1
|
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] [MESH Headings] [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.
Collapse
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.
| |
Collapse
|
2
|
Tang-Tan A, Chien CY, Park S, Schellenberg M, Lam L, Martin M, Inaba K, Matsushima K. Clinical factors and outcomes of spleen-conserving surgery versus total splenectomy in splenic injuries: A nationwide database study. Am J Surg 2024; 233:142-147. [PMID: 38490878 DOI: 10.1016/j.amjsurg.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/27/2024] [Accepted: 03/07/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND The objective of this study was to identify factors associated with the use of spleen-conserving surgeries, as well as patient outcomes, on a national scale. METHODS This retrospective cohort study (2010-2015) included patients (age≥16 years) with splenic injury in the National Trauma Data Bank. Patients who received a total splenectomy or a spleen-conserving surgery were compared for demographics and clinical outcomes. RESULTS During the study period, 18,425 received a total splenectomy and 1,825 received a spleen-conserving surgery. Total splenectomy was more likely to be performed for patients with age>65 (odds ratio [OR]: 0.63, p < 0.001), systolic blood pressure<90 (OR: 0.63, p < 0.001), heart rate>120 (OR: 0.83, p = 0.007), and high-grade injuries (OR: 0.18, p < 0.001). Penetrating trauma patients were more likely to undergo a spleen-conserving surgery (OR: 3.31, p < 0.001). The use of spleen-conserving surgery was associated with a lower risk of pneumonia (OR: 0.79, p = 0.009) and venous thromboembolism (OR: 0.72, p = 0.006). CONCLUSIONS Spleen-conserving surgeries may be considered for patients with penetrating trauma, age<65, hemodynamic stability, and low-grade injuries. Spleen-conserving surgeries have decreased risk of pneumonia and venous thromboembolism.
Collapse
Affiliation(s)
- Angela Tang-Tan
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, 90033, CA, USA.
| | - Chih Ying Chien
- Chang Gung Memorial Hospital, Keelung, No. 222, Maijin Rd, Anle District, Keelung City, 204, Taiwan.
| | - Stephen Park
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, 90033, CA, USA.
| | - Morgan Schellenberg
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, 90033, CA, USA.
| | - Lydia Lam
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, 90033, CA, USA.
| | - Matthew Martin
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, 90033, CA, USA.
| | - Kenji Inaba
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, 90033, CA, USA.
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, 90033, CA, USA.
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Boukobza M, Raffoul R, Rebibo L, Khalil A, Laissy JP. Splenic Artery Infectious Aneurysms in Infective Endocarditis - An Observational Study and Comprehensive Literature Review. Ann Vasc Surg 2024; 99:389-399. [PMID: 37918659 DOI: 10.1016/j.avsg.2023.09.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/01/2023] [Accepted: 09/02/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND To determine the prevalence, the clinical and radiological features, associated factors, treatment, and outcome of splenic artery aneurysms (SAAs) in infective endocarditis (IE). METHODS We retrospectively reviewed 474 consecutive patients admitted to our institution with definite IE (2005-2020). RESULTS Six patients had SAAs (1.3%; 3 women; mean age: 50 years). In all cases, the diagnosis was obtained by abdominal computed tomography angiography (CTA). SAAs-IE were solitary and saccular with a mean diameter of 30 mm (range: 10-90 mm). SAAs-IE were intrasplenic (n = 4) or hilar (n = 2). Streptococcus spp. were the predominant organisms (n = 4). In all cases, a left-sided native valve was involved (aortic, n = 3; mitral, n = 2; mitral-aortic, n = 1). SAAs were silent in half patients and were revealed by abdominal pain (n = 2) and by the resurgence of fever after cardiac surgery (n = 1). All patients underwent emergent valve replacement. One patient died within 24 hr from multiorgan failure. For the others, uneventful coil embolization was performed in 4 patients after valve replacement (3 diagnosed early and 1 at 8 weeks). In the remaining patient, SAA-IE diagnosed at abdominal CTA at day 16, with complete resolution under appropriate antibiotherapy alone. CONCLUSIONS SAAs-IE are a rare occurrence that may be clinically silent. SAAs-IE can be intrasplenic or hilar in location. Endovascular treatment in this context was safe. According to current guidelines, radiologic screening by abdominal CTA allowed the detection of silent SAAs which could be managed by endovascular treatment to prevent rupture. The delayed formation of these SAAs could justify a CTA control at the end of antibiotherapy.
Collapse
Affiliation(s)
- Monique Boukobza
- Department of Radiology, Bichat-Claude Bernard University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Richard Raffoul
- Department of Cardiac Surgery, Bichat-Claude Bernard University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lionel Rebibo
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat-Claude Bernard University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Antoine Khalil
- Department of Radiology, Bichat-Claude Bernard University Hospital, Paris, France; Assistance Publique-Hôpitaux de Paris, Paris, France; Paris University, France
| | - Jean-Pierre Laissy
- Department of Radiology, Bichat-Claude Bernard University Hospital, Paris, France; Assistance Publique-Hôpitaux de Paris, Paris, France; Paris University, France; INSERM U1148, Paris, France
| |
Collapse
|
5
|
Eshraghi R, Shamsi S, Safaee M. Surgical Treatment versus Conservative Management of Splenic Rupture: Outcomes and Risk Factors. Bull Emerg Trauma 2024; 12:15-20. [PMID: 38689793 PMCID: PMC11057449 DOI: 10.30476/beat.2024.101350.1489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 11/29/2023] [Accepted: 12/03/2023] [Indexed: 05/02/2024] Open
Abstract
Objective This study aimed to evaluate the outcome and risk factors in operative and non-operative management of splenic injury. Methods This cross-sectional study was conducted on patients with traumatic splenic injuries who were hospitalized in Kashani Hospital (Isfahan, Iran) from 2017 to 2019. The studied variables were extracted from the medical records of the enrolled participants. The outcomes such as mortality complications and risk factors were compared based on treatment methods. Results A total of 240 patients were investigated. The mean age of the patients was 29.8±12.2, with 180 (77.5%) patients being men. 154 (64.2%) patients underwent operative treatment. The mortality rate was 18.9% and 4.6% among operative and non-operative groups (p<0.001). Complications were observed in 11.5% and 46.1% of non-operative and operative groups, respectively (p<0.001). Operative treatment inversely correlated with mortality (p<0.001) and complications (p<0.05). Splenic injury severity was correlated positively with mortality (p<0.001) and negatively with complications (p<0.001). Unstable hemodynamic status was positively correlated with complications (p<0.001). Age had a positive correlation with mortality (p<0.001) and complications (p<0.001). Male sex had a negative correlation with complications (p<0.001). GCS score and admission were positively correlated with mortality (p<0.001). There was no statistically significant correlation between correlated injuries and outcomes (p≥0.05). Conclusion Patients who received surgery had higher rates of mortality and complications. However, after controlling for confounders, operative treatment was found to be inversely correlated with mortality and complications.
Collapse
Affiliation(s)
- Reza Eshraghi
- Department of Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sina Shamsi
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masoumeh Safaee
- Department of Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
6
|
Atkins K, Schneider A, Charles A. Splenic Salvage: Is There a Role for Splenorrhaphy in the Management of Adult Splenic Trauma? Am Surg 2023; 89:5599-5608. [PMID: 36878857 DOI: 10.1177/00031348231156760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
INTRODUCTION Nonoperative management of splenic injuries is recommended. Total splenectomy is the primary operative management, and the current role of splenorrhaphy in splenic salvage is not well delineated. METHODS We reviewed the National Trauma Data Bank (2007-2019) for adult splenic injuries. Operative splenic injury management were compared. We performed bivariate analysis and multivariable logistic regression to estimate the effect of surgical management on mortality. RESULTS 189,723 patients met the inclusion criteria. Splenic injury management was stable, with 18.2% undergoing a total splenectomy and 1.9% splenorrhaphy. Splenorrhaphy patients had lower crude mortality (2.7% vs 8.3%, P < .001) than total splenectomy patients. Failed splenorrhaphy patients had higher crude mortality (10.1% vs 8.3%, P < .001) than patients who underwent initial total splenectomy. Patients who underwent total splenectomy had an adjusted odd of 2.30 (95% CI 1.82-2.92, P < .001) for mortality compared to successful splenorrhaphy. Patients who failed splenorrhaphy had an adjusted odd of 2.36 (95% CI 1.19-4.67, P < .014) for mortality compared to successful splenorrhaphy. CONCLUSION Adults with splenic injuries requiring operative intervention have twice the odds of mortality when a total splenectomy is performed or when splenorrhaphy fails compared to successful splenorrhaphy.
Collapse
Affiliation(s)
- Kathryn Atkins
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrew Schneider
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
7
|
Barah A, Elmagdoub A, Aker L, M. Alahmad Y, Jaleel Z, Ahmed Z, Kaassamali R, Hasani AA, Al-Thani H, Omar A. The predictive value of CTSI scoring system in non-operative management of patients with splenic blunt trauma: The experience of a level 1 trauma center. Eur J Radiol Open 2023; 11:100525. [PMID: 37771658 PMCID: PMC10522900 DOI: 10.1016/j.ejro.2023.100525] [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: 07/24/2023] [Revised: 09/08/2023] [Accepted: 09/20/2023] [Indexed: 09/30/2023] Open
Abstract
Background The spleen is one of the most injured organs following blunt abdominal trauma. The management options can be either operative or non-operative management (NOM) with either conservative management or splenic artery embolization. The implementation of CT in emergency departments allowed the use of CT imaging as a primary screening tool in early decision-making. Consecutively, new splenic injury scoring systems, such as the CT severity index (CTSI) reported was established. Aim The main aim of this study is to evaluate the effect of the implementation of CTSI scoring system on the management decision and outcomes in patients with blunt splenic trauma over 8 years in a level 1 trauma center. Methods This is a retrospective study including all adult patients with primary splenic trauma, having NOM and admitted to our hospital between 2013 and 2021. Results The analyses were conducted on ninety-nine patients. The average sample age was 32.7 ± 12.3 years old. A total of (63/99) patients had splenic parenchyma injury without splenic vascular injury. There is a statistically significant association between CTSI grade 3 injury and the development of delayed splenic vascular injury (p < 0.05). There is an association between severity of initial CTSI score and the risk of NOM/clinical failure (p = 0.02). Conclusion Our findings suggest implementing such a system in a level 1 trauma center will further improve the outcome of treatment for splenic blunt trauma. However, CTSI grade 3 is considered an increased risk of NOM failure, and further investigations are necessary to standardize its management.
