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Non-operative Management In Solid Organ Injuries After Blunt Abdominal Trauma-Splenic Injuries

Year 2021, Volume: 31 Issue: 2, 105 - 110, 30.06.2021
https://doi.org/10.15321/GenelTipDer.2021.294

Abstract

Introduction: Non-operative management (NOM) is the current approach in patients with solid organ injury caused by blunt abdominal trauma. In recent years, conservative treatment is successfully employed by advances in imaging modalities, interventional radiology and intensive care management. However, there is no consensus on follow-up of trauma patients undergoing NOM. In this study, we aimed to highlight controversial issues in trauma patients undergoing NOM.

Materials and methods: In this study, we retrospectively assessed with splenic injury after blunt abdominal trauma. Criteria for conversion to laparotomy include hemodynamic instability despite adequate resuscitation and presence of peritoneal irritation findings. The patients were classified as those with NOM success and those with NOM failure requiring laparotomy. Groups were compared regarding demographic characteristics, mechanism of injury, additional trauma, hemodynamic status at admission, severity of injury on CT scan, transfusion need for blood and blood products, need for laparotomy, length of hospital stay, need for ICU admission, change in hemoglobin/hematocrit value and leukocyte count, and initiation time of oral intake

Results: In 72 cases with splenic injury after blunt abdominal trauma that was managed by NOM. In 10 patients, NOM was failed and the patients underwent laparotomy. All patients underwent CT scan during initial diagnostic workshop.

Conclusion: Imaging modalities should be used in the follow-up of patients with ≥grade 3 injury. Higher grades of injury result in increased costs and prolonged hospitalization. NOM failure is increased in high grade injuries. Another factor in NOM failure is perforation of non-solid organs. Close hemodynamic monitorization, frequent physical examination and effective fluid resuscitation are essential in patients undergoing NOM. It should be kept in mind that complications such as re-bleeding and splenic abscess may occur at early period after discharge.

