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Breeding T, Nasef H, Patel H, Bundschu N, Chin B, Hersperger SG, Havron WS, Elkbuli A. Clinical Outcomes of Splenic Artery Embolization Versus Splenectomy in the Management of Hemodynamically Stable High-Grade Blunt Splenic Injuries: A National Analysis. J Surg Res 2024; 300:221-230. [PMID: 38824852 DOI: 10.1016/j.jss.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 04/28/2024] [Accepted: 05/08/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION This study aims to compare the outcomes of splenic artery embolization (SAE) versus splenectomy in adult trauma patients with high-grade blunt splenic injuries. METHODS This retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2021) compared SAE versus splenectomy in adults with blunt high-grade splenic injuries (grade ≥ IV). Patients were stratified first by hemodynamic status then splenic injury grade. Outcomes included in-hospital mortality, intensive care unit length of stay (ICU-LOS), and transfusion requirements at four and 24 h from arrival. RESULTS Three thousand one hundred nine hemodynamically stable patients were analyzed, with 2975 (95.7%) undergoing splenectomy and 134 (4.3%) with SAE. One thousand eight hundred sixty five patients had grade IV splenic injuries, and 1244 had grade V. Patients managed with SAE had 72% lower odds of in-hospital mortality (odds ratio [OR] 0.28; P = 0.002), significantly shorter ICU-LOS (7 versus 9 d, 95%, P = 0.028), and received a mean of 1606 mL less packed red blood cells at four h compared to those undergoing splenectomy. Patients with grade IV or V injuries both had significantly lower odds of mortality (IV: OR 0.153, P < 0.001; V: OR 0.365, P = 0.041) and were given less packed red blood cells within four h when treated with SAE (2056 mL versus 405 mL, P < 0.001). CONCLUSIONS SAE may be a safer and more effective management approach for hemodynamically stable adult trauma patients with high-grade blunt splenic injuries, as demonstrated by its association with significantly lower rates of in-hospital mortality, shorter ICU-LOS, and lower transfusion requirements compared to splenectomy.
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Affiliation(s)
- Tessa Breeding
- NOVA Southeastern University, Dr Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, Florida
| | - Hazem Nasef
- NOVA Southeastern University, Dr Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, Florida
| | - Heli Patel
- NOVA Southeastern University, Dr Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, Florida
| | - Nikita Bundschu
- NOVA Southeastern University, Dr Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, Florida
| | - Brian Chin
- University of Hawaii, John A Burns School of Medicine, Honolulu, Hawaii
| | - Stephen G Hersperger
- Division of Trauma and Surgical Critical Care, Department of Surgery, Orlando Regional Medical Center, Orlando, Florida; Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
| | - William S Havron
- Division of Trauma and Surgical Critical Care, Department of Surgery, Orlando Regional Medical Center, Orlando, Florida; Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
| | - Adel Elkbuli
- Division of Trauma and Surgical Critical Care, Department of Surgery, Orlando Regional Medical Center, Orlando, Florida; Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida.
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Mahmood I, Younis B, Alabdallat M, Mathradikkal S, Abdelrahman H, El-Menyar A, Asim M, Kasim M, Mollazehi M, Al-Hassani A, Peralta R, Rizoli S, Al-Thani H. Pre- and post-implementation protocol for non-operative management of grade III-V splenic injuries: An observational study. Heliyon 2024; 10:e28447. [PMID: 38560121 PMCID: PMC10979267 DOI: 10.1016/j.heliyon.2024.e28447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/04/2024] Open
Abstract
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.
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Affiliation(s)
- Ismail Mahmood
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Basil Younis
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Mohammad Alabdallat
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Saji Mathradikkal
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Husham Abdelrahman
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Trauma and Vascular Surgery, Clinical Research, HMC, Doha, Qatar
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Mohammad Asim
- Department of Surgery, Trauma and Vascular Surgery, Clinical Research, HMC, Doha, Qatar
| | - Mohammad Kasim
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Monira Mollazehi
- Department of Surgery, Trauma Surgery, National Trauma Registry, HMC, Doha, Qatar
| | - Ammar Al-Hassani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Sandro Rizoli
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma and Vascular Surgery, HMC, Doha, Qatar
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Sammoud S, Ghelfi J, Barbois S, Beregi JP, Arvieux C, Frandon J. Preventive Proximal Splenic Artery Embolization for High-Grade AAST-OIS Adult Spleen Trauma without Vascular Anomaly on the Initial CT Scan: Technical Aspect, Safety, and Efficacy-An Ancillary Study. J Pers Med 2023; 13:889. [PMID: 37373879 DOI: 10.3390/jpm13060889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/18/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023] Open
Abstract
The spleen is the most commonly injured organ in blunt abdominal trauma. Its management depends on hemodynamic stability. According to the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS ≥ 3), stable patients with high-grade splenic injuries may benefit from preventive proximal splenic artery embolization (PPSAE). This ancillary study, using the SPLASH multicenter randomized prospective cohort, evaluated the feasibility, safety, and efficacy of PPSAE in patients with high-grade blunt splenic trauma without vascular anomaly on the initial CT scan. All patients included were over 18 years old, had high-grade splenic trauma (≥AAST-OIS 3 + hemoperitoneum) without vascular anomaly on the initial CT scan, received PPSAE, and had a CT scan at one month. Technical aspects, efficacy, and one-month splenic salvage were studied. Fifty-seven patients were reviewed. Technical efficacy was 94% with only four proximal embolization failures due to distal coil migration. Six patients (10.5%) underwent combined embolization (distal + proximal) due to active bleeding or focal arterial anomaly discovered during embolization. The mean procedure time was 56.5 min (SD = 38.1 min). Embolization was performed with an Amplatzer™ vascular plug in 28 patients (49.1%), a Penumbra occlusion device in 18 patients (31.6%), and microcoils in 11 patients (19.3%). There were two hematomas (3.5%) at the puncture site without clinical consequences. There were no rescue splenectomies. Two patients were re-embolized, one on Day 6 for an active leak and one on Day 30 for a secondary aneurysm. Primary clinical efficacy was, therefore, 96%. There were no splenic abscesses or pancreatic necroses. The splenic salvage rate on Day 30 was 94%, while only three patients (5.2%) had less than 50% vascularized splenic parenchyma. PPSAE is a rapid, efficient, and safe procedure that can prevent splenectomy in high-grade spleen trauma (AAST-OIS) ≥ 3 with high splenic salvage rates.
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Affiliation(s)
- Skander Sammoud
- Department of Radiology, Nîmes Carémeau University Hospital, 30900 Nimes, France
| | - Julien Ghelfi
- Institute for Advanced Biosciences, Inserm U 1209, CNRS UMR 5309, Université Grenoble Alpes, 38000 Grenoble, France
- Department of Radiology, Grenoble-Alpes University Hospital, 38000 Grenoble, France
| | - Sandrine Barbois
- Department of Digestive Surgery, University Hospital Grenoble Alpes, 38043 Grenoble, France
| | - Jean-Paul Beregi
- Department of Radiology, Nîmes Carémeau University Hospital, 30900 Nimes, France
| | - Catherine Arvieux
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, 38043 Grenoble, France
| | - Julien Frandon
- Department of Radiology, Nîmes Carémeau University Hospital, 30900 Nimes, France
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Stottlemyre RL, Notrica DM, Cohen AS, Sayrs LW, Naiditch J, St Peter SD, Leys CM, Ostlie DJ, Maxson RT, Ponsky T, Eubanks JW, Bhatia A, Greenwell C, Lawson KA, Alder AC, Johnson J, Garvey E. Hemodilution in pediatric trauma: Defining the expected hemoglobin changes in patients with liver and/or spleen injury: An ATOMAC+ secondary analysis. J Pediatr Surg 2023; 58:325-329. [PMID: 36428184 DOI: 10.1016/j.jpedsurg.2022.10.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Rachael L Stottlemyre
- Phoenix Children's, Phoenix, AZ 85016, United States; University of Miami Miller School of Medicine, Miami, FL 33136, United States
| | - David M Notrica
- Phoenix Children's, Phoenix, AZ 85016, United States; University of Arizona College of Medicine Phoenix, Phoenix, AZ 85004, United States; Mayo Clinic College of Medicine and Science, Phoenix, AZ 85054, United States.
