Correlation of multidetector CT findings with splenic arteriography and surgery: prospective study in 392 patients

BACKGROUND: To determine the accuracy of contrast-enhanced multidetector CT (MDCT) in demonstrating splenic vascular injury based on results of splenic angiography and operation. STUDY DESIGN: This institutional review board-approved study included 392 hemodynamically stable blunt trauma patients whose admission MDCTs demonstrated splenic injury. Images were assessed for parenchymal injury grade, hemoperitoneum volume, and evidence of bleeding and nonbleeding splenic vascular injury. Splenic arteriography was performed for high splenic injury grade and splenic vascular injury. Medical records were reviewed to determine arteriographic interpretation, surgery indications and findings, outcomes, and demographics. Sensitivity, specificity, predictive values, and accuracy of MDCT in detecting vascular injury were calculated based on results of arteriography and operation. RESULTS: Splenic vascular injury was seen in 22% of patients (86 of 392) on MDCT. Presence of a vascular injury correlated with the CT-based parenchymal splenic injury grade (p < 0.0001). Active splenic bleeding was associated with subsequent clinical deterioration (p < 0.0001). Overall, MDCT had a sensitivity of 76% (76 of 100); specificity of 90% (95 of 106); negative and positive predictive values of 80% (95 of 119) and 87% (76 of 87), respectively; and accuracy of 83% (171 of 206) in detecting vascular injury compared with reference standards. The success rate of nonoperative management was 96%. CONCLUSIONS: MDCT provides valuable information to direct initial clinical management of patients with blunt splenic trauma by demonstrating both active bleeding and nonbleeding vascular injuries. Not all vascular injuries are detected on MDCT, and splenic angiography is still indicated for high-grade parenchymal injury.     

The use of absorbable mesh in splenic trauma

Previous reports from this hospital documented a splenic preservation rate of 50% (18/36) in adults after blunt and penetrating trauma. Recently (January through December 1984), use of an absorbable mesh helped to attain a 67% (22/33) salvage rate. The mesh is applied in such a fashion that it acts by tamponade. It proved useful in patients with bleeding from a large surface area or from deep parenchymal injuries, even those extending into the hilum. No deaths occurred in the splenic salvage patients. There was no difference in postoperative complications among the splenectomy, conventional splenorraphy, or mesh wrap splenorraphy groups. However, workup of persistent postoperative fevers in two splenic wrap patients revealed perisplenic fluid collections on CT scan. Aspiration yielded sterile fluid. Possible cause and effect relationship is being studied in the dog lab. We conclude that splenic wrapping is both a safe and efficacious method of splenic preservation.     

Nonoperative treatment of adult splenic trauma: development of a computed tomographic scoring system that detects appropriate candidates for expectant management

We reviewed the charts of 87 patients with documented splenic injuries resulting from blunt trauma admitted to a regional trauma referral center during the 32-month period beginning in January 1984. Delayed celiotomy was defined as surgical intervention for splenic injury after a trail of nonoperative management lasting at least 24 hours. Delayed celiotomy was not required in any of the 16 cases in the pediatric age group (age less than or equal to 17 years) who were initially managed nonoperatively. In contrast, of the 27 adults who were initially treated nonoperatively, ten (37%) ultimately required celiotomy. Although splenorrhaphy was successfully performed in 21 of 44 patients undergoing early operation, all ten of the patients requiring celiotomy after an unsuccessful trial of observation underwent splenectomy rather than a spleen-preserving procedure. Of the 27 adults who were initially managed nonoperatively, 24 had abdominal computed tomography (CT) performed during their initial diagnostic evaluation. Twenty-three of these scans were reviewed by one of the authors. A CT scoring system was developed, based on the degree of splenic parenchymal and capsular injury and the amount of fluid in the abdomen and the pelvis. Adult patients who were successfully treated without operation had a significantly (p = 0.011) lower total CT score than did patients who required delayed celiotomy. No adult with a total CT score less than 2.5 required delayed operative intervention. These data support     

Admission angiography for blunt splenic injury: advantages and pitfalls.

