Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma

Frequency of splenectomy for pediatric splenic injury in Brazil: a retrospective analysis

Background

Non-operative management for pediatric blunt splenic injury is well established in high-income countries, leading to a low splenectomy rate in hemodynamically stable children. Splenectomy rate became a quality indicator for Trauma Center verification utilized by the American College of Surgeons Committee on Trauma. However, data on splenectomy rate in children from countries with different income levels, such as Brazil, remain limited. This study aimed to assess the post-traumatic splenectomy rate among Brazilian children over the past decade and the relation with local resources.

Methods

Data on pediatric splenic injuries and splenectomies from 2008 to 2019, including patient age and admitting service (adult or pediatric), were obtained from FioCruz database, a public, free, cloud-based platform that offers extensive national health data. The regional numbers of pediatric surgeons, pediatric intensive care unit (PICU) beds, and computed tomography scanners were obtained from Brazilian national databases. A national analysis of splenectomy rate by year and service of admission and an analysis of splenectomy rate by the level of regional resources, the number of pediatric surgeons, PICU beds, and computed tomography scanners was performed.

Findings

4061 children were hospitalized with a splenic injury, and 2287 (51.8%) of them underwent splenectomy, unchanged over time. 76.8% were male and 23.1% female patients with splenic injury. Mean age was 11.61 years old. The odds of splenectomy was 14.77 times higher for pediatric patients admitted under adult surgical service compared to pediatric service (OR = 14.77, 95% CI 11.75-18.56, p < 0.0001). The overall increase in pediatric surgeons, PICU beds, and CT scanner availability did not correspond with changes in splenectomy rate.

Interpretation

The post-traumatic splenectomy rate among Brazilian children is high, far exceeding that of high-income countries. Increased regional pediatric resources did not correspond to a decrease in splenectomy rate. Further research is essential to understand Brazil's barriers to adopting non-operative management for pediatric splenic injuries.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Pediatric trauma patients with isolated grade III blunt splenic injuries may be safely managed without intensive care unit admission

BACKGROUND

Non-operative management is the standard of care for pediatric blunt splenic injury. The American Pediatric Surgical Association recommends intensive care unit monitoring only for grade IV/V blunt splenic injury; however, variation remains regarding this practice. We hypothesized that pediatric trauma patients with near-isolated grade III blunt splenic injuries admitted to a non-intensive care unit setting would have similar outcomes to those admitted to the intensive care unit.

METHODS

The 2017 to 2019 Trauma Quality Improvement Program database was queried for blunt pediatric trauma patients (≤16 years) with near-isolated grade III blunt splenic injuries. Patients with systolic blood pressure <90 mmHg or heart rate >90 were excluded. Pediatric trauma patients admitted to the intensive care unit were compared to non-intensive care unit admissions. The primary outcome was splenectomy. Bivariate analyses were performed.

RESULTS

Of 461 pediatric trauma patients with near-isolated grade III blunt splenic injuries, 186 (40.3%) were admitted to the intensive care unit. Intensive care unit patients were older than their non-intensive care unit counterparts (15 vs 14 years, P = .03). Intensive care unit and non-intensive care unit patients had a similar rate of splenectomy (0.5% vs 0.7%, P = .80) and time to surgery (19.7 vs 19.8 hours, P = .98). Patients admitted to the intensive care unit had a longer length of stay (4 vs 3 days, P < .001). There were no significant complications or deaths in either group.

CONCLUSION

This national analysis demonstrated that hemodynamically stable pediatric trauma patients with near-isolated grade III blunt splenic injuries admitted to the floor or intensive care unit had a similar rate of splenectomy without complications or deaths. This aligns with American Pediatric Surgical Association recommendations that pediatric trauma patients with grade III blunt splenic injuries be managed in non-intensive care unit settings. Widespread adoption is warranted and should lead to decreased healthcare expenditures.

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

BACKGROUND

The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.

METHODS

Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.

RESULTS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.

CONCLUSIONS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

Splenic Trauma in the Immunocompromised: Unveiling Complexities and Dilemmas

The incidence of splenectomy due to traumatic injuries has decreased globally, owing to the advancements in hospital facilities and angioembolization techniques. Nevertheless, some patients still undergo splenectomy, leading to a lifelong risk of post-splenectomy sepsis. This risk is particularly heightened in immunocompromised individuals, presenting significant challenges in managing and preventing such infections. Compounding these challenges is the absence of comprehensive national guidelines and a splenic registry. While there have been improvements in postoperative prophylaxis through vaccination, patient education, and antibiotic usage, evidence supporting these strategies in immunocompromised patients remains lacking. Thus, there is an urgent need for expanded research in these areas to mitigate the morbidity and mortality associated with post-splenectomy sepsis in this vulnerable population. We report our experience of a young male having a penetrating abdominal injury who underwent splenectomy and had an immunocompromised status with both Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV) positive status.

Pre- and post-implementation protocol for non-operative management of grade III-V splenic injuries: An observational study

Background

Grade (III-V) blunt splenic injuries (BSI) in hemodynamically stable patients represent clinical challenges for successful non-operative management (NOM). In 2014, Our institution proposed a treatment protocol requiring splenic angiography and embolization for stable, intermediate, and high-grade BSI. It also included a follow-up CT scan for grade III BSI. We sought to assess the success rate of NOM in treating intermediate and high-grade BSI, following a standardized treatment protocol at a level 1 trauma center.

Methods

An observational retrospective study was conducted. Data of patients with BSI from June 2011 to September 2019 were reviewed using the Qatar National Trauma Registry. Patients' demographics, CT scan and angiographic findings, grade of splenic injuries, and outcomes were analyzed. The pre- and post-implementation of treatment protocol periods were compared.

Results

During the study period, a total of 552 hemodynamically stable patients with BSI were admitted, of which 240 had BSI with grade III to V. Eighty-one patients (33.8%) were admitted in the pre-protocol implementation period and 159 (66.2%) in the post-protocol implementation period. The NOM rate increased from 50.6% in the pre-protocol group to 65.6% in the post-protocol group (p = 0.02). In addition, failure of the conservative treatment did not significantly differ in the two periods, while the requirement for blood transfusion dropped from 64.2% to 45.9% (p = 0.007). The frequency of CT scan follow-up (55.3% vs. 16.3%, p = 0.001) and splenic arterial embolization (32.7% vs. 2.5%, p = 0.001) in NOM patients increased significantly in the post-protocol group compared to the pre-protocol group. Overall mortality was similar between the two periods. However, hospital and ICU length of stay and ventilatory days were higher in the post-protocol group.

Conclusions

NOM is an effective and safe treatment option for grade III-V BSI patients. Using standardized treatment guidelines for intermediate-to high-grade splenic injuries could increase the success rate for NOM and limit unnecessary laparotomy. Moreover, angioembolization is a crucial adjunct to NOM that could improve the success rate.

A pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms?

BACKGROUND

Splenic embolization for traumatic vascular abnormalities in stable patients is a common practice. We hypothesize that modern contrast-enhanced computed tomography (CT) over diagnoses posttraumatic splenic vascular lesions, such as intraparenchymal pseudoaneurysms (PSA) that may not require embolization.

