Splenic trauma: WSES classification and guidelines for adult and pediatric patients

Morphological Evaluation of the Splenic Artery, Its Anatomical Variations and Irrigation Territory

BACKGROUND

Precise knowledge of the topographic features of the splenic artery and its branches in the hilum region is of practical interest due to the various interventions on the vessels of the spleen.

MATERIALS AND METHODS

The anatomy of the spleen was studied by means of macroscopic dissection on 330 organ complexes, which were carefully documented and analyzed statistically.

RESULTS

The analysis of the splenic artery trajectory led to identification of four types: straight (43.03%), sinusoidal (27.58%), serpentine (20.91%) and alternating (8.48%). To assess the relation between the trajectory of the splenic artery and its branches we performed a chi square test. Sinuous or serpentine trajectory was associated with the presence of long splenic artery branches (dorsal pancreatic artery or the great pancreatic artery), X2 (2, N = 330) = 12.85, p = 0.001. The artery was located suprapancreatic in 70.30% of cases, anteropancreatic in 4.55%, the vessel had an intrapancreatic course in 14.85% and in 10.00% of cases the artery was located retropancreatic. The presence of inferior polar arteries was associated with a longer pancreas (Spearman's correlation; r = 0.37; p = 0.037). In a multiple regression analysis, inferior polar arteries predicted the length of the pancreas although only a small number of cases could be explained by this model (R2 = 0.127, Adjusted R2 = 0.098; Betta = 0.357; t(330) = 2.091; p = 0.045). There were 30 (9.09%) cases of accessory spleens.

CONCLUSIONS

The arterial supply of the spleen is highly variable in its trajectory, terminal branches, and relation to other organs. The splenic artery tends to be sinuous or serpentine in zones when a large artery branches off (e.g., the dorsal pancreatic or greater pancreatic artery). Multiple short branches tend to stabilize the trajectory of the splenic artery. Inferior polar arteries and accessory spleens contribute to the length of the pancreas, most likely due to increased vascular supply to the tail of the gland.

Variation in the utilization of angioembolization for splenic injury in hospitals: a nationwide cross-sectional study in Japan

Aim

Substantial variations in the utilization of angioembolization have been reported internationally. However, the existence of variations in the utilization of angioembolization in Japan is currently unknown.

Methods

This was a cross-sectional study using data from a nationwide trauma registry in Japan. Of the 4,896 registered adult patients with splenic injury, we investigated 3,319 patients in the top 25% of the hospitals that registered the highest number of splenic injury patients in the Japan Trauma Data Bank. The primary outcome of this study was initial angioembolization. We calculated the expected initial angioembolization rates using multiple regression analysis adjusted for patient factors. In addition, we evaluated the range of observed-to-expected initial splenic angioembolization ratio for each hospital. Moreover, we assessed whether this ratio was increased with time.

Results

The frequency of initial splenic angioembolization ranged from 0% to 52%. The median expected initial angioembolization rate, calculated through multiple logistic regression analysis, was 19.7%. The observed-to-expected initial splenic angioembolization ratio for each hospital ranged from 0 to 2.36. The observed initial angioembolization rate tended to increase with time (P < 0.001).

Conclusions

Despite adjustment for patient factors, substantial variations were observed in the utilization of splenic angioembolization among hospitals in Japan.

Management of blunt splenic injury: down the rabbit hole and into the bucket

Management of splenic trauma has changed dramatically over the past 30 years. Many of these advances were driven by the Memphis team under the leadership of Dr. Timothy Fabian. This review article summarizes some of those changes in clinical care, especially related to nonoperative management and angioembolization.

Splenic artery embolization changes the management of blunt splenic injury: an observational analysis of 680 patients graded by the revised 2018 AAST-OIS

BACKGROUND

This study aimed to evaluate the management of blunt splenic injury (BSI) and highlight the role of splenic artery embolization (SAE).

METHODS

We conducted a retrospective review of all patients with BSI over 15 years. Splenic injuries were graded by the 2018 revision of the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS). Our hospital provide 24/7 in-house surgeries and 24/7 in-house interventional radiology facility. Patients with BSI who arrived hypotensive and were refractory to resuscitation required surgery and patients with vascular injury on abdominal computed tomography were considered for SAE.

RESULTS

In total, 680 patients with BSI, the number of patients who underwent nonoperative management with observation (NOM-obs), SAE, and surgery was 294, 234, and 152, respectively. The number of SAEs increased from 4 (8.3%) in 2001 to 23 (60.5%) in 2015 (p < 0.0001); conversely, the number of surgeries decreased from 21 (43.8%) in 2001 to 4 (10.5%) in 2015 (p = 0.001). The spleen-related mortality rate of NOM-obs, SAEs, and surgery was 0%, 0.4%, and 7.2%, respectively. In the SAE subgroup, according to the 2018 AAST-OIS, 234 patients were classified as grade II, n = 3; III, n = 21; IV, n = 111; and V, n = 99, respectively.; and compared with 1994 AST-OIS, 150 patients received a higher grade and the total number of grade IV and V injuries ranged from 96 (41.0%) to 210 (89.7%) (p < 0.0001). On angiography, 202 patients who demonstrated vascular injury and 187 achieved hemostasis after SAE with a 92.6% success rate. Six of the 15 patients failed to SAE preserved the spleen after second embolization with a 95.5% salvage rate.

CONCLUSIONS

Our data confirm the superiority of the 2018 AAST-OIS and support the role of SAE in changing the trend of management of BSI.

Spleen size greater than 9.76 cm may impact the treatment strategy for blunt splenic injury in adults - A retrospective analysis of experience at a tertiary trauma center in Taiwan

BACKGROUND/OBJECTIVE

The present study investigated the impact of splenomegaly on the treatment outcomes of blunt splenic injury patients.

METHODS

All blunt splenic injury patients were enrolled between 2010 and 2018. The exclusion criteria were age less than 18 years, missing data, and splenectomy performed at another hospital. The patients were divided into two groups based on the presence of splenomegaly, defined as a spleen length over 9.76 cm on axial computed tomography. The primary outcome was the need for hemostatic interventions.

RESULTS

A total of 535 patients were included. Patients with splenomegaly had more high-grade splenic injuries (p = 0.007). Hemostatic treatments (p < 0.001) and transarterial embolization (p = 0.003) were more frequently required for patients with splenomegaly. Multivariate analysis showed that male sex (p = 0.023), more packed red blood cell transfusions (p = 0.001), splenomegaly (p = 0.019) and grade 3-5 splenic injury (p < 0.001) were predictors of hemostatic treatment. The failure rate of transarterial embolization was not significantly different between the two groups (p = 0.180). The sensitivity and specificity for splenomegaly in predicting hemostatic procedures were 48.8% and 66.5%, respectively. The positive and negative predictive values were 62.8% and 52.9%, respectively. The overall mortality rate was 3.7%.

CONCLUSION

Splenomegaly is an independent predictor for the requirement of hemostatic treatments in blunt splenic injury patients, especially transarterial embolization. Transarterial embolization is as effective for blunt splenic injury patients with splenomegaly as it is for those with a normal spleen.

