Delayed presentation of perisplenic abscess following arterial embolization

INTRODUCTIONSplenic abscess formation is a rare but significant complication that may occur after non-operative management (NOM) of a blunt splenic injury (BSI). we describe an unusual case of perisplenic abscess formation nearly 4 months after splenic artery angioembolization for a grade III splenic laceration.PRESENTATION OF CASEA 52-year-old male was transferred to the Emergency Department (ED) of our institution after falling off his bicycle. He was hemodynamically stable but complained of left upper quadrant pain. Computed tomography (CT) was notable for a Grade III splenic laceration. The patient underwent a successful splenic artery embolization on hospital day 1. He had an uneventful post-embolization course and was discharged 3 days later, afebrile, with a stable hematocrit. Four months after his initial presentation, the patient presented to the ED with fever, malaise, and left upper quadrant abdominal pain. A CT scan revealed a multiloculated perisplenic abscess. He underwent a splenectomy and drainage of peri-splenic abscess, received a course of antibiotics, and had an uneventful recovery.DISCUSSIONNOM including splenic angioembolization (SAE) is the standard of care for blunt splenic trauma in hemodynamically stable patients. Known complications from SAE include bleeding, missed injuries to the diaphragm and pancreas, and splenic abscess. This report documents a delayed perisplenic abscess following NOM of blunt splenic trauma, a rare but potential complication of SAE.CONCLUSIONFormation of a perisplenic abscess may occur several months after NOM of a blunt splenic injury. Prompt surgical management and antibiotic therapy are critical to avoid life-threatening complications.     

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.     

Splenic embolization for splenic laceration in a patient with mononucleosis

Splenomegaly is a sequela of infectious mononucleosis. The potential for traumatic rupture of an enlarged spleen is well recognized. Recently, splenic artery embolization has gained popularity for the treatment of splenic injury. However, embolization has not been described for splenic injury in an enlarged spleen secondary to mononucleosis. We report the case of a 15-year-old girl who was the restrained passenger in a motor vehicle crash. On examination at an American College of Surgeons-verified Level 1 trauma center, the patient was found to have abdominal pain. A focused assessment with sonography for trauma examination revealed fluid in Morison's pouch. A subsequent spiral CT scan with intravenous contrast revealed a markedly enlarged spleen with a shattered upper pole. The patient denied symptoms of mononucleosis; however, a spot mononucleosis test was positive. The patient was admitted to the pediatric intensive care unit for observation. She remained hemodynamically stable, but her initial hemoglobin of 9.2 g/dL fell to 7.1 g/dL 6 hours later. Splenic artery embolization was performed and the upper pole of the spleen was selectively embolized. The hemoglobin remained stable and the patient was transferred to the pediatric ward. On postembolization day five, the patient was dismissed with a hemoglobin of 9.7 g/dL. This case demonstrates that splenic embolization is a viable alternative to operative treatment even in the presence of splenomegaly secondary to mononucleosis.     

Nonoperative management of blunt hepatic trauma in adults

Although well accepted in pediatric patients, nonoperative management of blunt hepatic trauma in adults remains controversial. From January 1981 through May 1987, 66 adults were identified with blunt hepatic trauma that had been confirmed by abdominal exploration or abdominal computed tomography (CT): 46 underwent immediate operation, and 20 were initially managed nonoperatively. Patients were considered for nonoperative management only if they were hemodynamically stable and had no significant peritoneal irritation. CT criteria for nonoperative management included contained subcapsular or intrahepatic hematoma, unilobar fracture, absence of devitalized liver, minimal intraperitoneal blood, and absence of other significant intra-abdominal organ injuries. The predominant CT pattern in the 17 patients successfully managed nonoperatively included unilobar right-lobe fracture or intrahepatic hematoma. A small amount of blood in either gutter or in the pelvis did not portend failure of nonoperative management. No delayed complications were noted during an average follow-up of 27 months. Nonoperative management of blunt hepatic injury based on abdominal CT findings is a useful alternative in a select group of hemodynamically stable patients.     

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.     

