Bankstown Hospital - Grand Rounds - Further Reading

Liver Cirrhosis and Splenic Lacerations

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Bugaev, N., et al. (2014). "Management and outcome of patients with blunt splenic injury and preexisting liver cirrhosis." Journal of Trauma and Acute Care Surgery 76(6): 1354-1361.

                BACKGROUND The response of liver cirrhosis (LC) patients to abdominal trauma, including blunt splenic injury (BSI) is unfavorable. To better understand the response to BSI in LC patients, the present study reviewed a much larger group of such patients, derived from the National Trauma Data Bank. METHODS The National Trauma Data Bank was queried for 2002 to 2010, and all adult BSI patients without severe brain trauma were identified. LC and non-LC patients were compared using nonoperative management (NOM) failure and mortality as primary outcomes. Predictors of these outcomes in LC patients were identified. RESULTS Of the 77,753 identified BSI patients, 289 (0.37%) had LC. Overall, 90% of the patients underwent initial NOM (86% in LC and 90% in non-LC patients, p = 0.091) with a global 90% success rate. Compared with non-LC patients, LC patients had a lower NOM success rate (83% vs. 90%, p = 0.004) despite increased use of splenic artery angioembolization (13% vs. 8%, p = 0.001). LC patients also had more complications per patient, an increased hospital and intensive care unit lengths of stay, and a higher mortality (22% vs. 6%, p < 0.0001), which was independent of the treatment paradigm. In the LC group, mortality in those who underwent immediate surgery was 35% versus 46% in failed NOM (p = 0.418) and 14% (p = 0.019) in successful NOM patients. LC patients who did not require surgery were more likely to survive than those who had surgery alone (adjusted odds ratio [AOR], 0.30). Preexisting coagulopathy (AOR, 3.28) and Grade 4 to 5 BSI (AOR, 11.6) predicted NOM failure in LC patients, whereas male sex (AOR, 4.34), hypotension (AOR, 3.15), preexisting coagulopathy (AOR, 3.06), and Glasgow Coma Scale (GCS) score of less than 13 (AOR, 6.33) predicted mortality.

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Cook, M. R., et al. (2015). "Cirrhosis increases mortality and splenectomy rates following splenic injury." The American Journal of Surgery 209(5): 841-847.

                Background Cirrhosis may be a risk factor for mortality following blunt splenic injury (BSI) and it predicts the need for an operative intervention. Methods We performed a case–control study at 3 level 1 trauma centers. Comparisons were made with chi-square test, Wilcoxon rank-sum test, and binary logistic regression, and stratified by propensity for splenectomy. Data are presented as odds ratios (ORs) and 95% confidence intervals (95% CIs). Results Mortality was 27% (21/77) and cirrhosis was a strong risk factor for death (OR 8.8, 95% CI 3.7 to 21.1). Compared with controls, cirrhosis was an independent risk factor for splenectomy (OR 5.4, 95% CI 2.5 to 11.5), and only splenic injury grade was associated with splenectomy (OR 2.2, 95% CI 1.3 to 3.6). Only admission model for end-stage liver disease was independently associated with mortality after an operation (OR 1.7, 95% CI 1.1 to 2.8). After propensity score matching, we found no association between splenectomy and mortality in cirrhotic patients. Conclusion Cirrhosis dramatically increases mortality and the odds of an operative intervention in BSI patients with pre-existing cirrhosis, and BSI requires vigilant attention and early intervention should be considered.

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Fang, J.-F., et al. (2003). "Liver Cirrhosis: An Unfavorable Factor for Nonoperative Management of Blunt Splenic Injury." Journal of Trauma and Acute Care Surgery 54(6): 1131-1136.