Blunt splenic injury in adults: Association between volumetric quantitative CT parameters and intervention

BACKGROUND.

Several ordinal grading systems are employed in deciding whether to perform angioembolization or splenectomy following blunt splenic injury. The 2018 AAST Organ Injury Scale (OIS) incorporates vascular lesions but not hemoperitoneum, which is considered in the Thompson classifier. Granular and verifiable quantitative measurements of these features may have a future role in facilitating objective decision-making.

PURPOSE.

To compare performance of CT volumetry-based quantitative modeling to the 1994 and 2018 AAST OIS and Thompson classifier for the following endpoints: decision to perform splenectomy (SPY), and the composite of SPY or angioembolization (AE)

MATERIALS AND METHODS.

Adult BSI patients (age ≥ 18 years) scanned with dual-phase CT prior to intervention at a single level I trauma center from 2017-2019 were included in this retrospective study (n=174). Scoring using 2018 AAST, 1994 AAST, and Thompson systems was performed retrospectively by two radiologists and arbitrated by a third. Endpoints included 1. SPY and 2. The composite of SPY or AE. Logistic regression models were developed from segmented active bleed, contained vascular lesion, splenic parenchymal disruption, and hemoperitoneum volumes. AUCs for ordinal systems and volumetric models were compared.

RESULTS.

Forty-seven BSI patients (27%) underwent SPY, and 87 patients (50%) underwent SPY or AE. Quantitative model AUCs (0.85- SPY, 0.82-composite) were not significantly different from 2018 AAST AUCs (0.81, 0.88, p=0.66, 0.14) for both endpoints, and were significantly improved over Thompson scoring (0.76, p=0.02; 0.77, p=0.04).

CONCLUSION:

Quantitative CT volumetry can be used to model intervention for BSI with accuracy comparable to 2018 AAST scoring and significantly higher than Thompson scoring.

Study Type:

Prognostic

Level of Evidence:

IV

CT volumetry of blunt splenic injury-related features predicts splenectomy and angioembolization in adults and identifies clinically important target features for computer vision and automation research.

Timing of venous thromboembolism chemoprophylaxis using objective hemoglobin criteria in blunt solid organ injury

BACKGROUND

The purpose of this study was to evaluate the safety and efficacy of early venous thromboembolism (VTE) chemoprophylaxis following blunt solid organ injury.

METHODS

A retrospective review of patients was performed for patients with blunt solid organ injury between 2009-2019. Enoxaparin was initiated when patients had <1g/dl Hemoglobin decline over a 24 h period. These patients were then categorized by initiation: ≤48 h and >48 h.

RESULTS

There were 653 patients: 328 (50.2%) <48 h and 325 (49.8%) ≥48 h. Twenty-nine (4.4%) developed VTE. Patients in ≥48 h group suffered more frequent VTE events (6.5% vs 2.4%, p = 0.021). Non-operative failure occurred in 6 patients (1.9%) in ≥48 h group, and 5 patients (1.5%) < 48 h group. Blood transfusion following chemophrophylaxis initiation was required in 69 (21.3%) in ≥48 h group, and 46 (14.0%) in < 48 h group, occurring similarly between groups (p=0.021).

CONCLUSION

Stable hemoglobin in the first 24 h is an efficacious, objective measure that allows early initiation of VTE chemoprophylaxis in solid organ injury. This practice is associated with earlier initiation of and fewer VTE events.

European Pediatric Surgeons' Association Survey on the Use of Splenic Embolization in Blunt Splenic Trauma in Children

INTRODUCTION

 This article assesses (1) access to splenic embolization (SE), (2) indications for SE, and (3) post-embolization management in high-grade splenic trauma in children.

MATERIALS AND METHODS

 An online questionnaire was sent in 2021 to all members of European Pediatric Surgeons' Association.

RESULTS

 There were a total of 157 responses (50 countries, 83% academic hospitals). Among them, 68% have access to SE (SE) and 32% do not (nSE). For a hemodynamic stable patient with high-grade isolated splenic trauma without contrast extravasation (CE) on computed tomography (CT) scan, 99% SE and 95% nSE respondents use nonoperative management (NOM). In cases with CE, NOM decreases to 50% (p = 0.01) and 51% (p = 0.007) in SE and nSE centers, respectively. SE respondents report a significant reduction of NOM in stable patients with an associated spine injury requiring urgent surgery in prone position, both without and with CE (90 and 28%, respectively). For these respondents, in stable patients the association of a femur fracture only tends to decrease the NOM, both without and with CE (93 and 39%, respectively). There was no significant difference in NOM in group nSE with associated injuries with or without CE. After proximal SE with preserved spleen vascularization on ultrasound Doppler, 44% respondents prescribe antibiotics and/or immunizations.

CONCLUSION

 Two-thirds of respondents have access to SE. For SE respondents, SE is used even in stable patients when CE showed on initial CT scan and its use increased with the concomitant need for spinal surgery. There is currently a variation in the use of SE and antibiotics/immunizations following SE.

Abdominal pain is a main manifestation of delayed bleeding after splenic injury in patients receiving non-operative management

Delayed bleeding is a major issue in patients with high-grade splenic injuries who receive non-operative management (NOM). While only few studies addressed the clinical manifestations of delayed bleeding in these patients. We reviewed the patients with high-grade splenic injuries presented with delayed bleeding, defined as the need for salvage procedures following NOM. There were 138 patients received NOM in study period. Fourteen of 107 patients in the SAE group and 3 of 31 patients in the non-embolization group had delayed bleeding. Among the 17 delayed bleeding episodes, 6 and 11 patients were salvaged by splenectomy and SAE, respectively. Ten (58.9%, 10/17) patients experienced bleeding episodes in the intensive care unit (ICU), whereas seven (41.1%, 7/17) experienced those in the ward or at home. The clinical manifestations of delayed bleeding were a decline in haemoglobin levels (47.1%, 8/17), hypotension (35.3%, 6/17), tachycardia (47.1%, 8/17), new abdominal pain (29.4%, 5/17), and worsening abdominal pain (17.6%, 3/17). For the bleeding episodes detected in the ICU, a decline in haemoglobin (60%, 6/10) was the main manifestation. New abdominal pain (71.43%, 5/7) was the main presentation when the patients left the ICU. In conclusion, abdominal pain was the main early clinical presentation of delayed bleeding following discharge from the ICU or hospital.

