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Alomar Z, Alomar Y, Mahmood I, Alomar A, El-Menyar A, Asim M, Rizoli S, Al-Thani H. Complications and failure rate of splenic artery angioembolization following blunt splenic trauma: A systematic review. Injury 2024; 55:111753. [PMID: 39111269 DOI: 10.1016/j.injury.2024.111753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Revised: 07/22/2024] [Accepted: 07/24/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND Over recent decades, splenic angioembolization (SAE) as an adjunct to non-operative management (NOM) has emerged as a prominent intervention for patients with blunt splenic injuries (BSI). SAE improves patient outcomes, salvages the spleen, and averts complications associated with splenectomy. This systematic review aimed to evaluate the failure rate and complications related to SAE in patients with BSI. METHODS A systematic literature search (PubMed, SCOPUS, and Cochrane Library) focused on studies detailing splenic angioembolization in blunt trauma cases. Articles that fulfilled the predetermined inclusion criteria were included. This review examined the indications, outcomes, failure rate, and complications of SAE. RESULTS Among 599 identified articles, 33 met the inclusion criteria. These comprised 29 retrospective studies, three prospective studies, and one randomized control trial. The analysis encompassed 25,521 patients admitted with BSI and 3,835 patients who underwent SAE. The overall failure rate of SAE was 5.3 %. Major complications predominantly were rebleeding (4.8 %), infarction (4.6 %), and abscess formation (4 %). Minor complications were fever (18.4 %), pleural effusion (13.1 %), and coil migration (3.9 %). Other complications included splenic atrophy, splenic cyst, hematoma, and access site complications such as splenic/femoral dissection. Overall, post embolization mortality was 0.08 %. CONCLUSION SAE is a valuable adjunct in managing BSI, with a low failure rate. However, this treatment modality is not without the risk of potentially serious complications.
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Affiliation(s)
- Zubaidah Alomar
- Jordan University of Science and Technology (Student), Jordan
| | - Yousif Alomar
- Jordan University of Science and Technology (Student), Jordan
| | | | - Ali Alomar
- Jordan University of Science and Technology (Student), Jordan
| | - Ayman El-Menyar
- Trauma Surgery, Hamad Medical Corporation Qatar; Internal Medicine, Weill Cornell Medicine, Qatar.
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Nann S, Clark M, Kovoor J, Jog S, Aromataris E. Prophylactic embolization versus observation for high-grade blunt trauma splenic injury: a systematic review with meta-analysis. JBI Evid Synth 2024:02174543-990000000-00331. [PMID: 39028141 DOI: 10.11124/jbies-24-00110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
OBJECTIVE The objective of this systematic review was to compare the effectiveness of prophylactic angioembolization with observation as primary management strategies for patients with high-grade (grades 3-5) blunt trauma splenic injury. INTRODUCTION The spleen is frequently injured in abdominal trauma. Historical management practices involved splenectomy, but more recent evidence suggests an increased risk of severe infections and sepsis associated with this approach. Accordingly, non-operative management strategies, including prophylactic splenic artery embolization and clinical observation, have gained prominence. This systematic review with meta-analysis directly compares angioembolization with clinical observation for high-grade splenic injuries only, aiming to provide clarity on this matter amid ongoing debates and variations in clinical practice. INCLUSION CRITERIA This review included adult patients aged 15 years or older with high-grade splenic injuries (grade 3-5) due to blunt trauma. Outcomes of interest include the need for further intervention (failure of management), mortality, complications, red blood cell transfusion requirements, hospital length of stay, and intensive care unit length of stay. METHODS A comprehensive search of PubMed, Embase, and CINAHL (EBSCOhost), was performed with no restrictions on language or publication date. Gray literature was searched, including trial registries and relevant conference proceedings. After deduplication, 2 reviewers independently assessed titles and abstracts, and, subsequently, full-text articles for eligibility. Methodological quality of the included studies was assessed using standardized instruments from JBI. Data was extracted using predefined templates, and statistical meta-analysis was performed, where possible, using a random effects model. Heterogeneity was assessed using statistical methods, and potential publication bias was tested with a funnel plot. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the certainty of evidence. RESULTS Sixteen studies were included in this review. Methodological quality assessment indicated some risk of bias in most studies, with concerns primarily related to differences in injury severity and potential confounding factors. Meta-analysis revealed that prophylactic angioembolization significantly reduced risk of management failure by 57% (OR 0.43, 95% CI 0.28-0.68, I2=53%, 15 studies) and decreased patient mortality by 37% (OR 0.63, 95% CI 0.43-0.93, I2=0%, 9 studies) compared with clinical observation alone. There was a 47% reduction in risk of complications associated with prophylactic embolization compared with clinical observation (OR 0.53, 95% CI 0.29-0.95, I2=0%, 4 studies). Some statistical heterogeneity was observed, with I2 ranging from 0% to 53%. No significant differences were observed between the 2 management strategies for red blood cell transfusion requirements and hospital length of stay. CONCLUSIONS The results of this study support the use of prophylactic embolization for high-grade blunt trauma splenic injuries, indicated by lower failure of management rates, reduced need for additional interventions, lower mortality, and fewer complications. REVIEW REGISTRATION PROSPERO CRD42023420220.
