Tag Archives: spleen

Abdomen

More Targeted Angioembolization For Blunt Splenic Injury

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There has been a steady shift in the management of blunt splenic injury over the past thirty years. Prior to that, these injuries were usually treated with a trip to the operating room, and most often with splenectomy. There was a time when operative “splenic salvage” procedures were popular, like splenorrhaphy or wrapping the organ in a mesh bag.  But this faded as surgeons worried about the possibility of continued bleeding.

As CT scans improved in resolution, the ability to identify these injuries and grade them in a way that roughly predicted the risk of bleeding also improved, and the movement toward nonoperative splenic preservation began. As the availability of interventional radiology increased, it became an important tool in boosting the success rate of nonoperative management. The success rate numbers I typically cite for nonoperative management of carefully selected patients are 85% without IR, and up to 93% when it is used as an adjunct.

Different trauma centers developed their own indications for the use of interventional radiology. Some used this study on most of their patients with spleen injuries. Some based their usage on spleen injury grade. Some looked at the presence of contrast extravasation or pseudoaneurysm.

Any time different providers or groups or trauma centers treat the same problem differently, it’s important to ask, “Who is actually doing it right?” They can’t all be.

A multi-institutional group hypothesized that CT scans may now be so accurate that this study can help us use interventional radiology more selectively and maintain the same high success rate in avoiding surgery. Retrospective data on blunt splenic injury management were collected at a single Level I trauma center (the R Adams Cowley Shock Trauma Center) over a 7.5-year period. It focused on patients with injury grades above I, and reviewed the usual demographics, mechanisms, and the specific findings identified on CT scan. This center transitioned to a less aggressive treatment approach halfway through the study period.

During the first half, the management and use of angiography were at the discretion of the individual surgeons. In the second half, all Grade III and any Grade IV injury with “low-risk” features (isolated pseudoaneurysm, small hemoperitoneum, intact parenchyma) were scheduled for angiography within 12 hours and embolization of any vascular injuries identified.  Grade V injuries and grade IV injuries with “high-risk” features (large hemoperitoneum, pseudoaneurysm >10mm, significant parenchymal disruption) underwent angiography within two hours with mandatory splenic artery embolization.

All patients underwent repeat CT between 48 and 72 hours later.  The authors followed the change in their rate of splenic artery embolization, splenectomy, and delayed splenectomy. Their secondary endpoints were ICU and hospital lengths of stay.

Here are the factoids:

  • There were 369 patients enrolled in the first half of the trial, and 471 in the second half
  • The rate of embolization decreased from 29% to 17%
  • Splenectomy rate remained the same (30% vs 34%)
  • Delayed splenectomy rate increased from 1.9% to 3.6%, but was not statistically significant (p = 0.14)
  • Hospital length of stay increased significantly (by one day) after the transition to the new algorithm

The authors concluded that implementing their treatment algorithm reduced the use of angiography without increasing overall or delayed splenectomy rates.

Bottom line: The authors acknowledged several limitations in their study, including the arbitrary definition of “high-risk” findings, surgeon and angiography variability based on surgeon preference, and the study’s retrospective nature.

At first blush (heh-heh), their new algorithm looks like it could reduce the overall utilization of angiography and embolization. However, I see several issues that might make their results difficult to generalize to other trauma centers:

  • The algorithm was not religiously followed, and there were multiple opportunities for surgeon judgment to cloud the results
  • The splenectomy rate was over 30% both pre- and post-change!! This is the highest rate I’ve ever seen. This means that despite their decreased use of angiography, they are still losing far too many spleens.
  • Their new two-hour to angio algorithm does not fit into the 60-minute response required at ACS trauma centers, so those centers can’t readily adopt it.

I’m a big believer in conservative management of solid organ injuries in carefully selected patients (primarily vital signs and abdominal exam). This paper gives us a hint on how a change in indications for interventional radiology might favorably impact the use of this tool. However, this paper won’t change my practice because the parameters this center used are still too loose and variable, evidenced by their sky-high splenectomy rate to date.

For now, maintain a fixed set of indications for immediate (within 60 minutes) and delayed (add to elective IR schedule), and carefully select your patients for possible nonoperative management. In this way, you can optimize your use of interventional radiology and take out far fewer than 30% of injured spleens.

Reference: A more targeted embolization strategy in blunt splenic trauma reduces procedural volume without increasing splenectomy rates. Journal of Trauma and Acute Care Surgery:10.1097/TA.0000000000004710, July 17, 2025. 

Complications, Solid organ

Low Grade Spleen Injury With Contrast Blush

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It is almost a given that low-grade solid organ injuries are relatively benign and seldom require any intervention. In fact, some trauma centers actually discharge these patients home from the emergency department.

