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NONOPERATIVE MANAGEMENT OF SOLID ORGAN INJURIES . Arizona Trauma and Acute Care Consortium. SELECT UPDATES. Chris Salvino, MD, MS, MS, MT, FACS Trauma Director John C Lincoln Hospital. AGENDA Select Topics. EVALUATION.

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Arizona trauma and acute care consortium l.jpg

NONOPERATIVE MANAGEMENT OF SOLID ORGAN INJURIES

Arizona Trauma and Acute Care Consortium

SELECT UPDATES

Chris Salvino, MD, MS, MS, MT, FACS

Trauma Director

John C Lincoln Hospital


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AGENDASelect Topics


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EVALUATION

Throughout this presentation non-operative management (NOM) of blunt solid organ injuries is based on stability and CT scan evaluation



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HISTORY

  • 1900s

    • 100% Mortality with NOM

      • Splenectomy treatment of choice

  • 1952

    • Five cases of fatal infections in infants following splenectomy*

      • Start of NOM

  • Modern impetus for attempting NOM was concern for infection

* King H, Shumacker HB: Splenic Studies. Susceptibility to Infection After Splenectomy Performed in Infancy. Ann Surg 136: 239,1952


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IMMUNOLOGY

  • Function

    • Filter

      • Antigens, bacteria & old RBCs

    • Regulation

      • Helper/suppressor T-cell ratios

    • Produces host defense proteins

      • Immunoglobulin M

        • Antibodies produced by lymphocytes sequestered in the spleen that respond to antigens

      • Tuftsin

        • Tetra-peptide that stimulates phagocytes to destroy pathogens


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IMMUNOLOGY

  • Partial rationale for NOM

    • Overwhelming Post-Splenectomy Infection (OPSI) from encapsulated bacteria (S pneumoniae, N meningitidis, H influenzae)

      • Rare

      • Younger people with higher risk

      • Risk greatest 1st year after splenectomy

      • Risk of death based on population studies

        • ~0.03%-0.02% adults

        • ~0.6%--0.3% peds

    • Vaccine

      • Reduce OPSI

  • Risk for early post-operative complications

    • i.e., pneumonia, sub-phrenic abscess & others*

  • Immunology plays part of a role in the decision to attempt NOM; but definitely not the sole role

  • * Willis BK, Deitch EA: The Influence of Trauma to the Spleen on Post-Operative Complications and Mortality. J Trauma 26:1074,1986


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    GRADING SCALE Spleen

    Grading scale proposed by AAST from Moore EE, Cogbill TH, et al: Organ Injury Scaling: Spleen & Liver . J Trauma 38:1995


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    DEDICATED STUDY #1

    Early study (1989). Success of non-operative management; retrospective review from 6 institutions with 832 blunt splenic injuries. 14% (112) were treated with NOM. Indications for NOM vs. OM; stability?

    • Findings

    • Conclusions

      • Some study limitations

      • Success of NOM in stable Grade I-III

        • 98% Children

        • 83% Adults

    Cogbill TH, Moore EE, et al: Non-Operative Management of Blunt Splenic Trauma: A Multi-Center Experience. J Trauma 29:1312, 1989


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    DEDICATED STUDY #2

    Prospective study of 190 adult trauma patients with splenic injuries. 102 stable patients underwent 3-5 days of bed rest; regardless of grade

    • Findings

      • Of the 102 initially stable patients

        • 2% Required subsequent laparotomy

        • 15% Required blood transfusions

        • 0% Mortality rate

      • Of the 190 total patients

        • Infection rate

          • 31.9% In survivors with splenectomy

          • 3.2% In survivors who had splenic repair

          • 0.0% In NOM

        • Transfusion rate

          • 0.8 Average units for NOM

          • 6.0 Average units for splenectomy patients

    • Conclusions

      • If stable, a very high NOM rate should be seen

      • Splenectomy had a markedly higher infection and transfusion rate over NOM

      • Splenectomy had a markedly higher infection rate over splenic repair patients

    Pachter HL, Guth AA, et al: Changing Patterns in the Management of Splenic Trauma: The impact of Non-Operative Management. Ann Surge 227:708, 1998


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    DEDICATED STUDY #3

    35,767 Patients with splenic injuries identified in the ACS National Trauma Data Bank; 1994-03. 92.5% Blunt; 85.6% underwent NOM

    • Findings

      • > 18 years old 81.8% underwent successful NOM (blunt & penetrating combined)

      • < 18 years old 91.8% underwent successful NOM (blunt & penetrating combined)

      • The usage of NOM increased 140% from 1994-2003

      • AIS and successful NOM

        • II 68.0%

        • III 63.2%

        • IV 59.9%

        • V 60.7%

      • The odds for sucessful NOM were somewhat lower

        • Increased age

        • Increased initial systolic BP in the ED

        • Increased ISS

    • Conclusions

      • NOM increased significantly over the 10 years

      • Success rate of NOM

        • High in general

        • Slight decrease with increasing grade as well as ISS, age and initial high ED SBP

