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JHSGR Management of blunt splenic injuries Dr PT Chan /QEH.

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Presentation on theme: "JHSGR Management of blunt splenic injuries Dr PT Chan /QEH."— Presentation transcript:

1 JHSGR Management of blunt splenic injuries Dr PT Chan /QEH

2 Introduction Spleen is the most frequently injured organ in blunt trauma Spleen is the most frequently injured organ in blunt trauma Spleen plays an important role in immune function Spleen plays an important role in immune function Overwhelming Post splenectomy Infection (OPSI) % Overwhelming Post splenectomy Infection (OPSI) % Mortality 50%-70% Mortality 50%-70% Takehiro Okabayashi,.World Journal of Gastroenterology 2008

3 Change in the approach to splenic injury Change in the approach to splenic injury Operative splenic preservation achieved by splenorrhaphy has progressed to the non-operative management. Operative splenic preservation achieved by splenorrhaphy has progressed to the non-operative management.

4 Etiology and Risks Trauma Trauma Rapid deceleration Rapid deceleration Road Traffic Accidents Road Traffic Accidents Direct force Direct force Fell from height/ sports Fell from height/ sports Iatrogenic Iatrogenic Risks: Pre-existing illness Risks: Pre-existing illness Splenomegaly due to haematological disease / malaria/ Infectious mononucleosis Splenomegaly due to haematological disease / malaria/ Infectious mononucleosis

5 Clinical presentation Left upper quadrant abdominal pain Left upper quadrant abdominal pain Left shoulder tenderness (referred pain from subdiaphragmatic nerve root irritation) Left shoulder tenderness (referred pain from subdiaphragmatic nerve root irritation) Peritoneal sign Peritoneal sign Signs and symptoms of shock Signs and symptoms of shock e.g. tachycardia, restlessness, tachypnea e.g. tachycardia, restlessness, tachypnea

6 Investigation USG USG FAST :Look for any free peritoneal fluid FAST :Look for any free peritoneal fluid Sensitivity 55%-91%, specificity % Sensitivity 55%-91%, specificity % Splenic injuries Splenic injuries sensitivity 41-63%, specificity 99% sensitivity 41-63%, specificity 99% CT scan CT scan Splenic injuries Splenic injuries Sensitivity 95%, specificity 100% Sensitivity 95%, specificity 100%

7 AAST Grading of splenic injury

8 Grade 1 Subcapsular hematoma of less than 10% of surface area. Subcapsular hematoma of less than 10% of surface area. Capsular tear of less than 1 cm in depth. Capsular tear of less than 1 cm in depth.

9 Grade 2 Subcapsular hematoma 10-50% of surface area Subcapsular hematoma 10-50% of surface area Intraparenchyml hematoma < 5cm diameter Intraparenchyml hematoma < 5cm diameter Laceration of 1-3cm in depth and not involving trabecular vessels Laceration of 1-3cm in depth and not involving trabecular vessels

10 Grade 3 Subcapsular >50% surface area or expanding Subcapsular >50% surface area or expanding Ruptured subcapsular or intraparenchymal hematoma Ruptured subcapsular or intraparenchymal hematoma Intraparenchymal haematoma >5 cm or expanding Intraparenchymal haematoma >5 cm or expanding Laceration of greater than 3 cm in depth or involving trabecular vessels Laceration of greater than 3 cm in depth or involving trabecular vessels

11 Grade 4 Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen)

12 Grade 5 Shattered spleen / Hilar vascular injury Shattered spleen / Hilar vascular injury

13 Management

14 Haemodynamic unstable Surgical intervention Surgical intervention Laparotomy Laparotomy 4 quadrants packed 4 quadrants packed Assess the extent of splenic injuries Assess the extent of splenic injuries Only if feasible, may consider conserving the spleen Only if feasible, may consider conserving the spleen Otherwise, Splenectomy should be performed Otherwise, Splenectomy should be performed Excluded other injuries Excluded other injuries Splenorrhaphy Splenorrhaphy Parenchymal suture/Fibrin glue/ABC/ Laser/omental patch/mesh bag/partial splenectomy Parenchymal suture/Fibrin glue/ABC/ Laser/omental patch/mesh bag/partial splenectomy

15 Haemodynamic stable Non operative management with close monitoring Non operative management with close monitoring Vital signs, haemoglobin levels Vital signs, haemoglobin levels Successful rate 80% ~89.2% Successful rate 80% ~89.2% Jason Smith. Journal of Trauma 2007 Andrew B. Peitzman,.Journal of Trauma 2000.