METHODS

We reviewed the experience at our high-volume center with endovascular management of blunt splenic injuries from January 2016 to December 2021. Multidisciplinary review was used to compared initial CT findings with subsequent angiography, analyzing management and outcomes of identified vascular lesions.

RESULTS

Of 853 splenic injuries managed overall during the study period, 255 (29.9%) underwent angiography of the spleen at any point during hospitalization. Vascular lesions were identified on 58% of initial CTs; extravasation (12.2%) and PSA (51.0%). Angiography was performed a mean of 22 hours after admission, with 38% done within 6 hours. Embolization was performed for 90.5% (231) of patients. Among the 130 patients with PSA on initial CT, 36 (27.7%) had no visible lesion on subsequent angiogram. From the 125 individuals who did not have a PSA identified on their initial CT, 67 (54%) had a PSA seen on subsequent angiography. On postembolization CT at 48 hours to 72 hours, persistently perfused splenic PSAs were seen in 41.0% (48/117) of those with and 22.2% (2/9) without embolization. Only one of 24 (4.1%) patients with PSA on angiography observed without embolization required delayed splenectomy, whereas 6.9% (16/231) in the embolized group had splenectomy at a mean of 5.5 ± 4 days after admission.

CONCLUSION

There is a high rate of discordance between CT and angiographic identification of splenic PSAs. Even when identified at angiogram and embolized, close to half will remain perfused on follow-up imaging. These findings question the use of routine angioembolization for all splenic PSAs.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Embolization of Pseudoaneurysms is Associated With Improved Outcomes in Blunt Splenic Trauma

INTRODUCTION

The necessity of angioembolization for all splenic pseudoaneurysms (PSAs) is unknown after blunt trauma. We compared the outcomes of patients with PSAs managed with splenic artery embolization (EMBO) versus no embolization (NO-EMBO).

METHODS

We retrospectively reviewed all patients with blunt splenic trauma and PSA on initial computed tomography scan admitted to an academic, urban, Level I trauma center from 2016 to 2021. Patients who had emergent splenectomy or died before discharge were excluded. Demographics, injury and computed tomography characteristics, and details regarding angiography, if pursued, were collected. The primary outcome was failure of nonoperative management (FNOM), as defined by need for delayed splenectomy for the EMBO group versus delayed splenectomy or embolization for the NO-EMBO group.

RESULTS

One hundred and fifty-six patients were in the final study population, of which 96 (61.5%) were in the EMBO group and 60 (38.5%) were in the NO-EMBO group. Patient demographics and mechanism of injury were similar between the two cohorts. The two cohorts had similar imaging findings, however, EMBO patients had more compartments with hemoperitoneum (2 versus 1, P < 0.01). Patients who underwent embolization had a lower FNOM rate (3.1% versus 13.3%, P = 0.02).

CONCLUSIONS

Splenic artery embolization in the setting of PSA is associated with lower rates of FNOM versus nonembolization. It is unclear if addressing the PSA itself with embolization drives the decreased FNOM rate.

[Endovascular technologies in the treatment of patients with blunt abdominal trauma]

Trauma is one of the leading causes of disability and mortality in working-age population. Abdominal injuries comprise 20-30% of traumas. Uncontrolled bleeding is the main cause of death in 30-40% of patients. Among abdominal organs, spleen is most often damaged due to fragile structure and subcostal localization. In the last two decades, therapeutic management has become preferable in patients with abdominal trauma and stable hemodynamic parameters. In addition to clinical examination, standard laboratory tests and ultrasound, as well as contrast-enhanced CT of the abdomen should be included in diagnostic algorithm to identify all traumatic injuries and assess severity of abdominal damage. Development of interventional radiological technologies improved preservation of damaged organs. Endovascular embolization can be performed selectively according to indications (leakage, false aneurysm, arteriovenous anastomosis) and considered for severe damage to the liver and spleen, hemoperitoneum or severe polytrauma. Embolization is essential in complex treatment of traumatic vascular injuries of parenchymal abdominal organs. We reviewed modern principles and methods of intra-arterial embolization for the treatment of patients with traumatic injuries of the liver and spleen.

Alahmad Y, Jaleel Z, Ahmed Z, Kaassamali R, Hasani AA, Al-Thani H, Omar A. The predictive value of CTSI scoring system in non-operative management of patients with splenic blunt trauma: The experience of a level 1 trauma center

Background

The spleen is one of the most injured organs following blunt abdominal trauma. The management options can be either operative or non-operative management (NOM) with either conservative management or splenic artery embolization. The implementation of CT in emergency departments allowed the use of CT imaging as a primary screening tool in early decision-making. Consecutively, new splenic injury scoring systems, such as the CT severity index (CTSI) reported was established.

Aim

The main aim of this study is to evaluate the effect of the implementation of CTSI scoring system on the management decision and outcomes in patients with blunt splenic trauma over 8 years in a level 1 trauma center.

Methods

This is a retrospective study including all adult patients with primary splenic trauma, having NOM and admitted to our hospital between 2013 and 2021.

Results

The analyses were conducted on ninety-nine patients. The average sample age was 32.7 ± 12.3 years old. A total of (63/99) patients had splenic parenchyma injury without splenic vascular injury. There is a statistically significant association between CTSI grade 3 injury and the development of delayed splenic vascular injury (p < 0.05). There is an association between severity of initial CTSI score and the risk of NOM/clinical failure (p = 0.02).

Conclusion

Our findings suggest implementing such a system in a level 1 trauma center will further improve the outcome of treatment for splenic blunt trauma. However, CTSI grade 3 is considered an increased risk of NOM failure, and further investigations are necessary to standardize its management.

Angioembolization for Isolated Severe Blunt Splenic Injuries with Hemodynamic Instability: A Propensity Score Matched Analysis

BACKGROUND

This study aimed to compare patient outcomes after splenic angioembolization (SAE) or splenectomy for isolated severe blunt splenic injury (BSI) with hemodynamic instability, and to identify potential candidates for SAE.

METHODS

Adult patients with isolated severe BSI (Abbreviated Injury Scale [AIS] 3-5) and hemodynamic instability between 2013 and 2019 were identified from the American College of Surgeons Trauma Quality Improvement (ACS TQIP) database. Hemodynamic instability was defined as an initial systolic blood pressure (SBP) <90 mmHg, heart rate (HR) >120 bpm, or lowest SBP <90 mmHg within 1 h after admission, with ≥1 unit of blood transfused within 4 h after admission. In-hospital mortality was compared between splenectomy and SAE groups using 2:1 propensity-score matching. The characteristics of unmatched and matched splenectomy patients were also compared.

RESULTS

A total of 478 patients met our inclusion criteria (332 splenectomy, 146 SAE). After propensity-score matching, 166 splenectomy and 83 SAE patients were compared. Approximately 85% of propensity-score matched patients sustained AIS 3/4 injuries, and 50% presented with normal SBP and HR before becoming hemodynamically unstable. The median time to intervention (splenectomy or SAE) was 137 min (interquartile range 94-183). In-hospital mortality between splenectomy and SAE groups was not significantly different (5.4% vs. 4.8%, p = 1.000). More than half of unmatched patients in the splenectomy group sustained AIS 5 injuries and presented with initially unstable hemodynamics. The median time to splenectomy in such patients was significantly shorter than in matched splenectomy patients (67 vs. 132 min, p < 0.001).

