Blunt splenic injuries: nonsurgical treatment with CT, arteriography, and transcatheter arterial embolization of the splenic artery

Article Abstract:

The spleen was once considered expendable and it was quickly removed surgically (splenectomy) when seriously injured. Recent evidence showing the important immunologic functions of the spleen has led physicians to try and preserve the spleen when possible. Spleen-sparing treatments generally include partial splenectomy, removal of only the damaged portion of the spleen, or supportive care while the spleen heals. Computed tomography (CT), a scanning X-ray procedure, is used to diagnose splenic damage but it is not very useful in deciding the proper treatment for such damage. Patients treated with supportive care often experience bleeding from a damaged splenic artery that has gone undetected by CT. Such bleeding may lead to the need for a full splenectomy. This study examined the use of arteriography (X-rays of the arteries by means of a contrast material injected into the arteries) to evaluate splenic arterial damage before deciding upon supportive treatment or arterial embolization (a method of stopping arterial bleeding) in the event the artery was damaged. This type of evaluation and treatment was to be used on 44 consecutive patients with CT-diagnosed splenic damage. All had stable blood flow. CT results for all patients were similar. Arteriography was performed on 36 patients, with the physicians of eight patients refusing the treatment protocol. For 19 patients, the splenic artery was diagnosed as intact, and these patients were treated with bed rest only. For 17 patients, splenic arterial damage was found and arterial embolization performed. One patient initially diagnosed as intact was later found to have arterial damage and embolization was performed. Surgical exploration was performed on the eight remaining patients, and eventually was required by two of the 36 patients who underwent arteriography. Bed rest alone was a successful treatment for 18 of the 19 patients, and embolization stopped arterial bleeding whenever it was necessary. Overall, the spleens of 35 of 36 patients evaluated with arteriography were saved and only two patients had to undergo surgical evaluation. The results show that arteriography is very useful in helping to decide the proper treatment for splenic damage. (Consumer Summary produced by Reliance Medical Information, Inc.)

Diagnosis, Noninvasive, Noninvasive diagnosis

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Splenic trauma in adults: impact of CT grading on management

Article Abstract:

It is important to evaluate complications associated with damage to the spleen (an abdominal organ containing sponge-like lymphatic tissue composed of phagocytes, cells that destroy substances foreign to the body such as bacteria, protozoa, dust, and other matter). The spleen is the organ most often injured during blunt abdominal trauma which may cause extensive bleeding (intra-abdominal hemorrhage) that often results in the removal of the spleen (splenectomy). Although the spleen has a well-known ability to heal on its own, the use of conservative (non-surgical) treatment strategies is encouraged due to the high risk of infection following splenic surgery. Better diagnostic techniques will improve nonoperative treatment for adult patients with splenic injuries. Although nonoperative treatment of pediatric splenic trauma is common, it is difficult to treat adults with trauma to the spleen without surgery. Research was conducted to develop a computed tomography (CT) method for grading (ranking) the severity of adult splenic trauma as a means of improving the decision-making process that leads to either surgical or non-surgical treatment of splenic injuries. Improved CT imaging techniques may reduce the incidence of performing exploratory laparotomy (surgical opening of the abdomen). To date, however, CT has not been capable of revealing injuries that were not suspected. Splenic injury evaluation and grading took place among 64 adult patients 24 hours after trauma to the abdomen. A grading system was developed, through the evaluation of CT images, which evolved into a statistical tool for ranking the severity of splenic injury. This ranking system was applied to a probability value that helped the physician predict the severity of the injury and the likelihood that the CT image had not identified an injury to the spleen. The prediction was subsequently employed as a statistical test for the need to perform surgery. The CT splenic ranking system developed in this study helped confirm medical decisions to perform (or not perform) splenic exploratory surgery. The scoring system was particularly effective in prompting earlier surgical intervention which resulted in spleen-saving operation in those patients whose CT images did not uncover a hidden injury.

Blood vessels, Medical imaging equipment

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Blunt splenic trauma and the angiographer: will we go back to the future?

Article Abstract:

For many years, severely injured spleens were routinely treated by surgical removal (splenectomy). It was thought that the spleen was of little, if any, importance and that a person could live a completely normal life without it. More recently, the immunologic importance of the spleen has been recognized and physicians now try to save the spleen whenever possible. Spleen-saving treatments include nonoperative expectant management and partial splenectomy. The expectant treatment involves supportive care while allowing the spleen to recover from its injuries. The partial splenectomy involves removing the damaged portion of the spleen and saving the undamaged portion. The expectant treatment would seem preferable, except that in many cases the damaged spleen ruptures and severe internal bleeding occurs. Surgery is then required, but a partial splenectomy is often no longer possible and the whole spleen must be removed. Diagnostic procedures that can determine which patients are best suited for expectant treatment and which should undergo partial splenectomy are thus very important. Angiography, X-raying blood vessels after injecting them with a contrast material, was originally used in examining the spleen for injury. It was soon replaced by computed tomography (CT), a scanning X-ray technique. In the October 1991 issue of Radiology, a report by Sclafani et al shows a new use for angiography in the care and treatment of the damaged spleen. Their study shows that angiography results are very useful in determining the likelihood of successful treatment with expectant management. Patients whose angiograms did not show leakage of the injected contrast material outside the vessels were good candidates for treatment with expectant management, according to the study's findings. Further studies on the use of angiography in the care and treatment of the spleen are needed, but this study shows that angiography can again be considered a useful tool for evaluating patients with spleen injuries. (Consumer Summary produced by Reliance Medical Information, Inc.)

editorial

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