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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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Dariushnia SR, Redstone EA, Heran MKS, Cramer HR, Ganguli S, Gomes AS, Hogan MJ, Himes EA, Patel S, Schiro BJ, Lewis CA. Society of Interventional Radiology Quality Improvement Standards for Percutaneous Transcatheter Embolization. J Vasc Interv Radiol 2021; 32:476.e1-476.e33. [PMID: 33640083 DOI: 10.1016/j.jvir.2020.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 01/14/2023] Open
Affiliation(s)
- Sean R Dariushnia
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Dr, SE, Atlanta, GA, 30303.
| | - Ellen A Redstone
- Department of Interventional Radiology, St. Luke's University Health Network, 801 Ostrum St., Bethlehem, PA, 18015
| | - Manraj K S Heran
- Pediatric Interventional Radiology, Diagnostic & Therapeutic Neuroradiology, British Columbia's Children's Hospital, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, Canada
| | - Harry R Cramer
- Section of Interventional Radiology, Coastal Vascular and Interventional, PLLC, 3155 Hyde Park Place, Pensacola, FL, 32503
| | - Suvranu Ganguli
- Department of Radiology, Division of Interventional Radiology, Boston Medical Center, Boston University School of Medicine, 820 Harrison Avenue, FGH 4th Floor, Boston, MA, 02118
| | - Antoinette S Gomes
- Department of Radiological Sciences, Ronald Reagan UCLA Medical Center, 757 Westwood Plz Ste 2125, Los Angeles, CA, 90095-8358
| | - Mark J Hogan
- Department of Radiology, Section of Vascular and Interventional Radiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205
| | - Elizabeth A Himes
- Society of Interventional Radiology, 3975 Fair Ridge Drive, Suite 400 North, Fairfax, VA, 22033
| | - Sheena Patel
- Society of Interventional Radiology, 3975 Fair Ridge Drive, Suite 400 North, Fairfax, VA, 22033
| | - Brian J Schiro
- Department of Vascular & Interventional Radiology, Miami Cardiac & Vascular Institute, 8900 N. Kendall Drive, Miami, FL, 33156, United States
| | - Curtis A Lewis
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Dr, SE, Atlanta, GA, 30303
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Ren C, Lu H, Xia H, Zhang J, Cao B, Wang Y, Lu D, Cao R. Alterations of coagulation and fibrinolysis in patients with blunt splenic injury after splenic artery embolization. J Clin Lab Anal 2021; 35:e23801. [PMID: 33955612 PMCID: PMC8183903 DOI: 10.1002/jcla.23801] [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: 12/21/2020] [Revised: 03/24/2021] [Accepted: 04/02/2021] [Indexed: 11/22/2022] Open
Abstract
Background Thrombotic complications following splenectomy have been documented. However, there has been sparse literature regarding thrombotic complications following splenic artery embolization (SAE).The objective of this study was to determine changes in coagulation and fibrinolysis and assess the thrombotic risk after SAE in patients with blunt splenic injury (BSI). Methods This study included 38 BSI patients who were hemodynamically stable on admission. SAE was performed if the splenic injury was classed as grade III or greater and had no requirement of immediate surgery. Platelet (PLT), fibrinogen (FIB), D‐dimers (D‐D), fibrinogen/fibrin degradation products (FDP), antithrombin III (AT III), prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), hemoglobin (Hb), and hematocrit (Hct) were measured before SAE procedures and then 1d, 3d, and 7d after SAE. Results The technical success rate of SAE and the splenic salvage rate were 100%. There was no mortality. Compared with pre‐SAE values, the levels of PLT, FIB, D‐D, and FDP increased significantly at 3 days and 7 days after SAE (p < 0.05). However, AT III, PT, APTT, TT, Hb, and Hct showed no statistically significant difference at 1d, 3d, and 7d after SAE (p > 0.05). Conclusion Alterations in PLT and hemostatic parameters might contribute to the increased risk of thrombotic complications in BSI patients undergoing SAE. Thromboembolism following SAE should be considered and thrombotic prophylaxis should be recommended.