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Affiliation(s)
- Silas Nann
- JBI, School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
- The Gold Coast University Hospital, Southport, Qld, Australia
| | - Molly Clark
- JBI, School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Joshua Kovoor
- JBI, School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
- The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Shivangi Jog
- The Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Edoardo Aromataris
- JBI, School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
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Ahmad MU, Lee D, Tennakoon L, Chao TE, Spain D, Staudenmayer K. Angioembolization for splenic injuries: does it help? Retrospective evaluation of grade III-V splenic injuries at two level I trauma centers. Trauma Surg Acute Care Open 2024; 9:e001240. [PMID: 38646615 PMCID: PMC11029436 DOI: 10.1136/tsaco-2023-001240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 03/22/2024] [Indexed: 04/23/2024] Open
Abstract
Background Splenic angioembolization (SAE) has increased in utilization for blunt splenic injuries. We hypothesized lower SAE usage would not correlate with higher rates of additional intervention or mortality when choosing initial non-operative management (NOM) or surgery. Study design Trauma registries from two level I trauma centers from 2010 to 2020 were used to identify patients aged >18 years with grade III-V blunt splenic injuries. Results were compared with the National Trauma Data Bank (NTDB) for 2018 for level I and II centers. Additional intervention or failure was defined as any subsequent SAE or surgery. Mortality was defined as death during admission. Results There were 266 vs 5943 patients who met inclusion/exclusion criteria at Stanford/Santa Clara Valley Medical Center (SCVMC) versus the NTDB. Initial intervention differed significantly between cohorts with the use of SAE (6% vs 17%, p=0.000). Failure differed significantly between cohorts (1.5% vs 6.5%, p=0.005). On multivariate analysis, failure in NOM was significantly associated with NTDB cohort status, age 65+ years, more than one comorbidity, mechanism of injury, grade V spleen injury, and Injury Severity Score (ISS) 25+. On multivariate analysis, failure in SAE was significantly associated with Shock Index >0.9 and 10+ units blood in 24 hours. On multivariate analysis, a higher risk of mortality was significantly associated with NTDB cohort status, age 65+ years, no private insurance, more than one comorbidity, mechanism of injury, ISS 25+, 10+ units blood in 24 hours, NOM, more than one hospital complications, anticoagulant use, other Abbreviated Injury Scale ≥3 abdominal injuries. Conclusions Compared with national data, our cohort had less SAE, lower rates of additional intervention, and had lower risk-adjusted mortality. Shock Index >0.9, grade V splenic injuries, and increased transfusion requirements in the first 24 hours may signal a need for surgical intervention rather than SAE or NOM and may reduce mortality in appropriately selected patients. Level of evidence Level II/III.
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Affiliation(s)
- M Usman Ahmad
- Department of Surgery, Stanford University, Stanford, California, USA
| | - David Lee
- Loma Linda University School of Medicine, Loma Linda, California, USA
| | | | - Tiffany Erin Chao
- Department of Surgery, Stanford University, Stanford, California, USA
- Department of Surgery, Santa Clara Valley Medical Center, San Jose, California, USA
| | - David Spain
- Department of Surgery, Stanford University, Stanford, California, USA
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Osman M, Alam M, Iftikhar M, Khan AG. Conservative Management of Splenic Injury in Blunt Abdominal Trauma: A Single Center Experience. Cureus 2023; 15:e43014. [PMID: 37674958 PMCID: PMC10479248 DOI: 10.7759/cureus.43014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Road traffic accidents are the greatest cause of death worldwide. Most intra-abdominal injuries caused by blunt abdominal trauma have been treated surgically for a very long period. Over the past few decades, conservative care has gained in popularity and effectiveness as a treatment choice for blunt abdominal trauma. OBJECTIVE To determine the efficacy of conservative management in patients suffering from splenic injury in blunt abdominal trauma. METHODS The study included 62 cases of blunt abdominal trauma treated non-operatively in the general surgery department of the Hayatabad Medical Complex Peshawar between June 2021 and December 2022. RESULTS Minimal hemoperitoneum was observed in 47 (75.8%) cases, moderate hemoperitoneum was noted in 11 (17.7%) cases, and 4 (6.4%) patients didn't have free fluid in the abdomen. There was no massive hemoperitoneum among the study patients. No major complications were observed during the study period. Only 7 (11.3%) cases develop minimal pleural effusion while 2 (3.2%) patients developed splenic abscess. Mortality was observed in only 1 (1.6%) case. CONCLUSIONS Conservative management is a safe and efficient strategy and should be considered as a first line of treatment for all hemodynamically stable patients who suffered blunt splenic injury.
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Affiliation(s)
- Muhammad Osman
- Department of General, Benign Upper GI & Colorectal Surgery, Royal Bolton Hospital, Manchester, GBR
| | - Muhammad Alam
- Department of General Surgery, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Muhammad Iftikhar
- Department of General Surgery, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Ali Gohar Khan
- Department of General Surgery, Fauji Foundation Hospital, Peshawar, PAK
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Podda M, De Simone B, Ceresoli M, Virdis F, Favi F, Wiik Larsen J, Coccolini F, Sartelli M, Pararas N, Beka SG, Bonavina L, Bova R, Pisanu A, Abu-Zidan F, Balogh Z, Chiara O, Wani I, Stahel P, Di Saverio S, Scalea T, Soreide K, Sakakushev B, Amico F, Martino C, Hecker A, de'Angelis N, Chirica M, Galante J, Kirkpatrick A, Pikoulis E, Kluger Y, Bensard D, Ansaloni L, Fraga G, Civil I, Tebala GD, Di Carlo I, Cui Y, Coimbra R, Agnoletti V, Sall I, Tan E, Picetti E, Litvin A, Damaskos D, Inaba K, Leung J, Maier R, Biffl W, Leppaniemi A, Moore E, Gurusamy K, Catena F. Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document. World J Emerg Surg 2022; 17:52. [PMID: 36224617 PMCID: PMC9560023 DOI: 10.1186/s13017-022-00457-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Mauro Podda
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy.