| | - Aaron S Cohen
- University of Miami Miller School of Medicine, Miami, FL 33136, United States
| | - Lois W Sayrs
- Children's Hospital of Orange County Research Institute, Orange, CA 92868, United States
| | | | | | - Charles M Leys
- American Family Children's Hospital, Madison, WI 53792, United States
| | - Daniel J Ostlie
- Phoenix Children's, Phoenix, AZ 85016, United States; American Family Children's Hospital, Madison, WI 53792, United States
| | - R Todd Maxson
- Arkansas Children's Hospital, Little Rock, AR 72202, United States
| | - Todd Ponsky
- Dell Children's Medical Center, Austin, TX 78723, United States; Akron Children's Hospital, Akron, OH 44308, United States
| | - James W Eubanks
- Le Bonheur Children's Hospital, Memphis, TN 38103, United States
| | - Amina Bhatia
- Children's Healthcare of Atlanta, Atlanta, GA 30303, United States
| | | | - Karla A Lawson
- Dell Children's Medical Center, Austin, TX 78723, United States
| | - Adam C Alder
- Children's Medical Center Dallas, Dallas, TX 75235, United States
| | - Jeremy Johnson
- The Children's Hospital at OU Medical Center, Oklahoma City, OK 73104, United States
| | - Erin Garvey
- Phoenix Children's, Phoenix, AZ 85016, United States; University of Arizona College of Medicine Phoenix, Phoenix, AZ 85004, United States; Mayo Clinic College of Medicine and Science, Phoenix, AZ 85054, United States
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Sammartano F, Ferrara F, Benuzzi L, Baldi C, Conalbi V, Bini R, Cimbanassi S, Chiara O, Stella M. Comparison between level 1 and level 2 trauma centers for the management of splenic blunt trauma. Cir Esp 2022:S2173-5077(22)00256-3. [PMID: 35882313 DOI: 10.1016/j.cireng.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/18/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION The management of blunt splenic trauma has evolved in the last years, from mainly operative approach to the non-operative management (NOM). The aim of this study is to investigate whether trauma center (TC) designation (level 1 and level 2) affects blunt splenic trauma management. METHODS A retrospective analysis of blunt trauma patients with splenic injury admitted to 2 Italian TCs, Niguarda (level 1) and San Carlo Borromeo (level 2), was performed, receiving either NOM or emergency surgical treatment, from January 1, 2015 to December 31, 2020. Univariate comparison was performed between the two centers, and multivariate analysis was carried out to find predictive factors associated with NOM and splenectomy. RESULTS 181 patients were included in the study, 134 from level 1 and 47 from level 2 TCs. The splenectomy/emergency laparotomy ratio was inferior at level 1 TC for high-grade splenic injuries (30.8% for level 1 and 100% for level 2), whose patients presented higher incidence of other injuries. Splenic NOM failure was registered in only one case (3.3%). At multivariate analysis, systolic pressure, spleen organ injury scale (OIS) and injury severity score (ISS) resulted significant predictive factors for NOM, and only spleen OIS was predictive factor for splenectomy (Odds Ratio 0.14, 0.04-0.49 CI 95%, P < .01). CONCLUSION Both level 1 and 2 trauma centers demonstrated application of NOM with a high rate of success with some management difference in the treatment and outcome of patients with splenic injuries between the two types of TCs.
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Affiliation(s)
- Fabrizio Sammartano
- Department of Surgery, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Francesco Ferrara
- Department of Surgery, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy.
| | - Laura Benuzzi
- Department of Surgery, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Italy
| | - Caterina Baldi
- Department of Surgery, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Italy
| | - Valeria Conalbi
- Department of Surgery, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Italy
| | - Roberto Bini
- General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Osvaldo Chiara
- Department of Biomedical Sciences for Health, University of Milan, Italy; General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Stella
- Department of Surgery, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Italy
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Hirano T, Iwasaki Y, Ono Y, Ishida T, Shinohara K. Long-term incidence and timing of splenic pseudoaneurysm formation after blunt splenic injury: A descriptive study. Ann Vasc Surg 2022; 88:291-299. [PMID: 35817382 DOI: 10.1016/j.avsg.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 05/27/2022] [Accepted: 06/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Nonoperative management (NOM) has become a standard strategy for hemodynamically stable patients with blunt splenic injury; however, delayed rupture of splenic pseudoaneurysm (SPA) is a serious complication of NOM. In medical literature, data regarding the long-term incidence of SPA are scarce, and the appropriate timing for performing follow-up contrast-enhanced computed tomography (CT) has not yet been reported. This study aimed to elucidate the long-term incidence and timing of SPA formation after blunt splenic injury in patients treated with NOM. METHODS This descriptive study was conducted at a tertiary medical center in Japan. Patients with blunt splenic injury who were treated with NOM between April 2014 and August 2020 were included in the analysis. Included patients underwent repeated contrast-enhanced CT to detect SPA formation. The primary outcome was the cumulative incidence of delayed formation of SPA. We also evaluated differences in SPA formation between patients who received transcatheter arterial embolization (TAE; TAE group) and those who did not receive it (non-TAE group) on admission day. RESULTS Among 49 patients with blunt splenic injury who were treated with NOM, 5 patients (10.2%) had delayed formation of SPA. All cases of SPA formation occurred within 15 days of injury. The incidence of SPA formation was not significantly different between the TAE and non-TAE groups (1/19 vs. 4/30, P=.67). CONCLUSIONS SPA developed in 10% of patients within approximately 2 weeks after blunt splenic injury. Therefore, performing follow-up contrast-enhanced CT in this period after injury may be useful to evaluate delayed formation of SPA. Although our findings are novel, they should be confirmed through future studies with larger sample sizes.
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Affiliation(s)
- Takaki Hirano
- Department of Anesthesiology and Emergency Medicine, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima 963-8558, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
| | - Yuko Ono
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, 7-5-2 Kusunoki-cho, Chuo-ward, Kobe, 650-0017, Japan
| | - Tokiya Ishida
- Department of Anesthesiology and Emergency Medicine, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima 963-8558, Japan
| | - Kazuaki Shinohara
- Department of Anesthesiology and Emergency Medicine, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima 963-8558, Japan
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Jeong H, Jung S, Heo TG, Choi PW, Kim JI, Jung SM, Jun H, Shin YC, Um E. Could the Injury Severity Score be a new indicator for surgical treatment in patients with traumatic splenic injury? JOURNAL OF TRAUMA AND INJURY 2022. [DOI: 10.20408/jti.2021.0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Han J, Dudi-Venkata NN, Jolly S, Ting YY, Lu H, Thomas M, Dobbins C. Splenic artery embolization improves outcomes and decreases the length of stay in hemodynamically stable blunt splenic injuries - A level 1 Australian Trauma centre experience. Injury 2022; 53:1620-1626. [PMID: 34991862 DOI: 10.1016/j.injury.2021.12.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 12/06/2021] [Accepted: 12/23/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Jennie Han
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Department of Surgery, Austin Hospital, Melbourne, Victoria, Australia
| | | | - Samantha Jolly
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ying Yang Ting
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Ha Lu
- Department of Radiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Meredith Thomas
- Department of Radiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
| | - Christopher Dobbins
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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9
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Poupore NS, Boswell ND, Baginski B, Cull J, Pellizzeri KF. The Utility of Serial Hemoglobin Monitoring in Non-Operative Management of Blunt Splenic Injury. Am Surg 2021; 88:692-697. [PMID: 34730033 DOI: 10.1177/00031348211048829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Nicolas S Poupore
- 368074University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | - Nicole D Boswell
- 368074University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | - Bryana Baginski
- Department of Surgery, 22683Baylor University Medical Center, Dallas, TX, USA
| | - John Cull
- Department of Surgery, 3626Prisma Health, Greenville, SC, USA
| | - Katherine F Pellizzeri
- 368074University of South Carolina School of Medicine Greenville, Greenville, SC, USA.,Department of Surgery, 3626Prisma Health, Greenville, SC, USA
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10
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Arvieux C, Thony F. Management of splenic trauma in hemodynamically stable patients: Lessons to be drawn from the French SPLASH trial (Splenic Arterial Embolization to Avoid Splenectomy (SPLASH) Study Group). J Visc Surg 2021; 159:43-46. [PMID: 34716120 DOI: 10.1016/j.jviscsurg.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- C Arvieux
- CS 10-232, General and Digestive Surgery Department, Université Grenoble-Alpes, CHU de Grenoble-Alpes, 38043 Grenoble cedex, France.
| | - F Thony
- CS 10-232, University Center of Imaging and Interventional Radiology (CURIM), CHU de Grenoble-Alpes, 38043 Grenoble cedex, France
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Djordjevic I, Zivanovic D, Budic I, Kostic A, Djeric D. Importance of a Follow-Up Ultrasound Protocol in Monitoring Posttraumatic Spleen Complications in Children Treated with a Non-Operative Management. MEDICINA-LITHUANIA 2021; 57:medicina57080734. [PMID: 34440940 PMCID: PMC8400664 DOI: 10.3390/medicina57080734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/16/2021] [Accepted: 07/18/2021] [Indexed: 01/10/2023]
Abstract
Background and objectives: For the last three decades, non-operative management (NOM) has been the standard in the treatment of clinically stable patients with blunt spleen injury, with a success rate of up to 95%. However, there are no prospective issues in the literature dealing with the incidence and type of splenic complications after NOM. Materials and methods: This study analyzed 76 pediatric patients, up to the age of 18, with blunt splenic injury who were treated non-operatively. All patients were included in a posttraumatic follow-up protocol with ultrasound examinations 4 and 12 weeks after injury. Results: The mean age of the children was 9.58 ± 3.97 years (range 1.98 to 17.75 years), with no statistically significant difference between the genders. The severity of the injury was determined according to the American Association for Surgery of Trauma (AAST) classification: 7 patients had grade I injuries (89.21%), 21 patients had grade II injuries (27.63%), 33 patients had grade III injuries (43.42%), and 15 patients had grade IV injuries (19.73%). The majority of the injuries were so-called high-energy ones, which were recorded in 45 patients (59.21%). According to a previously created posttraumatic follow-up protocol, complications were detected in 16 patients (21.05%). Hematomas had the highest incidence and were detected in 11 patients (14.47%), while pseudocysts were detected in 3 (3.94%), and a splenic abscess and pseudoaneurysm were detected in 1 patient (1.31%), respectively. The complications were in a direct correlation with injury grade: seven occurred in patients with grade IV injuries (9.21%), five occurred in children with grade III injuries (6.57%), three occurred in patients with grade II injuries (3.94%), and one occurred in a patient with a grade I injury (1.31%). Conclusion: Based on the severity of the spleen injury, it is difficult to predict the further course of developing complications, but complications are more common in high-grade injuries. The implementation of a follow-up ultrasound protocol is mandatory in all patients with NOM of spleen injuries for the early detection of potentially dangerous and fatal complications.