References

  • Burch JM, Francoise RJ, Moore E. Trauma. In: Brunicardi FC editor. Schwartz Principles of Surgery 10. Edition. McGraw-Hill,2017.
  • Izu BS, Ryan M, Markert RJ, et al. Impact of splenic injury guidelines on hospital stay and charges in patients with isolated splenic injury. Surgery.2009;146:787-791.
  • Sabe AA, Claridge JA, Rosenblum DI, et al. The effects of splenic artery embolization on non-operative management of blunt splenic injury: a 16-year experience. J Trauma. 2009;67:565-572.
  • Sayek İ. Temel Cerrahi. In: Kayanaroğlu Z.V. Karın Travmaları. 3 th ed, Güneş Kitabevi Ltd. Şti. Ankara. 2004. P:466
  • Ruscelli P, Gemini A, Rimini M, Santella S, Candelari R et al. The role of grade of injury in non-operative management of blunt hepatic and splenic trauma: Case series from a multicenter experience. Medicine (Baltimore). 2019 Aug;98(35):e16746
  • TUİK, Ölüm Nedeni İstatistikleri. 2010,2011,2012.
  • Fu CY, Wu SC, Chen RJ, Chen YF, Wang YC et al. Evaluation of need for operative intervention in blunt splenic injury: intraperitoneal contrast extravasation has an increased probability of requiring operative intervention. World J Surg. 2010;34: 2745-2751
  • Taviloğlu K, Ertekin C, Güloğlu R. Travma ve resüsitasyon Kursu In: Ertekin C. Karın Travmaları. Logos yayıncılık Nisan 2006
  • Richard M Bell. Brent E. Krantz: Initial Assessment. In: Mattox KL, Felliciano DV, Moore EE. Trauma, 4th ed. McGraw Hill, New York, 154- 169, 2000.
  • Malhotra AK, Fabian TC, Croce MA, Gavin TJ, Kudsk KA, Minard G, Pritchard FE. Blunt hepatic injury: a paradigm shift from operative to nonoperative management in the 1990s. Ann Surg 231:804;2000
  • Fata P, Robinson L, Fakhry SM. Survey of EAST member practices in blunt splenic injury: a description of current trends and opportunities for improvement. J Trauma 59:836,2005
  • Burch JM, Moore E. Bölüm Türkçe Çeviri: Şahbaz A, Taviloğlu K. Karaciğer , Safra Yolları, Dalak ve Diyafragma Yaralanmaları. In: Sauba W, Fink M, editors. ACS Surgery Principles&Practice. Özmen M, Özmen V. Türkçe Çev. Ed. 6. Edition . BC Decker 2012.
  • King H, Shumacker HB, Splenic studies: Susceptibility to infection after splenektomi performed in infancy. Ann Surg 136: 239,1952
  • Karp MP, Cooney DR, Pros GA,et al: The nonoperative management of pediatric hepatic trauma. J Pediatr Surg 18:521,1983
  • Godley CD, Warren RL, Sheridan RL, et al: Nonoperative management of blunt splenic injury in adults: age over 55 years as a powerful indication for failure. J Am Coll Surg .183:133-138, 1996.
  • Gorge C. Velmahos, Linda S. Chan, Eman Kamel, et al:Nonoperative management of splenic injuries:Have we gone too far ?.Arch Surg. 135:674- 681,2000
  • Renz BM, Feliciano DV. Unnecessary laparotomies for trauma: a prospective study of morbidity. J Trauma 1995;38(3):350-6
  • Haan JM, Bochicchio GV, Kramer N, Scalea TM. Nonoperative management of blunt splenic injury: a 5-year experience. J Trauma. 2005;58:492-498
  • Olthof DC, Joosse P, van der Vlies CH, de Haan RJ, Goslings JC. Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: a systematic review. J Trauma Acute Care Surg. 2013 ;74(2):546-57
  • Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J Trauma. 1995;38(3):323-324.
  • van der Wilden GM, Velmahos GC, Emhoff T, Brancato S, Adams C. Successful nonoperative management of the most severe blunt liver injuries: a multicenter study of the research consortium of new England centers for trauma. Arch Surg. 2012 ;147(5):423-8.
  • Sartorelli KH, Frumiento C, Rogers FB, et al. Non-operative management of hepatic, splenic, and renal injuries in adults with multiple injuries. J Trauma. 2000;49:56-61.
  • Richardson JD, Franklin GA, Lukan JK, et al. Evolution in the management of hepatic trauma: a 25 year perspective. Ann Surg. 2000; 232:324-330.
