Abstract
Prupose
Review of the new horizons of management for splenic trauma and a proposal of an algorithm for its management.
Methods
Literature review using PubMed search engines using the keywords splenic trauma, splenic angioembolisation, management.
Results
Non-operative management (NOM) is the first strategy in stable patients with splenic traumatic injury. In AAST grade I-II patients’ observation with close monitoring should be considered. Endovascular management (EVM) improves the results of NOM and should be consider in AAST III-IV grade when its available. Fail of NOM should be considered when there are clinical, analytical or imagine signs of active bleeding. Surgery is mandatory in unstable patients. Also is indicate when NOM fails, in grade III-IV stable patients if EVM is unavailable, AAST grade V or if associated injuries that are suspected. Laparoscopy have probe to be a feasible and safe technique in stable trauma patients. Preserving the organ when possible is the trend in surgical strategy of splenic trauma.
Conclusions
The EVM has improve the success of NOM and it’s recommended in AAST grade III-V when its possible. The risk of NOM failure and its early detection must be taken into account. Laparoscopy is safe in stable trauma patients. Open splenectomy remains the gold-standard for unstable patients.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
1 Introduction
The spleen is one of the most frequent organs injured following blunt abdominal trauma. Usually this leads to emergent splenectomy with consequent loss of the hematologic and immunologic function. In light of the AAST classification of splenic lesions (Table 1), we can reconsider the appropriateness of total splenectomies [1, 2].
In the last century the paradigm in the management of these trauma has evolve. NOM had been implemented in the last decades, and its results had improved since the combination with endovascular techniques for bleeding control [3, 4]. The implementation of electrocauterization devices and topic haemostatics improves the organ salvage strategies. This paradigm shift raises pertinent questions about the optimal balance between aggressive surgical interventions and organ-preserving strategies in the context of splenic trauma. Our aim is to present a case of a AAST grade III splenic trauma treated with EVM and to review new horizons in the management of blunt splenic trauma. We suggest a step-up management and surgical approach algorithms in splenic trauma.
2 Case report
A 76-year-old man with a history of atrial fibrillation treated with oral anticoagulation, COPD, OSA with need for CPAP, and thoracic aneurysm, arrived complaining of acute abdominal pain, pallor and profuse sweating followed by fainting, to a first level hospital with 24-h EVM. On arrival he presented with arterial hypotension and confusion. Heart rate was 90 bpm. Abdomen was soft but painful in the left flank. Blood tests showed a haemoglobin of 10 mg/dl, which in the following hours dropped to 8.2 mg/dl. The patient responded to initial fluid resuscitation and was taken to CT scan showing moderate haemoperitoneum with perisplenic haematoma greater than 50% of the organ, corresponding to AAST grade III. The patient had taken oral anticoagulants 12 h earlier. The haematologist suggested a very high risk of haemorrhage in case of surgery. The patient was taken to EVM where intraparenchymal haemorrhage was observed and embolization of the splenic artery was performed. In the following days the patient recovered satisfactorily, but in the following weeks complained of fever and pain in the left quadrant. A Splenic abscess was diagnosed and delayed splenectomy was performed.
3 Discussion
In the last decades NOM of the splenic trauma had increased. Nowadays It should be considered in blunt splenic trauma in stable patient [4,5,6]. The implementation of EVM had decreased the failure of the NOM [7,8,9,10]. Currently we can follow a stepped strategy (Fig. 1) [11].
In NOM, close clinical and analytical must be monitored closely. Stability of the patient is the main need. Treatment of AAST grades I-II without signs of active bleeding could be treated just this way [12].
EVM continues with the NOM strategy and improves its results [13]. It can be considered for stable patients with grade III-IV or signs of active bleeding regardless the injury grade [5, 6, 14]. Some authors suggest that EMV should be consider in AAST grade V, but still controversial [8, 9]. In patients with a high surgical risk (heart disease, respiratory insufficiency, anticoagulation, etc.), regardless of the degree of trauma is a good alternative to surgery.
When contrast blush is described usually is used to describe two different scenarios: the presence of extravasation whitin the splenic parenchyma and active extravasation into the peritoneal cavity. The first one may lead to pseudoaneurysm formation in delay, and benefits from embolization; the second one is more likely to fail when EVM is perform [9].
Miller et al. [9] describes a higher rate of NOM failure in patients who had angiography but not embolisation and suggest embolization of all patients who have undergone angiography. However, although prophylactic embolization is described when there is a high risk of NOM failure, there is no consensus [6, 16,17,18,19,20].