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Affiliation(s)
- Ivona Djordjevic
- Pediatric Surgery Clinic, Clinical Center, 18000 Nis, Serbia; (D.Z.); (A.K.); (D.D.)
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia;
- Correspondence:
| | - Dragoljub Zivanovic
- Pediatric Surgery Clinic, Clinical Center, 18000 Nis, Serbia; (D.Z.); (A.K.); (D.D.)
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia;
| | - Ivana Budic
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia;
- Clinic for Anestesiology and Intensive Therapy, Clinical Center Nis, 18000 Nis, Serbia
| | - Ana Kostic
- Pediatric Surgery Clinic, Clinical Center, 18000 Nis, Serbia; (D.Z.); (A.K.); (D.D.)
| | - Danijela Djeric
- Pediatric Surgery Clinic, Clinical Center, 18000 Nis, Serbia; (D.Z.); (A.K.); (D.D.)
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A pilot randomized controlled trial of endovascular coils and vascular plugs for proximal splenic artery embolization in high-grade splenic trauma. Abdom Radiol (NY) 2021; 46:2823-2832. [PMID: 33386906 DOI: 10.1007/s00261-020-02904-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 09/28/2020] [Accepted: 12/06/2020] [Indexed: 01/20/2023]
Abstract
PURPOSE To evaluate the feasibility of enrolling patients in a randomized controlled trial (RCT) comparing endovascular coils (EC) and vascular plugs (VP) for proximal splenic artery embolization (pSAE) in high-grade splenic trauma, and to collect data to inform the design of a larger clinical effectiveness trial. METHODS Single-center, prospective, RCT of patients with Grade III-V splenic injuries selected for nonoperative management. Patients were randomized to pSAE with EC or VP. The main outcome was feasibility. We also evaluated technical success, time to stasis, complications, mortality, and splenectomy rates, by estimating rates and 95% confidence intervals. RESULTS 46 of 50 eligible patients were enrolled (92%, 95% CI 90-100%). Overall, splenic salvage was 98% (45/46; 95% CI 94-100%). Primary technical success was observed in 22 EC patients (96%; 95% CI 87-100%) and 20 VP patients (87%; 95% CI 73-100%). Bayesian analysis suggests a > 80% probability that primary technical success is higher for EC. Two complications (one major and one minor) occurred in the EC group (9%; CI 0-20%) and one major complication occurred in the VP group (4%; CI 0-13%). CONCLUSIONS Randomized comparisons of endovascular devices used for pSAE after trauma are feasible. pSAE using either EC or VP results in excellent rates of splenic salvage in trauma patients with high-grade splenic injuries. These high rates of splenic salvage and low rates of complications make their use as a primary outcome in a future trial problematic. Consideration should be given to technical parameters as a primary outcome for future trials.
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Predicting the Outcome of Non-operative Management of Splenic Trauma in South Africa. World J Surg 2021; 44:1485-1491. [PMID: 31933042 DOI: 10.1007/s00268-020-05370-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION We aimed to expand on the global surgical discussion around splenic trauma in order to understand locally and clinically relevant factors for operative (OP) and non-operative management (NOM) of splenic trauma in a South African setting. METHODS A retrospective cohort study was performed using 2013-2017 data from the Pietermaritzburg Metropolitan Trauma Service. All adult patients (≥15 years) were included. Those managed with OP or NOM for splenic trauma were identified and analyzed descriptively. Multiple logistic regression analysis identified patients and clinical factors associated with management type. RESULTS There were 127 patients with splenic injury. Median age was 29 [19-35] years with 42 (33%) women and 85 (67%) men. Blunt injuries occurred in the majority (81, 64%). Organ Injury Scale (OIS) grades included I (25, 20%), II (43, 34%), III (36, 28%), IV (15, 11%), and V (8, 6%). Nine patients expired. On univariate analysis, increasing OIS was associated with OP management, need for intensive care unit (ICU) admission, and hospital and ICU duration of stay, but not mortality. In patients with a delayed compared to early presentation, ICU utilization (62% vs. 36%, p = 0.008) and mortality (14% vs. 4%, p = 0.03) were increased. After adjusting for age, sex, presence of shock, and splenic OIS, penetrating trauma (adjusted odds ratio, 5.7; 95%CI, 1.7-9.8) and admission lactate concentration (adjusted odds ratio, 1.4; 95%CI 1.1-1.9) were significantly associated with OP compared to NOM (p = 0.002; area under the curve 0.81). CONCLUSIONS We have identified injury mechanism and admission lactate as factors predictive of OP in South African patients with splenic trauma. Timely presentation to definitive care affects both ICU duration of stay and mortality outcomes. Future global surgical efforts may focus on expanding non-operative management protocols and improving pre-hospital care in patients with splenic trauma.
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Nguyen A, Orlando A, Yon JR, Mentzer CJ, Banton K, Bar-Or D. Predictors of splenectomy after failure of non-operative management: An analysis of the nation trauma database from 2013 to 2014. TRAUMA-ENGLAND 2021. [DOI: 10.1177/1460408620911489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
| | - Alessandro Orlando
- Swedish Medical Center, Englewood, CO, USA
- St. Anthony Hospital, Lakewood, Colorado, USA
- The Medical Center of Plano, Plano, TX, USA
- Penrose Hospital, Colorado Springs, CO, USA
| | | | | | | | - David Bar-Or
- Swedish Medical Center, Englewood, CO, USA
- St. Anthony Hospital, Lakewood, Colorado, USA
- The Medical Center of Plano, Plano, TX, USA
- Penrose Hospital, Colorado Springs, CO, USA
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Angioembolization in intra-abdominal solid organ injury: Does delay in angioembolization affect outcomes? J Trauma Acute Care Surg 2020; 89:723-729. [PMID: 33017133 DOI: 10.1097/ta.0000000000002851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Angioembolization (AE) is an integral component in multidisciplinary algorithms for achieving hemostasis in patients with trauma. The American College of Surgeons Committee on Trauma recommends that interventional radiologists be available within 30 minutes to perform emergent AE. However, the impact of the timing of AE on patient outcomes is still not well known. We hypothesized that a delay in AE would be associated with increased mortality and higher blood transfusion requirements in patients with blunt intra-abdominal solid organ injury. METHODS A 4-year (2013-2016) retrospective review of the ACS Trauma Quality Improvement Program database was performed. We included adult patients (age, ≥18 years) with blunt intra-abdominal solid organ injury who underwent AE within 4 hours of hospital admission. Patients who underwent operative intervention before AE were excluded. The primary outcome was 24-hour mortality. The secondary outcome was blood product transfusions. Patients were grouped into four 1-hour intervals according to their time from admission to AE. Multivariate regression analysis was performed to accommodate patient differences. RESULTS We analyzed 1,009,922 trauma patients, of which 924 (1 hour, 76; 1-2 hours, 224; 2-3 hours, 350; 3-4 hours, 274) were deemed eligible. The mean ± SD age was 44 ± 19 years, and 66% were male. The mean ± SD time to AE was 144 ± 54 minutes, and 92% of patients underwent AE more than 1 hour after admission. Overall 24-hour mortality was 5.2%. On univariate analysis, patients receiving earlier AE had decreased 24-hour mortality (p = 0.016), but no decrease in blood products transfused. On regression analysis, every hour delay in AE was significantly associated with increased 24-hour mortality (p < 0.05). CONCLUSION Delayed AE for hemorrhagic control in blunt trauma patients with an intra-abdominal solid organ injury is associated with increased 24-hour mortality. Trauma centers should ensure timeliness of interventional radiologist availability to prevent a delay in vital AE, and it should be a focus of quality improvement projects. LEVEL OF EVIDENCE Prognostic, level III.
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Predictors of surgical management of high grade blunt splenic injuries in adult trauma patients: a 5-year retrospective cohort study from an academic level I trauma center. Patient Saf Surg 2020; 14:32. [PMID: 32774457 PMCID: PMC7398213 DOI: 10.1186/s13037-020-00257-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022] Open
Abstract
Backgrounds Splenic injury accounts for 40% of all injuries after blunt abdominal trauma. Blunt splenic injury in hemodynamically unstable patients is preferably treated by splenectomy. Nowadays hemodynamically stable patients with low grade splenic injuries are mostly treated by non-operative management (NOM). However no consensus exists about the management of high grade splenic injuries in hemodynamically stable patients. Therefore the aim of this study was to analyze patients with high grade splenic injuries in our institution. Methods We retrospectively included all patients with a splenic injury presented to our level I trauma center during the 5-year period from January 1, 2012, until December 31, 2017. Baseline characteristics, data regarding complications and mortality were collected from the electronic patient registry. Patients were grouped based on splenic injury and the treatment they received. Results A total of 123 patients were included, of which 93 (75.6%) were male with a median age of 31 (24–52) and a median injury severity score of 27 (17–34). High grade injuries (n = 28) consisted of 20 Grade IV injuries and 8 grade V injuries. Splenectomy was required in 15/28 (53.6%) patients, of whom all remained hemodynamically unstable after resuscitation, including all grade V injuries. A total of 13 patients with high grade injuries were treated with spleen preserving therapy. Seven of these patients received angio-embolization. One patient went for laparotomy and the spleen was treated with a hemostatic agent. Secondary hemorrhage was present in 3 of these patients (initial treatment: 1 embolization/ 2 observational), resulting in a success rate of 76.9%. There is no mortality seen in patient with high grade splenic injuries. Conclusion Non-operative treatment in high grade splenic injuries is a safe treatment modality in hemodynamically stable patients. Hemodynamic status and peroperative bleeding, not injury severity or splenic injury grade were the drivers for surgical management by splenectomy. This selected cohort of patients must be closely monitored to prevent adverse outcomes from secondary delayed bleeding in case of non-operative management.