| | - Belinda De Simone
- Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | - Marco Ceresoli
- General and Emergency Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Francesco Virdis
- Trauma and Acute Care Surgery Department, Niguarda Hospital, Milan, Italy
| | - Francesco Favi
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
| | - Johannes Wiik Larsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital University of Bergen, Stavanger, Norway
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | | | - Nikolaos Pararas
- Department of General Surgery, Dr Sulaiman Al Habib/Alfaisal University, Riyadh, Saudi Arabia
| | - Solomon Gurmu Beka
- School of Medicine and Health Science, University of Otago, Wellington Campus, Wellington, New Zealand
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Raffaele Bova
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
| | - Adolfo Pisanu
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy
| | - Fikri Abu-Zidan
- Department of Applied Statistics, The Research Office, College of Medicine and Health Sciences United Arab Emirates University, Abu Dhabi, UAE
| | - Zsolt Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Osvaldo Chiara
- Trauma and Acute Care Surgery Department, Niguarda Hospital, Milan, Italy
| | | | - Philip Stahel
- Department of Surgery, East Carolina University, Brody School of Medicine, Greenville, USA
| | - Salomone Di Saverio
- Department of Surgery, San Benedetto del Tronto Hospital, AV5, San Benedetto del Tronto, Italy
| | - Thomas Scalea
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital University of Bergen, Stavanger, Norway
| | - Boris Sakakushev
- Research Institute of Medical University Plovdiv/University Hospital St George Plovdiv, Plovdiv, Bulgaria
| | - Francesco Amico
- Trauma Service, John Hunter Hospital, Newcastle, Australia.,The University of Newcastle, Newcastle, Australia
| | - Costanza Martino
- Department of Anesthesiology and Acute Care, Umberto I Hospital of Lugo, Ausl della Romagna, Lugo, Italy
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Nicola de'Angelis
- Unit of General Surgery, Henri Mondor Hospital, UPEC, Créteil, France
| | - Mircea Chirica
- Service de Chirurgie Digestive, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Andrew Kirkpatrick
- General, Acute Care and Trauma Surgery Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Emmanouil Pikoulis
- General Surgery, Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Denis Bensard
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Luca Ansaloni
- Unit of General Surgery, San Matteo Hospital, Pavia, Italy
| | - Gustavo Fraga
- Division of Trauma Surgery, University of Campinas, Campinas, SP, Brazil
| | - Ian Civil
- Director of Trauma Services, Auckland City Hospital, Auckland, New Zealand
| | | | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, University of Catania, Catania, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Raul Coimbra
- Riverside University Health System Medical Center, Moreno Valley, CA, USA
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Ibrahima Sall
- Department of General Surgery, Military Teaching Hospital, Hôpital Principal Dakar, Dakar, Senegal
| | - Edward Tan
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Andrey Litvin
- Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
| | | | - Kenji Inaba
- University of Southern California, Los Angeles, USA
| | - Jeffrey Leung
- Division of Surgery and Interventional Science, University College London (UCL), London, UK.,Milton Keynes University Hospital, Milton Keynes, UK
| | | | - Walt Biffl
- Division of Trauma and Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, La Jolla, CA, USA
| | - Ari Leppaniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado School of Medicine, Denver, CO, USA
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Fausto Catena
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
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Jeong H, Jung S, Heo TG, Choi PW, Kim JI, Jung SM, Jun H, Shin YC, Um E. Could the Injury Severity Score be a new indicator for surgical treatment in patients with traumatic splenic injury? JOURNAL OF TRAUMA AND INJURY 2022; 35:189-194. [PMID: 39380608 PMCID: PMC11309234 DOI: 10.20408/jti.2021.0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/19/2021] [Accepted: 09/30/2021] [Indexed: 11/05/2022] Open
Abstract
Purpose The purpose of this study was to determine whether a higher Injury Severity Score (ISS) could serve as an indicator of splenectomy in patients with traumatic splenic lacerations. Methods A total of 256 cases of splenic laceration were collected from January 1, 2005 to December 31, 2018. After the application of exclusion criteria, 105 were eligible for this study. Charts were reviewed for demographic characteristics, initial vital signs upon presentation to the emergency room, Glasgow Coma Scale, computed tomography findings, ISS, and treatment strategies. The cases were then divided into nonsplenectomy and splenectomy groups for analysis. Results When analyzed with the chi-square test and t-test, splenectomy was associated with a systolic blood pressure lower than 90 mmHg, a Glasgow Coma Scale score lower than 13, active bleeding found on computed tomography, a splenic laceration grade greater than or equal to 4, and an ISS greater than 15 at presentation. However, in multivariate logistic regression analysis, only active bleeding on computed tomography showed a statistically significant relationship (P=0.014). Conclusions Although ISS failed to show a statistically significant independent relationship with splenectomy, it may still play a supplementary role in traumatic splenic injury management.
