search for




 

Treatment Option for High Grade Spleen Injury and Predictive Factors for Non-operative Management
J Korean Soc Traumatol 2017;30(3):91-97
Published online October 30, 2017
© 2017 The Korean Society of Traumatology.

Joung Won Na1, Jung Nam Lee2, Byung Chul Yu2, Min A Lee2, Jae Jung Park2, and Gil Jae Lee2

1Department of Surgery, Gachon University Gil Medical Center, Incheon, Korea,
2Gachon University Gil Hospital Trauma Center, Incheon, Korea
Correspondence to: Gil Jae Lee, M.D. Gachon University Gil Trauma Center, Namdong-daero 774 beon-gil, Namdong-gu, Incheon 21565, Korea Tel: +82-32-460-2299 Fax: +82-32-460-3247 E-mail: nonajugi@gilhospital.com
Received June 7, 2017; Revised July 27, 2017; Accepted July 28, 2017.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract

Purpose:

The prognostic factors of non-operative management (NOM) in high-grade spleen injuries have been extensively studied, but factors that would help treatment decisions are lacking. We compared the characteristics of the patients to identify the factors affecting treatment choices.

Methods:

This is a review of 207 blunt spleen injury patients from January 2004 to December 2013. We compared clinical features and mortality between surgery and NOM, and used multivariate regression analysis to find the factor most strongly associated with prognosis.

Results:

Of the 207 patients, 107 had high-grade spleen injury patents (grade III or above). Of these, 42 patients underwent surgery and 65 patients underwent NOM. The mortality was 7% following surgery, 3% with NOM. The amount of packed red blood cells transfused in the first 24 hours and spleen injury grade were associated with management type, and mortality was highly associated with activated partial thromboplastin time (aPTT) and spleen injury grade.

Conclusions:

 The grade of spleen injury was associated with management and mortality, so correctly assessing the spleen injury grade is important.

Keywords : Spleen injury, Blunt trauma, Non-operative management
INTRODUCTION

The spleen is the organ most often injured from blunt abdominal trauma [1]. Current management trends are shifting from immediate splenectomy to non-operative management (NOM). NOM should be considered for patients who are hemodynamically stable, lack of peritoneal signs, and capable of treatment by monitoring serial evaluations, with an operating room available for emergency laparotomy [2]. The benefits of spleen conservation include preservation of spleen function, avoiding complications after splenectomy, including overwhelming post-splenectomy sepsis [3]. The selective application of embolization has resulted in increasing success of NOM. However, in high grade spleen injuries, prognostic factors to help with treatment decisions are unclear. The variables considered important in many studies are patient age, concurrent trauma, spleen injury grade, abbreviated injury score (AIS), injury severity score (ISS), injury mechanism, initial vital signs, and initial blood test results [4,5]. If clearly applicable factors for management choices, whether NOM or surgery, can be described, that will be very useful.

The object of this study is to review 10 years of experience of treatment for blunt spleen injury and identify predictive factors.

METHODS

Our study was a retrospective study using medical records of 247 patients admitted to a university hospital between January 2004 and December 2013 for blunt spleen injury who had contrast enhanced computed tomography scans and confirmed spleen injuries. We excluded patients under 15 years old. The exposure variable of interest was surgery versus NOM. We compared patient characteristics (age, sex, injury mechanism), AIS, ISS, and spleen injury grade. Spleen injury grading follows the American Association for the Surgery of Trauma (AAST) Splenic Injury Scale [6-8] (Table 1).


The same comparison was made in patients with spleen injury grade III or above, and variables that were significantly related to management and mortality were analyzed [9,10].

Initial status, clinical features and mortality of the patients and their values were compared by the management types (surgical patients [SP] and NOM). Among these, categorical variables were expressed using chi-square analysis, and continuous items we are compared using independent sample t-test. We used bivariate regression analysis to assess factors associated with mortality and management type as the odds ratio [11]. We rejected null hypotheses of no difference if p-values were less than 0.05.

