MANAGEMENT OF SOLID ORGAN INJURIES: NON- OPERATIVE, INTERVENTIONAL AND OPERATIVE

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1 MANAGEMENT OF SOLID ORGAN INJURIES: NON- OPERATIVE, INTERVENTIONAL AND OPERATIVE April 4, 2017 Ellen Omi, MD, FACS Trauma and Critical Care Site Program Director, Surgery Advocate Christ Medical Center Clinical Assistant Professor, Department of Surgery University of Illinois-Chicago DISCLOSURES Gift of Hope: Consultant on Critical Care Advisory Board 1

2 OBJECTIVES To discuss the non-operative and operative management of splenic, renal and liver injuries To discuss the utilization of interventional radiology in solid organ injury and non-operative management To discuss cases that demonstrate the combined approach to solid organ injury. OBJECTIVES To discuss the non-operative and operative management of splenic, renal and liver injuries To discuss the utilization of interventional radiology in solid organ injury and non-operative management To discuss cases that demonstrate the combined approach to solid organ injury. 2

3 SPLENIC INJURY The most commonly injured solid organ. Mechanisms of splenic injury Blunt Penetrating Management Nonoperative Operative Expectant TRUTH OR MYTH Intentional injury of the spleen was a method of assassination. Giraffes were thought to have exceptional speed because they did not have a spleen. The amount of spleen needed to preserve immune and filtering functions of the spleen is about 30-50% Pediatric splenic capsules are thicker and the parenchyma firmer and thus are more likely to be managed successfully nonoperatively. About 45% of blunt splenic injuries will require emergency surgery 3

4 GRADES OF INJURY Grade I-V Low grade I-II Moderate III High grade IV-V Grade I: -Subcapsular hematoma <10% surface area -Laceration/Capsular tear <1cm deep LOW GRADE ATOM, 2 nd edition

5 LOW GRADE Grade II: Subcapsular hematoma 10-50% surface area Intra-parenchymal hematoma <5cm Laceration 1-3cm without vessel involvement ATOM, 2 nd edition MODERATE GRADE Grade III: -Subcapsular hematoma >50% surface area or expanding -Intra-parenchymal hematoma >5cm -Ruptured hematoma -Laceration >3cm or with trabecular vessel involvement ATOM, 2 nd edition

6 HIGH GRADE Grade IV: Laceration of segmental or hilar vessels causing major devascularization (>25% of spleen) ATOM, 2 nd edition HIGH GRADE Grade V: -Shattered spleen -Injury of hilar vessels with completely devascularized spleen ATOM, 2 nd edition

7 MANAGEMENT ABCDE Physicical examination Left upper quadrant pain Left lower chest wall pain Kehr s sign Left shoulder pain INITIAL MANAGEMENT Labs IV access Hemodynamic instability SBP <90 HR >130 Response to initial resuscitation 7

8 UNSTABLE BLUNT ABDOMINAL TRAUMA Grade 3-5 FAST Grade 3 FAST + Triage to CT if initial resuscitation responsive Grade 4 FAST + then to the operating room Selective CT scan if other suspected explanation for instability Grade 5 FAST + / - To the operating room EVOLUTION OF SPLENIC INJURY MANAGEMENT Adult Splenic salvage to avoid overwhelming post splenectomy sepsis (OPSI) Splenic salvage techniques Pediatrics-Best way to salvage the spleen was to not operate Non-operative management initiaily 30-70% Concern for missing intra-abdominal injuries Contra-indications: advanced age, fear of missing hollow viscous injury, >2U PRBC, neurological impairment, high grade injuries) Non-operative management increased to 85% Non-operative management with angio-embolization: Decrease in the failure rate to 10-20% 8

9 NONOPERATIVE MANAGEMENT EVOLUTION Emergence of new-generation CT scanners High success rate of angiographic embolization Better understanding of the natural history of solid organ injuries Conventional 67% nonthereapeutic exploratory laparotomy rate Goffete PP, Laterre PF. Traumatic injuries: imaging and intervention in post-traumatic complications (delayed intervention) Eur Ra MANAGEMENT DECISIONS FOR SPLENIC INJURY Presence and severity of hemodynamic instability Results of the initial workup of blunt abdominal trauma Availability of angiography Definition of failure Use of followup abdominal ct scanning 9

10 OPERATIVE MANAGEMENT Splenectomy Splenic salvage Stable patients Reimplantation Unproven method to preserve splenic function INTERVENTIONAL RADIOLOGY IR suite Monitoring in the same standards of an ICU Therapeutic embolization Aneurysm Arteriovenous fistula Extravasation How to embolize? Main splenic artery Reduces bleeding, but does not prevent late pseudoaneurysm rupture and will not likely treat AVF. Distal selective Stop bloodflow causing infarction and abscess Combination 10

11 VASCULAR BLUSH Hemodynamically stable (Grade 3-5) Angiography OR if angiography not immediately available Hemodynamically unstable (nonresponder) OR Aggressive angiography Highest rates of non-operative management (80%) High rate of complications Labor intensive RISK OF FAILURE OF NONOPERATIVE MANAGEMENT Advanced age Large hemoperitoneum Higher Injury Severity Score Brain Injury Subcapsular Hematoma Scalafini SJ, et al. Non-operative salvage of computed tomography diagnosed splenic injuries: utilization of angiography from triage and embolization for hemostasis. Lopez JM, et al. Subcapsular hematoma in blunt splenic injury: A significant predictor of failure of nonoperative management. J Trauma,

12 10 DOGS IN 1975 Artifical splenic trauma Embolization of the splenic artery 7 survived for 2 months Arteries were patent Parenchyma smaller, but trauma could not be identified Chuang VP, Reuter SR. Selective arterial embolization for the control of traumatic splenic bleeding. Invest Radiol 1975 Jan-Feb; 10(1): Diagnostic peritoneal lavage was the most reliable method of identifying intraperitoneal injuries. Cannot determine who can be treated nonoperatively based on the DPL CT was found to be reliable alternative to DPL but not practical to replace all DPL CT allowed for the nonoperative management of blunt abdominal trauma-no longer mandatory exploration 12

13 Splenic injury on CT Urgent angiography in those that did not require immediate operation Selective embolization with extravasation of contrast. Exravasation into the peritoneum-main splenic arterial branch embolization 13

14 Coil embolization was the best methods of occlusion of the proximal splenic artery Did not result in splenic infarction Blood flow returned to normal in a few weeks Pitressin was temporary and unpredictable Gelfoam embolized to the distal collateral circulation and caused infarction 14

15 39 WOMAN YEAR OLD HIGH SPEED ROLLOVER History of ETOH abuse and cirrhosis Primary Survey ABC intact, GCS 15 Secondary Survey Contusion forehead C-spine tenderness Left upper quadrant pain Seatbelt sign across the chest and abdomen DIAGNOSIS Grade 2 splenic laceration with blush Mild hemoperitoneum 15

16 PLAN IR for angiography Findings Superselective splenic artery catheterization and subsequent arteriogram. Coil embolization of the branches of the splenic artery feeding the inferior spleen Coil embolization of the mid portion of the splenic artery. Discharged home HD #7 Return to the clinic HD #14 with abdominal pain 16

17 INTRAOPERATIVE FINDINGS Laparoscopic splenectomy. Pathology: Benign splenic tissue with hemorrhage, ischemia and necrosis. Search s Failure rate 31-48% of non-operative splenic management The vascular blush was seen in 67% of patients who failed nonoperative management Shackford SR, Molin M. Management of splenic injuries. Surg Clin North Am Godley CD, et al. Nonoperative management of blunt splenic injuries in adults: age over 55 year a powerful indicator for failure. J Am Coll Su Schurr MJ, et al. Management of blunt splenic trauma: computed tomographic contrast blush predicts failure of nonoperative management. J 17

18 year interval ending in June 1997 Hemodynamically stable and no immediate need for operation CT scan of the abdomen within an hour of presentation Followup CT hours after presentation Blush Well-circumscribed, intraparenchymal collection of contrastthat is hyperdense with respect to the surrounding splenic parenchyma Arteriography Confirm the pseudoaneurysm Selective embolization No main splenic artery embolization 18

19 524 patients 180 (34%) underwent urgent exploration 344 stable patients CT scan 61 % non-operative management in this study. PSEUDOANEURYSM 31 pseudoaneurysms Initial CT: 8 Followup CT: 23 Angiography Mean time: 4 days 30 underwent angiography 23 managed nonoperatively 20 pseudoaneurysm confirmed on angiogram 3 without pseudoaneurysm 7 patients OR Unable to be embolized OR for exploration Davis, et al

20 FAILURE ON NONOPERATIVE MANAGEMENT AND NO PSEUDOANEURYSM Number of patients: 15 7 clinical evidence of hemorrhage 6 Worsening appearance on CT 1 delay in diagnosis pancreatic injury 1 splenic infacrction Davis, et al Retrospective chart review 126 patients Angiography at admission 68% negative 32% embolization 8% laparotomy 92% salvage rate J Trauma,

21 NONOPERATIVE MANAGEMENT IS AS EFFECTIVE AS IMMEDIATE SPLENECTOMY FOR ADULT PATIENTS WITH HIGH-GRADE BLUNT SPLENIC INJURY American College of Surgeons Trauma Quality Improvement Program (TQIP) Non-operative and Immediate Splenectomy Patients were matched (n=1516) Median duration of mechanical ventilation Infectious Complications 12.8% had embolization 11% embolized failed 21.4 not embolized failed ** ** Scarborough JE, et al. Nonoperative management is as effective as immediate splenectomy for adult patients with high-grade blunt sp J Am Col Surg, August 2016 National Trauma Databank 18 years or older with high grade blunt splenic injury Level 1-2 trauma centers Manage over 20 patients in one year Annals of Surgery, March

22 53689 patients Grade 3 or higher ** ** ** ** Patients treated in an angio center Higher ISS More commonly had Grade IV Lower admission Motor GCS scores More commonly Level 1 centers More commonly university affiliated Tended to be larger hospitals ** ** Dolejs SC, et al. Overall splenectomy rates stable despite increasing usage of angiography in the management of high-grade blunt splenic injury. Annals of Surgery March % rate of angiography in 2008 to 14.1% in 2014 Dolejs SC, et al. Overall splenectomy rates stable despite increasing usage of angiography in the management of high-grade blunt splenic injury. Annals of Surgery March

23 Splenectomy rates are the same at angio centers Spenectomy rates decreased in non-angiocenters in combined and grade 3 and 4 Dolejs SC, et al. Overall splenectomy rates stable despite increasing usage of angiography in the management of high-grade blunt splenic injury. Annals of Surgery March 2017 Splenectomy within 6h of admission Reduction only in the splenectomy rate in Grade III injuries in non-angio centers Dolejs SC, et al. Overall splenectomy rates stable despite increasing usage of angiography in the management of high-grade blunt splenic injury. Annals of Surgery March

24 Angio- Reduction 5.4% to 4.1% Non-angio Reduction 6.0% to 3.3% Reduction in the rate of late splenectomy in all groups except the Grade IV splenic injuries in the non-angio centers Dolejs SC, et al. Overall splenectomy rates stable despite increasing usage of angiography in the management of high-grade blunt splenic injury. Annals of Surgery March 2017 No differences in mortality over time Late splenectomy overall associated with increased mortality in Grade III and IV Dolejs SC, et al. Overall splenectomy rates stable despite increasing usage of angiography in the management of high-grade blunt splenic injury. Annals of Surgery March

25 CONCLUSIONS Angiography is not the only factor driving the decreased rate of late splenectomy Increase in total hospital costs with angiography Role of angiography in Blunt Splenic Injury needs to be further defined Dolejs SC, et al. Overall splenectomy rates stable despite increasing usage of angiography in the management of high-grade blunt splenic injury. Annals of Surgery March 2017 No difference in splenic embolization and observation 25

26 No difference in splenic embolization and observation No difference in splenic embolization and observation No difference in the mortality in the two groups 26

27 No difference in the mortality in the two groups Significant variation among Level 1 trauma centers. Higher rates of embolization have higher splenic salvage. SPLENIC ANATOMY AND FUNCTION White pulp B-cell follicles Marginal Zone Macrophages Memory B-cells Red Pulp Erythrocyte filtering Measure of Immune function Immune response upon vaccination or by evaluation of B-cell subsets. Erythrocyte filtering Radionucleotide tests (scintigraphy) Clearance of labelled erythrocytes Count of Howell Jolly bodies Count of pitted red blood cells Schimmer JAG, et al. Splenic function after angioembolization for splenic trauma in children and adults: Asystemic review. In 27

28 SPLENIC COMPLICATIONS Reported up to 8% Vascular Complications (70% occur within 2 weeks of injury) Delayed rupture Pseudoaneurysm Arteriovenous Fistula Pseudocyst Abscess Goffete PP, Laterre PF. Traumatic injuries: imaging and intervention in post-traumatic complications (delayed intervention) Eur Ra LATE COMPLICATIONS >48 hours from injury-5-8% incidence Splenic abscess Pseudoaneurysm Hemorrhage Most require splenectomy Cocanour, CS, et al. Delayed complications of nonoperative management of blunt adult spenic trauma, Arch Black JJ, et al. Subcapsular hematoma as a predictor of delayed splenic rupture. Am Surg,

29 OVERWHELMING POST-SPLENECTOMY SEPSIS (OPSS) Encapsulated organisms Pnemococcus Meningiococcus Hemophilus Influenza 2-5 per 1000 Asplenic patients All but one study demonstrate no compromise of immune function with splenic artery embolization. No reports of OPSS in the literature after splenic artery embolization 70% mortality Schimmer JAG, et al. Splenic function after angioembolization for splenic trauma in children and adults: Asystemic review. In EMBOLIZATION OF THE SPLEEN AND IMMUNE FUNCTION Clearance of opsonized autologous red blood cells in normal controls and in patient who underwent splenic artery ligation No significant difference The spleen undergoes hypertrophy and as much as 80% can be removed Short gastrics are adequate to protect against pneumococcal challenge Scintigraphy-reticulo-endothelial system remains viable. Schwalke, et al. Splenic artery ligation for splenic salvage: Clinical experience and immune function. JTrauma, 1991 Greco and Alvarez. Regeneration of the spleen after etopic implantation and partial splenectomy. Surg,

30 EAST PRACTICE GUIDELINES Level 1 Peritonitis or hemodynamic instability should go for urgent laparotomy Level 2 Routine laparotomy not necessary with isolate splenic in jury Grade of injury, age >55, neurologic status, and associated injuries do not exclude non-operative management Consider angiography in grade III or greater, presence of a blush, moderate hemoperitoneum, or evidence of ongoing bleeding. Nonoperative management should only be considered in an environment that allows. EAST.org, 2012 EAST PRACTICE GUIDELINES Level 3 Consider followup imaging with clinical changes Contrast blush is not an absolute indication for angiographic intervention Angiography can be used as an adjunct to non-operative management in high risk patients Venous thromboembolism can be used for patients with isolated blunt splenic injuries without increasing failure of nonoperative rate EAST.org,

31 THE LIVER INITIAL EVALUATION ABCDE Hemodynamically stable Associated abdominal injuries 31

32 GRADES OF LIVER INJURY trauma.org, 2017 APPROACH Operative Packing Hemostatic agents Suturing Total Hepatic Isolation Nonoperative % success Angiographic intervention ERCP (Endoscopic Retrograde Cholangiopancreatography) Percutaneous drainage Does surgery lead to further bleeding and unnecessary interventions and complications?? 32

33 SPLENIC AND LIVER BLUSH Patients with no blush on angiography were more than twice as likely to rebleed compared with those with angiographic evidence of blush. SPLEEN: 25% vs 10%, P <.05 LIVER 32% vs 11%, P =.046 Alarhayem, et al. Blush at first sight : Significance of computed tomographic and angiographic discrepancy in patient with blunt abdominal trauma. Am J Surgery,

