Age Does Not Affect Outcomes of Nonoperative Management of Blunt Splenic Trauma

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.

A clinical prediction model for non-operative management failure in patients with high-grade blunt splenic injury

Background

Nonoperative management (NOM) is the standard treatment for hemodynamically stable blunt splenic injury (BSI). However, NOM failure is a significant source of morbidity and mortality. We developed a clinical risk scoring system for NOM failure in BSI.

Methods

Data from the Japanese Trauma Data Bank from 2008 to 2018 were analyzed. Eligible patients were restricted to those who underwent NOM with high-grade BSI (Organ Injury Scale ≥3). The primary outcome was a predictive score for NOM failure based on risk estimation.

Results

There were 1651 patients included in this analysis, among whom 110 (6.7%) patients had NOM failure. Multivariate analysis identified seven variables associated with failed NOM: systolic blood pressure, Glasgow coma scale, Injury Severity Score, other concomitant abdominal injury, pelvic injury, high-grade BSI, and angioembolization. An eight-point predictive score was developed with a cut-off of greater than 5 points (specificity, 98.2%; sensitivity, 25.5%) with an area under the curve of 0.81.

Conclusion

The clinical predictive score had good ability to predict NOM failure and may help surgeons to make better decisions for BSI.

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

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

Trends in the Nature and Management of Serious Abdominal Trauma

BACKGROUND

There have been recommendations for increased non-operative management (NOM) of abdominal trauma in adults. To assess the impact of this trend and changes in the epidemiology of trauma, we examined the management of serious abdominal injuries and mortality, in Victorian major trauma patients 16 years or older, between 2007 and 2016.

METHODS

Using data from the population-based Victorian Trauma Registry, characteristics of patients who underwent laparotomy, embolisation, laparotomy and embolisation, or NOM, were compared with the Chi-square test. Poisson regression was used to determine whether the incidence of serious abdominal injury changed over time. Temporal trends in the management of abdominal injury and in-hospital mortality were analysed using, respectively, the Chi-square test for trend, and multivariable logistic regression.

RESULTS

Of 2385 patients with serious abdominal injuries, 69% (n = 1649) had an intervention; predominantly a laparotomy (n = 1166). The proportion undergoing laparotomy decreased from 60% in 2007 to 44% in 2016 (p < 0.001), whilst embolisation increased from 6 to 20% (p < 0.001). Population-adjusted incidence of abdominal injury increased 1.6% per year (IRR 1.016, 95% CI 1.002-1.031; p < 0.024), predominantly in people aged 65 years and over (4.6% per year). Adjusted odds of in-hospital mortality declined 6.0% per year (adjusted odds ratio 0.94; 95% CI 0.89, 1.00; p = 0.04).

CONCLUSIONS

Whilst the incidence of major abdominal trauma increased during the study period, there was a reduction in the proportion of patients managed with laparotomy and reduction in the adjusted odds of in-hospital mortality. Older patients, for whom management is influenced by the complex interplay of frailty and co-morbidities, had lower laparotomy rates.

The need for red blood cell transfusions in the emergency department as a risk factor for failure of non-operative management of splenic trauma: a multicenter prospective study

INTRODUCTION

The majority of patients with splenic trauma undergo non-operative management (NOM); around 15% of these cases fail NOM and require surgery. The aim of the current study is to assess whether the hemodynamic status of the patient represents a risk factor for failure of NOM (fNOM) and if this may be considered a relevant factor in the decision-making process, especially in Centers where AE (angioembolization), intensive monitoring and 24-h-operating room are not available. Furthermore, the presence of additional risk factors for fNOM was investigated.

MATERIALS AND METHODS

This is a multicentre prospective observational study, including patients presenting with blunt splenic trauma older than 17 years, managed between 2014 and 2016 in two Italian trauma centres (ASST Papa Giovanni XXIII in Bergamo and Sant'Anna University Hospital in Ferrara-Italy). The risk factors for fNOM were analyzed with univariate and multivariate analyses.