But what about low-grade isolated spleen injuries with a contrast blush? Apparently, a few authors believe that this may be a benign condition that doesn’t require any specific management. This didn’t sit well with some, and a multicenter study was launched to look at this group more closely.

A retrospective cohort study involving 21 trauma centers was organized via the Eastern Association for the Surgery of Trauma. It enrolled adults (>18 years) with a grade I or II injury on CT scan after blunt trauma, which also demonstrated a contrast blush. Hemodynamically unstable patients and those who had clotting disorders or were taking any anticoagulant other than aspirin were excluded.

Here are the factoids:

  • Although 209 patients were enrolled over a nearly six-year period, 64 were removed due to meeting exclusion criteria or undergoing some intervention or laparotomy for other injuries
  • The remaining 145 patients were 66% men with an average age of 47
  • About one-third had a grade I injury, and two-thirds had grade II
  • 20% of these patients failed nonoperative management
  • These results were unchanged between grade I (18%) and grade II (21%)
  • Those who failed had a longer hospital stay (8 days vs. 5 days), had a higher likelihood of blood transfusion (55% vs. 26%) and MTP activation (14% vs. 3%)
  • There was no difference in discharge disposition or mortality

Bottom line: This study was conducted between 2014 and 2019. During that period, the AAST spleen and liver injury grading scales did not consider vascular injury. The 2018 update automatically upgrades injuries with blush or extravasation to Grade IV. This has a significant impact on how we view these injuries.

I have always said that any patient with contrast extravasation is bleeding to death until we stop it. The only exception is pediatric patients, who seem to clot these on their own. The 2018 update bore this out, and this paper confirms that low-grade anatomic injuries become dangerous if extravasation is present. I would also extend this to patients with a CT showing significant pseudoaneurysm formation.

So what should you do? If you have a patient with a spleen or liver injury that has contrast extravasation or a pseudoaneurysm, consider this a patient that needs hemorrhage control by interventional radiology under Standard 4.15 in the 2022 ACS Resources for Optimal Care of the Injured Patient. This means that you must let your IR team know that you have a patient who needs an intervention within 60 minutes, or you will need to transfer to a center with those capabilities as soon as possible.

Reference: Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study. Trauma Surg Acute Care Open. 2024 Mar 7;9(1):e001159. doi: 10.1136/tsaco-2023-001159. PMID: 38464553; PMCID: PMC10921525.

Abdomen

Activity Guidelines After Solid Organ Injury: How Important Are They?

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Just about every practice guideline out there regarding liver and spleen injury has some physical activity restrictions associated with it. The accepted dogma is that moving around too much, climbing stairs, lifting objects, or getting tackled while playing rugby could exacerbate the injury and lead to complications or surgery.

But is it true? Activity restrictions after solid organ injury have been around longer than I have been a trauma surgeon. And the more people I poll on what they do, the more and very different answers I get. And there are no decent papers published that look critically at this question. Until now. 

A pediatric multi-center study of study on adherence to activity restrictions was published last year. Ten Level I pediatric trauma centers in the US tabulated their experience with solid organ injuries over 3.75 years from 2013 to 2016. Only patients with successful nonoperative management of their injury were included, and those with high-grade renal or pancreatic injuries were excluded.

Since this was a pediatric study, the American Pediatric Surgical Association (APSA) practice guideline was followed (activity restriction = organ injury grade + 2 weeks). Activity restrictions included all sports, any recreational activity with wheels, or any activity involving both feet off the ground. Patients with Grade III-V injuries were seen at an office visit after 2 weeks, and lower grade injuries had a phone follow-up.

Adherence to guidelines was assessed by a follow-up phone call two months after injury. Clinical outcomes assessed at 60 days included an unplanned return to the emergency department (ED), re-admission, complications, and development of new bleeding confirmed by surgery, ultrasound, or computed tomography (CT) at 60 days post-injury.

Here are the factoids:

  • Of the 1007 patients in the study, some 56% were either excluded (178) or lost to follow-up (463)
  • Of the remaining 366, roughly 46% had a liver injury, 44% spleen, and the remaining 10% had both
  • Median age was 10, so this was actually a younger population
  • 76% of patients claimed they abided by the guidelines, 14% said they did not, and 10% “didn’t know.” This means they probably did not.
  • For the 279 patients who said they adhered to activity restrictions, 13% returned to the ED, and half were admitted to the hospital
  • Of the 49 patients who admitted they did not follow the guidelines, 8% returned to the ED at some point, and none were readmitted
  • The most common reasons for returning to ED were abdominal pain, anorexia, fatigue, dizziness, and shoulder pain
  • There were no delayed operations in either of the groups

Bottom line: There were no significant differences between the compliant and noncompliant groups. Unfortunately, the authors did not include an analysis of the “I don’t know if I complied” group, which would have been interesting. However, there is one issue I always worry about in these low-number-of-subjects studies that don’t show a significant difference between groups. Did they have the statistical power to show such a difference? If not, then we still don’t know the answer. And unfortunately, I’m not able to guess the numbers well enough to do the power calculation for this study.

