Overall Splenectomy Rates Stable Despite Increasing Usage of Angiography in the Management of High-grade Blunt Splenic Injury

Splenectomy versus angioembolization for severe splenic injuries in a national trauma registry: To save, or not to save, the spleen, that is the question

BACKGROUND

The use of angioembolization as a first approach for treating severe, blunt splenic injuries has increased recently, yet evidence showing its superiority to immediate splenectomy is lacking. We compared the prognosis of angioembolization versus splenectomy in patients presenting hemodynamically unstable with high-grade, image-confirmed, blunt splenic injuries in a nationally representative dataset.

METHODS

We queried the 2017-2022 Trauma Quality Improvement Program database for adults with blunt splenic injury abbreviated injury scale = 4-5, with arrival systolic blood pressure <90 mm Hg, and treated with either angioembolization or splenectomy <6 hours of arrival after a computed tomography scan. Entropy balancing was used to adjust for confounders.

RESULTS

Of 1,360 patients, 328 (24.1%) underwent angioembolization and 1,032 (75.9%) splenectomy. Treatment with angioembolization first was more likely in recent years, in level 1 trauma centers, for less severe spleen injuries, in the absence of head injuries. Angioembolization and splenectomy had similar entropy balancing-adjusted survival (entropy balancing hazard ratio = 1.02; 95% confidence interval: 0.97-1.07, P = .49). One-fifth of those with angioembolization first required rescue splenectomy <6 hours, mostly those with spleen injury grade 5 and additional abdominal injuries. Although this resulted in worse survival (hazard ratio: 1.12; 95% confidence Interval: 0.99-1.26) than successful angioembolization, the survival was not significantly worse than those treated with splenectomy first (entropy balancing hazard ratio: 1.07; 95% confidence Interval: 0.96-1.20).

CONCLUSION

Angioembolization was associated with similar survival to splenectomy first for patients arriving hypotensive with severe, image-confirmed blunt splenic injuries, suggesting that it was an appropriate treatment decision. Although survival was worse after failed angioembolization than after successful angioembolization, it was not worse than splenectomy first, suggesting that the attempt to preserve the spleen was justified.

Angioembolization in patients with blunt splenic trauma in Germany -guidelines vs. Reality a retrospective registry-based cohort study of the TraumaRegister DGU®

PURPOSE

Nonoperative management (NOM) for blunt splenic injuries (BSIs) is supported by both international and national guidelines in Germany, with high success rates even for severe organ injuries. Angioembolization (ANGIO) has been recommended for stabilizable patients with BSI requiring intervention since the 2016 German National Trauma Guideline. The objectives were to study treatment modalities in the adult BSI population according to different severity parameters including NOM, ANGIO and splenectomy in Germany.

METHODS

Between 2015 and 2020, a retrospective registry-based cohort study was performed on patients with BSIs with an Abbreviated Injury Score ≥ 2 in Germany using registry data from the TraumaRegister DGU® (TR DGU). This registry includes patients which were treated in a resuscitation room and spend more than 24-h in an intensive care unit or died in the resuscitation room.

RESULTS

A total of 2,782 patients with BSIs were included in the analysis. ANGIO was used in 28 patients (1.0%). NOM was performed in 57.5% of all patients, predominantly those with less severe organ injuries measured by the American Association for the Surgery of Trauma Organ Injury Scale (AAST) ≤ 2. The splenectomy rate for patients with an AAST ≥ 3 was 58.5%, and the overall mortality associated with BSI was 15%.

CONCLUSIONS

In this cohort splenic injuries AAST ≥ 3 were predominantly managed surgically and ANGIO was rarely used to augment NOM. Therefore, clinical reality deviates from guideline recommendations regarding the use of ANGIO and NOM. Local interdisciplinary treatment protocols might close that gap in the future.

Surgical Repair vs Splenectomy in Patients With Severe Traumatic Spleen Injuries

Importance

The spleen is often removed in laparotomy after traumatic abdominal injury, with little effort made to preserve the spleen.