RESULTS

During the study period, 247 patients were hospitalized and among them, patients under 15 years of age were excluded. Children tend to have a slight degree of injury compared to adults at the same trauma. For example, in the case of in car traffic accident (TA), an adult often seats in the front seat as a driver, while children often wear seat belts in the back seat, resulting in a low degree of injury to children. Capsules of the spleen are thicker than adults, and the elastin and smooth muscle contents of the blood vessels and capsules of the spleen are large, so they are more resistant to injury and more resilient than adults. Therefore, the treatment direction is different for adults and children, and basic treatment methods are also different. For this reason, we excluded children younger than 15 years (n=40) [12]. Of the 207 patents, there were 160 (77.3%) NOM patients, mean age of 41.6±15.8 years. There were 40 (22.7%) surgical patients, with mean age of 41.1±16.1. Table 2 compares clinical characteristics by treatment type. The most common injury mechanism was an in-car crash (72 patients) and 17 patients (37.2%) underwent surgery. The second most common cause was out-of-car crash, 55 patients (34.4%), of whom 13 (27.7%) were surgical and 26.9% were NOM. Other mechanisms were slip, sports injury, and violence, and the SP or NOM ratios of these patients were 12 (25.5%) and 32 (20.0%), respectively. One patient (2.1%) underwent surgery for grade I, and splenectomy was performed due to mesentery bleeding, with spleen and vascular injury detected during emergency laparotomy. There were 46 (28.8%) grade I NOM patients. Among grade II patients, four patients (8.5%) underwent surgery and 49 (30.6%) were NOM. Among grade III, there were 20 (42.6%) SP and 58 (36.3%) NOM, while grade IV included 15 (31.9%) SP patients and seven (4.4%) NOM. All seven grade V patients had surgery. This means the higher spleen injury grades are more likely to be treated surgically [13].


The AIS did not differ significantly in the head, neck, chest, and extremity, but the abdomen AIS grade differed significantly between surgical and NOM patients. The overall ISS in surgical patients was 22.5±25.7, and in NOM cases 16.4±9.4 (p=0.001).

We classified the patients by NOM and SP, and compared their initial hemoglobin level, systolic blood pressure, international normalized ratio (INR), platelet, activated partial thromboplastin time (aPTT), lactate, Base-excess (Table 3). The results showed that the NOM patients’ values were closer to normal than the SP patients. Of the surgical patients, 91.5% (43 patients) received emergency surgery (immediate splenectomy) and four patients (8.5%) were switched to surgery (delayed splenectomy) during non-operative management. The activated PTT of NOM patients 29.5±6.3 sec was significantly lower than in the SP patients 35.2±15.8 seconds (p=0.020). Significantly more blood in first 24 hours was needed in patients managed surgically (SP 19.5±16.2 packs, NOM 7.2±8.8 packs, p<0.001). This was similar to the amount of fresh frozen plasma (FFP) and platelet transfusions. Intensive care unit stay was 9.8±13.5 days for SP and NOM 9.4±10.3 days, not significantly different. The mortality rate of NOM 3.1% was significantly lower than SP patients 14.9% (p=0.036).


The same comparative analysis was performed in 107 patients with spleen grade III or higher high spleen injury. Their mean age was SP 40.3±16.6, NOM 39.7±15.5, and in-car TA was the most frequent injury mechanism, similar to overall patients, but there are no significant differences between the two management types. In high grade spleen injury, abdomen AIS was significantly higher in patients managed by surgery (Table 4).


Most test results of high grade patients in SP case were more abnormal than NOM cases, but the differences were not significant. With activated PTT, the surgical were 36.2±16.4 seconds and non-surgical patients were 29.6±5.6 seconds (p<0.017). The surgical patients consumed an average of 20.1±17.1 packs of packed red blood cells (RBCs) in the first 24 hours, more than the NOM patients: a significant difference compared with other blood products (Table 5).


Mortality of surgically managed high grades patients was 16.7% and NOM was 4.6%. This was similar to the overall mortality (SP 14.9%, NOM 3.1%), meaning higher mortality rates at higher ratings, but the NOM nevertheless had a lower mortality rate. This means that even higher-grade patients can be considered for conservative management, and this is our main opinion.

