Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
4/3/2017
1
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
4/3/2017
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.
4/3/2017
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
4/3/2017
4
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
4/3/2017
5
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
4/3/2017
6
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
4/3/2017
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
4/3/2017
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%
4/3/2017
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
4/3/2017
10
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
4/3/2017
11
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
4/3/2017
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):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
4/3/2017
13
• 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
4/3/2017
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
4/3/2017
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
4/3/2017
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
4/3/2017
17
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...
4/3/2017
18
• 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
4/3/2017
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. 1998
4/3/2017
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. 1998
• Retrospective chart review
• 126 patients
• Angiography at admission
• 68% negative
• 32% embolization
• 8% laparotomy
• 92% salvage rate
J Trauma, 2001
4/3/2017
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 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
4/3/2017
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 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
4/3/2017
23
• 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
4/3/2017
24
• 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
4/3/2017
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
4/3/2017
26
No difference in splenic embolization and observation
No difference in splenic embolization and observation
No difference in the mortality in the two groups
4/3/2017
27
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
4/3/2017
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, 1992.
4/3/2017
29
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
4/3/2017
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, 2012
4/3/2017
31
THE LIVER
INITIAL EVALUATION
• ABCDE
• Hemodynamically stable
• Associated abdominal injuries
4/3/2017
32
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
4/3/2017
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, 2015
4/3/2017
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. 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
4/3/2017
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
4/3/2017
36
4/3/2017
37
• Chest tube placement
• 900mL out
• Stabilized.
• Saturations improved
4/3/2017
38
SECONDARY
• Left abdominal wall abrasion
• Left chest wall with crepitus.
• No rectal tone
• No extremity deformities
• FAST negative
4/3/2017
39
4/3/2017
40
4/3/2017
41
4/3/2017
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?
4/3/2017
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
4/3/2017
44
10 DAYS LATER
2.5 MONTHS LATER
4/3/2017
45
4/3/2017
46
4/3/2017
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
4/3/2017
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 allows.
EAST.org, 2012
4/3/2017
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 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
4/3/2017
50
THANK YOU
• Questions?