Non operative management of isolated traumatic splenic injury

Background: Road traffic accidents, sports injuries, assaults, and falls from height, are among most common causes of blunt splenic trauma. In 1970s, postsplenectomy complications were published by some authors, revealing the high mortality and morbidity related to overwhelming postsplenectomy infection (OPSI). Therefore, conservative management for splenic trauma was accepted as treatment of choice in all the patients to decrease mortality due to OPSI. Therefore, NOM of traumatic splenic injury has now been accepted as standard treatment of choice for all AAST grade I, II and III, whereas this was not found safe in higher grades of splenic trauma. Methods: This is a hospital based prospective observational study, done on 45 hemodynamically stable patients of splenic trauma. Results: Out of all studied parameters grade of injury, contrast blush on CT scan, grade of hemoperitoneum showed statistical significance with p value<0.001, however gender, age, mode of injury, showed no statistical significance. In our study, out of 45 patients, 38 (84.44%) patients had successful NOM of splenic trauma. Conclusions: Non-operative management (NOM) of blunt injury to the spleen in adults has become the standard of care in hemodynamically stable patients. This modality of treatment in paediatric patients is also highly successful and is standard treatment of choice in both adults and children. Success of NOM of isolated splenic injury depends on multiple factors such as availability of ICUs, high dependency units for strict monitoring, blood banks and availability of multidisciplinary team efforts encompassing anesthetics, trauma surgeons, radiologists, for successful outcome.

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Splenic artery embolisation in the non-operative management of blunt splenic trauma in adults

South African Journal of Radiology ◽

10.4102/sajr.v20i1.1014 ◽

2016 ◽

Vol 20 (1) ◽

Author(s):

Richard J. Cormack ◽

Mollie C.M. Ferris ◽

Jason K. Wong ◽

Stefan Przybojewski

Keyword(s):

Blunt Trauma ◽

Vascular Injury ◽

Splenic Artery ◽

Splenic Injury ◽

Operative Management ◽

Trauma Centre ◽

Splenic Trauma ◽

Non Operative Management ◽

Splenic Salvage ◽

Salvage Rate

Background: The purpose of this study was to evaluate the splenic salvage rate with angioembolisation in the non-operative management (NOM) of blunt splenic injury.Methods: We conducted a retrospective analysis of patients presenting to our Level I trauma centre with computed tomography (CT)-confirmed splenic injury following blunt trauma and in whom angioembolisation was utilised in the algorithm of NOM. Data review included CT and angiography findings, embolisation technique and patient outcomes.Results: Between January 2005 and April 2010, 60 patients with splenic injury following blunt trauma underwent NOM, which included splenic artery embolisation (SAE). All patients included in the study required a preadmission. CT scan was used to document the American Association for the Surgery of Trauma (AAST) grade of splenic injury. The average injury grade was 3.0. The non-operative splenic salvage rate following SAE was 96.7% with statistically similar salvage rates achieved for grades II to IV injuries. The quantity of haemoperitoneum and the presence of a splenic vascular injury did not significantly affect the splenic salvage rate. The overall complication rate was 27%, of which 15% were minor and 13% were major.Conclusion: SAE is a safe and effective treatment strategy in the NOM of blunt splenic injury. The quantity of haemoperitoneum, the presence of vascular injury and embolisation technique did not significantly affect the splenic salvage rate.

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Laparoscopic surgery for splenic injuries in the era of non-operative management: current status and future perspectives

Surgery Today ◽

10.1007/s00595-020-02177-2 ◽

2020 ◽

Author(s):

Luigi Romeo ◽

Francesco Bagolini ◽

Silvia Ferro ◽

Matteo Chiozza ◽

Serafino Marino ◽

...