We conducted bivariate regression analysis to identify factors associated with management types and mortality of blunt spleen injury patients. Variables associated with management type were the amount of packed RBC transfused within 24 hours, activated PTT and high grade spleen injury. The mortality-related variables were activated PTT and spleen in patients with high grade spleen injury (Table 6).

DISCUSSION

Non-operative management of hemodynamically stable blunt spleen injury is currently accepted as a standard option. NOM means surgical observation with serial physical examination, serial computed tomography, or angiographic embolization. Research reports the success rate of NOM is 78% to 98% [14]. With the development of angiographic intervention, the success rate increased up to 98% [15]. In high grade spleen injury of grade III and above, the prognostic consideration for treatment decision is unclear [16]. In a study by Olthof et al. [17], in hemodynamically stable patients, the factors affecting the failure of NOM were age 40 and older, spleen injury grade ≥III, ISS ≥25, abdominal AIS ≥3, trauma and injury score (TRISS) 〈 0.8. Watson et al. [18] reviewed 3,085 adults, and found that failure of NOM AIS ≥4 was up to 54.6%. Other studies on the relationship between failure of the NOM and the ISS note higher failure rates of NOM if the ISS is greater than 25 [19].

Rossaint et al. reported that it is important to monitor initial hemoglobin and coagulation factors in major trauma where massive bleeding is expected, such as spleen injury. Lactate and base deficit are sensitive tests to estimate and monitor the extent of bleeding and shock [20,21].

In our study, the factors affecting treatment and prognosis of blunt spleen injury were age, injury mechanism, spleen injury grade, initial vital status, CBC, coagulation battery, and the amount of transfusion in first 24 hours. These variables were compared by treatment type (NOM or SP), followed by bivariate regression analysis of the factors that were significantly different. The spleen injury grade, activated PTT, and the amount of transfused red blood cells were associated with surgical treatment of high grade spleen injury. We concluded that it could be more beneficial to consider NOM because the mortality of NOM was lower than surgery in even high spleen injury grade patients.

Our study had considerable limitations. The patient records of this study included 10 years of data before establishment of the trauma center in this hospital, so there could be many omissions. The study sample size was small. Most patients were of similar age, making comparisons of age differences difficult. Thus the importance of age, as mentioned in the literature, could be undervalued. During our patient`s treatment periods from 2004 to 2014, the intervention team for emergency embolization had not full-time activated. All grade V patients underwent surgery; therefore we could not obtain information about high grade spleen injury angiographic embolization results. Gaarder et al. [22] analyzed the effect of angiographic embolization in severe spleen injuries on outcomes measured by laparotomy and splenectomy rates for mandatory embolization in grade 3 to 5 whenever positive angiographic findings. They found that angiographic embolization use resulted in an increase of patients selected for NOM from 57% to 73% and failure rate decrease from 21% to 4% [22]. Another shortfall of our study was having no data about in high grade spleen injury patients converted from NOM to delayed operation. The information was limited to surgery management or NOM, making it impossible to assess prognostic factors. Despite these limitations, our study’s significance is confirmation of the importance of spleen injury grade in blunt trauma of spleen and analysis of definitive factors that affect treatment options. Further study analyzed by the cost effectiveness of treatment options, patient heterogeneity, and post NOM complications like pseudo-aneurysm or delayed hemorrhage is needed [23-25].

CONCLUSION

In conclusion, mortality of high grade spleen injury patients was higher than low grade injuries, and mortality of NOM patients was lower than in surgically managed patients. The factors that affect the treatment options in high grade splenic injury were aPTT and spleen injury grade.

TABLES

Grading of splenic injury (American Association for the Surgery of Trauma Organ Injury Scale)

Gradea   Description
 I Sub capsular hematoma 〈 10% of surface area; laceration 〈 1cm parenchymal depth
 II Sub capsular hematoma,10-50% of surface area, 〈 5 cm in diameter; laceration, 1-3 cm in depth
 III Sub capsular hematoma >50% of surface area or expanding; laceration >5 cm depth or expanding; intraparenchymal hematoma, >3 cm or expanding
 IV Laceration involving segmental or hilar vessels producing major revascularization
 V Completely shattered spleen; hilar injury that devascularizes the entire spleen

Advance 1 grade for multiple injuries up to grade III.


