Does splenic embolization and grade of splenic injury impact nonoperative management in patients sustaining blunt splenic trauma?

Nonoperative management (NOM) for blunt splenic trauma (BST) is an established practice. The impact of splenic embolization (SE) in the algorithm for NOM has not been well studied. This study evaluates the role of SE and spleen injury grade on failure of NOM. Retrospective cohort of trauma registry over a 7-year period (2000-2006) for patients who suffered BST was studied. Data including demographics, splenic injury grade, and SE were recorded. Characteristics were compared between the successful and failed NOM groups. Kaplan-Meier, life table, and Cox-proportional hazard regression analyses were performed. Of the 499 patients who suffered BST, 407 (81.6%) patients had successful NOM and 92 (18.4%) patients failed NOM (including splenectomies performed within 1 hour of admission). Failed NOM group had a higher splenic injury grade compared with the successful NOM group (P < 0.0001). Seventy-five per cent underwent a splenectomy within 7.7 hours of admission. Nearly all grade I and II splenic injuries that failed NOM occurred by 24 hours. Grade 3 and 4 injuries that failed NOM occurred by 150 hours. SE was protective against splenectomy (Hazard Ratio (HR) 0.18, 95% confidence interval: 0.06-0.55, P = 0.004), whereas splenic injury grades III or higher was associated with increased risk of splenectomy (grade III: HR 5.26, P = 0.003; grade IV: HR 6.84, P = 0.002; grade V: HR 9.81, P = 0.002) compared with those with splenic injury grade I. Splenic embolization is a protective measure to reduce the failure of NOM. Spleen injury grade III and higher was significantly associated with NOM failure and would require a 5-day inpatient observation.     

Non-operative management of adult blunt splenic injuries

Objective:To investigate the indication of non-operative management of adult blunt splenic injuries. Methods: A retrospective review was performed on all adult patients ( age > 15 years) with blunt splenic injuries admitted to the department of vascular surgery of Pellegrin hospital in France from 1999 to 2003. We managed splenic injuries non-operatively in all appropriate patients without regard to age. Results: During the 4 years, 54 consecutive adult patients with blunt splenic injuries were treated in the hospital. A total of 27 patients with stable hemodynamic status were treated non-operatively at first, of which 2 patients were failed to non-operative treatment. The successful percentage of non-operative management was 92.6%. In the 54 patients, 7 of 8 patients older than 55 years were treated with non-operative management. Two cases developing postoperatively subphrenic infection were healed by proper treatment. In the series, there was no death. Conclusions: Non-operative management of low-grade splenic injuries can be accomplished with an acceptable low-failure rate. If the clinical and laboratory parameters difficult for surgeons to make decisions, they can depend on Resciniti' s CT ( computed tomography) scoring system to select a subset of adults with splenic trauma who are excellent candidates for a trial of nonoperative management. The patients older than 55 years are not absolutely inhibited to receive non-operative management.     

Is anything new in adult blunt splenic trauma?

Several decades ago, a shift occurred in the management of adult splenic injuries. Influenced by the experience in pediatric trauma patients, adult trauma surgeons began turning from mandatory operative treatment of all splenic injuries toward nonoperative management. Nonoperative treatment is now the most common method of management for patients with splenic injuries and is the most common method of splenic salvage. However, controversy exists about how to appropriately select patients for nonoperative treatment since bleeding from splenic injuries can incur significant morbidity and mortality. Recent refinements in the management of adult blunt splenic injuries will be reviewed.     

Improved graft function in liver‐transplanted patients after partial splenic embolization: reversal of splenic artery steal syndrome?

AIM: To describe the functional effect of partial splenic embolization (PSE) in liver-transplanted (LT) patients with hypersplenism and hepatitis C virus (HCV) recurrence. PATIENTS AND METHODS: From May 2002 to May 2005, five LT patients with persistent hypersplenism, viral recurrence and graft dysfunction underwent PSE prior to pegylated interferon/ribavirin (peg-IFN/RBV). RESULTS: The mean splenic size was 19.5 cm (16-21) and there was evidence of an enlarged splenic artery (10.7+/-1 mm). PSE produced a median splenic infarction of 90% and a significant reduction in the splenic artery diameter to 5.8+/-0.4 mm (p=0.04). PSE significantly improved hematologic parameters, bilirubin levels, prothrombin activity, international normalized ratio and the Model for End-stage Liver Disease (MELD) score despite high HCV-RNA (6.2 log10 IU/mL). It was demonstrated histologic amelioration of ischemic changes in all subjects. PSE allowed the safe use of full-dose peg-IFN plus RBV in all subjects. CONCLUSIONS: In HCV LT patients with chronic graft dysfunction and cholestasis the improvement in the liver function following PSE might be due to the reversal of an undiagnosed splenic artery steal syndrome related to chronic hypersplenism masked by HCV recurrence.     