Objective

To explore the association of surgical management (splenic repair vs splenectomy) with outcomes in patients with traumatic splenic injuries undergoing laparotomy and to determine whether splenic repair is associated with lower mortality compared with splenectomy.

Design, Setting, and Participants

This is a trauma registry-based cohort study using the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2019. Participants included adult patients with severe splenic injuries (Abbreviated Injury Scale [AIS] grades 3-5) undergoing laparotomy after traumatic injury within 6 hours of admission. Data analysis was performed from April to August 2023.

Exposures

Splenic repair vs splenectomy in patients with severe traumatic splenic injury.

Main Outcomes and Measures

The primary outcome was in-hospital mortality. Outcomes were compared using different statistical approaches, including 1:1 exact matching with consecutive conditional logistic regression analysis as the primary analysis and multivariable logistic regression, propensity score matching, and inverse-probability weighting as sensitivity analyses.

Results

A total of 11 247 patients (median [IQR] age, 35 [24-52] years; 8179 men [72.7%]) with a severe traumatic splenic injury undergoing laparotomy were identified. Of these, 10 820 patients (96.2%) underwent splenectomy, and 427 (3.8%) underwent splenic repair. Among patients who underwent an initial splenic salvage procedure, 23 (5.3%) required a splenectomy during the subsequent hospital stay; 400 patients with splenic preservation were matched with 400 patients who underwent splenectomy (matched for age, sex, hypotension, trauma mechanism, AIS spleen grade, and AIS groups [0-2, 3, and 4-5] for head, face, neck, thorax, spine, and lower and upper extremity). Mortality was significantly lower in the splenic repair group vs the splenectomy group (26 patients [6.5%] vs 51 patients [12.8%]). The association of splenic repair with lower mortality was subsequently verified by conditional regression analysis (adjusted odds ratio, 0.4; 95% CI, 0.2-0.9; P = .03). Multivariable logistic regression, propensity score matching, and inverse-probability weighting confirmed this association.

Conclusions and Relevance

In this retrospective cohort study, splenic repair was independently associated with lower mortality compared with splenectomy during laparotomy after traumatic splenic injury. These findings suggest that efforts to preserve the spleen might be indicated in selected cases of severe splenic injuries.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The three-dimensional weakly supervised deep learning algorithm for traumatic splenic injury detection and sequential localization: an experimental study

BACKGROUND

Splenic injury is the most common solid visceral injury in blunt abdominal trauma, and high-resolution abdominal computed tomography (CT) can adequately detect the injury. However, these lethal injuries sometimes have been overlooked in current practice. Deep learning (DL) algorithms have proven their capabilities in detecting abnormal findings in medical images. The aim of this study is to develop a three-dimensional, weakly supervised DL algorithm for detecting splenic injury on abdominal CT using a sequential localization and classification approach.

MATERIAL AND METHODS

The dataset was collected in a tertiary trauma center on 600 patients who underwent abdominal CT between 2008 and 2018, half of whom had splenic injuries. The images were split into development and test datasets at a 4 : 1 ratio. A two-step DL algorithm, including localization and classification models, was constructed to identify the splenic injury. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Grad-CAM (Gradient-weighted Class Activation Mapping) heatmaps from the test set were visually assessed. To validate the algorithm, we also collected images from another hospital to serve as external validation data.

RESULTS

A total of 480 patients, 50% of whom had spleen injuries, were included in the development dataset, and the rest were included in the test dataset. All patients underwent contrast-enhanced abdominal CT in the emergency room. The automatic two-step EfficientNet model detected splenic injury with an AUROC of 0.901 (95% CI: 0.836-0.953). At the maximum Youden index, the accuracy, sensitivity, specificity, PPV, and NPV were 0.88, 0.81, 0.92, 0.91, and 0.83, respectively. The heatmap identified 96.3% of splenic injury sites in true positive cases. The algorithm achieved a sensitivity of 0.92 for detecting trauma in the external validation cohort, with an acceptable accuracy of 0.80.

