The Tricky Question List

I can give you a six-word formula for success: Think things through – then follow through.
Eddie Rickenbacker

Okay, you haven’t operated on the 20-year-old boy with a splenic AAST grade III injury, and he has been fine. After 48 hours, a CT scan shows no pseudoaneurysm or any other complications. Just at the discharge moment (3rd day), here comes the long list of (mommy) tricky questions:

Doctor, when can he play basketball again?
Doctor, can he drive? And a motorbike? Because he drives like a fool, you know? And his friends too. It’s better if he doesn’t go by motorbike, right?
Doctor, when can he go to the gym again?
Doctor, tell him he can’t go on a trip to Vietnam next month.
Doctor, how do we know that everything is fine? Doesn’t he need another CT?
But will his spleen work well? Because I have read that people with spleen injuries need extra vaccinations.

And a long etc…

So, what do you say? And if it’s an AAST grade I injury? Or an AAST grade IV that has been embolized? Do your answers change?

And still more: How long has he had to be in bed? Would you discharge this patient on the 3^rd day? What are your criteria for repeating a CT scan in splenic injuries after non-operative management (NOM)? Do you consider using contrast-enhanced ultrasound (CEUS) instead of CT?

Lots of questions I am sure you have had at some point. What is the evidence about it? Let’s bring it together!

Note that EAST guidelines on non-operative management of spleen injuries are from 2012 and WSES guidelines on splenic trauma are from 2017. In 2022, there was a WSES consensus document that covered areas not addressed by the WSES guidelines. The evidence presented here mainly derives from the WSES recommendations.

Before we begin, would you like a brief refresher on the AAST and WSES classifications for splenic injuries?

Great, let’s tackle all the tricky questions about follow-up in the non-operative management of spleen injuries!

1. Bed Rest:

Low-grade (WSES Class I, AAST Grades I-II):
- Allow early mobilization within 24h (conditional recommendation, low quality of evidence)

Moderate (WSES Class II, AAST grade III):
- Allow mobilization after 2 days from the trauma if no other contraindications exist (conditional recommendation, low quality of evidence)
- Clinical and laboratory observation associated with bed rest in the first 48-72h (Grade of recommendation (GoR) 1C)

High-grade (WSES Class III, AAST grade IV-V):
- If no other contraindications to early mobilization exist, the patient can be mobilized safely after 2 days from the trauma when three successive hemoglobin 8 h apart after the first are within 10% of each other, and if clinical parameters remain stable (conditional recommendation, low quality of evidence)
- Clinical and laboratory observation associated with bed rest in the first 48-72h (GoR 1C)

2. Hospital Admission:

Low-grade (WSES Class I, AAST Grades I-II):
- 1 day of hospital admission (conditional recommendation, moderate quality of evidence)

Moderate to high-grade (WSES Class II, AAST grade III):
- 3 days of hospital admission, with the duration of stay based on hemodynamic status, hemoglobin and hematocrit stability, and results of the follow-up CEUS/CT scan at 48–72 h for adult patients (conditional recommendation, moderate quality of evidence)

Early discharge after NOM for blunt splenic injury should be accompanied by education regarding the risk of outpatient rupture.

3. ICU Admission:

Admission to a monitored setting (i.e. ICU) is suggested for adult patients with high-grade splenic injuries treated with NOM (conditional recommendation, low quality of evidence).