Air following splenic embolization: infection or incidental finding?

The use of splenic embolization for nonoperative management has increased. With increased use of this adjunct, a new and frequent finding has been air within the areas of infarction in patients with or without clinical signs of infection. The purpose of this study was to determine if air within areas of splenic infarction is pathologic of infection or rather an incidental finding. A retrospective review over the past 3 years of inpatients undergoing splenic embolization and having pre- and postembolization abdominal computed tomography scans were reviewed for the findings of free air as well as any clinical signs of infection. A total of 96 consecutive patients were included. Of these, 12 had evidence of infarction with air. Six of these patients had undergone distal embolization with intraparenchymal air, but no symptoms. These were successfully observed. Two patients demonstrated subcapsular air/fluid levels, which underwent drainage with splenic preservation. Cultures were negative for infection. The remaining 4 underwent splenectomy. Of these, all had large collections of air. Two of these 4 spleens were infected: 1 with alpha-hemolytic Streptococcus and one with Clostridia perfringens. The remainder was sterile. This gave an overall infection rate of 17 per cent of patients with evidence of air. This yield increased to 33 per cent if the patient had symptoms and 50 per cent in those with large amounts of air and symptoms. Overall, we feel that air following embolization is a concern, but does not constitute infection. Patients with large amounts of air and signs and symptoms of infection will have a far higher infectious rate, 50 per cent in this limited series. In these patients, evaluation for infection is indicated; that being percutaneous sampling versus splenectomy.     

Metastatic splenic α-fetoprotein-producing adenocarcinoma: report of a case

Solitary carcinomatous metastases to the spleen are rare, and the presence of solitary splenic metastasis of hepatoid adenocarcinomas (HAC) has not yet been reported. We herein present the case of a 54-year-old male patient who developed a metastatic tumor to the spleen with enhanced levels of serum α-fetoprotein and carcinoembryonic antigen (CEA). The patient underwent a gastrectomy due to adenocarcinoma of the stomach 5 years previously. The tumor was diagnosed on the grounds of histopathology and immunohistochemical staining after splenectomy. The pathology slides showed both adenocarcinoma and hepatoid structures. α-Fetoprotein antibody staining was positive in the tumor, suggesting hepatoid characteristics. After the operation, the patient recovered well and had no signs of recurrence at a follow-up examination after 9 months. Together with this case, several aspects of the disease are discussed after a review of the current literature.     

Laparoscopic distal pancreatectomy: does splenic preservation affect outcomes?

Although the spleen is often routinely resected during both open and laparoscopic distal pancreatectomies, a splenectomy can increase the risk of postoperative and life-long infectious complications. Spleen-preserving laparoscopic pancreatectomies can technically be more difficult because of the delicate dissection of the splenic vessels. We performed a retrospective review of 34 laparoscopic pancreatectomies done at our institution. All procedures were done laparoscopically without hand assistance. Attempts were made in all patients to conserve the spleen, which was successful in 10 patients (29%). In the splenectomy group, 9 patients had 12 surgical complications (26%), which was statistically significant compared with the spleen-preserving group, in which there were no complications. This included 7 patients with a pancreatic leak (20%) and 3 with postoperative hemorrhage requiring reexploration (9%). Patients with spleen-preserving pancreatectomies had significantly less blood loss and shorter operative time compared with patients who underwent concomitant splenectomy. Splenic preservation should be attempted in all patients undergoing laparoscopic distal pancreatectomy unless there are overriding oncological or anatomic concerns.     

Nonsurgical management of blunt splenic injury: is it cost effective?

Background

This study analyzed outcomes and cost of splenic embolization compared with surgery for the management of blunt splenic injury.

Methods

We performed a retrospective chart review of all patients admitted with isolated, blunt splenic injury. An intent-to-treat analysis was initially conducted. Outcomes and cost/charges were compared in patients treated with embolization and surgical treatment.

Results

Of 236 patients admitted with isolated, blunt splenic injury, 190 patients were ultimately managed by observation, 31 by splenic embolization, and 15 by surgical management. Comparing outcomes and cost data for splenic embolization versus surgical management, there was no significant difference in intensive care unit use, hospital stay, complications, or re-admission. Surgical management patients required more blood transfusions and incurred higher procedure charges. Conversely, splenic embolization patients underwent more radiologic evaluations and charges. Total procedure-related charges were higher for surgical management when compared with splenic embolization ($28,709 vs $19,062; P = .016), but total hospital cost and total hospital charges were not significantly different.

