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JHSGR Management of blunt splenic injuries

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

2 Introduction Spleen is the most frequently injured organ in blunt trauma Spleen plays an important role in immune function Overwhelming 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 deceleration Road Traffic Accidents Direct force Fell from height/ sports Iatrogenic Risks: Pre-existing illness Splenomegaly due to haematological disease / malaria/ Infectious mononucleosis

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

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

7 AAST Grading of splenic injury

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 diameter Laceration of 1-3cm in depth and not involving trabecular vessels

10 Grade 3 Subcapsular >50% surface area or expanding
Ruptured subcapsular or intraparenchymal hematoma Intraparenchymal haematoma >5 cm or expanding 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)

12 Grade 5 Shattered spleen / Hilar vascular injury

13 Management

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

15 Haemodynamic stable Non operative management with close monitoring
Vital signs, haemoglobin levels 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? 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 days Highly dependency unit and step down afterwards Jason Smith. Journal of Trauma 2007

17 Successful rate of NOM Jason Smith. Journal of Trauma 2007

18 Non operative management
Risk factors for failure Higher grading of splenic injuries larger quantity of haemoperitoneum older age 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 Increase up to 97% Indications: Contrast extravasation, pseudoaneurysm, grade 4 injuries Ashraf 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 admission 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 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. 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 Pneumococcal , then booster after 5 years Hamemophilus influenza B Meningococcal every 3 -5 years Two weeks after emergency splenectomy Education Bracelet/Card Guidelines from the Centers for Disease Control and Prevention Shatz DV .Journal of trauma 2002, 1998

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

30 Summary Operation if haemodynamic unstable
Only stable patient are admitted for observation for 3-5 days CT for assessing degree of injuries Grade 5 injuries need operation 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 Advise activity restriction according to the grade of injuries Vaccination /education for infection prophylaxis Follow up CT scan should be considered in selected patients

31 Management

32 Thank You

33 Latent pseudoaneurysm may present ~ 24-48 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: Complications
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 Thicker and more fibrous splenic capsule Tolerate higher grade of injuries with non operative management Complications Very low incidence For delayed splenic rupture (0 case in one metaanalysis 1083 patient vs 5-6% in adult) 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) 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 Strenuous activity
Light housework, office work, low impact aerobic activity Strenuous activity Running, lifting over twenty pounds, cosntruction work, manual labor 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 Delayed rupture spleen 1% Splenic Pseudocyst Splenic necrosis/abscess Splenectomy Overwhelming postsplenectomy Infection (OPSI)

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