BACKGROUND: To analyze the use of admission angiography as a nonoperative adjunct for management of blunt splenic injury. METHODS: Retrospective chart review of all blunt splenic injuries to a Level I trauma center from March 1997 through July 1999. RESULTS: One hundred twenty-six patients underwent angiography for splenic injury. Eighty-six patients (68%) had a negative angiogram and were treated expectantly. Of these, seven patients (8%) required laparotomy, with a splenic salvage rate of 92%. Embolization was performed on 40 patients (32%) for evidence of vascular injury. Of these, three patients (8%) required laparotomy, for a total salvage of 92%. Repeat angiography was performed for suspicion of bleeding in 12 patients (10%), with 50% requiring embolization. Outcome based on CT grade demonstrated an average grade of 2.9, with a salvage rate of greater than 70% for grade IV and V injuries. CONCLUSION: Vascular injury increases with splenic injury grade. Embolization improves nonoperative salvage rates to 92%, even with high-grade injuries. Ten percent of patients require additional therapy including "second-look" angiography. A significant portion of patients with negative screening angiograms (10%) required either embolization or laparotomy to control delayed hemorrhage.     

Techniques of splenic preservation using fibrin glue

Fibrin glue (FG) was used to achieve hemostasis of 16 splenic injuries in 14 patients. The etiologies of injury included five gunshot wounds, two stab wounds, four iatrogenic injuries, and five patients with blunt splenic trauma. The intraoperative blood loss averaged 1.8 +/- 2.4 (SD) liters and patients were transfused 3 +/- 2 units of blood perioperatively. The amount of FG required to achieve splenic hemostasis averaged 11 +/- 8 ml and varied directly with the grade of injury. One patient with a splenic hilar vascular injury (Grade V) underwent splenectomy following failure to achieve complete hemostasis despite the use of 25 ml of FG. All other splenic injuries were successfully managed using less than 25 ml of FG. Postoperative computerized tomographic (CT) scanning, performed in ten patients, was negative for rebleeding or abscess formation. The overall splenic salvage rate was 86%. FG was effective in achieving hemostasis of both superficial and deep splenic injuries. Its use as an adjunct in trauma surgery should result in increased splenic salvage rates compared with that obtained using conventional surgical techniques.     

Subcapsular hematoma as a predictor of delayed splenic rupture.

Over the past 46 months at a level I trauma center, 966 computed tomography (CT) scans were performed for blunt abdominal trauma. Eighty-three (8.6%) demonstrated splenic injury, and 31 (3.2%) of these showed a subcapsular hematoma with or without associated parenchymal damage. Of the 31 patients, 23 were managed conservatively, based initially upon surgeons' preference (14 patients) and after March 1990 to conform to the authors' splenic trauma protocol (nine patients). The eight patients operated upon were hemodynamically stable and all underwent splenectomy. Subcapsular hematoma, as diagnosed by preoperative CT scan, was confirmed in each of the eight celiotomies. Parenchymal involvement, which had also been identified in these eight patients by CT, was evident at operation in all, and hilar involvement occurred in three. None of the 23 observed patients developed delayed splenic rupture. All were discharged home with outpatient follow-up in surgical clinic to at least 1 month without further complication. The authors came to the following conclusions: 1) Subcapsular hematoma is neither a predictor for delayed splenic rupture, nor by itself an indication for operative management of the injured spleen in the hemodynamically stable patient; 2) Degree of parenchymal injury based on CT morphology, specifically hilar involvement, signifies the need for laparotomy with splenectomy; 3) Splenorrhaphy has a reduced role in splenic trauma because most injuries now operated upon are severe.     

Computed tomography and nonoperative treatment for blunt abdominal trauma

Studies were undertaken to determine if computed tomography (CT) could reliably assist physical examination in the initial assessment of blunt abdominal trauma, and also to examine how various abdominal injuries were managed with the guidance of CT. A total of 255 patients underwent emergency abdominal CT following blunt abdominal trauma over a period of seven years. One hundred and fifty two patients had abnormal CT scans, including 58 hepatic, 36 renal, 25 splenic and 9 pancreatic injuries as well as 67 patients with intra-abdominal hemorrhage and 21 patients with free abdominal air. A comparative study on the detection of pneumoperitoneum revealed CT to be far superior to plain radiography. One hundred and three patients had normal CT scans, all of whom were managed nonoperatively, except for three false-negative cases and two nontherapeutic cases. The patients with injury to the parenchymal organs were given nonoperative treatment if they had stable vital signs and no evidence of associated injuries demanding immediate surgery and the majority of these patients were managed well nonoperatively. CT was thus found to be a useful adjunct in the management of victims of blunt abdominal trauma, since in a rapid and noninvasive fashion, CT accurately defined the extent of parenchymal organ injury and also disclosed any other abdominal injuries.     