RESULTS

In total, 124 patients were included in the study. In univariate analysis, the risk factors for fNOM were AAST grade > 3 (fNOM 37.5% vs 9.1%, p = 0.024), and the need of red blood cell (RBC) transfusion in the emergency department (ED) (fNOM 42.9% vs 8.9%, p = 0.011). Multivariate analysis showed that the only significant risk factor for fNOM was the need for RBC transfusion in the ED (p = 0.049).

CONCLUSIONS

The current study confirms the contraindication to NOM in case of hemodynamically instability in case of splenic trauma, as indicated by the most recent guidelines; attention should be paid to patients with transient hemodynamic stability, including patients who require transfusion of RBC in the ED. These patients could benefit from AE; in centers where AE, intensive monitoring and an 24-h-operating room are not available, this particular subgroup of patients should probably be treated with operative management.

The role of splenic angioembolization as an adjunct to nonoperative management of blunt splenic injuries: A systematic review and meta-analysis

BACKGROUND

Nonoperative management (NOM) of hemodynamically normal patients with blunt splenic injury (BSI) is the standard of care. Guidelines recommend additional splenic angioembolization (SAE) in patients with American Association for the Surgery of Trauma (AAST) Grade IV and Grade V BSI, but the role of SAE in Grade III injuries is unclear and controversial. The aim of this systematic review was to compare the safety and effectiveness of SAE as an adjunct to NOM versus NOM alone in adults with BSI.

METHODS

A systematic literature search (Medline, Embase, and CINAHL) was performed to identify original studies that compared outcomes in adult BSI patients treated with SAE or NOM alone. Primary outcome was failure of NOM. Secondary outcomes included morbidity, mortality, hospital length of stay, and transfusion requirements. Bayesian meta-analyses were used to calculate an absolute (risk difference) and relative (risk ratio [RR]) measure of treatment effect for each outcome.

RESULTS

Twenty-three studies (6,684 patients) were included. For Grades I to V combined, there was no difference in NOM failure rate (SAE, 8.6% vs NOM, 7.7%; RR, 1.09 [0.80-1.51]; p = 0.28), mortality (SAE, 4.8% vs NOM, 5.8%; RR, 0.82 [0.45-1.31]; p = 0.81), hospital length of stay (11.3 vs 9.5 days; p = 0.06), or blood transfusion requirements (1.8 vs 1.7 units; p = 0.47) between patients treated with SAE and those treated with NOM alone. However, morbidity was significantly higher in patients treated with SAE (SAE, 38.1% vs NOM, 18.6%; RR, 1.83 [1.20-2.66]; p < 0.01). When stratified by grade of splenic injury, SAE significantly reduced the failure rate of NOM in patients with Grade IV and Grade V splenic injuries but had minimal effect in those with Grade I to Grade III injuries.

CONCLUSION

Splenic angioembolization should be strongly considered as an adjunct to NOM in patients with AAST Grade IV and Grade V BSI but should not be routinely recommended in patients with AAST Grade I to Grade III injuries.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Surgical Management of Solid Organ Injuries

Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.

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

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

MAIN CONTROVERSIES IN THE NONOPERATIVE MANAGEMENT OF BLUNT SPLENIC INJURIES

Introduction :

The nonoperative management of traumatic spleen injuries is the modality of choice in patients with blunt abdominal trauma and hemodynamic stability. However, there are still questions about the treatment indication in some groups of patients, as well as its follow-up.

Aim:

Update knowledge about the spleen injury.

Method :

Was performed review of the literature on the nonoperative management of blunt injuries of the spleen in databases: Cochrane Library, Medline and SciELO. Were evaluated articles in English and Portuguese, between 1955 and 2014, using the headings "splenic injury, nonoperative management and blunt abdominal trauma".

Results :

Were selected 35 articles. Most of them were recommendation grade B and C.