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Affiliation(s)
- Chuanzeng Ren
- Department of Emergency Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Huadong Lu
- Department of Emergency Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Honghai Xia
- Department of Emergency Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Jia Zhang
- Department of Emergency Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Bin Cao
- Department of Emergency Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Ying Wang
- Department of Emergency Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Dong Lu
- Department of Interventional Radiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Rongge Cao
- Department of Emergency Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
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Predictors for Failure of Non-operative Management of Splenic Injuries. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02523-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Katsura M, Fukuma S, Kuriyama A, Takada T, Ueda Y, Asano S, Kondo Y, Ie M, Matsushima K, Murakami T, Fukuzato Y, Osaki N, Mototake H, Fukuhara S. Association between contrast extravasation on computed tomography scans and pseudoaneurysm formation in pediatric blunt splenic and hepatic injury: A multi-institutional observational study. J Pediatr Surg 2020; 55:681-687. [PMID: 31350043 DOI: 10.1016/j.jpedsurg.2019.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/29/2019] [Accepted: 07/06/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE We aimed to examine the association between contrast extravasation (CE) on initial computed tomography (CT) scan and pseudoaneurysm (PSA) development in pediatric blunt splenic and/or liver injury. METHODS We conducted a multi-institutional retrospective study in cases of blunt splenic and/or hepatic injury who underwent an initial attempt of nonoperative management. A logistic regression model was used to compare PSA formation and CE on initial CT scan, and the area under the receiver operating characteristic curve (AUC) with and without CE was used to assess the predictive performance of CE for PSA formation. RESULTS Of 236 cases enrolled from 10 institutions, PSA formation was observed in 17 (7.2%). Multivariate analysis showed a significant association between CE on initial CT scan and increased incidence of PSA formation (odds ratio, 4.96; 95% confidence interval, 1.37-18.0). There was no statistically significant association between the grade of injury and PSA formation. The AUC improved from 0.75 (0.64-0.87) to 0.80 (0.70-0.91) with CE. CONCLUSION Active CE on initial CT scan was an independent predictor of PSA formation. Selective use of follow-up CT in children who showed CE on initial CT may provide early identification of PSA formation, regardless of injury grade. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Affiliation(s)
- Morihiro Katsura
- Department of General Surgery, Okinawa, Chubu Hospital, Okinawa, Japan; Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Shingo Fukuma
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, Okayama, Japan.
| | - Tadaaki Takada
- Department of Emergency and Critical Care Medicine, Tokushima, Red Cross Hospital, Tokushima, Japan.
| | - Yasuhiro Ueda
- Tajima Emergency and Critical Care Medical Center, Toyooka, Public Hospital, Hyogo, Japan.
| | - Shima Asano
- Department of Surgery, Okinawa, Miyako Hospital, Okinawa, Japan.
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan; Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba, Japan.
| | - Masafumi Ie
- Department of General Surgery, Okinawa, Chubu Hospital, Okinawa, Japan.
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, University of Southern California, Los Angeles, California, USA.
| | - Takahiro Murakami
- Department of General Surgery, Okinawa, Chubu Hospital, Okinawa, Japan.
| | - Yoshimitsu Fukuzato
- Department of Pediatric Surgery, Okinawa, Nanbu Medical Center & Children's Medical Center, Okinawa, Japan.
| | - Nobuhiro Osaki
- Department of Surgery, Okinawa, Yaeyama Hospital, Okinawa, Japan.
| | | | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan.