  • Christmas AB, Wilson AK, Manning B, et al. Selective management of blunt hepatic injuries including non-operative management is a safe and effective strategy. Surgery. 2005;138:606-611
  • Stassen NA, Bhullar I, Cheng JD, Crandall M, Friese R, Guillamondegui O, et al. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 ;73(5 Suppl 4):288-93.
  • Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS, Guillamondegui O, et al. Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 ;73(5 Suppl 4):S294-300
  • Schroeppel TJ, Croce MA. Diagnosis and management of blunt abdominal solid organ injury. Curr Opin Crit Care. 2007 ;13(4):399-404.
  • Smith SJ, Cooney RN, Mucha P: Nonoperative management of the ruptured spleen: a revalidation of criteria. Surgery.1996; 120: 745-775.
  • Smith JS Jr, Wengrowitz DA, DeLong DS: Prospective validation of criteria, including age, for safe non-surgical management of the ruptured spleen. J Trauma. 1992; 33: 363-369.
  • Croce MA, Fabian TC, Menke PG, et al: Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. Ann Surg. 1995; 221:744-755.
  • Fang JF, Chen RJ, Lin BC, Hsu YB, Kao JL,Chen MF. Blunt hepatic injury: minimal intervention is the policy of treatment. J Trauma 2000;49:722-8
  • Scarborough JE, Ingraham AM, Liepert AE, et al. Nonoperative Management Is as Effectiveas Immediate Splenectomy for Adult Patients with High-Grade Blunt Splenic Injury. J Am Coll Surg 2016; 223:249.
  • Velmahos GC, Toutouzas K, Radin R, et al. High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ. Arch Surg. 2003;138:475Y480; discussion 480-481.
  • Watson GA, Rosengart MR, Zenati MS, et al. Nonoperative management of severe blunt splenic injury: are we getting better? J Trauma 2006; 61:1113.
  • Bhullar IS, Frykberg ER, Tepas JJ 3rd, et al. At first blush: absence of computed tomography contrast extravasation in Grade IV or V adult blunt splenic trauma should not preclude angioembolization. J Trauma Acute Care Surg 2013; 74:105.
  • Velmahos GC, Toutouzas K, Radin R, et al. Non-operative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg.2003;138:844-851.
  • Pachter HL, Knudson MM, Esrig B, et al. Status of non-operative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. J Trauma. 1996;40:31-38.
  • Cachecho R, Clas D, Gersin K, Grindlinger GA. Evolution of the complex liver injury at a Level I trauma center. J Trauma. 1998;45:79-82.
  • Falimirski ME, Provost D. Nonsurgical management of solid abdominal organ injury in patients over 55 years of age. Am Surg. 2000;66:631-635.
  • Sharma OP, Oswanski MF, Singer D, et al. Assessment of non-operative management of blunt spleen and liver trauma. Am Surg. 2005;71: 379-386.
  • Yanar H, Ertekin C, Taviloglu K, Kabay B, Bakkaloglu H et al. Nonoperative treatment of multiple intra-abdominal solid organ injury after blunt abdominal trauma. J Trauma. 2008;64(4):943-8.
  • Carrillo EH, SpainDA,WohltmannCD, et al. Interventional techniques are useful adjuncts in non-operative management of hepatic injuries.J Trauma. 1999;46:619-624.
  • Becker CD, Mentha G, Terrier F. Blunt abdominal trauma in adults: role of CT in the diagnosis and management of visceral injuries. Part 1: liver and spleen. Eur Radiol. 1998;8:553-562.
  • Brasel KJ, DeLisle CM, Olson CJ, et al. Trends in the management of hepatic injury. Am J Surg. 1997;174:674-677.
  • Swaid F, Peleg K, Alfici R, et al. Concomitant hollow viscus injuries in patients with blunt hepatic and splenic injuries: an analysis of a National Trauma Registry database. Injury 2014; 45:1409.
  • Mehall JR, Ennie JS, Saltzzman DA, et al. Prospective Results of a standardized algorithm based on hemodynamic status for managing pediatric solid organ injury. J Am Coll Surg. 2001;193:347-353.
  • Banerjee A, Duane TM, Wilson SP, et al. Trauma center variation in splenic artery embolization and spleen salvage: a multicenter analysis. J Trauma Acute Care Surg 2013;75:69.