Conclusion :

The spleen traumatic injuries are frequent and its nonoperative management is a worldwide trend. The available literature does not explain all aspects on treatment. The authors developed a systematization of care based on the best available scientific evidence to better treat this condition.

The impacts of different embolization techniques on splenic artery embolization for blunt splenic injury: a systematic review and meta-analysis

BACKGROUND

Splenic artery embolization (SAE) has been an effective adjunct to the Non-operative management (NOM) for blunt splenic injury (BSI). However, the optimal embolization techniques are still inconclusive. To further understand the roles of different embolization locations and embolic materials in SAE, we conducted this system review and meta-analyses.

METHODS

Clinical studies related to SAE for adult patients were researched in electronic databases, included PubMed, Embase, ScienceDirect and Google Scholar Search (between October 1991 and March 2013), and relevant information was extracted. To eliminate the heterogeneity, a sensitivity analysis was conducted on two reduced study sets. Then, the pooled outcomes were compared and the quality assessments were performed using Newcastle-Ottawa Scale (NOS). The SAE success rate, incidences of life-threatening complications of different embolization techniques were compared by χ² test in 1st study set. Associations between different embolization techniques and clinical outcomes were evaluated by fixed-effects model in 2nd study set.

RESULTS

Twenty-three studies were included in 1st study set. And then, 13 of them were excluded, because lack of the necessary details of SAE. The remaining 10 studies comprised 2nd study set, and quality assessments were performed using NOS. In 1st set, the primary success rate is 90.1% and the incidence of life-threatening complications is 20.4%, though the cases which required surgical intervention are very few (6.4%). For different embolization locations, there was no obvious association between primary success rate and embolization location in both 1st and 2nd study sets (P > 0.05). But in 2nd study set, it indicated that proximal embolization reduced severe complications and complications needed surgical management. As for the embolic materials, the success rate between coil and gelfoam is not significant. However, coil is associated with a lower risk of life-threatening complications, as well as less complications requiring surgical management.

CONCLUSIONS

Different embolization techniques affect the clinical outcomes of SAE. The proximal embolization is the best option due to the less life-threatening complications. For commonly embolic material, coil is superior to gelfoam for fewer severe complications and less further surgery management.

Nonoperative management of splenic injuries: significance of age

BACKGROUND

In the nonoperative management (NOM) of blunt splenic injuries (BSI), the clinical relevance of age as a risk factor has not been well studied.

METHODS

Using the 2011 National Trauma Data Bank data set, age was analyzed both as a continuous variable and a categorical variable (group 1 [13-54 y], group 2 [55-74 y], and group 3 [≥75 y]). BSI severity was stratified by abbreviated injury scale (AIS): group 1 (AIS ≤2), group 2 (AIS 3), and group 3 (AIS ≥4). A semiparametric proportional odds model was used to model NOM outcomes and effects due to age and BSI severity.

RESULTS

Of 15,113 subjects, 15.3% failed NOM. The odds of failure increased by a factor of 1.014 for each year of age, or factor of 1.5 for groups 2 and 3 each. BSI severity groups 2 and 3 had increases in the odds of failure by factors of 3.9 and 13, respectively, compared with those of group 1. Most failures occurred by 48 h irrespective of age. The effect of age was most pronounced in age groups 2 and 3 with the most severe BSI, where a NOM failure rate of >50% was seen. Both age and failure of NOM were independent predictors of mortality.

CONCLUSIONS

Age is associated with failure of NOM but its effect seems more clinically relevant only in high-grade BSI. Factors that could influence NOM success in elderly patients with high-grade injuries deserve further study.

Age-related mortality in blunt traumatic hemorrhagic shock: the killers and the life savers

BACKGROUND

There are sparse data on the association between age and mortality in hemorrhagic shock (HS). We examined this association in this study.