Follow-up abdominal CT is not necessary in low-grade splenic injury

Nonoperative management of splenic injury has become the standard of care in the hemodynamically stable patient. The time period of observation and the utility of follow-up scanning remain an area of debate. This study examined the utility of follow-up abdominal CT for detection of delayed vascular injury in patients with low-grade splenic injury. A retrospective review of all patients with low-grade splenic injuries undergoing nonoperative management from June 2000 to June 2004 was performed. Patients underwent follow-up abdominal CT 48 to 72 hours after admission to rule out delayed vascular injury and were discharged if the results were negative. Charts were reviewed for demographic data, abdominal CT results, and splenic salvage. A total of 472 patients underwent nonoperative management for splenic injury, with 140 patients treated with simple observation during this protocol. All patients were successfully managed with simple observation with no nonoperative failures; there were two instances of delayed vascular injury on follow-up CT. Both patients with progression of injury had decreasing hematocrit levels during admission prior to follow-up abdominal CT scan. Overall, the injury severity score was 22 points and the American Association for the Surgery of Trauma (AAST) splenic injury severity score was 1.8 points. Length of hospital stay was 2.8 days for patients with predominately splenic injury and 10 days for the overall cohort. Follow-up abdominal CT confers no benefit in patients with low-grade splenic injury, and a stable hematocrit level and abdominal exam.     

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.     

Changing patterns in the management of splenic trauma: the impact of nonoperative management.

OBJECTIVE: The recognition that splenectomy renders patients susceptible to lifelong risks of septic complications has led to routine attempts at splenic conservation after trauma. In 1990, the authors reported that over an 11-year study period involving 193 patients, splenorrhaphy was the most common splenic salvage method (66% overall) noted, with nonoperative management employed in only 13% of blunt splenic injuries. This report describes changing patterns of therapy in 190 consecutive patients with splenic injuries seen during a subsequent 6-year period (1990 to 1996). An algorithmic approach for patient management and pitfalls to be avoided to ensure safe nonoperative management are detailed. METHODS: Nonoperative management criteria included hemodynamic stability and computed tomographic examination without shattered spleen or other injuries requiring celiotomy. RESULTS: Of 190 consecutive patients, 102 (54%) were managed nonoperatively: 96 (65%) of 147 patients with blunt splenic injuries, which included 15 patients with intrinsic splenic pathology, and 6 hemodynamically stable patients with isolated stab wounds (24% of all splenic stab wounds). Fifty-six patients underwent splenectomy (29%) and 32 splenorrhaphy (17%). The mean transfusion requirement was 6 units for splenectomy survivors and 0.8 units for nonoperative therapy (85% received no transfusions). Fifteen of the 16 major infectious complications that occurred followed splenectomy. Two patients failed nonoperative therapy (2%) and underwent splenectomy, and one patient required splenectomy after partial splenic resection. There no missed enteric injuries in patients managed nonoperatively. The overall mortality rate was 5.2%, with no deaths following nonoperative management. CONCLUSIONS: Nonoperative management of blunt splenic injuries has replaced splenorrhaphy as the most common method of splenic conservation. The criteria have been extended to include patients previously excluded from this form of therapy. As a result, 65% of all blunt splenic injuries and select stab wounds can be managed with minimal transfusions, morbidity, or mortality, with a success rate of 98%. Splenectomy, when necessary, continues to be associated with excessive transfusion and an inordinately high postoperative sepsis rate.     

Nonoperative management of pediatric splenic injury with angiographic embolization

A 12-year-old girl was admitted after a bicycle accident, and a grade 4 splenic injury was diagnosed. She became hemodynamically unstable within the first hours after arrival and remained so despite fluid resuscitation and transfusions. As an alternative to laparotomy, splenic artery embolization was performed. The patient had an uneventful recovery without the need for further transfusions. Nonoperative management of blunt splenic trauma remains the gold standard in pediatric trauma care. In hemodynamically unstable patients, splenic artery embolization should be considered as an adjunct to that strategy.     

Laparoscopic splenectomy in blunt trauma.

We describe the first reported use of laparoscopic splenectomy as initial treatment in high-grade blunt splenic trauma. A 21-year-old man sustained a blow to the left flank from a large construction pipe and was transferred to our hospital with a grade V splenic laceration and a grade II left peri-renal hematoma with hematuria. He was hemodynamically stable. He underwent a laparoscopic splenectomy shortly after arrival. The patient's renal injury was managed nonoperatively, and he was discharged home with no complications and has remained well.     