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17
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Paredes-Bhushan V, Raffin EP, Denstedt JD, Chew BH, Knudsen BE, Miller NL, Monga M, Noble MJ, Pais VM. Outcomes of Conservative Management of Splenic Injury Incurred During Percutaneous Nephrolithotomy. J Endourol 2020; 34:811-815. [DOI: 10.1089/end.2020.0076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Eric P. Raffin
- Section of Urology, Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - John D. Denstedt
- Division of Urology, St. Joseph's Hospital, Western University, London, Canada
| | - Ben H. Chew
- Department of Urologic Sciences, University of British Columbia, Vancouver, Canada
- Endourology Disease Group for Excellence (EDGE) Research Consortium
| | - Bodo E. Knudsen
- Endourology Disease Group for Excellence (EDGE) Research Consortium
- Department of Urology, Ohio State University Medical Center, Columbus, Ohio, USA
| | - Nicole L. Miller
- Endourology Disease Group for Excellence (EDGE) Research Consortium
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Manoj Monga
- Endourology Disease Group for Excellence (EDGE) Research Consortium
- Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, Ohio, USA
| | - Mark J. Noble
- Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, Ohio, USA
| | - Vernon M. Pais
- Section of Urology, Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Endourology Disease Group for Excellence (EDGE) Research Consortium
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Guinto R, Greenberg P, Ahmed N. Emergency Management of Blunt Splenic Injury in Hypotensive Patients : Total Splenectomy Versus Splenic Angioembolization. Am Surg 2020; 86:690-694. [PMID: 32683975 DOI: 10.1177/0003134820923325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The purpose of this study is to examine the outcomes of splenic angioembolization (SAE) as the first modality for nonoperative management (NOM) in hypotensive patients with high-grade splenic injuries. METHODS Data were collected from the 2007-2010 National Trauma Data Bank data sets of the United States. The data included patients with massive blunt splenic injuries with an Abbreviated Injury Scale (AIS) of 4 or 5, initial systolic blood pressure ≤90, and who underwent either a total splenectomy or SAE (Group 1 and Group 2, respectively) within 4 hours of hospital arrival. The outcomes of interest are in-hospital mortality and complications. RESULTS Of the 1052 patients analyzed, 996 (94.7%) underwent total splenectomy while 56 (5.3%) underwent SAE. There were significant differences regarding injury mechanism (P = .01) and the proportion of patients with an AIS of 5 (57.6% vs 39.3% respectively, P = .01). A significantly higher number of patients, however, developed organ space infections (3.9% vs 11.6%, P = .02) in Group 2. The multivariate logistic regression model for mortality, which accounted for demography, Glasgow Coma Scale Motor (GCSM) score, Injury Severity Score (ISS), AIS, time to procedure, and procedure type showed the procedure type was not a contributing factor to patient mortality, but higher age, ISS, and lower GCSM score were strong predictors of mortality. CONCLUSION The treatment of approximately 95% of hypotensive patients with massive splenic injury was total splenectomy. However, if the interventional radiology resources are immediately available, SAE can be used as a first intervention without an increased risk of mortality.
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Affiliation(s)
- Robyn Guinto
- 23498 Division of Trauma & Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Patricia Greenberg
- 23498 Department of Research Administration, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Nasim Ahmed
- 23498 Division of Trauma & Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, USA.,Hackensack Meridian School of Medicine at Seton Hall University, Nutley, NJ, USA
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The Long-term Risk of Venous Thromboembolism After Blunt Splenic Injury Managed by Embolization. Ann Surg 2020; 271:e98-e100. [PMID: 31850979 DOI: 10.1097/sla.0000000000003755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Spijkerman R, Bulthuis LCM, Hesselink L, Nijdam TMP, Leenen LPH, de Bruin IGJM. Management of pediatric blunt abdominal trauma in a Dutch level one trauma center. Eur J Trauma Emerg Surg 2020; 47:1543-1551. [PMID: 32047960 PMCID: PMC8476366 DOI: 10.1007/s00068-020-01313-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 01/25/2020] [Indexed: 11/29/2022]
Abstract
Purpose Most children with intra-abdominal injuries can be managed non-operatively. However, in Europe, there are many different healthcare systems for the treatment of pediatric trauma patients. Therefore, the aim of this study was to describe the management strategies and outcomes of all pediatric patients with blunt intra-abdominal injuries in our unique dedicated pediatric trauma center with a pediatric trauma surgeon. Methods We performed a retrospective, single-center, cohort study to investigate the management of pediatric patients with blunt abdominal trauma. From the National Trauma Registration database, we retrospectively identified pediatric (≤ 18 years) patients with blunt abdominal injuries admitted to the UMCU from January 2012 till January 2018. Results A total of 121 pediatric patients were included in the study. The median [interquartile range (IQR)] age of patients was 12 (8–16) years, and the median ISS was 16 (9–25). High-grade liver injuries were found in 12 patients. Three patients had a pancreas injury grade V. Furthermore, 2 (1.6%) patients had urethra injuries and 10 (8.2%) hollow viscus injuries were found. Eighteen (14.9%) patients required a laparotomy and 4 (3.3%) patients underwent angiographic embolization. In 6 (5.0%) patients, complications were found and in 4 (3.3%) children intervention was needed for their complication. No mortality was seen in patients treated non-operatively. One patient died in the operative management group. Conclusions In conclusion, it is safe to treat most children with blunt abdominal injuries non-operatively if monitoring is adequate. These decisions should be made by the clinicians operating on these children, who should be an integral part of the entire group of treating physicians. Surgical interventions are only needed in case of hemodynamic instability or specific injuries such as bowel perforation. Electronic supplementary material The online version of this article (10.1007/s00068-020-01313-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Roy Spijkerman
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Lauren C M Bulthuis
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Lillian Hesselink
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Thomas M P Nijdam
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ivar G J M de Bruin
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Teuben M, Spijkerman R, Pfeifer R, Blokhuis T, Huige J, Pape HC, Leenen L. Selective non-operative management for penetrating splenic trauma: a systematic review. Eur J Trauma Emerg Surg 2019; 45:979-985. [PMID: 30972434 PMCID: PMC6910899 DOI: 10.1007/s00068-019-01117-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 03/27/2019] [Indexed: 12/02/2022]
Abstract
Introduction The treatment of abdominal solid organ injuries has shifted towards non-operative management (NOM). However, the feasibility of NOM for penetrating splenic trauma is unclear and outcome is believed to be worse than NOM for penetrating liver and kidney injuries. Hence, the aim of the current systematic review was to evaluate the feasibility of selective NOM in penetrating splenic injury. Methods A review of literature was performed using Pubmed, Embase and Cochrane databases. Studies on adult patients treated by NOM for splenic injuries were included and outcome was documented and compared. Results Five articles from exclusively level-1 and level-2-traumacenters were selected and a total of 608 cases of penetrating splenic injury were included. Nonoperative management was applied in 123 patients (20.4%, range 17–33%). An overall failure rate of NOM of 18% was calculated. Mortality was not seen in patients selected for nonoperative management. Contra-indicatons for NOM included hemodynamic instability, absence of abdominal CT-scanning to rule out concurrent injuries and peritonitis. Conclusions This review demonstrates that non-operative management for penetrating splenic trauma in highly selected patients has been utilized in several well-equipped and experienced trauma centers. NOM of penetrating splenic injury in selected patients is not associated with increased morbidity nor mortality. Data on the less well-equipped and experienced trauma centers are not available. More prospective studies are required to further define exact selection criteria for non-operative management in splenic trauma. Electronic supplementary material The online version of this article (10.1007/s00068-019-01117-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michel Teuben
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland.
| | - Roy Spijkerman
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Taco Blokhuis
- Department of Surgery, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Josephine Huige
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | | | - Luke Leenen
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Abbas Q, Jamil MT, Haque A, Sayani R. Use of Interventional Radiology in Critically Injured Children Admitted in a Pediatric Intensive Care Unit of a Developing Country. Cureus 2019; 11:e3922. [PMID: 30931193 PMCID: PMC6426563 DOI: 10.7759/cureus.3922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective The aim of this study was to describe the outcome of the use of interventional radiological procedures (IRP) (angioembolization) in critically injured children. Methods A retrospective review of medical records of all children who underwent an IRP from January 2010 to December 2015 was done. Data were collected on a structured proforma and results are presented as mean with standard deviation and frequency with percentages. Result Eighteen patients were identified who underwent IRP during the study period. The mean age was 10.4 ± 4.3 years and 10 (55%) were males. Ten patients had a road traffic accident, four had a history of fall, one patient had glass cut pelvic injury, and two patients had blunt abdominal trauma, while one patient had bleeding secondary to hemipelvectomy. The genitourinary system was involved in five patients, liver in four, and spleen in two and pancreas in one patient. Bleeding was from branches of internal iliac artery in seven patients, hepatic artery in three patients, splenic artery in two patients, and middle colic artery in one patient, while one patient had blood oozing from the bone after hemi-pelvictomy. Four French vascular access sheath was placed under ultrasound guidance; this was followed by the placement of C1 catheter (Cordis, Miami, FL). After vessel identification, a 2.7F Progreat microcatheter (Terumo, Tokyo) was used for super-selective cannulation of the bleeding vessel. Intravascular coil, polyvinyl alcohol (PVA) particles, or gel foam was used for the embolization of bleeding vessels. No procedural complications were observed except minor oozing in one patient. One patient expired due to multiorgan dysfunction. Conclusion Angioembolization is a useful and relatively safe procedure in the management of vitally stable children with hemorrhagic abdominopelvic injuries. However, further studies may be needed to evaluate the efficacy and cost-effectiveness of this practice, especially in resource-constrained settings.