    Hurtuk M, Reed R, et al: Trauma Surgeons Practice What They Preach: The NTDB Story on Solid Organ Injury Management. J Trauma 61:243-255, 2006


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    DEDICATED STUDY #4

    92 Children (average age 8.4 yrs) were evaluated. 53 Underwent NOM; 6 G I, 21G II, 24 G III, 2 G IV. All patients had serial HCT until stable. CT scan follow-up at day 5-7

    • Findings

      • 100% Successful NOM

      • All CT scans showed healing

      • LOS 7 days

      • HCT stabilized ~ PID #2 in non-transfused patients

      • Transfused patients

        • G II – mixed with multiple injuries; data not meaningful

        • G III – 12.5% required (9.7 ml/kg) in first 2 days only

    • Conclusions in children

      • No benefit to ICU

      • HCT checks after 2 days not normally helpful

      • Most could have been discharged POD 3

      • CT scan follow-up was not useful

    Lynch JM, Ford H, et al: Is Early Discharge Following Isolated Splenic Injury in the Hemodynamically Stable Child Possible?: J Pediatric Surg. 28:1403, 1993


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    DEDICATED STUDY #5

    108 Patients with splenic injuries; 73 (68%) NOM. Routine (not clinically indicated) follow-up CT scans were performed on many (not all) of the patients. 2 G I, 29 G II, 27 G III, 15 G IV, 0 G V

    • Findings

      • Children 88% successful NOM

      • Adults 92% successful NOM

      • ~2% of Routine CT scans actually changed management

        • 16 Scans performed < 10 days

          • 1 Changed management; pseudoaneurysm G IV with subsequent …angiographic embolization

        • 33 Scans performed > 10 days

          • No changes

    • Conclusions

      • Routine CT scan follow-up is not necessary in most patients undergoing NOM

        • A subset of patients may benefit from routine CT scans such as higher grades (IV) or initial CT scan blush

    Bradley TC, Gogbill TH, et al: Non-Operative Management of Splenic Injury: Are Follow-up CT Scans of Any Value?: J Trauma 43:748, 1997


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    DEDICATED STUDY #6

    Retrospective review of Washington State Trauma Registry. 1633 Patients with splenic injury underwent planned NOM. Grades not reported. Which presenting sings/symptoms can predict failure of NOM?

    • Findings

      • 15% Failed NOM

      • Increased risk of failure of NOM

        • > 55 years

        • > 25 ISS

        • Level III/IV > Level I/II

      • No change in risk of failure of NOM

        • GCS

        • Associated injuries

        • Presenting hemodynamics

    • Conclusions

      • Age > 55, ISS > 25 and admission to a Level III/IV were associated with a significant risk of failure

      • GCS, associated injuries and initial hemodynamics* were not associated with failure

      • Limited study from a data bank

    *< 5% of the total patients had a SBP < 90; therefore, is this conclusion valid?

    McIntyre LK, Schiff M, et al: Failure of Non-Operative Management of Splenic Injuries: Arch Surg140:563, 2005


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    DEDICATED STUDY #7

    Retrospective review of 3085 adults with blunt splenic injuries with a AIS > 4 obtained from the NTDB. NOM attempted in 1248 (40.5%). This study looked at higher grade injuries

    • Findings

      • NOM unsuccessful in 682 (54.6%)

      • Failure associated with

        • Age > 55

        • Low (unstable?) admission BP

        • Higher LOS

          • 16.9 vs. 8.6

        • Higher LOS ICU

          • 10.1 vs. 3.9

      • Mortality of NOM failure (12.3%) similar to successful NOM (13.8%)

    • Conclusions regarding higher grade splenic injuries

      • NOM is associated with a high rate of failure and longer LOS

      • No difference in mortality between success and failure of NOM

    Watson GA, Rosengart MR, et al: Non-Operative Management of Severe Blunt Splenic Injury: Are We Getting Better?: J Trauma 61:1113-1119, 2006


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    DEDICATED STUDY #8

    Retrospective EAST study from 27 institutions of 1488 adults with splenic injuries; of these, 97 patients failed NOM. 78 of these were available and form the basis of the review. Upon admission; 44% stable, 31% transient responders, 25% unstable

    • Findings

      • Failure of NOM

        • Increased LOS

        • Mortality of those failing NOM (note ISS similar from one group to the next)

          • Overall 12.8%

            • Stable 3%

            • Responders 8%

            • Unstable 37%

        • 60% (6) of the deaths caused by delayed treatment of splenic or other abdominal injuries – all from the Responder (1) and Unstable (5) categories

      • Conclusion

        • Majority of deaths were from delayed treatment of splenic or intra-abdominal injuries

        • Highest death rate of patients failing NOM is with patients presenting with instability

          • Unstable patients should not undergo an attempt at NOM

          • Transient responders and NOM?