CONCLUSIONS

The DL model can identify splenic injury on CT, and further application in trauma scenarios is possible.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Management of blunt splenic injury: down the rabbit hole and into the bucket

Management of splenic trauma has changed dramatically over the past 30 years. Many of these advances were driven by the Memphis team under the leadership of Dr. Timothy Fabian. This review article summarizes some of those changes in clinical care, especially related to nonoperative management and angioembolization.

Enhanced Bacteremia in Dextran Sulfate-Induced Colitis in Splenectomy Mice Correlates with Gut Dysbiosis and LPS Tolerance

Because both endotoxemia and gut dysbiosis post-splenectomy might be associated with systemic infection, the susceptibility against infection was tested by dextran sulfate solution (DSS)-induced colitis and lipopolysaccharide (LPS) injection models in splenectomy mice with macrophage experiments. Here, splenectomy induced a gut barrier defect (FITC-dextran assay, endotoxemia, bacteria in mesenteric lymph nodes, and the loss of enterocyte tight junction) and gut dysbiosis (increased Proteobacteria by fecal microbiome analysis) without systemic inflammation (serum IL-6). In parallel, DSS induced more severe mucositis in splenectomy mice than sham-DSS mice, as indicated by mortality, stool consistency, gut barrier defect, serum cytokines, and blood bacterial burdens. The presence of green fluorescent-producing (GFP) E. coli in the spleen of sham-DSS mice after an oral gavage supported a crucial role of the spleen in the control of bacteria from gut translocation. Additionally, LPS administration in splenectomy mice induced lower serum cytokines (TNF-α and IL-6) than LPS-administered sham mice, perhaps due to LPS tolerance from pre-existing post-splenectomy endotoxemia. In macrophages, LPS tolerance (sequential LPS stimulation) demonstrated lower cell activities than the single LPS stimulation, as indicated by the reduction in supernatant cytokines, pro-inflammatory genes (iNOS and IL-1β), cell energy status (extracellular flux analysis), and enzymes of the glycolysis pathway (proteomic analysis). In conclusion, a gut barrier defect after splenectomy was vulnerable to enterocyte injury (such as DSS), which caused severe bacteremia due to defects in microbial control (asplenia) and endotoxemia-induced LPS tolerance. Hence, gut dysbiosis and gut bacterial translocation in patients with a splenectomy might be associated with systemic infection, and gut-barrier monitoring or intestinal tight-junction strengthening may be useful.

Use of angioembolization in pediatric polytrauma patients: WITH BLUNT SPLENIC INJURYAngioembolization in Pediatric Blunt Splenic Injury

BACKGROUND/PURPOSE

We sought to analyze the use of angioembolization (AE) after pediatric splenic injuries at adult and pediatric trauma centers (ATCs/PTCs).

METHODS

The National Trauma Data Bank (2010-2015) was queried for patients (<18 years) who experienced blunt splenic trauma. Multivariate logistic regression was used to determine the association of AE with splenectomy. Propensity score matching was used to explore the relationship between trauma center designation and AE utilization.

RESULTS

14,027 encounters met inclusion criteria. 514 (3.7%) patients underwent AE. When compared to PTCs, patients were older, had a higher ISS, and more often presented in shock at ATCs (p<0.001 for all). Regression models demonstrated no difference in mortality between cohorts. Odds of splenectomy were lower for patients undergoing AE (OR 0.16 [CI: 0.08-0.31]), however this effect was mostly driven by utilization at ATCs. Using a 1:1 propensity score matching model, patients treated at ATCs were 4 times more likely to undergo AE and 7 times more likely to require a splenectomy compared to PTCs (p<0.001). Over 6 years, PTCs performed only 27 splenectomies and 23 AEs (1.1% and 0.9%, respectively).

