Q: 43 years old male with a known history of advanced cirrhosis and portal hypertension is admitted to ICU after a Motor Vehicle Accident (MVA). CT scan consists of Grade V spleen laceration. There is a conflict between the two teams regarding operative vs. nonoperative management. The ICU team suggests embolization via Interventional Radiology (non-operative approach), but the surgical team suggests splenectomy. Which approach seems appropriate for this patient? (select one)
A) operative
B) non-operative
Answer: A
Portal hypertension is a relative contraindication to nonoperative management of splenic injury. This is due to the evidence that increased venous pressures may prevent clot formation and control of hemorrhage even after successful splenic embolization.
Patients with advanced cirrhosis and high Model for End-stage Liver Disease (MELD) score usually have high complications after a non-operative approach in splenic injury. Any patient with hemodynamic instability, generalized peritonitis, or for patients with other intra-abdominal injuries usually needs a surgical approach.
Given the highest grade of splenic injury and underlying advanced portal hypertension, this patient has a better chance of survival with splenectomy.
#trauma
#surgical-critical-care
References:
1. Stassen NA, Bhullar I, Cheng JD, et al. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73:S288.
2. Bugaev N, Breeze JL, Daoud V, et al. Management and outcome of patients with blunt splenic injury and preexisting liver cirrhosis. J Trauma Acute Care Surg 2014; 76:1354.
3. Cook MR, Fair KA, Burg J, et al. Cirrhosis increases mortality and splenectomy rates following splenic injury. Am J Surg 2015; 209:841.
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