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Teuben M, Spijkerman R, Blokhuis T, Pfeifer R, Teuber H, Pape HC, Leenen L. Nonoperative management of splenic injury in closely monitored patients with reduced consciousness is safe and feasible. Scand J Trauma Resusc Emerg Med 2019; 27:108. [PMID: 31805978 PMCID: PMC6896516 DOI: 10.1186/s13049-019-0668-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 09/13/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Treatment of blunt splenic injury has changed over the past decades. Nonoperative management (NOM) is the treatment of choice. Adequate patient selection is a prerequisite for successful NOM. Impaired mental status is considered as a relative contra indication for NOM. However, the impact of altered consciousness in well-equipped trauma institutes is unclear. We hypothesized that impaired mental status does not affect outcome in patients with splenic trauma. METHODS Our prospectively composed trauma database was used and adult patients with blunt splenic injury were included during a 14-year time period. Treatment guidelines remained unaltered over time. Patients were grouped based on the presence (Group GCS: < 14) or absence (Group GCS: 14-15) of impaired mental status. Outcome was compared. RESULTS A total of 161 patients were included, of whom 82 were selected for NOM. 36% of patients had a GCS-score < 14 (N = 20). The median GCS-score in patients with reduced consciousness was 9 (range 6-12). Groups were comparable except for significantly higher injury severity scores in the impaired mental status group (19 vs. 17, p = 0.007). Length of stay (28 vs. 9 days, p < 0.001) and ICU-stay (8 vs. 0 days, p = 0.005) were longer in patients with decreased GCS-scores. Failure of NOM, total splenectomy rates, complications and mortality did not differ between both study groups. CONCLUSION This study shows that NOM for blunt splenic trauma is a viable treatment modality in well-equipped institutions, regardless of the patients mental status. However, the presence of neurologic impairment is associated with prolonged ICU-stay and hospitalization. We recommend, in institutions with adequate monitoring facilities, to attempt nonoperative management for blunt splenic injury, in all hemodynamically stable patients without hollow organ injuries, also in the case of reduced consciousness.
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Affiliation(s)
- Michel Teuben
- Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Suite G04.232, The Netherlands. .,Department of Traumatology, University Hospital Zurich, Zurich, Switzerland.
| | - Roy Spijkerman
- Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Suite G04.232, The Netherlands
| | - Taco Blokhuis
- Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Suite G04.232, The Netherlands
| | - Roman Pfeifer
- Department of Traumatology, University Hospital Zurich, Zurich, Switzerland
| | - Henrik Teuber
- Department of Traumatology, University Hospital Zurich, Zurich, Switzerland
| | | | - Luke Leenen
- Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Suite G04.232, The Netherlands
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Corn S, Reyes J, Helmer SD, Haan JM. Outcomes Following Blunt Traumatic Splenic Injury Treated with Conservative or Operative Management. Kans J Med 2019; 12:83-88. [PMID: 31489105 PMCID: PMC6710021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 06/04/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Laparotomy, embolization, and observation are described for blunt splenic injury management. This study evaluated outcomes of blunt splenic injury management based on baseline factors, splenic injury severity, and associated injuries. METHODS A nine-year retrospective review was conducted of adult patients with blunt splenic injury. Collected data included demographics, injury characteristics, treatment modality, complications, and outcomes (mechanical ventilation, days on mechanical ventilation, intensive care unit [ICU] admission and length of stay, hospital length of stay, and in-hospital mortality). Categorical and continuous variables were analyzed using χ2 analysis and one-way analysis of variance for normally distributed variables and a non-parametric test of medians for variables that did not meet the assumption of normality, respectively. RESULTS Splenic injury grade was similar between operative and embolization groups, but severe hemoperitoneum was more common in the operative group. Complications and mortality were highest in the operative group (50.7% and 26.3%, respectively) and lowest in the embolization group (5.3% and 2.6%, respectively). Operative patients required more advanced interventions (ICU admission, mechanical ventilation). There were no differences between those treated with proximal versus distal embolization. Observation carried a failure rate of 11.2%, with no failures of embolization. CONCLUSIONS Embolization patients had the lowest rates of complications and mortality, with comparable splenic injury grades to those treated operatively. Further prospective research is warranted to identify patients that may benefit from early embolization and avoidance of major abdominal surgery.