CONCLUSION

Splenectomy remains the mainstay of treatment for patients with AIS 5 BSI who present to hospital with hemodynamic instability. However, SAE might be a feasible alternative for patients with AIS 3/4 injuries.

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.

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.

Survival Secrets: Unmasking the Factors Predicting Failure of Non-operative Management (NOM) in Splenic Injuries

BACKGROUND

Splenic injuries are common solid organ injuries resulting from blunt abdominal trauma in road traffic accidents. Very often, splenic injuries can be life-threatening. Earlier, splenic injuries were often dealt with surgical intervention, such as splenectomy. With the recognition of the immunological function of the spleen and possible complications of splenectomy surgery, such as overwhelming post-splenectomy infections (OPSI), there has been a recent trend for non-operative management (NOM).

OBJECTIVE

To study the variables predicting failure of NOM in blunt abdominal trauma patients with splenic injury.

METHODS

This is a retrospective study that includes 235 patients who presented to the Safdarjung Hospital emergency room (New Delhi, India) with blunt trauma abdomen and splenic injuries with or without associated injuries between January 2019 and December 2021. The data was entered in a Microsoft Excel spreadsheet (Microsoft Corp., Redmond, WA, USA). Categorical variables were expressed as frequencies and percentages. Pearson's chi-square test of association was used to determine if there is a relationship between two variables. A p-value of <0.05 was considered statistically significant.

RESULTS

Out of 235 patients with blunt abdominal trauma and splenic injuries, 82 were hemodynamically unstable despite resuscitation and were taken up for emergency laparotomy. The remaining 153 patients, who were either hemodynamically stable or stabilized after adequate resuscitation, were managed on the lines of NOM. The number of patients with splenic injury in AAST grades 1, 2, 3, 4, and 5 was 36, 50, 40, 24, and three, respectively. Out of 153 patients, 130 (85%) were successfully managed by NOM, while eight (5%) had to discontinue NOM as they required surgical intervention. The failure of NOM (fNOM) is seen mostly with grade 5 injuries (2/2, 100%, p<0.01), followed by grade 4 (4/20, 20%) and grade 3 (2/37, 5.7%). The mean age in fNOM was 58.3 years, as compared to 42.2 years in the success of NOM (sNOM). All eight patients had multiple concomitant injuries, with femur fracture being the most common association in up to six patients (p<0.01), followed by liver injury in four patients. There were 15 mortalities, irrespective of AAST severity grade. All of these patients had associated concomitant injuries, with intracranial bleeding (n = 10, 32%, p<0.01) being the most common association, followed by femur fracture (n = 6, 20%) and liver injury (n = 5, 16%). Also, the cause of death was unrelated to splenic trauma (p = 0.67), with pulmonary embolism (n = 6, 40%, p<0.01) being the most common cause, followed by brain stem herniation (n = 5, 34%).

CONCLUSION

Non-operative management is a safe and efficient method for treating patients with splenic injuries who are hemodynamically stable or stabilized. The factors associated with fNOM include elderly age, a higher American Association for the Surgery of Trauma (AAST) grade of splenic injury, and associated concomitant injuries. Femur fracture was the most common concomitant injury present in cases where NOM failed, followed by liver injury. The presence of intracranial bleeds in these patients was a common association with mortality, irrespective of the grade of splenic injury.

Analysis of Need for Intervention in Low-Grade Traumatic Splenic Injury

BACKGROUND

Blunt splenic injuries are common traumatic injuries. Severe injuries may require blood transfusion, procedural, or operative intervention. Conversely, patients with low-grade injuries and normal vital signs frequently do not require intervention. The level and duration of monitoring required to safely manage these patients are unclear. We hypothesize that low-grade splenic trauma has a low rate of intervention and may not require acute hospitalization.

METHODS

This retrospective descriptive analysis included patients admitted to a level I trauma center with low injury burden (injury severity score <15) and The American Association for the Surgery of Trauma (AAST) grade 1 (G1) and 2 (G2) splenic injuries between January 2017 and December 2019 using the Trauma Registry of the American College of Surgeons (TRACS). The primary outcome was the need for any intervention. Secondary outcomes included time to intervention and length of stay.

RESULTS

107 patients met inclusion criteria. 87.9% required no intervention . 9.4% required blood products, with a median time to transfusion of 7.4 hours from arrival. All patients receiving blood products had extenuating circumstances such as bleeding from other injuries, anticoagulant use, or medical comorbidities. 2 patients required splenic artery embolization, one presenting with return precautions 9 days post-injury and 1 with significant comorbidities. One patient with concomitant bowel injury required splenectomy.

CONCLUSIONS

Low-grade blunt splenic trauma has a low rate of intervention, which typically occurs within the first 12 hours of presentation. This suggests that outpatient management with return precautions may be appropriate for select patients after a short interval of observation.

Abdominal trauma

Traumatic injuries are the leading cause of death in people aged<45 years, and abdominal trauma is a source of significant morbidity and mortality and high economic costs. Imaging has a fundamental role in abdominal trauma, where CT is a fundamental tool for rapid, accurate diagnosis that will be key for patients' clinical outcomes.

Hemodilution in pediatric trauma: Defining the expected hemoglobin changes in patients with liver and/or spleen injury: An ATOMAC+ secondary analysis

BACKGROUND

Many children with blunt liver and/or spleen injury (BLSI) never bleed intraperitoneally. Despite this, decreases in hemoglobin are common. This study examines initial and follow up measured hemoglobin values for children with BLSI with and without evidence of intra-abdominal bleeding.

METHODS

Children ≤18 years of age with BLSI between April 2013 and January 2016 were identified from the prospective ATOMAC+ cohort. Initial and follow up hemoglobin levels were analyzed for 4 groups with BLSI: (1) Non bleeding; (2) Bleeding, non transfused (3) Bleeding, transfused, and (4) Bleeding resulting in non operative management (NOM) failure.

RESULTS

Of 1007 patients enrolled, 767 were included in one or more of four study cohorts. Of 131 non bleeding patients, the mean decrease in hemoglobin was 0.83 g/dL (+/-1.35) after a median of 6.3 [5.1,7.0] hours, (p = 0.001). Follow-up hemoglobin levels in patients with and without successful NOM were not different. For patients with an initial hemoglobin >9.25 g/dL, the odds ratio (OR) for NOM failure was 14.2 times less, while the OR for transfusion was 11.4 times less (p = 0.001).

CONCLUSION

Decreases in hemoglobin are expected after trauma, even if not bleeding. A hemoglobin decrease of 2.15 g/dL [0.8 + 1.35] would still be within one standard deviation of a non bleeding patient. An initial low hemoglobin correlates with failure of NOM as well as transfusion, thereby providing useful information. By contrast, subsequent hemoglobin levels do not appear to guide the need for transfusion, nor correlate with failure of NOM. These results support initial hemoglobin measurement but suggest a lack of utility for routine rechecking of hemoglobin.

LEVEL OF EVIDENCE

Level II Prognostic Study.

Recent trends in the management of isolated high-grade splenic injuries: A nationwide analysis

BACKGROUND

The feasibility of nonoperative management for high-grade blunt splenic injuries (BSIs) has been suggested in recent studies. The purpose of this study was to assess nationwide trends in the management of isolated high-grade BSIs. We hypothesized that isolated high-grade BSIs are more frequently being managed nonoperatively.

