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JHSGR Management of blunt splenic injuries

JHSGR Management of blunt splenic injuries. Dr PT Chan /QEH. Introduction. Spleen is the most frequently injured organ in blunt trauma Spleen plays an important role in immune function Overwhelming Post splenectomy Infection (OPSI) 0.05-2% Mortality 50%-70%.

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JHSGR Management of blunt splenic injuries

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  1. JHSGRManagement 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) 0.05-2% • 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 • 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 • FAST :Look for any free peritoneal fluid • Sensitivity 55%-91%, specificity 97-100% • Splenic injuries • sensitivity 41-63%, specificity 99% • CT scan • Splenic injuries • 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

  22. 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

  23. 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. 2008.

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

  25. 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.

  26. 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

  27. 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

  28. 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

  29. 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

  30. Management

  31. Thank You

  32. Latent pseudoaneurysm may present ~ 24-48 hrs after injury (2.2%) Computed Tomography Identification of Latent Pseudoaneurysm after blunt splenic injury : Pathology or Technology

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

  34. 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

  35. Paediatric patients • Mechanism of injury: • 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)39:904-916

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

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

  38. 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

  39. 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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