The embolization must be proximal, occluding the splenic artery 2 cm distal to the dorsal pancreatic artery as distal AE associates more risk of segmental splenic infraction and abscess formation [10, 21]. The viability of the spleen is ensured by collateral circulation [16, 22]. Lauerman et al. [23] describe that embolization decreases the risk of secondary pseudoaneurysm in comparation with observation management. Complications after EVM include rebleeding, necrosis of the embolized segment, or abscess formation. Availability is the main the limitation of this technique as its implementation may not be feasible depending on the centre’s schedule or level [24].
Failure of the NOM, associated or not with EVM, should be considered if the patient shows signs of active bleeding such of drop of haemoglobine, need of repeated blood transfusions, suggestive radiological findings or if becomes unstable [4].
The Eastern Association of Surgery of Trauma (EAST) describes the failure of NOM as 5% in AAST grade I, 10% in grade II, 20% in grade III, 33% in grade IV and up to 75% in grade V [25]. Factors that increase the risk of failure of NOM include patient age > 55 years, hemoperitoneum > 300 cc (Table 2) [10], ISS > 25, need for transfusion, more than two organs affected, association with traumatic brain injury or AAST > III grades [4, 6, 7, 15, 26,27,28,29,30,31].
If the patient arrives unstable, the initial surgical approach is mandatory. Surgical approach should also be performed in case of no possibility of EVM, high risk of NOM failure, or associated lesions requiring surgery [32].
Classically, the surgical approach to splenic trauma has been total splenectomy. The organ function implies the risk overwhelming post-splenectomy infection (OPSI) by encapsulated bacteria and implies the need vaccination. The actual trend is organ preservation, although the techniques of partial splenectomy and splenorrhaphy are described, they are now obsolete [33].
Since the first reported trauma laparoscopy was described in the mid-1920 it has been implemented from the beginning of the 21th century, and splenic trauma is not left behind [4, 34,35,36,37,38,39,40,41,42,43]. A correct selection of the candidates is crucial. It can be considered in a centre with high experience in laparoscopy and by experience surgeons with adequate laparoscopy skills and able to convert to open surgery if needed. Some situations where laparoscopy splenectomy can be considered (Fig. 2) [4, 7]:
-
EVM fail, contraindicated (allergy to iodine contrast), no available or unsuccessful.
-
High risk of failure of NOM.
-
Penetrant injuries of thoracoabdominal area where diaphragm may be injured.
-
Discordance between clinical examination and radiological findings.
Coagulopathy induce by trauma and EVM increases the risk of thromboembolic events. The prophylaxis with low molecular weight heparin in the next 48 h is safe and does not increase the risk of failure of NOM [44, 45].
4 Conclusions
Although immediate open surgery is necessary in unstable splenic trauma, NOM should be considered in stable patients AAST grade I-IV. EMV improves the success rate of NOM, but we must be aware of the risk factors for failure and not delay the surgical approach when NOM fails. Laparoscopy is feasible and safe in some cases of splenic trauma.
Data availability
No datasets were generated or analysed during the current study.
Code availability
Not applicable.
References
Savage SA. Management of blunt splenic injury: down the rabbit hole and into the bucket. Trauma Surg Acute Care Open. 2023;8:8–10.
Tran S, Wilks M, Dawson J. Endovascular management of splenic trauma. Surg Pract Sci. 2022;8:100061. https://doi.org/10.1016/j.sipas.2022.100061.
Schneider A, Gallaher J, Raff L, Purcell L, Reid T, Charles A. Splenic preservation after isolated splenic blunt trauma: the angioembolization paradox. Surgery. 2021;170(2):628–33.
Di Saverio S, Birindelli A, Podda M, Segalini E, Piccinini A, Coniglio C, et al. Trauma laparoscopy and the six w’s: why, where, who, when, what, and how? J Trauma Acute Care Surg. 2019;86(2):344–67.
Podda M, De Simone B, Ceresoli M, Virdis F, Favi F, Wiik Larsen J, et al. Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World society of emergency surgery consensus document. World J Emerg Surg. 2022;17(1):1–37. https://doi.org/10.1186/s13017-022-00457-5.
Coccolini F, Montori G, Catena F, Kluger Y, Biffl W, Moore EE, et al. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg. 2017;12(1):1–26.
Romeo L, Bagolini F, Ferro S, Chiozza M, Marino S, Resta G, et al. Laparoscopic surgery for splenic injuries in the era of non-operative management: current status and future perspectives. Surg Today. 2021;51(7):1075–84.
Crichton JCI, Naidoo K, Yet B, Brundage SI, Perkins Z. The role of splenic angioembolization as an adjunct to nonoperative management of blunt splenic injuries: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2017;83(5):934–43.
