Non-Operative Management of Splenic Trauma
For several decades, splenectomy was considered the only acceptable surgical option for splenic injuries. Though the spleen is the second most frequently injured organ in blunt abdominal trauma, now with modern imaging techniques, many patients with splenic injuries can be safely managed without laparotomy. Since the 1980s, nonoperative management of blunt splenic injury has become widespread in children, but less so in adults, though that, too, is changing.
Diagnosing and Grading Splenic Injury
The early incidental CT observations of damaged spleens in stable patients ushered in the era of nonoperative management. In unstable patients, abdominal sonography is now the method of choice for rapid evaluation of the abdomen for blood, whereas abdominal CT scanning with contrast is preferred in stable patients. CT scanning identifies intraperitoneal blood and can define individual organ injuries. The technique of performing CT examinations is critical in obtaining an optimum study on which to base a treatment decision. The lower chest-to detect occult pneumothorax-and the pelvis-to detect intraperitoneal blood-should be included. Images of the upper abdomen before IV contrast help identify hyperdense hematoma, which can be difficult to visualize after IV contrast. Adequate IV contrast medium, appropriately delivered, is the most important prerequisite for accurate CT scans, and the involvement of an experienced radiologist greatly enhances the value of the study. The American Association for the Surgery of Trauma developed a splenic injury grading scale through a consensus methodology.
Using this grading system, initial large-scale studies in adults reported that the failure rate of nonoperative management varied with the grade of the injury: 0% failure for grade I, 8% for grade II, 19% for grade III, and 100% for grade IV. All patients with grade V injuries had splenectomies. On the other hand, children experience a 97% success rate despite the severity of their splenic injuries. The clearest indication for emergency surgery is hemodynamic instability, however, this is not a discrete factor. Because there is no standard criteria for hemodynamic instability, a general guideline is to operate when the systolic blood pressure drops below 90 mm Hg or a pulse is more than 120 beats/minute, if there is not an immediate response to 1-2 L of crystalloid resuscitation and when intra-abdominal blood loss is indicated.
Adults and children with splenic injuries detected by abdominal CT scanning can be considered candidates for nonoperative management if they are hemodynamically stable and have no other injuries that would require laparotomy, with an anticipated success rate of nearly 100% in children and at least 65% in adults. Patients with grade IV injuries should be monitored carefully, and their nonoperative failure rate should be expected to be higher. In a study of 105 patients, the risk factors for failure of nonoperative management were a grade III or higher injury and transfusion of more than 1 unit of blood. The existence of both risk factors predicted failure in 97% of the cases.
Another study of 222 adults and 45 children (<16 years) who were treated for splenic injury over a 7.5-year period were evaluated retrospectively. Overall, the adults had significantly higher splenic injury scale scores. Nonoperative management was planned for 61.3% of the adults and 94.4% of the children. This approach was successful in 77.2% of the adults and 100% of the children. The patients in whom nonoperative management was successful had significantly lower splenic injury scale scores. Generally, children were more appropriate candidates for nonoperative treatment because their injuries were significantly less severe in adults; however, if both groups present in the same physiologic status, they both do well with a nonoperative approach. The most plausible cause for the differences between adults and children likely relates to adults' lower proportion of myoepithelial cells, thinner splenic capsule, and less elastic rib cage, which may result in a more severe injury given the same mechanism of injury as in a child.
The current controversies in nonoperative management now center on the expansion of nonsurgical therapy to groups that were previously excluded, such as patients with neurological or mental problems, the elderly, those with previously diseased organs, some patients with penetrating injuries, and on the need for, the timing of, and the best method of reimaging these injured organs. Some researchers have reported a high failure rate in elderly patients, but other data did not show that to be the case.
Also, in the past, patients with altered mental status would require laparotomy, but more recent studies have not shown increased complications in this population, if their injuries are otherwise amenable to nonoperative management. Although advanced age, underlying splenic pathology, and the presence of a concomitant neurological injury are not absolute contraindications to the nonoperative approach, large, prospective, multicenter studies are needed in these groups before definitive recommendations can be made. Also, nonoperative management of patients with penetrating splenic injuries needs additional evaluation.
Patient Monitoring and Observation
No scientific evidence shows that bed rest improves the success rate of nonoperative management; similarly, the need for ICU observation among patients with isolated splenic injury is being challenged. Patients can be out of bed when the hematocrit is stable, and eating can resume when the ileus resolves. There are no objective data regarding returning to normal activity, but for injuries graded at I and II, 2-3 weeks should be adequate; more severe grades may take 6-8. Repeat CT scans should be considered in all patients who have a decrease in hematocrit that may be spleen-related. Also, repeat imaging should be considered before discharge in patients with known subcapsular hematomas of the spleen and in those with more severe grades of splenic injury (i.e., III or IV). It is also suggested that athletes have a confirmatory CT 6-8 weeks post injury, before they resume athletic activity.
Evidence from major trauma centers suggests that the incidence of missed intestinal injuries is low in adults and children managed nonoperatively, but surgeons should be careful in monitoring for increasing abdominal pain, abdominal distention, vomiting, and signs of inflammation, which may be delayed signs of intestinal disruption.
Beauchamp RD, Holzman MD, Fabian TC. Spleen. In Sabiston Textbook of Surgery, 16th ed. 2001:1144-1167. Philadelphia: W.B. Saunders Company.
Knudson MM, Maull KI. Nonoperative management of solid organ injuries: past, present, and future. Surg Clin North Am 1999; 79(6): 1357-1365.
Konstantakos AK, Barnoski AL, Plaisier BR et al. Optimizing the management of blunt splenic injury in adults and children. Surg 1999; 126:805-813.
Velmahos GC; Chan LS; Kamel E; Murray JA; Yassa N; Kahaku D, et al. Nonoperative management of splenic injuries: have we gone too far? Arch Surg 2000; 135(6):674-679.