34 CONSIDERATIONS No consistent correlation between the grade and failure on nonoperative management Hemodynamic status is more important Limitation of persistent bleeding or delayed bleeding with early angiography Poletti, et al CT grade III or higher Evidence of arterial injury (blush) Evidence of hepatic venous injury FAILURES OF NONOPERATIVE MANAGEMENT OF THE LIVER Hemodynamic instability is the cause of 75% of failures Delayed hemorrhage incidence is % Most common complication Most common cause of death Complication rate increases with the grade of injury 34

35 COMPLICATIONS LIVER 50-60% of patients with grade IV or V liver or splenic lacerations require some type of interventional treatment Vascular Delayed hemorrhage (2.4-5%) Vascular abnormalities 1-2% Pseudoaneurysm Arterivenous fistula Hemobilia (<1%) Liver and Biliary complications Bilhemia Bile leaks (biliary fistula and biloma) Bile peritonitis Biliary Stricture Sepsis Goffete PP, Laterre PF. Traumatic injuries: imaging and intervention in post-traumatic complications (delayed intervention) Eur R 30 YEAR OLD IN A MOTOR VEHICLE COLLISION Airway-Patent and breathing spontaneously Breathing-Saturation 100%, Breath sounds equal, crepitus left anterior chest wall Circulation-Intact. BP 130s, HR 90 GCS 3 Intubated for airway protection Left chest wall does not expand well and is smaller in volume than the right Desaturation Hypotension 35

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37 Chest tube placement 900mL out Stabilized. Saturations improved 37

38 SECONDARY Left abdominal wall abrasion Left chest wall with crepitus. No rectal tone No extremity deformities FAST negative 38

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42 TO THE OPERATING ROOM Pre-op diagnosis Left diaphragmatic rupture Free fluid/blood in the pelvis Hypoperfused left hepatic lobe Post-op diagnosis Left diaphragmatic rupture Grade 2 liver laceration stellate Grade 1 pancreatic hematoma Doppler signal in the porta hepatis, and palpable pulse Normal gallbladder THE NEXT DAY Hypotensive Acidotic Increased airway pressures Compartment syndrome Intestinal ischemia? 42

43 OPERATING ROOM Re-opened Compartment syndrome Gangrenous gallbladder Mottled liver at the gallbladder bed COURSE Hospitalized for 1.5 months Acute kidney Injury Acute respiratory failure Portal Hepatic Duplex Good flow in the heparic and portal vessels Limited study CT Abdomen and Pelvis 10 days later 43

44 10 DAYS LATER 2.5 MONTHS LATER 44

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47 FINDINGS Proper hepatic artery occlusion and pseudoaneurysm Replaced left hepatic artery whic h cross collateralizes to the right l obe of the liver Ischemic dilation of biliary ducts in the right lobe of the liver 1.5 YEARS LATER 47

48 EAST PRACTICE GUIDELINES Level 1 Patients who are hemodynamically unstable or who have diffuse peritonitis after blunt trauma should be taken urgently for laparotomy Level 2 A routine laparotomy in hemodynamically stable patients with liver injury is not indicated Angiography may be considered first line intervention in the transient responder to resuscitation as and adjunct to possible operative intervention Grade of injury, age >55, neurologic status, and associated injuries do not exclude non-operative management Angiographic embolization should be considered in the hemodynamically stable patient with evidence of extravasation on CT scan Nonoperative management should only be considered in an environment that EAST.org, 2012 allows. 48

49 EAST PRACTICE GUIDELINES Level 3 Consider followup imaging with clinical changes Interventional modalities including ERCP, angiography, laparoscopy, and drainage percutaneously may be required to manage complications Venous thromboembolism can be used for patients with isolated blunt splenic injuries without increasing failure of nonoperative rate EAST.org, 2012 CONCLUSIONS Splenic injury has evolved to increase the success of nonoperative management Need to define further the optimal role for angiographic embolization in splenic injuries. Liver injuries utilize both interventional, endoscopic and surgical strategies for salvage of function and have a high nonoperative rate 49

50 THANK YOU Questions? 50