METHODS

The American College of Surgeons Trauma Quality Improvement Program database was queried to identify patients (16 years or older) with isolated high-grade BSIs (Abbreviated Injury Scale, ≥3) between 2013 and 2019. Patients were divided into two groups based on their hemodynamic status (hemodynamically stable [HS] and hemodynamically unstable [HU]). The primary outcome was the rate of total splenectomy each year, and the secondary outcome was the use of splenic angioembolization (SAE). Multiple regression models were created to estimate annual trends in splenectomy and SAE.

RESULTS

A total of 6,747 patients with isolated high-grade BSIs were included: 5,714 (84.7%) and 1,033 (15.3%) in HS and HU groups, respectively. In the HS group, the rate of overall splenectomy was significantly decreased (from 22.9% in 2013 to 12.6% in 2019; odds ratio [OR] for 1-year increment, 0.850; 95% confidence interval [CI], 0.815-0.886; p < 0.001), and the use of SAE was significantly increased (from 12.5% in 2013 to 20.9% in 2019; OR, 1.107; 95% CI, 1.065-1.150; p < 0.001). In the HU group, the overall splenectomy rate was unchanged (from 69.8% in 2013 to 50.8% in 2019; OR, 0.931; 95% CI, 0.865-1.002; p = 0.071), whereas SAE was significantly increased (from 12.7% in 2013 to 28.8% in 2019; OR, 1.176; 95% CI, 1.079-1.284; p < 0.001).

CONCLUSION

We observed significant trends toward more frequent use of nonoperative management in high-grade BSIs with hemodynamic stability. Further studies are warranted to define the role of SAE, especially in patients with hemodynamic instability.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Blunt splenic injury in adults: Association between volumetric quantitative CT parameters and intervention

BACKGROUND.

Several ordinal grading systems are employed in deciding whether to perform angioembolization or splenectomy following blunt splenic injury. The 2018 AAST Organ Injury Scale (OIS) incorporates vascular lesions but not hemoperitoneum, which is considered in the Thompson classifier. Granular and verifiable quantitative measurements of these features may have a future role in facilitating objective decision-making.

PURPOSE.

To compare performance of CT volumetry-based quantitative modeling to the 1994 and 2018 AAST OIS and Thompson classifier for the following endpoints: decision to perform splenectomy (SPY), and the composite of SPY or angioembolization (AE)

MATERIALS AND METHODS.

Adult BSI patients (age ≥ 18 years) scanned with dual-phase CT prior to intervention at a single level I trauma center from 2017-2019 were included in this retrospective study (n=174). Scoring using 2018 AAST, 1994 AAST, and Thompson systems was performed retrospectively by two radiologists and arbitrated by a third. Endpoints included 1. SPY and 2. The composite of SPY or AE. Logistic regression models were developed from segmented active bleed, contained vascular lesion, splenic parenchymal disruption, and hemoperitoneum volumes. AUCs for ordinal systems and volumetric models were compared.

RESULTS.

Forty-seven BSI patients (27%) underwent SPY, and 87 patients (50%) underwent SPY or AE. Quantitative model AUCs (0.85- SPY, 0.82-composite) were not significantly different from 2018 AAST AUCs (0.81, 0.88, p=0.66, 0.14) for both endpoints, and were significantly improved over Thompson scoring (0.76, p=0.02; 0.77, p=0.04).

CONCLUSION:

Quantitative CT volumetry can be used to model intervention for BSI with accuracy comparable to 2018 AAST scoring and significantly higher than Thompson scoring.

Study Type:

Prognostic

Level of Evidence:

IV

CT volumetry of blunt splenic injury-related features predicts splenectomy and angioembolization in adults and identifies clinically important target features for computer vision and automation research.

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

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.

Predictors of transfer from a remote trauma facility to an urban level I trauma center for blunt splenic injuries: a retrospective observational multicenter study

Background

The decision-making for admission versus emergent transfer of patients with blunt splenic injuries presenting to remote trauma centers with limited resources remains a challenge. Although splenectomy is standard for hemodynamically unstable patients, the specific criterion for non-operative management continues to be debated. Often, lower-level trauma centers do not have interventional radiology capabilities for splenic artery embolization, leading to transfer to a higher level of a care. Thus, the aim of this study was to identify specific characteristics of patients with blunt splenic injuries used for admittance or transfer at a remote trauma center.

Methods

A retrospective observational study was performed to examine the management of splenic injuries at a mountainous and remote Level III trauma center. Trauma patients ≥ 18 years who had a blunt splenic injury and initially received care at a Level III trauma center prior to admittance or transfer were included. Data were collected over 4.5 years (January 1, 2016 – June 1, 2020). Patients who were transferred out in > 24 h were excluded. Patient demographics, injury severity, spleen radiology findings, and clinical characteristics were compared by decision to admit or transfer to a higher level of care ≤ 24 h of injury. Results were analyzed using chi-square, Fisher’s exact, or Wilcoxon tests. Multivariable logistic models were used to identify predictors of transfer.

Results

Of the 73 patients included with a blunt splenic injury, 48% were admitted and 52% were transferred to a Level I facility. Most patients were male (n = 58), were a median age of 26 (21–42) years old, most (n = 62) had no comorbidities, and 47 had been injured from a ski/snowboarding accident. Compared to admitted patients, transferred patients were significantly more likely to be female (13/38 vs. 3/36, p = 0.007), to have an abbreviated injury scale score ≥ 3 of the chest (31/38 vs. 7/35, p = 0.002), have a higher injury severity score (16 (16–22) vs. 13 (9–16), p = 0.008), and a splenic injury grade ≥ 3 (32/38 vs. 12/35, p < 0.001). After adjustment, splenic injury grade ≥ 3 was the only predictor of transfer (OR: 12.1, 95% CI: 3.9–37.3, p < 0.001). Of the 32 transfers with grades 3–5, 16 were observed, and 16 had an intervention. Compared to patients who were observed after transfer, significantly more who received an intervention had a blush on CT (1/16 vs. 7/16, p = 0.02) and a higher median spleen grade of 4 (3–5) vs. 3 (3–3.5), p = 0.01).

Conclusions

Our data suggest that most patients transferred from a remote facility had a splenic injury grade ≥ 3, with concomitant injuries but were hemodynamically stable and were successfully managed non-operatively. Stratifying by spleen grade may assist remote trauma centers with refining transfer criteria for solid organ injuries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13037-022-00339-4.

Impact of site of occlusion in proximal splenic artery embolisation for blunt splenic trauma

Background

Proximal splenic artery embolisation (PSAE) can be performed in stable patients with Association for the Surgery of Trauma (AAST) grade III-V splenic injury. PSAE reduces splenic perfusion but maintains viability of the spleen and pancreas via the collateral circulation. The hypothesized ideal location is between the dorsal pancreatic artery (DPA) and great pancreatic artery (GPA). This study compares the outcomes resulting from PSAE embolisation in different locations along the splenic artery.

