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EDITORIAL

Splenic trauma: Save patients in shock and save the spleen in stable patients! The spleen, the largest peripheral lymphoid organ in the human body, is the most frequently injured organ in blunt trauma. Its particular fragility is explained by its unique architecture consisting in a thin capsule, a rich capillary network and an elevated physiologic arterial pressure. Upon admission, patients with splenic trauma can present in shock or be hemodynamically stable. Initially, 10—15% of patients with splenic trauma undergo immediate laparotomy because of hemodynamic instability or signs of rupture [1]: of these, 10—15% require immediate splenectomy that can be called ‘‘unavoidable’’ (14% in our experience of 336 splenic injuries managed in the last 10 years). Post-splenectomy complications are not rare (10—20%) and are potentially severe [2] (pancreatitis, bleeding, intra-abdominal collections) occurring in as many as 14% of patients in the series reported by Chastang et al. [3]. Because of the immunologic role of the spleen [4], splenectomized patients have an increased risk of severe infection (‘‘overwhelming post-splenectomy syndrome’’) that appears early post-operatively, reaches its peak during the first two years postsplenectomy, but persists lifelong. This risk is smaller in the adult than in the child or a patient undergoing splenectomy for hematologic disease but nevertheless remains 100 times greater than that of the non-splenectomy population with a prevalence evaluated at 1.5/1000 [5]. This risk warrants several cumbersome measures, especially for the younger patients, including: • yearly vaccinations against pneumococcus, meningococcus, Haemophilus influenzae and influenza; • oral penicillin antibiotic prophylaxis during the first two years after splenectomy as well as lifelong prophylactic antibiotics for any and all ulterior infective episodes; • strong restrictive measures in particular for the young (avoiding traveling to endemic areas of malaria, shunning direct contact with domestic animals, tracking and treating tick bites). Complete observance of this regimen, however, is less than 20% [6], and even if compliance is improved by patient log-books (40% observance in our experience), this is not formally required and appears difficult to organize in France. Conversely, 80—85% of patients with splenic trauma do not have signs of rupture and are hemodynamically stable. Non-operative management has therefore become the standard, essentially because it has a much higher rate of splenic preservation than that observed after surgical preservation methods [7]. Surgical splenic salvage maneuvers are useful for only a minimum of patients who, in the end, frequently undergo total splenectomy during attempts at splenic preservation. In our series of 336 splenic injuries, we were able to find only two successful surgeries for splenic preservation out of 48 laparotomies performed for splenic trauma and this was the case for only one out of 17 laparotomies in the series of Chastang et al. [3].

http://dx.doi.org/10.1016/j.jviscsurg.2015.02.012 1878-7886/© 2015 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Arvieux C. Splenic trauma: Save patients in shock and save the spleen in stable patients! Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.02.012

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Tabulated salvage rates, including immediate and secondary splenectomies, have been noted to be as high as 60% in historical series [8]. In the report by Chastang et al. published in this issue [3], the 80% salvage rate has to be analyzed taking into account the referral bias, since this study did not include patients in severe shock who were admitted directly to the operating room and criteria of splenic injury for inclusion were based on computed tomography findings (mortality was 0%). The development of splenic arterial embolization (SAE), initially devised for pelvic and then liver trauma, has been rapid because SAE seems to preserve patient immunity [9], and has contributed to increase the salvage rate to over 80% [10,11]. SAE seems to be very effective in controlling bleeding with success rates exceeding 90% [12,13]. However, as pointed out by Chastang et al. [3], SAE is not without complications. Determination of the exact prevalence of complications is problematic however, especially for pancreatic tail involvement. In essence, it is difficult to distinguish lesions due to SAE from injury due to the initial trauma [14]. The post-SAE complication rate is less than 10% in experienced centers (so-called in the US when SAE is performed for more than 10% of splenic trauma) [9,15—17]. In the series published by Chastang et al. [3], splenic infarction of more than 50% of the spleen occurred in 26% of patients, a much higher rate than the 0—5% published in the literature [9,13,16]. This may be explained by inappropriateness of management or by interventional radiology performed under sub-optimal technical conditions, since SAE is not indicated in the hemodynamically unstable patient and some of the embolization patients in this series underwent laparotomy for hemorrhagic shock. Based on all of the above considerations, certain expert centers have enlarged their indications for embolization to patients who present predictive factors for secondary splenic bleeding, as identified from retrospective series of non-operative management with failure rates between 30 and 50% [1,13]. These factors include: • active blush (extravasation of contrast material within the spleen); • pseudo-aneurysms and arterial-venous splenic fistulas; • severe splenic injury (AAST grade 3) associated with voluminous hemoperitoneum, and/or the presence of associated extra-gastrointestinal injury; • high grade injury AAST (4 and 5). The so-called ‘‘curative’’ SAE is now widely performed in expert trauma centers for active blush found on CT scans. Preventive SAE for pseudo-aneurysms and arterial-venous splenic fistulas, sometimes confused with late blushes, is now widely performed in France, since there have been medicolegal issues arising from the vascular origins of ‘‘secondary’’ splenic ruptures in this setting. As concerns the other high risk conditions (AAST grade 3 associated with voluminous hemoperitoneum and/or multiorgan injuries and high [AAST grade 4 and 5] injury, a randomized multicenter study [SPLASH] [18]) is now open in France, the goal of which is to show whether ‘‘prophylactic’’ SAE can improve the splenic salvage rate at one month. Evaluation also includes side effects up to six months postintervention as well as medicolegal repercussions. In conclusion, thanks to better knowledge of the physiology of hemorrhagic shock and the pathophysiology of splenic injury on one hand, and to improved and optimal pluri-disciplinary management on the other, it now appears possible to provide access to centers with adequate surgical