Collapse
Affiliation(s)
- Ali Barah
- Radiology Department, Hamad Medical Corporation, Doha, Qatar
| | - Ayman Elmagdoub
- Radiology Department, Hamad Medical Corporation, Doha, Qatar
| | - Loai Aker
- Radiology Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Zeyad Jaleel
- Radiology Department, Hamad Medical Corporation, Doha, Qatar
| | - Zahoor Ahmed
- Radiology Department, Hamad Medical Corporation, Doha, Qatar
| | | | | | | | - Ahmed Omar
- Radiology Department, Hamad Medical Corporation, Doha, Qatar
| |
Collapse
|
8
|
Yang Y, Liu D, He Z, Zhang X, Liu H, Li X, Ma H, Shi W. Specific Spleen-Accumulated NIR-II Fluorescent Probe for Imaging-Guided Splenic Operation. Adv Healthc Mater 2023; 12:e2300434. [PMID: 36975845 DOI: 10.1002/adhm.202300434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/20/2023] [Indexed: 03/29/2023]
Abstract
Spleen is a large immune organ in the body. Splenic operations such as splenectomy and intrasplenic injection are of paramount importance for immunological research and splenic diseases. Fluorescence imaging can vastly simplify these operations, but a specific spleen-targeting probe is still unavailable. Herein, the first specific spleen-accumulated fluorescent probe, VIX-S is reported, which fluoresces at 1064 nm and is highly stable. Systematic studies reveal the superior targeting and imaging performance of VIX-S for the spleen in both nude and haired mice. In vivo imaging indicates that the probe can image the morphology of spleen with a signal-background ratio of at least two-fold higher than that of the liver. Moreover, the application of VIX-S in imaging-guided splenic operation, including splenic injury and intrasplenic injection, is demonstrated, which may provide a practice tool for spleen research in the animal model.
Collapse
Affiliation(s)
- Yiqing Yang
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
- Key Laboratory of Chemical Biology of Hebei Province, College of Chemistry and Environmental Science, Hebei University, Baoding, 071002, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Diankai Liu
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
| | - Zixu He
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
| | - Xiaofan Zhang
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
| | - Huihui Liu
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
| | - Xiaohua Li
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
| | - Huimin Ma
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Wen Shi
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| |
Collapse
|
9
|
Miftari R, Gazzetta J. Splenic Capsule Injury: A Rare Complication of Sigmoid Volvulus. Cureus 2023; 15:e41118. [PMID: 37519610 PMCID: PMC10382788 DOI: 10.7759/cureus.41118] [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] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Sigmoid volvulus can lead to life-threatening complications. We report a splenic capsule avulsion injury requiring laparotomy as a complication of sigmoid volvulus. A 73-year-old woman was admitted with abdominal distension, rigidity, and tenderness. CT abdomen revealed a splenic injury and hemoperitoneum along with possible sigmoid volvulus. The patient required an emergent exploratory laparotomy due to an acute abdomen and hemodynamic instability. A left colectomy, on-table sigmoidoscopy, hemostasis of the spleen, and temporary abdominal closure were performed. She required subsequent operations for end colostomy and abdominal closure. We establish that splenic lacerations are rare but life-threatening complications of sigmoid volvulus. Careful assessment of the spleen on abdominal imaging and clear visualization of the spleen during sigmoid volvulus surgery is recommended for early recognition and prompt management of splenic injury.
Collapse
Affiliation(s)
- Rrezane Miftari
- General Surgery, Saba University School of Medicine, The Bottom, BES
| | | |
Collapse
|
10
|
Bontrager AM, Ewing JK, Singh T, Medvecz AJ, Devasahayam RJ, Smith MC, Guillamondegui OD. Analysis of Need for Intervention in Low-Grade Traumatic Splenic Injury. Am Surg 2023:31348231161707. [PMID: 36893464 DOI: 10.1177/00031348231161707] [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: 03/11/2023]
Abstract
BACKGROUND Blunt splenic injuries are common traumatic injuries. Severe injuries may require blood transfusion, procedural, or operative intervention. Conversely, patients with low-grade injuries and normal vital signs frequently do not require intervention. The level and duration of monitoring required to safely manage these patients are unclear. We hypothesize that low-grade splenic trauma has a low rate of intervention and may not require acute hospitalization. METHODS This retrospective descriptive analysis included patients admitted to a level I trauma center with low injury burden (injury severity score <15) and The American Association for the Surgery of Trauma (AAST) grade 1 (G1) and 2 (G2) splenic injuries between January 2017 and December 2019 using the Trauma Registry of the American College of Surgeons (TRACS). The primary outcome was the need for any intervention. Secondary outcomes included time to intervention and length of stay. RESULTS 107 patients met inclusion criteria. 87.9% required no intervention . 9.4% required blood products, with a median time to transfusion of 7.4 hours from arrival. All patients receiving blood products had extenuating circumstances such as bleeding from other injuries, anticoagulant use, or medical comorbidities. 2 patients required splenic artery embolization, one presenting with return precautions 9 days post-injury and 1 with significant comorbidities. One patient with concomitant bowel injury required splenectomy. CONCLUSIONS Low-grade blunt splenic trauma has a low rate of intervention, which typically occurs within the first 12 hours of presentation. This suggests that outpatient management with return precautions may be appropriate for select patients after a short interval of observation.
Collapse
Affiliation(s)
| | - John K Ewing
- Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tanya Singh
- Department of Neurosurgery, 12292University at Buffalo, Buffalo, NY, USA
| | - Andrew J Medvecz
- Division of Acute Care Surgery, Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rebekah J Devasahayam
- Division of Acute Care Surgery, Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael C Smith
- Division of Acute Care Surgery, Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Oscar D Guillamondegui
- Division of Acute Care Surgery, Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
11
|
Shatz DV, de Moya M, Brasel KJ, Brown CVR, Hartwell JL, Inaba K, Ley EJ, Moore EE, Peck KA, Rizzo AG, Rosen NG, Sperry JL, Weinberg JA, Moren AM, Coimbra R, Martin MJ. Blunt splenic injury, Emergency Department to discharge: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2023; 94:448-454. [PMID: 36730563 DOI: 10.1097/ta.0000000000003829] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- David V Shatz
- From the Division of Trauma and Surgical Critical Care, Department of Surgery (D.V.S.), Davis Medical Center, University of California, Davis, Sacramento, California; Department of Surgery, Medical College of Wisconsin (M.d.M.), Milwaukee, Wisconsin; Department of Surgery, Oregon Health Science University (K.J.B.), Portland, Oregon; Department of Surgery, Dell Medical School (C.V.R.B.), University of Texas at Austin, Austin, Texas; Department of Surgery, University of Kansas Medical Center (J.L.H.), Kansas City, Kansas; Department of Surgery, University of Southern California (K.I.), Los Angeles, California; Department of Surgery, Cedars-Sinai Medical Center (E.J.L.), Los Angeles, California; Department of Surgery, Ernest E Moore Shock Trauma Center (E.E.M.), Denver, Colorado; Department of Surgery, Scripps Mercy Hospital (K.A.P.), San Diego, California; Department of Surgery, Guthrie Health System (A.G.R.), Sayre, Pennsylvania; Department of Surgery, Children's Hospital (N.G.R.), Cincinnati, Ohio; Department of Surgery, University of Pittsburgh (J.L.S.), Pittsburgh, Pennsylvania; Department of Surgery, St. Joseph's Medical Center (J.A.W.), Phoenix, Arizona; Department of Surgery, Salem Health Hospital (A.M.M.), Salem, Oregon; Department of Surgery, Riverside University Health System Medical Center (R.C.), Riverside, California; Department of Surgery, University of Southern California (M.J.M.), Los Angeles, California
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Therapeutic strategies for pseudoaneurysm following blunt liver and spleen injuries: A multicenter cohort study in the pediatric population. J Trauma Acute Care Surg 2023; 94:433-442. [PMID: 36245083 DOI: 10.1097/ta.0000000000003813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little guidance exists for the treatment of pseudoaneurysm (PA) following pediatric blunt liver and/or spleen injuries (BLSIs). We aimed to describe the incidence of delayed PA development and the subsequent clinical course of PA in pediatric BLSIs. METHODS This multicenter retrospective cohort study from Japan included pediatric patients (16 years and younger) who sustained BLSIs from 2008 to 2019. The cohort was divided into four groups based on hemostatic intervention within 48 hours of admission, namely, nonoperative management (NOM), NOM with interventional radiology (IR), operative management (OM), and combined IR/OM. Descriptive statistics were used to describe the incidence of delayed PA among the groups and to characterize the clinical course of any PAs. RESULTS A total of 1,407 children (median age, 9 years) from 83 institutions were included. The overall number (incidence) of cases of delayed PA formation was 80 (5.7%), and the number with delayed PA rupture was 16 cases (1.1%) in the entire cohort. Patients treated with NOM (1,056), NOM with IR (276), OM (53), and combined IR/OM (22) developed 43 (4.1%), 32 (12%), 2 (3.8%), and 3 (14%) delayed PAs, respectively. Among patients who developed any PAs, 39% of patients underwent prophylactic IR for unruptured PA, while 13% required emergency angioembolization for delayed PA rupture, with one ruptured case requiring total splenectomy. At least 45% of patients experienced spontaneous resolution of PA without any interventions. CONCLUSION Our results suggest that the risk of delayed PA still exists even after acute phase IR as an adjunct to NOM for BLSIs in children, indicating the necessity of a period of further observation. While endovascular interventions are usually successful for PA management, including rupture cases, given the high incidence of spontaneous resolution, the ideal management of PA remains to be investigated in future studies. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
Collapse
|
13
|
Savage SA. Management of blunt splenic injury: down the rabbit hole and into the bucket. Trauma Surg Acute Care Open 2023; 8:e001119. [PMID: 37082308 PMCID: PMC10111894 DOI: 10.1136/tsaco-2023-001119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 03/16/2023] [Indexed: 04/22/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Stephanie A Savage
- Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| |
Collapse
|
14
|
Abstract
Asplenia (the congenital or acquired absence of the spleen) and hyposplenism (defective spleen function) are common causes of morbidity and mortality. The spleen is a secondary lymphoid organ that is responsible for the regulation of immune responses and blood filtration. Hence, asplenia or hyposplenism increases susceptibility to severe and invasive infections, especially those sustained by encapsulated bacteria (namely, Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae type b). Asplenia is predominantly due to splenectomy for either traumatic events or oncohaematological conditions. Hyposplenism can be caused by several conditions, including haematological, infectious, autoimmune and gastrointestinal disorders. Anatomical disruption of the spleen and depletion of immune cells, especially IgM memory B cells, seem to be predominantly responsible for the clinical manifestations. Early recognition of hyposplenism and proper management of asplenia are warranted to prevent overwhelming post-splenectomy infections through vaccination and antibiotic prophylaxis. Although recommendations are available, the implementation of vaccination strategies, including more effective and immunogenic vaccines, is needed. Additionally, screening programmes for early detection of hyposplenism in high-risk patients and improvement of patient education are warranted.