Materials and methods

Retrospective review was performed of PSAE for blunt splenic trauma (2015–2020). Embolisation locations were divided into: Type I, proximal to DPA; Type II, DPA-GPA; Type III, distal to GPA. Fifty-eight patients underwent 59 PSAE: Type I (7); Type II (27); Type III (25). Data was collected on technical and clinical success, post-embolisation pancreatitis and splenic perfusion. Statistical significance was assessed using a chi-squared test.

Results

Technical success was achieved in 100% of cases. Clinical success was 100% for Type I/II embolisation and 88% for Type III: one patient underwent reintervention and two had splenectomies for ongoing instability. Clinical success was significantly higher in Type II embolisation compared to Type III (p = 0.02). No episodes of pancreatitis occurred post-embolisation. Where post-procedural imaging was obtained, splenic perfusion remained 100% in Type I and II embolisation and 94% in Type III. Splenic perfusion was significantly higher in the theorized ideal Type II group compared to Type I and III combined (p = 0.01).

Conclusion

The results support the proposed optimal embolisation location as being between the DPA and GPA.

Postoperative Pancreatic Fistula Following Traumatic Splenectomy: A Morbid and Costly Complication

INTRODUCTION

Development of clinically relevant postoperative pancreatic fistula (CR-POPF) in adult splenectomies following trauma occur in 1%-3% of cases. We hypothesized that the use of sutures in splenic hilum ligation compared to staples was associated with a reduced rate of CR-POPF incidence.

METHODS

Adult trauma patients (age ≥17 y) that underwent nonelective splenectomy from 2010 to 2020 were retrospectively evaluated from the trauma registries of all three adult level 1 trauma centers in Indiana. Patients were excluded if they were pregnant, currently incarcerated, expired within 72 h of admission, or had a pancreatic injury diagnosed preoperatively or intraoperatively. A Firth logistic regression using a penalized-maximum likelihood estimate for rare events was used for univariate predictive modeling (SPSS 28.0) of surgical technique on CR-POPF development.

RESULTS

Four hundred nineteen adult splenectomies following trauma were conducted; 278 were included. CR-POPF developed in 14 cases (5.0%). Sutures alone were used in 200 cases: seven developed CR-POPF (3.5%). Staples alone or in combination with sutures were used in 74 cases: seven developed CR-POPF (9.5%). There was no statistically significant difference between the use of sutures alone compared to the use of staples alone (P = 0.123) or in combination (P = 0.100) in CR-POPF incidence.

CONCLUSIONS

Our 10-y retrospective review of CR-POPF finds the complication to be rare but morbid. This study was underpowered to show any difference in surgical technique. However, we do propose a new institutional norm that CR-POPF develop in 5% of splenectomies after trauma and conclude that further study of optimal technique for emergent splenectomy is warranted.

Blunt splenic injury: Assessment of follow-up CT utility using quantitative volumetry

Purpose:

Trials of non-operative management (NOM) have become the standard of care for blunt splenic injury (BSI) in hemodynamically stable patients. However, there is a lack of consensus regarding the utility of follow-up CT exams and relevant CT features. The purpose of this study is to determine imaging predictors of splenectomy on follow-up CT using quantitative volumetric measurements.

Methods:

Adult patients who underwent a trial of non-operative management (NOM) with follow-up CT performed for BSI between 2017 and 2019 were included (n = 51). Six patients (12% of cohort) underwent splenectomy; 45 underwent successful splenic salvage. Voxelwise measurements of splenic laceration, hemoperitoneum, and subcapsular hematoma were derived from portal venous phase images of admission and follow-up scans using 3D slicer. Presence/absence of pseudoaneurysm on admission and follow-up CT was assessed using arterial phase images. Multivariable logistic regression was used to determine independent predictors of decision to perform splenectomy.

Results:

Factors significantly associated with splenectomy in bivariate analysis incorporated in multivariate logistic regression included final hemoperitoneum volume (p = 0.003), final subcapsular hematoma volume (p = 0.001), change in subcapsular hematoma volume between scans (p = 0.09) and new/persistent pseudoaneurysm (p = 0.003). Independent predictors of splenectomy in the logistic regression were final hemoperitoneum volume (unit OR = 1.43 for each 100 mL change; 95% CI: 0.99–2.06) and new/persistent pseudoaneurysm (OR = 160.3; 95% CI: 0.91–28315.3). The AUC of the model incorporating both variables was significantly higher than AAST grading (0.91 vs. 0.59, p = 0.025). Mean combined effective dose for admission and follow up CT scans was 37.4 mSv.

Conclusion:

Follow-up CT provides clinically valuable information regarding the decision to perform splenectomy in BSI patients managed non-operatively. Hemoperitoneum volume and new or persistent pseudoaneurysm at follow-up are independent predictors of splenectomy.

Update on Nonoperative Management of the Injured Spleen

Despite significant interest in trauma to the spleen over the past 130 years, splenectomy remained the preferred approach to splenic injures in children till the late 1950s and even later in adults. With recognition of the immunologic importance of the spleen and improvements in diagnostic imaging and angioembolization, there are now four pathways for the child or adult admitted with a possible, likely, or diagnosed injury to the spleen. These include the following: (1) operation with splenectomy; (2) operation with splenorrhaphy or partial splenectomy; (3) nonoperative management (observation); and (4) nonoperative management with splenic arteriography and possible angioembolization. This review will focus on the latter two options.

Management of High Grade Splenic Injuries in Rural America

BACKGROUND

Rural surgeons face unique challenges when managing patients with high-grade (III-V) blunt splenic injury (BSI) given limited access to interventional radiology and blood products. Patients therefore may require transfer for splenic artery embolization (SAE) when resuscitation may still be ongoing. This study aims to evaluate current resource utilization in a rural trauma population with limited access to SAE and blood products.

METHODS

Retrospective analysis of adult patients with high-grade BSI at one Level 1 trauma center and two Level 2 trauma centers was performed. Patients were evaluated for resources used after transfer to the regional trauma center. Primary outcomes measured were SAE, operative management (OM), and blood product utilization. Secondary outcomes measured included injury severity score (ISS) and mortality.

RESULTS

Final analysis included 134 transferred patients. 16% underwent SAE, 16% underwent OM, and 69% were treated successfully with nonoperative and non-procedural management (NOM). 52% of the SAE patients had sustained a grade III splenic injury, 38% grade IV, and 10% grade V. 84% of patients required <3 units of packed red blood cells (PRBC) and 57% of patients required none. 80% of transferred patients required <3 total units of all combined blood products.

DISCUSSION

The majority of patients with BSI transferred to a tertiary trauma center from a rural facility were successfully managed without SAE and required minimal transfusion of blood products. In the absence of other injuries necessitating transfer to a tertiary trauma center, rural surgeons should consider management of high grade splenic injuries at their home institution.

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

BACKGROUND

Splenic injuries are the most common visceral injury following blunt abdominal trauma. Increasingly, non-operative management (NOM) and the use of adjunctive splenic angioembolization (ASE) is favoured over operative management (OM) for the hemodynamically stable patient. However, clinical predictors for successful NOM, particularly the role of ASE as an adjunct, remain poorly defined. This study aims to evaluate the outcomes of patients undergoing ASE vs NOM.

