Evaluation of Nonoperative Management (NOM) In Blunt Splenic and Liver Injuries in Adults: A PROSPECTIVE STUDY

Transcription

1 Kasr El Aini Journal of Surgery VOL., 11, NO 3 September Evaluation of Nonoperative Management (NOM) In Blunt Splenic and Liver Injuries in Adults: A PROSPECTIVE STUDY Maged Rihan MD, MRCS, Nader Makram MD, MRCS, George A. Nashed, MD, MRCS Department of General Surgery, Faculty of Medicine, Cairo University ABSTRACT Isolated splenic or hepatic injuries represent about 30% of blunt abdominal trauma cases. Results of nonoperative management (NOM) for blunt hepatic and splenic injuries in adult patients with multiple injuries were evaluated in this prospective study. Adult patients who sustained a blunt abdominal trauma with documented liver and/or splenic injuries were selected. Associated injuries, clinical signs at presentation, investigations, injury Severity Score, grading of the injury, blood transfusion requirements, morbidity and mortality were documented. Data collection from 178 patients 129 males and 49 females with age range from 18 to 64 years with blunt splenic and/or liver trauma and associated injuries were analyzed. Surgery was indicated in 66 (37%) patients who had no response to resuscitation measures or with suspicious abdominal signs. 112 of 178 (63%) patients were selected for non operative management (NOM): 36 patients with isolated splenic injury, 28 patients with isolated liver injury and 3 patients with combined injuries to both organs; the remaining 45 patients had associated extra abdominal injuries. 28 patients were older than 50 years, 19 in the NOM group, and 9 in the operative group. The mean injury severity score was 12.1 in the NOM group and 15.4 in the operative group. Injury grade ranged from I-IV and the degree of hemoperitoneum was from mild to severe. Mean blood transfusion requirement during first 24 hours at admission was 0.43 units in the NOM group and 1.79 units in the operative group. Morbidity rate was 13.6% in the operative group. NOM failed in 7 patients (6%). Two patients died from severe head injuries, one from the operative, and the other from the NOM group. Conclusion: Nonoperative management is an accepted and safe strategy in blunt splenic and liver injuries in the vitally stable patients, irrespective of age, grade of injury (except grades V and VI in hepatic and grade IV in splenic trauma (not included in this study)), associated injuries or degree of hemoperitoneum (except massive one). Keywords: nonoperative -Blunt trauma- spleen-liver injuries. INTRODUCTION Isolated splenic or hepatic injuries are present in approximately 30% of all cases of adult blunt abdominal trauma [1,2]. In recent years, following the initial success of Upadhyaya and Simpson with nonoperative management of splenic injuries in children [3], more stable patients with blunt splenic injuries are treated nonoperatively with reported success rates of % [4,6]. Many studies documented successful extension of this approach to the care of hepatic, renal, pancreatic and multiple injuries [7,8,9,10,12]. Increasing use of high quality computed tomographic imaging and its interpretation leads to redefinition of the criteria for nonoperative management of splenic and hepatic injuries [13,14,15]. Many studies documented that the results of nonoperative management to children, and young adults with isolated organ injury are superior to those in older patients and in patients with associated injuries [18]. In this study, we present our experience with nonoperative management (NOM) of hepatic and splenic injuries in adult patients with and without additional extra abdominal injuries, and in older patients. MATERIALS & METHODS In this prospective study, among 512 patients (age over 18 years) admitted to Kasr Al- Aini Hospital over a period of one year (between April,2009 and March, 2010) suffering from blunt abdominal trauma,178 adult patients were found to have blunt splenic and /or liver injuries as documented by postcontrast CT examination and were included in this study. The following

