The lost art of the splenorrhaphy

Management of Pediatric Solid Organ Injuries

Solid organ injury (SOI) is common in children who experience abdominal trauma, and the management of such injuries has evolved significantly over the past several decades. In 2000, the American Pediatric Surgical Association (APSA) published the first societal guidelines for the management of blunt spleen and/or liver injury (BLSI), advocating for optimized resource utilization while maintaining patient safety. Nonoperative management (NOM) has become the mainstay of treatment for SOI, and since the publication of the APSA guidelines, numerous groups have evaluated how invasive procedures, hospitalization, and activity restrictions may be safely minimized in children with SOI. Here, we review the current evidence-based management guidelines in place for the treatment of injuries to the spleen, liver, kidney, and pancreas in children, including initial evaluation, inpatient management, and long-term care, as well as gaps that exist in the current literature that may be targeted for further optimization of protocols for pediatric SOI.

Treatment of Severe Blunt Splenic Injury Varies Across Race and Insurance Type of Pediatric Patients

INTRODUCTION

Racial and ethnic disparities in the management of adult patients with blunt splenic injuries (BSIs) have been previously demonstrated. It is unknown if similar disparities exist in pediatric patients with BSIs. Management of BSIs can include operative management, but nonoperative management (NOM) is preferred. This study assesses the association of race and insurance status on use of NOM among pediatric (aged < 18 y) patients following BSI.

MATERIALS AND METHODS

Data were abstracted from the American College of Surgeons Trauma Quality Improvement Program Participant Use Files for calendar years 2013-2017. Multivariate logistic regression was used to evaluate the associations between race or insurance status and NOM while controlling for injury severity, age, and facility type. Secondary outcomes included blood transfusion within 24 h and hospital length of stay.

RESULTS

We analyzed 1436 pediatric BSI patients. Black, non-Hispanic patients were less likely (odds ratio: 0.45, 95% confidence interval: 0.21-1.02, P = 0.043) to undergo NOM and stayed 0.6 d longer (P = 0.010) than White, non-Hispanic patients. Uninsured patients were less likely (odds ratio: 0.52, 95% CI: 0.25-1.11, P = 0.080) to undergo NOM and publicly insured patients stayed 0.24 d (P = 0.048) longer than privately insured patients.

CONCLUSIONS

We found disparities in use of NOM for Black patients and uninsured patients as well as differences in length of stay. These results extend the literature on racial and socioeconomic disparities in care of trauma patients to pediatric BSI patients. Addressing these disparities requires additional studies aimed at identifying the underlying causes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic surgery for splenic injuries in the era of non-operative management: current status and future perspectives

The spleen is one of the organs most commonly injured by blunt abdominal trauma. It plays an important role in immune response to infections, especially those sustained by encapsulated bacteria. Nonoperative management (NOM), comprising clinical and radiological observation with or without angioembolization, is the treatment of choice for traumatic splenic injury in patients who are hemodynamically stable. However, this strategy carries a risk of failure, especially for high-grade injuries. No clear predictors of failure have been identified, but minimally invasive surgery for splenic injury is gaining popularity. Laparoscopic surgery has been proposed as an alternative to open surgery for hemodynamically stable patients who require surgery, such as after failed NOM. We reviewed research articles on laparoscopic surgery for hemodynamically stable patients with splenic trauma to explore the current knowledge about this topic. After presenting an overview of the treatments for splenic trauma and the immunological function of the spleen, we try to identify the future indications for laparoscopic surgery in the era of NOM.