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Affiliation(s)
- HyeJeong Jeong
- Department of Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - SungWon Jung
- Department of Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Tae Gil Heo
- Department of Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Pyong Wha Choi
- Department of Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jae Il Kim
- Department of Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Sung Min Jung
- Department of Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Heungman Jun
- Department of Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Yong Chan Shin
- Department of Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Eunhae Um
- Department of Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
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Senekjian L, Robinson BR, Meagher AD, Gross JA, Maier RV, Bulger EM, Arbabi S, Cuschieri J. Nonoperative Management in Blunt Splenic Trauma: Can Shock Index Predict Failure? J Surg Res 2022; 276:340-346. [DOI: 10.1016/j.jss.2022.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 02/01/2022] [Accepted: 02/14/2022] [Indexed: 11/30/2022]
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Zhou Y, Dreizin D, Wang Y, Liu F, Shen W, Yuille AL. External Attention Assisted Multi-Phase Splenic Vascular Injury Segmentation With Limited Data. IEEE TRANSACTIONS ON MEDICAL IMAGING 2022; 41:1346-1357. [PMID: 34968179 PMCID: PMC9167782 DOI: 10.1109/tmi.2021.3139637] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The spleen is one of the most commonly injured solid organs in blunt abdominal trauma. The development of automatic segmentation systems from multi-phase CT for splenic vascular injury can augment severity grading for improving clinical decision support and outcome prediction. However, accurate segmentation of splenic vascular injury is challenging for the following reasons: 1) Splenic vascular injury can be highly variant in shape, texture, size, and overall appearance; and 2) Data acquisition is a complex and expensive procedure that requires intensive efforts from both data scientists and radiologists, which makes large-scale well-annotated datasets hard to acquire in general. In light of these challenges, we hereby design a novel framework for multi-phase splenic vascular injury segmentation, especially with limited data. On the one hand, we propose to leverage external data to mine pseudo splenic masks as the spatial attention, dubbed external attention, for guiding the segmentation of splenic vascular injury. On the other hand, we develop a synthetic phase augmentation module, which builds upon generative adversarial networks, for populating the internal data by fully leveraging the relation between different phases. By jointly enforcing external attention and populating internal data representation during training, our proposed method outperforms other competing methods and substantially improves the popular DeepLab-v3+ baseline by more than 7% in terms of average DSC, which confirms its effectiveness.
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Arvieux C, Frandon J, Tidadini F, Monnin-Bares V, Foote A, Dubuisson V, Lermite E, David JS, Douane F, Tresallet C, Lemoine MC, Rodiere M, Bouzat P, Bosson JL, Vilotitch A, Barbois S, Thony F. Effect of Prophylactic Embolization on Patients With Blunt Trauma at High Risk of Splenectomy: A Randomized Clinical Trial. JAMA Surg 2021; 155:1102-1111. [PMID: 32936242 DOI: 10.1001/jamasurg.2020.3672] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Catherine Arvieux
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Julien Frandon
- Department of Imaging and Interventional Radiology, Nîmes University Hospital (CHU), Nîmes, France
| | - Fatah Tidadini
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Valérie Monnin-Bares
- Department of Imaging and Interventional Radiology, Montpellier University Hospital (CHU), Montpellier, France
| | - Alison Foote
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Vincent Dubuisson
- Department of Vascular and General Surgery, Bordeaux University Hospital (CHU), Bordeaux, France
| | - Emilie Lermite
- Department of Visceral Surgery, Angers University Hospital (CHU), Angers, France
| | - Jean-Stéphane David
- Department of Anesthesia and Intensive Care, Lyon-Sud University Hospital (CHU), Pierre Bénite, France
| | - Frederic Douane
- Department of Imaging and Interventional Radiology, Nantes University Hospital (CHU), Nantes, France
| | - Christophe Tresallet
- Department of General, Digestive, Oncologic, Bariatric, and Metabolic Surgery, Avicenne University Hospital (CHU), Bobigny, France
| | | | - Mathieu Rodiere
- Department of Imaging and Interventional Radiology, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Pierre Bouzat
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Jean-Luc Bosson
- Department of Medical Information, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Antoine Vilotitch
- Department of Medical Information, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Sandrine Barbois
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Frédéric Thony
- Department of Imaging and Interventional Radiology, Grenoble-Alpes University Hospital (CHU), Grenoble, France
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10
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YILDIRIM MB, ŞAHİNER İT, KENDİRCİ M, ÖZKAN B, ERKENT M, TOPCU R, BOSTANOĞLU S. Non-surgical follow-up success in blunt abdominal trauma. Can we protect patients with blunt abdominal trauma from surgery? JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.896899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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11
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Marsh D, Day M, Gupta A, Huang EC, Hou W, Vosswinkel JA, Jawa RS. Trends in Blunt Splenic Injury Management: The Rise of Splenic Artery Embolization. J Surg Res 2021; 265:86-94. [PMID: 33894453 DOI: 10.1016/j.jss.2021.02.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 02/07/2021] [Accepted: 02/27/2021] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- D'Arcy Marsh
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Marilyn Day
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Amit Gupta
- Department of Radiology, Stony Brook University School of Medicine, Stony Brook New York
| | - Emily C Huang
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Wei Hou
- Department of Family, Population and Preventative Medicine, Stony Brook University School of Medicine, Stony Brook, New York
| | - James A Vosswinkel
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Randeep S Jawa
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York.