Atraumatic splenic rupture in a patient treated with rivaroxaban: A case report and a narrative review

Atraumatic splenic rupture (ASR) is a rare condition mostly associated with neoplastic, infectious, and inflammatory diseases. ASR associated with drug treatment is even rarer. In this case report, we highlight an unusual complication of the direct oral anticoagulant rivaroxaban. A 64-year-old male patient was admitted to the emergency department with complaints of faintness and diffuse abdominal cramps. The patient had no history of recent trauma. Clinical examination revealed hemodynamic instability with a moderate response to filling and mild abdominal discomfort on palpation. His medical history included chronic hypertension, constipation, and recent atrial flutter ablation. The patient was taking amiodarone, bisoprolol, atorvastatin, and rivaroxaban. Splenic rupture was diagnosed several hours later on contrast-enhanced abdominal computed tomography scan. Massive blood transfusions and emergency laparotomy for splenectomy were performed. Anatomopathological analysis did not reveal any neoplastic, inflammatory, or infectious causes. The patient was successfully discharged from the intensive care unit 3 days later. Clinicians must consider the possibility of ASR as a complication of rivaroxaban in patients with abdominal tenderness and hemodynamic instability. Unfortunately, clinical presentation is not always typical of a ruptured spleen. Delayed diagnosis can be life threatening or fatal. Splenectomy via laparotomy remains the best therapeutic option in cases of splenic rupture in unstable patients on direct oral anticoagulants.

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

BACKGROUND

In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved.

METHODS

Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.

RESULTS

Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I-II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II-III, AAST Grades III-V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries-WSES Class I, AAST Grades I-II) to 3 days (for high-grade splenic injuries-WSES Classes II-III, AAST Grades III-V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48-72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV-V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48-72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications.

CONCLUSION

This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.

Pathological and ATR-FTIR spectral changes of delayed splenic rupture and medical significance

Traumatic delayed splenic rupture often follows by a "latent period" without typical symptoms after injury. During this period, though there are no obvious symptoms, the injury is still present and changing. In this study, we constructed an SD rat model of delayed splenic rupture; evaluated the model by HE staining, Perl's staining, Masson trichrome staining and immunohistochemical staining; observed the pathological changes of spleen tissue in delayed splenic rupture at different times after splenic injury; we found that pathological change of injured tissues were different from non-injured, and has phases-change patterns, it can be roughly divided into three phases: 2-7 d, 10-14 d, and 18-28.We then investigated the relationship between the pathological changes and FTIR spectroscopy by chemometric methods. The main distinction of injured and non-injured tissue was the protein secondary structure of amide I, and the main distinctions of different phases of delayed splenic rupture were protein secondary structures and content of amide I and amide II.A classification model developed by SVM-DA was used to infer three phases (2-7 days, 10-12 days and 14-28 days). According to the most probable class, the accuracy of external validation is 96.7%. The results indicate that FTIR spectroscopy combined with various types of pathological staining has a potential for forensic identification and can provide theoretical support and diagnostic reference on clinical persistent injury.

Importance of the neutrophil‑to‑lymphocyte ratio as a prognostic factor in patients with spleen trauma: A single center experience

Abdominal trauma is a common diagnosis for patients admitted to the emergency room. Evaluation of the severity of such patients can sometimes be difficult due to rapid hemodynamic changes caused by the activation of inflammatory and anti-inflammatory regulatory mechanisms. To evaluate the prognosis of trauma patients, it is crucial to identify these changes and adapt various treatment strategies. Using the records of the Mures County Emergency Clinical Hospital, 126 patients were included in the present study with traumatic splenic injury admitted over 6 years. Blood parameters such as the neutrophil, lymphocyte, and platelet counts, the neutrophil to lymphocyte ratio (NLR), and the platelet to lymphocyte ratio (PLR) were determined, and the association between these and the severity of the traumatic injury [quantified as the injury severity score (ISS)] was calculated. We used linear and multiple regression analyses to identify and quantify the relationships. We found statistically significant associations between the ISS and the NLR (P=0.002), with an AUC of 0.816 and a cut-off value of NLR=6.075 (sensitivity=76.7%, specificity=74.3%), and between the ISS and hemoglobin (P<0.0001), hematocrit (P<0.0001), neutrophil count (P<0.0001), lymphocyte count (P=0.0224), and platelet count (P=0.0163). No association was found between the PLR and the severity of trauma. An elevated NLR at admission in trauma patients had significant predictive power for the severity of trauma. Patients with an NLR greater than the cut-off value of 6.075 were more likely to have suffered serious injuries and undergone deterioration.

Delayed splenic rupture after a minor blunt trauma: A case report and literature review

Delayed Splenic Rupture (DSR) is a rare but well-known manifestation of Blunt Splenic Injury (BSI), which most commonly occurs following a car accident, a fall from a great height, or a direct blow to the left thorax or abdomen. If the history of trauma is remote or unknown, the diagnosis can be difficult or missed, and a high index of suspicion is not warranted. Regardless of the time and mechanism of the inciting event, DSR should be considered in the differential diagnosis of an acute surgical abdomen. We present a case of DSR in an 81-year-old woman caused by a remote minor blunt abdominal trauma four weeks prior to her admission to our emergency department for acute abdominal pain and hemorrhagic shock (ATLS CLASS III). Starting with this case report, we conducted a literature review on the subject in order to raise awareness, knowledge, and understanding of DSR among emergency clinicians.

Non-operative management for abdominal solidorgan injuries: A literature review

The philosophy of abdominal injury management is currently changing from mandatory exploration to selective non-operative management (NOM). The patient with hemodynamic stability and absence of peritonitis should be managed non-operatively. NOM has an overall success rate of 80%-90%. It also can reduce the rate of non-therapeutic abdominal exploration, preserve organ function, and has been defined as the safest choice in experienced centers. However, NOM carries a risk of missed injury such as hollow organ injury, diaphragm injury, and delayed hemorrhage. Adjunct therapies such as angiography with embolization, endoscopic retrograde cholangiopancreatography with stenting, and percutaneous drainage could increase the chances of successful NOM. This article aims to describe the evolution of NOM and define its place in specific abdominal solid organ injury for the practitioner who faces this problem.

Update on Nonoperative Management of the Injured Spleen

Despite significant interest in trauma to the spleen over the past 130 years, splenectomy remained the preferred approach to splenic injures in children till the late 1950s and even later in adults. With recognition of the immunologic importance of the spleen and improvements in diagnostic imaging and angioembolization, there are now four pathways for the child or adult admitted with a possible, likely, or diagnosed injury to the spleen. These include the following: (1) operation with splenectomy; (2) operation with splenorrhaphy or partial splenectomy; (3) nonoperative management (observation); and (4) nonoperative management with splenic arteriography and possible angioembolization. This review will focus on the latter two options.

Splenic artery embolization improves outcomes and decreases the length of stay in hemodynamically stable blunt splenic injuries - A level 1 Australian Trauma centre experience

BACKGROUND

Splenic injuries are the most common visceral injury following blunt abdominal trauma. Increasingly, non-operative management (NOM) and the use of adjunctive splenic angioembolization (ASE) is favoured over operative management (OM) for the hemodynamically stable patient. However, clinical predictors for successful NOM, particularly the role of ASE as an adjunct, remain poorly defined. This study aims to evaluate the outcomes of patients undergoing ASE vs NOM.

