Splenic trauma – conservative versus operative treatment

Summary

Introduction:
Due to the important function of the spleen in human immune responses, the world is currently seeking means of conservative or minimally invasive therapy. Extended criteria for conservative procedures necessitate more patient monitoring, available angioembolization of the spleen, or urgent laparotomy.

Methods:
Evaluation of a group of patients treated with conservative or surgical procedures after thoracoabdominal spinal injury with splenic injury at the Department of Trauma Surgery of the University Hospital Brno for the period 01/2012 - 01/2017. We evaluated the grade of splenic injury, type of treatment of individual injury grades, baseline circulatory stability and possible complications during hospitalization.

Results:
The evaluated group consisted of 37 patients with an average age of 39.6 years. 21.6% of patients were treated for problems occurring within 24 hours or more after injury. Primarily conservatively were treated 51.4% of patients with the average grade AAST 1.9. 48.6% of the patients were treated primarily, with the average incidence of AAST 3.2. Only 2 patients (5.4%) showed signs of haemodynamic instability and were indicated for emergency laparotomy. Conservative treatment failure occurred in 15.8% of patients. Complications following splenectomy occurred in 15% of patients (bleeding from gastrices breves arteries, incipient obstructive ileus requiring adhesiolysis, abscess collection in the spleen bed).

Conclusion:
The current trend in treating splenic injuries in haemodynamically stable patients is a non-surgical procedure, regardless of the grade of injury. Consideration should be given to associated co-morbidities, age of the patient and the nature of associated injuries. The likelihood of failure of the conservative treatment regimen at our workplace is consistent with the world outcomes.

Keywords:
Emergency splenectomy, delayed splenectomy, conservative treatment.

INTRODUCTION

Splenic trauma is the most frequent cause of haemoperitoneum in patients with blunt abdominal injuries or thoracoabdominal trauma, with the energy of the impact being directed towards the left half of the lower chest and hypochondrium. The mechanism of injury typically includes high-energy trauma, such as traffic accidents and falls from heights, which occur mostly as a part of polytrauma, or may occur as direct abdominal injuries caused with hitting or falling onto a foreign object in monotrauma. Open injuries are observed only rarely in our country, when compared with blunt thoracoabdominal injuries.

Spleen is located in the upper left quadrant of the abdomen, below the diaphragm, and is protected on the outside with the 9^th-11^th rib (Saegesser’s ribs); the parenchyma is covered with a wrapping – capsula. From the physiological point of view, spleen is a significant source of antibodies, namely against encapsulated pathogens, such as Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitides, and also protozoan organisms [1, 9, 17, 24, 28].

The diagnostic methods used in patients with abdominal injuries include mainly anamnestic data obtained from the patient, and overall clinical examination, including per rectum exam. Paraclinical methods include laboratory examinations and diagnostic imaging methods. CT examination with intravenous administration of the contrast agent is considered a golden standard. The overall precondition for CT performance is a hemodynamic stability of the patient. In many cases, “bed-side” ultrasonography examination, known as FAST (Focused Assessment with Sonography in Trauma), is the first treatment of choice. Experienced radiologists may be able to diagnose the approximate grade of splenic or hepatic trauma, active haemorrhage, with sensitivity, specificity and accuracy of up to 89%, 97% and 96% respectively. Nevertheless, up to 42% of false negative findings of ultrasonography examination are reported. Considering the above-stated, the significance of multidetector CT in case of inconsistent findings is clear [6, 20]. FAST is a clear technique of choice in haemodynamically unstable patients. Another technique, which is practically not used any more, is so called diagnostic peritoneal lavage; this procedure is highly sensitive for the presence of blood in the abdominal cavity, however, it is not specific and has been replaced with imaging modalities. Laboratory examination and findings are not absolutely reliable criteria, especially early after injury. However, they are required for further controls and continuous monitoring of coagulation and complete blood count parameters [20].

Regarding therapeutic interventions, we have the possibility of conservative treatment, which includes admission of the patient to the hospital to a monitored surgical bed, and intensive monitoring of vital functions, laboratory parameters of complete blood count and coagulation, clinical controls and regular ultrasonography or CT examinations of the abdominal cavity [3, 4, 13, 29].

Other treatment options include miniinvasive procedures, such as selective embolization of arteria lienalis and its branches performed by interventional radiologists [8, 13, 14, 16, 22, 28]. Suitable surgical procedures include saving operations, such as splenorrhaphy, partial splenectomy, and packing with the use of resorbable nets or fibrin glues. In haemodynamically stable patients, diagnostic laparoscopy is a treatment of choice, which has been used with success also in cases of penetrating abdominal injuries [10, 24, 28]. The last resort remaining is the performance of radical procedure, splenectomy.