Keyword(s):

Laparoscopic Surgery ◽

Splenic Injury ◽

Nonoperative Management ◽

Current Knowledge ◽

Operative Management ◽

Current Status ◽

Splenic Trauma ◽

Future Perspectives ◽

Encapsulated Bacteria ◽

Non Operative Management

AbstractThe spleen is one of the organs most commonly injured by blunt abdominal trauma. It plays an important role in immune response to infections, especially those sustained by encapsulated bacteria. Nonoperative management (NOM), comprising clinical and radiological observation with or without angioembolization, is the treatment of choice for traumatic splenic injury in patients who are hemodynamically stable. However, this strategy carries a risk of failure, especially for high-grade injuries. No clear predictors of failure have been identified, but minimally invasive surgery for splenic injury is gaining popularity. Laparoscopic surgery has been proposed as an alternative to open surgery for hemodynamically stable patients who require surgery, such as after failed NOM. We reviewed research articles on laparoscopic surgery for hemodynamically stable patients with splenic trauma to explore the current knowledge about this topic. After presenting an overview of the treatments for splenic trauma and the immunological function of the spleen, we try to identify the future indications for laparoscopic surgery in the era of NOM.

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Recent Changes in the Management of Blunt Splenic Injury: Effect on Splenic Trauma Patients and Hospital Implications

Annals of The Royal College of Surgeons of England ◽

10.1308/003588408x242033 ◽

2008 ◽

Vol 90 (2) ◽

pp. 109-112 ◽

Cited By ~ 11

Author(s):

S Sinha ◽

SVV Raja ◽

MH Lewis

Keyword(s):

Blood Transfusion ◽

Hospital Stay ◽

Splenic Injury ◽

Transfusion Requirement ◽

Operative Management ◽

Splenic Trauma ◽

Trauma Patients ◽

Blunt Splenic Injury ◽

Non Operative Management

INTRODUCTION Management of blunt splenic injury has been controversial with an increasing trend towards splenic conservation. A retrospective study was performed to identify the effect of this changed policy on splenic trauma patients and its implications. PATIENTS AND METHODS Data regarding patient demography, mode of splenic injury, CT grading, blood transfusion requirement, operative findings hospital stay and follow-up were collected. Statistical analysis of the data was performed using non-parametric Mann–Whitney tests RESULTS Over an 8-year period, only 21 patients were admitted with blunt splenic injury. Ten patients were managed operatively and 11 non-operatively. Non-operative management failed in one patient due to continued bleeding. Using Buntain's CT grading, the majority of grades I and II splenic injuries were managed non-operatively and grades III and IV were managed operatively (P = 0.008). Blood transfusion requirement was significantly higher among the operative group (P = 0.004) but the non-operative group had a significantly longer hospital stay (P = 0.029). Among those managed non-operatively (median age, 24.5 years), a number of patients were followed up with CT scans with significant radiation exposure and unknown long-term consequences. CONCLUSIONS Non-operative management of blunt splenic trauma in adults can be performed with an acceptable outcome. Although CT is classed as the ‘gold standard’, initial imaging for detection and evaluation of blunt splenic injury, ultrasound can play a major role in follow-up imaging and potentially avoids major radiation exposure.

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Nonoperative Management of Blunt Splenic Trauma in the Elderly: Does Age Play a Role?

The American Surgeon ◽

10.1177/000313480707300610 ◽

2007 ◽

Vol 73 (6) ◽

pp. 585-589 ◽

Cited By ~ 13

Author(s):

Kris Siriratsivawong ◽

Mazen Zenati ◽

Gregory A. Watson ◽

Brian G. Harbrecht

Keyword(s):

