservative Interventional radiology Splenic angioembolization Operative management Splenorraphy procedure to preserve spleen done in past, now replaced by NOMSI Splenectomy

41. Why NOMSI? S plenic fractures following blunt abdominal trauma are most frequently perpendicular (transverse) on the organ’s long axis therefore the risk of segmental vascular damage is quite small(the intersegmental avascular planes) I mportant immunological role of the spleen (risk of OPSI) Improvement of non-invasive diagnostic methods (especially CT ).

42. Advantages of NOMSI lower hospital cost earlier discharge avoiding nontherapeutic celiotomies (and their associated cost and morbidity), fewer intra-abdominal complications, and reduced transfusion rates _____________________________________________ associated with an overall improvement in mortality of these injuries

43. NOMSI 65 % of all blunt splenic injuries could be managed nonoperatively with minimal transfusions, morbidity, or mortality, with a success rate of 98%

44. EAST 2012 Recommendations LEVEL 1 Patients who have diffuse peritonitis or who are hemodynamically unstable (a positive FAST examination result or positive DPL ) after blunt abdominal trauma should be taken urgently for laparotomy . ________________________________________________________________________LEVEL 1: Recommendation is convincingly justifiable based on the available scientific information alone

45. EAST 2012 Recommendations LEVEL 2 A routine laparotomy is not indicated in the hemodynamically stable patient without peritonitis presenting with an isolated splenic injury. _________________________________________________________________________LEVEL 2: Recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion

46. EAST 2012 Recommendations LEVEL 2 2 . Following parameters are NO LONGER contraindications to a trial of nonoperative management in a hemodynamically stable patient The severity of splenic injury (as suggested by CT grade or degree of hemoperitoneum ), neurologic status,(ASOC, head injury) age >55 Number of tranfusions Blush on CT and/or the presence of associated injuries. _________________________________________________________________________LEVEL 2: Recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion

47. EAST 2012 Recommendations LEVEL 2 3. In the hemodynamically normal blunt abdominal trauma patient without peritonitis, an abdominal CT scan with IV contrast should be performed to identify and assess the severity of injury to the spleen __________________________________________________________________________LEVEL 2: Recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion

48. EAST 2012 Recommendations LEVEL 2 4 . Angiography should be considered for patients with AAST grade > III injuries, presence of a contrast blush, moderate hemoperitoneum , or evidence of ongoing splenic bleeding _____________________________________________________________________________LEVEL 2: Recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion

49. EAST 2012 Recommendations LEVEL 2 5 . Nonoperative management of splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. ____________________________________________________________________________LEVEL 2: Recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion

50. EAST 2012 Recommendations LEVEL 3 After blunt splenic injury, clinical factors such as a persistent systemic inflammatory response, increasing/persistent abdominal pain, or an otherwise unexplained drop in hemoglobin should dictate the frequency of and need for follow-up imaging for a patient with blunt splenic injury. _______________________________________________________________________ The recommendation is supported by available data, but adequate scientific evidence is lacking

51. EAST 2012 Recommendations LEVEL 3 2.Contrast blush on CT scan alone is not an absolute indication for an operation or angiographic intervention. Factors such as patient age, grade of injury, and presence of hypotension need to be considered in the clinical management of these patients. ________________________________________________________________________ The recommendation is supported by available data, but adequate scientific evidence is lacking

52. EAST 2012 Recommendations LEVEL 3 3. Angiography may be used either as an adjunct to nonoperative management for patients who are thought to be at high risk for delayed bleeding or as an investigative tool to identify vascular abnormalities such as pseudoaneurysms that pose a risk for delayed hemorrhage. _______________________________________________________________________ The recommendation is supported by available data, but adequate scientific evidence is lacking

53. EAST 2012 Recommendations 4. Pharmacologic prophylaxis to prevent venous thromboembolism can be used for patients with isolated blunt splenic injuries without increasing the failure rate of nonoperative management, although the optimal timing of safe initiation has not been determined _______________________________________________________________________ The recommendation is supported by available data, but adequate scientific evidence is lacking

54. Unanswered Queries According to EAST 2012 guidelines, there was not enough literature available to make recommendations regarding the following: 1 . Frequency of hemoglobin measurements 2 . Frequency of abdominal examinations 3 . Intensity and duration of monitoring 4 . Is there a true transfusion threshold after which operation or angiography should be considered? 5.Optimal time to reinitiating oral intake

55. Unanswered Queries 6. The duration and intensity of restricted activity (both in-hospital and after discharge) 7 . Optimum length of stay for both the intensive care unit (ICU) and hospital 8 . Necessity of repeated imaging 9 . Timing of initiating chemical deep venous thrombosis (DVT) prophylaxis after a splenic injury 10 . Necessity of postsplenectomy vaccination for patients with severe injuries/or embolized injuries 11 . Is there an immunologic deficiency after splenic embolization ? 12. What exactly constitutes a ‘‘failure’’ of nonoperative management?