Collapse
|
15
|
Kanlerd A, Auksornchart K, Boonyasatid P. Non-operative management for abdominal solidorgan injuries: A literature review. Chin J Traumatol 2022; 25:249-256. [PMID: 34654595 PMCID: PMC9459001 DOI: 10.1016/j.cjtee.2021.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 07/18/2021] [Accepted: 07/26/2021] [Indexed: 02/04/2023] Open
Abstract
The philosophy of abdominal injury management is currently changing from mandatory exploration to selective non-operative management (NOM). The patient with hemodynamic stability and absence of peritonitis should be managed non-operatively. NOM has an overall success rate of 80%-90%. It also can reduce the rate of non-therapeutic abdominal exploration, preserve organ function, and has been defined as the safest choice in experienced centers. However, NOM carries a risk of missed injury such as hollow organ injury, diaphragm injury, and delayed hemorrhage. Adjunct therapies such as angiography with embolization, endoscopic retrograde cholangiopancreatography with stenting, and percutaneous drainage could increase the chances of successful NOM. This article aims to describe the evolution of NOM and define its place in specific abdominal solid organ injury for the practitioner who faces this problem.
Collapse
Affiliation(s)
- Amonpon Kanlerd
- Unit of Trauma and Surgical Critical Care, Division of General Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand.
| | - Karikarn Auksornchart
- Unit of Trauma and Surgical Critical Care, Division of General Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| | - Piyapong Boonyasatid
- Unit of Trauma and Surgical Critical Care, Division of General Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| |
Collapse
|
16
|
Arnold P, Belchos J, Meagher A, Robbins C, Sparks Joplin T, Ortiz D, Ferries I, Hartwell J. Postoperative Pancreatic Fistula Following Traumatic Splenectomy: A Morbid and Costly Complication. J Surg Res 2022; 280:35-43. [PMID: 35952555 DOI: 10.1016/j.jss.2022.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Development of clinically relevant postoperative pancreatic fistula (CR-POPF) in adult splenectomies following trauma occur in 1%-3% of cases. We hypothesized that the use of sutures in splenic hilum ligation compared to staples was associated with a reduced rate of CR-POPF incidence. METHODS Adult trauma patients (age ≥17 y) that underwent nonelective splenectomy from 2010 to 2020 were retrospectively evaluated from the trauma registries of all three adult level 1 trauma centers in Indiana. Patients were excluded if they were pregnant, currently incarcerated, expired within 72 h of admission, or had a pancreatic injury diagnosed preoperatively or intraoperatively. A Firth logistic regression using a penalized-maximum likelihood estimate for rare events was used for univariate predictive modeling (SPSS 28.0) of surgical technique on CR-POPF development. RESULTS Four hundred nineteen adult splenectomies following trauma were conducted; 278 were included. CR-POPF developed in 14 cases (5.0%). Sutures alone were used in 200 cases: seven developed CR-POPF (3.5%). Staples alone or in combination with sutures were used in 74 cases: seven developed CR-POPF (9.5%). There was no statistically significant difference between the use of sutures alone compared to the use of staples alone (P = 0.123) or in combination (P = 0.100) in CR-POPF incidence. CONCLUSIONS Our 10-y retrospective review of CR-POPF finds the complication to be rare but morbid. This study was underpowered to show any difference in surgical technique. However, we do propose a new institutional norm that CR-POPF develop in 5% of splenectomies after trauma and conclude that further study of optimal technique for emergent splenectomy is warranted.
Collapse
Affiliation(s)
- Peter Arnold
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana.
| | - Jessica Belchos
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana; Ascension St. Vincent Hospital, Indianapolis, Indiana
| | - Ashley Meagher
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
| | - Christopher Robbins
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
| | - Tasha Sparks Joplin
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
| | - Damaris Ortiz
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana; Sidney & Lois Eskenazi Hospital, Indianapolis, Indiana
| | - Ian Ferries
- Ascension St. Vincent Hospital, Indianapolis, Indiana
| | - Jennifer Hartwell
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
| |
Collapse
|
17
|
Dreizin D, Yu T, Motley K, Li G, Morrison JJ, Liang Y. Blunt splenic injury: Assessment of follow-up CT utility using quantitative volumetry. FRONTIERS IN RADIOLOGY 2022; 2. [PMID: 36120383 PMCID: PMC9479763 DOI: 10.3389/fradi.2022.941863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose: Trials of non-operative management (NOM) have become the standard of care for blunt splenic injury (BSI) in hemodynamically stable patients. However, there is a lack of consensus regarding the utility of follow-up CT exams and relevant CT features. The purpose of this study is to determine imaging predictors of splenectomy on follow-up CT using quantitative volumetric measurements. Methods: Adult patients who underwent a trial of non-operative management (NOM) with follow-up CT performed for BSI between 2017 and 2019 were included (n = 51). Six patients (12% of cohort) underwent splenectomy; 45 underwent successful splenic salvage. Voxelwise measurements of splenic laceration, hemoperitoneum, and subcapsular hematoma were derived from portal venous phase images of admission and follow-up scans using 3D slicer. Presence/absence of pseudoaneurysm on admission and follow-up CT was assessed using arterial phase images. Multivariable logistic regression was used to determine independent predictors of decision to perform splenectomy. Results: Factors significantly associated with splenectomy in bivariate analysis incorporated in multivariate logistic regression included final hemoperitoneum volume (p = 0.003), final subcapsular hematoma volume (p = 0.001), change in subcapsular hematoma volume between scans (p = 0.09) and new/persistent pseudoaneurysm (p = 0.003). Independent predictors of splenectomy in the logistic regression were final hemoperitoneum volume (unit OR = 1.43 for each 100 mL change; 95% CI: 0.99–2.06) and new/persistent pseudoaneurysm (OR = 160.3; 95% CI: 0.91–28315.3). The AUC of the model incorporating both variables was significantly higher than AAST grading (0.91 vs. 0.59, p = 0.025). Mean combined effective dose for admission and follow up CT scans was 37.4 mSv. Conclusion: Follow-up CT provides clinically valuable information regarding the decision to perform splenectomy in BSI patients managed non-operatively. Hemoperitoneum volume and new or persistent pseudoaneurysm at follow-up are independent predictors of splenectomy.