After the immunology function of the spleen has been recognized, namely in paediatric age, a shift in the treatment occurred, turning away from radical surgical removal following the injury, towards saving therapeutic procedures, or conservative treatment options, which are currently preferred [1, 9, 23, 24, 28]. After splenectomy, the patients are threatened with the syndrome of post-splenectomy fulminant sepsis, so-called OPSI (overwhelming post-splenectomy infection), which was first described in 1952, and the prevalence of which is estimated at 2-5 cases/1,000 persons following splenectomy per year. The mortality may reach 40-80% within the first few hours after onset. Vaccination against encapsulated pathogens is vital in patients after splenectomy. The opinions regarding long-term antibiotic prophylaxis following splenectomy vary across the world; this option has been abandoned during the last years, with the exception of paediatric patients younger than five years of age [17, 28]. Another consequence of splenectomy is thrombocytosis, with the levels of thrombocytes reaching very high values, especially early after surgery. This condition is associated with risks of arterial and venous circulation. Depending on the degree of risk for the patient, it is possible to react with appropriate antiaggregation or anticoagulation treatment [12].

MATERIALS

The authors performed a retrospective analysis of 37 adults patients treated at the Department of Trauma Surgery, University Hospital Brno between 01/2012 and 01/2017, who did not fulfil the criteria of polytrauma, and who presented with a dominant life-threatening injury of the spleen. The average age in the analysed group of 37 patients (31 males, 6 females) was 39.6 years (18-86 years).

METHODS

Using the hospital information system, we obtained the following patient data: sex, age, mechanism of injury, associated injuries, time between injury and treatment, significant comorbidities, baseline values of blood pressure, pulse, haemoglobin, possible complications of the treatment and length of stay in the hospital.

By analysing CT findings, splenic trauma was classified in each patient, according to the AAST classification [7], together with the size of haemoperitoneum [2]. Only the systolic value of blood pressure was used, Algöwer’s shock index was calculated, when the value < 1 represents normal condition, 1.0 imminent shock, 1.2 light shock, 1.5 moderate shock, and the value > 2 represents serious shock. However, the values are indicative only, the shock index cannot be used with valid results in children, patients with pacemakers and users of beta-blockers [5]. The size of haemoperitoneum was assessed as small in cases of perisplenic haematomas (one compartment, approx. 100 ± 200 ml of blood), middle sized, with paracolic presence of blood (two compartments, approx. 250 ± 500 ml of blood), and large-sized haemoperitoneum, in cases when the blood was present in the small pelvis (three compartments, approx. > 500 ml of blood). [2, 15].

RESULTS

During the five-year period (01/2012-01/2017), we treated a total of 37 patients with isolated splenic trauma, or other associated injuries, who did not meet the criteria of polytrauma. The most frequent cause of injury was fall on the left side of the body, and less serious traffic accidents. However, we encountered also an injury caused with a horse kick, being hit with a snowball to the abdominal area, attack and alleged fall of a prisoner onto a chair. Associated injuries included mostly fractures of left-side ribs, less frequently minor pneumothorax or haemothorax not requiring a surgical intervention, and cerebral contusion. One patient presented with a serious comorbidity, haemophilia type A. Eight of the patients (21.6%) came for treatment to the hospital after more than 24 after the injury. Of these 8 patients, three (8.1%) came initially to the clinic of abdominal surgery with abdominal pains, no primary relation to the injury was reported (33, 8 and five days after the injury).

Nineteen patients (51.4%) were treated conservatively, i.e. with observation during hospitalization, with laboratory and ultrasonography controls, when compared with 18 patients (48.6) who underwent primary surgery. Among the patients over 55 years of age, 33.3% underwent a primary surgical procedure, 66.7% were treated primarily conservatively; failure of conservative treatment was observed in one of these patients (aged 63). The surgical technique used included transverse laparotomy, most frequently in the left subcostal region, with subsequent revision of the abdominal cavity and performance of splenectomy. The average grade of splenic trauma according to AAST was 1.9 / Grade I. – eight patients (42.1%), Grade II. – four patients (21.1%), Grade III. – seven patients (36.8%). Among the patients treated primarily surgically, the average degree of injury according to AAST was 3.2 / Grade II. – two patients (11.1%), Grade III. – 10 patients (55.6 %), Grade IV. – six patients (33.3 %). In the group of patients treated primarily conservatively, small haemoperitoneum was diagnosed in thirteen cases (68.4 %) and large haemoperitoneum in six (31.6 %) cases. Among the patients primarily treated with surgery, the finding of medium-size haemoperitoneum was observed in four cases (22.2 %) and large haemoperitoneum in fourteen (77.8 %) cases.