METHODS

A retrospective clinical audit was performed of all patients admitted with blunt splenic injury (BSI) from January 2005 to January 2018 at the Royal Adelaide Hospital. The primary outcome was ASE or NOM failure rate. Secondary outcomes were grade of splenic injury, Injury Severity Score (ISS), length of hospital stay (LOS), and delayed OM or re-angioembolization rates.

RESULTS

Of 208 patients with BSI, 60 (29%) underwent OM, 54 (26%) ASE, and 94 (45%) NOM only. Patients were predominantly male 165 (79%), with a median age of 33 (IQR 24-51) years. The median ISS was 29 (20-38). There was no difference in the overall success rates for each modality of primary management (48 (89%) ASE vs 77 (82%) NOM, p = 0.374), though patients managed with ASE were older (38 vs 30 years, p = 0.029), had higher grade of splenic injury (grade ≥ IV 42 (78%) vs 8 (8.5%), p<0.001), with increased rates of haemo-peritoneum (46 (85%) vs 51 (54%), p<0.001) and contrast blush (42 (78%) vs 2 (2%), p<0.001). However, for grade III splenic injury, patients managed with ASE had a trend towards better outcome with no failures when compared to the NOM group (0 (0%) vs 8 (35%), p = 0.070) with a significant reduction in LOS (7.2 vs 10.8 days, p = 0.042). Furthermore, the ASE group overall had a significantly shorter LOS compared to the NOM group (10.0 vs 16.0 days, p<0.001).

CONCLUSION

ASE as an adjunct to NOM significantly reduces the length of stay in BSI patients and is most successful in managing AAST grade III injuries.

Very large haematoma following the nonoperative management of a blunt splenic injury in a patient with preexisting liver cirrhosis: a case report

The spleen is the most commonly injured organ after blunt abdominal trauma. Nonoperative management (NOM) is the standard treatment for blunt splenic injuries in haemodynamically stable patients without peritonitis. Complications of NOM include rebleeding, new pseudoaneurysm formation, splenic abscess, and symptomatic splenic infarction. These complications hinder the NOM of patients with blunt splenic injuries. We report a case in which a large haemorrhagic fluid collection that occurred after angio-embolisation was resolved by percutaneous drainage in a patient with liver cirrhosis who experienced a blunt spleen injury.

Delayed splenic pseudoaneurysm identification with surveillance imaging

BACKGROUND

Recent studies have shown that non-operative management of patients with splenic injury has up to a 90% success rate. However, delayed hemorrhage secondary to splenic artery pseudoaneurysm occurs in 5-10% of patients with up to 27% of patients developing a pseudoaneurysm on delayed imaging. The goal of our study was to evaluate the safety and utility of delayed CT imaging for blunt splenic injury patients.

METHODS

A retrospective evaluation of all traumatic splenic injuries from 2018 to 2020 at a single level 1 trauma center was undertaken. Patients were sub-divided into 4 groups based on the extent of splenic injury: Grades I-II, Grade III, Grade IV, and Grade V. Patient injury characteristics along with hospital length of stay, imaging, procedures, and presence/absence of pseudoaneurysm were documented.

RESULTS

588 trauma patients were initially included for evaluation with 539 included for final analysis. 297 patients sustained Grades I-II, 123 Grade III, 61 Grade IV, and 58 Grade V splenic injuries. 129 patients (24%) underwent either emergent or delayed (>6 hours) splenectomy with an additional 6 patients having a splenorrhaphy on initial operation. Of the patients who were treated non-operatively, 98% of Grade III, 91% of Grade IV, and 100% of Grade V splenic injury patients underwent follow up CT imaging. The mean time from admission to follow-up abdominal CT scan was 5 ± 4.4 days. 22 pseudoaneurysms were identified including 10/84 Grade III, 7/22 Grade IV, and 2/5 Grade V; of these patients 33% Grade III and 30% Grade IV required subsequent splenectomy.

CONCLUSIONS

Routine follow up CT imaging after high grade splenic injury identifies splenic artery pseudoaneurysm in a significant proportion of patients. Standardized surveillance imaging for high grade splenic trauma promotes prospective identification of pseudoaneurysms, allowing for interventions to minimize delayed splenic injury complications.

LEVEL OF EVIDENCE

Level 4; therapeutic.

Early initiation of thromboembolic prophylaxis in critically ill trauma patients with high-grade blunt liver and splenic lacerations is not associated with increased rates of failure of non-operative management

Background

Non-operative management (NOM) is the current standard of care of hemodynamically stable patients with traumatic blunt solid abdominal organ injuries. Guidelines do not define the optimal timing of initiation of venous thromboembolism (VTE) prophylaxis in this population, and fear of failure of NOM may lead to delayed initiation of prophylaxis specifically in patients with high-grade injuries.

Methods

This was a single-center, retrospective study of patients with high-grade (AAST grades ≥3) blunt liver and splenic lacerations presenting to our level 1 trauma center between January 2010 and October 2017. Patients were divided into groups based on timing of low-molecular weight heparin (LMWH) initiation for VTE prophylaxis. The primary outcome was rate of failure of NOM, defined as the need for interventional radiology or surgical intervention for management of abdominal organ bleeding. Secondary outcomes included rates of VTE, lengths of ICU and hospital stay, and in-hospital mortality.

Results

A total of 207 patients with high-grade blunt liver and splenic injuries undergoing an initial attempt at NOM were identified. The distribution of grades 3, 4, and 5 liver and splenic injuries were similar across all groups. Overall, 55.5% of patients received LMWH during their index admission. Early administration of LMWH was not associated with a statistically significant increased risk of failure of NOM ( p = 0.054). Rates of VTE and in-hospital mortality were similar.

Conclusions

Early initiation of VTE prophylaxis was not associated with an increased rate of failure of NOM in patients with high-grade blunt abdominal organ injuries in patients who survived 24 h post-admission and did not require massive transfusion; however, the study was likely underpowered to detect a difference among groups due to small sample size.

A Rare Case of Spontaneous Splenic Rupture as the Index Presentation of Chronic Myeloid Leukemia

Splenic injury is usually caused by blunt trauma to the abdomen. Very rarely, spontaneous rupture can occur in patients with splenomegaly due to various underlying pathological conditions such as hematological, neoplastic, inflammatory, and infectious diseases. Here, we report the case of a 48-year-old gentleman who presented to the emergency department with sudden-onset pain in the abdomen and hypotension. Blood investigation revealed anemia and leukocytosis with blast cells on peripheral smear, suggestive of chronic myeloid leukemia (CML) in the chronic phase. Contrast-enhanced computed tomography revealed splenomegaly with grade three splenic laceration and a subcapsular hematoma with hemoperitoneum. Because of persistent hemodynamic instability, despite resuscitation, he underwent emergency splenectomy. The postoperative period was uneventful. Bone marrow biopsy revealed CML in the chronic phase with World Health Organization grade I reticulin fibrosis. Subsequently, he was started on hydroxyurea and discharged for further follow-up with medical oncology.

The Utility of Serial Hemoglobin Monitoring in Non-Operative Management of Blunt Splenic Injury

BACKGROUND

The Eastern Association for the Surgery of Trauma (EAST) states there is not enough evidence to recommend a particular frequency of measuring Hgb values for non-operative management (NOM) of blunt splenic injury (BSI). This study was performed to compare the utility of serial Hgb (SHgb) to daily Hgb (DHgb) in this population.

