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

Prophylactic embolization versus observation for high-grade blunt trauma splenic injury: a systematic review with meta-analysis

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.

Angioembolization for splenic injuries: does it help? Retrospective evaluation of grade III-V splenic injuries at two level I trauma centers

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.

Non-operative management of high-grade splenic injury: a systematic review protocol

OBJECTIVE

The objective of this review is to establish whether embolization is more effective than clinical observation for adult patients with grade III-V splenic injuries. The findings will be used to guide future practice and, if necessary, inform future research design and conduct.

INTRODUCTION

The spleen is one of the most frequently injured intra-abdominal organs, with a reported adult mortality of 7% to 18% following trauma. Non-operative management has become a standard of care for hemodynamically stable patients. In clinical practice, the decision whether to prophylactically embolize or manage high-grade injuries with observation alone remains controversial.

INCLUSION CRITERIA

Sources including adult patients with grade III-V splenic injuries secondary to blunt trauma will be included in this review. Eligible studies must include comparisons between 2 cohorts of patients undergoing either prophylactic embolization or clinical observation only. Outcomes will include mortality rate, failure of treatment, intensive care unit admission, length of hospital stay, blood transfusion requirements, and patient satisfaction.

METHODS

A systematic review with meta-analysis will be conducted. PubMed, Embase, and CINAHL will be searched for eligible studies, as will trial registries and sources of gray literature. Study selection, quality appraisal, and data extraction of outcomes will be performed in duplicate. Methodological quality will be evaluated using JBI critical appraisal tools. Studies will, where possible, be pooled in statistical meta-analysis. A random effects model will be used and statistical analysis will be performed. The certainty of the findings will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

REVIEW REGISTRATION

PROSPERO CRD42023420220.

Splenic artery embolisation for splenic injury during colonoscopy: A systematic review

BACKGROUND

Splenic injury due to colonoscopy is rare, but has high mortality. While historically treated conservatively for low-grade injuries or with splenectomy for high-grade injuries, splenic artery embolisation is increasingly utilised, reflecting modern treatment guidelines for external blunt trauma. This systematic review evaluates outcomes of published cases of splenic injury due to colonoscopy treated with splenic artery embolisation.

METHODS

A systematic review was performed of published articles concerning splenic injury during colonoscopy treated primarily with splenic artery embolisation, splenectomy, or splenorrhaphy from 1977 to 2022. Datapoints included demographics, past surgical history, indication for colonoscopy, delay to diagnosis, treatment, grade of injury, splenic artery embolisation location, splenic preservation (salvage), and mortality.

RESULTS

The 30 patients treated with splenic artery embolisation were of mean age 65 (SD 9) years and 67% female, with 83% avoiding splenectomy and 6.7% mortality. Splenic artery embolisation was proximal to the splenic hilum in 81%. The 163 patients treated with splenectomy were of mean age 65 (SD 11) years and 66% female, with 5.5% mortality. Three patients treated with splenorrhaphy of median age 60 (range 59-70) years all avoided splenectomy with no mortality. There was no difference in mortality between splenic artery embolisation and splenectomy cohorts (p = 0.81).

CONCLUSIONS

Splenic artery embolisation is an effective treatment option in splenic injury due to colonoscopy. Given the known benefits of splenic salvage compared to splenectomy, including preserved immune function against encapsulated organisms, low cost, and shorter hospital length of stay, embolisation should be incorporated into treatment pathways for splenic injury due to colonoscopy in suitable patients.

Blunt abdominal trauma: watch and wait

PURPOSE OF REVIEW

This review examines recent advancements in nonoperative management (NOM) of hemodynamically stable blunt abdominal trauma, focusing on expanding patient selection for observation-first strategies, particularly for high-grade solid organ injuries.