    Peitzman AB, Harbrecht GB, et al: EAST Multi-Institutional Trials Working Group: Failure of Observation of Blunt Splenic Injury in Adults: Variability in Practice and Adverse Consequences. J Am Coll Surg 201:179-187, 2005


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    DEDICATED STUDY #9

    Retrospective WEST study from 4 institutionsof 140 patients (96% blunt) with splenic injuries who had (+) CT findings and subsequent Angiography & Embolization (A&E) followed by NOM. It is unclear how many patients with (+) CT had active bleeding vs. aneurysm vs. hemoperitoneum w/o active bleeding. Results compared to EAST

    • Findings

      • Success of NOM

      • Hemoperitoneum did not affect success

      • Presence of A-V fistula had a high failure rate (40%) despite A & E

      • Salvage rates similar between main and selective artery

      • 4.3% (6) developed abscesses

    • Conclusion

      • A & E can increase salvage especially at the higher grades

    Haan JM, Knudson M, et al: WEST Multi-Institutional Trials Committee: Splenic Embolization Revisited: a Multi-Center Review. J Trauma 56:542-547, 2004


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    SELECT COMPLICATIONSAbscess

    • Mechanism

      • Proximity injuries (i.e., stomach)

      • Contamination of splenic hematoma from systemic infections

    • Gram (-) enteric bacteria most common

    • Treatment

      • Antibiotics

      • Mechanical

        • Percutaneous drainage

        • Splenectomy

    Sarr MG, Zuidema GD, Splenic Abscess- Presentation, Diagnosis & Treatment. Surgery 1982;92:480-485


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    CONTROVERSIESAngiography & Embolization (A&E)

    • No controversy

      • A & E has a role in certain splenic injuries

    • Controversy

      • Indications

        • All patients with a blush?

        • Patients without a blush of a higher grade?

        • Other

      • Method of embolization

        • Main artery

          • Reduce perfusion pressure while maintaining splenic blood flow via short gastric vessels/collaterals to prevent infarcts

        • Distal (segmental) artery

          • Attacks vascular injury more directly, but associated with a higher infarct rate?

      • Complications of T & E

        • Delayed bleeding

        • Abscess and false abscess

        • Difficulty getting angio team in at some hospitals

        • Other

    Forsythe RM, Harbrecht BG, et al: Blunt Splenic Trauma. Scan J Surg



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    HISTORY

    • In 1908 Pringle implied that the structural integrity of the liver was incapable of achieving spontaneous hemostasis*

    • The technical breakthroughs in CT imaging were principally responsible for the reversal of the long standing above belief now that the liver could be imaged and imaged repeatedly

    • 1983, Karp et al (pediatric surgeons) were the first to demonstrate that the liver is capable of spontaneous hemostasis and healing**

    • 1990, Knudson et al reported on 52 patients with liver injuries treated successfully with NOM***

    Pringle JH: Notes on the Arrest of Hepatic Hemorrhage Due to Trauma: Ann Surg 48:541, 1908

    **Karp M, Cooney DR, et al: The Non-Operative Management of Pediatric Hepatic Trauma: J Pediatric Surg. 18:512, 1983

    ***Knudson MM, Lim RC, et al: Non-Operative Management of Blunt Liver Injuries in Adults: The Need for Continued Surveillance. J Trauma 30:1494, 1990


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    GRADING SCALELiver

    Grading scale proposed by AAST from Moore EE, Cogbill TH, et al: Organ Injury Scaling: Spleen and Liver. J Trauma 38:323-4, 1995


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    DEDICATED STUDY #1

    Retrospective 13 institution study of 404 patients in stable blunt liver injuries. 19% G I, 31% G II, 36% G III, 10% G IV, 4% G V

    • Findings

      • 98.5% Success of NOM

      • 0.4% (2) Mortality attributed to hepatic injury

      • 5% (21) Complication rate

        • 14 Bleeding the most common

          • 3 OR; of these, 2 had underlying hemostatic disorders

          • 4 Embolizations

          • 6 Transfusions

          • 1 Observed

        • 2 Bilomas (percutaneous drainage)

        • 3 Abscesses (percutaneous drainage)

        • 0 Hemobilia

    • LOS overall and for those with complications was 13.1 and 26.9 respectively

  • Conclusions

    • High rate of successful NOM in patients with blunt liver injuries

    • Mortality attributed to liver injury is very low

    • Unlike splenic injuries, rate of successful NOM is less dependent on grade

    • Complications result in a much higher LOS

  • Pachter HL, Knudson MM, et al: Status of Non-Operative Management of blunt Hepatic Injuries in 1995: A Multi-Center Experience with 404Patients. J Trauma 140:31, 1996


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    DEDICATED STUDY #2

    35,510 Patients with hepatic injuries identified in the ACS National Trauma Data Bank; 1994-03. 78% Blunt; 95.1% underwent NOM

    • Key findings

      • Age and successful NOM

        • > 18 years old 91.9% (blunt & penetrating combined)