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12
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Birindelli A, Martin M, Khan M, Gallo G, Segalini E, Gori A, Yetasook A, Podda M, Giuliani A, Tugnoli G, Lim R, Di Saverio S. Laparoscopic splenectomy as a definitive management option for high-grade traumatic splenic injury when non operative management is not feasible or failed: a 5-year experience from a level one trauma center with minimally invasive surgery expertise. Updates Surg 2021; 73:1515-1531. [PMID: 33837949 PMCID: PMC8397689 DOI: 10.1007/s13304-021-01045-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 03/01/2021] [Indexed: 02/08/2023]
Abstract
Technique, indications and outcomes of laparoscopic splenectomy in stable trauma patients have not been well described yet. All hemodynamically non-compromised abdominal trauma patients who underwent splenectomy from 1/2013 to 12/2017 at our Level 1 trauma center were included. Demographic and clinical data were collected and analysed with per-protocol and an intention-to-treat comparison between open vs laparoscopic groups. 49 splenectomies were performed (16 laparoscopic, 33 open). Among the laparoscopic group, 81% were successfully completed laparoscopically. Laparoscopy was associated with a higher incidence of concomitant surgical procedures (p 0.016), longer operative times, but a significantly faster return of bowel function and oral diet without reoperations. No significant differences were demonstrated in morbidity, mortality, length of stay, or long-term complications, although laparoscopic had lower surgical site infection (0 vs 21%).The isolated splenic injury sub-analysis included 25 splenectomies,76% (19) open and 24% (6) laparoscopic and confirmed reduction in post-operative morbidity (40 vs 57%), blood transfusion (0 vs 48%), ICU admission (20 vs 57%) and overall LOS (7 vs 9 days) in the laparoscopic group. Laparoscopic splenectomy is a safe and effective technique for hemodynamically stable patients with splenic trauma and may represent an advantageous alternative to open splenectomy in terms of post-operative recovery and morbidity.
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Affiliation(s)
- Arianna Birindelli
- Department of Surgery, University of Bologna, Bologna, Italy.,General, Trauma and Emergency Surgery Unit, Bufalini Hospital, Cesena, Italy.,General and Emergency Surgery Unit, Esine General Hospital, ASST Valcamonica, Breno, BS, Italy
| | - Matthew Martin
- Department of Trauma and Acute Care Surgery, Scripps Mercy Hospital, San Diego, CA, USA
| | - Mansoor Khan
- Digestive Diseases Department, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - Edoardo Segalini
- Department of General and Emergency Surgery, ASST, Crema, CR, Italy
| | - Alice Gori
- Department of Surgery, University of Bologna, Bologna, Italy
| | - Amy Yetasook
- Harbor-UCLA Department of Surgery, Torrence, CA, USA
| | - Mauro Podda
- Emergency and Minimally Invasive Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Antonio Giuliani
- General and Emergency Surgery Unit, Azienda Ospedaliera Regionale San Carlo, Potenza, Italy
| | - Gregorio Tugnoli
- Trauma Surgery Unit, Emergency Department, Maggiore Hospital, Bologna, Italy
| | - Robert Lim
- Department of Surgery, Tripler Army Medical Center, Tripler, Honolulu, HI, USA
| | | | - Salomone Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, UK. .,General Surgery Unit 1, Department of General Surgery, Ospedale Di Circolo, University of Insubria, ASST Sette Laghi, Regione Lombardia, Varese, Italy.
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13
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Fransvea P, Costa G, Serao A, Cortese F, Balducci G, Sganga G, Marini P. Laparoscopic splenectomy after trauma: Who, when and how. A systematic review. J Minim Access Surg 2021; 17:141-146. [PMID: 31670290 PMCID: PMC8083752 DOI: 10.4103/jmas.jmas_149_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Importance: A deep knowledge of the indication for laparoscopic splenectomy (LS) in trauma case can lead trauma surgeon to offer in a wider number of situations a minimally invasive approach to a common injuries. Objective: To present and review the advantages and disadvantages of laparoscopic approach for spleen trauma and to identify patient whose can benefit from a minimally invasive approach versus patient that need open surgery to assess the whole severity of trauma. Evidence Review: A systematic review was performed according to the PRISMA statement in order to identify articles reporting LS after trauma. A literature search was performed through MEDLINE (through PubMed), Embase and Google Scholar from January 1990 to December 2018. Studies conducted on animals were not considered. All other laparoscopic procedures for spleen trauma were excluded. Results: Nineteen articles were included in this study, reporting 212 LS after trauma. The most study includes blunt trauma patient. All LS were performed in haemodynamically stable patient. Post-operative complications were reported in all articles with a median post-operative morbidity rate of 30 patients (14.01%), including 16 (7.5%) post-operative deaths. Conclusions and Relevance: This article reports the feasibility and safety of a minimally invasive approach for common trauma injuries which can help non-advanced laparoscopic skill trauma surgeon to develop the best indication to when to adopt this kind of approach.