METHODS

A retrospective clinical audit was performed of all patients admitted with blunt splenic injury (BSI) from January 2005 to January 2018 at the Royal Adelaide Hospital. The primary outcome was ASE or NOM failure rate. Secondary outcomes were grade of splenic injury, Injury Severity Score (ISS), length of hospital stay (LOS), and delayed OM or re-angioembolization rates.

RESULTS

Of 208 patients with BSI, 60 (29%) underwent OM, 54 (26%) ASE, and 94 (45%) NOM only. Patients were predominantly male 165 (79%), with a median age of 33 (IQR 24-51) years. The median ISS was 29 (20-38). There was no difference in the overall success rates for each modality of primary management (48 (89%) ASE vs 77 (82%) NOM, p = 0.374), though patients managed with ASE were older (38 vs 30 years, p = 0.029), had higher grade of splenic injury (grade ≥ IV 42 (78%) vs 8 (8.5%), p<0.001), with increased rates of haemo-peritoneum (46 (85%) vs 51 (54%), p<0.001) and contrast blush (42 (78%) vs 2 (2%), p<0.001). However, for grade III splenic injury, patients managed with ASE had a trend towards better outcome with no failures when compared to the NOM group (0 (0%) vs 8 (35%), p = 0.070) with a significant reduction in LOS (7.2 vs 10.8 days, p = 0.042). Furthermore, the ASE group overall had a significantly shorter LOS compared to the NOM group (10.0 vs 16.0 days, p<0.001).

CONCLUSION

ASE as an adjunct to NOM significantly reduces the length of stay in BSI patients and is most successful in managing AAST grade III injuries.

Complications Following Splenic Embolization for Trauma: Have Things Changed Over Time?

INTRODUCTION

Splenic artery embolization (SAE) is a routinely used adjunct in the nonoperative management (NOM) of blunt splenic injury (BSI). The purpose of this study was to evaluate the rate and type of adverse events that occur in patients undergoing SAE and to compare this with the previous data.

METHODS

Patients who had SAE for BSI between 2011 and 2018 were identified. Splenic abscess, splenic infarction, and contrast-induced renal insufficiency were considered major complications. Coil migration, fever, and pleural effusions were regarded minor complications. The results were compared with data from a prior study examining similar indices at the same trauma center between 2000 and 2010.

RESULTS

There were 716 patients admitted with BSI. SAE was performed in 74 (13.3%) of the 557 (78%) NOM patients. The overall complication rate was 33.8%. Major complications occurred in 11 patients (14.9%) and minor in 13 patients (18.9%). There was no association between complications and coil location by logistic regression.

CONCLUSIONS

SAE continues to be a useful adjunct in the NOM of BSI though complications continue to occur. Fewer minor complications were noted in the period studied compared to past similar studies.

Non-operative management in blunt splenic trauma: A ten-years-experience at a Level 1 Trauma Center

Trauma; Spleen injuries are among the most frequent trauma-related injuries. The approach for diagnosis and management of Blunt Splenic Injury (BSI) has been considerably shifted towards Non- Operative Management (NOM) in the last few decades. NOM of blunt splenic injuries includes Splenic Angio-Embolization (SAE). Aim of this study was to analyze Pisa Level 1 trauma center (Italy) last 10-years-experience in the management of Blunt Splenic Trauma (BST), and more specifically to evaluate NOM rate and failure. Retrospective analysis of all patients admitted with blunt splenic trauma was done. They were divided into two groups according to the treatment: hemodynamically unstable patients treated operatively (OM group) and patients underwent a nonoperative management (NOM group). The CT scan performed in all NOM group patients. Univariate analysis was performed to identify differences between the two groups. Multivariate analysis adjusting for factors with a p value < 0.05 or with clinical relevance was used to identify possible risk factors for NOM failure. 193 consecutive patients with blunt splenic trauma were admitted. Emergency splenectomies were performed in 53 patients (OM group); 140 were managed non-operatively with or without SAE (NOM group). NOM rate in high grade injuries is 57%. Overall NOM failure rate is 9%, and success rate in high grade splenic injuries is 48%; multivariate analysis showed AAST score ≥3 as a risk factor for NOM failure. Non-operative management currently represents the gold standard management for hemodynamically stable patient with blunt splenic trauma even in high grade splenic injuries. AAST ≥3 spleen lesion is a failure risk factor but not a contraindication to for non-operative management.

Venous Thromboembolism Following Major Abdominal Surgery for Cancer: A Guide for the Surgical Intern

BACKGROUND

Venous thromboembolism (VTE) is a term used to compositely describe deep vein thrombosis (DVT) and pulmonary embolism (PE). Overall, the incidence of VTE after major abdominal and pelvic surgery has been reported to be between 10% and 40%.

OBJECTIVE

To estimate the incidence of post-operative VTE in patients undergoing major abdominal surgery for cancer, to identify risk factors associated with VTE, and to assess available thromboprophylaxis tools.

METHODS

A Medline and Cochrane literature search from database inception until February 1st, 2021 was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.

RESULTS

Thirty-one studies met our eligibility criteria and were included in the current review. In total, 435,492 patients were identified and the overall incidence of VTE was 2.19%( 95% CI: 1.82-2.38). Τhe following risk factors were associated with VTE: smoking, advanced age (>70 years), a history of diabetes mellitus, American Society of Anesthesiologists' (ASA) classification of Physical Health class III or IV, a history of cardiovascular or pulmonary disease, a history of DVT or PE, elevated plasma fibrinogen level, c-reactive protein (CRP) level, cancer stage III or IV, postoperative acute respiratory distress syndrome (ARDS), prolonged postoperative hospital stay, previous steroid use, history of Inflammatory Bowel Disease (IBD), heart failure and neoadjuvant and adjuvant chemotherapy.

CONCLUSION

VTE remains an important complication after major abdominal surgery for cancer and seems to increase mortality rates.

A thrombopoietin receptor agonist to rescue an unusual platelet transfusion-induced reaction in a p.V1316M-associated von Willebrand disease type 2B patient

This report describes the first case of splenic injury in a patient with p.V1316M-associated von Willebrand disease type 2B (VWD2B) with chronic thrombocytopenia, successfully treated with nonoperative management including von Willebrand factor (VWF) replacement therapy, and platelet transfusions relayed by a thrombopoietin receptor agonist (TPO-RA, Eltrombopag). Eltrombopag was initially introduced to rescue an unusual post-platelet-transfusion reaction exacerbating the thrombocytopenia. In-depth analysis of the dramatic platelet count drop and VWF measurements timeline ruled out an allo-immune reaction and supported an alternative hypothesis of a sudden platelet clearance as a consequence of stress-induced release of abnormal VWF. One year later, a second life-threatening bleeding episode required urgent surgery successfully managed with VWF replacement therapy and platelet transfusions. Eltrombopag was further introduced in the post-surgery period to allow bleeding-free and platelet-transfusion-free successful recovery. Treatment decisions are particularly challenging in patients with VWD2B, and this case highlights how such decisions can benefit from understanding the molecular origin of platelet count fluctuations observed in these patients. Here, we successfully used a new therapeutic approach combining VWF-replacement therapy and initial platelet-transfusion relayed by TPO-RA to optimize patient management.