MATERIALS AND METHODS

The Glue Grant database was analyzed. Patients aged ≥16 y with blunt traumatic HS were stratified into eight age groups (16-24, 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and ≥85 y) to identify the mortality inflection point. Subsequently, patients were restratified into young age (16-44 y), middle age (45-64 y), and elderly (≥65 y). Multivariate analysis was used to determine predictors of mortality by group.

RESULTS

A total of 1976 patients were included, with mortality of 16%. Mortality by initial age group is as follows: 16-24 (13.0%), 25-34 (11.9%), 35-44 (11.9%), 45-54 (15.6%), 55-64 (15.7%), 65-74 (20.3%), 75-84 (38.2%), and ≥85 y (51.6%), delineating 65 y as the mortality inflection point. Overall, 55% were young, 30% middle age, and 15% elderly. Predictors of mortality in the young include multiple-organ dysfunction score (MODS; odds ratio [OR]: 1.93, confidence interval [CI]: 1.62-2.30), emergency room lactate (OR: 1.14, CI: 1.02-1.27), injury severity score (OR: 1.06, CI: 1.03-1.09), and cardiac arrest (OR: 10.60, CI: 3.05-36.86). Predictors of mortality in the middle age include MODS (OR: 1.38, CI: 1.24-1.53), cardiac arrest (OR: 12.24, CI: 5.38-27.81), craniotomy (OR: 5.62, CI: 1.93-16.37), and thoracotomy (OR: 2.76, CI: 1.28-5.98). In the elderly, predictors of mortality were age (OR: 1.07, CI: 1.02-1.13), MODS (OR: 1.47, CI: 1.26-1.72), laparotomy (OR: 2.04, CI: 1.02-4.08), and cardiac arrest (OR: 11.61, CI: 4.35-30.98). Open fixation of nonfemoral fractures was protective against mortality in all age groups.

CONCLUSIONS

In blunt HS, mortality parallels increasing age, with the inflection point at 65 y. MODS and cardiac arrest uniformly predict mortality across all age groups. Craniotomy and thoracotomy are associated with mortality in the middle age, whereas laparotomy is associated with mortality in the elderly.

Cirrhosis increases mortality and splenectomy rates following splenic injury

BACKGROUND

Cirrhosis may be a risk factor for mortality following blunt splenic injury (BSI) and it predicts the need for an operative intervention.

METHODS

We performed a case-control study at 3 level 1 trauma centers. Comparisons were made with chi-square test, Wilcoxon rank-sum test, and binary logistic regression, and stratified by propensity for splenectomy. Data are presented as odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

Mortality was 27% (21/77) and cirrhosis was a strong risk factor for death (OR 8.8, 95% CI 3.7 to 21.1). Compared with controls, cirrhosis was an independent risk factor for splenectomy (OR 5.4, 95% CI 2.5 to 11.5), and only splenic injury grade was associated with splenectomy (OR 2.2, 95% CI 1.3 to 3.6). Only admission model for end-stage liver disease was independently associated with mortality after an operation (OR 1.7, 95% CI 1.1 to 2.8). After propensity score matching, we found no association between splenectomy and mortality in cirrhotic patients.

CONCLUSION

Cirrhosis dramatically increases mortality and the odds of an operative intervention in BSI patients with pre-existing cirrhosis, and BSI requires vigilant attention and early intervention should be considered.

Nonoperative management of splenic injury grade IV is safe using rigid protocol

OBJECTIVE

To demonstrate the protocol and experience of our service in the nonoperative management (NOM) of grade IV blunt splenic injuries.

METHODS

This is a retrospective study based on trauma registry of a university hospital between 1990-2010. Charts of all patients with splenic injury were reviewed and patients with grade IV lesions treated nonoperatively were included in the study.

