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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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Bäumler W, Dollinger M, Rennert J, Beutl M, Stroszczynski C, Schicho A. Occurrence of spontaneous fistulas detected by contrast filling during computed tomography-guided percutaneous drainage placement of splenic and perisplenic fluid collections. Acta Radiol 2022; 63:719-726. [PMID: 33892607 DOI: 10.1177/02841851211010424] [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: 11/15/2022]
Abstract
BACKGROUND Fistulas are serious complications of splenic and perisplenic fluid accumulations, which are often difficult to detect by routine imaging methods. PURPOSE To evaluate the occurrence of spontaneous fistulas detectable during computed tomography-guided percutaneous drainage placement (CTGDP) with contrast filling of splenic or perisplenic fluid collections and to assess characteristics in comparison with perihepatic or peripancreatic fluid accumulations, also being treated with CTGDP. MATERIAL AND METHODS In 127 CTGDP-procedures, pre-interventional CTs conducted with intravenous contrast agent were compared to post-interventional CTs including contrast filling of the drain to identify spontaneous fistulas. Patient and case characteristics were evaluated, and therapeutic consequences of fistula identification were analyzed. RESULTS A total of 43 perisplenic, 40 peripancreatic, and 44 perihepatic drains were evaluated; 13 (30.2%) perisplenic, 7 (17.5%) peripancreatic, and 10 (22.7%) perihepatic fistulas were observed. Concerning the frequency of fistulas, no significant difference was found between the patient groups (P = 0.39). All fistulas were solely proven in CT scans including contrast filling of the drain. Seven fistulas (23.3%) required additional interventions. Perihepatic drains were significantly more often associated with recent surgery (P < 0.001). The mean size of peripancreatic drains was significantly greater (11.8 ± 3.9 F; P < 0.001) than in perihepatic or perisplenic fluid collections. CONCLUSION Spontaneous fistulas detected during CTGDP of splenic or perisplenic fluid collections are common. Post-interventional contrast filling of the drain drastically improves the detection rate of perisplenic, peripancreatic and perihepatic fistulas simultaneously initiating appropriate follow-up interventions.
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Affiliation(s)
- Wolf Bäumler
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Marco Dollinger
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Janine Rennert
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Michael Beutl
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | | | - Andreas Schicho
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
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Ruscelli P, Gemini A, Rimini M, Santella S, Candelari R, Rosati M, Paci E, Marconi V, Renzi C, Commissari R, Cirocchi R, Santoro A, D’Andrea V, Parisi A. The role of grade of injury in non-operative management of blunt hepatic and splenic trauma: Case series from a multicenter experience. Medicine (Baltimore) 2019; 98:e16746. [PMID: 31464904 PMCID: PMC6736468 DOI: 10.1097/md.0000000000016746] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This retrospective study shows the results of a 2 years application of a clinical pathway concerning the indications to NOM based on the patient's hemodynamic answer instead of on the injury grade of the lesions.We conducted a retrospective study applied on a patient's cohort, admitted in "Azienda Ospedaliero-Universitaria Ospedali Riuniti of Ancona" and in the Digestive and Emergency Surgery Department of the Santa Maria of Terni hospital between September 2015 and December 2017, all affected by blunt abdominal trauma, involving liver, spleen or both of them managed conservatively. Patients were divided into 3 main groups according to their hemodynamic response to a fluid administration: stable (group A), transient responder (group B) and unstable (group C). Management of patients was performed according to specific institutional pathway, and only patients from category A and B were treated conservatively regardless of the injury grade of lesions.From October 2015 to December 2017, a total amount of 111 trauma patients were treated with NOM. Each patient underwent CT scan at his admission. No contrast pooling was found in 50 pts. (45.04%). Contrast pooling was found in 61 patients (54.95%). The NOM overall outcome resulted in success in 107 patients (96.4%). NOM was successful in 100% of cases of liver trauma patients and was successful in 94.7% of splenic trauma patients (72/76). NOM failure occurred in 4 patients (5.3%) treated for spleen injuries. All these patients received splenectomy: in 1 case to treat pseudoaneurysm, (AAST, American Association for the Surgery of Trauma, grade of injury II), in 2 cases because of re-bleeding (AAST grade of injury IV) and in the remaining case was necessary to stop monitoring spleen because the patient should undergo to orthopedic procedure to treat pelvis fracture (AAST grade of injury II).Non-operative management for blunt hepatic and splenic lesions in stable or stabilizable patients seems to be the choice of treatment regardless of the grade of lesions according to the AAST Organ Injury Scale.