Clinical features of 207 patients with blunt spleen injury

OP (n=47) NOM (n=160) p-value
Age 41.1±16.1 41.6±15.8 0.839
Sex 0.295
 Male (n=165 [79.7]) 40 (85.1) 125 (78.1)
 Female (n=42 [20.3]) 7 (14.9) 35 (21.8)
Injury mechanism 0.577
 In car TA 17 (36.2) 55 (34.4)
 Out car TA 13 (27.7) 43 (26.9)
 Fall down 5 (10.6) 30 (18.8)
 Othersa 12 (25.5) 32 (20.0)
AIS
 Head 2.7±0.5 2.7±0.8 0.869
 Neck 2.0±0.8 1.8±0.8 0.707
 Chest 2.9±0.7 2.7±0.7 0.070
 Abdomen 3.4±0.8 2.4±0.7 0.000
 Extremity 3±0.5 2.9±1.6 0.771
ISS 22.49 ± 25.82 16.38±17.86 0.001
Spleen injury grade <0.001
 I 1 (2.1) 46 (28.7)
 II 4 (8.5) 49 (30.6)
 III 20 (42.6) 58 (36.2)
 IV 15 (31.9) 7 (4.4)
 V 7 (14.9) 0 (0.0)

Values are presented as mean±deviation or number (%).

OP: operation, NOM: non-operative management, TA: traffic accident, AIS: abbreviated injury scale, ISS: injury severity score.

Others: slip, sports injury, violence.


Initial clinical features and management, outcomes of 207 patients

OP (n=47) NOM (n=160) p-value
Hb 11.6±2.7 12.7±2.3 0.006
SBP 107.8±27.8 117.5±29.2 0.051
Platelet (×103) 187.7±82.1 218.1±80.4 0.024
aPPT (sec) 35.2±15.8 29.5±6.3 0.020
INR 1.49±1.8 1.2±1.3 0.285
Lactate 3.4±2.7 2.7±2.3 0.113
BE -5.1±5.4 - 4.5±4.7 0.489
Management <0.001
 Emergency OP 43 (91.5) 0 (0.0)
 Delayed OP 4 (8.5) 0 (0.0)
 Embolization 0 (0.0) 9 (5.6)
 Conservative mx. 0 (0.0) 151 (94.4)
Transfusion
 pRBC 19.5±16.1 7.2±8.8 0.001
 PC 10.7±14.8 6.8±9.6 0.192
 FFP 9.4±9.1 4.5±6.2 0.020
ICU stay (days) 9.8±13.5 9.4±10.3 0.872
Hospital stay (days) 25.9±24.9 27.7±26.2 0.853
In hospital mortality (%) 7 (14.9) 5 (3.1) 0.036

Values are presented as mean±deviation or number (%).

OP: operation, NOM: non-operative management, Hb: hemoglobin, SBP: systolic blood pressure, aPPT: activated partial thromboplastin time, INR: international normalized ratio, BE: base excess, mx.: management, pRBC: packed red blood cell, PC: platelet, FFP: fresh frozen plasma, ICU: intensive care unit.


Clinical features of grade ≥III patients

OP (n=42) NOM (n=65) p-value
Age 40.3±16.6 39.7±15.5 0.845
Sex 0.197
 Male (n=85) 36 (85.7) 49 (75.4)
 Female (n=22) 6 (14.3) 16 (24.6)
Injury mechanism 0.053
 In car TA 15 (35.7) 18 (27.7)
 Out car TA 13 (31.0) 19 (29.2)
 Fall down 2 (4.8) 16 (24.6)
 Othersa 12 (28.6) 12 (18.5)
AIS
 Head 2.7±0.5 2.7±0.7 0.878
 Neck 2.0±0.8 2.1±0.9 0.800
 Chest 2.9±0.7 2.9±0.6 0.963
 Abdomen 3.6±0.7 2.9±0.4 <0.001
 Extremity 3.0±0.5 2.9±0.6 0.506
ISS 23.7±10.9 19.7±10.4 0.063

Values are presented as mean±deviation or number (%).