METHODS

We conducted a retrospective chart review of patients with BSI between 2013 and 2019. Demographics, comorbidities, lab values, clinical decisions, and outcomes were gathered through a trauma database.

RESULTS

A total of 562 patients arrive in the trauma bay with BSI. In the NOM group, 297 were successful and 37 failed NOM. Of those that failed NOM, 8 (21.6%) changed to OM due to a drop in Hgb. 5 (62.5%) were hypotensive first, 2 (25%) were no longer receiving SHgb, and 1 (12.5%) had a repeat CT scan and was embolized. DHgb patients were not significantly different from SHgb patients in injury severity, length of stay, the largest drop in Hgb, and incidence of failing NOM. Patients taking aspirin were more likely to fall below 7 g/dl at 48 and 72 hours into admission.

CONCLUSIONS

These results suggest that that trending SHgb may not influence clinical decision-making in NOM of BSI. Besides taking aspirin, risk factors for who would benefit from SHgb were not identified. Patients who received DHgb had similar injuries and outcomes than patients who received SHgb. Prospective studies are needed to evaluate the clinical utility of SHgb compared to DHgb.

Delayed splenic rupture following trivial trauma: A case report and review of literature

Introduction and importance

Delayed Splenic Rupture (DSR) is a rare but well-known presentation of Blunt Splenic Injury (BSI), most of which occur due to motor accidents, fall from height or direct blow to the left thorax or abdomen. Here we present a case of DSR five days after a trivial trauma.

Case presentation

A 37-year-old female presented with pain in the left-hypochondrium after an accidental bump against a furniture at home. Initially, it was a grade III splenic injury but upon arrival to our hospital from her hometown it had progressed to grade IV. Since the patient was hemodynamically stable, non-operative management (NOM) was chosen with close monitoring at the intensive care unit (ICU). However, the next morning, the patient deteriorated, showing signs of hemorrhagic shock, and a successful emergency splenectomy was done.

Clinical discussion

Over the last two decades, there has been an increasing inclination of surgeons towards NOM, even for high grade injury. NOM failure has been found to be associated with advancing age, high Injury Severity Score (ISS) or splenic injury. Some factors that improve the success of NOM are admission to ICU/floor, frequent monitoring of hemoglobin/hematocrit, vital signs, abdominal examination, and limiting heavy physical activity.

Conclusion

Clinicians should not limit the possibility of occurrence of DSR to only major traumatic events. It is imperative that a detailed history of major or trivial trauma in the preceding weeks be elicited for any patients presenting with abdominal pain.

•

Delayed Splenic Rupture is a rare but well reported presentation following blunt splenic injury.

•

Delayed Splenic Rupture can even occur following trivial trauma.

•

Clinicians must consider the entire clinical scenario to decide between operative or non-operative management.

•

A detailed history of major or minor trauma must be elicited for any patients with abdominal pain.

Non-Operative Management of Delayed Splenic Rupture 4 Months Following Blunt Abdominal Trauma

BACKGROUND Delayed splenic rupture is a rare complication of non-operative management of a primary splenic trauma which, without proper clinical vigilance, may result in life-threatening events. It usually occurs 4-8 days after injury and, in most cases, surgery is the treatment of choice. Since non-operative management of splenic trauma, which allows splenic salvage, has become increasingly popular, the same approach could also be applied in delayed splenic rupture. We herein present a case of delayed splenic rupture that occurred 4 months after the trauma and was successfully managed non-operatively. CASE REPORT A 32-year-old woman presented with diffuse abdominal pain, chest pain, and dyspnea 4 months after sustaining minor thoracoabdominal blunt trauma due to a car accident. That event was inadequately investigated and was not admitted for further monitoring. Computerized tomography revealed a rupture of a splenic hematoma in the context of the previous splenic trauma. She was closely monitored and remained hemodynamically stable. She was discharged and followed up, with no reported relapse of her clinical condition. CONCLUSIONS Delayed splenic rupture occurring 4 months after the primary splenic trauma is extremely rare. Due to its prolonged delay, delayed rupture of the spleen can easily be overlooked and not be included in the original differential diagnosis. Negligence of this event can result in dreaded complications with hemodynamic instability or even death. Furthermore, its higher mortality rate compared to primary splenic rupture highlights the importance of proper clinical vigilance. Non-operative management should be attempted in hemodynamically stable patients.

Damage control surgery for splenic trauma: "preserve an organ - preserve a life"

The spleen is one of the most commonly injured solid organs of the abdominal cavity and an early diagnosis can reduce the associated mortality. Over the past couple of decades, management of splenic injuries has evolved to a prefered non-operative approach even in severely injured cases. However, the optimal surgical management of splenic trauma in severely injured patients remains controversial. This article aims to present an algorithm for the management of splenic trauma in severely injured patients, that includes basic principles of damage control surgery and is based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. The choice between a conservative or a surgical approach depends on the hemodynamic status of the patient. In hemodynamically stable patients, a computed tomography angiogram should be performed to determine if non-operative management is feasible and if angioembolization is required. While hemodynamically unstable patients should be transferred immediately to the operating room for damage control surgery, which includes splenic packing and placement of a negative pressure dressing, followed by angiography with embolization of any ongoing arterial bleeding. It is our recommendation that both damage control principles and emerging endovascular technologies should be applied to achieve splenic salvage when possible. However, if surgical bleeding persists a splenectomy may be required as a definitive lifesaving maneuver.

Non-operative management of blunt splenic trauma: evolution, results and controversies

The spleen is one of the most frequently affected organs in blunt abdominal trauma. Since Upadhyaya, the treatment of splenic trauma has undergone important changes. Currently, the consensus is that every splenic trauma presenting with hemodynamic stability should be initially treated nonoperatively, provided that the hospital has adequate structure and the patient does not present other conditions that indicate abdominal exploration. However, several topics regarding the nonoperative management (NOM) of splenic trauma are still controversial. Splenic angioembolization is a very useful tool for NOM, but there is no consensus on its precise indications. There is no definition in the literature as to how NOM should be conducted, neither about the periodicity of hematimetric control, the transfusion threshold that defines NOM failure, when to start venous thromboembolism prophylaxis, the need for control imaging, the duration of bed rest, and when it is safe to discharge the patient. The aim of this review is to make a critical analysis of the most recent literature on this topic, exposing the state of the art in the NOM of splenic trauma.

Trends in Blunt Splenic Injury Management: The Rise of Splenic Artery Embolization

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.

Splenic Artery Embolization for Patients with High-Grade Splenic Trauma: Indications, Techniques, and Clinical Outcomes

The spleen is the most commonly injured organ in blunt abdominal trauma. Patients who are hemodynamically unstable due to splenic trauma undergo definitive operative management. Interventional radiology plays an important role in the multidisciplinary management of the hemodynamically stable trauma patient with splenic injury. Hemodynamically stable patients selected for nonoperative management have improved clinical outcomes when splenic artery embolization is utilized. The purpose of this article is to review the indications, technical aspects, and clinical outcomes of splenic artery embolization for patients with high-grade splenic injuries.