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Affiliation(s)
- Pietro Fransvea
- Division of Emergency Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University of Rome, Rome, Italy
| | - Gianluca Costa
- Department of Translational Medicine, Sant' Andrea Teaching Hospital, Sapienza University of Rome, Rome, Italy
| | - Angelo Serao
- Department of General Surgery, Ospedale Dei Castelli, Ariccia, Rome, Italy
| | - Francesco Cortese
- Emergency Surgery and Trauma Care Unit, St Filippo Neri Hospital, Rome, Italy
| | - Genoveffa Balducci
- Department of Translational Medicine, Sant' Andrea Teaching Hospital, Sapienza University of Rome, Rome, Italy
| | - Gabriele Sganga
- Division of Emergency Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University of Rome, Rome, Italy
| | - Pierluigi Marini
- Department of General and Emergency Surgery, St. Camillo Forlanini's Hospital, Rome, Italy
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14
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Amico F, Anning R, Bendinelli C, Balogh ZJ. Grade III blunt splenic injury without contrast extravasation - World Society of Emergency Surgery Nijmegen consensus practice. World J Emerg Surg 2020; 15:46. [PMID: 32746885 PMCID: PMC7397620 DOI: 10.1186/s13017-020-00319-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/07/2020] [Indexed: 11/25/2022] Open
Abstract
Background Recent trauma guidelines recommend non-operative management for grade III splenic injury without contrast extravasation on computed tomography. Nevertheless, such recommendations rely on low-quality evidence, and practice variation characterizes clinical management for this type of injury. We aimed to identify the role of eleven selected clinical factors influencing the management of grade III splenic injury without contrast extravasation by expert consensus and a modified Delphi approach. Methods A questionnaire was developed with the endorsement of the World Society of Emergency Surgery (WSES). This was delivered and answered live by acute care surgeons attending the 6th WSES congress in Nijmegen in 2019. A dedicated mobile phone application was utilized to collect the answers. All answers were evaluated for areas of discrepancy with an 80% threshold for consensus between respondents. Results Three factors generated discrepancy in opinion for managing this pattern of injury: the patients’ injury severity, the presence of a bleeding diathesis, and an associated intra-abdominal injury. Agreement was obtained for the other eight factors. Conclusion Researchers should focus their efforts on the identified area of discrepancy. Clinicians should use additional care in the presence of the three factors for which discordant opinions were found.
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Affiliation(s)
- Francesco Amico
- Department of Traumatology, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, 2310, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Rebecca Anning
- Department of Surgery, John Hunter Hospital, Newcastle, NSW, Australia
| | - Cino Bendinelli
- Department of Traumatology, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, 2310, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW, 2310, Australia. .,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia.
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15
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Wang Y, Cao R, Ye N, Lv D, Zhao T, Chen D. Efficacy evaluation of different conservative treatments for blunt spleen rupture. Minerva Med 2020; 112:615-621. [PMID: 32486610 DOI: 10.23736/s0026-4806.20.06574-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND This study aims to provide a reference for the clinical treatment of patients with spleen ruptures by analyzing and discussing the clinical effects of the conservative treatment. METHODS The clinical data of 93 patients with blunt spleen rupture treated in the First Affiliated Hospital of University of Science and Technology of China from April 2015 to April 2018 were retrospectively analyzed. Among them, 84 cases were treated conservatively and 9 cases were treated surgically. The general information of conservative treatment and surgical treatment were compared. The relationship between different conservative treatment methods and CT classification of spleen rupture and the changes of abdominal drainage were analyzed. RESULTS The CT classification grade and trauma score of patients with spleen rupture in surgical treatment were higher than those in conservative treatment group (P <0.05). A total of 90.3% patients were treated conservatively. Among them, 7.1% (83.4% were in CT classification of spleen injury grade 1-2) were from the observation group, 14.3% (83.3% were in CT classification of spleen injury grade 1-2) were from abdominal drainage group, 3.6% were from splenic artery embolization group, and 75% (9.5% were in CT classification of spleen injury grade 2, 77.8% in grade 3 and 12.7% in grade 4) were from splenic artery embolization plus abdominal drainage group. There was no significant difference in the total amount of abdominal drainage on Day 1, Day 2 and Day3, and the CT classification of spleen rupture (P>0.05). However, there significant differences on the amount of abdominal drainage among Day 1, Day 2 and Day3 (P <0.05). Meanwhile, 2 complications occurred in the splenic artery embolization plus abdominal drainage group. CONCLUSIONS Conservative treatment is feasible in blunt spleen rupture patients of CT classification grade of 1-4 with stable hemodynamical. Splenic rupture patients of CT classification grade 4-5 with instable hemodynamical should be treated surgically.
