Trauma to Solid Organs

Educational Objectives

The goal of this program is to improve the management of traumatic injuries to the liver and spleen. After hearing and assimilating this program, the clinician will be better able to:

1.   Discuss key principles in the management of splenic injuries.

2.   Recognize indications for splenectomy vs those for nonoperative management of splenic injuries.

3.   Evaluate data on the utility of angioembolization.

4.   List the possible complications of blunt hepatic injury.

5.   Identify the risk factors associated with failure of nonoperative management of splenic injuries.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of in­terest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Peitzman spoke at Detroit Trauma Symposium, held November 12-13, 2009, in Detroit, MI, and sponsored by the De­troit Receiving Hospital. Drs. Jurkovich and Sise were recorded at 17th Annual University of Southern California Trauma, Emergency Surgery, and Surgical Critical Care Symposium, held May 13-14, 2010, in Pasadena, CA, and cosponsored by the Keck School of Medicine of USC and the Institute for Continuing Education for Nurses, Los Angeles County-USC Medical Center. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Management of Blunt Spleen Injury

Andrew B. Peitzman, MD, Mark M. Ravitch Professor and Vice-Chair, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA

Background: patients have lifelong risk of dying from overwhelming postsplenectomy infection (OPSI); splenec­tomy once performed for all splenic injuries; in 1980s, more emphasis on repair of spleen; currently, splenorrhaphy rarely performed, especially in cases of blunt trauma (patients observed instead); nonoperative management now primary method of splenic preservation

Key management principles: hemodynamically unstable patients require surgery; consider nonoperative manage­ment only if patient hemodynamically stable; no patient should die as consequence of nonoperative management

Nonoperative management of blunt injury to liver and spleen: guideline from Eastern Association for the Surgery of Trauma (EAST) incorrectly states that injury severity does not contraindicate nonoperative management; liver and spleen do not have similar natural histories of injury (“spleens bleed late, livers don’t”); guideline based on studies that combine children and adults, with few grade IV and grade V injuries

Multicenter study: conducted by speaker and colleagues at 27 trauma centers, involving 1488 adult patients (>15 yr of age) with blunt splenic trauma in 1997; 38% went directly from emergency department to operating room (group 1); observation planned for remaining 62% (group II); 11% of patients failed nonoperative management (group III); of 78 patients with grade V splenic injuries (shattered spleen), 74 went directly to surgery; overall, risk that nonoperative management will fail increases as grade of injury severity increases; nonoperative man­agement almost always successful with grade I and grade II injuries; almost never with grade V injuries; out­comes more variable with grades III and IV

Degree of hemoperitoneum: small  —  “a little blood around the spleen”; moderate  —  blood in gutters; large  —“bellyful of blood”; severity of splenic injury roughly correlates with amount of hemoperitoneum

Lessons of study: in adults, need for operation based on hemodynamic instability, higher-grade splenic injuries, and more hemoperitoneum; of patients who fail nonoperative management, two-thirds do so in first 24 hr

Follow-up study of patients failing nonoperative management: patients fell into 3 groups, based on hemodynamics; stable (no hypotension or tachycardia; 44% of patients); responders (1 or 2 episodes of hypotension or tachycar­dia, then stabilized; 31%); and unstable (25%); acute decompensation in 15%; most common risk factors for failure  —  increased abdominal pain or decreasing hematocrit; injury severity similar across patient groups; mortality  —  3% among stable patients; 9% among responders; and 39% among hemodynamically unstable pa­tients; 60% of deaths resulted from delayed diagnosis and treatment, or nontreatment of abdominal injuries; 3 pa­tients exsanguinated; factors in deaths  —  no laparotomy for unstable patients (poor surgical judgment); misreading of computed tomography (CT); 42% rate of false negative abdominal ultrasonography (at speaker’s center, ultrasonography rarely used as definitive test); measurement of blood pressure and heart rate on admis­sion only misses many unstable patients

Risk of death due to OPSI: lifelong risk in adults with traumatic injury 0.02%; risk of dying from delayed or inap­propriate treatment 35 times higher

Angioembolization: every published study based on historical comparison; not valid because of drastic changes in practice over time; some data misleadingly reported

Conclusions: “pendulum has swung too far” in favor of nonoperative management; surgery always indicated for grade V injuries; “nonoperative management does not mean neglect the patient”; role of angioembolization re­mains unclear

Current Management of Hepatic Injury

Dr. Peitzman

Background: 80% of blunt abdominal injuries managed nonoperatively; vascular injuries and complications often treated by interventional radiologists; surgery often complex; surgeons should maintain operative skills

