Abdomen—Interventions for solid organ injury
Introduction
Non-operative management of solid organ injury after blunt abdominal trauma (BAT) is the widely accepted standard of care in patients who are haemodynamically stable. This is particularly true for blunt hepatic and splenic injuries where success rates for non-operative management often exceed 90%.30, 43, 41, 18 There are less established but evolving rates for non-operative management strategies in patients with other solid organ BAT injuries including pancreatic and renal injuries. More controversial indications for non-operative treatment include solid organ injuries in less stable patients and patients with penetrating solid organ injuries.
In this article, current concepts in non-operative management of BAT solid organ injuries will be reviewed. Each abdominal organ will be discussed separately. Diagnosis, patient selection, interventional techniques, results and complications will be discussed. Finally, interventional experience in penetrating solid organ injury will be reviewed. Patients with blunt abdominal trauma with no evidence of solid organ injury have a high incidence of hollow viscus and mesenteric injury54 but the imaging and management of these injuries will not be discussed in this article.
Section snippets
Splenic injury
The spleen is the most common solid organ injured after BAT. Splenic injuries may occur in isolation or in association with other solid organ or hollow viscus injuries. Splenic preserving techniques including partial splenectomy and non-operative techniques have been evaluated to avoid the serious complications of overwhelming post-splenectomy sepsis and impaired immune function.41, 20
Hepatic injury
Hepatic injuries may also occur in isolation or in association with other injuries. While non-operative treatment is widely used in haemodynamically stable patients following hepatic injury, treatment strategies have also evolved in unstable patients. Definitive operative resection and repair have been replaced in selected cases by modern surgical techniques (including debridement and surgical packing) with ancillary endovascular techniques also used in some patients.
Renal injury
The majority of blunt renal injuries are minor and can be managed non-operatively.3 Indications for open surgical repair include haemodynamic instability, injury to the renal vascular pedicle and a major renal pyelocalyceal injury. However, there are increasing applications for non-operative management for high grade renal injuries.13, 21
Pancreatic injury
Blunt traumatic injury to the pancreas is uncommon, accounting for less than 2% of abdominal injuries.7 Most patients with pancreatic injury are polytraumatised with concomitant abdominal injuries, most frequently involving the liver and spleen.6 Hyperamylasaemia may not be marked or delayed. As a result, pancreatic injuries often overlooked with delayed diagnosis leading to significant morbidity. Pancreatic injury usually results from a severe, direct antero-posterior compressive force,
Further applications for intervention
In addition to solid organ injury after blunt abdominal trauma in the haemodynamically stable patient, interventional techniques can be selectively used in other clinical situations. These include intervention after iatrogenic injury, penetrating injury and intervention in the haemodynamically unstable patient.
Conclusion
The paradigm shift from surgery to non-operative management of haemodynamically stable patients after abdominal solid organ injury is well validated. The key components of non-operative management include accurate assessment and staging of injuries with high quality CT. Clinical and imaging findings are now well established that indicate early use of interventional techniques such as angiography and embolisation.
Conflict of interest
None.
Acknowledgments
Thanks to Prof. Richard Mendelson (Figure 5, Figure 6, Figure 9), Dr. Duncan Ramsay (Figure 2, Figure 3, Figure 5) and Dr. Philip Misur (Fig. 6) of Royal Perth Hospital, Perth as well as Dr. Stuart Lyon (Figure 1, Figure 10) of The Alfred Hospital, Melbourne for kindly supplying images for this article.
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