I am still intrigued by this study! Our trauma program originally set a fixed time period (6 weeks) of limited activity in our practice guideline for pediatric solid organ injury patients. This was reduced based on our experience of no delayed complications and guidance from our sister pediatric trauma center at Children’s Hospital in Minneapolis. We are also moving toward making a similar change to our adult practice guidelines. But even our current guideline of injury grade + 2 weeks is probably too much.

Too many centers wait too long to make changes in their practice guidelines. They bide their time waiting for new, published research that they can lean on for their changes. Unfortunately, they will be waiting for a long time because many of our questions are not interesting enough for acceptance by the usual journals. Rely on the expertise and experience of your colleagues and then make those changes. Be sure to follow with your performance improvement program to make sure that they actually do work as well as you think!

Reference: Adherence to APSA activity restriction guidelines and 60-day clinical outcomes for pediatric blunt liver and splenic injuries (BLSI). J Ped Surg 54:335-339, 2019.

Abdomen, Solid organ

Use Of A Solid Organ Injury Protocol For Pediatrics

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Kids are frequent flyers when it comes to abdominal injury, with about 15% of their injuries involving this anatomic area. Solid organ injuries, mainly the liver and spleen, are the most prevalent ones. The American Pediatric Surgical Association (APSA) published a practice guideline way back in 2000 that outlined a consistent way to care for children with solid organ injuries.

Unfortunately, they were very conservative, recommending days of bedrest, extended NPO status, very frequent blood draws, and a lengthy hospital stay. Many hospitals, including mine, developed less conservative management routines, noting that children nearly always tolerate liver and spleen injury better than adults.

The trauma group at Vanderbilt modified the APSA guidelines and, more recently, made additional changes based on a new algorithm released by the organization. This new guideline moved away from organ injury grade-based factors and embraced hemodynamic status as the overall guide to care. The Vanderbilt group performed a retrospective study comparing hospital and ICU length of stay, patient costs, readmission, and death rates using the two guidelines.

Under the old protocol, grade I-III injuries were admitted to a floor bed and higher grades to an ICU at the discretion of the surgeon. The minimum hospital stay was, at minimum, the organ injury grade. Children were kept NPO overnight and placed on bed rest for nearly one day per injury grade.

With the new protocol, children were admitted to the floor if their vital signs normalized after volume resuscitation.  Hematocrit was obtained on admission and possibly again after 6 hours, then only repeated if < 21 or a change in vitals was noted. There were no diet or activity restrictions. Children with abnormal vital signs after volume were admitted to the ICU and kept on bed rest until they normalized. Labs were drawn regularly. Length of stay was based on meeting pain control, diet, and activity goals.

Here are the factoids:

  • There were 176 children (age < 18) enrolled in the old protocol during a four-year period and 170 in the new protocol over 3.5 years
  • Both groups were similar demographically and in injury grade and ISS
  • ICU length of stay was “significantly” shorter under the new protocol (.54 vs .78 days)
  • Hospital length of stay was also “significantly” shorter (2.9 vs 3.5 days)
  • Inflation-adjusted costs were slightly higher under the new protocol ($68,042 vs $65,437) even though the authors claim the opposite in the abstract once injury grade and ISS are factored in
  • Survival was the same at 99.4%
  • Readmission rates were significantly higher under the new protocol (7.1% vs 2.3%)

The authors’ conclusions parroted these results and recommended larger studies to detail any cost advantage and identify the cause for the difference in readmission rates.

Bottom line: This study leaves a lot to be desired. The authors’ definition of “pediatric” is age < 18. As we all know, there is a big difference in “kids” who are pre- vs post-puberty. The good news is that the mean and median ages are about 11 in the study, so there should be fewer older “kids” to cause interference.

The authors reported hazard ratios for the lengths of stay, which were statistically significantly different. However, their clinical significance is in doubt. A difference of 6 ICU hours? Or two-thirds of a hospital day? I’m not impressed. 

Cost differences are basically a wash, and a deep read of the paper shows that many kids did not have an isolated solid organ injury. Non-abdominal injuries could have an Abbreviated Injury Scale score of up to 3. It is easy to imagine that these could impact both length of stay and cost.  

Finally, the readmission rates include many problems related to non-abdominal injuries, including the thorax, soft tissues, and even an epidural hematoma. After excluding these non-abdominal complications, the numbers for both protocols are so low it’s hard to believe that a good significance test can be performed.