American Society of Emergency Radiology Multicenter Blunt Splenic Trauma Study: CT and Clinical Findings

Background Treatment of blunt splenic trauma (BST) continues to evolve with improved imaging for detection of splenic vascular injuries. Purpose To report on treatments for BST from 11 trauma centers, the frequency and clinical impact of splenic vascular injuries, and factors influencing treatment. Materials and Methods Patients were retrospectively identified as having BST between January 2011 and December 2018, and clinical, imaging, and outcome data were recorded. Patient data were summarized descriptively, both overall and stratified by initial treatment received (nonoperative management [NOM], angiography, or surgery). Regression analyses were used to examine the primary outcomes of interest, which were initial treatment received and length of stay (LOS). Results This study evaluated 1373 patients (mean age, 42 years ± 18; 845 men). Initial treatments included NOM in 849 patients, interventional radiology (IR) in 240 patients, and surgery in 284 patients. Rates from CT reporting were 22% (304 of 1373) for active splenic hemorrhage (ASH) and 20% (276 of 1373) for contained vascular injury (CVI). IR management of high-grade injuries increased 15.6%, from 28.6% (eight of 28) to 44.2% (57 of 129) (2011-2012 vs 2017-2018). Patients who were treated invasively had a higher injury severity score (odds ratio [OR], 1.04; 95% CI: 1.02, 1.05; P < .001), lower temperature (OR, 0.97; 95% CI: 0.97, 1.00; P = .03), and a lower hematocrit (OR, 0.96; 95% CI: 0.93, 0.99; P = .003) and were more likely to show ASH (OR, 8.05; 95% CI: 5.35, 12.26; P < .001) or CVI (OR, 2.70; 95% CI: 1.64, 4.44; P < .001) on CT images, have spleen-only injures (OR, 2.35; 95% CI: 1.45, 3.8; P < .001), and have been administered blood product for fewer than 24 hours (OR, 2.35; 95% CI: 1.58, 3.51; P < .001) compared with those chosen for NOM, after adjusting for key demographic and clinical variables. After adjustment, factors associated with a shorter LOS were female sex (OR, 0.84; 95% CI: 0.73, 0.96; P = .009), spleen-only injury (OR, 0.72; 95% CI: 0.6, 0.86; P < .001), higher admission hematocrit (OR, 0.98; 95% CI: 0.6, 0.86; P < .001), and presence of ASH at CT (OR, 0.74; 95% CI: 0.62, 0.88; P < .001). Conclusion Contained vascular injury and active splenic hemorrhage (ASH) were frequently reported, and rates of interventional radiologic management increased during the study period. ASH was associated with a shorter length of stay, and patients with ASH had eight times the odds of undergoing invasive treatment compared with undergoing nonoperative management. © RSNA, 2021 See also the editorial by Patlas in this issue.

Minimally invasive splenectomy in grade IV splenic trauma: A case report associated with high-grade renal trauma

INTRODUCTION AND IMPORTANCE

In closed abdominal trauma, the spleen is the most frequently injured organ (30-45%). Splenic lesions grades IV-V have higher failure rates with nonoperative management (NOM). The minimally invasive approach is an alternative when NOM fails. This is the first reported case of a patient with splenic and left renal trauma, both grade IV, with combined management, which consisted of a minimally invasive surgical resolution of the splenic trauma and a conservative management of the renal trauma, with a satisfactory recovery of the patient. This contributes to understanding the benefits of minimally invasive surgery in moderate splenic trauma associated with other high-grade injuries.

CASE PRESENTATION

We present a 45-year-old woman with a multiple trauma after a motorbike vs car traffic accident. On physical examination, she was hemodynamically stable, with abdominal guarding and generalized rebound tenderness associated with multiple upper and lower limb fractures. An abdominal CT scan revealed grade IV splenic and left renal trauma, with moderate hemoperitoneum. A minimally invasive laparoscopic approach for hemoperitoneum drainage and splenectomy was performed.

CLINICAL DISCUSSION

There is currently no consensus to define the indications for minimally invasive treatment on splenic trauma. While laparotomy is the standard treatment, it is not without potential severe complications, while laparoscopy providing a treatment option in selected cases with hemodynamic stability.

CONCLUSION

The role of the minimally invasive approach is safe and feasible in selected patients with high-grade splenic lesions and hemodynamic stability, including the association with other organic lesions such as kidney trauma.

Increased hospital treatment volume of splenic injury predicts higher rates of successful non-operative management and reduces hospital length of stay: a Swiss Trauma Registry analysis

Purpose

First time analysis of the epidemiology, management and outcomes of patients with splenic injuries in Switzerland. This study aims to assess the effect of hospital treatment volume on successful non-operative management (NOM) in splenic injuries.

Methods

A multicentric registry-based study including all patients with splenic injuries entered into the Swiss Trauma Registry from 2015 to 2018 was conducted. Patients were stratified according to the hospitals treatment volume of splenic injuries. Primary outcome was the rate of successful NOM.

Results

During the 4-year study period, 652 patients with splenic injury were included in the study. Median age of the study population was 42 (IQR 27–59) years, and median ISS was 26 (20–34). The overall rate of successful NOM was 86.5%. Median HLOS was 13 (8–21) days. In-hospital mortality was 7.2% (n = 47). The mean number of patients with splenic injuries per center and year was 14. Five out of 12 Level I trauma centers treating more patients than the mean (≥ 15/year) were defined as high-volume centers.

Multivariable analysis adjusting for differences in baseline and injury characteristics revealed treatment in a high-volume center as an independent predictor for successful NOM (OR 2.15, 95% CI 1.28–3.60, p = 0.004) and shorter HLOS (RC − 2.39, 95% CI − 4.91/− 0.48, p = 0.017), however, not for reduced in-hospital mortality (OR 0.92, 95% CI 0.39–2.18, p = 0.845).

Conclusion

Higher hospital treatment volume was associated with a higher rate of NOM and shorter HLOS, but not lower mortality. These results constitute the basis for further quality improvement in the care of splenic injury patients within the trauma system in Switzerland.

Predictors of splenectomy after failure of non-operative management: An analysis of the nation trauma database from 2013 to 2014

Introduction

There is practice variability in non-operative management (NOM) of blunt splenic trauma. This is particularly true for management decisions following failure of NOM, i.e. splenectomy versus angioembolization (AE). The objective of this study was to identify predictors of splenectomy versus AE in patients who failed NOM.

Methods

We included adult patients from the National Trauma Data Bank for 2013–2014, who had a splenic injury and who were admitted to a Level I Trauma Center (L1TC). Patients undergoing splenectomy after 2 h of emergency department arrival were deemed to have failed NOM. Multivariate logistic regression modeling was used to identify independent predictors of intervention after failed NOM.

Results

There were 2284 patients admitted for splenic injury between 2013 and 2014 who failed NOM. A total of 1253 patients underwent AE and 1031 patients underwent splenectomy. Seven independent factors were identified that predicted failure of NOM: penetrating injury, community L1TC, hospital bed size, number of trauma surgeons on call, functional dependence, chronic steroid use, and cirrhosis.

Conclusions

Seven independent variables were identified that predicted failure of NOM. These results contribute to the body of data regarding management of blunt splenic injury. Knowing predictive factors could help personalize management of patients, minimize delay of care, efficient resource allocation, and inform future studies.

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.