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Affiliation(s)
- Sarah Corn
- University of Kansas School of Medicine-Wichita, Department of Surgery, Wichita, KS
| | - Jared Reyes
- University of Kansas School of Medicine-Wichita, Department of Surgery, Wichita, KS
| | - Stephen D. Helmer
- University of Kansas School of Medicine-Wichita, Department of Surgery, Wichita, KS,Department of Medical Education, Via Christi Hospital Saint Francis, Wichita, KS
| | - James M. Haan
- University of Kansas School of Medicine-Wichita, Department of Surgery, Wichita, KS,Department of Trauma Services, Via Christi Hospital Saint Francis, Wichita, KS
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Teuben MPJ, Spijkerman R, Blokhuis TJ, Pfeifer R, Teuber H, Pape HC, Leenen LPH. Safety of selective nonoperative management for blunt splenic trauma: the impact of concomitant injuries. Patient Saf Surg 2018; 12:32. [PMID: 30505349 PMCID: PMC6260576 DOI: 10.1186/s13037-018-0179-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 11/13/2018] [Indexed: 11/10/2022] Open
Abstract
Background Nonoperative management for blunt splenic injury is the preferred treatment. To improve the outcome of selective nonoperative therapy, the current challenge is to identify factors that predict failure. Little is known about the impact of concomitant injury on outcome. Our study has two goals. First, to determine whether concomitant injury affects the safety of selective nonoperative treatment. Secondly we aimed to identify factors that can predict failure. Methods From our prospective trauma registry we selected all nonoperatively treated adult patients with blunt splenic trauma admitted between 01.01.2000 and 12.21.2013. All concurrent injuries with an AIS ≥ 2 were scored. We grouped and compared patients sustaining solitary splenic injuries and patients with concomitant injuries. To identify specific factors that predict failure we used a multivariable regression analysis. Results A total of 79 patients were included. Failure of nonoperative therapy (n = 11) and complications only occurred in patients sustaining concomitant injury. Furthermore, ICU-stay as well as hospitalization time were significantly prolonged in the presence of associated injury (4 versus 13 days,p < 0.05). Mortality was not seen. Multivariable analysis revealed the presence of a femur fracture and higher age as predictors of failure. Conclusions Nonoperative management for hemodynamically normal patients with blunt splenic injury is feasible and safe, even in the presence of concurrent (non-hollow organ) injuries or a contrast blush on CT. However, associated injuries are related to prolonged intensive care unit- and hospital stay, complications, and failure of nonoperative management. Specifically, higher age and the presence of a femur fracture are predictors of failure.
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Affiliation(s)
- Michel Paul Johan Teuben
- 1Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Roy Spijkerman
- 1Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Taco Johan Blokhuis
- 2Department of Surgery, Maastricht University Medical Center, P. Debyelaan 24, 6229 HX Maastricht, The Netherlands
| | - Roman Pfeifer
- 3Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zürich, Switzerland
| | - Henrik Teuber
- 3Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zürich, Switzerland
| | - Hans-Christoph Pape
- 3Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zürich, Switzerland
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Roy P, Mukherjee R, Parik M. Splenic trauma in the twenty-first century: changing trends in management. Ann R Coll Surg Engl 2018; 100:1-7. [PMID: 30112955 PMCID: PMC6204520 DOI: 10.1308/rcsann.2018.0139] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2018] [Indexed: 12/16/2022] Open
Abstract
Over the past three decades, management of blunt splenic trauma has changed radically. Use of improved diagnostic techniques and proper understanding of disease pathology has led to nonoperative management being chosen as the standard of care in patients who are haemodynamically stable. This review was undertaken to assess available literature regarding changing trends of management of blunt splenic trauma, and to identify the existing lacunae in nonoperative management. The PubMed database was searched for studies published between January 1987 and August 2017, using the keywords 'blunt splenic trauma' and 'nonoperative management'. One hundred and fifty-three articles were reviewed, of which 82 free full texts and free abstracts were used in the current review. There is clear evidence in published literature of the greater success of nonoperative over operative management in patients who are haemodynamically stable and the increasing utility of adjunctive therapies like angiography with embolisation. However, the review revealed a lack of universal guidelines for patient selection criteria and diagnostic and grading procedures needed for nonoperative management. Indications for splenic artery embolisation, the current role of splenectomy and spleen-preserving surgeries, together with the place of minimal access surgery in blunt splenic trauma remain grey areas. Moreover, parameters affecting the outcomes of nonoperative management and its failure and management need to be defined. This shows a need for future studies focused on these shortcomings with the ultimate aim being the formulation and implementation of universally accepted guidelines for safe and efficient management of blunt splenic trauma.