Blunt injury to liver: most frequently injured abdominal organ; patients present either with complete hemodynamic decompensation or stable; if patient stable enough for CT, usually candidate for nonoperative management (re­gardless of injury severity or amount of hemoperitoneum; true in »85% of such patients); decreasing mortality over last 25 yr largely due to nonoperative management of severe hepatic injuries; »25% of patients observed will have complication requiring intervention (most common with grade IV and V injuries [relatively rare]); lac­erations in grades I, II, and III injuries range from <1 cm to >3 cm

Complications: bleeding, bile leaks or bile duct injuries, hemobilia, bilhemia, hepatic necrosis, and hepatic abscess; late bleeding from hepatic injuries rare, but does occur (more often in portal, rather than arterial branches); may occur £1 mo after injury; bile duct leaks more common (follow patients carefully and consider surgery when problems persist despite nonoperative management)

Findings in paper by Richardson et al: authors reviewed »1800 liver injuries occurring over 25 yr; proportion of grade IV and V injuries remained relatively constant at »16%; overall mortality declined from 19% to 9%; dramatic decline in mortality from hepatic injury; 85% of deaths from hepatic injury consistently due to bleed­ing; reasons for decline in mortality due to hepatic bleeding  —  improved management of major venous inju­ries; improved results with packing and reoperation (ie, damage control); use of arteriography and embolization; fewer venous injuries requiring operation (which eliminates exacerbation of injuries in operating room)

Types of grade V injuries: intraparenchymal  —  involves most of lobe or liver; patients usually can be managed nonoperatively; juxtahepatic  —  most patients in danger of exsanguination on presentation to hospital; at Univer­sity of Pittsburgh, 92% of patients require urgent operation; published mortality consistently 65% to 85%; papers by Cogbill and Beal reported 55% mortality associated with anatomic resection; led to cessation of resection for hepatic injuries; surgery still indicated for most grade IV and V injuries, but mortality still high (66%); suggests that appropriate surgical techniques for grades IV and V liver injuries yet to be developed; conservative surgery associated with even higher mortality (in contradiction to current paradigm, taking more aggressive approach perhaps indicated)

Management: operate only when necessary; decide on definitive treatment plan early; keep procedure simple (eg, packing only) whenever possible; if minor interventions fail, change quickly (resectional debridement, or nonan­atomic or anatomic resection), because patient unlikely to survive once hypothermia and coagulopathy estab­lished; use wide exposure and get expert help; know when to quit and do damage control

Surgical goals for major hepatic injury: stop hemorrhage; control bile leak; debridement of dead tissue; drainage; make incision large enough to accomplish goals; use retractors to lift chest wall off table (creates adequate room to go over top of liver during mobilization of triangular and coronary ligaments)

Conclusions: speaker and others now seeing low rates of mortality and bleeding with resection of liver (true even when resection done as second, third, or fourth operation); in general, approach depends on anatomic injury, patient stability, and resources and expertise available at hospital

Splenectomy Is the Safe and Easy Way

Gregory J. Jurkovich, MD, Professor of Surgery, University of Washington School of Medicine, and Chief, Trauma Service, Harborview Medical Center, Seattle, WA

Background: nonoperative management of splenic injuries widely adopted in 1990s for pediatric and adult patients; generally accepted that splenectomy is optimal management of hemodynamically unstable patient with splenic in­jury; surgical indications for stable patient based on serial hematocrit levels, with or without bedrest, and with or without repeat imaging; optimal duration of observation unclear, but success rate should be »35% (unacceptable); challenge is to identify risk factors for failure of nonoperative management

Findings of 2005 review by speaker and colleagues: authors studied data registry from state of Washington of >2000 patients with blunt splenic trauma over 5-yr period; 27% had immediate splenectomy (occurring within 4 hr); nonoperative management attempted in remaining 73% of cases; failure rate 15%, including 62 late failures (>48 hr); 18 (1.1%) failed after discharge from hospital, 38% of whom required splenectomy; risk factors for failure of nonop­erative management  —  age (patients >56 yr of age had failure rate of 25%) and injury severity score (ISS) >55; du­ration of attempted nonoperative management associated with “worrisome trend” toward increased mortality, although not statistically significant; summary implications  —  surgeons should know how to do splenectomies; older age and higher ISS associated with higher nonoperative failure rates; most, but not all failures occur within first 4 to 5 days of injury; failure may occur £21 days out; overall failure rate 2% within 5 days; in paper by Peitzman et al of patients with grade IV or V trauma, nonoperative management associated with 50% failure rate and worsening mortality rate over past decade; nonoperative management also associated with longer length of stay; over last 30 yr, splenectomy associated with mortality rate <6%; sets benchmark for nonoperative manage­ment; risk of OPSI “inconsequential” (<0.04% per 100 yr of patient exposure); insufficient reason to avoid splenec­tomy