Collapse
Affiliation(s)
- David Dreizin
- Trauma and Emergency Radiology, Department of Diagnostic Radiology and Nuclear Medicine, School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, United States
- CORRESPONDENCE: David Dreizin
| | - Theresa Yu
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Kaitlynn Motley
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Guang Li
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Jonathan J. Morrison
- Vascular Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Yuanyuan Liang
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
| |
Collapse
|
18
|
Perea LL, Fletcher KL, Morgan ME, Otaibi BW, Hazelton JP. Routine repeat imaging of blunt splenic injuries identifies complications prior to clinical change. TRAUMA-ENGLAND 2022. [DOI: 10.1177/14604086221103060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background There are no definitive recommendations guiding repeat imaging, or its timing, in patients with blunt splenic injury managed non-operatively. This study examines delayed complications and interventions in patients with blunt splenic injuries who undergo repeat imaging. Imaging was prompted either by a clinical change (CC) or non-clinical change (NCC) including institutional recommendations and individual physician practice patterns. Methods A 3-year, retrospective, dual-institution study was conducted of adult patients with blunt splenic injuries. Patients who underwent repeat imaging were grouped based on the reason for scan: CC or NCC. The incidence of delayed complications and interventions was examined. Results Of 235 patients, 105 (45%) underwent repeat imaging [CC n = 67 (64%), NCC n = 38 (36%)]. Median time to repeat imaging was shorter in the NCC group [CC = 96 (IQR 48–192) hours, NCC = 48 (IQR 36–68) hours, p = .0005]. Delayed complications were found in 28 (42%) CC patients versus 18 (47%) NCC patients ( p = .683). Interventions for complications were performed in 6 (21%) CC versus 10 (56%) NCC ( p = .027). Discussion Nearly half of patients reimaged because of NCC were found to have complications, with more than half undergoing intervention. Complications were identified and treated earlier in the NCC group than the CC group. This suggests patients with blunt splenic injuries should undergo routine repeat imaging to allow for prompt identification and treatment of delayed complications.
Collapse
Affiliation(s)
- Lindsey L Perea
- Division of Trauma and Acute Care Surgery, Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Kelsey L Fletcher
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Madison E Morgan
- Division of Trauma and Acute Care Surgery, Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Banan W Otaibi
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Joshua P Hazelton
- Department of Surgery, Division of Trauma and Acute Care Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
19
|
Byerly SE, Jones MD, Lenart EK, Seger CP, Filiberto DM, Lewis RH, Kerwin AJ, Magnotti LJ. Serial CT for Nonoperatively Managed Splenic Injuries. Am Surg 2022; 88:1504-1509. [PMID: 35341346 DOI: 10.1177/00031348221082285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The role of serial computed tomography (CT) in the nonoperative management of blunt splenic injuries (NOMSIs) remains unclear. The purpose of the study was to determine the utility of serial CT of Grade 2-5 NOMSI in the modern era. METHODS Blunt splenic injuries were identified over a 3.5-year period, ending in 6/2020. Our institutional protocol for NOMSI mandates a repeat 24-hour CT for Grade 2-5 injuries. Patients age<18, Grade 1 injuries and patients that underwent intervention prior to repeat scan were excluded. Demographics, comorbidities, timing of events (admission, CTs, splenectomy, and angiography), injury details, procedural details, total transfusion requirements, complications, length of stay, mortality, and discharge disposition were recorded. Descriptive statistics were performed. RESULTS 219 patients with Grade 2-5 NOMSI had both an initial and 24-hour CT after exclusions. 24-hour CT identified 14 patients with new PSA(s) and 11 (5%) went to angiography within 24 hours with 9 (4%) undergoing angioembolization and 4 (2%) had splenectomy. Two hundred and four (93%) had no intervention though eventually 12 went on to angiography and 6 went for splenectomy. The 24-hour CT rarely altered management in the absence of clinical indication or prior PSA on initial CT with 5 (2%) receiving a therapeutic embolization and 2 (1%) had a nontherapeutic angiogram. No deaths were attributable to splenic injury. CONCLUSIONS Routine 24-hour CT for NOMSI did not impact management. Clinical status and change in exam may warrant repeat CT in select cases in the setting of a plausible alternate explanation. Prompt angioembolization or splenectomy is more appropriate in clear-cut cases of failed NOMSI.
Collapse
Affiliation(s)
- Saskya E Byerly
- Department of Surgery, 12325University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Michael D Jones
- Department of Surgery, 12325University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Emily K Lenart
- Department of Surgery, 12325University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Catherine P Seger
- Department of Surgery, 3989Baylor College of Medicine, Houston, TX, USA
| | - Dina M Filiberto
- Department of Surgery, 12325University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Richard H Lewis
- Department of Surgery, 12325University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Andrew J Kerwin
- Department of Surgery, 12325University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Louis J Magnotti
- Department of Surgery, 12325University of Tennessee Health Science Campus, Memphis, TN, USA
| |
Collapse
|
20
|
Glenn AM, Huang J, Gunn AJ, Pollak J, Quencer KB. Vascular plugs are associated with reduced fluoroscopy times compared to endovascular coils in proximal splenic artery embolization in trauma. SAGE Open Med 2022; 10:20503121211069840. [PMID: 35070310 PMCID: PMC8772009 DOI: 10.1177/20503121211069840] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/10/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose: Proximal splenic artery embolization plays an important role in the treatment of hemodynamically stable blunt splenic trauma patients with medium- to high-grade injuries. Proximal splenic artery embolization is most often performed utilizing endovascular coils or vascular plugs. The objective of this study was to compare technical and clinical outcomes of proximal splenic artery embolization using either endovascular coils or vascular plugs in patients with traumatic splenic injuries. Materials and methods: A single-institution retrospective review of all proximal splenic artery embolizations for trauma over a 5-year period was performed. Patients who underwent embolization using both endovascular coils and vascular plugs were excluded. Baseline characteristics, including patient age, sex, and grade of splenic injury, were recorded. Complication rates, rates of splenic salvage, and total fluoroscopy time were recorded and compared. Results: A total of 26 patients were included in the analysis (17 males, 9 females, median age: 50 years). Of these, 15 patients were treated with vascular plugs (57.7%), while 11 patients (42.3%) were treated with endovascular coils. Mean grade of injury was 3.5 and 4.1 in the vascular plug and endovascular coils groups, respectively. There were no differences between the groups regarding these baseline characteristics. Splenic salvage was 100% in both groups. No major complications were identified in either group. Mean fluoroscopy time was significantly lower in the vascular plug group (14.5 versus 34.0 min; p < 0.0001). Conclusion: Proximal splenic artery embolization for splenic trauma can be satisfactorily achieved with either vascular plugs or endovascular coils with no differences in splenic salvage or complication rates in this retrospective study. However, embolization utilizing vascular plugs had significantly reduced fluoroscopy times.
Collapse
Affiliation(s)
- Austin M Glenn
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Junjian Huang
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew J Gunn
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffrey Pollak
- Division of Interventional Radiology, Department of Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Keith B Quencer
- Division of Interventional Radiology, Department of Radiology, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
21
|
Newcomer JB, Gabriel GE, Raissi D. Seurat Spleen: A Pathognomonic Sign in Angiography. Cureus 2021; 13:e19439. [PMID: 34926022 PMCID: PMC8654136 DOI: 10.7759/cureus.19439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 12/04/2022] Open
Abstract
Splenic injury commonly occurs following abdominal trauma and can result in severe complications and death if it goes unrecognized. The Seurat spleen is a term used to describe the angiographic appearance of splenic injury following blunt trauma, given its resemblance to the pointillistic artwork of French neo-impressionist Georges Seurat. We present a case of a 43-year-old man who presented following a motor vehicle collision and was found to have multiple punctate foci of contrast extravasation in the spleen consistent with the Seurat spleen angiographic sign. This angiographic pattern can be used as a pathognomonic sign to identify splenic injury, with early identification crucial to preventing further complications of the injury.
Collapse
Affiliation(s)
- Jack B Newcomer
- Interventional Radiology, University of Kentucky College of Medicine, Lexington, USA
| | - Gaby E Gabriel
- Radiology, University of Kentucky College of Medicine, Lexington, USA
| | - Driss Raissi
- Radiology, University of Kentucky College of Medicine, Lexington, USA
| |
Collapse
|
22
|
Santorelli JE, Costantini TW, Berndtson AE, Kobayashi L, Doucet JJ, Godat LN. Readmission after splenic salvage: How real is the risk? Surgery 2021; 171:1417-1421. [PMID: 34857387 DOI: 10.1016/j.surg.2021.10.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/23/2021] [Accepted: 10/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemorrhage due to delayed splenic rupture is a potentially fatal complication of nonoperative management of splenic injuries. Suboptimal postdischarge follow-up has made measuring the incidence of failed splenic salvage challenging. We hypothesized that readmission after splenic salvage is rare; however, readmissions for splenic conditions would be associated with a high rate of splenectomy. METHODS The National Readmission Database for 2016 and 2017 was queried for trauma admissions with the International Classification of Diseases 10th revision codes for splenic injury. Patients with missing discharge disposition, discharge to a short-term hospital, death during index admission, or admitted in December were excluded. The primary endpoint was nonelective 30-day readmission for splenic diagnoses after nonoperative management during the index admission. Outcomes collected included transfusions, complications, interventions at readmission, and mortality. RESULTS There were 22,736 patients admitted for a traumatic splenic injury; 15,596 (68.6%) underwent no intervention, 2,261 (9.9%) were treated with embolization only, and 4,509 (19.8%) underwent splenectomy. The overall 30-day readmission rate was 8.4%, whereas the spleen-related readmission rate was 2.0%. For those treated with embolization or no intervention, the spleen-related 30-day readmission rate was 2.4%, with the majority (69.4%) occurring within 7 days of discharge. The most common complications were pleural effusion (23.0%), sepsis (4.4%), splenic abscess (3.9%), and splenic infarct (3.0%). Those patients readmitted for spleen-related diagnoses after undergoing splenic salvage during the index admission had a 22.3% rate of splenectomy and mortality of 1.6%. CONCLUSION Readmission after splenic salvage is rare, with the majority presenting within 1 week of discharge. However, of those readmitted for spleen injury-related diagnoses there was a high rate of splenectomy. Patients managed with splenic salvage should be counseled on the risk of potential failure and need for readmission and operation after discharge.