RECENT FINDINGS

Advances include a more deliberate nonoperative approach, allowing for broader patient inclusion in diagnostic and interventional angiography. Strict clinical monitoring and appropriate follow-up strategies are crucial to identify early signs of clinical progression and complications. Repeated contrast-enhanced CT (CECT) scan can be used for close observation of high-risk injuries, while the repetition of CECTs may be avoided for lower-risk cases, such as specific high-grade kidney injuries. The role of contrast-enhanced ultrasound (CEUS) in detecting sequelae of nonoperative approaches is still debated and has lot of potential, with ongoing trials exploring possible advantages.

SUMMARY

Multidisciplinary trauma teams play a crucial role in nonoperative management, particularly for high-grade injuries. A careful selection of patients is essential to minimize failure rates. Complications of nonoperative and angiographic approaches should be managed according to local expertise.

Splenic trauma in the Northern Territory; the impact of an interventional radiology service on splenic trauma management and outcomes

Background

The spleen is the most commonly injured organ in abdominal trauma. Guidelines suggest non-operative management (NOM) is preferred over splenectomy for all haemodynamically stable patients, regardless of injury severity. The availability of splenic angioembolization has been shown to improve outcomes for high-grade splenic injuries by decreasing failure rates of NOM. Trauma incidence and fatality rates are higher in regional and remote areas, and rurality is associated with increased mortality from trauma. Additionally, rural hospitals have difficulty with staff retention and may offer less specialist services compared with urban centres.

Methods

A single-centre retrospective cohort study was conducted at the Royal Darwin Hospital, using the National Critical Care and Trauma Response Centre database. All patients with splenic injury admitted between January 2018 and December 2021 were selected, and divided into control and intervention cohorts, before and after January 1, 2020, correlating with interventional radiology availability. Demographic information included age, gender, mechanism of injury, AIS grade of splenic injury, injury severity score, and shock index. The primary outcome was management of splenic injury and failure rate of NOM. Secondary outcomes included mortality, ICU length of stay and hospital length of stay.

Results

Sixty-six patients met inclusion criteria, 32 controls and 34 interventions. Intervention and control groups were statistically similar for baseline demographics, and outcome measures of mortality and ICU length of stay. There was significant difference in the management of splenic injury, either OM or NOM, between intervention and control cohorts among high-grade splenic injury patients (AIS grade 4 and 5). In logistic regression analysis, the absence of interventional radiology was associated with increased OM (OR 12.8, SE 15.7, p = 0.04, 95%CI 1.15-142).

Conclusion

The absence of an interventional radiology service was associated with an increased risk of operative management, suggesting interventional radiology helps to prevent splenectomy, improving long term outcomes for splenic trauma patients in regional settings. The effects of availability of IR seen in international publications on decreased mortality and shorter length of stay were not replicated in this study.

Splenic Heterogeneity in Focused Assessment With Sonography for Trauma (FAST) Scan Led to the Diagnosis of Grade 2 Splenic Injury in a Pediatric Blunt Abdominal Trauma

Splenic injuries are one of the most common injuries following blunt abdominal trauma. It occurs in 32% of blunt abdominal trauma, with motor vehicle accidents being the most common cause. The patient may present with generalized abdominal pain or left upper quadrant pain associated with left shoulder pain. Hemodynamic instability is one of the most reliable signs of splenic injuries. A focused assessment with sonography for trauma (FAST) scan is the initial imaging used to assess for solid organ injury in the abdomen, followed by computed tomography (CT) scans. Evidence of free fluid in the abdomen in the FAST scan indicates a solid organ injury. However, the absence of the before-mentioned finding does not rule out the presence of solid organ injury. Hereby a case of a 13-year-old Saudi male with left-sided abdominal pain after falling from a motorbike. A set of the investigation was done with insignificant results. However, FAST revealed a heterogenous appearance in the spleen. Thus, the patient subsequently underwent abdominal CT scans. The patient was managed conservatively and then discharged against medical advice (DAMA). Previously documented cases have mentioned the presence of free fluid in the abdomen in FAST scan in a stable patient leading to undergoing a CT scan and further managing trauma victim patients, which was absent in the present case.