Computed tomography and nonoperative treatment for blunt abdominal trauma

Studies were undertaken to determine if computed tomography (CT) could reliably assist physical examination in the initial assessment of blunt abdominal trauma, and also to examine how various abdominal injuries were managed with the guidance of CT. A total of 255 patients underwent emergency abdominal CT following blunt abdominal trauma over a period of seven years. One hundred and fifty two patients had abnormal CT scans, including 58 hepatic, 36 renal, 25 splenic and 9 pancreatic injuries as well as 67 patients with intra-abdominal hemorrhage and 21 patients with free abdominal air. A comparative study on the detection of pneumoperitoneum revealed CT to be far superior to plain radiography. One hundred and three patients had normal CT scans, all of whom were managed nonoperatively, except for three false-negative cases and two nontherapeutic cases. The patients with injury to the parenchymal organs were given nonoperative treatment if they had stable vital signs and no evidence of associated injuries demanding immediate surgery and the majority of these patients were managed well nonoperatively. CT was thus found to be a useful adjunct in the management of victims of blunt abdominal trauma, since in a rapid and noninvasive fashion, CT accurately defined the extent of parenchymal organ injury and also disclosed any other abdominal injuries.     

Nonoperative management of blunt splenic injury: a 5-year experience

OBJECTIVES: The purpose of this study was to examine the success rate of nonoperative management of blunt splenic injury in an institution using splenic embolization. METHODS: 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. RESULTS: 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. CONCLUSION: 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.     

Rapid technique for splenectomy

The spleen is the most commonly injured organ in blunt trauma of the abdomen. In the haemodynamically unstable patient bleeding from a splenic injury, rapid control of the splenic hilum can be a technically demanding operation. We describe a technique which allows for rapid control of the splenic hilum and unhurried ligation of splenic vessels. This technique has been used on 30 patients without any complications related to splenectomy. It is most helpful when one is working with an inexperienced assistant.     

Factors affecting the outcome of patients with splenic trauma

This is a report of 546 consecutive patients with penetrating and blunt splenic trauma seen over a 17 1/2-year period (1980-1997). The etiology of the splenic injuries and the associated mortality rates were: blunt injuries 45 of 298 (15%), gunshot wounds 48 of 199 (24%), and stab wounds four of 49 (8%). The overall mortality rate was 97 of 546 (18%). The most significant risk factors for death were all associated with major blood loss: transfusion requirements > or = 6 units of blood, low initial operating room blood pressure, associated abdominal vascular injuries, and performance of a thoracotomy. The two most important organs injured in conjunction with the spleen that were significant predictors of postoperative infectious complications were colon and pancreas. The need for splenectomy was most significantly correlated with higher grades of splenic injury especially grades IV and V. The evolution in management of blunt splenic trauma has led to a significant improvement in splenic preservation and avoidance of laparotomy for many patients. Operative splenic salvage is reduced in patients subjected to laparotomy who are candidates for nonoperative treatment. Improved results with splenic injury should be obtained by rapid control of bleeding. This may require more liberal criterial in selecting patients with splenic trauma for early operative treatment.     

Twenty Years of Splenic Preservation in Trauma: Lower Early Infection Rate Than in Splenectomy

BACKGROUND: Retrospective studies concerning the operative preservation and nonoperative management of splenic injuries in patients with splenic trauma have been published; however, few studies have analyzed prospectively the results and early complication rates of a defined management in splenic injury. METHODS: From 1986 to 2006, adult patients with blunt splenic injuries were evaluated prospectively with the intent of splenic preservation. Hemodynamically unstable patients underwent laparotomy. Stable patients were treated conservatively regardless of the grade of splenic injury determined by ultrasound and/or CT scan. RESULTS: During a 20-year period, 155 patients were prospectively evaluated. In 98 patients (63%), the spleen could be preserved by nonoperative (64 patients, 65%) or operative (34 patients, 35%) treatment and 57 patients (37%) needed splenectomy. There were no differences in age, sex, or trauma score between the groups, but a higher early infection rate in patients with splenectomy compared with patients with splenic preservation (p < 0.005) was observed, even if the patients were matched with respect to multiple trauma using the Injury Severity Score (p < 0.01). CONCLUSIONS: Splenic preservation in patients with blunt splenic injury by operative or nonoperative treatment leads to lower early infection rates in adults and, therefore, should be advocated.     