RESULTS

ninety-four patients with grade IV blunt splenic injury were admitted during this period. Twenty-six (27.6%) met the inclusion criteria for NOM. The average systolic blood pressure on admission was 113.07 ± 22.22 mmHg, RTS 7.66 ± 0.49 and ISS 18.34 ± 3.90. Ten patients (38.5%) required blood transfusion, with a mean of 1.92 ± 1.77 packed red cells per patient. Associated abdominal injuries were present in two patients (7.7%). NOM failed in two patients (7.7%), operated on due to worsening of abdominal pain and hypovolemic shock. No patient developed complications related to the spleen and there were no deaths in this series. Average length of hospital stay was 7.12 ± 1.98 days.

CONCLUSION

Nonoperative treatment of grade IV splenic injuries in blunt abdominal trauma is safe when a rigid protocol is followed.

Literature review of non-operative management of patients with blunt splenic injury: impact of splenic artery embolization

Splenic injuries constitute the most common injuries accompanying blunt abdominal traumas. Non-operative treatment is currently the standard for treating hemodynamically stable patients with blunt splenic injuries. The introduction of splenic angiography has increased the possibility of non-operative treatment for patients who, in the past, would have qualified for surgery. This cohort includes mainly patients with severe splenic injuries and with active bleeding. The results have indicated that applying splenic angioembolization reduces the frequency of non-operative treatment failure, especially in severe splenic injuries; however, it is still necessary to perform prospective, randomized clinical investigations.

Trauma center variation in splenic artery embolization and spleen salvage: a multicenter analysis

BACKGROUND

This study aimed to evaluate if variation in management of blunt splenic injury (BSI) among Level I trauma centers is associated with different outcomes related to the use of splenic artery embolization (SAE).

METHODS

All adult patients admitted for BSI from 2008 to 2010 at 4 Level I trauma centers were reviewed. Use of SAE was determined, and outcomes of spleen salvage and nonoperative management (NOM) failure were evaluated. A priori, a 10% SAE rate was used to group centers into high- or low-use groups.

RESULTS

There were 1,275 BSI patients. There were intercenter differences in age, injury severity, and grade of spleen injury (Spleen Injury Scale [SIS]). Mortality was similar by center; however, BSI treatment varied significantly by center. Overall, SAE use was highest at center A compared with B, C, and D (19%, 11%, 1%, and 4%, respectively; p < 0.01). High SAE use centers had significantly higher spleen salvage rates and fewer NOM failures. Differences in the use of SAE (25% vs. 2%, p < 0.01) and salvage rate (67% vs. 56%, p = 0.03) were most dramatic between high- and low-use SAE centers for Grade 3 and 4 injured spleens. In patients who received initial NOM, multivariate logistic regression analysis showed that SAE was an independent predictor of spleen salvage (odds ratio, 5; 95% confidence interval, 1.8-13.5; p < 0.01) as were lower age, lower SIS, and Injury Severity Score (ISS). Patients treated at high SAE use centers were more likely to leave the hospital with their spleen in situ (odds ratio, 3; 95% confidence interval, 1.7-6.3; p < 0.01).

CONCLUSION

Significant practice variation exists in the use of SAE in treating BSI at Level I trauma centers. Centers with higher rates of SAE use have higher spleen salvage and less NOM failure. SAE was shown to be an independent predictor of spleen salvage.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Starting the clock: defining nonoperative management of blunt splenic injury by time

BACKGROUND

There is no consensus when the designation of nonoperative management (NOM) for splenic injury (BSI) should start. We evaluated NOM success rates based on different time points after admission.

METHODS

The National Trauma Data Bank was evaluated for BSI for the year 2008. Observations were evaluated by facility, the time to splenectomy, and the volume of BSI admissions.

RESULTS

Of 15,732 BSIs identified, the overall splenectomy salvage rate was 81%. After the 5th hour, the NOM success rate was 95%. Multivariable analysis revealed that higher BSI grades, level 2 centers and community hospitals, and age ≥55 were associated with failed NOM.

CONCLUSIONS

The grade of injury is an important predictor for failure of NOM. If a 5% failure rate is to be considered a benchmark, then the 5-hour time point after admission should be used for the calculation of NOM success rates.