Delayed presentation of blunt splenic injury

Eleven patients with delayed presentation of splenic injury after blunt abdominal trauma treated during a 10 year period have been described. They represented 24 percent of all patients treated for blunt splenic injury in our department in that time period. Ten patients required operative treatment and one was treated nonoperatively. There were no deaths. The value of computerized tomography and ultrasonography in the accurate preoperative assessment of splenic injury has been documented. In addition, the various diagnostic and therapeutic possibilities in blunt splenic trauma have been discussed.     

钝性脾损伤非手术治疗探讨

目的 探讨钝性脾损伤非手术治疗的监测和治疗方法.方法 回顾分析2005年9月至2008年4月连续收治的95例钝性脾损伤患者中行非手术治疗的82例(86.3%)患者的临床资料.其中75例应用经皮腹腔穿刺置管引流、监测腹腔出血,38例行非术中自体血回输.全部病例随访3周～8个月.结果 82例非手术治疗全部成功,其中Ⅲ～Ⅳ级钝性脾损伤34例、55岁以上者6例、损伤严重度评分≥16分者14例.37例腹腔出血量500 ml,引流腹腔血量30～2400 ml.38例回输自体血量共23 300 ml,平均613 ml.随访除脾介入术后并发脾假性囊肿1例外,无延迟出血、腹腔感染等并发症发生.结论 大多数血流动力学稳定的钝性脾损伤可通过非手术治疗治愈.运用经皮腹腔穿刺置管引流回收并监测腹腔出血及非术中自体血回输技术,可明显提高钝性脾损伤的非手术治疗率和成功率.     

Limitations of splenic angioembolization in treating blunt splenic injury

BACKGROUND: When angiography is performed in all hemodynamically normal patients with splenic injury, only 30% require embolization. This study examines the use of selective splenic angioembolization (SAE) as part of a management algorithm for adult splenic injury. METHODS: Criteria for selective SAE were added to our adult splenic injury protocol in July 1999. SAE was performed in hemodynamically stable patients if computed tomographic (CT) scan revealed injury to the hilum or vascular blush and when nonoperative patients had a gradual decrease in hematocrit. Patients were grouped by management strategy: nonoperative; operative; or SAE. Demographics, injury severity, and outcomes of the different groups were compared. Medical records, CT scans, and registry data were reviewed for all SAE cases, deaths, and treatment failures. Data are means +/- SE. p < 0.05 versus nonoperative management by analysis of variance. RESULTS: From July 1999 to August 2003, 194 adults were treated for splenic injury. Nine patients underwent SAE, six for CT findings (1 vascular blush) and three for decreasing hematocrit. Three patients failed SAE (33%), one for bleeding and two for delayed splenic infarction. Eleven patients failed nonoperative therapy (8%); splenorrhaphy was performed in three and splenectomy in eight. Operative patients were more seriously injured and had higher Injury Severity Scores and mortality; splenectomy (39 of 48) was more commonly performed than splenorrhaphy (9 of 48) in this group. CONCLUSION: Use of a splenic injury algorithm is associated with a high success rate for nonoperative management of splenic trauma. Using selective criteria, only 5% of patients were treated with SAE. SAE salvaged six patients with high-grade splenic injury or decreasing hematocrit but had a 33% failure rate. Failure of nonoperative management was most commonly caused by errors in judgment, primarily recognition of "high-risk" injury patterns on CT scan or attempting nonoperative management in anticoagulated or coagulopathic patients.     

脾部分切除术治疗闭合性脾破裂

目的 探讨外伤性脾破裂脾部分切除的治疗效果。方法 回顾性分析行部分性脾切除治疗的28例外伤性脾破裂患者的临床资料。结果 本组脾部分治疗失败进行脾切除1例，治疗成功率96．4％，无死亡病例。27例出院随访1－58个月，未发现并发症；其中15例随访22个月以上，血液学检查，免疫学功能测定等指标均在正常范围，^99mTC扫描和B型超声检查示保留脾显像良好。结论 脾部分切除对合适的脾破裂病例是安全，有效的治疗，且保留的脾具有正常的脾功能。     

Ultrasound features of blunt testicular injury

This is a retrospective study of ultrasound examination for patients with blunt scrotal trauma. Fifteen patients were examined over an 18-month period. The purpose of the study was to discover the ultrasonic features of blunt testicular trauma and to distinguish less severe from more severe injury with testicular rupture requiring surgery. Three had ultrasonic findings of acute testicular rupture and this was confirmed by surgery. The ultrasound features of testicular trauma with rupture are irregularity of testicular outline and inhomogeneity of testicular texture. The value of ultrasound in diagnosing patients with testicular rupture and, therefore, requiring urgent surgery is discussed. In our limited study, irregularity of testicular outline was the distinguishing feature of rupture.     