Interventional radiology and open surgery: An effective partnership for solid organ trauma

BACKGROUND

Management algorithms of paediatric blunt abdominal solid organ injury (BASOI) are evolving to include interventional radiology, but there are few studies documenting the application and clinical outcomes of cases in children.

METHODS

A retrospective case note review of all paediatric BASOI at a single Paediatric Major Trauma Centre was completed. CT scans and injuries have been retrospectively graded according to AAST guidelines.

RESULTS

In the period February 2012 - October 2019, there were 106 children (median age 10.6 years (range 10 days - 16 years)) with BASOI. Of these, 71% (n = 75) suffered liver injuries, 29% (n = 31) spleen, and 27% (n = 29) renal. 95 children (89.6%) were treated with non-operative management, of which 15% (n = 14) went on to require secondary operative management (surgery, n = 1 & interventional radiology, n = 14). There were no deaths or loss of organ in the group which required secondary operative management, regardless of the grade of injury.

CONCLUSION

The majority of BASOI can be successfully treated conservatively, but IR is a useful additional tool in management for all grades of injury and is complementary to open surgery.

LEVEL OF EVIDENCE

Level IV Case Series.

Vascular plugs are associated with reduced fluoroscopy times compared to endovascular coils in proximal splenic artery embolization in trauma

Purpose:

Proximal splenic artery embolization plays an important role in the treatment of hemodynamically stable blunt splenic trauma patients with medium- to high-grade injuries. Proximal splenic artery embolization is most often performed utilizing endovascular coils or vascular plugs. The objective of this study was to compare technical and clinical outcomes of proximal splenic artery embolization using either endovascular coils or vascular plugs in patients with traumatic splenic injuries.

Materials and methods:

A single-institution retrospective review of all proximal splenic artery embolizations for trauma over a 5-year period was performed. Patients who underwent embolization using both endovascular coils and vascular plugs were excluded. Baseline characteristics, including patient age, sex, and grade of splenic injury, were recorded. Complication rates, rates of splenic salvage, and total fluoroscopy time were recorded and compared.

Results:

A total of 26 patients were included in the analysis (17 males, 9 females, median age: 50 years). Of these, 15 patients were treated with vascular plugs (57.7%), while 11 patients (42.3%) were treated with endovascular coils. Mean grade of injury was 3.5 and 4.1 in the vascular plug and endovascular coils groups, respectively. There were no differences between the groups regarding these baseline characteristics. Splenic salvage was 100% in both groups. No major complications were identified in either group. Mean fluoroscopy time was significantly lower in the vascular plug group (14.5 versus 34.0 min; p < 0.0001).

Conclusion:

Proximal splenic artery embolization for splenic trauma can be satisfactorily achieved with either vascular plugs or endovascular coils with no differences in splenic salvage or complication rates in this retrospective study. However, embolization utilizing vascular plugs had significantly reduced fluoroscopy times.

Splenic injuries in native Africans: Presentation, limitations of management, and treatment outcomes in a civilian trauma service in Southeast Nigeria

Background

Splenic trauma has emerged as a major global health burden, especially in developing nations with limited diagnostic and therapeutic facilities. The current trend toward nonoperative management (NOM) and adoption of splenic salvage whenever feasible calls for local evaluation of our current practice. The aim of this study was to document the epidemiology and outcomes of management of splenic injuries in our setting.

Patients and Methods

This was a multicenter, prospective study of epidemiology and outcomes of patients with splenic injuries recruited over 10 years in southeast Nigeria.

Results

Approximately 66% of all patients with abdominal injuries sustained splenic trauma. A total of 313 patients with splenic trauma were recruited; 226 (72.2%) were managed operatively (OM) and 87 (27.8%) conservatively (NOM). Majority (75.7%) had blunt abdominal trauma (BAT), while 24.3% sustained penetrating injuries. Sonographic grading showed that 46 (14.7%), 58 (18.5%), 79 (25.2%), 106 (33.9%), and 24 (7.7%) patients had grades I, II, III, IV, and V injuries, respectively. Isolated splenic injuries occurred in 172 (55%) patients, and the rest (141, 45%) had associated intra-abdominal injuries. Two-thirds (67.1%) were aged 16-45 years. In the OM group, 178 (78.7%) had total splenectomy, while 48 (21.3%) had splenic salvage. There was a statistically significant difference (P = 0.022) in the rate of postoperative complications between the splenectomy and splenorrhaphy groups. The overall mortality rate was 4.5%. Major predictors of morbidity and mortality were high-grade splenic injuries, total splenectomy, multiple injuries, advanced age, and comorbidities.

Conclusion

Splenic injuries complicate approximately two-thirds of all abdominal injuries in our environment and majority of these injuries were due to BAT. In this study, majority had OM and splenic salvage rate was relatively low.

Factors associated with prolonged procedure time of embolization for trauma patients

Aim

Limited information exists on the factors associated with prolonged procedural time in embolization for trauma patients. We clarified the clinical application of embolization in trauma patients and factors associated with a prolonged procedure time.

Methods

Medical records of 162 trauma patients who underwent embolization between January 2007 and December 2020 at a regional trauma care center were reviewed retrospectively. Patients were divided into four embolized body regions: chest, abdomen, pelvis, and other. Patient demographics, trauma mechanism, physiology, trauma severity, embolization procedures, and 30‐day mortality were examined. The outcomes were identifying an embolized body region, embolized arteries, and procedure time. Multiple regression model was created to investigate the factors associated with prolonged procedural time in embolization.

Results

Embolization was mainly undertaken in pelvic fractures (n = 96, 59%) and abdominal organ injuries (n = 57, 35%) and extended to the chest (n = 17, 10%), and other (n = 20, 12%). Approximately 13% (n = 21) of patients underwent embolization in two or more regions. Embolization was more strictly performed in minor artery injuries, for example, external iliac (n = 15, 16%) and lumbar artery (n = 22, 23%) branches in pelvic fractures, and inferior phrenic artery (n = 2, 3.5%) branches in liver injuries. Multiple regression model indicated that the number of embolized arteries (P = 0.021) and number of embolized regions (P < 0.001) were associated with prolonged procedural time in embolization.

Conclusions

Embolization for trauma patients extended to various trauma regions. In time‐sensitive embolization, emergency interventional radiologists showed superior knowledge of expected embolizing arteries and factors associated with procedure time.

Retrospective review of intervention for traumatic blunt spleen injuries in adolescents by trauma center type

BACKGROUND

Management guidelines for pediatric blunt spleen injuries (BSI) include adolescent patients but few studies have compared current management of adolescents with respect to other age groups by center type.

METHODS

A retrospective review of 2017-2018 National Trauma Quality Improvement (TQIP) data of children (6-12), adolescents (13-17) and young adults (18-24) with BSI presenting to an adult, pediatric only, or adult/pediatric trauma center, comparing the rate of splenic intervention for adolescents by trauma center was performed.

