Splenic trauma: Definition, classifications, clinical profiles and best treatments

Abstract

The spleen is an organ commonly injured in abdominal trauma of the upper left quadrant and until just under two decades the first choice was always splenectomy; however, based on new research and clinical experience, there is a tendency to preserve the spleen as much as possible, precisely because of its immune function and risk of infection. On the basis of the trauma and of the patient’s anamnesis, after an objective examination, the primary ABCDE evaluation, the Eco-FAST, and if necessary also the CT scan (with contrast), it is possible to choose between surgical (OM) and non-surgical (NOM) management: in the first hypothesis are included total or partial splenectomy surgery, raffia, direct hemostasis through drugs or devices with hemostatic-adhesive action, and laparoscopy; in the second hypothesis are included treatments such as controlled nutrition, rest, anticoagulant drug therapy (and antibiotic, if necessary), and angioembolization (exclusive or accessory to a NOM). In particular, in the last few years, a dual interpretation has emerged on the findings necessary to favour splenectomy (total or partial) over angioembolization. From the best clinical practice emerges therefore the answer to the question at hand, namely that the patient is a candidate for angioembolization if 1) is hemodynamically stable (with systolic blood pressure > 90 mmHg, heart rate < 100 bpm, and transfusion of < 3 units of blood in 24 hours) or stabilizable (positive response to rapid infusion of 1000-2000 cc of crystalloids-Ringer Lactate-with restoration of blood pressure and heart rate values in the range of hemodynamic stability); 3) there is no open trauma to the abdomen or evidence of vasoconstriction (cold, sweaty skin, decreased capillary refill) or obvious intestinal lesions or perforative peritonitis or high-grade lesions to the spleen or peritoneal irritation or signs of exsanguination or contrast blush or effusion (exceeding 300ml) detected by Eco-FAST. This preference is optimal concerning both the risks of postoperative infection and immunological risks; finally, age and head trauma, compared to the past, seem to be no longer discriminating conditions to favour splenectomy regardless. Splenic immune function is thought to be preserved after embolization, with no guidelines for prophylactic vaccination against encapsulated bacteria. Other clinical signs finally, however, might argue for discontinuation of NOM treatment in favour of a surgical approach: 1) need to transfuse more than 3 units of blood or simply the need for transfusion in 24 hours to maintain a maximum systolic blood pressure greater than 90 mmHg, correct anaemia less than 9 g/100 ml, or a hematocrit less than 30%; 2) persistence of paralytic ileus or gastric distension beyond 48 hours (despite a nasogastric aspiration); 3) increased hemoperitoneum (on ultrasound or CT); 4) aggravation of the lesion evidenced by ultrasound and/or CT (so-called “expansive” lesions); and 5) subsequent appearance of signs of peritoneal irritation. A complete understanding of post-embolization immune changes remains an area in need of further investigation, as do the psychological and mental health profiles of the surgical patient.