4. Venous Thromboembolic Prophylaxis:

EAST guidelines in 2012 established that pharmacologic prophylaxis to prevent deep venous thromboembolism (DVT) could be used for patients with isolated blunt splenic injuries without increasing the failure rate of NOM. However, until ten years later, the optimal timing of safe initiation was not determined. In 2022, a systematic review and meta-analysis evaluated early (< 48 h) compared to late initiation of VTE prophylaxis (VTEp) in adult trauma patients with blunt abdominal solid organ injury managed nonoperatively. Ten cohort studies met inclusion criteria, with a total of 4642 patients. Meta-analysis revealed a statistically significant increase in the risk of failure of NOM among patients receiving early VTEp (OR 1.76, 95% CI 1.01–3.05, p = 0.05). Odds of DVT were significantly lower in the early group (OR 0.36, 95% CI 0.22–0.59, p < 0.0001). There was no difference in mortality (OR 1.50, 95% CI 0.82–2.75, p = 0.19). All studies were at serious risk of bias due to confounding. The conclusion was that initiation of VTEp earlier than 48 h following hospitalization is associated with an increased risk of failure of NOM but a decreased risk of DVT, so initiation of VTEp at 48 h may balance the risks of bleeding and DVT. The WSES consensus suggested that in blunt splenic injuries treated non-operatively (with/without splenic artery embolization), in the absence of specific complications, VTEp with low-molecular-weight heparin can be started (conditional recommendation, moderate quality of evidence):

WSES Class I (AAST Grades I–II): Within 24 h from hospital admission
WSES Class II–III (AAST Grades III–V): Within 48–72 h from hospital admission

5. Splenic Artery Embolization:

The WSES panel suggested (conditional recommendations, moderate quality of evidence):

Splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan irrespective of injury grade
WSES Class III injuries (AAST Grades IV-V): Angiography and eventual SAE in all hemodynamically stable adult patients even in the absence of CT blush (especially when concomitant surgery that requires a change of position is needed)
WSES Class II injuries (AAST Grade III) without contrast extravasation: low threshold for SAE in the presence of risk factors for NOM failure (age >55 years old, high injury severity score, need for red cell transfusions, anticoagulant therapy, HIV disease, cirrhosis, and drug addiction)

6. Follow-Up Imaging:

6.1 During Admission:

Radiological follow-up is used, but there is no clear information regarding the timing and type of imaging (CT vs. CEUS); thus, imaging follow-up is usually based on clinical judgment and has been widely debated. In expert hands and dedicated institutions, using CEUS as an alternative imaging modality in the follow-up of conservatively managed splenic trauma allows to reduce the number of CT examinations, especially important in children. There is a multi-centric international diagnostic cross-sectional study (i.e. PseAn Study) going on with the aim to evaluate and compare the CT scan with the CEUS in the follow-up of hepatic, splenic, and renal trauma in adults for the detection of post-traumatic vascular lesions (i.e. pseudoaneurysms), with the primary objective to verify whether CT scan and CEUS have a sensitivity and specificity statistically comparable in the identification of post-traumatic intraparenchymal vascular lesions.

At the moment, WSES recommendations are:

Low grade (WSES Class I or AAST Grades I–II):
- No routine imaging follow-up (conditional recommendation, low quality of evidence)
Moderate or Severe (WSES Class II/ AAST Grade III or higher):
- Repeat imaging with CT scan in 48–72 h post-admission and, eventually, at 5–7 days of trauma (only if remarkable changes in CT scan at 72 h are detected, or new signs/symptoms related to the trauma occur), regardless of whether SAE has been performed or not (conditional recommendation, low quality of evidence)
CT scan repetition during the admission should also be considered in (GoR 2A):
- Decreasing of the hematocrit, presence of vascular anomalies or underlying splenic pathology, coagulopathy, or neurologically impaired patients

6.2 Post-Discharge:

The role of radiological follow-up before returning to normal activity remains controversial. The mean time to healing in AAST grade I, II, III, and IV injuries is 3.1, 8.2, 12.1, and 20.7 weeks, respectively. More than 50% of patients present progressive healing at CT scan after 6 weeks, and complete healing of almost all grades is observed 3 months after the injury. Overall, the choice to perform imaging follow-up after discharge includes several considerations:

Presence of risk factors for long-term complications: underlying splenic pathology, coagulopathy, neurologically impaired patients;
Level of activity: professional athletes, those practicing high-impact sports, heavy lifting;
Association with other injuries that would warrant other specific follow-ups;
Age: in pediatric patients, it is recommended the use of CEUS;
Type of NOM utilized (e.g., strictly observational or including interventional radiology).

