Trauma Surgery

Saving Private Spleen – Part 1

If you’re not a liberal at twenty, you have no heart. If you’re not a conservative at forty, you have no brain.

Winston Churchill

Ok guys… Let’s talk about basic trauma… But maybe not so basic after all…

In first-world countries blunt trauma rule over penetrating injuries… Car crashes, pedestrian-vehicle accidents, falls, assaults, sports clashes, etc…

The spleen is quite a delicate organ located in the left upper quadrant of the abdominal cavity. Although it is well protected by the ribcage, it is frequently involved in blunt trauma. Until a few years ago, splenic trauma was a clear and direct indication for surgery… but, is it still true?

Let’s start with our usual case scenario…

It’s about 10 PM, and you are on-call. You are leaving the Emergency Department after a couple of calls, but the ED doctor tells you a new patient has just come in.

A – Kenny, 24-year-old male;
T – Around 8.30 PM;
M – Soccer game clash;
I – Pain on the left lower ribcage, increased during the respiratory movements and at touching;
S – BP 105/70; HR 85 bpm; RR 16 bpm; SatO2 98% in room air; Temperature 36.4°C;
T – Nil. He came on his own after having finished the game.

You start your usual ATLS protocol (always follow the rules, even if the trauma seems stupid).

A – Airways patent; no C-spine pain;
B – Pain on the left ribcage, normal bilateral lung sounds;
C – Pain on the left ribcage when touching the abdominal left upper quadrant, pelvis stable;
D – GCS 15, pupils equal and reactive to light, no neurologic impairment;
E – Nil.

As your ATLS protocol expects, you conclude your evaluation with blood gas, chest and pelvic x-rays, and E-FAST…

Blood Gas – pH 7.38, HCO3 22.2 mmol/L, pO2 94 mmHg, pCO2 37 mmHg, Hb 13.4 g/dL, Lac 4.3 mmol/L, BE -5.3 mmol/L;
Chest X-Ray – Left IX, X, XI rib fractures, no pneumothorax;
Pelvic X-Ray – Nil;
E-FAST – Small amount of free fluid in the left upper quadrant and the pelvis.

Ok, now… What are you going to do? Surgery? CT scan? Monitoring? Discharge?…
Easy answer: contrast-enhanced abdominal CT scan (he is hemodynamically stable and he has free abdominal fluid )…
So then… The CT scan showed an isolated splenic injury. In detail, the CT scan report describes a 6×4 cm subcapsular hematoma with active intraperitoneal bleeding, and free fluid in the left upper quadrant and the pelvis.
Now, the million-dollar question is: What do you do?…

Obviously, not all patients can be managed in the same way. Each patient deserves the best treatment available for his/her specific conditions.

To avoid any confounding factors and to make it easier to understand, we are going to consider only isolated splenic blunt injuries.

Let’s begin…

Operative Management

As we said before, splenectomy was the mainstream treatment for splenic trauma until a few years ago. However, nowadays, operative management should be used only in selected cases, and the indication of splenectomy is quite straightforward. This is the reason why we started our digression with the most invasive treatment option. Once we have ruled it out, we can focus more accurately on which are the other “innovative” alternatives.

But, first thing first: why splenectomy should be avoided whenever possible?

The reasons are essentially the following:

  • Surgery always carries intraoperative and postoperative morbidity (further bleeding, infections, adhesive small bowel obstruction, etc…);
  • Patients are not so happy about laparotomies (do not even think about laparoscopy);
  • Overwhelming post-splenectomy infection (OPSI).

The principal indication of splenectomy is hemodynamic instability despite appropriate resuscitation. An additional acceptable indication is moderate and severe injuries in stable patients in centers where close monitoring and/or conservative management is not available (and the patient cannot be transferred to a higher-level center).

Remember that failure of conservative management is not an absolute indication of surgery.

As you have probably noticed, we didn’t talk about splenic salvage techniques, such as topical hemostatic agents, cautery, argon beam coagulation, splenorrhaphy, mesh wrapping, and partial splenectomy. We do not believe in such techniques in isolated splenic injuries requiring surgery. Moreover, they should be used only in high-volume centers with extensive trauma experience.

Similarly, we cannot advocate the use of laparoscopy in such patients.

Splenic Injury Classification

The first step to take in the management of splenic trauma is to classify the injury according to a severity grading.

Two main classifications exist for splenic injuries: one by the American Association for the Surgery of Trauma (AAST) and the other by the World Society of Emergency Surgery (WSES).

The AAST classification was revised in 2018 and it is a radiological classification. It divides the splenic injuries into 5 grades:

AAST Grade CT Findings
Grade ISubcapsular hematoma <10% surface area Parenchymal laceration <1 cm depth Capsular tear
Grade IISubcapsular hematoma 10-50% surface area; intraparenchymal hematoma <5 cm Parenchymal laceration 1-3 cm
Grade IIISubcapsular hematoma >50% surface area; ruptured subcapsular or intraparenchymal hematoma ≥5 cm Parenchymal laceration >3 cm
Grade IVAny injury in the presence of a splenic vascular injury or active bleeding confined within the splenic capsule Parenchymal laceration involving segmental or hilar vessels producing >25% devascularization
Grade VAny injury in the presence of splenic vascular injury with active bleeding extending beyond the spleen into the peritoneum Shattered spleen
Vascular injury is defined as a pseudoaneurysm or arteriovenous fistula. More than one grade of splenic injury may be present and should be classified by the higher grade of injury.

On the other hand, the WSES classification is based upon the AAST one, but it adds a parameter: the hemodynamic status.

WSES ClassAAST GradeHemodynamic Status
MinorWSES II-IIStable
ModerateWSES IIIIIStable
WSES IIIIV-VStable
SevereWSES IVI-VUnstable

From this classification, it is possible to easily determine that patients needing immediate operative management are those with a WSES IV splenic injury. However, since the AAST classification was revised in 2018, the WSES classification is now “outdated”. Moreover, if a patient is hemodynamically unstable and he/she does not respond to appropriate resuscitation, surgery needs to be performed way before CT scan. Therefore, you don’t have the radiological features to categorize the splenic injury and, consequently, you don’t have either the AAST or the WSES classification.

To avoid any source of confusion, we will use only the 2018 updated AAST classification.

Conservative Management

Ok… Now it is pretty clear that you have to remove the spleen when your patient is hemodynamically unstable… But, what to do with all the others?

The so-called conservative management in splenic trauma is not as simple and immediate as it may seem… And everything depends upon one thing… The CT scan result.

Conservative management includes different options:

  • Non-operative management (i.e. observation with/without monitoring);
  • Interventional radiology (i.e. angiography with/without angioembolization).

The questions many surgeons ask on the conservative management of splenic trauma are: Is it really safe? What if it fails?

Well… Like everything in medicine, conservative management is not fully effective in 100% of cases. However, the literature reports the failure rate of conservative management is about 10%.

Be careful when you read the term “conservative management” because it is not always perfectly clear what the authors consider as conservative management. Sometimes it is just observation, other times it includes splenic artery embolization as well.

Considering the AAST splenic injury grading, failure of conservative management increases along with the increase of the grading (from 5% of grade I injuries to 75% of grade 5 injuries). Similarly, the higher the Injury Severity Score, the higher the failure rate.

Nevertheless, Peitzman et al. showed that patients who failed the conservative management had a higher mortality rate compared to those who were successfully observed. Yet, patients who went directly to the OR had higher mortality compared to those who failed the observation. Moreover, the literature agrees on the fact that more than half of patients fail the non-operative management (NOM) within the first 24 hours from the admission, 75% within 48 hours, and 95% within 72 hours. This means these patients need to be closely monitored in an intensive setting for the first 1-3 days and can be safely discharged afterward.

As we said earlier, the CT scan is the cornerstone in deciding the best approach to patients with an isolated blunt splenic injury. For this reason, it must be done properly in order to obtain adequate images and to avoid missing any important information. The golden rules to obtain a satisfactory CT scan in suspected splenic injuries are:

  • Acquire images in at least two phases (arterial and venous/delayed);
  • Put the patient’s arms away from the torso;
  • Administer at least 100 mL of contrast volume;
  • The contrast bolus timing should be >4 mL/sec.

Remember: adequate images allow adequate treatment, otherwise it is possible to underestimate the splenic injury grading.
You need to decrease as much as possible the failure rate of your conservative management.

Let’s stop here for now…
Next time we will discuss the splenic artery embolization technique and all that comes after the initial management.

And remember… be strong, be brave, be an acute care surgeon!

Acknowledgment

We want to thank our friend Alan Biloslavo for helping us in the collection of all the literature required to write this post.

References
  1. Kozar RA, et al. Organ injury scaling 2018 update: spleen, liver, and kidney. J Trauma Acute Care Surg 2018;85:1119-22.
  2. Rowell SE, et al. Western Trauma Association Critical Decisions in Trauma: Management of adult blunt splenic trauma – 2016 updates. J Trauma Acute Care Surg 2016;82:787-93.
  3. Coccolini F, et al. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg 2017;12:40.
  4. Cirocchi R et al. Is non-operative management safe and effective for all splenic blunt trauma? A systematic review. Critical Care 2013;17:R185.
  5. Sartorelli KH, et al. Nonoperative management of hepatic, splenic, and renal injuries in adults with multiple injuries. J Trauma Acute Care Surg 2000;49:56-61.
  6. Watson GA, et al. Nonoperative management of blunt splenic injury: what is new? Eur J Trauma Emerg Surg 2015;41:219-28.
  7. Teuben MPJ, et al. Safety of selective nonoperative management for blunt splenic trauma: the impact of concomitant injuries. Patient Safety in Surgery 2018;12:32.
  8. Peitzman AB, et al. Blunt splenic injury in adults: multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2000;49:177-87.
  9. Harmon L, et al. Delayed splenic hemorrhage: myth or mystery? A Western Trauma Association multicenter study. Am J Surg 2019;218:579-83.
  10. Scarborough JE, et al. Nonoperative management is as effective as immediate splenectomy for adult patients with high-grade blunt splenic injury. J Am Coll Surg 2016;223:249-58.
  11. Amico F, et al. Grade III blunt splenic injury without contrast extravasation – World Society of Emergency Surgery Nijmegen consensus practice. World Journal of Emergency Surgery 2020;15:46.
  12. Stassen NA, et al. Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012:73:S294-300.
  13. Zarzaur BL, et al. An update on nonoperative management of the spleen in adults. TSACO 2017;2:e000075.
  14. Miller PR, et al. Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management. J Trauma Acute Care Surg 2002;53:238-42.
How to Cite This Post

Bellio G, Marrano E. Saving Private Spleen – Part 1. Surgical Pizza. Published on April 24, 2021. Accessed on July 31, 2021. Available at [https://surgicalpizza.org/trauma/saving-private-spleen-part-1/].

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