Presentation on theme: "JHSGR Management of blunt splenic injuries"— Presentation transcript:
1 JHSGR Management of blunt splenic injuries Dr PT Chan /QEH
2 IntroductionSpleen is the most frequently injured organ in blunt traumaSpleen plays an important role in immune functionOverwhelming Post splenectomy Infection (OPSI) %Mortality 50%-70%Takehiro Okabayashi,.World Journal of Gastroenterology 2008
3 Change in the approach to splenic injury Operative splenic preservation achieved by splenorrhaphy has progressed to the non-operative management.
4 Etiology and Risks Trauma Iatrogenic Risks: Pre-existing illness Rapid decelerationRoad Traffic AccidentsDirect forceFell from height/ sportsIatrogenicRisks: Pre-existing illnessSplenomegaly due to haematological disease / malaria/ Infectious mononucleosis
5 Clinical presentation Left upper quadrant abdominal painLeft shoulder tenderness (referred pain from subdiaphragmatic nerve root irritation)Peritoneal signSigns and symptoms of shocke.g. tachycardia, restlessness, tachypnea
6 Investigation USG CT scan FAST :Look for any free peritoneal fluid Sensitivity 55%-91%, specificity %Splenic injuriessensitivity 41-63%, specificity 99%CT scanSensitivity 95% , specificity 100%
8 Grade 1 Subcapsular hematoma of less than 10% of surface area. Capsular tear of less than 1 cm in depth.
9 Grade 2 Subcapsular hematoma 10-50% of surface area Intraparenchyml hematoma < 5cm diameterLaceration of 1-3cm in depth and not involving trabecular vessels
10 Grade 3 Subcapsular >50% surface area or expanding Ruptured subcapsular or intraparenchymal hematomaIntraparenchymal haematoma >5 cm or expandingLaceration of greater than 3 cm in depth or involving trabecular vessels
11 Grade 4Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen)
14 Haemodynamic unstable Surgical interventionLaparotomy4 quadrants packedAssess the extent of splenic injuriesOnly if feasible, may consider conserving the spleenOtherwise, Splenectomy should be performedExcluded other injuriesSplenorrhaphyParenchymal suture/Fibrin glue/ABC/ Laser/omental patch/mesh bag/partial splenectomy
15 Haemodynamic stable Non operative management with close monitoring Vital signs, haemoglobin levelsSuccessful rate 80% ~89.2%Jason Smith. Journal of Trauma 2007Andrew B. Peitzman,.Journal of Trauma 2000.
16 Non operative management How long should be monitored?most failure( 95%) occur within 3 days(72hrs) of admission.(97% in 5 days, 99 % in 30 days)Suggested patients to be closely monitored for 3-5 daysHighly dependency unit and step down afterwardsJason Smith. Journal of Trauma 2007
17 Successful rate of NOMJason Smith. Journal of Trauma 2007
18 Non operative management Risk factors for failureHigher grading of splenic injurieslarger quantity of haemoperitoneumolder ageContrast extravasations in CTJason Smith.Journal of Trauma 2007Siriratsivawong K Am Surg 2007Andrew B. Peitzman. Journal of Trauma 2000.
21 AngioembolizationIncreased successful rate of non-operative management in selected policyIncrease up to 97%Indications:Contrast extravasation, pseudoaneurysm, grade 4 injuriesAshraf A. Journal of Trauma 2009
23 Complications of embolization 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?No definite guidelines, earlier for low grade injuries.77% mobilization within 72hrs after admissionDay 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 injuryAcceptable to engage in light activity for the first 3 months and then gradually return to full activityElizabeth H.American College of Sports Medicine.2010.
27 Follow upNo 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 symptomsThaemert BC. Journal of Trauma 1997
28 Prevention of Infection VaccinationPneumococcal , then booster after 5 yearsHamemophilus influenza BMeningococcal every 3 -5 yearsTwo weeks after emergency splenectomyEducationBracelet/CardGuidelines from the Centers for Disease Control and PreventionShatz DV .Journal of trauma 2002, 1998
29 Antibiotic prophylaxis No clinical trials in adults“Standby” antibioticsSome suggest 2-5 years prophylaxisLong term prophylaxis not generally recommendedDC. The Netherlands Journal of Medicine 2004
30 Summary Operation if haemodynamic unstable Only stable patient are admitted for observation for 3-5 daysCT for assessing degree of injuriesGrade 5 injuries need operationMajority of grade 4 splenic injuries are unstable and likely need to be operatedAngio/embolization can be considered for stable patients with contrast extravasation or pseudoaneurysmAdvise activity restriction according to the grade of injuriesVaccination /education for infection prophylaxisFollow up CT scan should be considered in selected patients
36 Paediatric patients Mechanism of injury: Complications More fall or sports than RTAElastic ribs readily change contour and cause rapid flexion of organs along its axis -> lacertions are more oriented to the larger segmental vesselsThicker and more fibrous splenic capsuleTolerate higher grade of injuries with non operative managementComplicationsVery low incidenceFor delayed splenic rupture (0 case in one metaanalysis 1083 patient vs 5-6% in adult)Most pseudoaneurysm will spontaneously resolve or self tamponadeNon-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 reviewPediatr 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.