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Affiliation(s)
- Qalab Abbas
- Pediatrics, Aga Khan University Hospital, Karachi, PAK
| | | | - Anwar Haque
- Pediatrics, The Indus Hospital, Karachi, PAK
| | - Raza Sayani
- Radiology, Aga Khan University Hospital, Karachi, PAK
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Teuben MPJ, Spijkerman R, Blokhuis TJ, Pfeifer R, Teuber H, Pape HC, Leenen LPH. Safety of selective nonoperative management for blunt splenic trauma: the impact of concomitant injuries. Patient Saf Surg 2018; 12:32. [PMID: 30505349 PMCID: PMC6260576 DOI: 10.1186/s13037-018-0179-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 11/13/2018] [Indexed: 11/10/2022] Open
Abstract
Background Nonoperative management for blunt splenic injury is the preferred treatment. To improve the outcome of selective nonoperative therapy, the current challenge is to identify factors that predict failure. Little is known about the impact of concomitant injury on outcome. Our study has two goals. First, to determine whether concomitant injury affects the safety of selective nonoperative treatment. Secondly we aimed to identify factors that can predict failure. Methods From our prospective trauma registry we selected all nonoperatively treated adult patients with blunt splenic trauma admitted between 01.01.2000 and 12.21.2013. All concurrent injuries with an AIS ≥ 2 were scored. We grouped and compared patients sustaining solitary splenic injuries and patients with concomitant injuries. To identify specific factors that predict failure we used a multivariable regression analysis. Results A total of 79 patients were included. Failure of nonoperative therapy (n = 11) and complications only occurred in patients sustaining concomitant injury. Furthermore, ICU-stay as well as hospitalization time were significantly prolonged in the presence of associated injury (4 versus 13 days,p < 0.05). Mortality was not seen. Multivariable analysis revealed the presence of a femur fracture and higher age as predictors of failure. Conclusions Nonoperative management for hemodynamically normal patients with blunt splenic injury is feasible and safe, even in the presence of concurrent (non-hollow organ) injuries or a contrast blush on CT. However, associated injuries are related to prolonged intensive care unit- and hospital stay, complications, and failure of nonoperative management. Specifically, higher age and the presence of a femur fracture are predictors of failure.
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Affiliation(s)
- Michel Paul Johan Teuben
- 1Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Roy Spijkerman
- 1Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Taco Johan Blokhuis
- 2Department of Surgery, Maastricht University Medical Center, P. Debyelaan 24, 6229 HX Maastricht, The Netherlands
| | - Roman Pfeifer
- 3Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zürich, Switzerland
| | - Henrik Teuber
- 3Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zürich, Switzerland
| | - Hans-Christoph Pape
- 3Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zürich, Switzerland
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Markert K, Haltmeier T, Khatsilouskaya T, Keel MJ, Candinas D, Schnüriger B. Early Surgery in Prone Position for Associated Injuries in Patients Undergoing Non-operative Management for Splenic and Liver Injuries. World J Surg 2018; 42:3947-3953. [DOI: 10.1007/s00268-018-4739-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Non-surgical Management of Blunt Splenic Trauma: A Comparative Analysis of Non-operative Management and Splenic Artery Embolization—Experience from a European Trauma Center. Cardiovasc Intervent Radiol 2018; 41:1324-1332. [DOI: 10.1007/s00270-018-1953-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/30/2018] [Indexed: 12/12/2022]
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Rosenberg GM, Knowlton L, Rajasingh C, Weng Y, Maggio PM, Spain DA, Staudenmayer KL. National Readmission Patterns of Isolated Splenic Injuries Based on Initial Management Strategy. JAMA Surg 2018; 152:1119-1125. [PMID: 28768329 DOI: 10.1001/jamasurg.2017.2643] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Options for managing splenic injuries have evolved with a focus on nonoperative management. Long-term outcomes, such as readmissions and delayed splenectomy rate, are not well understood. Objective To describe the natural history of isolated splenic injuries in the United States and determine whether patterns of readmission were influenced by management strategy. Design, Setting, and Participants The Healthcare Cost and Utilization Project's Nationwide Readmission Database is an all-payer, all-ages, longitudinal administrative database that provides data on more than 35 million weighted US discharges yearly. The database was used to identify patients with isolated splenic injuries and the procedures that they received. Adult patients with isolated splenic injuries admitted from January 1 through June 30, 2013, and from January 1 through June 30, 2014, were included. Those who died during the index hospitalization or who had an additional nonsplenic injury with an Abbreviated Injury Score of 2 or greater were excluded. Univariate and mixed-effects logistic regression analysis controlling for center effect were used. Weighted numbers are reported. Exposures Initial management strategy at the time of index hospitalization, including nonprocedural management, angioembolization, and splenectomy. Main Outcomes and Measures All-cause 6-month readmission rate. Secondary outcome was delayed splenectomy rate. Results A weighted sample of 3792 patients (2146 men [56.6%] and 1646 women [43.4%]; mean [SE] age, 48.5 [0.7] years) with 5155 admission events was included. During the index hospitalization, 825 (21.8%) underwent splenectomy, 293 (7.7%) underwent angioembolization, and 2673 (70.5%) had no procedure. The overall readmission rate was 21.1% (799 patients). Readmission rates did not differ based on initial management strategy (195 patients undergoing splenectomy [23.6%], 70 undergoing angioembolism [23.9%], and 534 undergoing no procedure [20%]; P = .33). Splenectomy was performed in 36 of 799 readmitted patients (4.5%) who did not have a splenectomy at their index hospitalization, leading to an overall delayed splenectomy rate of 1.2% (36 of 2967 patients). In mixed-effects logistic regression analysis controlling for patient, injury, clinical, and hospital characteristics, the choice of splenectomy (odds ratio, 0.93; 95% CI, 0.66-1.31) vs angioembolization (odds ratio, 1.19; 95% CI, 0.72-1.97) as initial management strategy was not associated with readmission. Conclusions and Relevance This national evaluation of the natural history of isolated splenic injuries from index admission through 6 months found that approximately 1 in 5 patients are readmitted within 6 months of discharge after an isolated splenic injury. However, the chance of readmission for splenectomy after initial nonoperative management was 1.2%. This finding suggests that the current management strategies used for isolated splenic injuries in the United States are well matched to patient need.
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Affiliation(s)
- Graeme M Rosenberg
- Department of Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California
| | - Lisa Knowlton
- Department of Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California
| | - Charlotte Rajasingh
- Department of Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California
| | - Yingjie Weng
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
| | - Paul M Maggio
- Department of Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California
| | - David A Spain
- Department of Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California
| | - Kristan L Staudenmayer
- Department of Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California
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Crichton JCI, Naidoo K, Yet B, Brundage SI, Perkins Z. The role of splenic angioembolization as an adjunct to nonoperative management of blunt splenic injuries: A systematic review and meta-analysis. J Trauma Acute Care Surg 2017; 83:934-943. [PMID: 29068875 DOI: 10.1097/ta.0000000000001649] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- James Charles Ian Crichton
- From the Department of General Surgery (J.C.I.C.), Waikato Hospital, Hamilton, New Zealand; Queen Mary University of London, Barts, and The London School of Medicine and Dentistry, London, United Kingdom (K.N., B.Y., Z.P., S.I.B.)