CONCLUSIONS

AE was associated with improved splenic salvage at ATCs in select patients but appeared overutilized when compared to outcomes at PTCs. PTCs accomplished a higher splenic salvage rate with a lower AE utilization.

LEVEL OF EVIDENCE

III - Retrospective cohort study.

Management of Splenic Trauma in Contemporary Clinical Practice: A National Trauma Data Bank Study

BACKGROUND

To evaluate the utilization and efficacy of various treatments for management of adult patients with splenic trauma, highlighting the evolving role of splenic artery embolization.

MATERIALS AND METHODS

The National Trauma Data Bank (NTDB) was queried for patients who sustained splenic trauma between 2007 and 2015, excluding those with death on arrival and selected nonsplenic high-grade injuries. Patients were categorized into (1) nonoperative management (NOM), (2) embolization, (3) splenectomy, (4) splenic repair, and (5) combined treatment groups. Evaluated outcomes included hospital length of stay (LOS), intensive care unit LOS, mortality, and NOM and embolization failures.

RESULTS

Overall, 117,743 patients with splenic predominant trauma were included in this study. Over the 9-year study period, 85,793 (72.9%) were treated with NOM, 21,999 (18.9%) with splenectomy, 3895 (3.3%) with embolization, and 2131 (1.8%) with splenic repair. From 2007 to 2015, mortality rates declined from 7.6% to 4.7%. The rate of NOM did not significantly change over time, while embolization increased 369% (1.3%-4.8%). Failure of NOM was 4.4% in 2007 and decreased to 3.4% in 2015. Across all injury grades, NOM had the shortest LOS (8.3 days), followed by splenic repair (12.3), embolization (12.6), and splenectomy (13.8) (p < 0.001). When adjusted for various clinical factors including severity of splenic injury, mortality rates were 7.1% for splenectomy, 3.2% for embolization, and 2.5% for NOM.

CONCLUSION

Most patients with splenic-dominant blunt trauma are managed with NOM. Over time, the use of embolization has increased while open surgery has declined, and mortality has improved for all treatment methods. Compared to splenectomy, embolization is associated with shorter hospital LOS but is still used relatively infrequently.

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

INTRODUCTION

Splenic injury is common in blunt trauma. We sought to evaluate the injury characteristics and outcomes of BSI admitted over a 10-y period to an academic trauma center.

METHODS

A retrospective review of adult blunt splenic injury patients admitted between January 2009 and September 2018.

RESULTS

The 423 patients meeting inclusion criteria were divided by management: Observational (OBS, n = 261), splenic surgery (n = 114 including 4 splenorrhaphy patients), SAE (n = 43), and multiple treatment modalities (3 had SAE followed by surgery and 2 OBS patients underwent splenic surgery at readmission). The most common mechanism of injury was motor vehicle collision (47.8%). The median ISS (OBS 17, SAE 22, Surgery 34) and spleen AIS (OBS 2, SAE 3, Surgery 4) were significantly different.  Complication rates (OBS 21.8%, SAE 9.3%, Surgery 45.6%) rates were significantly different, but mortality (OBS 7.3%, SAE 2.3%, Surgery 13.2%), discharge to home and readmission rates were not. Additional abdominal injuries were identified in 26.3% of the surgery group and 2.7% of OBS group. SAE rate increased from 3.0% to 28%; median spleen AIS remained 2-3. Thirty-five patients expired; 28 had severe head, chest, and/or extremity injuries (AIS ≥4).

CONCLUSION

SAE rates increased over time. Splenorrhaphy rates were low. SAE was associated with relatively low rates of mortality and complications in appropriately selected patients.