OP: operation, NOM: non-operative management, TA: traffic accident, AIS: abbreviated injury score, ISS: injury severity score.

Others: Slip, sports injury, violence.


Initial clinical features and management , outcomes of grade ≥III patients

OP (n= 42) NOM (n=65) p-value
Hb 11.6±2.7 12.1±2.0 0.267
SBP 107.9±28.3 112.4±27.4 0.445
Platelet(×103) 181.8±78.8 211.3±84.9 0.074
PTT (sec) 36.2±16.4 29.6±5.6 0.017
INR 1.2±0.3 1.3±1.7 0.806
Lactate 3.4±2.8 2.6±1.6 0.093
BE -5.1±5.5 -4.4±4.8 0.528
Transfusion (packs)
 pRBC 20.1±17.1 2.6±1.6 0.003
 PC 11.1±15.2 4.6±8.6 0.109
 FFP 9.7±9.6 5.1±8.2 0.097
ICU stay (days) 9.8±14.3 11.7±13.2 0.631
Hospital stays (days) 27.4±25.7 30.0±26.5 0.625
In hostpital mortality (%) 7 (16.7) 3 (4.6) 0.036

Values are presented as mean±deviation or number (%).

OP: operation, NOM: non-operative management, Hb: hemoglobin, SBP: systolic blood pressure, PTT: partial thromboplastin time, INR: international normalized ratio, BE: base excess, pRBC: packed red blood cell, PC: platelet, FFP: fresh frozen plasma, ICU: intensive care unit.


Factors associated with operative management and mortality for blunt spleen injury

Exp (B) 95% CI p-value
Factors associated with management
 RBC transfusion 0.918 0.858-0.982 0.012
 aPTT 1.101 1.052-1.153 <0.001
 Spleen injury grade ≥III 0.207 0.061-0.700 0.011
Factors associated with mortality
 aPTT 1.226 1.063-1.413 0.005
 Spleen injury grade ≥III 9.253 1.779-48.123 0.008

CI: confidence interval, RBC: red blood cell, aPPT: activated partial thromboplastin time.