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Affiliation(s)
- P Roy
- RG Kar Medical College and Hospital, General Surgery, Kolkata, India
| | - R Mukherjee
- RG Kar Medical College and Hospital, General Surgery, Kolkata, India
| | - M Parik
- RG Kar Medical College and Hospital, General Surgery, Kolkata, India
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Belli AK, Özcan Ö, Elibol FD, Yazkan C, Dönmez C, Acar E, Nazlı O. Splenectomy proportions are still high in low-grade traumatic splenic injury. Turk J Surg 2018; 34:106-110. [PMID: 30023973 DOI: 10.5152/turkjsurg.2018.3735] [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: 10/25/2016] [Accepted: 05/18/2017] [Indexed: 11/22/2022]
Abstract
Objective The spleen is the most vulnerable organ in blunt abdominal trauma. Spleen-preserving treatments are non-operative management with or without splenic angioembolization, partial splenectomy, and splenorrhaphy. The aim of the present study was to determine the rate of SPTs and to evaluate the usefulness of Injury Severity Score after traumatic splenic injury. Material and Methods We searched our institution's database between May 2012 and December 2015. Patients' clinicopathological features, surgeon's title, type of treatment, admission and discharge dates, duration of surgery, intensive care unit requirement, and Glasgow Coma Scale were recorded. Results The mean age of patients was 33.36±11.58 years. Of the 33 patients, 26 (78.8%) were males, and 7 (21.2%) were females. Thirty (90.9%) had total splenectomy (TS), and 3 (9.1%) had spleen preserving treatment (2 Nonoperative management and 1 partial splenectomy). No fatal hemorrhage developed after nonoperative management. Exitus rates were 5/30 (15.1%) and 0/3 in the total splenectomy and spleen preserving treatment groups, respectively. Of the 18 hemodynamically stable patients, only 2 (11.1%) had spleen preserving treatment. Of the 19 patients with grade I-III splenic injury, only 3 (15.8%) had spleen preserving treatment. For academic and non-academic surgeons, spleen preserving treatment rates were 3/11 (27.3%) and 0/22 (0%), respectively (p<0.05). Injury severity score and mean arterial pressure, number of transfusions, control hematocrit, and GCS had statistically significant relationships. Conclusions Spleen preserving treatment proportions were low after traumatic splenic injury. Following trauma, guidelines will not only improve spleen preservation rates but also improve the overall health status of the patients and it will also prevent complications of splenectomy.