2 Kasr El Aini Journal of Surgery VOL., 11, NO 3 September variables were recorded: age, gender, mechanism of injury, initial Glasgow Coma Scale score (GCS) and systolic blood pressure on presentation, associated injuries, injury severity score (ISS), injury grade by CT scan with oral and IV contrast, number of units of blood transfused within the first 24 hours after admission, morbidity and mortality rates. The Injury Severity Score (ISS) as described by Baker et al, 1974 [19] is an anatomical scoring system that provides an overall score for patients with multiple injuries. Each injury is assigned an Abbreviated Injury Scale (AIS) score and is allocated to one of six body regions (Head, Face, Chest, Abdomen, Extremities including the Pelvis, External structures). Only the highest AIS score in each body region is used. The 3 most severely injured body regions have their score squared and added together to produce the ISS score. The ISS score takes values from 0 to 75. If an injury is assigned an AIS of 6 (unsurvivable injury), the ISS score is automatically assigned to 75. The ISS score is virtually the only anatomical scoring system in use and correlates linearly with mortality, morbidity, hospital stay and other measures of severity. The diagnosis of hemoperitoneum was confirmed by abdominal ultrasonography and post- contrast computerized tomography (CT)- scan. Liver and splenic injuries were classified by using the Organ Injury Scale Committee of the American Association for the Surgery of Trauma according to the results of abdominal CT-scan as in table[1and 2]. [20]. Table 1: Liver Injury Scale Grade Type Description I Hematoma Subcapsular, nonexpanding, < 10% surface area. Laceration Capsular tear, nonbleeding; < 1 cm deep in parenchyma. II Hematoma Subcapsular, none expanding, 10-50% surface area; intraparenchymal, nonexpanding, < 2 cm in diameter. Laceration Capsular tear, active bleeding; 1-3 cm deep into the parenchyma, < 10 cm long. III Hematoma Subcapsular, > 50% surface area or expanding; ruptured subcapsular hematoma with active bleeding; intraparenchymal hematoma > 2 cm or expanding. Laceration > 3 cm deep into the parenchyma. IV Hematoma Ruptured intraparenchymal hematoma with active bleeding. Laceration Parenchymal disruption involving > 50% of hepatic lobe. V Laceration Parenchymal disruption involving > 50% of hepatic lobe. Vascular VI Vascular Hepatic avulsion. Juxtahepatic venous injuries; i.e. retro-hepatic vena cava or major hepatic veins. Table 2: Splenic Injury Scale Grade Description I Minor subcapsular tear or haematoma II Parenchymal injury not extending to the hilum III Major parenchymal injury involving vessels and hilum IV Shattered spleen Patients included in this study were divided into 2 groups: 1. Group A (Operative Management (OM) Group): included those patients who were Vitally unstable on presentation and those patients with signs of massive hemoperitoneum. The signs of vital instability included arterial hypotension (systolic pressure lower than 100 mmhg) and/or persistent tachycardia (pulse more than 100 beats per minute) in spite of intensive resuscitative measures. Those patients underwent urgent abdominal exploration 2. Group B (Non Operative Management (NOM) Group): included stable patients

3 Kasr El Aini Journal of Surgery VOL., 11, NO 3 September without tachycardia and/or hypotension on admission or after resuscitation and were treated nonoperatively. After CT scan examination and documentation of the presence of injured liver or spleen or both and its grade, they were admitted to the intermediate care unit under close monitoring by serial physical examination, vital signs and hematocrit measurement. Complete bed rest, intra venous fluids and third generation cephalosporins for the first 48 hours were applied. RESULTS During the period of the study, among 512 blunt abdominal trauma patients, 178 were found to have liver and/or splenic injuries (34.7%). The patients were 129 males and 49 females with age range from 18 to 64 years (mean years). Twenty eight patients (16%) were older than 50 years. Mechanism of injury was motor vehicle accident in 149(84%) of cases, fall from height in 27(15%), assault in 2(1%). GCS score on admission was more than 12 in 156 patients (87.6 %), from 9 to 12 in 18 patients (10.1 %) and less than 9 in 4 patients (2.2 %). Group A: included 66 patients (37%) with no response to resuscitation measures or with suspicious abdominal signs and were found to have liver and/or splenic injuries on exploration. The mean age of those patients was years, with 9 patients (13.6%) older than 50 years. The male to female ratio was 53/13; the mean systolic blood pressure on admission was 89.7 mmhg, mean ISS was 15.4, mean GCS was All patients needed blood transfusion with a mean number of 1.79 units of packed RBCs in the first 24 hours. In this group 11 (16.6%) patients had isolated splenic injury, 3(4.6%) patients had isolated liver injury and 1(1.5%) patient with isolated combined splenic and liver injuries. The remaining 51(77.3%) patients had associated extra abdominal injuries [table 3]. From these 51 patients; 35 had splenic injuries, 13 had liver injuries, and 3 had injuries to both. Splenectomy was done for all patients with splenic injuries and control of bleeding by resectional debridement and/or repair was done for hepatic injuries. Table 3: Associated injuries in both groups Injury Number operative patients Number nonoperative patients Head only Chest only 8 7 Skeletal only 1 3 More than one extra abdominal system injury Total The grading of injury in this group ranged from I to IV and only 14 patients (21%) had an injury grading less than III. Morbidity (9 patients, 13.6%): One patient in the operative group developed an infected subphrenic bile collection, which was treated by Ultrasound guided percutaneous drainage. Four patients developed superficial wound infection, 3 developed chest infection, and 1 developed unilateral lower limb infrapopliteal DVT. Mortality: In this group there was a single mortality in a patient with GCS 3 and died from complication of severe head trauma. Group B: included 112 patients (63%) who were vitally stable on admission and were selected for NOM. The mean age of those patients was 38 years, with 19 patients (17%) older than 50 years. The male to female ratio was 92/20; the mean systolic blood pressure on admission was mmhg, the mean ISS was 12.1, the mean GCS was patients required blood transfusion with a mean number of 0.43 units of packed RBCs in the first 24 hours. Isolated splenic and/ or liver injuries were present in 67 (60%) patients. CT scan examination revealed 36 patients (32%) with isolated splenic injury, 28 patients (25%) with isolated liver injury and 3 patients (2.5%) with

4 Kasr El Aini Journal of Surgery VOL., 11, NO 3 September injuries to both organs; the remaining 45 patients have associated extra abdominal injuries (40%) [Table3]. From these 45 patients; 26 had splenic injuries, 17 had liver injuries, and 2 had injuries of both organs. The CT grading of the patients in this group ranged from I to IV and 104 patients (93%) had a CT grading less than III. [Table 4] Table 4: Injury grades in nonoperative management patients Grade Splenic injury Liver injury I II III 5 5 IV 1 2 Total Morbidity (7 patients, 6%): Exploratory laparotomy was necessary in 7 patients (6%). Four patients due to decrease in the blood pressure, hematocrit and/or the need for more than 2 blood units during the first 24 hours from admission, splenectomy was done for the four patients. Two patients were explored due to missed diaphragmatic injury, diagnosed by follow up CT scan 24 hours from admission and treated by splenectomy with diaphragmatic repair. One patient with pancreatic transection diagnosed by follow up abdominal CT scan performed 24 hours after admission was also explored, and pancreatico-jejunal anastomosis with splenectomy were performed. [Table 5]. Table 5: Morbidity in group B patients Morbidity Number of Surgical management patients 4 Splenectomy Decrease in BP, hematocrit and/or >2 blood units needed in the 1 st 24 hours Missed diaphragmatic injury 2 Splenectomy with diaphragmatic repair Pancreatic transection 1 Splenectomy with pancreatico-jejunal anastomosis Mortality: One patient with admission GCS score 3, died two days later from complications of head injury. The patients bed stay ranged from 3 days to one week in isolated liver injuries, and two weeks in patients with splenic injuries. Patients characteristics are summarized in [Table 6]. Table 6: Patients characteristics in both groups Parameter OM group (A) NOM group (B) Age(Y) (mean) Sex(M/F) 53/13 92/20 Systolic blood pressure on presentation (mean) ISS (mean) GCS score (mean) Blood use/mean(units) Morbidity (%) Mortality (%)