Splenic embolization revisited: a multicenter review

BACKGROUND: Splenic embolization can increase nonoperative salvage. However, complications are not clearly defined. A retrospective multicenter review was performed to delineate the risks and benefits of splenic embolization. METHODS: A retrospective chart review of all patients undergoing splenic embolization from 1997 to 2002 at four separate Level I trauma centers was performed. Reviewed results included patient demographics, admission and follow-up computed tomographic scan results, angiographic technique, and patient outcomes including splenic salvage rate and procedural complications. RESULTS: A total of 140 patients were reviewed. The majority were young male patients involved in motor vehicle crashes. These patients had high abdominal computed tomographic grades of splenic injury and moderate Injury Severity Scores. The splenic salvage rate was 87%, which decreased with increasing injury grade. However, over 80% of splenic injury grades 4 and 5 were successfully managed nonoperatively. Significant hemoperitoneum did not affect success, but the presence of arteriovenous fistula was associated with a high failure rate, even with embolization. Salvage rates were similar between main coil and subselective embolization groups. Patients over 55 years of age did no worse than younger patients. Major complications included bleeding in 16 patients; 6 splenic abscesses, with 5 patients requiring splenectomy; and 1 episode of arterial injury requiring operative repair. CONCLUSION: Splenic embolization remains a valuable technique in splenic salvage, especially in higher grade injuries. Complications are common but do not seem to affect outcome.     

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.     

Complications Associated With Embolization in the Treatment of Blunt Splenic Injury

Background Nonoperative management (NOM) of blunt splenic injuries is widely accepted, and the use of splenic artery embolization (SAE) has become a valuable adjunct to NOM. We retrospectively review and discuss the complications derived from SAE. Materials and methods The medical records of 152 consecutive patients with blunt splenic trauma admitted to our trauma center during a 33-month period were retrospectively reviewed. The patients were managed according to an established algorithm. The record review focused on the method of patient management (operative versus nonoperative) and use of SAE. The complications encountered following SAE are discussed in detail. Results Altogether, 73 patients underwent emergency surgery (58 splenectomies, 15 splenorrhaphies), and 79 patients had NOM. Of the 79 patients with NOM, 58 were successfully treated; 2 patients required splenectomy after 24 hours. The remaining 21 patients had SAE, including 18 distal and 3 proximal embolizations. Major complications occurred in 28.5% of the SAE-treated patients and included total splenic infarction, splenic atrophy, and postprocedure bleeding. Minor complications occurred in 61.9% of the patients and included fever, pleural effusion, and partial splenic infarction. Conclusion SAE is considered a valuable adjunct to NOM in the treatment of blunt splenic injuries; however, risks of major and minor complications do exist, and SAE should be offered with caution and followed up appropriately.     

Laparoscopic treatment of blunt splenic injuries: initial experience with 11 patients

Background Nonoperative treatment of splenic injuries is the current standard of care for hemodynamically stable patients. However, uncertainty exists about its efficacy for patients with major polytrauma, a high Injury Severity Score (ISS), a high grade of splenic injury, a low Glasgow Coma Score (GCS), and important hemoperitoneum. In these cases, the videolaparoscopic approach could allow full abdominal cavity investigation, hemoperitoneum evacuation with autotransfusion, and spleen removal or repair. Methods This study investigated 11 hemodynamically stable patients with severe politrauma who underwent emergency laparoscopy. The mean ISS was 29.0 ± 3.9, and the mean GCS was 12.1 ± 1.6. A laparoscopic splenectomy was performed for six patients, whereas splenic hemostasis was achieved for five patients, involving one electrocoagulation, one polar resection, and three polyglycolic mesh wrappings. Results The average length of the operation was 121.4 ± 41.6 min. There were two complications (18.2%), with one conversion to open surgery (9.1%), and no mortality. Conclusions Laparoscopy is a safe, feasible, and effective procedure for evaluation and treatment of hemodynamically stable patients with splenic injuries for whom nonoperative treatment is controversial.     

Nonoperative management of the adult ruptured spleen

The risk of postsplenectomy sepsis has led to increased enthusiasm for preservation of the spleen. From January 1984 to December 1988, 51 consecutive adult patients with ruptured spleen sustained from blunt trauma were examined. Thirty-four patients (67%) had their conditions hemodynamically stabilized at the time of hospital admission and were placed on a regimen of strict bed rest with intensive monitoring. The average hemoglobin value at hospital admission in this group was 126 +/- 18 g/L, with an average drop of 17 +/- 14 g/L during their hospitalization; 14 patients required transfusions averaging 3 U each. Nonoperative treatment was successful in 33 (97%) of 34 patients; one patient whose condition deteriorated clinically underwent splenectomy on the fifth hospital day. These patients have been followed up for an average of 28 months with no sequelae from their splenic injury. We conclude that a nonoperative approach is a viable alternative in stable adult patients with splenic injuries due to blunt trauma when intensive monitoring is available.     

