Abstract
There have been enormous advances in our understanding of the role of the spleen in the immunological response. As a consequence, traumatologists now try to preserve splenic function in splenic injuries. Surgical procedures such as partial splenectomy and splenorrhaphy have been employed to achieve splenic salvage. However, one of the crucial things to manage is hemorrhage from the injured spleen. Many patients with blunt splenic injury can be managed nonoperatively if continued bleeding from the injured spleen can be controlled. Transcatheter arterial embolization (TAE) is a less invasive technique to control splenic bleeding. In the past 12 years 3 months, 173 patients with blunt splenic injury have been treated at Kitasato University Hospital. Of these patients, 128 (74.0%) underwent surgery, and 45 (26.0%) were treated nonoperatively, including by TAE. Since April 1986, when we started to actively introduce nonoperative management of splenic injuries, the number of patients treated nonsurgically has increased to 41 out of 94 (43.6%). According to the classification of splenic injuries proposed by the Japanese Association for the Surgery of Trauma, type I included 3 patients, type II 30 patients, type III a 41 patients, type III b 22 patients, type III c 31 patients, type III d 41 patients, and type IV 5 patients. Most of the hemodynamically stable type I and type II patients without associated injuries requiring surgical intervention were managed by observation or underwent possibly unnecessary surgery, such as exploratory laparotomy with manual compression. Thirty-three of the 173 patients with blunt splenic injury underwent abdominal angiography. Twenty-one patients showed extravasation of the contrast material on arteriograms, and all were type III. Subsequently, TAE was performed on 18 of these 21 patients, using particles of gelatin sponge or autogenous clot infused into the splenic artery or a main branch of the splenic artery. TAE was successfully completed in 16 patients. The 2 patients in which TAE was unsuccessful were hemodynamically unstable and required cathecholamine support to maintain blood pressure, and showed marked vascular spasm on arteriograms. No severe complications were observed in the 16 patients who underwent successful TAE. Fourteen of the patients in which TAE was completed were successfully managed without any further surgical intervention for their splenic injuries. We conclude that TAE is a safe and useful technique to manage blunt splenic injuries nonoperatively in hemodynamically stable type III patients with continued hemorrhage, as indicated by extravasation of contrast material on arteriograms.