Older Patients ◽

Injury Severity ◽

Splenic Injury ◽

Nonoperative Management ◽

Age Groups ◽

Operative Management ◽

Hospital Length Of Stay ◽

P Value ◽

Splenic Trauma ◽

Blunt Splenic Injury

Nonoperative management (NOM) of blunt splenic injury has become more frequent in the past several decades. Criteria that predict successful NOM remain poorly defined, and one factor that has been studied previously has been patient age. Previous studies have defined older patients as those greater than 55 years of age, but no studies have compared younger patients (55–75 years) with older patients (75+ years) within this age group. A total of 1008 patients ≥55 years of age who sustained blunt splenic injury between 1993 and 2001 were analyzed from the Pennsylvania Trauma Systems Foundation database. Statistical analysis was performed using regression analysis. Data was expressed as mean ± SD, and a P value of ≤ 0.05 was considered significant. Patients were classified as operative management (OM; 39.9%) or NOM (60.1%) according to their initial plan of treatment. Of the patients in the NOM group, 75.3 per cent were successfully managed nonoperatively (SNOM), whereas 24.7 per cent eventually required surgery. The Injury Severity Score of the OM group was highest (34) compared with the SNOM group (22) and failed NOM (FNOM; 27) groups. The mean splenic injury grade for OM, SNOM, and FNOM was 3.5, 2.4, and 3.3, respectively. The number of pre-existing conditions did not differ among the three groups. An upward trend in the failure rate of NOM was observed with increasing age (19.0%, 27.1%, and 28.3%, respectively) for three age groups, 55–64, 65–74, and 75+, but this trend was not statistically significant. Mortality rate was highest in the OM group (35.6%) compared with the successful (16.7%) and failed NOM (17.9%). Hospital length of stay (LOS) and intensive care unit (ICU) LOS were highest among patients who failed NOM (mean hospital LOS = 20.7 days, mean ICU LOS = 13.2 days) compared with OM (17.2 and 10.4, respectively) and successful NOM (12.4 and 6.9, respectively). The majority of patients ≥55 years with blunt splenic injuries can be managed nonoperatively when carefully selected. In the subset of patients older than 55 years of age, increasing age is associated with a trend toward higher failure rates. Mortality was high regardless of management, and failure of NOM in older patients is associated with significantly longer hospital and ICU LOS.

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Failure Risk Factor For Non-Operative Treatment of Splenic Trauma

10.21203/rs.3.rs-39924/v1 ◽

2020 ◽

Author(s):

Alexandre Maubert ◽

Jonathan Douissard ◽

Pierre-Alain Tokoto ◽

Damien Massalou

Keyword(s):

Statistical Significance ◽

Operative Management ◽

University Hospital ◽

Splenic Trauma ◽

Level Of Evidence ◽

Failure Group ◽

The Hours ◽

Successful Group ◽

Grade 3 ◽

Non Operative Management

Abstract Background: Splenic trauma is a common pattern for admission in blunt abdominal trauma. The objective of this study is to identify risk factors for failure of non-operative management (NOM) in splenic trauma.Methods: This is a retrospective monocentric analysis of a prospectively collected database. All patients admitted in the university hospital of Nice [Centre Hospitalier Universitaire (CHU) de Nice, France] for a splenic trauma from January 1st 2006 to January 6th 2018 were included. Primary outcome was the need for delayed splenectomy as an indicator of NOM failure.Results: Two-hundred-eighty patients were included in this study. Most splenic lesions were severe grades (grade 3 or higher). In total, 83 splenectomies were performed urgently, i.e. 29% of patients; 88 angio-embolizations, i.e., 31% of patients with a success rate greater than 80%; 14.7% of 136 patients who had no previous angio-embolization required secondary splenectomy; 19.7% of the 61 patients who had anterior angio-embolization required secondary splenectomy. Age was not found associated with a higher failure rate (44 years in successful embolization vs 37.5 years in NOM-failure group, p = 0.15). Higher drop in hemoglobin levels between admission and 6 hours after admission was detected in the embolization failure group (-1.44 g/dl) as compared with the successful group (-0.68 g/dl), which approached statistical significance (p = 0.064).Conclusions: Hemoglobin monitoring in the hours following the admission of a patient with splenic trauma might be an important factor during the medical supervision of hemodynamically stable patients. Early identification of patients at high risk of NOM failure by hemoglobin monitoring may prevent late splenectomy.Level of evidence: IV (retrospective study)

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Splenic trauma, the way forward in reducing splenectomy: our 15-year experience

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2019.0164 ◽

2020 ◽

Vol 102 (4) ◽

pp. 263-270

Author(s):

H Jesani ◽

L Jesani ◽

A Rangaraj ◽

A Rasheed

Keyword(s):