Laparoscopic splenectomy as a definitive management option for high-grade traumatic splenic injury when non operative management is not feasible or failed: a 5-year experience from a level one trauma center with minimally invasive surgery expertise

Technique, indications and outcomes of laparoscopic splenectomy in stable trauma patients have not been well described yet. All hemodynamically non-compromised abdominal trauma patients who underwent splenectomy from 1/2013 to 12/2017 at our Level 1 trauma center were included. Demographic and clinical data were collected and analysed with per-protocol and an intention-to-treat comparison between open vs laparoscopic groups. 49 splenectomies were performed (16 laparoscopic, 33 open). Among the laparoscopic group, 81% were successfully completed laparoscopically. Laparoscopy was associated with a higher incidence of concomitant surgical procedures (p 0.016), longer operative times, but a significantly faster return of bowel function and oral diet without reoperations. No significant differences were demonstrated in morbidity, mortality, length of stay, or long-term complications, although laparoscopic had lower surgical site infection (0 vs 21%).The isolated splenic injury sub-analysis included 25 splenectomies,76% (19) open and 24% (6) laparoscopic and confirmed reduction in post-operative morbidity (40 vs 57%), blood transfusion (0 vs 48%), ICU admission (20 vs 57%) and overall LOS (7 vs 9 days) in the laparoscopic group. Laparoscopic splenectomy is a safe and effective technique for hemodynamically stable patients with splenic trauma and may represent an advantageous alternative to open splenectomy in terms of post-operative recovery and morbidity.

Splenic preservation after isolated splenic blunt trauma: The angioembolization paradox

BACKGROUND

The spleen is the most commonly injured organ in blunt abdominal trauma. The management for splenic trauma includes nonoperative management, splenectomy, and splenic artery angioembolization. The aim of this study is to investigate recent trends in the usage of splenic artery angioembolization in patients with isolated blunt splenic trauma.

METHODS

Adult patients (age >15) with isolated blunt splenic trauma were identified from the National Trauma Databank (2007-2015) using International Classification of Diseases, Ninth Revision, codes. The defined groups included nonoperative management, splenectomy, and splenic artery angioembolization. Patient variables collected included year of traumatic injury, age, sex, race, insurance status, and geographic region. Clinical variables collected included vital signs (systolic blood pressure, pulse, respiratory rate) recorded upon arrival to the emergency room, injury severity score, abbreviated injury severity scores, diagnoses, procedures, and mechanism. Outcome measures included mortality, hospital duration of stay, and complications. We performed 2 independent Poisson logistic regression models to assess relative risk for both splenectomy and angioembolization.

RESULTS

A total of 10,812 patients were included in the analysis (nonoperative management: 7,920; splenectomy: 2,083; angioembolization: 809). Angioembolization proportion increased from 2007 (4.6%) to 2015 (10%), while splenectomy proportion remained unchanged (19.2% to 18.3%). Poisson logistic regression suggests the adjusted probability of receiving angioembolization for a splenic injury increased year-to-year, while the adjusted probability of receiving a splenectomy remained unchanged.

CONCLUSION

The use of angioembolization for isolated blunt splenic injuries has increased over the past decade without a reciprocal change in splenectomy. Based on this study, angioembolization may be an overused resource without a significant benefit.

The cost to perform splenic artery embolisation following blunt trauma: Analysis from a level 1 Australian trauma centre

INTRODUCTION

Splenic artery embolisation (SAE) has been shown to be an effective treatment for haemodynamically stable patients with high-grade blunt splenic injury. However, there are no local estimates of how much treatment costs. The purpose of this study was to evaluate the cost of providing SAE to patients in the setting of blunt abdominal trauma at an Australian level 1 trauma centre.

METHODS

This was a single-centre retrospective review of 10 patients who underwent splenic embolisation from December 2017 to December 2018 for the treatment of isolated blunt splenic injury, including cost of procedure and the entire admission. Costs included angiography costs including equipment, machine, staff, and post-procedural costs including pharmacy, general ward costs, orderlies, ward nursing, allied health, and further imaging.