Management of paediatric blunt splenic injury in Zaria, Nigeria

The management of paediatric blunt splenic injury is predominantly non-operative in developed countries at the present time. In developing countries however, imaging facilities for diagnosis and monitoring are frequently not readily available. Over a decade, 32 children had blunt splenic injury in Zaria. 28 (87.5%) injuries were isolated. Nineteen (59.4%) had grade II or III injuries and their spleens were preserved (splenorrhaphy, 12; partial splenectomy, 4; laparotomy only, 2; observation, 1) while 13 (40.6%) had grade IV or V injury necessitating total splenectomy. There was no difference in blood transfusion requirements in any group. The average duration of hospital stay was 17 days for splenic preservation and 20 days for total splenectomy. Mortality was 2 (6.3%), both patients had total splenectomy and one had associated liver injury. With adequate facilities, laparotomy would have been avoided in 16 (51.6%) patients. It is hoped that as appropriate imaging facilities become more readily available in developing countries, less children with blunt splenic injury will be subjected to surgery.     

Use of splenic artery embolization as an adjunct to nonsurgical management of blunt splenic injury

BACKGROUND: Splenic artery embolization (SAE) has been used as an adjunct to the nonsurgical treatment of blunt splenic injuries since 1981. It is imperative to define the role of SAE in the management of splenic trauma and to establish a guideline for its use. METHODS: In this study, 39 consecutive patients with blunt splenic ruptures were evaluated. All the patients were treated according to the authors' protocol, which included SAE as an adjunct. Angiographic study was performed for patients with any of the following presentations: recurrent hypotension despite fluid resuscitation, significant hemoperitoneum or extravasation of contrast media on computed tomography, grade 4 or 5 splenic injury, or progressive need for blood transfusion. Laparotomy was reserved for patients with unstable hemodynamics or failure of SAE. RESULTS: Four patients were excluded from the study, and 6 of the 35 remaining patients (male-to-female ratio, 22:13) received SAE. One of the six SAE patients underwent operation because of persistent hemorrhage after SAE. Nonoperative treatment was successful for 31 patients. Splenic artery embolization increased the success rate for nonsurgical management from 74% (26 of 35 patients) to 89% (31 of 35 patients). CONCLUSIONS: Judicious use of SAE for patients with blunt splenic injury avoids unnecessary surgery and expands the number of patients who can retain their spleen.     

Immune function and the role of vaccination after splenic artery embolization for blunt splenic injury

The spleen is the most commonly injured solid organ following blunt abdominal trauma. Over recent decades, splenic artery embolization (SAE) has become the mainstay treatment for haemodynamically stable patients with high-grade blunt splenic trauma, with splenectomy the mainstay of treatment for unstable patients. Splenic function is complex but the spleen has an important role in immune function, particularly in protection against encapsulated bacteria. Established evidence suggests that following splenectomy immune function is impaired resulting in increased susceptibility to overwhelming post-splenectomy infection, however, immune function may be preserved following SAE. This review will discuss the current state of the literature on immune function following different treatments of blunt splenic injury, and the controversies surrounding what constitutes a quantitative test of splenic immune function.     

Reliability of injury grading systems for patients with blunt splenic trauma

Objectives

The most widely used grading system for blunt splenic injury is the American Association for the Surgery of Trauma (AAST) organ injury scale. In 2007 a new grading system was developed. This ‘Baltimore CT grading system’ is superior to the AAST classification system in predicting the need for angiography and embolization or surgery. The objective of this study was to assess inter- and intraobserver reliability between radiologists in classifying splenic injury according to both grading systems.

Methods

CT scans of 83 patients with blunt splenic injury admitted between 1998 and 2008 to an academic Level 1 trauma centre were retrospectively reviewed. Inter and intrarater reliability were expressed in Cohen's or weighted Kappa values.

Results

Overall weighted interobserver Kappa coefficients for the AAST and ‘Baltimore CT grading system’ were respectively substantial (kappa = 0.80) and almost perfect (kappa = 0.85). Average weighted intraobserver Kappa's values were in the ‘almost perfect’ range (AAST: kappa = 0.91, ‘Baltimore CT grading system’: kappa = 0.81).

Conclusion

The present study shows that overall the inter- and intraobserver reliability for grading splenic injury according to the AAST grading system and ‘Baltimore CT grading system’ are equally high. Because of the integration of vascular injury, the ‘Baltimore CT grading system’ supports clinical decision making. We therefore recommend use of this system in the classification of splenic injury.     

Nonoperative management of blunt hepatic and splenic injury in children.