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Affiliation(s)
- Ahmet Korkut Belli
- Departmant of General Surgery, Muğla Sıtkı Koçman University School of Medicine, Muğla, Turkey
| | - Önder Özcan
- Departmant of General Surgery, Muğla Sıtkı Koçman University School of Medicine, Muğla, Turkey
| | - Funda Dinç Elibol
- Department of Radiology, Muğla Sıtkı Koçman University School of Medicine, Muğla, Turkey
| | - Cenk Yazkan
- Departmant of General Surgery, Muğla Sıtkı Koçman University School of Medicine, Muğla, Turkey
| | - Cem Dönmez
- Departmant of General Surgery, Muğla Sıtkı Koçman University School of Medicine, Muğla, Turkey
| | - Ethem Acar
- Department of Emergency Medicine, Muğla Sıtkı Koçman University School of Medicine, Muğla, Turkey
| | - Okay Nazlı
- Departmant of General Surgery, Muğla Sıtkı Koçman University School of Medicine, Muğla, Turkey
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Na JW, Lee JN, Yu BC, Lee MA, Park JJ, Lee GJ. Treatment Option for High Grade Spleen Injury and Predictive Factors for Non-operative Management. JOURNAL OF TRAUMA AND INJURY 2017. [DOI: 10.20408/jti.2017.30.3.91] [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
Affiliation(s)
- Joung Won Na
- Department of Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Jung Nam Lee
- Gachon University Gil Hospital Trauma Center, Incheon, Korea
| | - Byung Chul Yu
- Gachon University Gil Hospital Trauma Center, Incheon, Korea
| | - Min A Lee
- Gachon University Gil Hospital Trauma Center, Incheon, Korea
| | - Jae Jung Park
- Gachon University Gil Hospital Trauma Center, Incheon, Korea
| | - Gil Jae Lee
- Gachon University Gil Hospital Trauma Center, Incheon, Korea
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Dingemans SA, Sier MAT, Peters RW, Goslings JC, Schepers T. Two-stage treatment in patients with patients with high-energy femoral fractures does not lead to an increase in deep infectious complications: a propensity score analysis. Eur J Trauma Emerg Surg 2017; 44:125-131. [PMID: 28755132 PMCID: PMC5808064 DOI: 10.1007/s00068-017-0822-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 07/21/2017] [Indexed: 11/18/2022]
Abstract
Purpose In patients following severe trauma sometimes the physiological condition or soft tissue status may not allow definitive fixation of a femoral fracture. In these patients, an external fixator can be placed to temporarily stabilise the fracture, after which definitive fixation can be performed in a second procedure. The aim of this study was to compare the postoperative wound infection and union rates of patients treated with direct intramedullary nailing (IMN) and patients treated with the ‘two-stage treatment’. Methods All patients with high-energy femoral fractures treated with IMN between 2000 and 2016 in a single Level 1 trauma centre were eligible. Electronic charts were reviewed for patient and surgical characteristics; furthermore, the development of complications was noted. A propensity score analysis was performed to assess the attributed risk of the external fixator on the development of postoperative wound infections. Results A total of 149 patients were included in this study; 93 underwent direct IMN and 56 underwent the two-stage treatment. Patients who underwent two-stage treatment were more severely injured, reflected by lower EMV and higher ISS on admission. Patients in the two-stage treatment group had a significant higher risk of postoperative wound infections (OR: 4.698, 95% CI: 1.203–18.339) but not a higher risk on deep postoperative wound infections (OR 2.345, 95% CI: 0.439–12.540). Union rate did not differ between the two groups (94% vs 94% NS). Conclusions The two-stage treatment is a safe treatment option in patients with a high-energy femoral fracture in terms of postoperative wound infections. Union rates are also comparable between the two treatment groups.