RESULTS

Children had lower odds of spleen intervention than adolescents at both adult (OR 0.61 95%CI 0.39, 0.95) and adult/pediatric (OR 0.55 95%CI 0.35, 0.87) centers but did not differ at pediatric centers (OR 0.94 95%CI 0.39, 2.2) (n = 10,494). Adolescents adjusted odds of intervention was equal to adults at adult trauma centers (OR 1.2 95%CI 0.95, 1.4).

CONCLUSION

Adolescents are more likely to undergo interventions for BSI as compared to children at both adult and adult/pediatric trauma centers.

A case report of atraumatic splenic rupture after coronary stenting and dual antiplatelet therapy: Causality or relationship?

INTRODUCTION AND IMPORTANCE

Atraumatic splenic rupture(ASR) is a rare event with challenging management, due to absence of clinical history of trauma and delayed diagnosis. Current clinical report could provide detailed information regarding clinical presentation and management to physicians.

CASE PRESENTATION

A 61 years-old woman underwent percutaneous coronary intervention(PTCA) after ST elevation myocardial infarction(STEMI). In the first day after PTCA epigastric abdominal disconfort was reported, and new PTCA excluded early complication. During hospitalization, due to anemization and hypotension CT scan was performed which revealed ASR with large hemoperitoneum. Emergency surgical splenectomy was performed. Postoperative course was uneventful and patient started 90 mg Ticageclor twice daily in the first post-operative day(POD) plus low molecular weight Heparin and restarted dual antiplatelet therapy(DAPT) the seventh POD. During follow up, patient underwent to assessment of platelet function showing normal level of DAPT inhibition. Due to the lack of pathological aggregation activity, DAPT was maintained.

CLINICAL DISCUSSION

ASR is mainly linked to oncological, malformative, inflammatory and thromboembolic conditions. Despite anticoagulant and anti-aggregating drug-related ASR has been already described, we report the first case of drug-related ASR as immediate complication of PTCA due to DAPT. After surgery, careful anti-aggregating management was required to balance in stent restenosis and hemorragic risk. Assessment of platelet activity was performed to design a tailored anti-aggregating therapy.

CONCLUSION

Drug-related ASR is dangerous complication due to the high mortality rate and misleading symptoms. After major bleeding events, such as drug-related ASR, evaluation of platelet function could provide a tailored DAPT.

School Nurses on the Front Lines of Healthcare: Emergencies Associated With Sport and Physical Activities (Part 2): Sudden Cardiac Arrest, Hypovolemic Shock, and Spinal Cord Injury

Sport participation is an important part of the development, both physically and mentally, of children and adolescents in the United States. Illness and injury associated with sport and physical activities may occur in the school setting. Although most sport-related illness and injury in students are considered minor emergencies, life-threatening illnesses or injuries may occur. It is important for the school nurse to recognize potential life-threatening emergencies associated with sport and physical activity, to initiate stabilization of the student with life-threatening symptoms, and to triage these students to an appropriate level of care (back to the classroom, home with their guardian with follow up at their primary healthcare provider's office, or directly to the closest emergency department via Emergency Medical Services). This article specifically describes the initial assessment and management of three potentially life-threatening conditions associated with sport and physical activity, namely sudden cardiac arrest, hypovolemic shock, and spinal cord injury.

Near Disappearance of Splenorrhaphy as an Operative Strategy for Splenic Preservation After Trauma

BACKGROUND

Splenorrhaphy was once used to achieve splenic preservation in up to 40% of splenic injuries. With increasing use of nonoperative management and angioembolization, operative therapy is less common and splenic injuries treated operatively are usually high grade. Patients are often unstable, making splenic salvage unwise. Modern surgeons may no longer possess the knowledge to perform splenorrhaphy.

METHODS

The records of adult trauma patients with splenic injuries from September 2014 to November 2018 at an urban level I trauma center were reviewed retrospectively. Data including American Association for the Surgery of Trauma splenic organ injury scale, type of intervention, splenorrhaphy technique, and need for delayed splenectomy were collected. This contemporary cohort (CC) was compared to a historical cohort (HC) of splenic injuries at a single center from 1980 to 1989 (Ann Surg 1990; 211: 369).

RESULTS

From 2014 to 2018, 717 adult patients had splenic injuries. Initial management included 157 (21.9%) emergent splenectomy, 158 (22.0%) angiogram ± embolization, 371 (51.7%) observation, and only 10 (1.4%) splenorrhaphy. The HC included a total of 553 splenic injuries, of which 313 (56.6%) underwent splenectomy, while splenorrhaphy was performed in 240 (43.4%). Those who underwent splenorrhaphy in each cohort (CC vs HC) were compared.

CONCLUSION

The success rate of splenorrhaphy has not changed. However, splenorrhaphy now involves only electrocautery with topical hemostatic agents and is used primarily in low-grade injuries. Suture repair and partial splenectomy seem to be "lost arts" in modern trauma care.

Management of Splenic Trauma in Contemporary Clinical Practice: A National Trauma Data Bank Study

BACKGROUND

To evaluate the utilization and efficacy of various treatments for management of adult patients with splenic trauma, highlighting the evolving role of splenic artery embolization.

MATERIALS AND METHODS

The National Trauma Data Bank (NTDB) was queried for patients who sustained splenic trauma between 2007 and 2015, excluding those with death on arrival and selected nonsplenic high-grade injuries. Patients were categorized into (1) nonoperative management (NOM), (2) embolization, (3) splenectomy, (4) splenic repair, and (5) combined treatment groups. Evaluated outcomes included hospital length of stay (LOS), intensive care unit LOS, mortality, and NOM and embolization failures.

RESULTS

Overall, 117,743 patients with splenic predominant trauma were included in this study. Over the 9-year study period, 85,793 (72.9%) were treated with NOM, 21,999 (18.9%) with splenectomy, 3895 (3.3%) with embolization, and 2131 (1.8%) with splenic repair. From 2007 to 2015, mortality rates declined from 7.6% to 4.7%. The rate of NOM did not significantly change over time, while embolization increased 369% (1.3%-4.8%). Failure of NOM was 4.4% in 2007 and decreased to 3.4% in 2015. Across all injury grades, NOM had the shortest LOS (8.3 days), followed by splenic repair (12.3), embolization (12.6), and splenectomy (13.8) (p < 0.001). When adjusted for various clinical factors including severity of splenic injury, mortality rates were 7.1% for splenectomy, 3.2% for embolization, and 2.5% for NOM.

CONCLUSION

Most patients with splenic-dominant blunt trauma are managed with NOM. Over time, the use of embolization has increased while open surgery has declined, and mortality has improved for all treatment methods. Compared to splenectomy, embolization is associated with shorter hospital LOS but is still used relatively infrequently.