        • < 18 years old 96.5% (blunt & penetrating combined)

      • AIS and successful NOM

        • II 90.5%

        • III 76.6%

        • IV 69.3%

        • V 62.3%

      • The usage of NOM increased 17% from 1994-2003

        • Mortality was relatively constant

      • The chance of sucess of NOM was lower

        • Increased age

        • Increased initial systolic BP in the ED

        • Increased Revised Trauma Score

        • Increased for level II trauma centers

    Hurtuk M, Reed R, et al: Trauma Surgeons Practice What They Preach: The NTDB Story on Solid Organ Injury Management. J Trauma 61:243-255, 2006


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    DEDICATED STUDY #3

    Single institution retrospective study of 243 hepatic injuries, 95 of these were stable and treated with NOM. 29 G I, 30 G II, 33 G III, 3 G IV*, 0 G V*. 51 (54%) had more than one CT scan

    • Findings

      • 0% NOM failure

      • 0% Direct mortality

      • 3 Patients (2 G III 1 G IV) with (+) clinical findings (pain & elevated bilirubin) prompted CT scans leading to percutaneous bile drainage

      • 48 Patients had at least routine 1 F/U CT scan with no intervention performed

    • Conclusions

      • No patients failed NOM

      • Positive clinical findings did lead to helpful CT scans and altered treatment

      • Findings on routine repeat CT scan did not alter the decision to discharge clinically or change the management plan in stable patients with Grade I-III injuries

      • Study was weak beyond these global conclusions

    *Population too small for statistical evaluation

    Ciraulo DL, Nikkanen HE, et al: Clinical Analysis of the Utility of Repeat CT Scan Before Discharge in Blunt Hepatic Trauma. J Trauma 41:821, 1996


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    DEDICATED STUDY #4

    11 Patients with grade IV/V hepatic injuries and a mean ISS of 36 underwent angiography; 7 were found to have arterial bleeding and underwent embolization. Study entrance criteria included only those patients who were unstable upon presentation & then stabilized only with continuous aggressive resuscitation

    • Findings

      • Aggressive resuscitation was successfully withdrawn after embolization in all patients

      • Mean

        • 12 PRBCs

        • 9.1 ICU LOS

        • 23.9 LOS

      • 2 Complications

        • 1 Biloma (percutaneous drainage)

        • 1 Large devitalized tissue in a Grade V injury -> debridement ((-) for infection). Subsequent MSOF-> death

      • 14.3% Mortality

    • Conclusions

      • Pushed the limits of conservative management

      • Study was directed to a subset of hepatic injuries; initially unstable G IV/V

      • Embolization negated the need for surgical intervention in patients that normally would have gone to surgery.

      • Literature review of patients undergoing surgery for hepatic injuries had similar LOS, blood transfusion and mortality rates (4-76%)

    Ciraulo DL, Luk S, et al: Selective Hepatic Arterial Embolization of Grade IV and V Blunt Hepatic Injuries: An Extension of Resuscitation in the Non-Operative Management of Traumatic Hepatic Injuries. J Trauma 45:353, 1998


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    DEDICATED STUDY #5

    Single institution review of 126 blunt liver injuries; 74.6%(94) underwent NOM w/o A & E (Group 1) , 4.8% (6) underwent NOM with A & E for bleeding seen on CT (Group 2) (stable?). 90% of Group 1 were G I-III. Group 2 consisted of 3 G III, 3 G IV

    • Findings of Group 2

      • Success?

        • 66% Successful resolution of bleeding

        • 33% (2) Unsuccessful embolization

          • 1 Bad head injury and instability

          • 1 Inability to cannulate atherosclerotic celiac trunk -OR no liver bleeding; massive retropertioneal bleed

      • Mortality

        • 33% Overall

        • 0 Hepatic related

      • 3 OR

        • 1 Delayed nephrectomy

        • 1 Retroperitoneal bleed; not hepatic

        • 1 Bile leak

      • Success of stopping bleeding from embolization 100%

    • Conclusions

      • A & E can be used successfully in Grade III and IV liver injuries with bleeding seen on CT

      • Other meaningful data cannot be extracted

    Wahl Wl, Ahrns KS, et al: The Need for Early Angiographic Embolization in Blunt Liver Injuries. J Trauma 52:1097-1101, 2002


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    DEDICATED STUDY #6

    Single institution retrospective study of 106 patients with blunt injury; of those, 64 (60%) were stable and evaluated with CT. Angiography was performed on 26 with suspected vascular injuries on CT

    • Findings

      • 92% were Grade III

      • 13 (50%) had positive findings on angiogram

        • Extra-vascular leakage of contrast

        • Pseudoaneurysm

        • A-V fistula

        • 12 Had successful embolization

        • 1 A-V fistula was extensive ->OR

      • Complications associated with A & E

        • 1 Developed a delayed A-P fistula

    • Conclusions

      • A & E can be highly successful stopping bleeding

      • Not all (+) CT findings (~50%) lead to actual findings of bleeding on angiogram