The average baseline value of systolic blood pressure (SBP) was 137 mm/Hg (200-85). The average value of SBP was 142 mm/Hg (120-200) among conservatively treated patients and 126 mm/Hg (85-173) among primarily operated patients. The average value of Algöwer’s shock index among conservatively treated patients was 0.58, and 0.73 among patients undergoing surgery. The baseline values of haemoglobin were 138.8 g/L, (107-168 g/L) among conservatively managed patients, and 135.4 g/L (55-166 g/L) in the group of surgical patients. Two patients (5.4%) manifested signs of haemodynamic instability, with the average value of Algöwer’s shock index reaching 1.46; both patients sustained Grade IV. splenic trauma and presented with the finding of a large haemoperitoneum. Both these patients were indicated for emergency laparotomy.

Conservative treatment failed in three patients (15.8%); in these cases, with progression of the amount of fluid on ultrasonography (USG) controls, and laboratory decrease of the haemoglobin level, with signs of haemodynamic decompensation. This group included two patients with Grade II. splenic trauma, with progreding large haemoperitoneum, and one patient with Grade III. splenic trauma, with progreding small haemoperitoneum.

Iatrogenic postoperative complications included only a minor deserosation of the liver, which was resolved without any consequences.

Postoperative complications were observed in three patients (15%) with primarily indicated laparotomy. In the first case, repeated bleeding into the abdominal cavity was diagnosed, with a large output into drains and anaemization of the patient; the cause was haemorrhage from aa. gastricae breves. Second complication was an obstructive ileus, which required further surgical revision of the abdominal cavity with adhesiolysis. Third complication was a formation of an abscess collection in the splenic bed, without any development of a septic condition; in this case, surgical revision was not possible due to acute myocardial infarction in the patient. Radiologist did not indicate a drainage, the symptoms subsequently receded and the finding diminished.

Prophylactic vaccination in the prevention of OPSI was performed by a physician specialized in infectious diseases in all patients undergoing splenectomy, following discharge of patients into home care. The length of hospitalization varied between one day, in a patient who was subsequently transferred to a prison hospital, and 24 days in a patient with haematological comorbidity, requiring a long-term substitution of coagulation factors.

The patients were followed at outpatient clinics for several weeks, the ultrasonography controls were gradually abandoned, considering the recovery of the injured organ as seen on ultrasound. The period of follow-up did not fully correspond with the grade of injury, and varied also depending on the outpatient specialist. The recommended period of rest and exclusion of sporting activities lasted from several weeks up to several months.

DISCUSSION

The indication for laparotomy has precise criteria, such as haemodynamic instability with the development of hypovolemic shock, which cannot be stabilized with fluid resuscitation, pneumoperitoneum, peritoneal manifestations, significant haemoperitoneum, suspected injury of the gastrointestinal tract, which cannot be ruled out, and penetrating abdominal injury [4, 26, 27]. Among the patients included in our analysis, there were only two patients (5.4%) with circulatory instability, hypotension, developing shock state, and low level of haemoglobin. The rest of the study subjects did not present with any signs of haemodynamic instability upon retrospective evaluation.

In 2005, a survey was carried out among trauma surgeons, which revealed that 97% of them considered sole haemodynamic instability to be an indication for laparotomy and splenectomy, without taking into account the grade of organ injury. However, another study from 2001 showed that, apart from haemodynamic instability, also the grade of splenic trauma was being considered, which resulted in a decrease in the number of laparotomies, and increase of conservative and miniinvasive therapeutic procedures [6].

The treatment strategy in haemodynamically stable patients with blunt abdominal injuries significantly changed in the scientific works presented in the course of the last 20 years [1, 2, 4, 13, 20, 24, 28]. Even in the 1970s, diagnostic peritoneal lavage was used for diagnosing haemoperitoneum, and positivity of this test was considered an absolute indication for laparotomy. Perioperative negative findings in the abdominal cavity were observed in up to 39% of cases [11]. According to the current literature, conservative treatment in cases of blunt splenic trauma is used in approximately 70% of patients [25]; however, other literary sources state 80% and more. Among our selected patient population, conservative treatment was applied in 51.4% of cases, 15.8% of which failed, with subsequently indicated laparotomy and splenectomy. Furthermore, it is apparent from the result that laparotomy was indicated in patients with a higher grade of splenic trauma and the presence of a larger or extensive haemoperitoneum. This applies even though these patients, except for two of them (5.5%) were haemodynamically completely stable, with satisfactory values of blood pressure and haemoglobin, and did not manifest any signs of haemodynamic instability during the preoperative stage.