Künt Karın Travmasına Bağlı Solid Organ Yaralanmalarında Non operatif Tedavi-Dalak Yaralanmaları

Year 2021, Volume: 31 Issue: 2, 105 - 110, 30.06.2021
https://doi.org/10.15321/GenelTipDer.2021.294

Abstract

Amaç: Künt karın travmasına bağlı solid organ yaralanması olan hastalarda nonoperatif tedavi (NOT) uygulaması güncel yaklaşımdır.NOT uygulanan travmalı hastaların takibinde halen birliktelik yoktur. Çalışmamızda literatürde NOT uygulama aşamasında bazı aydınlatılmayan alanlara ışık tutmayı amaçladık.

Materyal-Metod: Çalışmamızda künt karın travmasına bağlı dalak yaralanması tespit edilen hastalar değerlendirildi. NOT başarılı olan hastalar ve NOT başarısız olup laparatomi yapılan hastalar tasnif edildi. Laparotomiye dönüş kriterlerimiz ise yeterli resusitasyona rağmen hemodinaminin instabil olması ve peritoneal irritasyon bulgularının varlığıydı.Yaralanma derecesine göre kendi içlerinde karşılaştırılarak analiz edildi.Gruplar karşılaştırılırken demografik bilgiler, travmanın oluş şekli,girişteki hemodinamik durum, BT’de yaralanmanın derecesi, yatış süresi boyunca kan ve kan ürünleri transfüzyonu gereksinimi, laparatomi gereksinimi, hastanede kalış süreleri, yoğun bakım ihtiyacı, ilk başvurudaki hemoglobin/hematokrit/lökosit sayısı değişimi ve oral beslenme zamanının tayini parametreleri kullanıldı.

Bulgular: NOT uygulanan 72 vaka retrospektif olarak değerlendirildi. 10 hastada NOT uygulanırken başarısızlıkla sonuçlandı ve laparatomi uygulandı.

Sonuç: Grade 3 ve üzeri yaralanmaların takibinde görüntüleme tetkikleri gerekebilir. NOT uygulanan hastalara hastaneye girişten itibaren yakın hemodinamik izlem, sık tekrarlayan fizik muayene ve etkin sıvı resusitasyonu yapılmalıdır. NOT uygulanan dalak travmalı hastalarda taburculuk sonrası erken dönemde yeniden kanama ve splenik abse gibi komplikasyonların olabileceği akılda tutulmalıdır.