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Affiliation(s)
- Paolo Ruscelli
- Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Via Conca 71, Torrette, Ancona
| | - Alessandro Gemini
- Department of Digestive Surgery, St. Maria Hospital, Viale Tristano di Joannuccio, Terni
| | - Massimiliano Rimini
- Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Via Conca 71, Torrette, Ancona
| | - Sergio Santella
- Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Via Conca 71, Torrette, Ancona
| | - Roberto Candelari
- Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Via Conca 71, Torrette, Ancona
| | - Marzia Rosati
- Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Via Conca 71, Torrette, Ancona
| | - Enrico Paci
- Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Via Conca 71, Torrette, Ancona
| | - Vittorio Marconi
- Emergency Surgery Unit, Torrette Hospital, Polytechnic University of Marche, Via Conca 71, Torrette, Ancona
| | - Claudio Renzi
- Department of Surgical Sciences, University of Perugia, Piazza dell’Università 1, Perugia
| | - Rita Commissari
- Department of Emergency, St. Maria Hospital, Viale Tristano di Joannuccio, Terni
| | - Roberto Cirocchi
- Department of Surgical Sciences, University of Perugia, Piazza dell’Università 1, Perugia
| | - Alberto Santoro
- Department of Surgical Sciences, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, Italy
| | - Vito D’Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, Italy
| | - Amilcare Parisi
- Department of Digestive Surgery, St. Maria Hospital, Viale Tristano di Joannuccio, Terni
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Brillantino A, Iacobellis F, Festa P, Mottola A, Acampora C, Corvino F, Del Giudice S, Lanza M, Armellino M, Niola R, Romano L, Castriconi M, De Palma M, Noschese G. Non-Operative Management of Blunt Liver Trauma: Safety, Efficacy and Complications of a Standardized Treatment Protocol. Bull Emerg Trauma 2019; 7:49-54. [PMID: 30719466 PMCID: PMC6360015 DOI: 10.29252/beat-070107] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objective: To evaluate the safety and effectiveness of NOM (non-operative management) in the treatment of blunt liver trauma, following a standardized treatment protocol. Methods: All the hemodynamically stable patients with computed tomography (CT) diagnosis of blunt liver trauma underwent NOM. It included strict clinical and laboratory observation, 48-72h contrast enhanced ultrasonography (CEUS) or CT follow-up, a primary angioembolization in case of admission CT evidence of vascular injuries and a secondary angioembolization in presence of vascular injuries signs at follow-up CEUS. Results: 181 patients (85.4%) [55 (30.4%) women and 126 (69.6%) men, median age 39 (range 14–71)] were included. Of these, 63 patients (34.8%) had grade I, 48 patients (26.5%) grade II, 39 patients (21.5%) grade III, 21 patients (11.6%) grade IV and 10 patients (5.5%) grade V liver injuries. The overall success rate of NOM was 96.7% (175/181). There was not significant difference in the success rate between the patients with different liver injuries grade. Morbidity rate was 7.4% (13/175). Major complications (2 bilomas, 1 liver hematoma and 2 liver abscesses) were successfully treated by CEUS or CT guided drainage. Eighteen (18/181) patients (9.9%) underwent angioembolization with successful results. Conclusion: Non-operative management of blunt liver trauma represents a safe and effective treatment for both minor and severe injuries, achieving an high success rate and an acceptable morbidity rate. The angiographic study with embolization, although required only in selected cases of vascular injuries, represents a fundamental therapeutic option in a significant percentage of patients.
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Affiliation(s)
- Antonio Brillantino
- Department of Surgery, A. Cardarelli Hospital, Via A. Cardarelli 9 80131 Naples, Italy.,Antonio Brillantino and Francesca Iacobellis are equally contributors
| | - Francesca Iacobellis
- Department of Radiology, A. Cardarelli Hospital, Via A. Cardarelli 9 80131 Naples, Italy.,Antonio Brillantino and Francesca Iacobellis are equally contributors
| | - Patrizio Festa
- Department of Surgery, A. Cardarelli Hospital, Via A. Cardarelli 9 80131 Naples, Italy
| | - Arianna Mottola
- Department of Surgery, A. Cardarelli Hospital, Via A. Cardarelli 9 80131 Naples, Italy
| | - Ciro Acampora
- Department of Radiology, A. Cardarelli Hospital, Via A. Cardarelli 9 80131 Naples, Italy
| | - Fabio Corvino
- Interventional Radiology Department, A Cardarelli Hospital, Via A. Cardarelli 9 80131 Naples, Italy
| | - Santolo Del Giudice
- Department of Surgery, A. Cardarelli Hospital, Via A. Cardarelli 9 80131 Naples, Italy
| | - Michele Lanza
- Department of Surgery, A. Cardarelli Hospital, Via A. Cardarelli 9 80131 Naples, Italy
| | - Mariano Armellino
- Department of Surgery, A. Cardarelli Hospital, Via A. Cardarelli 9 80131 Naples, Italy
| | - Raffaella Niola
- Interventional Radiology Department, A Cardarelli Hospital, Via A. Cardarelli 9 80131 Naples, Italy
| | - Luigia Romano
- Department of Radiology, A. Cardarelli Hospital, Via A. Cardarelli 9 80131 Naples, Italy
| | - Maurizio Castriconi
- Department of Surgery, A. Cardarelli Hospital, Via A. Cardarelli 9 80131 Naples, Italy
| | - Maurizio De Palma
- Department of Surgery, A. Cardarelli Hospital, Via A. Cardarelli 9 80131 Naples, Italy
| | - Giuseppe Noschese
- Department of Surgery, A. Cardarelli Hospital, Via A. Cardarelli 9 80131 Naples, Italy
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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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Rafailidis V, Apostolou D, Kaitartzis C, Rafailidis D. Ultrasonography of the healing process during a 3-month follow-up after a splenic injury. Ultrasonography 2015; 34:226-30. [PMID: 25623053 PMCID: PMC4484285 DOI: 10.14366/usg.14057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 12/29/2014] [Accepted: 12/30/2014] [Indexed: 11/22/2022] Open
Abstract
We present a 14-year-old boy with a grade III splenic injury due to a bicycle accident, who was treated conservatively. The boy’s medical history included splenomegaly due to thalassemia. The splenic lesion was initially investigated with computed tomography (CT) and then, was followed by ultrasonography for 3 months. CT revealed a large intraparenchymal hematoma which appeared hyperechoic on ultrasonography. During follow-up, the hematoma developed a more complex echogenicity and became gradually hypoechoic. The hematoma increased in size during the first week but then, started decreasing until it eventually resolved completely. The patient had an uneventful full recovery. In this report, we discuss the ultrasonographic changes of the hematoma throughout the healing process.
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Affiliation(s)
- Vasileios Rafailidis
- Postgraduate Programme in Medical Research Methodology, Aristotle University of Thessaloniki, Thessaloniki, Greece
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