Although nonoperative management of splenic injuries is the norm in children, its use in adults has been far less successful. Failure rates have been reported to be as high as 20 to 30 percent. This relatively high failure rate has prompted some authors to advocate limiting nonoperative management to patients under 55 years of age and those with a CT injury grade no higher than 3 (TableJ^-d).
TABLE 252-4 American Association for the Surgery of Trauma (AAST) Spleen Injury Scale (1994 Revision)
The addition of angiography to the treatment algorithm has radically changed the nature of nonoperative management for splenic injury. First reported by Sclafani and colleagues from Kings County Hospital, sequential DPL, CT, and angiography was used as a management algorithm in the care of patients with blunt trauma. 16 Stable patients with a positive DPL underwent CT. All patients with CT-diagnosed splenic injury were then treated angiographically. All vascular injuries identified at the time of angiography were treated with proximal coil embolization. Proximal embolization, similarly to splenic artery ligation, decreases the pressure head to the spleen, allowing for spontaneous hemostasis. Splenic viability and immune function are preserved by collateral vessels via the pancreatic branches of the splenic artery, the short gastric vessels, and collaterals from the superior mesenteric artery. In a series of approximately 150 patients, splenic salvage was 95 percent when this algorithm was used. Most important, a negative splenic arteriogram predicted successful nonoperative management 100 percent of the time.
The group from Memphis recently reported on 524 consecutive patients with blunt trauma. 20 Nonoperative management was attempted in 344 patients. Ninety-four percent were managed successfully nonoperatively, which represented 60 percent of the total splenic injuries. The indication for angiography was the presence of a pseudoaneurysm seen on helical CT. They used subselective embolization as opposed to proximal coil embolization. Only one patient developed clinically significant splenic infarction despite the subselective embolization. Importantly, nearly three-quarters of the patients had a pseudoaneurysm seen at the time of follow-up CT scan that was not seen at the time of initial scanning. The authors stressed the importance of follow-up CT even in asymptomatic patients.
It would seem that an initial helical CT scan, while valuable, is not definitive and that injuries evolve. In both series, higher-grade injuries had an increased likelihood of having a vascular injury identified. However, in the Brooklyn series, 12 percent of patients with grade 1 injuries had vascular injuries identified and embolized at the time of angiography.16 Thus simple CT grading may not be sufficient to predict the success of nonoperative therapy. It would seem that careful follow-up is mandatory for all patients in whom nonoperative management is attempted. Follow-up CT scan has the potential to identify the progression, if any, of injury. In addition, it appears to reliably identify pseudoaneurysms not seen at the time of initial scanning. Alternatively, early, liberal use of angiography should help to identify patients with vascular injuries. Either of these techniques appears to radically decrease the incidence of delayed splenic rupture. This often presents at 7 to 10 days in patients who were stable initially following the diagnosis of splenic injury.
In fact, the term delayed splenic rupture is probably a misnomer. Instead, this more correctly is misdiagnosis of splenic vascular injury at the time of initial presentation, almost certainly small injuries such as pseudoaneurysms or AV fistulas. Over 7 to 10 days they expand and ultimately rupture, producing blood loss and corresponding symptoms. The term pulsating splenic hemorrhage more correctly describes this entity.
Neither of these series had a large proportion of high-grade splenic injuries contained within them. Recently, the group at the Shock Trauma Center prospectively evaluated a series of 73 patients.21 All patients diagnosed with splenic injuries underwent early angiography. There was a large proportion of CT grade 3 and 4 injuries contained within this series. The presence of a vascular abnormality correlated with grading. The higher the grade, the more likely the patient was to have vascular injury at the time of angiography. Patients with high-grade injuries tended to have more severe injuries and often had multiple injuries. These were treated with a combination of proximal coil and subselective embolotechniques ( Fig. 252-7). Nonoperative management was successful 88 percent of the time, and the splenic salvage rate was 94 percent in this series.
FIG. 252-7. Nonoperative management of splenic injuries. A. FAST in this 21-year-old female with blunt abdominal trauma clearly demonstrates hemoperitoneum. B. The patient remains hemodynamically stable and CT scan demonstrates a grade 4 splenic injury.
Nonoperative management for splenic injuries is certainly a safe and effective technique. However, this must involve a committed team of emergency physicians, surgeons, and invasive radiologists in order to safely manage patients with high-grade injuries nonoperatively. Coil embolization is a safe technique and an effective method of hemostasis. These innovative techniques should be performed in a tertiary care center under strict protocol in order to be managed safely.
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