      • Higher grades are more likely to have initial bleeding

    Sugimoto K , Horiike S, et al: The Role of Angiography in the Assessment of Blunt Liver Injury. Injury, 25:283-287, 1994


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    DEDICATED STUDY #7

    Retrospective review of 202 pediatric patients with blunt hepatic injury at a single pediatric level I trauma center, 185 were stable and underwent NOM. 65 G I, 62 G II, 53 G III, 4 G IV, 0 G V, 0 G VI

    • Findings

      • 90.8% (168) were managed successfully w/o complications

      • Mortality

        • 5.4% Overall

        • 0% Attributed to the hepatic injury

      • Complications

        • 3.8% (7)

          • Grade III-IV

          • All right lobe

          • All with symptoms

            • 1 Hepatic A-V fistula (embolization)

            • 5 Bilomas (2 OR, 1 drainage, 2 drainage and stent)

            • 1 Necrotic gallbladder (OR)

    • Conclusions

      • NOM very successful in pediatric patients

      • Complications

        • Rate low

        • Grade III or higher

        • Most non-operative

        • All associated with symptoms

    Giss SR, Dobrilovic N, et al: Complications of Non-Operative Management of Pediatric Blunt Hepatic Injury: Diagnosis, Management, and Outcomes. J Trauma 61:334-339, 2006


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    Findings

    Mortality

    66% OM

    8.3% NOM

    Conclusions

    Data analysis was limited

    ~ 50% Of severe hepatic injuries overall will

    require surgery

    Mortality is high with OM

    Mortality was much lower in those undergoing NOM; however, this may be a function of other factors not just liver grade

    Bleeding is common in those undergoing NOM of G IV-V and subsequently A & E was useful and sucessful

    This does not extrapolate to a recommendation that all NOM G IV-V have A & E automatically

    DEDICATED STUDY #8

    Single institution retrospective review of 80 G IV-V hepatic injuries; 36 underwent NOM and 44 underwent OM. All 36 NOM had a CT. Indications for NOM vs. OM?

    Duane TM, Como JJ, et al: Re-Evaluating the Management and Outcomes of Severe Blunt Liver Injury. J Trauma 57:494-500, 2004


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    DEDICATED STUDY #9

    Single institution retrospective review of 135 patients with blunt hepatic trauma who were treated with NOM; 24% (32) of which developed complications that required additional interventional treatment. Of the 135; 18 G I, 22 G II, 43 G III, 35 G IV, 17 G V. Of the 32; 0 G I-II, 2 G III, 18 G IV, 12 G V

    • Findings

      • 58% of G IV-V developed complications requiring intervention

      • 94% of those (32) developing complications were G IV-V

      • Interventional treatment

        • 12 A & E 2 unsuccessful -> OR

        • 10 CT drainage of abscesses 2 unsuccessful -> OR

        • 8 ERCP and stenting 1 unsuccessful -> OR

        • 2 Laparoscopy

      • 15% Unsuccessful non-operative intervention

      • 0% Mortality

    • Conclusions

      • Complications with severe hepatic trauma managed with NOM are common; > 50% in G IV-V

      • The majority of complications can be managed with non-operative intervention

    Carrillo ED, Spain DA, et al: Interventional Techniques Are Useful Adjuncts in Non-Operative Management of Hepatic Injuries. J Trauma 46:619-624, 1999


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    INFLAMMATORY HOST RESPONSE SYNDROME

    • Occurs PID 2-5

    • Generalized inflammatory response; similar to sepsis

      • Fever, WBC, tachycardia, tenderness, ileus

      • Normal Hgb

    • Mechanism?

      • Liver ischemia

      • Inflammatory mediators

        • Bile and/or blood

      • Infection ~ 7-13%

    • Treatment

      • Infected – drain and ABX

      • Non-infected

        • Watch

        • Drain? Reduction in inflammatory response duration?

          • Laparoscopically

          • Open

    Carrillo EH, Wohltmann Chris, et al: Current Problems in Surgery. 9-60, 2001


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    HEMOBILIA

    • 0.2-3% Of blunt liver injuries

    • Etiology

      • Communication between arterial and biliary system

    • Presentation

      • RUQ pain, jaundice, GI hemorrhage

    • Diagnosis

      • Angiography

    • Treatment

      • Selective embolization

        • OR for failures

    Carrillo EH, Richardson JD: The Current Management of Hepatic Trauma. Advances in Surgery 35:39-59, 2001


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    DELAYED HEMORRHAGE

    • 0-3.5% Of blunt liver injuries

      • More frequent at higher grades

      • Blood transfusion requirements

        • 20% Of the patients

        • Most requiring < 4 units

    Carrillo EH, Richardson JD: The Current Management of Hepatic Trauma. Advances in Surgery 35:39-59, 2001


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    NOM BENEFITS

    Overview summary from 5 articles regarding additional benefits of NOM vs. OM

    • Less

      • Transfusions

      • Abdominal complications

      • LOS

      • ICU LOS

    Stein DM, Scalea TMl: Non-Operative Management of Spleen and Liver Injuries. J of Intensive Care Med 21:296-294, 2006


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    CONTROVERSYRoutine Follow-Up CT Scan

    • Is there a role in stable patients with no clinical symptom to have routine CT scans in follow-up to blunt liver injury with NOM?