References

  • Burch JM, Francoise RJ, Moore E. Trauma. In: Brunicardi FC editor. Schwartz Principles of Surgery 10. Edition. McGraw-Hill,2017.
  • Izu BS, Ryan M, Markert RJ, et al. Impact of splenic injury guidelines on hospital stay and charges in patients with isolated splenic injury. Surgery.2009;146:787-791.
  • Sabe AA, Claridge JA, Rosenblum DI, et al. The effects of splenic artery embolization on non-operative management of blunt splenic injury: a 16-year experience. J Trauma. 2009;67:565-572.
  • Sayek İ. Temel Cerrahi. In: Kayanaroğlu Z.V. Karın Travmaları. 3 th ed, Güneş Kitabevi Ltd. Şti. Ankara. 2004. P:466
  • Ruscelli P, Gemini A, Rimini M, Santella S, Candelari R et al. The role of grade of injury in non-operative management of blunt hepatic and splenic trauma: Case series from a multicenter experience. Medicine (Baltimore). 2019 Aug;98(35):e16746
  • TUİK, Ölüm Nedeni İstatistikleri. 2010,2011,2012.
  • Fu CY, Wu SC, Chen RJ, Chen YF, Wang YC et al. Evaluation of need for operative intervention in blunt splenic injury: intraperitoneal contrast extravasation has an increased probability of requiring operative intervention. World J Surg. 2010;34: 2745-2751
  • Taviloğlu K, Ertekin C, Güloğlu R. Travma ve resüsitasyon Kursu In: Ertekin C. Karın Travmaları. Logos yayıncılık Nisan 2006
  • Richard M Bell. Brent E. Krantz: Initial Assessment. In: Mattox KL, Felliciano DV, Moore EE. Trauma, 4th ed. McGraw Hill, New York, 154- 169, 2000.
  • Malhotra AK, Fabian TC, Croce MA, Gavin TJ, Kudsk KA, Minard G, Pritchard FE. Blunt hepatic injury: a paradigm shift from operative to nonoperative management in the 1990s. Ann Surg 231:804;2000
  • Fata P, Robinson L, Fakhry SM. Survey of EAST member practices in blunt splenic injury: a description of current trends and opportunities for improvement. J Trauma 59:836,2005
  • Burch JM, Moore E. Bölüm Türkçe Çeviri: Şahbaz A, Taviloğlu K. Karaciğer , Safra Yolları, Dalak ve Diyafragma Yaralanmaları. In: Sauba W, Fink M, editors. ACS Surgery Principles&Practice. Özmen M, Özmen V. Türkçe Çev. Ed. 6. Edition . BC Decker 2012.
  • King H, Shumacker HB, Splenic studies: Susceptibility to infection after splenektomi performed in infancy. Ann Surg 136: 239,1952
  • Karp MP, Cooney DR, Pros GA,et al: The nonoperative management of pediatric hepatic trauma. J Pediatr Surg 18:521,1983
  • Godley CD, Warren RL, Sheridan RL, et al: Nonoperative management of blunt splenic injury in adults: age over 55 years as a powerful indication for failure. J Am Coll Surg .183:133-138, 1996.
  • Gorge C. Velmahos, Linda S. Chan, Eman Kamel, et al:Nonoperative management of splenic injuries:Have we gone too far ?.Arch Surg. 135:674- 681,2000
  • Renz BM, Feliciano DV. Unnecessary laparotomies for trauma: a prospective study of morbidity. J Trauma 1995;38(3):350-6
  • Haan JM, Bochicchio GV, Kramer N, Scalea TM. Nonoperative management of blunt splenic injury: a 5-year experience. J Trauma. 2005;58:492-498
  • Olthof DC, Joosse P, van der Vlies CH, de Haan RJ, Goslings JC. Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: a systematic review. J Trauma Acute Care Surg. 2013 ;74(2):546-57
  • Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J Trauma. 1995;38(3):323-324.
  • van der Wilden GM, Velmahos GC, Emhoff T, Brancato S, Adams C. Successful nonoperative management of the most severe blunt liver injuries: a multicenter study of the research consortium of new England centers for trauma. Arch Surg. 2012 ;147(5):423-8.
  • Sartorelli KH, Frumiento C, Rogers FB, et al. Non-operative management of hepatic, splenic, and renal injuries in adults with multiple injuries. J Trauma. 2000;49:56-61.
  • Richardson JD, Franklin GA, Lukan JK, et al. Evolution in the management of hepatic trauma: a 25 year perspective. Ann Surg. 2000; 232:324-330.
  • Christmas AB, Wilson AK, Manning B, et al. Selective management of blunt hepatic injuries including non-operative management is a safe and effective strategy. Surgery. 2005;138:606-611
  • Stassen NA, Bhullar I, Cheng JD, Crandall M, Friese R, Guillamondegui O, et al. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 ;73(5 Suppl 4):288-93.
  • Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS, Guillamondegui O, et al. Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 ;73(5 Suppl 4):S294-300