OBJECTIVE: The authors assessed the risks of nonoperative management of solid visceral injuries in children (age range, 4 months-14 years) who were consecutively admitted to a level I pediatric trauma center during a 6-year period ending in 1991. METHOD: One hundred seventy-nine children (5.0%) sustained injury to the liver or spleen. Nineteen children (11.2%) died. Of the 160 children who survived, 4 received emergency laparotomies; 156 underwent diagnostic computer tomography and were managed nonoperatively. The percentage of children who were successfully treated nonoperatively was 97.4%. Delayed diagnosis of enteric perforations occurred in two children. Fifty-three children (34.0%) received transfusions (mean volume 16.7 mL/kg); however, transfusion rates during the latter half of the study decreased from 50% to 19% in children with hepatic injuries, despite increasing grade of injury, and decreased from 57% to 23% in the splenic group with similar injury grade (p < 0.005, chi square test and Student's t test). CONCLUSION: Pediatric blunt hepatic and splenic trauma is associated with significant mortality. Nonoperative management based on physiologic parameters, rather than on computed tomography grading of organ injury, was highly successful, with few missed injuries and a low transfusion rate.     

Improved outcome of adult blunt splenic injury: a cohort analysis

BACKGROUND: The purpose of this study was to review our 15-year experience in the treatment of blunt splenic injury in adults. Our hypothesis was that the implementation of a change in practice, with stress on splenic preservation and splenic artery embolization for the management of splenic injury, would result in improved splenic salvage rates without negatively affecting mortality rates. METHODS: A retrospective cohort analysis was performed on all consecutive adults with blunt splenic injury who were admitted to a Level One Trauma Center. The cohorts were defined by 2 separate 7.5-year periods (1991-1998 and 1998-2005). RESULTS: Six hundred twenty-five patients with blunt splenic trauma were identified; 403 patients who were treated from 1998 to 2005 were compared with 222 patients whose cases had been reviewed previously (1991 to 1998). The present cohort differed in age (35 vs 40 years; P < .001) and injury severity score (27 vs 21; P < .0001). Nonoperative treatment was implemented in 136 patients (61%) in the initial cohort and 344 patients (85%) in the present cohort. The frequency of splenic artery embolization increased from 2.7% to 22.6% (P < .001). The success of nonoperative management increased from 77% to 96% (P < .001); the splenic salvage rate for all patients improved from 57% to 88% (P < .0001). Hospital mortality rates decreased from 12% to 6% (P < .001), and the mean hospital length of stay decreased from 15 to 9 days (P < .001). CONCLUSION: These results demonstrate that the success of nonoperative management and the splenic preservation for blunt injury has improved over time. This improvement correlated with a greater use of splenic artery embolization.     

Management of blunt splenic injury in patients with concurrent infectious mononucleosis

Selective nonoperative management is appropriate for most blunt splenic injuries in adults and children, but the efficacy of this approach is unknown when injury occurs in patients with concurrent infectious mononucleosis. We have reviewed our experience during the past 23 years with the selective nonoperative management of blunt splenic injury in these patients. Medical record review identified nine patients with blunt splenic injury and infectious mononucleosis from 1978 to 2001, representing 3.3 per cent of our total trauma population with blunt splenic injury treated during that interval. Two patients underwent immediate splenectomy because of hemodynamic instability. Seven patients were admitted with the intent to treat nonoperatively. Five patients were successfully managed nonoperatively. Two patients failed nonoperative management and underwent splenectomy, one because of hemodynamic instability and one because of an infected splenic hematoma. Concurrent infectious mononucleosis does not preclude the successful nonoperative management of blunt splenic injury. This small subset of patients may be managed nonoperatively using the same criteria as for patients whose splenic injuries are not complicated by infectious mononucleosis.     

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.     

Pleural effusion following blunt splenic injury in the pediatric trauma population

Background

Pleural effusion is a potential complication following blunt splenic injury. The incidence, risk factors, and clinical management are not well described in children.

Methods

Ten-year retrospective review (January 2000–December 2010) of an institutional pediatric trauma registry identified 318 children with blunt splenic injury.

Results

Of 274 evaluable nonoperatively managed pediatric blunt splenic injures, 12 patients (4.4%) developed left-sided pleural effusions. Seven (58%) of 12 patients required left-sided tube thoracostomy for worsening pleural effusion and respiratory insufficiency. Median time from injury to diagnosis of pleural effusion was 1.5 days. Median time from diagnosis to tube thoracostomy was 2 days. Median length of stay was 4 days for those without and 7.5 days for those with pleural effusions (p < 0.001) and 6 and 8 days for those pleural effusions managed medically or with tube thoracostomy (p = 0.006), respectively. In multivariate analysis, high-grade splenic injury (IV–V) (OR 16.5, p = 0.001) was associated with higher odds of developing a pleural effusion compared to low-grade splenic injury (I–III).

Conclusions

Pleural effusion following pediatric blunt splenic injury has an incidence of 4.4% and is associated with high-grade splenic injuries and longer lengths of stay. While some symptomatic patients may be successfully managed medically, many require tube thoracostomy for progressive respiratory symptoms.