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Bordlee B, Schiro B, Peña C. Trauma in the Great Vessels: from the Aorta to the Pelvis. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0100-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Splenic trauma in a patient with portal hypertension and splenomegaly: A case report. JOURNAL OF SURGERY AND MEDICINE 2017. [DOI: 10.28982/josam.344391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
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Jabbour G, Al-Hassani A, El-Menyar A, Abdelrahman H, Peralta R, Ellabib M, Al-Jogol H, Asim M, Al-Thani H. Clinical and Radiological Presentations and Management of Blunt Splenic Trauma: A Single Tertiary Hospital Experience. Med Sci Monit 2017; 23:3383-3392. [PMID: 28700540 PMCID: PMC5519223 DOI: 10.12659/msm.902438] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 01/10/2017] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Splenic injury is the leading cause of major bleeding after blunt abdominal trauma. We examined the clinical and radiological presentations, management, and outcome of blunt splenic injuries (BSI) in our institution. MATERIAL AND METHODS A retrospective study of BSI patients between 2011 and 2014 was conducted. We analyzed and compared management and outcome of different splenic injury grades in trauma patients. RESULTS A total of 191 BSI patients were identified with a mean (SD) age of 26.9 years (13.1); 164 (85.9%) were males. Traffic-related accident was the main mechanism of injury. Splenic contusion and hematoma (77.2%) was the most frequent finding on initial computerized tomography (CT) scans, followed by shattered spleen (11.1%), blush (11.1%), and devascularization (0.6%). Repeated CT scan revealed 3 patients with pseudoaneurysm who underwent angioembolization. Nearly a quarter of patients were managed surgically. Non-operative management failed in 1 patient who underwent splenectomy. Patients with grade V injury presented with higher mean ISS and abdominal AIS, required frequent blood transfusion, and were more likely to be FAST-positive (p=0.001). The majority of low-grade (I-III) splenic injuries were treated conservatively, while patients with high-grade (IV and V) BSI frequently required splenectomy (p=0.001). Adults were more likely to have grade I, II, and V BSI, blood transfusion, and prolonged ICU stay as compared to pediatric BSI patients. The overall mortality rate was 7.9%, which is mainly association with traumatic brain injury and hemorrhagic shock; half of the deaths occurred within the first day after injury. CONCLUSIONS Most BSI patients had grade I-III injuries that were successfully treated non-operatively, with a low failure rate. The severity of injury and presence of associated lesions should be carefully considered in developing the management plan. Thorough clinical assessment and CT scan evaluation are crucial for appropriate management of BSI.
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Affiliation(s)
- Gaby Jabbour
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | | | - Ayman El-Menyar
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | | | - Ruben Peralta
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Ellabib
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Hisham Al-Jogol
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohammad Asim
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad Medical Corporation, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
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Oliver M, Dinh MM, Curtis K, Paschkewitz R, Rigby O, Balogh ZJ. Trends in Procedures at Major Trauma Centres in New South Wales, Australia: An Analysis of State-Wide Trauma Data. World J Surg 2017; 41:2000-2005. [DOI: 10.1007/s00268-017-3993-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Rong JJ, Liu D, Liang M, Wang QH, Sun JY, Zhang QY, Peng CF, Xuan FQ, Zhao LJ, Tian XX, Han YL. The impacts of different embolization techniques on splenic artery embolization for blunt splenic injury: a systematic review and meta-analysis. Mil Med Res 2017; 4:17. [PMID: 28573044 PMCID: PMC5450228 DOI: 10.1186/s40779-017-0125-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 05/10/2017] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Jing-Jing Rong
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Dan Liu
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Ming Liang
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Qing-Hua Wang
- Department of Cardiology, Xinqiao Hospital of Third Military Medical University, Chongqing, 400038 China
| | - Jing-Yang Sun
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Quan-Yu Zhang
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Cheng-Fei Peng
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Feng-Qi Xuan
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Li-Jun Zhao
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Xiao-Xiang Tian
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Ya-Ling Han
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
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Frandon J, Rodiere M, Arvieux C, Vendrell A, Boussat B, Sengel C, Broux C, Bricault I, Ferretti G, Thony F. Blunt splenic injury: are early adverse events related to trauma, nonoperative management, or surgery? Diagn Interv Radiol 2016; 21:327-33. [PMID: 26081719 DOI: 10.5152/dir.2015.14800] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE We aimed to compare clinical outcomes and early adverse events of operative management (OM), nonoperative management (NOM), and NOM with splenic artery embolization (SAE) in blunt splenic injury (BSI) and identify the prognostic factors. METHODS Medical records of 136 consecutive patients with BSI admitted to a trauma center from 2005 to 2010 were retrospectively reviewed. Patients were separated into three groups: OM, NOM, and SAE. We focused on associated injuries and early adverse events. Multivariate analysis was performed on 23 prognostic factors to find predictors. RESULTS The total survival rate was 97.1%, with four deaths all occurred in the OM group. The spleen salvage rate was 91% in NOM and SAE. At least one adverse event was observed in 32.8%, 62%, and 96% of patients in NOM, SAE, and OM groups, respectively (P < 0.001). We found significantly more deaths, infectious complications, pleural drainage, acute renal failures, and pancreatitis in OM and more pseudocysts in SAE. Six prognostic factors were statistically significant for one or more adverse events: simplified acute physiology score 2 ≥25 for almost all adverse events, age ≥50 years for acute respiratory syndrome, limb fracture for secondary bleeding, thoracic injury for pleural drainage, and at least one associated injury for pseudocyst. Adverse events were not related to the type of BSI management. CONCLUSION Patients with BSI present worse outcome and more adverse events in OM, but this is related to the severity of injury. The main predictor of adverse events remains the severity of injury.
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Affiliation(s)
- Julien Frandon
- Clinique Universitaire de Radiologie et d'Imagerie Médicale, Grenoble University Hospital, Grenoble, France.
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Kang DY, Yeom JW, Jo YG, Park YC, Kang WS, Kim JC. Therapeutic Options in Patients with Traumatic Splenic Injury. JOURNAL OF ACUTE CARE SURGERY 2016. [DOI: 10.17479/jacs.2016.6.2.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Dong Yeon Kang
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Ji Woong Yeom
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Young Goun Jo
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Yun Chul Park
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Wu Seong Kang
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jung Chul Kim
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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Van der Cruyssen F, Manzelli A. Splenic artery embolization: technically feasible but not necessarily advantageous. World J Emerg Surg 2016; 11:47. [PMID: 27625701 PMCID: PMC5020467 DOI: 10.1186/s13017-016-0100-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/11/2016] [Indexed: 11/16/2022] Open
Abstract
Background The spleen is the second most commonly injured organ in cases of abdominal trauma. Management of splenic injury depends on the clinical status of the patient and can include nonoperative management (NOM), splenic artery embolization (SAE), surgery (operative splenic salvage or splenectomy), or a combination of these treatments. In nonoperatively managed cases, SAE is sometimes used to control haemorrhage. However, the indications for SAE have not been clearly defined and, in some cases, the potential complications of the procedure may outweigh its benefits. Review of the literature Through review of the literature we address the question of when SAE is indicated in combination with NOM of splenic injury, and whether SAE may delay needed surgical treatment in some cases. This systematic review highlighted the use of imperfect and inconsistent scoring systems in the diagnosis of splenic injury, the lack of consensus regarding indications for SAE, and the potential for severe morbidities associated with this procedure. Based on current literature and evidence we provide a new, non-verified, decision algorithm. Conclusions NOM+ SAE involves potential risks and operative management may be preferable to SAE for certain patients. To clarify current literature, we propose a new algorithm for blunt abdominal trauma that should be validated prospectively. New evidence-based protocols should be developed to guide diagnosis and management of patients with splenic trauma. Electronic supplementary material The online version of this article (doi:10.1186/s13017-016-0100-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- F Van der Cruyssen
- Third year master's student, Faculty of Medicine, Catholic University of Leuven (KU Leuven), Gasthuisberg, Belgium
| | - A Manzelli
- Department of Upper Gastrointestinal Surgery, Royal Devon & Exeter Hospital, Exeter, UK
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Outcomes and complications of angioembolization for hepatic trauma: A systematic review of the literature. J Trauma Acute Care Surg 2016; 80:529-37. [PMID: 26670113 DOI: 10.1097/ta.0000000000000942] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The liver is one of the most frequently injured abdominal organs. Hepatic hemorrhage is a complex and challenging complication following hepatic trauma. Significant shifts in the treatment of hepatic hemorrhage, including the increasing use of angioembolization, are believed to have improved patient outcomes. We aimed to describe the efficacy of angioembolization in the setting of acute hepatic arterial hemorrhage as well as the complications associated with this treatment modality. METHODS A systematic review of published literature (MEDLINE, SCOPUS, and Cochrane Library) describing hepatic angioembolization in the setting of trauma was performed. Articles that fulfilled the predetermined inclusion and exclusion criteria were included. We analyzed the efficacy rate of angioembolization in the setting of traumatic hepatic hemorrhage as well as the complications associated with hepatic angioembolization. RESULTS Four hundred fifty-nine articles were identified in the literature search. Of these, 10 retrospective studies and 1 prospective study met inclusion and exclusion criteria. Efficacy rate of angioembolization was 93%. The most frequently reported complications following hepatic angioembolization included hepatic necrosis (15%), abscess formation (7.5%), and bile leaks. CONCLUSION Although the outcomes of hepatic angioembolization were generally favorable with a high success rate, the treatment modality is not without associated morbidity. The most frequently associated major complication was hepatic necrosis. Rates of complications were affected by study heterogeneity and should be better defined in future studies. LEVEL OF EVIDENCE Systematic review, level III.