RESULTS

During the study period, patients remained an inpatient for a mean of 4.8 days and the rate of splenic salvage was 100%. The mean total cost of splenic embolisation at our centre was AUD$10,523 and median cost AUD$9959.6 (range of $4826-$16,836). The use of a plug as embolic material was associated with increased cost than for coils. Overall cost of patients requiring ICU was mean AUD$11,894 and median AUD$11,435.8. Overall cost for those not requiring ICU was mean AUD$7325 and median AUD$8309.8.

CONCLUSION

Splenic embolisation is a low-cost procedure for management of blunt splenic injury. The cost to provide SAE at our centre was much lower than previously modelled data from overseas studies. From a cost perspective, the use of ICU for monitoring after the procedure significantly increased cost and necessity may be considered on a case-by-case basis. Further research is advised to directly compare the cost of SAE and splenectomy in an Australian setting.

A Review of "Changes in the Management of Injuries to the Liver and Spleen" (2005)

Introduction: The article "Changes in the Management of Injuries to the Liver and Spleen" was originally presented as the Scudder Oration on Trauma at the American College of Surgeons' (ACS) 90th Annual Clinical Congress in New Orleans, Louisiana, in October 2004. Charles L. Scudder, MD, a founding member of the College, was the originator and first Chairman of the Committee on the Treatment of Fractures from 1922 to 1933. The first "Fracture Oration" of the ACS by Dr Scudder was entitled "Oration on Fractures," was presented at the Clinical Congress in October 1929, and was published in Surg Gynecol Obstet 1930; 50:193-195. Fracture Orations were presented from 1929 to 1941 and 1946 to 1951, while an Oration on Trauma was presented from 1952 to 1962. From 1963 to present, the Scudder Oration on Trauma has been presented at the annual Clinical Congress by an individual with significant contributions to the field.

Splenic artery angioembolization for high-grade splenic injury: Are we wasting money?

BACKGROUND

Non-operative management (NOM) is accepted treatment of splenic injury, but this may fail leading to splenectomy. Splenic artery embolization (SAE) may improve rate of salvage. The purpose is to determine the cost-utility of the addition of SAE for high-grade splenic injuries.

METHODS

A cost-utility analysis was developed to compared NOM to SAE in patients with blunt splenic injury. Sensitivity analysis was completed to account for uncertainty. Utility outcome was quality-adjusted life years (QALY).

RESULTS

For patients with grade III, IV and V injury NOM is the dominant strategy. The probability of NOM being the more cost-effective strategy is 87.5% in patients with grade V splenic injury. SAE is not the favored strategy unless the probability of failure of NOM is greater than 70.0%.

CONCLUSION

For grade III-V injuries, NOM without SAE yields more quality-adjusted life years. NOM without SAE is the most cost-effective strategy for high-grade splenic injuries.

Defining the role of angioembolization in pediatric isolated blunt solid organ injury

PURPOSE

To determine the incidence and outcomes of angiography in pediatric patients with blunt solid organ injury (SOI).

METHODS

The National Trauma Data Bank (2010-2014) was queried for patients ≤19 years who experienced isolated blunt SOI. Multivariate logistic regression was used to evaluate characteristics associated with radiological and surgical intervention.

RESULTS

Patients with isolated blunt injuries to the spleen (n = 7542), liver (n = 4549), and kidney (n = 2640) were identified. Use of angiography increased yearly from 1.6% to 3.1% of cases (p = 0.001) and was associated with older age (OR 2.61 [CI: 1.94-3.50], p < 0.001) and grade III or higher injury (OR 4.63 [CI: 3.11-6.90], p < 0.001). Odds of angiography were 4.9 times higher at adult trauma centers (TCs) than pediatric TCs overall, and almost 9 times higher for isolated splenic trauma (p < 0.001 for each). There was no improvement in splenic salvage after angiography for high grade injuries (3.5% vs. 4.8%, p = NS). Only 1.8% of cases began within 30 min of arrival (median time = 3.6 h).

CONCLUSION

Variability exists in the utilization of angiography in pediatric blunt SOI between adult and pediatric TCs, with no improvement in splenic salvage.