5 Kasr El Aini Journal of Surgery VOL., 11, NO 3 September DISCUSSION Senn in 1903 described nonoperative management of splenic injury [16]. Kocher, who reported a NOM mortality rate of about 90% [17], quickly challenged him. Since Kocher's report, splenectomy became the standard of care for the injured spleen. In 1968, however, due to concerns with overwhelming post splenectomy sepsis, the Hospital for Sick Children in Toronto published its successful experience of nonsurgical approach to paediatric splenic injuries [3].From 1980's numerous investigators reported variable success rates ranging from 14 to 100% in the NOM of blunt splenic injuries in adults. [4,6,7,8] Complex splenic injuries, preexisting splenic pathologic conditions, older age, blood transfusion requirement or neurologic injuries are not universally accepted as reasons to avoid NOM, as was mandated in early reports. [21,22,23,24] Success in NOM of splenic injuries and high complication rate in liver trauma surgery led to its application for patients with hepatic trauma. NOM of liver injury has now evolved into a common practice, following reports revealing success in 85 to 100% of patients. [12,25,26] Immediately available hospital facilities including intensive care unit and 24-hours emergency operating room are important resources for success in NOM of patients with blunt abdominal trauma. In our series the overall success rate of non-operative management was 94%. Most studies of NOM have excluded patients with extra-abdominal conditions particularly neurologically impaired patients. A recent review of blunt splenic injuries suggested that candidates for conservative treatment "must have suffered an isolated splenic injury in minimally injured patients" [5]. In contrast, both Archer [9] in adults and Coburn [11] in children and adolescents did not find increased morbidity or failure rate in the multiply injured patients with NOM. The rationale for excluding neurologically impaired patients was the inability to perform reliable physical examination. However, the reason for converting NOM to OM in these studies was either falling hematocrit or hemodynamic deterioration. We have elected early to extend NOM to selected stable patients with associated injuries that do not require an abdominal operation. 32 patients in this group had head injury; other 13 had associated multiple injuries. CT should be used preferentially over DPL and US to increase overall splenic and hepatic salvage [4,15]. Data obtained from CT scan included grade of injury, quantity of hemoperitoneum, presence of arterial extravasation and concomitant abdominal injuries. Diagnosis of active bleeding per CT requires performing an angiographic embolization of bleeding source when possible [27,28]. This was done for one patient in the operative group after damage control packing for his liver trauma in the first exploration. The grading of injury in both groups ranged from I to IV, but 104 patients (93%) had a CT grading less than III in the non operative group in comparison to 14 patients (21%) in the operative group; denoting that the higher the grade of injury, the less liability for success of the non operative management. The need for blood products in treatment of splenic and liver injuries had led to further questions and controversy because of the risk of transfusion diseases. [29] Luna and Dellinger [30] suggested that the risk of death due to blood transfusion in successful NOM of splenic injury exceed that of immediate operation of injured spleen. Two blood units in isolated spleen injury limit spleen NOM. Nonoperative treatment may be continued in patients with higher transfusion requirements only if could be establish that these additional transfusions were necessitated by associated injuries. Our data in multiple trauma patients is consistent with other recent reports in literature [9,10] and demonstrates significantly lower transfusion rate in NOM