      • Adults vs. peds

      • If not for all grades, then certain grades?

      • Discharge from the ICU?

      • Discharge in general?

      • Activity?

    Stein DM, Scalea TMl: Non-Operative Management of Spleen and Liver Injuries. J of Intensive Care Med 21:296-294, 2006


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    RESUMPTION OF ACTIVITES

    Overview review

    • Trauma patients typically show complete resolution of injury

      • 9-12 weeks in one pediatric study

      • 4-12 weeks in other studies

    • In an experimental model wound breaking strength of an injury is normal at 3-6 weeks

    • This topic is still unclear

    Carrillo EH, Wohltmann Chris, et al: Current Problems in Surgery. 9-60, 2001



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    IMAGING

    • CT scan > IVP

      • Fast

      • Allows evaluation of other organ injuries

      • Identifies contusions

      • Depth and extent of injuries

      • Size of surrounding hematoma

      • Other

    • IVP

      • Some usage in the OR

    • Angiography

      • Acute

        • Arterial bleeding/embolization

      • Chronic

        • Renal hypertension


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    GRADING SCALEKidney

    Grading scale proposed by AAST from Moore EE, Cogbill TH, et al: Organ Injury Scaling: Spleen, Liver & Kidney. J Trauma 29:1989


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    HISTORY

    • Conservative management of blunt renal has evolved over the past 30-40 years as investigators have realized that the nephrectomy rate is higher for renal exploration than NOM

    • 1987 Bergen et al reported on renal trauma*

      • 12.6% Overall nephrectomy rate

        • 35% Nephrectomy rate in those explored

    *Bergen CT, Chan TN, et al: IVP Results in Association with Renal Pathology and Therapy in Trauma Patients. J Trauma 27:515, 1987


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    DEDICATED STUDY #1

    Single institution retrospective review of 2 series of patients with diagnosed/suspected renal injuries (series I 1964-73, series II 1977-81). Series II much more reliant on imaging to dictate surgical intervention and OR management. Series I – 185 pts, series II – 190 pts

    • Findings

    • Conclusions

      • Early study 1960s <-> early 80s

      • High NOM success rate

      • Imaging helped reduce the incidence of nephrectomy

    McAninch JW, Carroll PR: Renal Trauma: Kidney Preservation Through Improved Vascular Control: A refined Approach. J Trauma 22:285, 1982


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    DEDICATED STUDY #2

    Single institution retrospective review of 1007 blunt trauma patients with hematuria most who underwent radiographic evaluation. Shock =SBP < 90 in field/ED

    *408 did not get imaged so excluded from this chart

    • Conclusions

      • Definition of “microscopic hematuria”?

      • Did not evaluate other groups; for example, macrohematuria

      • No imaging required if no shock AND only microhematuria or dip positive

      • Imaging of those in shock AND with micro/marcohematuria should be done

    Mee SL, et al: Radiographic Assessment of Renal Trauma: A 10-Year Prospective Study of Patient Selection. J Urol 141:1095-1098, 1989


    Dedicated study 344 l.jpg
    DEDICATED STUDY #3

    Single institution retrospective review of 329 children with blunt trauma. 97 Had a CT upon admission – indications? 22% (21) had a renal injury. Of these, 6 had isolated renal injuries; this study specifically looks at these 6

    • Findings

      • All had a painful tender flank with bruises, micro/macro-hematuria

      • Grade and management

        • 2 G III NOM

        • 3 G IV OM

        • 1 G V OM

    • Conclusions

      • Small study with limitations

        • Is flank pain/bruising and micro/marco-hematuria always associated with significant renal injuries?

      • This subset of patients all had positive clinical findings and G III-IV injuries

      • Operative rate appears high; 66%

    Rathaus V, Pomeranz A, et a: Isolated Severe Renal Injuries After Minimal Blunt Trauma to the Upper Abdomen and Flank: CT Findings Emergency Radiology 10:190-192, 2004


    Dedicated study 445 l.jpg
    DEDICATED STUDY #4

    Single institution retrospective review of CT findings in 47 children with blunt renal trauma. 18 G I, 9 G II, 7 GIII, 7 G IV, 6 G V. This study looked at the subset with GIV-V

    • Findings

      • Other injuries

        • 50% abdominal

        • 33% Head

      • 13 G IV-V

        • 4 Nephrectomy (indications?; 2 from outside facilities before transfer)

        • 9 Non-nephrectomy

          • 2 Renal repair

          • 1 Return of kidneys to abdomen from thorax

          • 6 Observation

      • Neither the nephrectomy or non-nephrectomy group required hemodialysis, had significant HTN or elevated Creatine at the time of D/C

      • 66% Non-nephrectomy & 100% nephrectomy groups were available for f/u (mean 120 months) and were normotensive

    • Conclusions

      • Indications for the 4 nephrectomies?