Computed Tomography ◽

Splenic Injury ◽

District General Hospital ◽

Operative Management ◽

Therapeutic Modality ◽

Splenic Trauma ◽

Female Ratio ◽

Non Operative Management ◽

Male To Female ◽

Retrospective Database

Introduction The aim of this study was to study radiological assessment, management and outcome of traumatic splenic injury over 15 years in a UK district general hospital. Method A retrospective database was established including all splenic injury cases from June 2002 to June 2017 by searching the clinical electronic database. We searched the radiological database for computed tomography reported phrases ‘spleen injury’, ‘laceration’, ‘haematoma’, ‘trauma’. We interrogated theatre records for operations coded as splenectomy and cross-referenced this with pathology. Records were reviewed for demographics, vital observations, documentation of American Association for the Surgery of Trauma (AAST) grading of splenic injury, subsequent management and outcomes. Results There were 126 patients identified with traumatic splenic injury, with male to female ratio three to one. Operative management was undertaken in 54/126 (43%) patients and selective non-operative management in the remaining. Splenic artery embolisation was undertaken in 5/126 (4%) and 2/126 underwent splenorrhaphy. Computed tomography was undertaken in 109/126 (87%) patients and AAST grading was reported in 18 (17%) patients. AAST grade reporting did not improve significantly when comparing the first 7.5 years with the latter (2/30, 7%; 16/79, 20%), respectively; p = 0.09). Selective non-operative management increased significantly over the studied period (14/34, 42%; 58/93, 62%; p = 0.04). The overall hospital mortality was 10.3%. Discussion and conclusion AAST grade reporting of splenic injury has remained sub-optimal over 15 years. Despite progression towards selective non-operative management, operative intervention remained unacceptably high, with splenectomy being the main therapeutic modality. Standardisation through an integrated multidisciplinary diagnostic and management pathway offers the optimal strategy to reduce trauma-induced splenectomy.

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HEMODYNAMIC STATUS- PREDICTOR OF OUTCOME IN NON OPERATIVE MANAGEMENT OF ISOLATED TRAUMATIC SPLENIC INJURY

10.36106/gjra/6914610 ◽

2021 ◽

pp. 194-198

Author(s):

Shiwani Thakur ◽

Naseer Ahmad Awan ◽

Shaukat Jeelani ◽

Umer Mushtaq ◽

Ishfaq Gilkar ◽

...

Keyword(s):

Blood Pressure ◽

Ct Scan ◽

Splenic Injury ◽

Surgical Intervention ◽

Successful Outcome ◽

P Value ◽

Blood Transfusions ◽

Splenic Trauma ◽

Unstable Patient ◽

Low Threshold

Background: Blunt abdominal trauma is the most common cause of splenic injury and spleen is the most common organ injured in trauma patients both in children and adults. Abdomino-pelvic ultrasound is very efcient radiological investigation in the diagnosis of splenic injuries; it can detect intraperitoneal hemorrhage, splenic capsular tears, and the vascularity of the spleen. Moreover, computed tomography (CT) scan is investigation of choice in hemodynamically stable.CT also guides the surgeon towards management of injuries, and maintaining the low threshold for surgical intervention in correlation with hemodynamic unstable patient with traumatic splenic injury.CT also guides the surgeon towards management of injuries, and maintaining the low threshold for surgical intervention in correlation with hemodynamic unstable patient with traumatic splenic injury. However, even patients with CT scan nding of “blush on CT”, indicating higher grades of injury, if hemodynamically stable still can be managed successfully with NOM as per literature. Methods: This is a hospital based prospective observational study, done on 45 hemodynamically stable patients of splenic trauma, in Accident and Emergency Department of General Surgery, Government Medical College and hospital Srinagar, over a period of 24 months from September 2018 to September 2020. Results:Haemodynamics Status of patient: Our study showed that various parameters dening haemodynamic status of patient are predictors for outcome of study. Various parameters arePulse rate (P-value 0.001), Systolic blood pressure (P-value <0.001), Diastolic blood pressure (P-value 0.001), Haemoglobin (Pvalue <0.001), Haematocrit (P-value <0.001), and Blood transfusions (P-value <0.001). All parameters showed statistical signicance with P-values <0.001. Conclusion: Success of NOM increases, if patient is hemodynamically stable which is predicted by various parameters like pulse rate, blood pressure, urine output, fall in hemoglobin and hematocrit, number of blood transfusions, saturation, temperature and others. NOM in splenic trauma should be management of choice in all hemodynamically stable patients, regardless of blood group and neurological status of patient on admission.Success of isolated splenic injury depends on multiple factors such as availability of ICUs, high dependency units for strict monitoring,blood banks and availability of multidisciplinary team efforts encompassing anesthetics, trauma surgeons, radiologists, for successful outcome. NOM of isolated splenic trauma, is associated with very low morbidity, no complications, and no mortality, when applied in hemodynamically stable patient. Every patient of splenic trauma who is considered for NOM, should be properly counselled about emergency signs and should be advised to report to emergency if any of emergency signs were present. This group of patients must be closely monitored for delayed bleeding in case of NOM of splenic trauma.