According to older criteria [3, 23], conservative treatment was reserved for patients younger than 55 years of age, patients without any serious concomitant injuries, patients receiving less than four units of erythrocytes, or with absence of craniocerebral haemorrhage. These factors were presented as positive predictors of successful conservative therapy with a low risk of failure. At present, these criteria have been extended, which is why the conservative approach is being used worldwide in patients with blunt splenic trauma [4, 19, 21, 23]. In accordance with other authors [13], age or mild craniocerebral injury of the patient were not considered contraindication of conservative therapy at our centre.

Although the conservative therapy of splenic injuries, or injuries of parenchymatous organs, is considered to be a “golden standard” today, it is necessary to bear in mind the possible failure of this treatment in haemodynamically unstable patients.

Various studies have confirmed a relation between the grade of organ injury and the size of haemoperitoneum, with the possible prediction of conservative treatment failure [6, 15, 25]. This means that the higher the grade of injury, and the larger the present haemoperitoneum in a patient indicated for conservative treatment, the higher attention should be paid to patient monitoring, in the duration of at least one week, and exclusion of administration of anticoagulation medication for the period of the following six months. Previously reported parameters for prediction of conservative therapy failure, such as Injury Severity Score and the number of associated injuries, have not been proven totally reliable, especially considering the significant advancements in assessment and yield of CT, interventional radiology or significant increase of quality of intensive care [4, 21]. Failure of non-surgical, or conservative treatment depends on the grade of splenic trauma and the size of haemoperitoneum. A multicentre clinical trial [25] evaluating 388 patients with splenic trauma Grade IV. and V. showed that laparotomy and splenectomy was required in 64% of patients. The EAST study concluded that the higher the grade of splenic trauma, and the higher the degree and haemoperitoneum and ISS value exceeding 15 were strong predictors of conservative therapy failure in the treatment of patients with blunt splenic trauma [21, 28].

It has also been shown that 12% of patients do not suffer from a significant extravasation from the injured organ, and that classification of splenic trauma is difficult, or even impossible, using ultrasonography or CT. The retrospective study shows significant differences bet­ween the grade of splenic lesion when compared with CT scans and perioperative findings during performed laparotomy [6]. The reasons may include for example correctness of timing during intravenous administra­tion of the contrast agent but also the fact that in patients with higher grades of injury, the amount of blood may mask the injury or the leak of contrast agent in the splenic hilum. Thus, it has been confirmed that grade I. and II. injuries correlate with the actual condition of the organ, whereas grade III. to V. injuries may cover a hilar lesion and thus mask or underestimate the real condi­tion of the organ, with all consequences for decision-making concerning conservative treatment. The Eastern Association for Surgery and Trauma (EAST), in their retrospective multicentre clinical trial studied a sample of 1,488 patients with blunt splenic injuries [15]; conservative treatment was indicated in 54.8% of cases, with subsequent failure in 10.8% of patients.

Emergency laparotomy was indicated in 24% of patients with grade I lesion and 95% of patients with Grade V. lesion. The conservative therapy failed most frequently within the first 48 hours, when 60.9% of treatments failed within the first 24 hours, and 13.8% between 24 and 48 hours.

Among the patients undergoing surgery, spleen was preserved in 10% of cases only; this was most probably due to the attempt to prevent possible secondary haemorrhage, or failure of the saving procedure [28]. This would correspond with the procedure applied at our centre. The reason may be also fear of rupture of subcapsular splenic haematoma in the later period.

Literary sources also present 15% of patients, in whom secondary rupture of the spleen occurred within days or weeks after the abdominal trauma. Two-stage splenic rupture is a rare type of injury, which was first described in 1902 by Baudet. The interval between the initial trauma and subsequent haemorrhage is one week in 50% of patients, two weeks in 25% of patients, and more than four weeks in 10% of patients. The presented mortality in patients with two-stage rupture reaches approximately 15% [18, 19]. This complication was not observed in our patient population, when compared with polytraumatized patients during the same period (four cases). Considering the above-stated, it is necessary to bear this possibility in mind.

Di Giacomo et al. have shown in their study that also significant subcapsular splenic haematomas following blunt injury develop up to 12 hours after injury, which means that the CT examination may show normal image of the spleen [18, 19, 24]. This fact may be also explained with decreased circulation in the splachnic area following trauma, i.e. also decreased flow in arteria lienalis. The authors came to the conclusion that the development of a subcapsular splenic haematoma is not a predictor of two-stage splenic rupture, or indication for surgical management of splenic injuries in haematologically unstable patients. It has been reported, that two stage ruptures of the spleen may cause minor, atypical traumas, and the patients usually do not associate the symptoms with the injury.