Non-Operative Management of Delayed Splenic Rupture 4 Months Following Blunt Abdominal Trauma

BACKGROUND Delayed splenic rupture is a rare complication of non-operative management of a primary splenic trauma which, without proper clinical vigilance, may result in life-threatening events. It usually occurs 4-8 days after injury and, in most cases, surgery is the treatment of choice. Since non-operative management of splenic trauma, which allows splenic salvage, has become increasingly popular, the same approach could also be applied in delayed splenic rupture. We herein present a case of delayed splenic rupture that occurred 4 months after the trauma and was successfully managed non-operatively. CASE REPORT A 32-year-old woman presented with diffuse abdominal pain, chest pain, and dyspnea 4 months after sustaining minor thoracoabdominal blunt trauma due to a car accident. That event was inadequately investigated and was not admitted for further monitoring. Computerized tomography revealed a rupture of a splenic hematoma in the context of the previous splenic trauma. She was closely monitored and remained hemodynamically stable. She was discharged and followed up, with no reported relapse of her clinical condition. CONCLUSIONS Delayed splenic rupture occurring 4 months after the primary splenic trauma is extremely rare. Due to its prolonged delay, delayed rupture of the spleen can easily be overlooked and not be included in the original differential diagnosis. Negligence of this event can result in dreaded complications with hemodynamic instability or even death. Furthermore, its higher mortality rate compared to primary splenic rupture highlights the importance of proper clinical vigilance. Non-operative management should be attempted in hemodynamically stable patients.

Effect of Prophylactic Embolization on Patients With Blunt Trauma at High Risk of Splenectomy: A Randomized Clinical Trial

Importance

Splenic arterial embolization (SAE) improves the rate of spleen rescue, yet the advantage of prophylactic SAE (pSAE) compared with surveillance and then embolization only if necessary (SURV) for patients at high risk of spleen rupture remains controversial.

Objective

To determine whether the 1-month spleen salvage rate is better after pSAE or SURV.

Design, Setting, and Participants

In this randomized clinical trial conducted between February 6, 2014, and September 1, 2017, at 16 institutions in France, 133 patients with splenic trauma at high risk of rupture were randomized to undergo pSAE or SURV. All analyses were performed on a per-protocol basis, as well as an intention-to-treat analysis for specific events.

Interventions

Prophylactic SAE, preferably using an arterial approach via the femoral artery, or SURV.

Main Outcomes and Measures

The primary end point was an intact spleen or a spleen with at least 50% vascularized parenchyma detected on an arterial computed tomography scan at 1 month after trauma, assessed by senior radiologists masked to the treatment group. Secondary end points included splenectomy and pseudoaneurysm, secondary SAE after inclusion, complications, length of hospital stay, quality-of-life score, and length of time off work or studies during the 6-month follow-up.

Results

A total of 140 patients were randomized, and 133 (105 men [78.9%]; median age, 30 years [interquartile range, 23-47 years]) were retained in the study. For the primary end point, data from 117 patients (57 who underwent pSAE and 60 who underwent SURV) could be analyzed. The number of patients with at least a 50% viable spleen detected on a computed tomography scan at month 1 was not significantly different between the pSAE and SURV groups (56 of 57 [98.2%] vs 56 of 60 [93.3%]; difference, 4.9%; 95% CI, -2.4% to 12.1%; P = .37). By the day 5 visit, there were significantly fewer splenic pseudoaneurysms among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 8 of 65 [12.3%]; difference, -10.8%; 95% CI, -19.3% to -2.1%; P = .03), significantly fewer secondary embolizations among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 19 of 65 [29.2%]; difference, -27.7%; 95% CI, -41.0% to -15.9%; P < .001), and no difference in the overall complication rate between the pSAE and SURV groups (19 of 65 [29.2%] vs 27 of 65 [41.5%]; difference, -12.3%; 95% CI, -28.3% to 4.4%; P = .14). Between the day 5 and month 1 visits, the overall complication rate was not significantly different between the pSAE and SURV groups (11 of 59 [18.6%] vs 12 of 63 [19.0%]; difference, -0.4%; 95% CI, -14.4% to 13.6%; P = .96). The median length of hospitalization was significantly shorter for patients in the pSAE group than for those in the SURV group (9 days [interquartile range, 6-14 days] vs 13 days [interquartile range, 9-17 days]; P = .002).

Conclusions and Relevance

Among patients with splenic trauma at high risk of rupture, the 1-month spleen salvage rate was not statistically different between patients undergoing pSAE compared with those receiving SURV. In view of the high proportion of patients in the SURV group needing SAE, both strategies appear defendable.

Trial Registration

ClinicalTrials.gov Identifier: NCT02021396.

Splenic embolization in trauma: results of a survey from an international cohort

PURPOSE

A questionnaire regarding splenic embolization in trauma was submitted to an international sample of IR faculty members, to compare their practice to the available recommendations.

METHODS

A 21 multiple-choice questionnaire was sent to an international cohort of 96 IR faculty. Questions included the initial patient evaluation, embolization materials and techniques, post-procedure management, availability of an institutional protocol, and use of guidelines.

RESULTS

For each question, there were from a minimum of 45 to a maximum of 52 responders: 94% require a CT with contrast prior to embolization, and 87% use the American Association for the Surgery of Trauma (AAST) scale to grade the splenic injuries. Embolization is performed across all values of the AAST scale. Of the patients with injuries of grade III or greater, embolization is primarily done for those patients who are hemodynamically stable. Unstable patients are embolized less frequently and primarily in cases in which the injuries are of a lower grade. Coils are the preferred material for proximal embolization (69%). Particles/Gelfoam is the preferred material for distal embolization (38%). In total, 63% administer intravenous antibiotics before the procedure and 15% administer intra-arterial antibiotics during the procedure. After embolization, follow-up imaging is recommended by 87%, antibiotics are administered regularly by 33%, clinical follow-up is recommended by 73%, and vaccination against encapsulated organisms is routinely recommended by 39%.

CONCLUSIONS

There is significant variability among a heterogeneous cohort of respondents. Available recommendations may not be sufficiently addressing the practice of splenic embolization.

Embolization versus Surgery for Stabilized Patients with Solid Organ Injury

PURPOSE

To compare embolization with laparotomy for the management of hemodynamically unstable patients with solid organ injury who responded to initial resuscitation.

MATERIALS AND METHODS

Data from a Japanese nationwide trauma registry were analyzed. Included were hemodynamically unstable patients (systolic blood pressure <90 mm Hg and blood transfusion within the first 24 hours) whose initial computed tomography assessment confirmed the presence of solid organ injuries (liver and/or spleen). A total of 224 patients were included (median age: 53 years, interquartile range: 32-69; 73.3% male; liver injury = 131 [58%] and spleen injury = 98 [44%]; median organ injury scale: 3, interquartile range: 3-4; median injury severity score: 19, interquartile range: 16-25). Patients who underwent embolization were compared with those who underwent laparotomy. The primary outcome was in-hospital survival. The data were evaluated using a propensity score matching analysis.

RESULTS

Laparotomy and embolization were performed in 133 (59.1%) and 91 (40.4%) patients, respectively. Of those, 111 (84%) and 84 (92%) patients achieved in-hospital survival after laparotomy and embolization, respectively. No significant difference in in-hospital survival (P = .053) was noted. The propensity score matching model did not reveal a significant difference in in-hospital survival (P = .276).