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Affiliation(s)
- S A Dingemans
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - M A T Sier
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - R W Peters
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - J C Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - T Schepers
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
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Olthof DC, van der Vlies CH, Goslings JC. Evidence-Based Management and Controversies in Blunt Splenic Trauma. CURRENT TRAUMA REPORTS 2017; 3:32-37. [PMID: 28303214 PMCID: PMC5332509 DOI: 10.1007/s40719-017-0074-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW The study aims to describe the evidence-based management and controversies in blunt splenic trauma. RECENT FINDINGS A shift from operative management to non-operative management (NOM) has occurred over the past decades where NOM has now become the standard of care in haemodynamically stable patients with blunt splenic injury. Splenic artery embolisation (SAE) is generally believed to increase the success rate of NOM. Not all the available evidence is that optimistic about SAE however. A morbidity specifically related to SAE of up to 47% has been reported. Although high-grade splenic injury is a prognostic factor for failure of NOM, an American research group has published a study in which NOM is performed in over half of haemodynamically stable patients with grade IV or V splenic injury without leading to an increased morbidity (in terms of complications) or mortality. Another area of current investigation in the literature is the exact indication for SAE. Although the generally accepted indication is the presence of vascular injury, a topic of current investigation is whether there might be a role for pre-emptive embolisation in patients with high-grade splenic injury. On the other hand, evidence is also emerging that not all blushes require an intervention (small blushes <1 or 1.5 cm do not). Lastly, the available evidence shows that splenic function is preserved after embolisation, and therefore, the routine administration of vaccinations seems not to be necessary. There might be a difference between proximal and distal embolisations; however, with regard to splenic function, in favour of distal embolisation. SUMMARY Nowadays, NOM is the standard of care in haemodynamically stable patients with blunt splenic injury. The available evidence (although with a relatively small number of patients) shows that splenic function is preserved after NOM, a major advantage compared to splenectomy. SAE is used as an adjunct to observation in order to increase the success rate of NOM. Operative management should be applied in case of haemodynamic instability or if associated intra-abdominal injuries requiring surgical treatment are present. Patient selection (which patient can be safely treated non-operatively, does every blush needs to be embolised?, which patients might be better off with direct operative intervention given the patient and injury characteristics) is an ongoing subject of further research. Future studies should also focus on long-term outcomes of patients treated with embolisation (e.g. total number of lifetime infectious episodes requiring antibiotic treatment or hospital admission, quality of life).
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Affiliation(s)
- D. C. Olthof
- Trauma Unit, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - C. H. van der Vlies
- Division of Trauma Surgery, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, Netherlands
| | - J. C. Goslings
- Trauma Unit, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
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Van der Cruyssen F, Manzelli A. Splenic artery embolization: technically feasible but not necessarily advantageous. World J Emerg Surg 2016; 11:47. [PMID: 27625701 PMCID: PMC5020467 DOI: 10.1186/s13017-016-0100-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/11/2016] [Indexed: 11/16/2022] Open
Abstract
Background The spleen is the second most commonly injured organ in cases of abdominal trauma. Management of splenic injury depends on the clinical status of the patient and can include nonoperative management (NOM), splenic artery embolization (SAE), surgery (operative splenic salvage or splenectomy), or a combination of these treatments. In nonoperatively managed cases, SAE is sometimes used to control haemorrhage. However, the indications for SAE have not been clearly defined and, in some cases, the potential complications of the procedure may outweigh its benefits. Review of the literature Through review of the literature we address the question of when SAE is indicated in combination with NOM of splenic injury, and whether SAE may delay needed surgical treatment in some cases. This systematic review highlighted the use of imperfect and inconsistent scoring systems in the diagnosis of splenic injury, the lack of consensus regarding indications for SAE, and the potential for severe morbidities associated with this procedure. Based on current literature and evidence we provide a new, non-verified, decision algorithm. Conclusions NOM+ SAE involves potential risks and operative management may be preferable to SAE for certain patients. To clarify current literature, we propose a new algorithm for blunt abdominal trauma that should be validated prospectively. New evidence-based protocols should be developed to guide diagnosis and management of patients with splenic trauma. Electronic supplementary material The online version of this article (doi:10.1186/s13017-016-0100-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- F Van der Cruyssen
- Third year master's student, Faculty of Medicine, Catholic University of Leuven (KU Leuven), Gasthuisberg, Belgium
| | - A Manzelli
- Department of Upper Gastrointestinal Surgery, Royal Devon & Exeter Hospital, Exeter, UK
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