Make Every Effort to Save the Spleen

Michael J. Sise, MD, Clinical Professor of Surgery, University of California, San Diego, School of Medicine, and Medical Director of Trauma, Scripps Mercy Hospital, San Diego, CA

Reasons to save spleen: spleen has function; spares patients from long midline incision; 28-yr follow-up study of 740 servicemen splenectomized during World War II showed significantly increased risk for pneumonia and coro­nary artery disease; “not all splenic injuries are created equal, and not all cause life-threatening hemorrhage”; sev­eral studies show no increase in mortality associated with thoughtfully applied nonoperative management, especially for injury grades I to III; in review of late septic complications postsplenectomy in 144 patients, speaker and colleagues noted one death from fulminant pneumococcal sepsis; 4 cases of septicemia requiring intensive care; 5 cases of pneumonia, 2 abscesses, 1 infection of prosthetic heart valve, meningitis, and fever of unknown or­igin; all but 2 infections due to encapsulated organisms; minor complications noted in 30% of patients

Conclusions: splenectomy indicated for clearly unstable patients; for stable patients with injury grades I to III, non­operative management usually successful; splenectomy strongly recommended for stable patients with grade IV or V injuries; consider blood transfusion failure of nonoperative management; embolize selectively; use common sense in operating room (suture spleen when possible; control hemorrhage)

Questions and Answers

Dr. Jurkovich and Dr. Sise

Dr. Jurkovich: OPSI does occur, but is rare; usually prevented through use of trivalent vaccine; splenectomized pa­tient should carry antibiotics if traveling to place where medical care not available within 48 hr; patient immunized before leaving hospital (no 10-yr booster)

Dr. Sise: base management decisions on how patient fares; do not arbitrarily cling to initial treatment plan if indica­tions say otherwise

Current trends: Dr. Jurkovich  —  surgeons under heavy pressure to attempt nonoperative management at all costs; too many transfusions performed in effort to avoid surgery; Dr. Sise  —  examine grade of splenic injury carefully; compelling evidence supports operating on grade IV and V injury, even if patient stable; thoughtful nonoperative management appropriate for grades I to III; if older patient has ruptured spleen, perform splenectomy (life expec­tancy probably not long enough for patient to experience untoward consequences of losing spleen)

Role of angioembolization in splenic injury: Dr. Jurkovich and Dr. Sise  —  none; splenectomy indicated for stable patient with grade IV injury and active extravasation

Definition of unstable patient: Dr. Jurkovich and Dr. Sise  —reproducible systolic blood pressure <90 mm Hg in adults <65 yr of age (or <100 mm Hg if patient >65 yr of age), accompanied by tachycardia; blood pressure main­tained only through ongoing fluid administration (in excess of initial 2-L bolus); Dr. Sise  —  blood transfusion be­gun immediately (crystalloid not administered); major cause of preventable death at all centers is failure to recognize or adequately treat abdominal trauma

Suggested Reading

Beal SL: Fatal hepatic hemorrhage: an unresolved problem in the management of complex liver injuries. J Trauma 1990 Feb;30(2):163-9; Cogbill TH et al: Conservative management of duodenal trauma: a multicenter perspective. J Trauma 1990 Dec;30(12)1469-75; Duane TM et al: Reevaluating the management and outcomes of severe blunt liver injury. J Trauma 2004 Sep;57(3):494-500; Green JB et al: Late septic complications in adults following splenectomy for trauma: a prospective analysis in 144 patients. J Trauma 1986 Nov;26(11):999-1004; Haan JM et al: Nonoperative management of blunt splenic injury: a 5-year experience. J Trauma 2005 Mar;58(3):492-8; McIntyre LK et al: Failure of nonoperative management of splenic injuries: causes and consequences. Arch Surg 2005 Jun;140(6):563-8; Peitzman AB et al: Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma. J Trauma 2000 Aug;49(2):177-87; Peitzman AB et al: Failure of observation of blunt splenic injury in adults: variability in practice and adverse consequences. J Am Coll Surg 2005 Aug;201(2):179-87; Polanco P et al: Hepatic resection in the management of complex injury to the liver. J Trauma 2008 Dec;65(6):1264-9; Richardson D et al: Evolution in the management of hepatic trauma: a 25-year perspective. Ann Surg 2000 Sep;232(3):324-30; Robinette CD, Fraumeni JF Jr: Splenectomy and sub­sequent mortality in veterans of the 1939-45 war. Lancet 1977 Jul 16;2(8029):127-9; Watson GA et al: Nonoperative man­agement of severe blunt splenic injury: are we getting better? J Trauma 2006 Nov;61(5):1113-8.