A nonoperative approach to the adult ruptured spleen sustained from blunt trauma

From 1978 to 1983, 53 consecutive adult patients with ruptured spleens documented by radionuclide studies, computerized axial tomography, or surgery, were evaluated at William Beaumont Hospital. Thirty-four patients (64%) underwent an exploratory laparotomy; 33 resulted in a splenectomy and one patient had an attempted splenorraphy which failed. Nineteen patients (36%) were hemodynamically stable on admission, or had transient episodes of hypotension readily reversed by intravenous fluids. They were placed at strict bedrest under intensive monitoring. Two patients deteriorated clinically and were taken to surgery, resulting in a splenectomy on the fourth and sixth hospital day, respectively. Seventeen patients (32%) were successfully treated nonoperatively, representing an 89 per cent success rate. The average admitting hemoglobin in the nonoperative group was 13.2 gm/dl, with an average drop of 1.6 gm/dl, and an average total blood transfusion of 1.2 units. These patients were followed for an average of 19.2 months, with no sequelae from their splenic injury. In a hemodynamically stable adult patient with a splenic injury sustained from blunt trauma, a nonoperative approach is a viable alternative when close intensive monitoring is available.     

Ruptured spleen following laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is generally a safe and well-accepted procedure. However, in a small percentage of patients, it is associated with complications, such as bleeding and injury to the bile duct and other viscera. Splenic injury as a result of laparoscopic surgery has been reported only in the context of direct trauma, for example due to retraction in hand-assisted urologic surgery. To date, there have been no reported cases of patients requiring splenectomy following laparoscopic cholecystectomy. We report an unusual case of ruptured spleen presenting less than 28 days following "uncomplicated" laparoscopic cholecystectomy. RESULTS: A 52-year-old female presented to our Accident and Emergency department 3 weeks following "uncomplicated" laparoscopic cholecystectomy, complaining of severe left upper quadrant pain radiating to the left shoulder tip. Clinical examination revealed a patient in hypovolemic shock, with localized left upper quadrant peritonism. Abdominal computed tomography supported a diagnosis of splenic rupture, and the patient required an emergency splenectomy. DISCUSSION: Splenic injury rarely complicates laparoscopic cholecystectomy. We postulate that either congenital or posttraumatic adhesions of the parietal peritoneum to the spleen may have caused the capsule to tear away from the spleen when the pneumoperitoneum was established, resulting in subcapsular hematoma and subsequent rupture in this patient. Videoscopic assessment of the spleen at the end of laparoscopic cholecystectomy might be a worthwhile exercise to aid early recognition and management in such cases.     

Early embolization in the non-operative management of blunt splenic injuries: a retrospective multicenter study

AIM OF THE STUDY: Splenic artery embolization has been used as an adjunct to the non-surgical management of blunt splenic injury. No consensus on its indications has emerged from the literature. This multicentric study aimed to evaluate the results of this technique in France. PATIENTS AND METHODS: Between March 2000 and April 2006, 22 patients older than 15 years of age (mean age 29, range: 15-59) with splenicv rupture due to blunt trauma underwent splenic artery embolization in six Level I Trauma Centers in France. Splenic rupture was classified Moore II in 3 cases, Moore III in 12 cases, and Moore IV in 7 cases. Angiography was performed within 4 hours of admission in half of the cases. The main indications for splenic artery embolization were: extravasation of contrast medium on CT scan (10 cases, 45%); early pseudo-aneurysm (6 cases, 23%); hypotension despite fluid resuscitation and/or progressive need for transfusion (5 cases, 22%). RESULTS: There was no mortality. Nine patients experienced complications (41%) including 6 (27%) who developed left pleural effusion. Two patients eventually underwent splenectomy (one for persistent hemorrhage, one for splenic necrosis). The overall splenic salvage rate was 91%. CONCLUSION: Splenic artery embolization is a valuable techniche that hels to lower the rate of splenectomy for traumatic splenic rupture with relatively low morbidity.     

Imaging and transcatheter arterial embolization for traumatic splenic injuries: review of the literature

The spleen is the most commonly injured visceral organ in blunt abdominal trauma in both adults and children. Nonoperative management is the current standard of practice for patients who are hemodynamically stable. However, simple observation alone has been reported to have a failure rate as high as 34%; the rate is even higher among patients with high-grade splenic injuries (American Association for the Surgery of Trauma [AAST] grade III–V). Over the past decade, angiography with transcatheter splenic artery embolization, an alternative nonoperative treatment for splenic injuries, has increased splenic salvage rates to as high as 97%. With the help of splenic artery embolization, success rates of more than 80% have also been described for high-grade splenic injuries. We discuss the role of computed tomography and transcatheter splenic artery embolization in the diagnosis and treatment of blunt splenic trauma. We review technical considerations, indications, efficacy and complication rates. We also propose an algorithm to guide the use of angiography and splenic embolization in patients with traumatic splenic injury.