Collapse
Affiliation(s)
- Jarrett E Santorelli
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, CA. https://twitter.com/JE_Santorelli
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, CA. https://twitter.com/TWCostantini
| | - Allison E Berndtson
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, CA. https://twitter.com/ABerndtson
| | - Leslie Kobayashi
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, CA
| | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, CA. https://twitter.com/jaydoucet
| | - Laura N Godat
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego School of Medicine, CA.
| |
Collapse
|
23
|
Ko A, Radding S, Feliciano DV, DuBose JJ, Kozar RA, Morrison J, Kundi R, Maddox J, Scalea TM. Near Disappearance of Splenorrhaphy as an Operative Strategy for Splenic Preservation After Trauma. Am Surg 2021; 88:429-433. [PMID: 34732074 DOI: 10.1177/00031348211050591] [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 Splenorrhaphy was once used to achieve splenic preservation in up to 40% of splenic injuries. With increasing use of nonoperative management and angioembolization, operative therapy is less common and splenic injuries treated operatively are usually high grade. Patients are often unstable, making splenic salvage unwise. Modern surgeons may no longer possess the knowledge to perform splenorrhaphy. METHODS The records of adult trauma patients with splenic injuries from September 2014 to November 2018 at an urban level I trauma center were reviewed retrospectively. Data including American Association for the Surgery of Trauma splenic organ injury scale, type of intervention, splenorrhaphy technique, and need for delayed splenectomy were collected. This contemporary cohort (CC) was compared to a historical cohort (HC) of splenic injuries at a single center from 1980 to 1989 (Ann Surg 1990; 211: 369). RESULTS From 2014 to 2018, 717 adult patients had splenic injuries. Initial management included 157 (21.9%) emergent splenectomy, 158 (22.0%) angiogram ± embolization, 371 (51.7%) observation, and only 10 (1.4%) splenorrhaphy. The HC included a total of 553 splenic injuries, of which 313 (56.6%) underwent splenectomy, while splenorrhaphy was performed in 240 (43.4%). Those who underwent splenorrhaphy in each cohort (CC vs HC) were compared. CONCLUSION The success rate of splenorrhaphy has not changed. However, splenorrhaphy now involves only electrocautery with topical hemostatic agents and is used primarily in low-grade injuries. Suture repair and partial splenectomy seem to be "lost arts" in modern trauma care.
Collapse
Affiliation(s)
- Ara Ko
- Department of Surgery, Section of Acute Care Surgery, 10624Stanford University, Stanford, CA, USA
| | - Sydney Radding
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| | - David V Feliciano
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| | - Joseph J DuBose
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| | - Rosemary A Kozar
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| | - Jonathan Morrison
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| | - Rishi Kundi
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| | - John Maddox
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| | - Thomas M Scalea
- R. Adams Cowley Shock Trauma Center, 12264University of Maryland, Baltimore, MD, USA
| |
Collapse
|
24
|
Arvieux C, Frandon J, Tidadini F, Monnin-Bares V, Foote A, Dubuisson V, Lermite E, David JS, Douane F, Tresallet C, Lemoine MC, Rodiere M, Bouzat P, Bosson JL, Vilotitch A, Barbois S, Thony F. Effect of Prophylactic Embolization on Patients With Blunt Trauma at High Risk of Splenectomy: A Randomized Clinical Trial. JAMA Surg 2021; 155:1102-1111. [PMID: 32936242 DOI: 10.1001/jamasurg.2020.3672] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Splenic arterial embolization (SAE) improves the rate of spleen rescue, yet the advantage of prophylactic SAE (pSAE) compared with surveillance and then embolization only if necessary (SURV) for patients at high risk of spleen rupture remains controversial. Objective To determine whether the 1-month spleen salvage rate is better after pSAE or SURV. Design, Setting, and Participants In this randomized clinical trial conducted between February 6, 2014, and September 1, 2017, at 16 institutions in France, 133 patients with splenic trauma at high risk of rupture were randomized to undergo pSAE or SURV. All analyses were performed on a per-protocol basis, as well as an intention-to-treat analysis for specific events. Interventions Prophylactic SAE, preferably using an arterial approach via the femoral artery, or SURV. Main Outcomes and Measures The primary end point was an intact spleen or a spleen with at least 50% vascularized parenchyma detected on an arterial computed tomography scan at 1 month after trauma, assessed by senior radiologists masked to the treatment group. Secondary end points included splenectomy and pseudoaneurysm, secondary SAE after inclusion, complications, length of hospital stay, quality-of-life score, and length of time off work or studies during the 6-month follow-up. Results A total of 140 patients were randomized, and 133 (105 men [78.9%]; median age, 30 years [interquartile range, 23-47 years]) were retained in the study. For the primary end point, data from 117 patients (57 who underwent pSAE and 60 who underwent SURV) could be analyzed. The number of patients with at least a 50% viable spleen detected on a computed tomography scan at month 1 was not significantly different between the pSAE and SURV groups (56 of 57 [98.2%] vs 56 of 60 [93.3%]; difference, 4.9%; 95% CI, -2.4% to 12.1%; P = .37). By the day 5 visit, there were significantly fewer splenic pseudoaneurysms among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 8 of 65 [12.3%]; difference, -10.8%; 95% CI, -19.3% to -2.1%; P = .03), significantly fewer secondary embolizations among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 19 of 65 [29.2%]; difference, -27.7%; 95% CI, -41.0% to -15.9%; P < .001), and no difference in the overall complication rate between the pSAE and SURV groups (19 of 65 [29.2%] vs 27 of 65 [41.5%]; difference, -12.3%; 95% CI, -28.3% to 4.4%; P = .14). Between the day 5 and month 1 visits, the overall complication rate was not significantly different between the pSAE and SURV groups (11 of 59 [18.6%] vs 12 of 63 [19.0%]; difference, -0.4%; 95% CI, -14.4% to 13.6%; P = .96). The median length of hospitalization was significantly shorter for patients in the pSAE group than for those in the SURV group (9 days [interquartile range, 6-14 days] vs 13 days [interquartile range, 9-17 days]; P = .002). Conclusions and Relevance Among patients with splenic trauma at high risk of rupture, the 1-month spleen salvage rate was not statistically different between patients undergoing pSAE compared with those receiving SURV. In view of the high proportion of patients in the SURV group needing SAE, both strategies appear defendable. Trial Registration ClinicalTrials.gov Identifier: NCT02021396.
Collapse
Affiliation(s)
- Catherine Arvieux
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Julien Frandon
- Department of Imaging and Interventional Radiology, Nîmes University Hospital (CHU), Nîmes, France
| | - Fatah Tidadini
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Valérie Monnin-Bares
- Department of Imaging and Interventional Radiology, Montpellier University Hospital (CHU), Montpellier, France
| | - Alison Foote
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Vincent Dubuisson
- Department of Vascular and General Surgery, Bordeaux University Hospital (CHU), Bordeaux, France
| | - Emilie Lermite
- Department of Visceral Surgery, Angers University Hospital (CHU), Angers, France
| | - Jean-Stéphane David
- Department of Anesthesia and Intensive Care, Lyon-Sud University Hospital (CHU), Pierre Bénite, France
| | - Frederic Douane
- Department of Imaging and Interventional Radiology, Nantes University Hospital (CHU), Nantes, France
| | - Christophe Tresallet
- Department of General, Digestive, Oncologic, Bariatric, and Metabolic Surgery, Avicenne University Hospital (CHU), Bobigny, France
| | | | - Mathieu Rodiere
- Department of Imaging and Interventional Radiology, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Pierre Bouzat
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Jean-Luc Bosson
- Department of Medical Information, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Antoine Vilotitch
- Department of Medical Information, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Sandrine Barbois
- Department of General and Digestive Surgery, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | - Frédéric Thony
- Department of Imaging and Interventional Radiology, Grenoble-Alpes University Hospital (CHU), Grenoble, France
| | | |
Collapse
|
25
|
Meira Júnior JD, Menegozzo CAM, Rocha MC, Utiyama EM. Non-operative management of blunt splenic trauma: evolution, results and controversies. Rev Col Bras Cir 2021; 48:e20202777. [PMID: 33978122 PMCID: PMC10683451 DOI: 10.1590/0100-6991e-20202777] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/14/2020] [Indexed: 11/22/2022] Open
Abstract
The spleen is one of the most frequently affected organs in blunt abdominal trauma. Since Upadhyaya, the treatment of splenic trauma has undergone important changes. Currently, the consensus is that every splenic trauma presenting with hemodynamic stability should be initially treated nonoperatively, provided that the hospital has adequate structure and the patient does not present other conditions that indicate abdominal exploration. However, several topics regarding the nonoperative management (NOM) of splenic trauma are still controversial. Splenic angioembolization is a very useful tool for NOM, but there is no consensus on its precise indications. There is no definition in the literature as to how NOM should be conducted, neither about the periodicity of hematimetric control, the transfusion threshold that defines NOM failure, when to start venous thromboembolism prophylaxis, the need for control imaging, the duration of bed rest, and when it is safe to discharge the patient. The aim of this review is to make a critical analysis of the most recent literature on this topic, exposing the state of the art in the NOM of splenic trauma.