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Wernick B, Cipriano A, Odom SR, MacBean U, Mubang RN, Wojda TR, Liu S, Serres S, Evans DC, Thomas PG, Cook CH, Stawicki SP. Temporal changes in hematologic markers after splenectomy, splenic embolization, and observation for trauma. Eur J Trauma Emerg Surg 2016; 43:399-409. [PMID: 27167236 DOI: 10.1007/s00068-016-0679-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 05/02/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The spleen is one of the most commonly injured abdominal solid organs during blunt trauma. Modern management of splenic trauma has evolved to include non-operative therapies, including observation and angioembolization to preclude splenectomy in most cases of blunt splenic injury. Despite the shift in management strategies, relatively little is known about the hematologic changes associated with these various modalities. The aim of this study was to determine if there are significant differences in hematologic characteristics over time based on the treatment modality employed following splenic trauma. We hypothesized that alterations seen in hematologic parameters would vary between observation (OBS), embolization (EMB), and splenectomy (SPL) in the setting of splenic injury. METHODS An institutional review board-approved, retrospective study of routine hematologic indices examined data between March 2000 and December 2014 at three academic trauma centers. A convenience sample of patients with splenic trauma and admission lengths of stay >96 h was selected for inclusion, resulting in a representative sample of each sub-group (OBS, EMB, and SPL). Basic demographics and injury severity data (ISS) were abstracted. Platelet count, red blood cell (RBC) count and RBC indices, and white blood cell (WBC) count with differential were analyzed between the time of admission and a maximum of 1080 h (45 days) post-injury. Comparisons between OBS, EMB, and SPL groups were then performed using non-parametric statistical testing, with statistical significance set at p < 0.05. RESULTS Data from 130 patients (40 SPL, 40 EMB, and 50 OBS) were analyzed. The median age was 40 years, with 67 % males. Median ISS was 21.5 (21 for SPL, 19 for EMB, and 22 for OBS, p = n/s) and median Glasgow Coma Scale (GCS) was 15. Median splenic injury grade varied by interventional modality (grade 4 for SPL, 3 for EMB, and 2 for OBS, p < 0.05). Inter-group comparisons demonstrated no significant differences in RBC counts. However, mean corpuscular volume (MCV) and RBC distribution width (RDW) were elevated in the SPL and EMB groups (p < 0.01). Similarly, EMB and SPL groups had higher platelet counts than the OBS group (p < 0.01). In aggregate, WBC counts were highest following SPL, followed by EMB and OBS (p < 0.01). Similar trends were noted in neutrophil and monocyte counts (p < 0.01), but not in lymphocyte counts (p = n/s). CONCLUSION This study describes important trends and patterns among fundamental hematologic parameters following traumatic splenic injuries managed with SPL, EMB, or OBS. As expected, observed WBC counts were highest following SPL, then EMB, and finally OBS. No differences were noted in RBC count between the three groups, but RDW was significantly greater following SPL compared to EMB and OBS. We also found that MCV was highest following OBS, when compared to EMB or SPL. Finally, our data indicate that platelet counts are similarly elevated for both SPL and EMB, when compared to the OBS group. These results provide an important foundation for further research in this still relatively unexplored area.
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Affiliation(s)
- B Wernick
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - A Cipriano
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - S R Odom
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - U MacBean
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - R N Mubang
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - T R Wojda
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - S Liu
- Temple University School of Medicine-St. Luke's University Hospital Campus, Bethlehem, PA, USA
| | - S Serres
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - D C Evans
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - P G Thomas
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - C H Cook
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - S P Stawicki
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA. .,Department of Research & Innovation, St. Luke's University Health Network, EW2 Research Administration, 801 Ostrum Street, Bethlehem, PA, 18020, USA.
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Ierardi AM, Duka E, Lucchina N, Floridi C, De Martino A, Donat D, Fontana F, Carrafiello G. The role of interventional radiology in abdominopelvic trauma. Br J Radiol 2016; 89:20150866. [PMID: 26642310 DOI: 10.1259/bjr.20150866] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
The management of trauma patients has evolved in recent decades owing to increasing availability of advanced imaging modalities such as CT. Nowadays, CT has replaced the diagnostic function of angiography. The latter is considered when a therapeutic option is hypothesized. Arterial embolization is a life-saving procedure in abdominopelvic haemorrhagic patients, reducing relevant mortality rates and ensuring haemodynamic stabilization of the patient. Percutaneous transarterial embolization has been shown to be effective for controlling ongoing bleeding for patients with high-grade abdominopelvic injuries, thereby reducing the failure rate of non-operative management, preserving maximal organ function. Surgery is not always the optimal solution for stabilization of a patient with polytrauma. Mini-invasivity and repeatability may be considered as relevant advantages. We review technical considerations, efficacy and complication rates of hepatic, splenic, renal and pelvic embolization to extrapolate current evidence about transarterial embolization in traumatic patients.
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Affiliation(s)
- Anna Maria Ierardi
- 1 Interventional Radiology Unit, Radiology Department, Uninsubria, Varese, Italy
| | - Ejona Duka
- 1 Interventional Radiology Unit, Radiology Department, Uninsubria, Varese, Italy
| | - Natalie Lucchina
- 1 Interventional Radiology Unit, Radiology Department, Uninsubria, Varese, Italy
| | - Chiara Floridi
- 1 Interventional Radiology Unit, Radiology Department, Uninsubria, Varese, Italy
| | | | - Daniela Donat
- 2 Clinical Center of Vojvodina, Department of Radiology, Novi Sad, Serbia
| | - Federico Fontana
- 1 Interventional Radiology Unit, Radiology Department, Uninsubria, Varese, Italy
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Abstract
OBJECTIVE The purpose of this article is to define the role of splenic embolization in trauma patients and in patients presenting for treatment of thrombocytopenia and portal hypertension. This article reviews the indications, technical considerations, outcomes, and complications of splenic artery embolization. CONCLUSION Transcatheter splenic artery embolization has a major role in the management of traumatic splenic injuries and as an adjunctive procedure in the treatment of thrombocytopenia and portal hypertension.
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Brillantino A, Iacobellis F, Robustelli U, Villamaina E, Maglione F, Colletti O, De Palma M, Paladino F, Noschese G. Non operative management of blunt splenic trauma: a prospective evaluation of a standardized treatment protocol. Eur J Trauma Emerg Surg 2015; 42:593-598. [DOI: 10.1007/s00068-015-0575-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 09/03/2015] [Indexed: 11/28/2022]
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Rialon KL, Englum BR, Gulack BC, Guevara CJ, Bhattacharya SD, Shapiro ML, Rice HE, Scarborough JE, Adibe OO. Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population. Am J Surg 2015; 212:786-793. [PMID: 26303881 DOI: 10.1016/j.amjsurg.2015.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 05/31/2015] [Accepted: 06/10/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Splenic angioembolization (SAE) is increasingly used in the management of splenic injuries in adults, although its value in pediatric trauma is unclear. We sought to assess outcomes related to splenectomy vs SAE. METHODS The National Trauma Data Bank was queried for patients 0 to 15 years of age from 2007 to 2011. Subgroup analysis of splenectomy vs SAE was performed for high-grade injuries using propensity analysis and inverse probability weighting. RESULTS Of 11,694 children presenting with splenic trauma, over 90% were treated nonoperatively. Adjusted analysis of high-grade injuries included 265 children who underwent splenectomy and 199 who underwent SAE. The Injury Severity Score, number of transfusions, and complications rates were not significantly different between the 2 groups. Overall adjusted mortality for children with high-grade injuries was 13.4% following splenectomy and 10.0% following SAE (P = .31) CONCLUSION: Patients undergoing SAE for high-grade splenic trauma have comparable morbidity and mortality with splenectomy.
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Affiliation(s)
- Kristy L Rialon
- Division of General Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brian R Englum
- Division of General Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brian C Gulack
- Division of General Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Carlos J Guevara
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Syamal D Bhattacharya
- Division of Pediatric Surgery, Department of Surgery, Vanderbilt Children's Hospital, Nashville, TN, USA
| | - Mark L Shapiro
- Division of Trauma and Critical Care, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Henry E Rice
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, 2301 Erwin Road, HAFS Building, Room 6680, Durham, NC 27710, USA
| | - John E Scarborough
- Division of Trauma and Critical Care, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Obinna O Adibe
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, 2301 Erwin Road, HAFS Building, Room 6680, Durham, NC 27710, USA.
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Foley PT, Kavnoudias H, Cameron PU, Czarnecki C, Paul E, Lyon SM. Proximal Versus Distal Splenic Artery Embolisation for Blunt Splenic Trauma: What is the Impact on Splenic Immune Function? Cardiovasc Intervent Radiol 2015; 38:1143-51. [PMID: 26139039 DOI: 10.1007/s00270-015-1162-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/04/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare the impact of proximal or distal splenic artery embolisation versus that of splenectomy on splenic immune function as measured by IgM memory B cell levels. MATERIALS AND METHODS Patients with splenic trauma who were treated by splenic artery embolisation (SAE) were enrolled. After 6 months splenic volume was assessed by CT, and IgM memory B cells in peripheral blood were measured and compared to a local normal reference population and to a post-splenectomy population. RESULTS Of the 71 patients who underwent embolisation, 38 underwent proximal embolisation, 11 underwent distal embolisation, 22 patients were excluded, 1 had both proximal and distal embolisation, 5 did not survive and 16 did not return for evaluation. There was a significant difference between splenectomy and proximal or distal embolisation and a trend towards greater preservation of IgM memory B cell number in those with distal embolisation-a difference that could not be attributed to differences in age, grade of injury or residual splenic volume. CONCLUSION IgM memory B cell levels are significantly higher in those treated with SAE compared to splenectomy. Our data provide evidence that splenic embolisation should reduce immunological complications of spleen trauma and suggest that distal embolisation may maintain better function.