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Affiliation(s)
- Ying Wang
- Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China -
| | - Rongge Cao
- Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Ning Ye
- Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Dechao Lv
- Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Tao Zhao
- Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Dong Chen
- Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
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16
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Liechti R, Fourie L, Stickel M, Schrading S, Link BC, Fischer H, Lehnick D, Babst R, Metzger J, Beeres FJP. Routine follow-up imaging has limited advantage in the non-operative management of blunt splenic injury in adult patients. Injury 2020; 51:863-870. [PMID: 32111461 DOI: 10.1016/j.injury.2020.02.089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND To date, limited evidence exists regarding follow-up imaging during the non-operative management (NOM) of blunt splenic injury (BSI), especially concerning ultrasound as first-line imaging modality. The aim of this study was to investigate the incidence and time to failure of NOM as well as to evaluate the relevance of follow-up imaging. METHODS All adult patients with BSI admitted to our level I trauma center, including two associated hospitals, between 01/01/2010 and 31/12/2017 were retrospectively analyzed. Demographic data, comorbidities, injury pattern, trauma mechanism, Injury Severity Score, splenic injury grade and free intra-abdominal fluid were reviewed. Additional analysis of indication, frequency, modality, results and consequences of follow-up imaging was performed. Risk factors for failure of NOM were evaluated using fisher's exact test. RESULTS A total of 122 patients with a mean age of 43.8 ± 20.7 years (16-84 years) met inclusion criteria. Twenty patients (16.4%) underwent immediate intervention. One-hundred-and-two patients (83.6%) were treated by NOM. Failure of NOM occurred in 4 patients (3.9%). Failure was significantly associated with active bleeding (3 of 4 [75%] failures vs. 8 of 98 [8.2%] non-failures, OR 33.75, 95% CI 3.1, 363.2, p = 0.004), and liver cirrhosis (2 of 4 [50%] failures vs. 0 of 98 [0%] non-failures, OR 197, 95% CI 7.4, 5265.1, p = 0.001). Eighty patients (78.4%) in the NOM-Group received follow-up imaging by ultrasound (US, n = 51) or computed tomography (CT, n = 29). In 57 cases, routine imaging examinations were conducted (43 US and 14 CT scans) without prior clinical deterioration. Fifty-fife (96.4%) of these imaging results revealed no new significant findings. Every failure of NOM was detected following clinical deterioration in the first 48 h. CONCLUSION To our knowledge this study includes the largest single centric patient cohort undergoing ultrasound as first-line follow-up imaging modality in the NOM setting of BSI in adult patients. The results indicate that a routine follow-up imaging, regardless of the modality, has limited therapeutic advantage. Indication for radiological follow-up should be based on clinical findings. If indicated, a CT scan should be used as preferred imaging modality.
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Affiliation(s)
- Rémy Liechti
- Department of General and Visceral Surgery, Cantonal Hospital of Lucerne, Spitalstrasse, CH-6000 Lucerne 16, Switzerland.
| | - Lana Fourie
- Department of General and Visceral Surgery, Cantonal Hospital of Lucerne, Spitalstrasse, CH-6000 Lucerne 16, Switzerland
| | - Michael Stickel
- Interdisciplinary Emergency Department, Cantonal Hospital of Lucerne, Switzerland
| | - Simone Schrading
- Department of Radiology, Cantonal Hospital of Lucerne, Switzerland
| | - Björn-Christian Link
- Department of Orthopedic and Trauma Surgery, Cantonal Hospital of Lucerne, Switzerland
| | - Henning Fischer
- Interdisciplinary Emergency Department, Cantonal Hospital of Lucerne, Switzerland
| | - Dirk Lehnick
- Department of Health Sciences and Medicine, University of Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopedic and Trauma Surgery, Cantonal Hospital of Lucerne, Switzerland
| | - Jürg Metzger
- Department of General and Visceral Surgery, Cantonal Hospital of Lucerne, Spitalstrasse, CH-6000 Lucerne 16, Switzerland
| | - Frank J P Beeres
- Department of Orthopedic and Trauma Surgery, Cantonal Hospital of Lucerne, Switzerland
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Fransvea P, Costa G, Massa G, Frezza B, Mercantini P, BaIducci G. Non-operative management of blunt splenic injury: is it really so extensively feasible? a critical appraisal of a single-center experience. Pan Afr Med J 2019; 32:52. [PMID: 31143357 PMCID: PMC6522183 DOI: 10.11604/pamj.2019.32.52.15022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 10/19/2018] [Indexed: 02/04/2023] Open
Abstract
Introduction The spleen is one of the most commonly injured organ following blunt abdominal trauma. Splenic injuries may occur in isolation or in association with other intra-and extra-abdominal injury. Nonoperative management of blunt injury to the spleen has become routine in children. In adult most minor splenic injuries are readily treated nonoperatively but controversy exists regarding the role of nonoperative management for higher grade injuries above all in multi-trauma patients. The aim of this study is the assessment of splenic trauma treatment, with particular attention to conservative treatment, its limits, its efficiency, and its safety in multi-trauma patient or in a severe trauma patient. Methods The present research focused on a retrospective review of patients with splenic injury. The research was performed by analyzing data of the trauma registry of St. Andrea University Hospital in Rome. The St. Andrea University Hospital trauma registry includes 1859. The variables taken into account were spleen injury and general injuries, age, sex, cause and dynamic of trauma, hemoglobin, hematocrit, white blood cells count, INR, number and time blood transfusion, hemodynamic stability, type of treatment provided, hospitalization period, morbidity and mortality. Assessment of splenic injuries was evaluated according to Abbreviated Injury Scale (AIS). Results The analysis among the general population of spleen trauma patients identified 68 patients with a splenic injury representing the 41.2% of all abdomen injury. The Average age was of 37.01 ± 17.18 years. The Average ISS value was of 22.88 ± 12.85; mediana of 24.50 (range 4-66). The average Spleen AIS value was of 3.13 ± 0.88; mediana 3.00 (range 2-5). The overall mortality ratio was of 19.1% (13 patients). The average ISS value in patients who died was of 41.92 ± 12.48, whereas in patients who survided was of 23.33 ± 10.15. The difference was considered to be statistically significant (p <0.001). The relashionship between the ISS and AIS values in patients who died was considered directly proportional but not statistically significant (Pearson test AIS/ISS = 0.132, p = n.s.). The initial management was a conservative treatment in 27 patients (39.7%) of them 4 patients (15%) failed, in the other 41 cases urgent splenectomies were performed. The average spleen AIS in all the patients who underwent splenectomy was 3.61 ± 0.63 whereas in the patients who were not treated surgically was 2.42 ± 0.69. The difference was deemed statistically significant (p <0.001). Conclusion Splenic injury, as reported in our statistic as well as in literature, is the most common injury in closed abdominal trauma. Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The preference of a conservative treatment must be based on the hemodynamic stability indices as well as on the spleen lesion severity and on the general trauma severity. The conservative treatment represent a feasible and safe therapeutic alternative even in case of severe lesions in politrauma patients, but the choice of the treatment form requires an assessment for each singular case.