WSES recommendations about imaging follow-up before returning to major physical activity (conditional recommendations, low quality of evidence) are:

Low grade (WSES Class I or AAST Grades I–II): not necessary
Moderate or severe grade (WSES Class II-III, AAST Grade III-V): contrast-enhanced imaging follow-up (i.e. CT/CEUS) before returning to major physical activity (2-4 months in high-grade injuries)

7. Activity Restriction:

The return to normal activity is recommended 3 weeks after splenectomy and after 2.5–3 months after NOM.

WSES conditional recommendations for adults based on low-quality evidence (GoR 2C) are:

Major activity restrictions (athletic activities, no-contact sports, heavy lifting):
- Low-grade (WSES Class I, AAST Grades I–II): 3-5 weeks
- Moderate or high grades (WSES Classes II–III, AAST Grade III–V): 2-4 months. A follow-up imaging with contrast-enhanced CT/CEUS is suggested before returning to full activities to confirm healing
Long trips: Patients undergoing NOM should be counseled to not remain alone or in isolated places for the first weeks after the discharge, and they should be warned regarding the alert symptoms.

8. Vaccination After Splenic Angioembolization:

In 2022 a systematic review and meta-analysis driven by the EAST identified nine studies that compared a total of 240 embolization patients to 443 control patients who neither underwent splenectomy nor were embolized. There was no statistical difference between the splenic immune function of embolized and control patients. In addition, a total of 3974 splenectomy patients were compared with 686 embolization patients. Embolization patients had fewer infectious complications and a greater degree of preserved splenic immune function. The conclusion was that post-splenectomy vaccinations were not recommended in adult patients who have undergone splenic angioembolization (Level III of evidence).

WSES recommendations for adults are:

No routine vaccination for overwhelming post-splenectomy infection (OPSI) from encapsulated bacteria in patients treated with NOM for splenic injury with or without embolization (conditional recommendation based on moderate quality of evidence)
A tailored approach driven by the immunologic state of the patient before the splenic injury and taking into account possible effects of SAE in losing 50% or more of spleen mass. If 50% or more of the splenic mass is lost, and in every case of WSES Class III (AAST Grade V) injuries, patients might be considered as asplenic and potentially more susceptible to OPSI; therefore, they could receive immunization against encapsulated organisms (conditional recommendation based on low quality of evidence)

Just in case, if you have an immunodeficient patient with a AAST Grade V injury with NOM (or if you have operated on this patient), remember the vaccination recommendations:

So, this is all, folks!

We hope you’re now ready to answer all parents’ questions…

See you soon!

Namasté!

References:

1. Stassen NA, et al. Selective nonoperative management of blunt splenic injury: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma 2012;73:S294-300.
2. Coccolini F, et al. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg 2017;18:12:40.
3. Podda M, et al. Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document. World J Emerg Surg 2022;17:52.
4. Lamb T, et al. Timing of pharmacologic venous thromboembolism prophylaxis initiation for trauma patients with nonoperatively managed blunt abdominal solid organ injury: a systematic review and meta-analysis. World J Emerg Surg 2022;17:19.
5. Freeman JJ, et al. Vaccination after spleen embolization: A practice management guideline from the Eastern Association for the Surgery of Trauma. Injury 2022;53:3569-74.
6. Virdis F, et al. Detection of post-traumatic abdominal pseudoaneurysms by CEUS and CT: A prospective comparative global study (the PseAn study)-study protocol. Front Surg 2023:10:112408.
7. Bonanni P, et al. Recommended vaccinations for asplenic and hyposplenic adult patients. Hum Vaccin Immunother 2017;13:359-68.

How to Cite This Post

Llaquet H, Marrano E, Bellio G, Cioffi SPB. The Tricky Question List. Surgical Pizza. Published on July 13, 2024. Accessed on October 1, 2024. Available at [https://surgicalpizza.org/trauma/the-tricky-question-list/].