Conclusions

Nonsurgical treatment of blunt splenic injury is safe and cost effective. Angioembolization was statistically similar to surgical therapy regarding cost.     

Nonoperative observation therapy for splenic injuries: A safe therapeutic option?

Combining these reported and estimated incidences of mortality from overwhelming postsplenectomy infection, splenic salvage with nonoperative observation therapy and operative therapy, and the incidence of posttransfusion hepatitis and related mortality provides a conditional probability estimation of the risks of death with nonoperative observation therapy and operative therapy (Figure 4). The combined mortality rates for nonoperative observation and operative therapies are based on the following measured and estimated statistics: (1) The posttransfusion hepatitis death rate per unit of blood transfused is 0.14 percent. (2) Forty percent of children and 20 percent of adults who have successful nonoperative observation therapy receive an average of 2 units of blood. (3) One hundred percent of children and adults in whom nonoperative observation therapy is unsuccessful receive an average of 4 units of blood. (4) Twenty percent of children and adults who undergo operation initially receive an average of 2 units of blood. (5) Ten percent of observed children require laparotomy and 75 percent of these patients then undergo splenectomy. (6) Forty percent of adults who have nonoperative observation initially later require laparotomy, 93 percent of whom also require splenectomy. (7) Ten percent of children and adults treated with initial operation later require splenectomy. (8) Death from overwhelming postsplenectomy infection occurs in 0.026 percent of adults who undergo splenectomy and 0.052 percent of children who undergo splenectomy.Given these assumptions, the conditional probability of death in a child who initially undergoes nonoperative observation therapy is 0.17 percent compared with 0.06 percent for initial operative therapy. In adults, 0.26 percent of the observed patients die compared with 0.06 percent for those operated on initially.As stated, many of the percentages or probabilities listed are estimations based on the best available clinical data. The inability to establish a mortality rate from overwhelming postsplenectomy infection remotely resembling that reported for otherwise healthy patients required an unsubstantiated estimate. However, even when mortality rates from overwhelming postsplenectomy infection of 0.43 percent and 0.6 percent [3] were substituted, early laparotomy still produced lower mortality rates. This continues to be true if one assumes that early laparotomy will result in 50 percent or even 100 percent of patients undergoing splenectomy, although in these cases the statistical differences would be less.We acknowledge that these statistics may exceed or underestimate the true risk of either treatment plan. We also acknowledge that assignment of probabilities to an individual patient is a measure of the clinician or statistician's ignorance of the individual characteristics of any given patient [24]. One of the benefits of conditional probability models is that alternate probabilities can be substituted along the probability chain if there is disagreement with the percentages used for computation. We encourage physicians who disagree with our probabilities based on solid clinical data to substitute their figures in a similar model as a means to arrive at a logical approach to the management of a child or adult with an apparently isolated splenic injury.     

Isolated splenic metastasis from clear cell renal carcinoma – A case report

Back groundMetastatic deposits in spleen are rare owing to its physiological functions and sharp angle of splenic artery with coelic axis.Case reportWe report a case of a 53 year old male with clear cell carcinoma of left kidney. Isolated splenic metastasis was detected on a follow up PET CT scan 2 months post radical nephrectomy. Splenectomy was performed; histopathology confirmed multiple metastatic lesions within the spleenConclusionTimely treatment of isolated metastasis in case of renal cell carcinoma carries good prognosis.     

Observation of splenic trauma: when is a little too much?

A 12-year-old boy was treated conservatively for a grade II splenic laceration. On discharge, he was instructed to avoid contact sports, running, and strenuous physical activity. Thirty-eight days later, after diving off the side of a swimming pool, he had abdominal pain, nausea, and diaphoresis. On admission, he was hemodynamically unstable. Results of a diagnostic lavage showed gross blood. At laparotomy, a fractured spleen was found, and splenectomy was performed. He recovered without complication. This case questions the activity restrictions placed on patients with conservatively managed splenic trauma. Avoidance of only contact sports and heavy exertion may be inadequate.     

Pure alcohol injection of a congenital splenic cyst: a valid alternative?

Congenital splenic cysts are a rare entity. They are more frequent in children and young adults. They are true cysts, lined by epithelium with a typical trabeculation. Aspiration and injection with antibiotics (minocycline-tetracycline) or pure alcohol has been reported sparsely with variable results. The purpose of this case study is to report our experience with ultrasound (US)-guided aspiration and injection of a congenital splenic cyst, which, in our case, did not prove a viable alternative to surgical defenestration.