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Affiliation(s)
- Pietro Fransvea
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Gianluca Costa
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Giulia Massa
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Barbara Frezza
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Paolo Mercantini
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Genoveffa BaIducci
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
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Lee MA, Yu B, Lee J, Choi KK, Park JJ, Park Y, Han A, Gwak J, Lee GJ. Comparison of outcomes before and after establishing a regional trauma center and following a protocol to treat blunt splenic injury in South Korea: A retrospective study. HONG KONG J EMERG ME 2018. [DOI: 10.1177/1024907918773202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Nonoperative management for hemodynamically stable splenic injury has been accepted as appropriate treatment. Objectives: This study aimed to investigate the changes in management and clinical outcomes of splenic injury by introducing a protocol for splenic injury at a newly established regional trauma center. Methods: From January 2005 to December 2016, we reviewed the outcomes of all 257 patients who sustained blunt trauma to the spleen at the first regional trauma center in South Korea. This 11-year period was divided into two intervals, before 1 January 2014 (period I, n = 189 patients) and after 1 January 2014 (period II, n = 68 patients), when the trauma center was established and a formal management protocol was followed for patients with blunt traumatic splenic injuries. Results: The proportion of emergency operations performed for patients with more serious (grades 3–5) splenic injuries was lower in period II than in period I (29% vs 22%, respectively, p < 0.001) whereas the rate of angioembolization was higher (89% vs 39.0%, respectively, p < 0.001). The time to intervention, irrespective of whether emergency operation or angioembolization was performed, was shorter in period II than in period I (312.8 min vs 129 min, respectively, p = 0.001). A greater proportion of patients was managed non-operatively in period II (78% vs 71%), and the non-operative management success rate was higher in period II than it was in period I (100% vs 83%; p = 0.014). Similarly, the splenic salvage rate was higher in period II (78% vs 59%, p = 0.03). Conclusion: After establishing a regional trauma center and introducing a protocol for the management of blunt splenic injuries, the rates of non-operative management and splenic salvage improved significantly. The reasons for this may be multifactorial, being related to the early involvement of a trauma surgeon, expansion of angiographic facilities and resources, and the introduction and application of a protocol for managing blunt splenic injury.
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Affiliation(s)
- Min A Lee
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, South Korea
| | - Byungchul Yu
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, South Korea
| | - Jungnam Lee
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, South Korea
| | - Kang Kook Choi
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, South Korea
| | - Jae Jeong Park
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, South Korea
| | - Youngeun Park
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, South Korea
| | - Ahram Han
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, South Korea
| | - Jihun Gwak
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, South Korea
| | - Gil Jae Lee
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, South Korea
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19
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Ardley R, Carone L, Smith S, Spreadborough S, Davies P, Brooks A. Blunt splenic injury in children: haemodynamic status key to guiding management, a 5-year review of practice in a UK major trauma centre. Eur J Trauma Emerg Surg 2018; 45:791-799. [PMID: 30251151 DOI: 10.1007/s00068-018-1014-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 09/20/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE To review the management of children and adolescents (0-18 years), with blunt splenic injury treated at a single UK major trauma centre over a 5-year period, focusing upon efficacy of non-operative management and the use of haemodynamic stability as a guide to planning treatment strategy, rather than radiological injury grading. To produce a treatment pathway for management of blunt splenic injury in children. METHODS Retrospective, cross-sectional study of all paediatric patients admitted with radiologically proven blunt splenic injury between January 2011 and March 2016. Penetrating injuries were excluded. Follow up was for at least 30 days. RESULTS 30 Patients were included, mean age was 14.5 (SD 3.6), median injury severity score was 16 (IQR 10-31). 6 Patients (20%) had a splenectomy, whilst 22 patients (73%) were successfully treated non-operatively with 100% efficacy at index admission. 5/8 (63%) patients with radiological grade V injuries were managed non-operatively, injury grade was not associated with surgical intervention (p = 1.57). Haemodynamic instability was initially treated with fluid resuscitation leading to successful non-operative management in 5/11 (45%) patients. However, haemodynamic instability is a significant predictor of requirement for surgical intervention (p = 0.03), admission to critical care (p = 0.017), presence of additional injuries (p = 0.015) and increased length of stay (p = 0.038). No such relationships were found to be associated with increased radiological injury grade. CONCLUSIONS Non-operative management should be first-line treatment in the haemodynamically stable child with a blunt splenic injury and may be carried out with a high degree of efficacy. It may also be successfully implemented in those initially showing signs of haemodynamic instability that respond to fluid resuscitation. Radiological injury grade does not predict definitive management, level of care, or length of stay; however, haemodynamic stability may be utilised to produce a treatment algorithm and is key to guiding management.
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Affiliation(s)
- Rohan Ardley
- East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham, UK.
| | - Laura Carone
- East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham, UK
- LNR deanery, Nottingham, UK
| | - Stella Smith
- East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham, UK
| | | | - Patrick Davies
- East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham, UK
| | - Adam Brooks
- East Midlands Major Trauma Centre, Queens Medical Centre, Nottingham, UK
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