According to the study, there exists a demonstrable difference between a fresh injury of the spleen and rupture of subcapsular haematoma in the sense of two-stage splenic rupture, which bears medico-legal significance namely for forensic medicine [18, 24]. As far as the fear of two-stage splenic rupture and its high mortality is concerned, the authors Zabinskey and Harkins analysed 177 cases from the literature in 1943. They found an overall incidence of 15-30% of cases of two-stage splenic rupture, which is a significantly high number. Later analyses and works showed that two-stage rupture of the spleen is not so common, and represents a delayed diagnosis of splenic injury in most patients [24]. This applies also to our patients who came for treatment after more than 24 hours from the injury, and most probably did not suffer from a two-stage splenic rupture but the condition was rather the result of a gradual development of organ injury.

Regarding common administration of low-molecular weight heparins as a prevention of thromboembolic disease (TED) in hospitalized patients, studies have not shown that administration of LMWH in the early stage (<48 hours) increases the risk of failure of conservative treatment or increase in the need for transfusions. Nevertheless, no consensus has been made among physicians regarding the timing of initiation of medication prevention of TED [23].

The possibility of saving surgical procedures, such as partial splenectomy, splenorrhaphy, or autotransplantation of the spleen remains open. Some of the saving methods have been questioned, and the studies have not shown conclusive results [24, 28]. In our centre, we rather prefer to use dexon meshes for the treatment of the injured liver, and not the injured spleen, due to the risk of ischaemization caused with mesh tightening. Another modern conservative procedure is embolization of splenic arteries by interventional radiologist [8, 14, 16, 22, 24], which is usually indicated in patients who are haemodynamically stable, most frequently with splenic trauma Grade III.-V., active extravasation of the contrast agent and apparent vascular lesion. Part of the patients in our file could have probably been treated with selective embolization of the spleen, and this remains a challenge in the area of organization of complex care. Three pa­tients from our group in whom conservative therapy failed, and the patients were indicated for laparotomy and splenectomy, did not develop a shock state, according to the medical records. This presents the possibility [23, 28] to continue in the fluid resuscitation, administration of infusions, frozen plasma, regular laboratory controls and other ultrasonography or CT controls, subsequently, it is also possible to consider selective embolization of the spleen [8, 14, 23]. In these cases, the risk of OPSI is limited during the postoperative period, contrary to the invasive procedures with splenectomy. Based upon the results of clinical trials performed so far, the immune function of the embolized spleen remains without any significant changes when compared to a healthy spleen [3, 14].

The recommendation of limiting physical activities after discharging the patient into home care depends [3] on the grade of splenic injury and the clinical condition of the patient. Rest is recommended from the beginning in patients with Grade I. and II. injuries, light activities may be performed after two weeks at the earliest, and more demanding activities and works only six to eight weeks after injury. Ultrasonography or CT controls are recommended depending on the clinical condition of the pa­tient. In cases of Grade III. injury, regular ultrasonography controls are recommended, together with rest lasting at least one month, light activities are recommended for the next one or two months, and sporting activities are allowed after three months at the earliest. In the patients with conservatively managed Grade IV.- V. lesions, rest is recommended for the period of three months after the injury. The period of follow-up and physical limitation of our patients approximately correlated with these literary recommendations. We did not observe any complica­tions in the treatment or failure of the procedure among the patients followed at our clinic.

CONCLUSION

Conservative approach is a trend applied worldwide nowadays in the treatment of splenic injuries in haemodynamically stable patients, regardless of the injury grade. However, it is necessary to take into account the associated comorbidities, age of the patient, and character of other injuries. Nevertheless, the above-listed factors are not a contraindication of the conservative approach. This is recommended for centres with the possibility of high-quality monitoring of patients, unlimited paraclinical examinations, and namely 24-hour availability of emergency operating theatre, where surgical revision may be performed.

Our evaluation shows that the probability of conservative treatment failure corresponds with the conclusions presented in the literature. We see certain reserves in the early consideration of splenectomy indication prior to continuous resuscitation with adjustment of haematology parameters, and in the use of angiography selective embolization of the spleen in indicated cases. In case of differences between the perioperative findings and the outcomes of ultrasonography or CT examination, we always provide feedback for the radiologist.

Certain drawback of our work is the retrospective character of the analysis, which was performed in a rather small and heterogeneous group of patients, together with complicated obtaining of all intended comparative factors.

Jiří Hlaváč, MD

jurahlavac@seznam.cz