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Predictors of splenectomy after failure of non-operative management: An analysis of the nation trauma database from 2013 to 2014

Trauma ◽

10.1177/1460408620911489 ◽

2020 ◽

pp. 146040862091148

Author(s):

Allan Nguyen ◽

Alessandro Orlando ◽

James R Yon ◽

Caleb J Mentzer ◽

Kaysie Banton ◽

...

Keyword(s):

Splenic Injury ◽

Functional Dependence ◽

Data Bank ◽

Operative Management ◽

The Body ◽

Splenic Trauma ◽

Efficient Resource ◽

Level I ◽

Delay Of Care ◽

Non Operative Management

Introduction There is practice variability in non-operative management (NOM) of blunt splenic trauma. This is particularly true for management decisions following failure of NOM, i.e. splenectomy versus angioembolization (AE). The objective of this study was to identify predictors of splenectomy versus AE in patients who failed NOM. Methods We included adult patients from the National Trauma Data Bank for 2013–2014, who had a splenic injury and who were admitted to a Level I Trauma Center (L1TC). Patients undergoing splenectomy after 2 h of emergency department arrival were deemed to have failed NOM. Multivariate logistic regression modeling was used to identify independent predictors of intervention after failed NOM. Results There were 2284 patients admitted for splenic injury between 2013 and 2014 who failed NOM. A total of 1253 patients underwent AE and 1031 patients underwent splenectomy. Seven independent factors were identified that predicted failure of NOM: penetrating injury, community L1TC, hospital bed size, number of trauma surgeons on call, functional dependence, chronic steroid use, and cirrhosis. Conclusions Seven independent variables were identified that predicted failure of NOM. These results contribute to the body of data regarding management of blunt splenic injury. Knowing predictive factors could help personalize management of patients, minimize delay of care, efficient resource allocation, and inform future studies.

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Splenic Artery Embolization for Patients with High-Grade Splenic Trauma: Indications, Techniques, and Clinical Outcomes

Seminars in Interventional Radiology ◽

10.1055/s-0041-1724010 ◽

2021 ◽

Vol 38 (01) ◽

pp. 105-112

Author(s):

Majd Habash ◽

Darrel Ceballos ◽

Andrew J. Gunn

Keyword(s):

Clinical Outcomes ◽

Splenic Artery ◽

Splenic Injury ◽

Nonoperative Management ◽

Operative Management ◽

Splenic Trauma ◽

Trauma Patients ◽

High Grade ◽

Artery Embolization ◽

Splenic Artery Embolization

AbstractThe spleen is the most commonly injured organ in blunt abdominal trauma. Patients who are hemodynamically unstable due to splenic trauma undergo definitive operative management. Interventional radiology plays an important role in the multidisciplinary management of the hemodynamically stable trauma patient with splenic injury. Hemodynamically stable patients selected for nonoperative management have improved clinical outcomes when splenic artery embolization is utilized. The purpose of this article is to review the indications, technical aspects, and clinical outcomes of splenic artery embolization for patients with high-grade splenic injuries.

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