16 Non operative management How long should be monitored? How long should be monitored? most failure( 95%) occur within 3 days(72hrs) of admission. most failure( 95%) occur within 3 days(72hrs) of admission. (97% in 5 days, 99 % in 30 days) (97% in 5 days, 99 % in 30 days) Suggested patients to be closely monitored for 3-5 days Suggested patients to be closely monitored for 3-5 days Highly dependency unit and step down afterwards Highly dependency unit and step down afterwards Jason Smith. Journal of Trauma 2007

17 Successful rate of NOM

18 Non operative management Risk factors for failure Risk factors for failure Higher grading of splenic injuries Higher grading of splenic injuries larger quantity of haemoperitoneum larger quantity of haemoperitoneum older age older age Contrast extravasations in CT Contrast extravasations in CT Jason Smith.Journal of Trauma 2007 Siriratsivawong K Am Surg 2007 Andrew B. Peitzman. Journal of Trauma 2000.

19 Non operative management

20 Andrew B. Peitzman. Journal of Trauma 2000.

21 Angioembolization Increased successful rate of non-operative management in selected policy Increased successful rate of non-operative management in selected policy Increase up to 97% Increase up to 97% Indications: Indications: Contrast extravasation, pseudoaneurysm, grade 4 injuries Contrast extravasation, pseudoaneurysm, grade 4 injuries Ashraf A. Journal of Trauma 2009

22

23 Complications of embolization Total splenic infarction (9.5%), rebleeding (19%), splenic atrophy (4.8%), partial infarction (38%), pleural effusion (33%). Total splenic infarction (9.5%), rebleeding (19%), splenic atrophy (4.8%), partial infarction (38%), pleural effusion (33%). Shih-chi Wu. World journal of surgery 2008

24 Resolution and Progression Time of mobilization? Time of mobilization? No definite guidelines, earlier for low grade injuries. No definite guidelines, earlier for low grade injuries. 77% mobilization within 72hrs after admission 77% mobilization within 72hrs after admission Day of mobilization was not associated with delayed splenic rupture. Day of mobilization was not associated with delayed splenic rupture. London JA.Arch Surg

25 % of patients remained unhealed over time (days) Stephanie A.Journal of Trauma. 2008

26 Activity Restriction-Athletes No consensus on return to play after splenic injury No consensus on return to play after splenic injury Acceptable to engage in light activity for the first 3 months and then gradually return to full activity Acceptable to engage in light activity for the first 3 months and then gradually return to full activity Elizabeth H.American College of Sports Medicine.2010.

27 Follow up No evidence that routine follow up serial CT scans without clinical indications influenced the outcome or management. No evidence that routine follow up serial CT scans without clinical indications influenced the outcome or management. Imaging maybe considered if patient has a high grade of injury/ still experiencing symptoms Imaging maybe considered if patient has a high grade of injury/ still experiencing symptoms Thaemert BC. Journal of Trauma 1997

28 Prevention of Infection Vaccination Vaccination Pneumococcal, then booster after 5 years Pneumococcal, then booster after 5 years Hamemophilus influenza B Hamemophilus influenza B Meningococcal every 3 -5 years Meningococcal every 3 -5 years Two weeks after emergency splenectomy Two weeks after emergency splenectomy Education Education Bracelet/Card Bracelet/Card Guidelines from the Centers for Disease Control and Prevention Shatz DV.Journal of trauma 2002, 1998