LEVEL OF EVIDENCE

Level III - Treatment study.

Predictors of splenic artery embolization as an adjunct to non-operative management of stable blunt splenic injury: a multi-institutional study

Background

We sought to identify predictors of splenic artery embolization (SAE) over observation for hemodynamically stable patients with blunt splenic injury (BSI), by Organ Injury Scale (OIS) grade.

Methods

This was a multi-institutional retrospective study of all adults (≥18) with BSI who were initially managed non-operatively between 2014 and 2016. Multivariate logistic regression analysis was used to identify predictors of SAE by OIS grade. Covariates included radiographic characteristics (presence/quantity of hemoperitoneum, blush, vascular injury), demographics (age, sex, cause), Injury Severity Score, vital signs, and hemoglobin values. We also examined outcomes of death, length of stay (LOS), intensive care unit (ICU) admission, blood products, and failed non-operative management (NOM).

Results

Among 422 patients with stable BSI, 93 (22%) had SAE and 329 (78%) were observed. The rate of SAE increased by grade (p<0.001). In grade I and II BSI, 7% had SAE; significant predictors of SAE were blush (OR: 5.9, p=0.02), moderate or large hemoperitoneum (OR: 3.0, p=0.01), and male sex (OR: 6.3, p=0.05). In grade III BSI, 26% had SAE; significant predictors included moderate or large hemoperitoneum (OR: 3.9, p=0.04), motor vehicle crash (OR: 6.1, p=0.005), and age (OR=1.4, 40% with each decade increase in age, p=0.02). The rate of SAE was 52% for grade IV and 85% for grade V BSI; there were no independent predictors of SAE in either grade. Clinical outcomes were comparable by NOM strategy and grade, except longer LOS with SAE in grades I–III (p<0.05) and longer ICU LOS with SAE in grades I–IV (p<0.05). Only 5 (1.2%) patients failed NOM (4 observation, 1 SAE).

Conclusion

These results strongly support SAE consideration for patients with stable grade IV and V BSI even if there are no other high-risk clinical or radiographic findings. For grades I–III, the identified predictors may help refine consideration for SAE.

Level of evidence

Level III, retrospective epidemiological study.

Emergency CT for assessment and management of blunt traumatic splenic injuries at a Level 1 Trauma Center: 13-year study

PURPOSE

To determine the relationship between multidetector computed tomography (MDCT) findings, management strategies, and ultimate clinical outcomes in patients with splenic injuries secondary to blunt trauma.

MATERIALS AND METHODS

This Institutional Review Board-approved study collected 351 consecutive patients admitted at the Emergency Department (ED) of a Level I Trauma Center with blunt splenic trauma between October 2002 and November 2015. Their MDCT studies were retrospectively and independently reviewed by two radiologists to grade splenic injuries according to the American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) and to detect intraparenchymal (type A) or extraparenchymal (type B) active bleeding and/or contained vascular injuries (CVI). Clinical data, information on management, and outcome were retrieved from the hospital database. Statistical analysis relied on Student's t, chi-squared, and Cohen's kappa tests.

RESULTS

Emergency multiphase MDCT was obtained in 263 hemodynamically stable patients. Interobserver agreement for both AAST grading of injuries and vascular lesions was excellent (k = 0.77). Operative management (OM) was performed in 160 patients (45.58% of the whole cohort), and high-grade (IV and V) OIS injuries and type B bleeding were statistically significant (p < 0.05) predictors of OM. Nonoperative management (NOM) failed in 23 patients out of 191 (12.04%). In 75% of them, NOM failure occurred within 30 h from the trauma event, without significant increase of mortality. Both intraparenchymal and extraparenchymal active bleeding were predictive of NOM failure (p < 0.05).

CONCLUSION

Providing detection and characterization of parenchymal and vascular traumatic lesions, MDCT plays a crucial role for safe and appropriate guidance of ED management of splenic traumas and contributes to the shift toward NOM in hemodynamically stable patients.