Miller PR, Chang MC, Hoth JJ, Mowery NT, Hildreth AN, Martin RS, et al. Prospective trial of angiography and embolization for all grade III to V blunt splenic injuries: nonoperative management success rate is significantly improved. J Am Coll Surg. 2014;218(4):644–8.
Venter DP, Beuran M, Gulie L, Popiel M, Venter MD, Oprescu C, et al. Interventional radiology in splenic trauma: if not now, then when? Chir. 2021;116(6):700–17.
Dhillon NK, Harfouche MN, Hawley KL, DuBose JJ, Kozar RA, Scalea TM. Embolization of pseudoaneurysms is associated with improved outcomes in blunt splenic trauma. J Surg Res. 2024;293:656–62.
Cirocchi R, Boselli C, Corsi A, Farinella E, Listorti C, Trastulli S, et al. Is non-operative management safe and efective for all splenic blunt trauma? A systematic review. Crit Care. 2013;17(5):185.
Arvieux C, Frandon J, Tidadini F, Monnin-Bares V, Foote A, Dubuisson V, Splenic Arterial Embolization to Avoid Splenectomy (SPLASH) Study Group, et al. Effect of prophylactic embolization on patients with blunt trauma at high risk of splenectomy: a randomized clinical trial. JAMA Surg. 2020;155(12):1102–11.
Zarzaur B, Savage S, Croce M, Fabian T. Trauma center angiography use in high-grade blunt splenic injuries: timing is everything. J Trauma Acute Care Surg. 2014;77(5):666–73.
Harfouche M, Dhillon N, Hawley K, DuBose J, Kozar R, Feliciano D, et al. Time to splenic angioembolization does not impact splenic salvage rates. Am Surg. 2023;89(8):3493–5.
Hoppe H, Kos S. Splenic artery embolization: proximal or distal? A review of when proximal or distal embolization should be used, optimal technique, and results of studies evaluating outcomes. Endovasc Today. 2018;17(4):73–6.
Thony F. Embolization for splenic trauma. Healing the spleen with curative and preventive embolization. Endovasc Today. 2016;15(4):72–91.
Arvieux C, Frandon J, Tidadini F, Monnin-Bares V, Foote A, Dubuisson V. Effect of prophylactic embolization on patients with blunt trauma at high risk of splenectomy: a randomized clinical trial. JAMA Surg. 2020;155:1102–11.
Yoo R, Evanson D, Gaziano M, Muller A, Martin A, Chauhan N, et al. Negative splenic angiography in blunt trauma: does embolization affect splenic salvage? Am Surg. 2023;89(7):3209–11.
Haan J, Scott J, Boyd-Kranis R, Al E. Admission angiography for blunt splenic injury: advantages and pitfalls. J Trauma. 2001;51:1161–5.
van der Vlies C, Hoekstra J, Ponsen K, Reekers J, van Delden O, Goslings J. Impact of splenic artery embolization on the success rate of nonoperative management for blunt splenic injury. Cardiovasc Interv Radiol. 2012;35(1):76–81.
Quencer K, Smith T. Review of proximal splenic artery embolization in blunt abdominal trauma. CVIR Endovasc. 2019;2(1):11.
Lauerman M, Brenner M, Simpson N, Shanmuganathan K, Stein D, Scalea T. Angioembolization significantly improves vascular injuries in blunt splenic trauma. Eur J Trauma Emerg Surg. 2021;47(1):99–103.
Spittle A, Britcliffe A, Hamilton MJ. Splenic trauma in the Northern Territory; the impact of an interventional radiology service on splenic trauma management and outcomes. Heliyon. 2023;9(6): e16993. https://doi.org/10.1016/j.heliyon.2023.e16993.
Peitzman A, Heil B, Rivera L, Al E. Blunt splenic injury in adults: multi- institutional study of the eastern association for the surgery of trauma. J Trauma. 2000;49(2):177–87.
Davis KA, Coimbra R. Blunt Abdominal trauma. In: Surgical Decision Making in Acute Care Surgery. 2020. p. 47–59.
Romeo L, Bagolini F, Ferro S, Chiozza M, Marino S, Resta G, et al. Laparoscopic surgery for splenic injuries in the era of non-operative management: current status and future perspectives. Surg Today. 2021;51(7):1075–84. https://doi.org/10.1007/s00595-020-02177-2.
Júnior JDM, Metidieri Menegozzo CA, Rocha MC, Utiyama EM. Non-operative management of blunt splenic trauma: evolution, results and controversies. Rev Col Bras Cir. 2021;48:1–9.