Contusions of the liver in adults. Initial non-operative management with computerized tomography follow-up is a reasonable therapeutic option. Report of 16 cases

Nonoperative management of blunt liver injury in adults still remains controversial. From February 1985 through September 1989, 27 patients were treated for blunt hepatic trauma: 11 required immediate operation and 16 (59%) were initially managed nonoperatively after evaluation of intraabdominal injury by computerized tomography. All of these 16 patients were hemodynamically stable and had no significant peritoneal signs. CT criteria for nonoperative management included subcapsular and intrahepatic hematoma, capsular tear or unilobar fracture, absence of large hemoperitoneum, absence of large devitalized liver and absence of other intraabdominal organ injuries. Clinical follow-up, repeated radiologic examinations and surgery confirmed the accuracy of CT. Only 2 patients required delayed operation (12.5%). Serial abdominal CT studies are an integral part of the conservative treatment of blunt hepatic injuries and showed complete resolution of hepatic injuries in the fourteen nonoperated patients in less than six months. No death and no delayed septic or biliary complications were noted. Mean hospital stay was seventeen days for all of the patients (multiple injuries or not) and only ten days for isolated blunt liver injury. These good results depend on identification of candidates for nonoperative management on strict clinical and CT criteria. Nonoperative management of adult blunt liver injury based on these findings is a useful alternative in a selected group of hemodynamically stable patients and decreases the rate of non-therapeutic coeliotomy.     

AAST organ injury scale: correlation of CT-graded liver injuries and operative findings

The Organ Injury Scaling Committee of the AAST recently published a consensus classification of splenic, hepatic, and renal injuries (J Trauma, 29:1664, 1989). The hepatic injury scale (HIS), based on parenchymal laceration and intrahepatic hematoma, includes grades 1 to 6, representing the least to most severe injury. This study classifies liver injuries by findings at celiotomy, correlates operative findings with transfusion requirements and method of management of liver injury, and relates preoperative CT to anatomic findings at laparotomy. Thirty-seven patients with blunt liver injury were evaluated by abdominal CT with and without intravenous contrast and then underwent celiotomy. Increasing operative HIS correlated well with increasing severity of injury as measured by transfusions and operative management. Thirty-one CT grades did not correlate with operative findings (84%). Four patients had intrahepatic hematomas that were not discovered at operation. Twelve lacerations were graded too high by CT and 15 too low. Of these 15, ten CT scores were at least two grades lower than operative findings. Injuries around the falciform ligament occurred in three of the low misclassifications. One patient with intrahepatic hematoma developed hepatic artery pseudoaneurysm. We conclude that the HIS readily characterizes operative findings of hepatic lacerations and that increasing operative grade correlates well with transfusion requirements and operative management. CT can define intrahepatic hematomas, but does not correlate well with hepatic lacerations. Extreme caution is required when using CT alone to define "minimal" liver injury for prospective management of blunt trauma victims.     

Evolution, not revolution: splenic salvage for blunt trauma in a statewide voluntary trauma system--a 10-year experience

BACKGROUND: State-legislated trauma systems have been enacted in an attempt to improve trauma care. Blunt splenic injury incidence without a legislated trauma system was examined for changes in care with a hypothesis that a voluntary system may perform equally with a legislated system. METHODS: Data from a statewide discharge database for the years 1993 to 2002 were examined. RESULTS: There were 276,425 trauma admissions overall, with blunt splenic injury occurring in 1.76%. Average Injury Severity Score (ISS) increased in trauma centers and decreased in the community. Trauma centers (TC) had more multisystem injuries. Splenic injury diagnosis increased 44% in TC between the early and late periods but only 7% in community facilities. Splenectomies increased 16% in TC but declined 16% in community hospital. Splenic salvage rate improved at both types of facilities. CONCLUSIONS: Splenic salvage rates improved over time in hospitals with no formal trauma system. Community hospitals cared for more than 50% of splenic injuries but transferred complex multisystem injuries, including splenic injuries, suggesting evolving care. Non-invasive imaging has increased the recognition of splenic injuries in both community hospitals and TC. Splenectomies are performed less, but have increased in TC with increasing ISS scores.     

Management of splenic trauma: a new CT-guided splenic injury grading system

The aim of this study was to assess a newly developed computerized tomography (CT)-based splenic injury index in predicting the outcome of splenic injury. Twelve patients with isolated splenic injuries were studied. Splenic parenchymal injury was graded from 1 to 4 based on CT. The splenic injury index was obtained by multiplying the parenchymal score by the volume haemoperitoneum, which was measured on the CT scanner. The 12 patients with CT-proven splenic injuries had a mean injury index of 193.5 +/- 191 (mean +/- s.d.). The 3 patients who failed conservative management had a mean index of 475 +/- 50, compared with an index of 99.5 +/- 100 in the nine managed non-operatively (P less than 0.001). This new CT-based splenic injury index allows morphological assessment of splenic injury and may predict the outcome of splenic trauma.     