      • Conservative management, when performed in these high grade lesions, was successful without long term sequele and should be attempted in all stable severe pediatric patients with renal injuries

        • No patient developed significant reno-vascular HTN

    Barsness KA, Bensard DD, et al: Reno-Vascular Injury: An Argument for Renal Preservation. J Trauma 57: 310-315, 2004


    Dedicated study 546 l.jpg
    DEDICATED STUDY #5

    Single institution retrospective review of 178 initially stable adults with blunt renal trauma. 26 With G IV-V form the basis of this review

    • Findings

      • All patients had micro or macroscopic hematuria

      • 14 NOM

        • 1 required a stent; otherwise uneventful

      • 12 OM Patients developed

        • 9 Instability -> nephrectomy & other organ injury repair in some?

        • 3 Acute abdomen -> renal repair & other organ injury repair

      • Morbidity same between NOM and OM

      • 50% available for f/u average 7.5 months; none with renal insufficiency or HTN

    • Conclusions

      • This subset of patients all had micro/macro-hematuria

      • Stable G IV-V have a high rate of successful NOM

      • Unstable G IV-V undergoing OM have a high nephrectomy rate (75%)

    Bozeman C, Carver B, et al: Selective Operative Management of Major Blunt Renal Trauma. J Trauma 57:305-309, 2004


    Dedicated study 647 l.jpg
    DEDICATED STUDY #6

    Retrospective review of the NTDB of 742,774 patients; 6890 blunt trauma patients with renal injuries. NOM and OM combined

    • Findings

      • Overall

        • 4.1% Nephrectomy

        • 0.5% Dialysis

        • 10.2% Death

      • Grade of injuries

        • Nephrectomy, dialysis and death increased with grade

          • Nephrectomy rate highest correlation for grade

            • ~0.1% Grade II

            • ~10% Grade V

    • Conclusions

      • Grading predicts nephrectomy, dialysis and death

        • Nephrectomy correlation strongest

    Kuan JK, Wright JL, et al: AAST Organ Injury Scale for Kidney Injuries Predicts Nephrectomy, Dialysis, and Death in Patients with Blunt Injury and Nephrectomy for Penetrating Injuries. J trauma 60:351-356, 2006


    Renovascular htn nom l.jpg
    RENOVASCULAR HTN & NOM

    • Etiology

      • Renal artery stenosis or occlusion

        • Internal – thrombosis or flap

        • External – compression

      • Restrictive fibrous capsule around kidney (“Page” kidney)

        • Compress parenchyma and restrict blood flow

    • Incidence – low

      • 3.2% Monstrey et al, 1989

      • 0.0% Barsness et al, 2004 (peds)

      • “Low” Montgomery et al, 1998


    Dedicated study 749 l.jpg
    DEDICATED STUDY #7

    Single institution retrospective review over 20 years to identify those with arterial hypertension as a direct result of renal injury. 7 patients found who developed new onset of HTN after discharge that was renal in origin. Study was not designed to look at frequency.

    • Findings

      • Time from injury to diagnosis of HTN 2-32 weeks

      • No history of HTN before accident or during hospital

      • Initial w/u at time of accident

        • 1 No workup

        • 3 Negative CT

        • 3 Negative IVP

      • All 7 underwent renal angiography and 6 had renal-vein renin sampling

        • 100% abnormal renin analysis

    • Conclusions

      • Development of renal HTN is not immediate

      • Angiography & renin analysis important

      • Treatment based on response to RX and angio findings

      • This study only “guesses” at renal HTN as “low” by the authors

    Montgomery RC, Richardson JD, et al: Post-Traumatic Reno-Vascular Hypertension After Occult Renal Injury. J Trauma 45:106-110, 1998


    Vascular injuries l.jpg
    VASCULAR INJURIES

    Bux S, Tarry WF, et al: Contemporary Management of Renal Trauma. W Virg Medical J. 88:152-155, 2002


    Urinary leak l.jpg
    URINARY LEAK

    • Diagnosis

      • CT

    • Treatment

      • NOM with stent

      • OM

        • Most injuries at the renal pelvis

        • Infection?