Collapse
Affiliation(s)
- José Donizeti Meira Júnior
- - Hospital das Clínicas da Universidade de São Paulo, Departamento de Cirurgia - São Paulo - SP - Brasil
| | | | - Marcelo Cristiano Rocha
- - Hospital das Clínicas da Universidade de São Paulo, Departamento de Cirurgia - São Paulo - SP - Brasil
| | - Edivaldo Massazo Utiyama
- - Hospital das Clínicas da Universidade de São Paulo, Departamento de Cirurgia - São Paulo - SP - Brasil
| |
Collapse
|
26
|
Gill S, Hoff J, Mila A, Sanchez C, McKenney M, Elkbuli A. Post-traumatic Splenic Injury Outcomes for Nonoperative and Operative Management: A Systematic Review. World J Surg 2021; 45:2027-2036. [PMID: 33834284 DOI: 10.1007/s00268-021-06063-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Splenectomies are widely performed, but there exists controversy regarding care for splenic injury patients. The purpose of this study is to provide a comprehensive review of the literature over the last 20 years for operative management (OM) versus nonoperative management (NOM) versus splenic artery embolization (SAE) for traumatic splenic injuries and associated outcomes. METHODS A review of literature was performed following the PRISMA guidelines through a search of PubMed, EMBASE, Cochrane Library, JAMA Network, and SAGE journals from 2000 to 2020 regarding splenic injury in trauma patients and their management. Articles were then selected based on inclusion/exclusion criteria with GRADE criteria used on the included articles to assess quality. RESULTS Twenty retrospective cohorts and one prospective cohort assessed patients who received OM versus NOM or SAE. Multiple studies indicated that NOM, in properly selected patients, provided better outcomes than its operative counterpart. CONCLUSION This review provides additional evidence to support the NOM of splenic injuries for hemodynamically stable patients with benign abdomens as it accounts for consistently shorter hospital length of stay, fewer complications, and lower mortality than OM. For hemodynamically unstable patients, management continues to be intervention with surgery. More studies are needed to further investigate outcomes of post-splenectomy patients based on grade of injury, hemodynamic status, type of procedure (i.e., SAE), and failure of NOM in order to provide additional evidence and improve outcomes for this patient population.
Collapse
Affiliation(s)
- Sabrina Gill
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, 11750 Bird Road, Miami, FL, 33175, USA
| | - John Hoff
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, 11750 Bird Road, Miami, FL, 33175, USA
| | - Ashley Mila
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, 11750 Bird Road, Miami, FL, 33175, USA
| | - Carol Sanchez
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, 11750 Bird Road, Miami, FL, 33175, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, 11750 Bird Road, Miami, FL, 33175, USA
- Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, 11750 Bird Road, Miami, FL, 33175, USA.
| |
Collapse
|
27
|
Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
28
|
Karachentsev S. Blunt trauma to abdominal solid organs: an experience of non-operative management at a rural hospital in Zambia. Pan Afr Med J 2021; 38:89. [PMID: 33889255 PMCID: PMC8033190 DOI: 10.11604/pamj.2021.38.89.20061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/13/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction although non-operative management of patients with blunt trauma to abdominal solid organs has become standard care, the role of peripheral hospitals remains poorly defined. This study reviews treatment and outcomes in patients with liver and spleen injuries at a regional hospital over a 10-year period. Methods a retrospective review of prospectively collected data was performed and supplemented by case notes retrieval. All patients with solid visceral injuries managed between 2009 and 2019 at a rural surgical hospital in Zambia were included. On admission, the patients were offered either urgent laparotomy or non-operative management (NOM) depending on their haemodynamic status. Continuous variables were expressed as median and mean ± standard deviation; categorical data were expressed as percentages. Statistical evaluation of data was performed by two-sample t-test. Statistical significance was assigned at p<0.05. Results fourty-three patients were included. The majority of victims sustained isolated spleen or liver injury. Twenty-three patients were urgently operated due to haemodynamic instability. Splenectomy performed in 17 patients, liver laceration sutured in 5 patients. One patient underwent concomitant splenectomy and liver repair. Conservative management was attempted in 20 (47%) patients and was successful in 18 (42%). In two patients NOM failed and splenectomy was performed urgently. Two patients died postoperatively. There were no deaths in NOM group. Conclusion NOM of patients with injury to solid abdominal organs could be safely initiated in rural hospitals provided there is uninterrupted monitoring of patients' condition, well-trained staff and unrestricted access to the operating theatre (OT).
Collapse
|
29
|
Value of repeat CT for nonoperative management of patients with blunt liver and spleen injury: a systematic review. Eur J Trauma Emerg Surg 2021; 47:1753-1761. [PMID: 33484276 DOI: 10.1007/s00068-020-01584-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate the effectiveness of routine repeat computed tomography (CT) for nonoperative management (NOM) of adults with blunt liver and/or spleen injury. METHODS We conducted a systematic review of randomized and non-randomized controlled trials (RCTs), quasi-experimental and observational studies of repeat CT in adult patients with blunt abdominal injury. We searched Medline, Embase, Web of Science, and Cochrane Central from their inception to October 2020 using Cochrane guidelines. Primary outcomes were change in clinical management (e.g., emergency surgery, embolization, blood transfusion, clinical surveillance), mortality, and complications. Secondary outcomes were hospital readmission and length of stay. RESULTS Search results yielded 1611 studies of which 28 studies including 2646 patients met our inclusion criteria. The majority reported on liver (n = 9) or spleen injury (n = 16) or both (n = 3). No RCTs were identified. Meta-analyses were not possible because no study performed direct comparisons of study outcomes across intervention groups. Only seven of the twenty-eight studies reported whether repeat CT was routine or prompted by clinical indication. In these 7 studies, among the 254 repeat CT performed, 188 (74%) were routine and 8 (4%) of these led to a change in clinical management. Of the 66 (26%) repeated CT prompted by clinical indication, 31 (47%) led to a change in management. We found no data allowing comparison of any other outcomes across intervention groups. CONCLUSION Routine repeat CT without clinical indication is not useful in the management of patients with liver and/or spleen injury. However, effect estimates were imprecise and included studies were of low methodological quality. Given the risks of unnecessary radiation and costs associated with repeat CT, future research should aim to estimate the frequency of such practices and assess practice variation. LEVEL OF EVIDENCE Systematic reviews and meta-analyses, Level II.
Collapse
|
30
|
Arumugam S, Subbiah NK. A Cadaveric Study of Splenic Fissures and Bilobed Spleen. Sultan Qaboos Univ Med J 2021; 20:e346-e351. [PMID: 33414940 PMCID: PMC7757930 DOI: 10.18295/squmj.2020.20.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/19/2020] [Accepted: 04/08/2020] [Indexed: 11/16/2022] Open
Abstract
Objectives Anatomical knowledge regarding the external morphology of the spleen is essential for surgical intervention and radiological diagnosis. A characteristic feature of the spleen is the presence of splenic notches at the superior border; however, such notches rarely extend deep enough to be considered fissures or to separate the spleen into multiple lobes. To date, there are very few cadaveric reports of splenic fissures. This study aimed to examine the anatomy and morphological structure of spleens collected from cadavers in order to identify the prevalence and clinical significance of splenic notches, fissures and lobation. Methods This study was conducted at the Department of Anatomy, Katuri Medical College and Hospital, Guntur, Andhra Pradesh, India. A total of 50 spleens were collected from cadavers over a period of seven years from 2012-2019 and examined to determine the presence of splenic notches or fissures. Results Of the 50 spleens, 40% had notches at the superior border, 10% had notches at the inferior border and 50% had no notches at either border. Fissures were present in five spleens (10%); of these, three showed incomplete fissures and the remaining two had complete fissures that divided the spleen into two lobes. Conclusion The findings of this study provide valuable information regarding the anatomy and prevalence of splenic fissures and bilobed spleens. A bilobed spleen is a rare congenital malformation which should be considered distinct from other known splenic anomalies. The presence of splenic fissures in bilobed spleens can serve as a guide for surgeons during conservatory splenectomy procedures.
Collapse
Affiliation(s)
- Sangeetha Arumugam
- Department of Anatomy, Katuri Medical College & Hospital, Guntur, Andhra Pradesh, India
| | - Nandha K Subbiah
- Department of Anatomy, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
| |
Collapse
|
31
|
Abstract
The liver is one of the most commonly injured solid organs in blunt abdominal trauma. Non-operative management is considered to be the gold standard for the care of most blunt liver injuries. Angioembolization has emerged as an important adjunct that is vital to the success of the non-operative management strategy for blunt hepatic injuries. This procedure, however, is fraught with some possible serious complications. The success, as well as rate of complications of this procedure, is determined by degree and type of injury, hepatic anatomy and physiology, and embolization strategy among other factors. In this review, we discuss these important considerations to help shed further light on the contribution and impact of angioembolization with regards to complex hepatic injuries.
Collapse
Affiliation(s)
- Ali Cadili
- Department of Surgery, University of Connecticut, CT, USA
| | - Jonathan Gates
- Department of Surgery, University of Connecticut, CT, USA
| |
Collapse
|
32
|
Feliciano DV. A Review of "Changes in the Management of Injuries to the Liver and Spleen" (2005). Am Surg 2020; 87:212-218. [PMID: 33342252 DOI: 10.1177/0003134820979587] [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
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.
Collapse
Affiliation(s)
- David V Feliciano
- Department of Surgery, 12264University of Maryland School of Medicine, MD, USA
| |
Collapse
|
33
|
Romeo L, Bagolini F, Ferro S, Chiozza M, Marino S, Resta G, Anania G. Laparoscopic surgery for splenic injuries in the era of non-operative management: current status and future perspectives. Surg Today 2020; 51:1075-1084. [PMID: 33196920 PMCID: PMC8215029 DOI: 10.1007/s00595-020-02177-2] [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: 04/22/2020] [Accepted: 09/12/2020] [Indexed: 11/28/2022]
Abstract
The spleen is one of the organs most commonly injured by blunt abdominal trauma. It plays an important role in immune response to infections, especially those sustained by encapsulated bacteria. Nonoperative management (NOM), comprising clinical and radiological observation with or without angioembolization, is the treatment of choice for traumatic splenic injury in patients who are hemodynamically stable. However, this strategy carries a risk of failure, especially for high-grade injuries. No clear predictors of failure have been identified, but minimally invasive surgery for splenic injury is gaining popularity. Laparoscopic surgery has been proposed as an alternative to open surgery for hemodynamically stable patients who require surgery, such as after failed NOM. We reviewed research articles on laparoscopic surgery for hemodynamically stable patients with splenic trauma to explore the current knowledge about this topic. After presenting an overview of the treatments for splenic trauma and the immunological function of the spleen, we try to identify the future indications for laparoscopic surgery in the era of NOM.
