MANAGEMENT OF SOLID ORGAN INJURIES: NON- … Omi Handout.pdfand liver injuries • To discuss the...

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MANAGEMENT OF SOLID ORGAN INJURIES: NON-

OPERATIVE, INTERVENTIONAL AND

OPERATIVEApril 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

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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.

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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

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GRADES OF INJURY

• Grade I-V

• Low grade I-II

• Moderate III

• High grade IV-V

LOW GRADE

Grade I: -Subcapsular hematoma

<10% surface area-Laceration/Capsular tear

<1cm deep

ATOM, 2nd edition. 2010

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ATOM, 2nd edition. 2010

LOW GRADE

• Grade II:• Subcapsular hematoma

10-50% surface area • Intra-parenchymal

hematoma <5cm• Laceration 1-3cm without

vessel involvement

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, 2nd edition. 2010

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HIGH GRADE

Grade IV:

Laceration of segmental

or hilar vessels causing

major

devascularization

(>25% of spleen)

ATOM, 2nd edition. 2010

HIGH GRADE

Grade V:

-Shattered spleen

-Injury of hilar vessels

with completely

devascularized spleen

ATOM, 2nd edition. 2010

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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

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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%

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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

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OPERATIVE MANAGEMENT

• Splenectomy

• Splenic salvage

• Stable patients

• Reimplantation

• Unproven method to preserve splenic

function

INTERVENTIONAL RADIOLOGY

• 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

• IR suite

• Monitoring in the same standards

of an ICU

• Therapeutic embolization

• Aneurysm

• Arteriovenous fistula

• Extravasation

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VASCULAR BLUSH

• Hemodynamically stable (Grade 3-5)

• Angiography

• OR if angiography not immediately

available

• Hemodynamically unstable (non-

responder)

• OR

• Aggressive angiography

• Highest rates of non-operative

management (80%)

• High rate of complications

• Labor intensive

RISK OF FAILURE OF NONOPERATIVEMANAGEMENT

• 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, 2015

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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):18-24.

• 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

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• Splenic injury on CT 1981-1993

• 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

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• 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

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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

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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

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INTRAOPERATIVE FINDINGS

• Laparoscopic splenectomy.

• Pathology: Benign splenic tissue with hemorrhage, ischemia and necrosis.

• 1980-1990s

• 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. 1990Godley CD, et al. Nonoperative management of blunt splenic injuries in adults: age over 55 year a powerful indicator for failure. J Am Coll SuSchurr MJ, et al. Management of blunt splenic trauma: computed tomographic contrast blush predicts failure of nonoperative management. J

Search...

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• 1993-1997

• 4.5 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 48-72 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

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• 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. 1998

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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. 1998

• Retrospective chart review

• 126 patients

• Angiography at admission

• 68% negative

• 32% embolization

• 8% laparotomy

• 92% salvage rate

J Trauma, 2001

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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 spJ 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 201

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• 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 2017

• 5.7% 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 2017

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• Splenectomy rates are the same at angio centers

• Spenectomy rates decreased in non-angiocenters in combined and grade 3

and 4Dolejs 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

• Reduction only in the splenectomy rate in Grade III injuries in non-angio

centers

Splenectomy within 6h of admission

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

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• Reduction in the rate of late splenectomy in all groups except the Grade IV splenic injuries in the non-angio centers

Angio-Reduction 5.4% to 4.1%

Non-angioReduction 6.0% to 3.3%

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 IVDolejs 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

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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

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No difference in splenic embolization and observation

No difference in splenic embolization and observation

No difference in the mortality in the two groups

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No difference in the mortality in the two groups

Significant variation among Level 1 trauma centers. Higher ratesof 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

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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, 1992.

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OVERWHELMING POST-SPLENECTOMY SEPSIS(OPSS)

• Encapsulated organisms

• Pnemococcus

• Meningiococcus

• Hemophilus Influenza

• 2-5 per 1000 Asplenic patients

• 70% mortality

• 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

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, 1991Greco and Alvarez. Regeneration of the spleen after etopic implantation and partial splenectomy. Surg,1980

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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, 2012

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THE LIVER

INITIAL EVALUATION

• ABCDE

• Hemodynamically stable

• Associated abdominal injuries

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GRADES OF LIVER INJURY

trauma.org, 2017

APPROACH

• Operative

• Packing

• Hemostatic agents

• Suturing

• Total Hepatic Isolation

• Does surgery lead to further

bleeding and unnecessary

interventions and complications??

• Nonoperative 82-100% success

• Angiographic intervention

• ERCP (Endoscopic Retrograde

Cholangiopancreatography)

• Percutaneous drainage

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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, 2015

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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. 2000

• CT grade III or higher

• Evidence of arterial injury (blush)

• Evidence of hepatic venous injury

FAILURES OF NONOPERATIVEMANAGEMENT OF THE LIVER

• Hemodynamic instability is the cause of 75% of failures

• Delayed hemorrhage incidence is 2.8-3.5%

• Most common complication

• Most common cause of death

• Complication rate increases with the grade of injury

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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

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• Chest tube placement

• 900mL out

• Stabilized.

• Saturations improved

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SECONDARY

• Left abdominal wall abrasion

• Left chest wall with crepitus.

• No rectal tone

• No extremity deformities

• FAST negative

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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?

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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

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10 DAYS LATER

2.5 MONTHS LATER

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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

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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 allows.

EAST.org, 2012

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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 non-

operative 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 non-

operative rate

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THANK YOU

• Questions?