29 Antibiotic prophylaxis Antibiotic prophylaxis No clinical trials in adults No clinical trials in adults Standby antibiotics Standby antibiotics Some suggest 2-5 years prophylaxis Some suggest 2-5 years prophylaxis Long term prophylaxis not generally recommended Long term prophylaxis not generally recommended DC. The Netherlands Journal of Medicine 2004

30 Summary Operation if haemodynamic unstable Operation if haemodynamic unstable Only stable patient are admitted for observation for 3-5 days Only stable patient are admitted for observation for 3-5 days CT for assessing degree of injuries CT for assessing degree of injuries Grade 5 injuries need operation Grade 5 injuries need operation Majority of grade 4 splenic injuries are unstable and likely need to be operated Majority of grade 4 splenic injuries are unstable and likely need to be operated Angio/embolization can be considered for stable patients with contrast extravasation or pseudoaneurysm Angio/embolization can be considered for stable patients with contrast extravasation or pseudoaneurysm Advise activity restriction according to the grade of injuries Advise activity restriction according to the grade of injuries Vaccination /education for infection prophylaxis Vaccination /education for infection prophylaxis Follow up CT scan should be considered in selected patients Follow up CT scan should be considered in selected patients

31 Management

32 Thank You

33 Latent pseudoaneurysm may present ~ hrs after injury (2.2%) Latent pseudoaneurysm may present ~ hrs after injury (2.2%) Computed Tomography Identification of Latent Pseudoaneurysm after blunt splenic injury : Pathology or Technology

34 Hunter B.Long-Term Follow up of Children with nonoperative management of blunt spenic trauma. Journal of Trauma 2010.

35 Splenorraphy Grade 1: haemostatic agent Grade 2 : 43% + suture/mesh Grade 3 : 100% + suturing /parenchymal suture Grade 4: anatomical resection Grade 5: splenectomy PickhardtB, Operative splenic salvage in adults: a decade perspectives. Journal of Trauma 1989

36 Paediatric patients Mechanism of injury: Mechanism of injury: More fall or sports than RTA More fall or sports than RTA Elastic ribs readily change contour and cause rapid flexion of organs along its axis -> lacertions are more oriented to the larger segmental vessels Elastic ribs readily change contour and cause rapid flexion of organs along its axis -> lacertions are more oriented to the larger segmental vessels Thicker and more fibrous splenic capsule Thicker and more fibrous splenic capsule Tolerate higher grade of injuries with non operative management Tolerate higher grade of injuries with non operative management Complications Complications Very low incidence Very low incidence For delayed splenic rupture (0 case in one metaanalysis 1083 patient vs 5-6% in adult) For delayed splenic rupture (0 case in one metaanalysis 1083 patient vs 5-6% in adult) Most pseudoaneurysm will spontaneously resolve or self tamponade Most pseudoaneurysm will spontaneously resolve or self tamponade Non-operative management is the standard for all grades of splenic injuries in all haemodynamic stable patients (75-93% successful rate) Non-operative management is the standard for all grades of splenic injuries in all haemodynamic stable patients (75-93% successful rate) Peditric blunt splenic trauma: a comprehensive review Pediatr Radiol (2009)39:

37 Andrew B. Peitzman, Blunt Splenic Injury in Adults: Multi- institutional Study of the Eastern Association for the surgery of Trauma. Journal of Trauma 2000.

38 Activity Restriction Light activity Light activity Light housework, office work, low impact aerobic activity Light housework, office work, low impact aerobic activity Strenuous activity Strenuous activity Running, lifting over twenty pounds, cosntruction work, manual labor Running, lifting over twenty pounds, cosntruction work, manual labor Full activity (contact sport) Full activity (contact sport)

39 Fata P.A survey of EAST member practices in blunt splenic injury; a description of current trends and opportunities for improvement. Journal of Trauma 2005

40 Late complication of splenic injuries Non operative Non operative Delayed rupture spleen 1% Delayed rupture spleen 1% Splenic Pseudocyst Splenic Pseudocyst Splenic necrosis/abscess Splenic necrosis/abscess Splenectomy Splenectomy Overwhelming postsplenectomy Infection (OPSI) Overwhelming postsplenectomy Infection (OPSI)


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