Significance of minimal or no intraperitoneal fluid visible on CT scan associated with blunt liver and splenic injuries: a multicenter analysis

BACKGROUND: The use of ultrasound (U/S) for the evaluation of patients with blunt abdominal trauma is gaining increasing acceptance. Patients who would have undergone computed tomographic (CT) scan may now be evaluated solely with U/S. Solid organ injuries with minimal or no free fluid may be missed by surgeon sonographers. OBJECTIVE: The purpose of this study was to describe the incidence and clinical importance of liver and splenic injuries with minimal or no free intraperitoneal fluid visible on CT scan. We hypothesized that these solid organ injuries occur infrequently and are of minor clinical significance. METHODS: Patient records and CT scans were reviewed for the presence of and outcome associated with blunt liver and splenic injuries with minimal (<250 mL) or no free fluid detected by an attending radiologist. Data were collected from six major trauma centers during a 4-year period before the introduction of U/S and included demographics, grade of injury (American Association for the Surgery of Trauma scale), need for operative intervention, and outcome. RESULTS: A total of 938 patients with liver and splenic injuries were identified. In this group, 11% of liver injuries and 12% of splenic injuries had no free fluid visible on CT scan and could be missed by diagnostic peritoneal lavage or U/S. Of the 938 patients, 267 (28%) met the inclusion criteria; 161 had injury to the spleen and 125 had injury to the liver. In the 267 patients studied, 97% of the injuries were managed nonoperatively. However, 8 patients (3%) required operative intervention for bleeding. Compared with the liver, the spleen was significantly more likely to bleed (p = 0.01), but the grade of splenic injury was not related to the risk for hemorrhage (p = 0.051). CONCLUSION: Data from this study suggest that injuries to the liver or spleen with minimal or no intraperitoneal fluid visible on CT scan occur more frequently than predicted but usually are of minimal clinical significance. However, patients with splenic injuries may be missed by abdominal U/S. We found a 5% associated risk of bleeding. Therefore, abdominal U/S should not be used as the sole diagnostic modality in all stable patients at risk for blunt abdominal injury.     

The utility of serial computed tomography imaging of blunt splenic injury: still worth a second look?

BACKGROUND: Serial computed tomography (CT) imaging of blunt splenic injury (BSI) can identify the latent formation of splenic artery pseudoaneurysms (PSAs), contributing to improved success in splenic salvage. The practice of serial CT imaging, however, has not been embraced. The purpose of this study was to reevaluate the clinical practice of serial CT imaging within the context of an institutional protocol for the nonoperative management (NOM) of BSI. METHOD: Consecutive patients with BSI selected for NOM were identified from our trauma registry. Patients were managed according to protocol, whereby hemodynamically stable patients with PSA on initial or follow-up CT imaging were referred for angiography. Follow-up CT was performed 24 to 48 hours after the initial CT. Data were abstracted from hospital, clinic, and radiology records, and included age, Injury Severity Score, splenic injury grade (SIG), and CT findings. The incidence and timing of PSA identification with respect to subsequent management and outcome were reviewed. RESULTS: Of 426 BSI admissions during a 2.5-year period, 341 (80%) were selected for NOM. Mean follow-up was 39 days, with 76% followed for >or=7 days. Serial CT imaging resulted in the angiographic detection of 14 (4%) early PSAs and 11 (3%) latent PSAs. PSAs were associated with increasing SIG (p<0.001); however, 24% of PSAs were observed in SIG 1 and 2. Embolization was successful in 13 of 14 (93%) patients with early PSAs and 10 of 11 (91%) with latent PSAs. The splenic salvage rate for all patients selected for NOM during the study period was 329 of 341 (97%). CONCLUSIONS: Adherence to a NOM protocol guided by serial CT imaging has resulted in one of the highest splenic salvage rates reported to date. Identification and embolization of latent PSA likely contributes to NOM success, given the unfavorable natural history of these lesions. Although PSA formation is correlated with increasing SIG, PSAs are not exclusive to higher-grade injury, warranting serial CT surveillance regardless of SIG.     

Blunt splenic trauma.

The treatment of blunt splenic injury has evolved over time from splenectomy in all patients to nonoperative management in stable patients with operation reserved for failures of NOM. While rates of OPSI remain low in trauma patients, splenic salvage in stable patients should be attempted. However, clinical evidence of ongoing blood loss or instability should be addressed with prompt splenectomy. Careful patient selection is of paramount importance in nonoperative management of blunt splenic injury.