Collapse
Affiliation(s)
- Luigi Romeo
- Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.
| | - Francesco Bagolini
- Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Silvia Ferro
- Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Matteo Chiozza
- Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Serafino Marino
- Department of Surgery, Surgery 1 Unit, Sant'Anna University Hospital, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Giuseppe Resta
- Department of Surgery, Surgery 1 Unit, Sant'Anna University Hospital, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Gabriele Anania
- Department of Morphology, Surgery and Experimental Medicine, Sant'Anna University Hospital, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.,Department of Surgery, Surgery 1 Unit, Sant'Anna University Hospital, Via Aldo Moro 8, 44124, Ferrara, Italy
| |
Collapse
|
34
|
Sodagari F, Katz DS, Menias CO, Moshiri M, Pellerito JS, Mustafa A, Revzin MV. Imaging Evaluation of Abdominopelvic Gunshot Trauma. Radiographics 2020; 40:1766-1788. [DOI: 10.1148/rg.2020200018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
35
|
Bankhead-Kendall B, Teixeira P, Musonza T, Donahue T, Regner J, Harrell K, Brown CVR. Risk Factors for Failure of Splenic Angioembolization: A Multicenter Study of Level I Trauma Centers. J Surg Res 2020; 257:227-231. [PMID: 32861100 DOI: 10.1016/j.jss.2020.07.058] [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: 02/28/2020] [Revised: 07/02/2020] [Accepted: 07/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Angioembolization (AE) is an adjunct to nonoperative management (NOM) of splenic injuries. We hypothesize that failure of AE is associated with blood transfusion, grade of injury, and technique of AE. METHODS We performed a retrospective (2010-2017) multicenter study (nine Level I trauma centers) of adult trauma patients with splenic injuries who underwent splenic AE. Variables included patient physiology, injury grade, transfusion requirement, and embolization technique. The primary outcome was NOM failure requiring splenectomy. Secondary outcomes were mortality, complications, and length of stay. RESULTS A total of 409 patients met inclusion criteria; only 33 patients (8%) required delayed splenectomy. Patients who failed received more blood in the first 24 h (P = 0.009) and more often received massive transfusion (P = 0.01). There was no difference in failure rates for grade of injury, contrast blush on computed tomography, and branch embolized. After logistic regression, transfusion in the first 24 h was independently associated with failure of NOM (P = 0.02). Patients who failed NOM had more complications (P = 0.002) and spent more days in the intensive care unit (P < 0.0001), on the ventilator (P = 0.0001), and in the hospital (P < 0.0001). Patients who failed NOM had a higher mortality (15% versus 3%, P = 0.007), and delayed splenectomy was independently associated with mortality (odds ratio, 4.2; 95% confidence interval, 1.2-14.7; P = 0.03). CONCLUSIONS AE for splenic injury leads to effective NOM in 92% of patients. Transfusion in the first 24 h is independently associated with failure of NOM. Patients who required a delayed splenectomy suffered more complications and had higher hospital length of stay. Failure of NOM is independently associated with a fourfold increase in mortality.
Collapse
Affiliation(s)
- Brittany Bankhead-Kendall
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas at Austin, Austin, Texas.
| | - Pedro Teixeira
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas at Austin, Austin, Texas
| | | | - Tim Donahue
- University of Texas Health Science Center in Houston, Houston, Texas
| | | | | | - Carlos V R Brown
- Department of Surgery and Perioperative Care, Dell Seton Medical Center at the University of Texas at Austin, Austin, Texas
| | | |
Collapse
|
36
|
Leung E, Maingard J, Yeh J, Lee MJ, Brooks DM, Asadi H, Burrows DA, Kok HK. Contemporary endovascular management of splenic vascular pathologies. Clin Radiol 2020; 75:960.e23-960.e34. [PMID: 32819705 DOI: 10.1016/j.crad.2020.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 07/06/2020] [Indexed: 11/28/2022]
Abstract
The spleen is a commonly injured organ and the splenic vasculature is also susceptible to inflammation and trauma, often resulting in aneurysm formation. Splenic artery aneurysms carry a high risk of rupture and are associated with high mortality and morbidity. Due to the advances in endovascular techniques and devices, endovascular management of splenic vascular pathologies is now considered a first-line strategy. Endovascular embolisation and advance techniques including balloon- or stent-assisted coil embolisation enables minimally invasive management option while preserving splenic function.
Collapse
Affiliation(s)
- E Leung
- Interventional Radiology Service - Department of Radiology, Northern Health, Melbourne, Australia.
| | - J Maingard
- Interventional Neuroradiology Service - Monash Imaging, Monash Health, Melbourne, Australia; School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia
| | - J Yeh
- Interventional Radiology Service - Department of Radiology, Northern Health, Melbourne, Australia
| | - M J Lee
- Department of Radiology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - D M Brooks
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia; Interventional Neuroradiology Service - Radiology Department, Austin Hospital, Melbourne, Australia
| | - H Asadi
- Interventional Neuroradiology Service - Monash Imaging, Monash Health, Melbourne, Australia; School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia; Interventional Neuroradiology Service - Radiology Department, Austin Hospital, Melbourne, Australia
| | - D A Burrows
- Interventional Radiology Service - Department of Radiology, Northern Health, Melbourne, Australia
| | - H K Kok
- Interventional Radiology Service - Department of Radiology, Northern Health, Melbourne, Australia; School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia
| |
Collapse
|
37
|
Rani S, Sharma N, Takkar N. Conservative Management of a Splenic Injury in Second Trimester of Pregnancy. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2019.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Shikha Rani
- Department of Obstetrics and Gynecology, Government Medical College and Hospital, Chandigarh, India
| | | | - Navneet Takkar
- Department of Obstetrics and Gynecology, Government Medical College and Hospital, Chandigarh, India
| |
Collapse
|
38
|
Salottolo K, Madayag RM, O'Brien M, Yon J, Tanner A, Topham A, Lieser M, Carrick MM, Mains CW, Bar-Or D. Quantity of hemoperitoneum is associated with need for intervention in patients with stable blunt splenic injury. Trauma Surg Acute Care Open 2020; 5:e000406. [PMID: 32154378 PMCID: PMC7046947 DOI: 10.1136/tsaco-2019-000406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/27/2019] [Accepted: 12/23/2019] [Indexed: 11/03/2022] Open
Abstract
Background In patients with hemodynamically stable blunt splenic injury (BSI), there is no consensus on whether quantity of hemoperitoneum (HP) is a predictor for intervention with splenic artery embolization (SAE) or failing nonoperative management (fNOM). We sought to analyze whether the quantity of HP was associated with need for intervention. Methods This retrospective cohort study included adult trauma patients with hemodynamically stable BSI admitted to six trauma centers between 2014 and 2016. Quantity of HP was defined as small (perisplenic blood or blood in Morrison's pouch), moderate (blood in one or both pericolic gutters), or large (additional finding of free blood in the pelvis). Multivariate logistic regression was performed to identify predictors of intervention with SAE or fNOM versus successful observation. Results There were 360 patients: hemoperitoneum was noted in 214 (59%) patients, of which the quantity was small in 92 (43%), moderate in 76 (35.5%), and large in 46 (21.5%). Definitive management was as follows: 272 (76%) were observed and 88 (24%) had intervention (83 SAE, 5 fNOM). The rate of intervention was univariately associated with quantity of HP, even after stratification by American Association for the Surgery of Trauma (AAST) grade. After adjustment, larger quantities of HP significantly increased odds of intervention (p=0.01). Compared with no HP, the odds of intervention were significantly increased for moderate HP (OR=3.51 (1.49 to 8.26)) and large HP (OR=2.89 (1.03 to 8.06)), with similar odds for small HP (OR=1.21 (0.46 to 2.76)). Other independent predictors of intervention were higher AAST grade, older age, and presence of splenic vascular injury. Conclusion Greater quantity of HP was associated with increased odds of intervention, with no difference in risk for moderate versus large HP. These findings suggest quantity of HP should be incorporated in the management algorithm of BSI as a consideration for angiography and/or embolization to maximize splenic preservation and reduce the risk of splenic rupture. Level of evidence III, retrospective epidemiological study.