        • Worsening leak on subsequent CT scans

    Bux S, Tarry WF, et al: Contemporary Management of Renal Trauma. W Virg Medical J. 88:152-155, 2002



    Conclusions general l.jpg
    CONCLUSIONSGeneral

    • All stable patients with blunt spleen, liver &/or kidney injuries diagnosed on CT scan should be considered for NOM

    • NOM should not be used in unstable patients with blunt spleen, liver &/or kidney injuries

    • Rate of successful NOM is less dependent on grade with liver and kidney as opposed to splenic injuries

    • Usage rate of NOM has increased over the past 10 years

      • 140% Spleen

      • 17% Liver

      • 0% Kidney

    • Most studies on this topic are retrospective; many small sample sizes


    Future questions general l.jpg
    FUTURE QUESTIONSGeneral

    • Indications for follow-up imaging

      • Routine?

      • Grade?

      • Organ injured?

      • Specific injuries?

    • Type of imaging for follow-up

      • CT vs. U/S?

    • Angiography & embolization

      • Blush only?

      • Higher grades?

      • Spleen specific – main or segmental arteries

    • Hospitalization issues

      • Bedrest?

      • ICU vs. floor

    • Resumption of activity

      • Mild -> contact sports


    Conclusions spleen l.jpg
    CONCLUSIONSSpleen

    • Predictors of success of NOM

      • Very high in children

      • High in adults

      • Medium in those > 55

      • Lower with higher grades

        • G I-III success rate 83% and 98% with adults and peds respectively

      • Lower with higher ISS

    • Higher grades of injury (III-V) and NOM

      • Higher failure rate

      • Same mortality as successful NOM

    • Very low OPSI is not a modern deterrent to splenectomy

    • Post operative infection may be much higher in those undergoing splenectomy as opposed to repair or NOM

      • 31% vs. 0% in one study


    Conclusions spleen56 l.jpg
    CONCLUSIONSSpleen

    • Pediatric patients with NOM

      • No benefit to ICU for most

      • Earlier discharge possible (PID 3)

    • Routine CT scan follow-up is not necessary in most patients

      • May be helpful in subsets such as those with blush on initial CT and/or higher grades of injury

    • Higher rate of failure of NOM with level III/IV centers

    • A & E has a higher rate of successful NOM than no A & E for grade III-V (WEST vs. EAST study)

      • Indications were a bit unclear (active and non-active bleeding mixed)

      • Presence of a A-V fistula was associated with 40% failure rate of embolization

    • Gram (-) enteric most common bacteria in abscesses


    Conclusions liver l.jpg
    CONCLUSIONS Liver

    • Mortality directly attributed to liver injuries is very low

    • Complications from NOM

      • Much longer LOS

      • ~50% overall with G IV-V

    • Predictors of success of NOM

      • Very high in adults and children

      • Lower

        • Higher grades – but not as signifcant of a drop as splenic injuries

        • Higher Revised Trauma Scores

    • Follow-up CT scans

      • Useful with (+) clinical findings

      • Not useful with (-) clinical findings

    • Embolization

      • Improved the success of NOM with G IV-V & some G III

      • Almost always stopped bleeding

      • Consider using with G IV-V with or without signs of bleeding?


    Conclusions liver58 l.jpg
    CONCLUSIONS Liver

    • Inflammatory Host Response Syndrome

      • Occurs PID 2-5

      • Infection rate ~7-13%

      • Usually self limiting

    • Hemobilia

      • Associated with (+) clinical findings

      • Embolization usually successful

    • Delayed hemorrhage

      • < 5% of all liver injuries

        • ~20% will require a transfusion

    • NOM additional benefits

      • Less

        • Transfusions

        • Abdominal complications

        • LOS


    Conclusions kidney l.jpg
    CONCLUSIONS Kidney

    • High sucessful NOM rate including G III-V

    • Hematuria

      • No shock & only microscopic hematuria

        • 0% Significant injuries

      • Shock & micro/macro hematuria

        • 22% Significant injuries

    • Pediatric patients with flank pain/bruising & micro/marcohematuria

      • Frequently have GIII-V injuries?


    Conclusions kidney60 l.jpg
    CONCLUSIONS Kidney

    • Nephrectomy, dialysis and death correlate with increasing grade

      • Nephrectomy having the highest correlation

    • NOM and OM and nephrectomy rate

      • NOM ~ 10%

      • OM ~ 75%?

    • Renovascular HTN

      • Develops over weeks not days

      • Angiography and renin sampling important in dictating management


    Conclusions kidney61 l.jpg
    CONCLUSIONS Kidney

    • Vascular injuries

      • Main artery

        • Thrombosis/bleeding -> OM

      • Segmental artery

        • Thrombosis -> NOM

        • Bleeding -> NOM or embolization

    • Urinary leak

      • Most controlled with stent

      • Exceptions

        • Injury to pelvis

        • Infection

        • Worsening leak


    Difference between spleen and liver l.jpg
    DIFFERENCE BETWEEN SPLEEN AND LIVER

    • Liver may rely less on grading than spleen

    • Delayed bleeding from the liver is rare


    Large hemoperitoneum l.jpg
    LARGE HEMOPERITONEUM

    • Require intervention

      • Embolization

      • Repair extra-hepatic bile ducts

      • Drain hemoperitoneum

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