Fugazzola P, Morganti L, Coccolini F, Magnone S, Montori G, Ceresoli M, et al. The need for red blood cell transfusions in the emergency department as a risk factor for failure of non-operative management of splenic trauma: a multicenter prospective study. Eur J Trauma Emerg Surg Off Publ Eur Trauma Soc. 2020;46(2):407–12.
Hawley KL, Dhillon NK, DuBose JJ, Kozar RA, Scalea TM, Harfouche MN. Surveillance imaging associated with delayed splenectomy in high-grade blunt splenic trauma. Am Surg. 2023;89(7):3214–6.
Fransvea P, Costa G, Serao A, Cortese F, Balducci G, Sganga G, et al. Laparoscopic splenectomy after trauma: who, when and how. A systematic review. J Minim Access Surg. 2021;17(2):141.
Serna C, Serna JJ, Caicedo Y, Padilla N, Gallego LM, Salcedo A, et al. Damage control surgery for splenic trauma: “preserve an organ-preserve a life.” Colomb Med. 2021;52(2):1–9.
Ko A, Radding S, Feliciano D, Al E. Near disappearance of splenorrhaphy as an operative strategy for splenic preservation after trauma. Am Surg. 2022;88(3):429–33.
Basso N, Silecchia G, Raparelli L, Pizzuto G, Picconi T. Laparoscopic splenectomy for ruptured spleen: lessons learned from a case. J Laparoendosc Adv Surg Tech A. 2003;13(2):109–12.
Catellani B, Caracciolo D, Magistri P, Guidetti C, Menduni N, Yu H, et al. Laparoscopic management of blunt pancreatic trauma in adults and pediatric patients: a systematic review. Biomed Res Int. 2023;2023:1–10.
Ren CJ, Salky B, Reiner M. Hand-assisted laparoscopic splenectomy for ruptured spleen. Surg Endosc. 2001;15(3):324.
Dissanaike S, Frezza EE. Laparoscopic splenectomy in blunt trauma. JSLS J Soc Laparoendosc Surg. 2006;10(4):499–503.
Agarwal N. Laparoscopic splenectomy in a case of blunt abdominal trauma. J Minim Access Surg. 2009;5:78–81.
Ayiomamitis GD, Alkari B, Owera A, Ammori BJ. Emergency laparoscopic splenectomy for splenic trauma in a Jehovah’s Witness patient. Surg Laparosc Endosc Percutan Tech. 2008;18(6):626–30.
Rolton DJ, Lovegrove RE, Dehn TC. Laparoscopic splenectomy and diaphragmatic rupture repair in a 27-week pregnant trauma patient. Surg Laparosc Endosc Percutan Tech. 2009;19(4):e159–60.
Nasr WI, Collins CL, Kelly JJ. Feasibility of laparoscopic splenectomy in stable blunt trauma: a case series. J Trauma Inj Infect Crit Care. 2004;57(4):887–9.
Huscher CGS, Mingoli A, Sgarzini G, Brachini G, Ponzano C, Di Paola M, et al. Laparoscopic treatment of blunt splenic injuries: initial experience with 11 patients. Surg Endosc. 2006;20(9):1423–6.
Carobbi A, Romagnani F, Antonelli G, Bianchini M. Laparoscopic splenectomy for severe blunt trauma: initial experience of ten consecutive cases with a fast hemostatic technique. Surg Endosc. 2010;24(6):1325–30.
Lewis M, Piccinini A, Benjamin E, Demetriades D. Splenic artery angioembolization is associated with increased venous thromboembolism. World J Surg. 2021;45(2):638–44.
Lamb T, Lenet T, Zahrai A, Shaw JR, McLarty R, Shorr R, et al. Timing of pharmacologic venous thromboembolism prophylaxis initiation for trauma patients with nonoperatively managed blunt abdominal solid organ injury: a systematic review and meta-analysis. World J Emerg Surg. 2022;17(1):19.
Funding
Not applicable.
Author information
Authors and Affiliations
Contributions
AAMF, AOS, AFJ and MJCS prepared the main manuscript. MJCS and MDCM where the surgeons that made the initiall aproach to the patient and made a literature review about the topic. MJCS, MDCM and JMPG reviewed and correct the manuscript and advised on the implementation of the systemic review. All authors reviewed the manuscript. All authors made substantial contributions in the conception or design of the work and approved the final version.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing interests.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
About this article
Cite this article
Maestu Fonseca, A.A., Fernández Jiménez, Á., Ortiz Sánchez, Á. et al. New horizonts in splenic traumatism management: literature review. Discov Med 1, 25 (2024). https://doi.org/10.1007/s44337-024-00039-1
Received:
Accepted:
Published:
DOI: https://doi.org/10.1007/s44337-024-00039-1