  • Schroeppel TJ, Croce MA. Diagnosis and management of blunt abdominal solid organ injury. Curr Opin Crit Care. 2007 ;13(4):399-404.
  • Smith SJ, Cooney RN, Mucha P: Nonoperative management of the ruptured spleen: a revalidation of criteria. Surgery.1996; 120: 745-775.
  • Smith JS Jr, Wengrowitz DA, DeLong DS: Prospective validation of criteria, including age, for safe non-surgical management of the ruptured spleen. J Trauma. 1992; 33: 363-369.
  • Croce MA, Fabian TC, Menke PG, et al: Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. Ann Surg. 1995; 221:744-755.
  • Fang JF, Chen RJ, Lin BC, Hsu YB, Kao JL,Chen MF. Blunt hepatic injury: minimal intervention is the policy of treatment. J Trauma 2000;49:722-8
  • Scarborough JE, Ingraham AM, Liepert AE, et al. Nonoperative Management Is as Effectiveas Immediate Splenectomy for Adult Patients with High-Grade Blunt Splenic Injury. J Am Coll Surg 2016; 223:249.
  • Velmahos GC, Toutouzas K, Radin R, et al. High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ. Arch Surg. 2003;138:475Y480; discussion 480-481.
  • Watson GA, Rosengart MR, Zenati MS, et al. Nonoperative management of severe blunt splenic injury: are we getting better? J Trauma 2006; 61:1113.
  • Bhullar IS, Frykberg ER, Tepas JJ 3rd, et al. At first blush: absence of computed tomography contrast extravasation in Grade IV or V adult blunt splenic trauma should not preclude angioembolization. J Trauma Acute Care Surg 2013; 74:105.
  • Velmahos GC, Toutouzas K, Radin R, et al. Non-operative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg.2003;138:844-851.
  • Pachter HL, Knudson MM, Esrig B, et al. Status of non-operative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. J Trauma. 1996;40:31-38.
  • Cachecho R, Clas D, Gersin K, Grindlinger GA. Evolution of the complex liver injury at a Level I trauma center. J Trauma. 1998;45:79-82.
  • Falimirski ME, Provost D. Nonsurgical management of solid abdominal organ injury in patients over 55 years of age. Am Surg. 2000;66:631-635.
  • Sharma OP, Oswanski MF, Singer D, et al. Assessment of non-operative management of blunt spleen and liver trauma. Am Surg. 2005;71: 379-386.
  • Yanar H, Ertekin C, Taviloglu K, Kabay B, Bakkaloglu H et al. Nonoperative treatment of multiple intra-abdominal solid organ injury after blunt abdominal trauma. J Trauma. 2008;64(4):943-8.
  • Carrillo EH, SpainDA,WohltmannCD, et al. Interventional techniques are useful adjuncts in non-operative management of hepatic injuries.J Trauma. 1999;46:619-624.
  • Becker CD, Mentha G, Terrier F. Blunt abdominal trauma in adults: role of CT in the diagnosis and management of visceral injuries. Part 1: liver and spleen. Eur Radiol. 1998;8:553-562.
  • Brasel KJ, DeLisle CM, Olson CJ, et al. Trends in the management of hepatic injury. Am J Surg. 1997;174:674-677.
  • Swaid F, Peleg K, Alfici R, et al. Concomitant hollow viscus injuries in patients with blunt hepatic and splenic injuries: an analysis of a National Trauma Registry database. Injury 2014; 45:1409.
  • Mehall JR, Ennie JS, Saltzzman DA, et al. Prospective Results of a standardized algorithm based on hemodynamic status for managing pediatric solid organ injury. J Am Coll Surg. 2001;193:347-353.
  • Banerjee A, Duane TM, Wilson SP, et al. Trauma center variation in splenic artery embolization and spleen salvage: a multicenter analysis. J Trauma Acute Care Surg 2013;75:69.
There are 47 citations in total.

Details

Primary Language Turkish
Subjects Clinical Sciences
Journal Section Original Article
Authors

Mehmet Aykut Yıldırım

Ahmet Tekin This is me 0000-0001-9261-8243

Mehmet Sinan İyisoy 0000-0001-8789-8199

Murat Çakır 0000-0001-8789-8199

Cengiz Kadıyoran 0000-0002-7173-3530

Tevfik Küçükkartallar

Celalettin Vatansev 0000-0002-0094-1703

Faruk Aksoy 0000-0003-1560-3034

Metin Belviranlı This is me 0000-0003-1974-255X

Adil Kartal This is me 0000-0002-5045-3273

Publication Date June 30, 2021
Submission Date July 16, 2019
Published in Issue Year 2021 Volume: 31 Issue: 2

Cite

Vancouver Yıldırım MA, Tekin A, İyisoy MS, Çakır M, Kadıyoran C, Küçükkartallar T, Vatansev C, Aksoy F, Belviranlı M, Kartal A. Künt Karın Travmasına Bağlı Solid Organ Yaralanmalarında Non operatif Tedavi-Dalak Yaralanmaları. Genel Tıp Derg. 2021;31(2):105-10.