CONCLUSIONS

No significant difference was observed between embolization and laparotomy in terms of in-hospital survival among unstable patients who responded to initial resuscitation with solid organ injury.

Managing Massive Splenic Hematoma: Exploratory Laparotomy or Active Surveillance?

Splenic hematoma is a known complication of blunt force abdominal trauma. Traditional management of splenic hematomas has been primarily surgical. However, more recently, spleen-sparing management has been favored over surgical management for cases that meet certain criteria, with surgery now reserved for patients with complications. In this report, we present a case of a massive splenic hematoma that was managed conservatively and analyze the challenges faced in clinical decision making.

Damage control surgery for splenic trauma: "preserve an organ - preserve a life"

The spleen is one of the most commonly injured solid organs of the abdominal cavity and an early diagnosis can reduce the associated mortality. Over the past couple of decades, management of splenic injuries has evolved to a prefered non-operative approach even in severely injured cases. However, the optimal surgical management of splenic trauma in severely injured patients remains controversial. This article aims to present an algorithm for the management of splenic trauma in severely injured patients, that includes basic principles of damage control surgery and is based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. The choice between a conservative or a surgical approach depends on the hemodynamic status of the patient. In hemodynamically stable patients, a computed tomography angiogram should be performed to determine if non-operative management is feasible and if angioembolization is required. While hemodynamically unstable patients should be transferred immediately to the operating room for damage control surgery, which includes splenic packing and placement of a negative pressure dressing, followed by angiography with embolization of any ongoing arterial bleeding. It is our recommendation that both damage control principles and emerging endovascular technologies should be applied to achieve splenic salvage when possible. However, if surgical bleeding persists a splenectomy may be required as a definitive lifesaving maneuver.

Non-operative management of blunt splenic trauma: evolution, results and controversies

The spleen is one of the most frequently affected organs in blunt abdominal trauma. Since Upadhyaya, the treatment of splenic trauma has undergone important changes. Currently, the consensus is that every splenic trauma presenting with hemodynamic stability should be initially treated nonoperatively, provided that the hospital has adequate structure and the patient does not present other conditions that indicate abdominal exploration. However, several topics regarding the nonoperative management (NOM) of splenic trauma are still controversial. Splenic angioembolization is a very useful tool for NOM, but there is no consensus on its precise indications. There is no definition in the literature as to how NOM should be conducted, neither about the periodicity of hematimetric control, the transfusion threshold that defines NOM failure, when to start venous thromboembolism prophylaxis, the need for control imaging, the duration of bed rest, and when it is safe to discharge the patient. The aim of this review is to make a critical analysis of the most recent literature on this topic, exposing the state of the art in the NOM of splenic trauma.

Abdominal angiography is associated with reduced in-hospital mortality among pediatric patients with blunt splenic and hepatic injury: A propensity-score-matching study from the national trauma registry in Japan

PURPOSE

The aim of this study was to assess the association between the implementation of abdominal angiography and outcome among pediatric patients with blunt splenic or hepatic injury.

METHODS

This was a retrospective observational study, with a study period of 14 years, from January 2004 to December 2017. Blunt-trauma patients with splenic or hepatic injury who were less than 19 years old were included in this study. We used propensity-score-(PS) matching analysis to assess the relationship between abdominal angiography and in-hospital mortality.

RESULTS

In total, 639 patients were eligible for analysis, with 257 patients included in the abdominal-angiography group and 382 patients in the no-abdominal-angiography group. After PS matching, 224 patients from each group were selected. In the PS matched patients, in-hospital mortality was lower in the abdominal-angiography group than in the no-abdominal-angiography group (4.9% vs. 11.2%, odds ratio 0.416, 95% confidence interval 0.177-0.903).

CONCLUSION

In this population, the implementation of abdominal angiography was significantly associated with lower in-hospital mortality among pediatric patients with blunt splenic or hepatic injury compared with nonimplementation of abdominal angiography.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

III.

The Efficacy and Safety of Laparoscopy for Blunt Abdominal Trauma: A Systematic Review and Meta-Analysis

The efficacy and safety of laparoscopy for blunt trauma remain controversial. This systemic review and meta-analysis aimed to evaluate the usefulness of laparoscopy in blunt trauma. The PubMed, EMBASE, and Cochrane databases were searched up to 23 February 2021. Meta-analyses were performed using odds ratios (ORs), standardized mean differences (SMDs), and overall proportions. Overall, 19 studies with a total of 1520 patients were included. All patients were hemodynamically stable. In the laparoscopy group, meta-analysis showed lesser blood loss (SMD −0.28, 95% confidence interval (CI) −0.51 to −0.05, I² = 62%) and shorter hospital stay (SMD −0.67, 95% CI −0.90 to −0.43, I² = 47%) compared with the laparotomy group. Pooled prevalence of missed injury (0.003 (95% CI 0 to 0.023), I² = 0%), nontherapeutic laparotomy (0.004 (95% CI 0.001 to 0.026), I² = 0%), and mortality (0.021 (95% CI 0.010 to 0.043), I² = 0%) were very low in blunt trauma. In subgroup analysis, recently published studies (2011–present) showed lesser conversion rate (0.115 (95% CI 0.067 to 0.190) vs. 0.391 (95% CI 0.247 to 0.556), test for subgroup difference: p < 0.01). This meta-analysis suggests that laparoscopy is a safe and feasible option in hemodynamic stable patients with blunt abdominal trauma.

Trends in Blunt Splenic Injury Management: The Rise of Splenic Artery Embolization

INTRODUCTION

Splenic injury is common in blunt trauma. We sought to evaluate the injury characteristics and outcomes of BSI admitted over a 10-y period to an academic trauma center.

METHODS

A retrospective review of adult blunt splenic injury patients admitted between January 2009 and September 2018.

RESULTS

The 423 patients meeting inclusion criteria were divided by management: Observational (OBS, n = 261), splenic surgery (n = 114 including 4 splenorrhaphy patients), SAE (n = 43), and multiple treatment modalities (3 had SAE followed by surgery and 2 OBS patients underwent splenic surgery at readmission). The most common mechanism of injury was motor vehicle collision (47.8%). The median ISS (OBS 17, SAE 22, Surgery 34) and spleen AIS (OBS 2, SAE 3, Surgery 4) were significantly different.  Complication rates (OBS 21.8%, SAE 9.3%, Surgery 45.6%) rates were significantly different, but mortality (OBS 7.3%, SAE 2.3%, Surgery 13.2%), discharge to home and readmission rates were not. Additional abdominal injuries were identified in 26.3% of the surgery group and 2.7% of OBS group. SAE rate increased from 3.0% to 28%; median spleen AIS remained 2-3. Thirty-five patients expired; 28 had severe head, chest, and/or extremity injuries (AIS ≥4).

CONCLUSION

SAE rates increased over time. Splenorrhaphy rates were low. SAE was associated with relatively low rates of mortality and complications in appropriately selected patients.

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

The 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.