The authors’ conclusions are correct: more work needs to be done. This paper doesn’t really teach us much since all the conclusions are extremely weak. A much better, prospective, multicenter trial should be performed. Unfortunately, getting buy-in from multiple centers/surgeons to use the same protocol in children is hard.

But with all that being said, there is no reason you can’t adopt something similar to the new protocol at your center. My own experience has shown that a more aggressive guideline gets kids home sooner and healthier and that there is no difference in readmission rates. I just need a bunch of other surgeons to duplicate these results and write them up!

Reference: A Protocol Driven Approach to Reduce Lengths of Stay for Pediatric Blunt Liver and Spleen Injury Patients. Journal of Trauma and Acute Care Surgery ():10.1097/TA.0000000000004259, January 26, 2024. | DOI: 10.1097/TA.0000000000004259 

Practice guidelines, Solid organ

New EAST Practice Guideline: Spleen Vaccines After Angioembolization

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I am trying to figure out how I missed it! The Eastern Association for the Surgery of Trauma (EAST) snuck a new practice management guideline into the Injury journal last fall. And it desperately tries to answer a question that has been hanging around for several years. Do we vaccinate spleen injury patients who undergo angioembolization or not?

I’ve been pondering this for some time and have reached my own conclusion based on some very old literature. Decades ago, we figured out that removing the spleen significantly affects immune function. Splenectomy patients are known to be more susceptible to encapsulated bacteria like Neisseria meningiditis, Streptococcus pneumoniae, and Haemophilus influenzae. Most trauma centers routinely vaccinate these patients before they are discharged home.

With the more recent emphasis on splenic salvage and nonoperative management of injury to this organ, angioembolization has become commonplace. This technique can be done in two ways: proximal and distal. Proximal embolization blocks the splenic artery, so there is no further blood flow to the spleen through it. Distal embolization (selective or super-selective) strives to block flow to very specific areas of the organ.

Do we need to give the vaccines if we cut off blood flow to pieces of the spleen or the main splenic artery? Based on my appreciation of very old splenectomy and partial splenectomy papers, it looked like we should in some cases. One report showed that splenic protection from encapsulated bacteria required about 50% of the spleen to be present and perfused by the splenic artery. This caveat stems from a time when we would perform a trauma splenectomy, dice the spleen up on the back table, and then implant a bunch of spleen cubes into the mesentery to try to provide some immune protection. Turns out that the pieces lived but didn’t do a damn thing.

My practice, then, has been to look at the fluoro images and estimate how much of the spleen was left. I would order the vaccines if a main splenic artery embolization (proximal) was performed. If a distal embolization were performed, I would eyeball the amount of devascularized spleen and give the vaccines if it looked like more than half was dark. Not very precise, I know.

But what would EAST say? They tried to perform a systematic review and meta-analysis of studies that compared outcomes in splenectomy vs. angioembolization patients. Unfortunately, there isn’t a lot of research material out there. So they settled on looking at papers that analyzed immune function, typically using B-cells, T-cells, and antibodies. The authors performed two comparisons: angioembolization vs. splenectomy and angioembolization vs. control.

Angioembolization vs. Splenectomy

These papers compared embolization patients who may or may not have spleen function to splenectomy patients who definitely have none. Embolization patients had fewer infectious complications during their hospital stay and better immune function using the indirect methods noted above. Unfortunately, the data quality was poor, with a significant risk of bias. There was no stratification of proximal vs. distal embolization. Nevertheless, this suggests that, at least overall, the embolization patients retained immune function.

Angioembolization vs. Controls

What about comparing embolization patients to spleen-injured patients who did not undergo any procedure? They should have normal function. Again, the quality of the very few papers available was low. But overall, there was no difference in immune function between the groups.

Bottom line: The EAST review team conditionally recommended against routine spleen vaccines after angioembolization for spleen injury. They concluded that immune function was maintained, so it should not be necessary.

What, you ask, about patients with proximal splenic embolization? The reality is that this only stops inflow from the splenic artery, and only for a few days or weeks. It may slowly resume over time. And it does nothing to the inflow from the short gastric arteries. Apparently, this is enough to provide immune protection against infection.

Whether this is actually true is open to debate. We have no idea if the numbers of T- and B-cells seen and the antibody titers are actually enough to avoid overwhelming post-splenectomy sepsis. And unfortunately, this condition is so rare that we will never accumulate enough cases to make a definitive statement.

But for now, it is probably okay to forgo the vaccines in patients undergoing angioembolization. Besides, the differing guidelines on which vaccines to use, when to give them, and when to schedule boosters were getting way out of hand! Please keep it simple!

Reference: Vaccination after spleen embolization: a practice management guideline from the Eastern Association for the Surgery of Trauma. Injury 53:3569-3574, 2022.