group as only 18 from 112 patients (16%) needed blood transfusion with a mean number of only 0.43 units of packed RBCs in the first 24 hours. Some authors [9] in 1990-s argued that age over 50 years prohibits NOM in splenic or hepatic injuries. However, the data supporting this argument leave a lot to be discussed. With growing experience of NOM in elderly patients different reports [31,32] conclude that age should not be criteria for NOM of blunt splenic injuries. Older patients with high-grade injuries and pelvic free fluid are greater risk for NOM failure. Patients with these findings must be monitored closely. Failure of NOM in this population is

6 Kasr El Aini Journal of Surgery VOL., 11, NO 3 September associated with increased morbidity and mortality [32]. Careful selection of patients older than 50 years must be made to minimize morbidity and mortality from failed attempts. In this study, the 19 patients older than 50 years old selected for NOM in the present series were managed successfully. As in our study Markogiannakis and others concluded that NOM of adult blunt hepatic and splenic trauma patients is safe and efficient. Hemodynamic stability is important for selecting these patients for NOM and splenic trauma patients need more intense observation. [33] Peitzman and others reported that most blunt hepatic and splenic injuries could be managed nonoperatively, and the management of blunt splenic injury with observation and organ preservation will avoid the lifelong risk of overwhelming post-splenectomy infection. [34] Jennifer and others documented a significant difference in deep venous thrombosis formation between splenectomy patients and nonoperative patients in traumatic splenic injuries, and reported that coagulation assays indicated persistent hypercoagulability following splenectomy. [35] In our study one patient from the operative group developed unilateral lower limb DVT while none of the patients in the nonoperative group developed DVT. Currently, the reported failure rates for NOM ranges from 15 to 25%. [4,5,6,25,26] In this series, the failure rate was 6%. In addition, there were 9(14%) of non-therapeutic laparotomies done in the operative group and therefore these 9 patients were suitable for nonoperative management. This fact indicates that still more patients could have been managed conservatively. This is a field for more experience in management of blunt splenic and liver injuries. Conclusion We conclude that NOM in vitally stable patients with blunt trauma to the liver or spleen is highly successful. It appears that neither age, injury grade, degree of hemoperitoneum, nor associated injuries, are contra-indications to NOM. The most important selection criterion is hemodynamic stability. The indication for conversion from NOM to operative one is based on additional injuries detected by subsequent imaging and on hemodynamic criteria. REFERENCES 1. Cogbill TH, Moore EE, Jurkovich GJ, Morris JA, Mucha P Jr, Shackford SR, et al. Nonoperative management of blunt splenic trauma: A multicenter experience. J Trauma 1989; 29: Hollands MJ, Little JM. Non-operative management of blunt liver injuries. Br J Surg 1991; 78: Upadhyaya P, Simpson JS. Splenic trauma in children. Surg Gynecol Obstet 1968;126: Brasel KJ, DeLisle NOM, Olson CJ, Borgstrom DC. Splenic injury: Trends in evaluation and management. J Trauma 1998; 44: Rappaport W, McIntyre KE Jr, Carmona R. The management of splenic trauma in the adult patient with blunt multiple injuries. Surg Gynecol Obstet 1990;170: Smith JS Jr, Cooney RN, Mucha P Jr. Nonoperative management of the ruptured spleen: A revalidation of criteria. Surgery 1996;120: Hashemzadeh SH, Hashemzadeh KH, Dehdilani M, Rezaei S. Non-operative management of blunt trauma in abdominal solid organ injuries: a prospective study to evaluate the success rate and predictive factors of failure. Minerva Chir Jun;65(3): Marmorale C, Guercioni G, Siquini W, Asselhab S, Stortoni P, Fianchini M, Fianchini A, Landi E. [Non-operative management of blunt abdominal injuries].chir Ital Jan-Feb;59(1): Archer LP, Rogers FB, Shackford SR. Selective nonoperative management of liver and spleen injuries in neurologically impaired adult patients. Arch Surg 1996;131: Bond SJ, Eichelberger MR, Gotschall CS, Sivit CJ, Randolph JG. Nonoperative management of blunt hepatic and splenic injury in children. Ann Surg 1996;223: Coburn MC, Pfeifer J, DeLuca FG. Nonoperative management of splenic and hepatic trauma in the multiply injured pediatric and adolescent patient. Arch Surg 1995;130: Pachter HL, Knudson MM, Esrig B, Ross S, Hoyt D, Cogbill T, et al. Status of