and interventional facilities for all patients for whom SAE is indicated. This implicates all those involved in trauma management, locally or nationally [19], and should contribute to reduce the rate of post-traumatic splenectomies in France with no increased risk for these trauma patients.

References [1] Zarzaur BL, Croce MA, Fabian TC. Variation in the use of urgent splenectomy after blunt splenic injury in adults. J Trauma 2011;71:1333—9. [2] Arvieux C, Reche F, Breil P, Létoublon C. Traumatismes de la rate. Principes de techniques et de tactique chirurgicale. In: EMC. Paris: Elsevier; 2009. p. 40—750. [3] Chastang L, Bège T, Prudhomme M, et al. Is the nonoperative management of severe blunt splenic injury more safe? J Visc Surg 2015, http://dx.doi.org/10.1016/j.jviscsurg.2015.01.003 [in press]. [4] Schmidt EE, MacDonald IC, Groom AC. Interactions of leukocytes with vessel walls and with other blood cells, studied by high-resolution intravital videomicroscopy of spleen. Microvasc Res 1990;40:99—117. [5] Benoist S. Les complications à moyen et long termes de la splenectomie. Ann Chir 2000;125:317—24. [6] Kotsanas D, Al-Souffi MH, Waxman BP, et al. Adherence to guidelines for prevention of post-splenectomy sepsis. Age and sex are risk factors: a five-year retrospective review. ANZ J Surg 2006;76:542—7. [7] Bain IM, Kirby RM. 10-year experience of splenic injury: an increasing place for conservative management after blunt trauma. Injury 1998;29:177—82. [8] Harbrecht BG, Zenati MS, Ochoa JB, et al. Management of adult blunt splenic injuries: comparison between level I and level II trauma centers. J Am Coll Surg 2004;198: 232—9. [9] Bessoud B, Duchosal MA, Siegrist CA, et al. Proximal splenic artery embolization for blunt splenic injury: clinical, immunologic, and ultrasound-Doppler follow-up. J Trauma 2007;62:1481—6. [10] Haan JM, Biffl W, Knudson MM, et al. Splenic embolization revisited: a multicenter review. J Trauma 2004;56: 542—7. [11] Gaarder C, Dormagen JB, Eken T, et al. Nonoperative management of splenic injuries: improved results with angioembolization. J Trauma 2006;61:192—8. [12] Frandon J, Rodiere M, Arvieux C, et al. Blunt splenic injury: outcomes of proximal versus distal and combined splenic artery embolization. Diagn Interv Imaging 2014;95: 825—31. [13] Sabe AA, Claridge JA, Rosenblum DI, et al. The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16-year experience. J Trauma 2009;67:565—72 [discussion 562—71]. [14] Ekeh AP, McCarthy MC, Woods RJ, Haley E. Complications arising from splenic embolization after blunt splenic trauma. Am J Surg 2005;189:335—9. [15] 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—74 [discussion 65—74]. [16] Frandon J, Rodière M, Arvieux C, et al. Blunt splenic injury: outcomes of proximal versus distal and combined splenic artery embolization. Diagn Interv Imaging 2014;95(9):825—31, http://dx.doi.org/10.1016/j.diii.2014.03.009. [17] Dent D, Alsabrook G, Erickson BA, et al. Blunt splenic injuries: high nonoperative management rate can be achieved with selective embolization. J Trauma 2004;56: 1063—7.

Please cite this article in press as: Arvieux C. Splenic trauma: Save patients in shock and save the spleen in stable patients! Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.02.012

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Editorial [18] Arvieux C, Thony F, Bouzat P. PHRC national SPLASH — Bénéfice de l’embolisation prophylactique sur le sauvetage splénique chez les patients traumatisés à haut risque de splénectomie; 2012 [No. 12-026-0465]. [19] Bouzat P, Ageron F-X, Brun J, et al. A regional trauma system to optimize the pre-hospital triage of trauma patients. Crit Care 2015 [in press].

3 C. Arvieux Trauma System du Réseau Nord Alpin des Urgences (TRENAU), Université Joseph Fourier, Clinique universitaire de chirurgie digestive et de l’urgence, CHU de Grenoble, BP 217, 38043 Grenoble cedex 9, France E-mail address: [email protected]

Please cite this article in press as: Arvieux C. Splenic trauma: Save patients in shock and save the spleen in stable patients! Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.02.012

Splenic trauma: Save patients in shock and save the spleen in stable patients!

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