                Background: Nonoperative management (NOM) of blunt splenic injury (BSI) is currently a well-accepted treatment modality for hemodynamically stable patients. More than 60% of BSI patients can be successfully treated without operation. Old age, high-grade injury, contrast blush, and multiple associated injuries were reported to have a higher failure rate but not to be exclusive of NOM. The purpose of this study was to review the treatment courses and results of a special group of BSI patients with coexistent liver cirrhosis. Factors leading to poor results were analyzed and treatment strategy was proposed accordingly. Methods: During a 5-year period, 487 patients with BSI were treated following a standard protocol. Twelve of them had underlying liver cirrhosis. The medical records, radiographic findings, laboratory data, and operative variables were retrospectively reviewed. Results: Eighty-nine (18%) patients had immediate celiotomy for splenic hemorrhage with unstable hemodynamic status, 59 (12%) had non-spleen-related or nontherapeutic laparotomy, and 339 (70%) patients received NOM initially. Failure of NOM was found in 74 patients (22%). Twelve patients with initial NOM had coexistent liver cirrhosis. The amount of blood transfusion within 72 hours after admission for these 12 patients ranged from 4 to 26 units. Patients with coexistent liver cirrhosis and BSI had a significantly higher NOM failure rate (92% vs. 19%). In NOM failure patients, those with liver cirrhosis had lower Injury Severity Scores, lower splenic injury severity grades, more blood transfusions, and a higher mortality rate. Risk factors for mortality in these patients included a higher Injury Severity Score, a severely elevated prothrombin time (PT), a larger transfusion requirement, and a lower serum albumin level. Conclusion: Liver cirrhosis with subsequent development of portal hypertension, splenomegaly, and coagulopathy makes spontaneous hemostasis of the injured spleen difficult. NOM for BSI patients with coexistent liver cirrhosis carries a high failure and mortality rate. NOM may be successful in only a small group of patients with low-grade singleorgan injury and with a normal or mildly elevated PT. Aggressive correction of coagulopathy should be performed in these patients. High-grade splenic injury, multiple associated injuries, and an elevated PT are indicators for early surgery. The mortality rate is high in patients with a severely prolonged PT irrespective of treatment modalities. FULL ARTICLE AVAILABLE

Fodor, M., et al. (2019). "Non-operative management of blunt hepatic and splenic injury: a time-trend and outcome analysis over a period of 17 years." World Journal of Emergency Surgery 14(1): 29.

                A widespread shift to non-operative management (NOM) for blunt hepatic and splenic injuries has been observed in most centers worldwide. Furthermore, many countries introduced safety measures to systematically reduce severe traffic and leisure sports injuries. This study aims to evaluate the effect of these nationwide implementations on individual patient characteristics and outcomes through a time-trend analysis over 17 years in an Austrian high-volume trauma center.  FULL ARTICLE AVAILABLE

Olthof, D. C., et al. (2013). "Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: A systematic review." Journal of Trauma and Acute Care Surgery 74(2): 546-557.

                BACKGROUND Contradictory findings are reported in the literature concerning prognostic factors for failure of nonoperative management (NOM) in the treatment of adults with blunt splenic injury. The objective of this systematic review was to identify prognostic factors for failure of NOM, with or without angiography and embolization. METHODS MEDLINE, Embase, and the Cochrane Library databases were searched. Prospective or retrospective cohort studies addressing failure of nonoperative treatment, with and/or without angiography and embolization, of blunt abdominal injuries were included. Methodological quality of the studies was assessed. RESULTS A total of 335 titles and abstracts were screened, of which 31 fulfilled the inclusion criteria. No randomized controlled trials were found. Ten articles were qualified as high-quality articles and used for data extraction (best-evidence synthesis). A total of 25 prognostic factors were investigated, of which 14 were statistically significant in one or more studies. Strong evidence exists that age of 40 years or above, Injury Severity Score (ISS) of 25 or greater, and splenic injury grade of 3 or greater are prognostic factors for failure of NOM. Moderate evidence was found for a splenic Abbreviated Injury Scale score of 3 or greater, trauma and ISS of less than 0.80, the presence of an intraparenchymal contrast blush, as well as transfusion of 1 unit of packed red blood cells or more. Limited evidence was found for large hemoperitoneum, lower Revised Trauma Score, lower Glasgow Coma Scale score, lower systolic blood pressure, male sex, the presence of traumatic brain injury, and splenic embolization as protective factor for failure of NOM. CONCLUSION Awareness for failure of NOM is required in patients aged 40 years or older, in patients with an ISS of 25 or higher or those with splenic injury grade 3 or higher. The prognostic factors for failure that we identified should be confirmed in future prospective cohort studies or meta-analyses using individual patient data. LEVEL OF EVIDENCE Systematic review, level III. FULL ARITCLE AVAILABLE