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Affiliation(s)
- P T Foley
- Department of Medical Imaging, The Canberra Hospital, Yamba Drive, Garran, ACT, 2605, Australia.
| | - H Kavnoudias
- Radiology Research Unit, Radiology Department, The Alfred Hospital, Commercial Rd, Melbourne, VIC, 3004, Australia.
| | - P U Cameron
- Infectious Diseases Unit, The Alfred Hospital, Commercial Rd, Melbourne, VIC, 3004, Australia. .,Department of Microbiology and Immunology, Doherty Institute for Infection and Immunity, University of Melbourne, 792 Elizabeth St, Melbourne, VIC, 3000, Australia.
| | - C Czarnecki
- Radiology Department, Royal Melbourne Hospital, 300 Grattan St, Parkville, VIC, 3050, Australia.
| | - E Paul
- Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Alfred Hospital, Monash University, Commercial Rd, Melbourne, VIC, 3004, Australia.
| | - S M Lyon
- Melbourne Endovascular, 5 Chesterville Rd, Cheltenham, VIC, 3192, Australia. .,Radiology Department, The Alfred Hospital, Commercial Rd, Melbourne, VIC, 3004, Australia.
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Affiliation(s)
- C Arvieux
- Trauma System du Réseau Nord Alpin des Urgences (TRENAU), Université Joseph Fourier, Clinique universitaire de chirurgie digestive et de l'urgence, CHU de Grenoble, BP 217, 38043 Grenoble cedex 9, France.
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Dalton BGA, Dehmer JJ, Gonzalez KW, Shah SR. Blunt Spleen and Liver Trauma. J Pediatr Intensive Care 2015; 4:10-15. [PMID: 31110844 DOI: 10.1055/s-0035-1554983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Blunt abdominal trauma is an important cause of pediatric morbidity and mortality. The spleen and liver are the most common abdominal organs injured. Trauma to either organ can result in life-threatening bleeding. Controversy exists regarding which patients should be imaged and the correct imaging modality depending on the level of clinical suspicion for injury. Nonoperative management of blunt abdominal trauma is the standard of care for hemodynamically stable patients. However, the optimal protocol to maximize patient safety while minimizing resource utilization is a matter of debate. Adjunctive therapies for pediatric spleen and liver trauma are also an area of ongoing research. A review of the current literature on the diagnosis, management, and follow-up of pediatric spleen and liver blunt trauma is presented.
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Affiliation(s)
- Brian G A Dalton
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
| | - Jeff J Dehmer
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
| | - Katherine W Gonzalez
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
| | - Sohail R Shah
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
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Abstract
The pediatric patient is especially prone to blunt renal trauma due to the size and location of pediatric kidneys. No clear guidelines have been established for the management of these injuries in children to achieve the highest rate of renal salvage with low morbidity. Wide-ranging literature exists on this subject, but consists of vastly different management strategies. This review is written to summarize the different approaches to blunt renal trauma and highlight opportunities for further research.
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Affiliation(s)
- Brian G A Dalton
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Jeff J Dehmer
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Sohail R Shah
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
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Blunt splenic injury: Outcomes of proximal versus distal and combined splenic artery embolization. Diagn Interv Imaging 2014; 95:825-31. [DOI: 10.1016/j.diii.2014.03.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Smith A, Ouellet JF, Niven D, Kirkpatrick AW, Dixon E, D'Amours S, Ball CG. Timeliness in obtaining emergent percutaneous procedures in severely injured patients: how long is too long and should we create quality assurance guidelines? Can J Surg 2014; 56:E154-7. [PMID: 24284155 DOI: 10.1503/cjs.020012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Modern trauma care relies heavily on nonoperative, emergent percutaneous procedures, particularly in patients with splenic, pelvic and hepatic injuries. Unfortunately, specific quality measures (e.g., arrival to angiography times) have not been widely discussed. Our objective was to evaluate the time interval from arrival to initiation of emergent percutaneous procedures in severely injured patients. METHODS All severely injured trauma patients (injury severity score [ISS] > 12) presenting to a level 1 trauma centre (2007-2010) were analyzed with standard statistical methodology. RESULTS Among 60 severely injured patients (mean ISS 31, hypotension 18%, mortality 12%), the median time interval to the initiation of an angiographic procedure was 270 minutes. Of the procedures performed, 85% were therapeutic embolizations and 15% were diagnostic procedures. Splenic (median time 243 min, range 32-801 min) and pelvic (median time 278 min, range 153-466 min) embolizations accounted for 43% and 25% of procedures, respectively. The median embolization procedure duration for the spleen was 28 (range 15-153) minutes compared with 59 (range 34-171) minutes for the pelvis. Nearly 22% of patients required both an emergent percutaneous and subsequent operative procedure. Percutaneous therapy typically preceded open operative explorations. CONCLUSION The time interval from arrival at the trauma centre to emergent percutaneous procedures varied widely. Improved processes emphasizing patient transition from the trauma bay to the angiography suite are essential. Discussion regarding the appropriate time to angiography is needed so this marker can be used as a quality outcome measure for all level 1 trauma centres.
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Affiliation(s)
- Andrew Smith
- From the Department of Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alta
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Preserved function after angioembolisation of splenic injury in children and adolescents: a case control study. Injury 2014; 45:156-9. [PMID: 23246563 DOI: 10.1016/j.injury.2012.10.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 10/03/2012] [Accepted: 10/27/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Non-operative management for blunt splenic injuries was introduced to reduce the risk of overwhelming post splenectomy infection in children. To increase splenic preservation rates, splenic artery embolization (SAE) was added to our institutional treatment protocol in 2002. In the presence of clinical signs of ongoing bleeding, SAE was considered also in children. To our knowledge, the long term splenic function after SAE performed in the paediatric population has not been evaluated and constitutes the aim of the present study. METHODS A total of 11 SAE patients less than 17 years of age at the time of injury were included with 11 healthy volunteers serving as matched controls. Clinical examination, medical history, general blood counts, immunoglobulin quantifications and flowcytometric analysis of lymphocyte phenotypes were performed. Peripheral blood smears were examined for Howell-Jolly bodies (H-J bodies) and abdominal ultrasound was performed in order to assess the size and perfusion of the spleen. RESULTS On average 4.6 years after SAE (range 1-8 years), no significant differences could be detected between the SAE patients and their controls. Total and Pneumococcus serospecific immunoglobulins and H-J bodies did not differ between the study groups, nor did general blood counts and lymphocyte numbers, including memory B cell proportions. The ultrasound examinations revealed normal sized and well perfused spleens in the SAE patients when compared to their controls. CONCLUSION This case control study indicates preserved splenic function after SAE for splenic injury in children. Mandatory immunization to prevent severe infections does not seem warranted.
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Skattum J, Gaarder C, Naess PA. Splenic artery embolisation in children and adolescents--an 8 year experience. Injury 2014; 45:160-3. [PMID: 23137799 DOI: 10.1016/j.injury.2012.10.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 10/03/2012] [Accepted: 10/12/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Non-operative management (NOM) is the treatment of choice in blunt splenic injuries in the paediatric population, with reported success rates exceeding 90%. Splenic artery embolisation (SAE) was added to our institutional treatment protocol for splenic injury in 2002. We wanted to review indications for SAE and the clinical outcome of splenic injury management in children admitted between August 1, 2002 and July 31, 2010. METHODS Patients aged <17 years with splenic injury were identified in the institutional trauma and medical code registries. Patient charts and computed tomographic (CT) scans were reviewed. RESULTS Of the 72 children and adolescents with splenic injury included during the 8 year study period, 66 patients (92%) were treated non-operatively and six underwent operative management. Severe splenic injury (OIS grade 3-5) was diagnosed in 67 patients (93%). SAE was performed in 22 of the NOM patients. Indications for SAE included - bleeding (n=8), pseudoaneurysms (n=2), contrast extravasation (n=2), high OIS injury grade (n=8) and prophylactic due to specific disease (n=2). NOM was successful in all but one case (98%). For the patients aged ≤ 14 years, extravasation on initial CT scan correlated to delayed bleeding (p<0.001). Two SAE procedure specific complications were registered, but resolved without significant sequelae. CONCLUSION After SAE was added to the institutional treatment protocol, 22 of 66 NOM paediatric patients underwent SAE. NOM was successful in 98% and a 90% splenic preservation rate was achieved. Contrast extravasation correlated to delayed splenic bleeding in children ≤ 14 years.
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Affiliation(s)
- Jorunn Skattum
- Department of Traumatology, Oslo University Hospital Ullevaal, PO Box 4950, Nydalen, N-0424 Oslo, Norway.
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Abstract
PURPOSE OF REVIEW To review the current care of the patient with an injured spleen. RECENT FINDINGS The initial care of the patient with splenic injury is dictated by their hemodynamic presentation and the institution's resources. Although most high-grade injuries require splenectomy, up to 38% are successfully managed nonoperatively. Angioembolization has increased splenic salvage with a minimum of complications. In the absence of injuries that mandate longer hospital stays, patients with low-grade injuries are successfully discharged in 1-2 days and high-grade injuries in 3-4 days. Delayed splenic hemorrhage remains a feared complication, but fortunately the 180-day readmission rate for splenectomy is low with the majority of those returning within 8 days of injury. SUMMARY Nonoperative management (NOM) is the standard of care for the hemodynamically stable patient with an isolated blunt splenic injury. Splenic salvage can be safely increased, even in higher grade injuries, with the use of angioembolization. Patients managed nonoperatively are successfully discharged as early as 1-2 days for low-grade injuries and as early as 3-4 days for higher grade. Safe management of the patient with blunt splenic injury requires careful selection for NOM, meticulous monitoring and follow-up.
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