References
  1. Davis JJ, Cohn I Jr, and Nance FC. Diagnosis and management of blunt abdominal trauma. Ann Surg 1976;183:672-8.
    Pubmed KoreaMed CrossRef
  2. Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS, and Guillamondegui OD et al. Selective nonoperative management of blunt splenic injury:an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012;73:S294-300.
    Pubmed CrossRef
  3. Wani MA, Shah M, and Malik AA. Non-operative treatment of splenic injury in patients with blunt abdominal trauma. Int Surg J 2017;4:278-81.
    CrossRef
  4. Hildebrand DR, Ben-Sassi A, Ross NP, Macvicar R, Frizelle FA, and Watson AJ. Modern management of splenic trauma. BMJ 2014;348:g1864.
    Pubmed CrossRef
  5. Olthof DC, Joosse P, van der Vlies CH, de Haan RJ, and Goslings JC. Prognostic factors for failure of nonoperative management in adults with blunt splenic injury:a systematic review. J Trauma Acute Care Surg 2013;74:546-57.
    CrossRef
  6. Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, and Champion HR et al. Organ injury scaling:spleen, liver, and kidney. J Trauma 1989;29:1664-6.
  7. Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, and Champion HR. Organ injury scaling:spleen and liver (1994 revision). J Trauma 1995;38:323-4.
    Pubmed CrossRef
  8. Tinkoff G, Esposito TJ, Reed J, Kilgo P, Fildes J, and Pasquale M et al. American Association for the Surgery of Trauma Organ Injury Scale I:spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg 2008;207:646-55.
    Pubmed CrossRef
  9. Tohira H, Jacobs I, Mountain D, Gibson N, and Yeo A. Comparisons of the outcome prediction performance of injury severity scoring tools using the abbreviated injury scale 90 Update 98 (AIS 98) and 2005 Update 2008 (AIS 2008). Ann Adv Automot Med 2011;55:255-65.
    Pubmed KoreaMed
  10. Lesko MM, Woodford M, White L, O'Brien SJ, Childs C, and Lecky FE. Using Abbreviated Injury Scale (AIS) codes to classify computed tomography (CT) features in the Marshall System. BMC Med Res Methodol 2010;10:72.
    Pubmed KoreaMed CrossRef
  11. Rosati C, Ata A, Siskin GP, Megna D, Bonville DJ, and Stain SC. Management of splenic trauma:a single institution's 8-year experience. Am J Surg 2015;209:308-14.
    Pubmed CrossRef
  12. Powell M, Courcoulas A, Gardner M, Lynch J, Harbrecht BG, and Udekwu AO et al. Management of blunt splenic trauma:significant differences between adults and children. Surgery 1997;122:654-60.
    CrossRef
  13. Aseervatham R, and Muller M. Blunt trauma to the spleen. ANZ Journal of Surgery 2000;70:333-7.
    CrossRef
  14. Watson GA, Rosengart MR, Zenati MS, Tsung A, Forsythe RM, and Peitzman AB et al. Nonoperative management of severe blunt splenic injury:are we getting better?. Aust N Z J Surg 2006;61:1113-9.
  15. Peitzman AB, Heil B, Rivera L, Federle MB, Harbrecht BG, and Clancy KD et al. Blunt splenic injury in adults:multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma 2000;49:177-87. discussion 187-9
    Pubmed CrossRef
  16. Scarborough JE, Ingraham AM, Liepert AE, Jung HS, O'Rourke AP, and Agarwal SK. Nonoperative management is as effective as immediate splenectomy for adult patients with high-grade blunt splenic injury. J Am Coll Surg 2016;223:249-58.
    Pubmed CrossRef
  17. Olthof DC, Joosse P, Bossuyt PM, de Rooij PP, Leenen LP, and Wendt KW et al. Observation versus embolization in patients with blunt splenic injury after trauma:a propensity score analysis. World J Surg 2016;40:1264-71.
    Pubmed KoreaMed CrossRef
  18. Watson G, Hoffman M, and Peitzman A. Nonoperative management of blunt splenic injury:what is new?. Eur J Trauma Emerg Surg 2015;41:219-28.
    Pubmed CrossRef
  19. Sondeen JL, Prince MD, Kheirabadi BS, Wade CE, Polykratis IA, and de Guzman R et al. Initial resuscitation with plasma and other blood components reduced bleeding compared to hetastarch in anesthetized swine with uncontrolled splenic hemorrhage. Transfusion 2011;51:779-92.
    Pubmed CrossRef
  20. Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, and Fernández-Mondéjar E et al. Management of bleeding following major trauma:an updated European guideline. Crit Care 2010;14:R52.
    Pubmed KoreaMed CrossRef
  21. Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, and Fernández-Mondéjar E et al. The European guideline on management of major bleeding and coagulopathy following trauma:fourth edition. Crit Care 2016;20:100.
    Pubmed KoreaMed CrossRef
  22. Gaarder C, Dormagen JB, Eken T, Skaga NO, Klow NE, and Pillgram-Larsen J et al. Nonoperative management of splenic injuries:improved results with angioembolization. J Trauma 2006;61:192-8.
    Pubmed CrossRef
  23. Leeper WR, Leeper TJ, Ouellette D, Moffat B, Sivakumaran T, and Charyk-Stewart T et al. Delayed hemorrhagic complications in the nonoperative management of blunt splenic trauma:early screening leads to a decrease in failure rate. J Trauma Acute Care Surg 2014;76:1349-53.
    Pubmed CrossRef
  24. Muroya T, Ogura H, Shimizu K, Tasaki O, Kuwagata Y, and Fuse T et al. Delayed formation of splenic pseudoaneurysm following nonoperative management in blunt splenic injury:multi-institutional study in Osaka, Japan. J Trauma Acute Care Surg 2013;75:417-20.
    Pubmed CrossRef
  25. Bruce PJ, Helmer SD, Harrison PB, Sirico T, and Haan JM. Nonsurgical management of blunt splenic injury:is it cost effective?. Am J Surg 2011;202:810-6. discussion 815-6
    Pubmed CrossRef


August 2018, 31 (2)
Full Text(PDF) Free

Social Network Service
Services

Cited By Articles
  • CrossRef (0)