7 Kasr El Aini Journal of Surgery VOL., 11, NO 3 September nonoperative management of blunt hepatic injuries in 1995: A multicenter experience with 404 patients. J Trauma 1996;40: Levine CD, Patel UJ, Wachsberg RH, Simmons MZ, Baker SR, Cho KC. CT in patients with blunt abdominal trauma: Clinical significance of intraperitoneal fluid detected on a scan with otherwise normal findings. AJR Am J Roentgenol 1995;164: Schurr MJ, Fabian TC, Gavant M, Croce MA, Kudsk KA, Minard G, et al. Management of blunt splenic trauma: Computed tomographic contrast blush predicts failure of nonoperative management. J Trauma 1995;39: Franklin GA, Casós SR. Current advances in the surgical approach to abdominal trauma. Injury Dec;37(12): Senn N. The surgical treatment of traumatic hemorrhage of the spleen. JAMA 1903;41: Kocher E. In: Textbook of Operative Surgery. A and C Black: London; p Cogbill, Thomas H; Moore, Ernest E; Gregory J; Morris, John A. et al. Nonoperative Management of Blunt Splenic Trauma: A Multicenter Experience. Journal of Trauma-Injury Infection & Critical care Oct 1989 volume 29 issue Baker, S., B. O'Neill, W. Haddon, and W.B. Long. The injury severity score: A method for describing patients with multiple injuries and evaluating medical care. J Trauma 14:187 Mar Moore EE, Cogbill TH, Jurkovich GJ: Organ injury scaling: spleen and liver (1994 revision). J Trauma 38(3): , Myers JG, Dent DL, Stewart RM, Gray GA, Smith DS, Rhodes JE, et al. Blunt splenic injuries: Dedicated trauma surgeons can achieve a high rate of nonoperative success in patients of all ages. J Trauma 2000;48: Peitzman AB, Heil B, Rivera L, Federle MB, Harbrecht BG, Clancy KD, et al. Blunt splenic injury in adults: Multiinstitutional Study of the Eastern Association for the Surgery of Trauma. J Trauma 2000;49: Schwab CW. Selection of nonoperative management candidates. World J Surg 2001;25: 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: Maull KI. Current status of nonoperative management of liver injuries. World J Surg 2001;25: Ochsner MG. Factors of failure for nonoperative management of blunt liver and splenic injuries. World J Surg 2001;25: Delgado Millan MA, Deballon PO. Computed tomography, angiography and endoscopic retrograde cholangiopancreatography in the nonoperative management of hepatic and splenic trauma. World J Surg 2001;25: Wallis A, Kelly MD, Jones L. Angiography and embolisation for solid abdominal organ injury in adults - a current perspective. World J Emerg Surg Jun 28;5: Duke BJ, Modin GW, Schecter WP, Horn JK. Transfusion significantly increases the risk for infection after splenic injury. Arch Surg 1993;128: Luna GK, Dellinger EP. Nonoperative observation therapy for splenic injuries: A safe therapeutic option? Am J Surg 1987;153: Cocanour CS, Moore FA, Ware DN, Marvin RG, Duke JH. Age should not be a consideration for nonoperative management of blunt splenic injury. J Trauma 2000;48: Harbrecht BG, Peitzman AB, Rivera L, Heil B, Croce M, Morris JA Jr, et al. Contribution of age and gender to outcome of blunt splenic injury in adults: Multicenter study of the eastern association for the surgery of trauma. J Trauma 2001;51: Markogiannakis H, Sanidas E, Messaris E, Michalakis I, Kasotakis G, Melissas J, Tsiftsis D. Management of blunt hepatic and splenic trauma in a Greek level I trauma centre. Acta Chir Belg Sep- Oct;106(5): Peitzman AB, Ferrada P, Puyana JC. Nonoperative management of blunt

8 Kasr El Aini Journal of Surgery VOL., 11, NO 3 September abdominal trauma: have we gone too far? Surg Infect (Larchmt) Oct; 10(5): Jennifer M. Watters, Chitra N. Sambasivan, Karen Zink, Igor Kremenevskiy, Michael S. Englehart, Samantha J. UnderwoodMartin A. Schreiber. Splenectomy leads to a persistent hypercoagulable state after trauma. Am J Surg 2010; 199: