Trauma Surgery

Saving Private Spleen – Part 2

The truth usually lies somewhere in the middle.

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Hello guys…

Last time we explored the two extremes of splenic trauma management. In this post, we are going to see what’s in the middle and what stands after that…

Splenic Artery Embolization

Ok then… Let’s take one more step and explore the option in the middle… the splenic artery embolization (SAE).

This interventional radiology procedure seems to be the only protecting factor against failure of conservative management. In fact, in patients with grade 4 and 5 splenic injuries, SAE halves the conservative management failure rate compared to NOM.

However, even if SAE is not surgery, it carries possible complications (e.g. bleeding from the catheter insertion site, arterial dissection, etc…). Therefore, it is not appropriate to use it in all patients. Consequently, adequate patient selection is vital to balance the pros and cons of this procedure.

Splenic artery embolization finds its indications in case of:

  • Active bleeding in stable patients;
  • Splenic vascular anomalies, such as splenic artery pseudoaneurysm and/or arteriovenous fistula;
  • High-grade splenic injuries without active bleeding.

In other words, SAE is indicated in all patients with grade 4 or 5 splenic injury.

The role of SAE in patients with a grade 3 splenic injury without active bleeding is a matter of debate. A reasonable choice may be to advocate its use in patients with risk factors for failure of NOM (e.g. large subcapsular hematoma, older patients, higher ISS, large hemoperitoneum, etc…).

Once SAE is chosen as the treatment option, the choice of which embolization technique to adopt needs to be addressed. The technique is determined by the embolization location and the material used to achieve it.

Splenic arterial blood flow after proximal splenic angioembolization by Quencer et al.

For what concerns the location, it can be either proximal, distal, or combined (i.e. proximal + distal). Proximal embolization means to occlude the main trunk of the splenic artery between the dorsal pancreatic artery and the greater pancreatic artery. This means that the spleen is still vascularized through the inferior pancreatic artery, but the pressure gradient is lower, thus enhancing the chance of clot formation. On the other hand, distal embolization blocks the blood flow in the segmental vessels. In this case, splenic areas may not be vascularized, increasing the risk of wedge infarctions, abscess formation, and further bleeding, because some of the bleeding vessels may be bypassed because of vasospasm caused by hematoma.

Between the three options, proximal embolization appears more reliable and involves a lower incidence of severe complications. Proximal embolization is easier and faster to perform, needs less contrast dye and radiations, can stop the bleeding in multiple foci at once, and can be used safely even in patients without a clear bleeding site.

Similarly, embolization using coils seems to improve the overall success rate and to reduce the incidence of post-procedural complications compared to Gelfoam.

Splenic artery angioembolization with coils.

Antibiotic prophylaxis (i.e. cefazolin 1 g IV) is recommended before the procedure begins, and its switch into therapy (i.e. amoxicillin/clavulanic acid 1 g three times daily for 7 days) when a distal embolization is performed or when the splenic blood flow is severely reduced at the post-procedural angiography.

Whether to immunize patients after SAE is needed is not clear yet.

Remember that whether you decide to treat your patient either conservatively, operatively, or surgically, the deep venous thrombosis prophylaxis (low-molecular-weight heparin 100 units/kg daily) should be started as soon as the bleeding stops.

Follow-Up

The in-hospital observation and the follow-up depend upon the grading of the splenic injury:

GradingICU AdmissionDuration of MonitoringHb and Ht MeasurementsBed RestReturn to Full Activity
1No24 h3 times/dayNo4 weeks
2-3At least 24 h24 h4 times/day*24 h8 weeks
4-5At least 48 h48 h4/times/day*24-48 h12 weeks
*Afterward check every 12 h until stable (i.e. drop <0.5 g/dL between two consecutive measurements). Hb = hemoglobin; Ht = hematocrit

Another important matter of discussion is whether to perform a follow-up contrast-enhanced CT scan or not. The choice depends on the grade of injury and, consequently, on how the patient was managed:

  • Conservative management: the CT scan should be repeated in case of clinical indications (e.g. acute pain, shock, etc…), suspicion of active bleeding (e.g. drop in Hb or Ht, persistent acidosis, continuous blood transfusion requirements, increase in lactate levels, etc…), high risk of small bowel injury, suspicion of conservative management complications. Otherwise, the follow-up imaging may be repeated after a scheduled timeframe:
    • Non-operative management (i.e. observation): the CT scan should be repeated after 24-48 h;
    • Splenic artery embolization: the CT scan should be repeated after 48-72 h;
  • Splenectomy: the CT scan should be repeated every time a surgical complication is suspected (e.g. bleeding, deep collection, etc…).

However, it seems adequate not to repeat a CT scan in patients with grade 1 splenic injury. The two main reasons to repeat the imaging in all the other patients treated conservatively are to rule out new pseudoaneurysm development and to monitor the situation after the angioembolization.

In low-grade splenic injuries, the follow-up CT scan can be replaced by a contrast-enhanced ultrasound, which avoids additional radiation exposure to patients.

Treatment Recap
GradeManagement
Grade 1-2
&
Hemodynamically stable
– The failure rate of NOM is low (<10%);
– NOM is the best treatment option;
– SAE is generally not needed.
Grade 3
&
Hemodynamically stable
– The management is still controversial;
– The success rate of SAE is high (70-90%), however both observation and SAE are acceptable options.
Grade 4-5
&
Hemodynamically stable
– Observation carries a high failure rate (>40%);
– SAE should be considered in all patients because its high success rate (>90%);
– Patients who develop hypotension after SAE should be managed surgically (i.e. splenectomy).
Any grade
&
Hemodynamically unstable after adequate resuscitation
– Splenectomy.

As you have seen, what once was simple and linear has become complex. This shows exactly why there is the need to have a specialized surgeon who can manage adequately these patients.

In some countries, trauma surgeons, as well as emergency general surgeons or acute care surgeons, are recognized and active figures in everyday hospital activities. However, in many other countries, these specialists do not exist, and their role is played by elective surgeons, thus increasing the avoidable splenectomy rate.

We want to finish this post with a clinical scenario… Try to think about what should be done to treat this patient properly, and how he would be managed by an elective surgeon…

Peace…

Handover:
A – Kenny, 19-year-old male;
T – Around 10.30 AM;
M – Pedestrian-vehicle accident;
I – Pain on the left ribcage, left displaced mid-shaft femur fracture;
S – BP 103/62; HR 98 bpm; RR 23 bpm; SatO2 95% in room air; Temperature 36.2°C;
T – Spinal board with head block and straps, pelvic binder, left leg splinted, IV lines (2x) and 500 mL crystalloids infused, oxygen mask at 4 L/min.

ATLS evaluation:
A – Airways patent; no C-spine pain;
B – Pain on the left ribcage, reduced left lung sound;
C – No abdominal tenderness, pelvis not evaluated because pelvic binder in place;
D – GCS 14, pupils equal and reactive to light, no neurologic impairment;
E – Left closed mid-shaft femur fracture already splinted, peripheral pulses present and symmetrical.

ATLS adjuncts:
Blood Gas – pH 7.33, HCO3 17.4 mmol/L, pO2 98 mmHg, pCO2 32 mmHg, Hb 11.2 g/dL, Lac 6.7 mmol/L, BE -7.6 mmol/L;
Chest X-Ray – Left VIII, IX, X rib fractures, left pneumothorax;
Pelvic X-Ray – Nil;
Left Femur X-Ray – left mid-shaft fracture;
E-FAST – free fluid in all the abdominal windows, left pneumothorax.

An intercostal drain is inserted into the left chest to drain the pneumothorax, and the pelvic binder is removed.

Contrast-enhanced CT scan: Small pneumothorax, well-positioned left ICD, left VII, VIII, IX, X, XI rib fractures. Large hemoperitoneum. Splenic laceration along with a large subcapsular hematoma (7×5 cm), pseudoaneurysm, arteriovenous fistula, and active intraperitoneal bleeding.

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. 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.
  8. Harmon L, et al. Delayed splenic hemorrhage: myth or mystery? A Western Trauma Association multicenter study. Am J Surg 2019;218:579-83.
  9. 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.
  10. Wei B, et al. Angioembolization reduces operative intervention for blunt splenic injury. J Trauma Acute Care Surg 2008;64:1472-7.
  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. Rong JJ, et al. The impacts of different embolization techniques on splenic artery embolization for blunt splenic injury: a systematic review and meta-analysis. Mil Med Res 2017;4:17.
  13. Quencer KB, et al. Review of proximal splenic artery embolization in blunt abdominal trauma. CVIR Endovascular 2019;2:11.
  14. Bankhead-Kendall B, et al. Vaccination practices in trauma patients undergoing splenic artery embolization: a split practice. Am Surg 2020;86:1202-4.
  15. 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.
  16. Zarzaur BL, et al. An update on nonoperative management of the spleen in adults. TSACO 2017;2:e000075.
How to Cite This Post

Bellio G, Marrano E. Saving Private Spleen – Part 2. Surgical Pizza. Published on May 1, 2021. Accessed on July 31, 2021. Available at [https://surgicalpizza.org/trauma/saving-private-spleen-part-2/].

3 Comments

  • Kobe

    Thanks for the useful infomation.

    What reference indicates the table of Follow-Up?

    Is the grade AAST’s one or WSES’s one?

    • SurgicalPizza
      SurgicalPizza

      Hi Kobe.. Thank you for your question and for following our blog!!!
      The follow-up table refers to the paper by Rowell et al. (Ref.2).
      As stated in the previous post, to avoid any source of confusion, we only used the AAST classification.
      Hope it will help you in your everyday practice..😁

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