Collapse
Affiliation(s)
- Kristin Salottolo
- Trauma Research, Swedish Medical Center, Englewood, Colorado, USA.,St. Anthony Hospital, Lakewood, Colorado, USA.,Penrose-St. Francis Health Services, Colorado Springs, Colorado, USA.,Radiology, Wesley Medical Center Trauma Services, Wichita, Kansas, USA.,Trauma Services, Research Medical Center, Kansas City, Missouri, USA.,Medical Center of Plano, Plano, Texas, USA
| | | | - Michael O'Brien
- Penrose-St. Francis Health Services, Colorado Springs, Colorado, USA
| | - James Yon
- Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
| | - Allen Tanner
- Penrose-St. Francis Health Services, Colorado Springs, Colorado, USA
| | - Andrew Topham
- Radiology, Wesley Medical Center Trauma Services, Wichita, Kansas, USA
| | - Mark Lieser
- Trauma Services, Research Medical Center, Kansas City, Missouri, USA
| | | | | | - David Bar-Or
- Trauma Research, Swedish Medical Center, Englewood, Colorado, USA.,St. Anthony Hospital, Lakewood, Colorado, USA.,Penrose-St. Francis Health Services, Colorado Springs, Colorado, USA.,Radiology, Wesley Medical Center Trauma Services, Wichita, Kansas, USA.,Trauma Services, Research Medical Center, Kansas City, Missouri, USA.,Medical Center of Plano, Plano, Texas, USA
| |
Collapse
|
39
|
Odedra D, Mellnick V, Patlas M. A 2019 international survey to assess trends in follow-up imaging of blunt splenic trauma. Emerg Radiol 2019; 27:51-56. [PMID: 31691876 DOI: 10.1007/s10140-019-01734-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE There are no published guidelines on the follow-up imaging of non-operatively managed blunt splenic trauma (BST). We conducted an international survey of emergency radiologists to determine the ideal patient population, time period, and technique for follow-up imaging of BST. METHODS An anonymous 10-question online survey was distributed via email to 34 emergency radiologists around the world. The survey was open for a 2-week period in 2019. A commercially available website (SurveyMonkey®) was used for survey generation and data acquisition. RESULTS We received 29 responses (85% response rate) primarily from USA, Canada, and Europe. Majority of the institutions handled > 1000 trauma cases (69%). The initial protocol consisted of arterial and portal venous phases (PVP) in 72% of responses. Sixty-two percent of the institutions did not have a routine protocol for follow-up imaging of BST. There was no consensus on which patients received follow-up imaging. The most frequent responses had been case-per-case basis or injuries above a set AAST grade (42% and 37%, respectively). There was no set time period for follow-up imaging, but MDCT was most often performed at 24-48 h. Dual-phase protocol was utilized most commonly (69%). Majority of the institutions (88%) utilized angioembolization for hemodynamically stable patients with contained vascular injury or active extravasation. CONCLUSION There is no consensus on the optimal patient population or time period for follow-up imaging of BST. A dual-phase follow-up MDCT protocol is utilized for follow-up by majority of institutions.
Collapse
Affiliation(s)
- Devang Odedra
- Department of Radiology, McMaster Universitiy, 237 Barton St. E., Hamilton, ON, L8L 2X2, Canada.
| | - Vincent Mellnick
- Abdominal Imaging Division, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8131, St. Louis, MO, 63110, USA
| | - Michael Patlas
- Division of Emergency/Trauma Radiology, McMaster University, 237 Barton St. E., Hamilton, ON, L8L 2X2, Canada.,Department of Radiology, Hamilton General Hospital, 237 Barton St. E, Hamilton, ON, L8L 2X2, Canada
| |
Collapse
|
40
|
Lin B, Matsushima K, De Leon L, Piccinini A, Recinos G, Love B, Inaba K, Demetriades D. Early Venous Thromboembolism Prophylaxis for Isolated High-Grade Blunt Splenic Injury. J Surg Res 2019; 243:340-345. [DOI: 10.1016/j.jss.2019.05.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/23/2019] [Accepted: 05/30/2019] [Indexed: 11/30/2022]
|
41
|
Hsieh TM, Liu CT, Wu BY, Hsieh CH. Reply letter to the commentary on "Is strict adherence to the nonoperative management protocol associated with better outcome in patients with blunt splenic injuries?: A retrospective comparative cross-sectional study" Int J Surg 2019;69:116-123. Int J Surg 2019; 72:45-46. [PMID: 31593775 DOI: 10.1016/j.ijsu.2019.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 09/27/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Ting-Min Hsieh
- Division of Trauma, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan.
| | - Chun-Ting Liu
- Department of Chinese Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan.
| | - Bei-Yu Wu
- Department of Chinese Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan.
| | - Ching-Hua Hsieh
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan.
| |
Collapse
|
42
|
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.
Collapse
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
| |
Collapse
|
43
|
Harmon L, Bilow R, Shanmuganathan K, Lauerman M, Todd SR, Cardenas J, Haugen CE, Albrecht R, Pittman S, Cohen M, Kaups K, Dirks R, Burlew CC, Fox CJ, Con J, Inaba K, Harrison PB, Berg GM, Waller CJ, Kallies KJ, Kozar RA. Delayed splenic hemorrhage: Myth or mystery? A Western Trauma Association multicenter study. Am J Surg 2019; 218:579-583. [PMID: 31284948 DOI: 10.1016/j.amjsurg.2019.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/17/2019] [Accepted: 06/29/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Multi-detector computed tomography imaging is now the reference standard for identifying solid organ injuries, with a high sensitivity and specificity. However, delayed splenic hemorrhage (DSH), defined as no identified injury to the spleen on the index scan but delayed bleeding from a splenic injury, has been reported. We hypothesized that the occurrence of DSH would be minimized by utilization of modern imaging techniques. METHODS Data was retrospectively collected from 2006 to 2016 in 12 adult Level I and II trauma centers. All patients had an initial CT scan demonstrating no splenic injury but subsequently were diagnosed with splenic bleeding. Demographic, injury characteristics, imaging parameters and results, interventions and outcomes were collected. RESULTS Of 6867 patients with splenic injuries, 32 cases (0.4%) of blunt splenic hemorrage were identified. Patients were primarily male, had blunt trauma, severely injured (ISS 32 (9-57) and with associated injuries. Injuries of all grades were identified up to 16 days following admission. Overall, half of patients required splenectomy. All index images were obtained using multi-detector CT (16-320 slice). Secondary review of imaging by two trauma radiologists judged 72% (n = 23) of scans as suboptimal. This was due to poor scan quality primary from artifact(23), single phase contrast imaging (16), and/or poor contrast bolus timing or volume (6). Notably, only 28% of scans in patients with DSH were performed with optimal scanning techniques. CONCLUSION This is the largest reported series of DSH in the era of modern imaging. Although the incidence of DSH is low, it still occurs despite the use of multi-detector imaging and when present, is associated with a high rate of splenectomy. Most cases of DSH can be attributed to missed diagnosis from suboptimal index imaging and ultimately be avoided.
Collapse
Affiliation(s)
- Laura Harmon
- Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA.
| | - Ronald Bilow
- Department of Radiology, UTHealth McGovern Medical School, Houston, TX, USA.
| | - Kathirkama Shanmuganathan
- Shock Trauma and Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Margret Lauerman
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore MD, USA.
| | - S Rob Todd
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
| | - Justin Cardenas
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
| | | | | | | | - Mitchell Cohen
- University of Colorado, Denver Health Medical Center, Denver CO, USA.
| | | | | | | | - Charles J Fox
- University of Colorado, Denver Health Medical Center, Denver CO, USA.
| | - Jorge Con
- Department of Surgery, New York Medical College-Westchester, Valhalla, NY, USA.
| | - Kenji Inaba
- University of Southern California, Los Angeles County, Los Angeles, CA, USA.
| | | | - Gina M Berg
- Wesley Medical Center Trauma Services, Wichita, KS, USA.
| | | | | | - Rosemary Ann Kozar
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore MD, USA.
| |
Collapse
|
44
|
Gilmartin S, Hatton S, Ryan J. Teenage kicks: splenic rupture secondary following infectious mononucleosis. BMJ Case Rep 2019; 12:12/5/e229030. [PMID: 31133551 DOI: 10.1136/bcr-2018-229030] [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: 11/03/2022] Open
Abstract
A 16-year-old man was brought to the emergency department by his father with apparent alcohol intoxication. While in the department, it was noted that the patient had ongoing tachycardia, hypotension and abdominal pain. His recent medical history included a self-resolving illness of fatigue, muscle aches and sore throat. A CT scan of his abdomen revealed an enlarged spleen with a splenic infarct and rupture, likely secondary to infectious mononucleosis. The patient was treated conservatively for 12 days.
Collapse
Affiliation(s)
- Stephen Gilmartin
- Emergency Department, St Vincent's University Hospital, Dublin, Ireland
| | - Stephen Hatton
- Emergency Department, St Vincent's University Hospital, Dublin, Ireland
| | - John Ryan
- Emergency Department, St Vincent's University Hospital, Dublin, Ireland
| |
Collapse
|
45
|
Tagliati C, Argalia G, Graziani B, Salmistraro D, Giuseppetti GM, Giovagnoni A. Contrast-enhanced ultrasound in the evaluation of splenic injury healing time and grade. Radiol Med 2018; 124:163-169. [DOI: 10.1007/s11547-018-0954-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 10/18/2018] [Indexed: 12/11/2022]
|
46
|
Wang KY, Abbassi O, Warsi A. Delayed presentation of iatrogenic splenic injury 21 days after laparoscopic donor left nephrectomy. BMJ Case Rep 2018; 2018:bcr-2018-224712. [PMID: 29909389 DOI: 10.1136/bcr-2018-224712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report the case of a 46-year-old woman who had presented with left-sided abdominal pain 21 days after undergoing a left-sided laparoscopic nephrectomy for donation. Initial haemoglobin and haematocrit levels were within normal range, and vital signs on admission were unremarkable. Significant intra-abdominal pathology was not suspected; however, inpatient CT scan of the abdomen showed a posterolateral subcapsular splenic haematoma with free abdominal fluid. Initial trial of conservative management was not successful as the patient became hypotensive on the third day of admission with a sudden decrease in haemoglobin and haematocrit. The patient was immediately taken to theatre for laparotomy and splenectomy. Recovery was uneventful and was discharged home on the fifth postoperative day. In this article, we aim to discuss several important clinical lessons involving iatrogenic injury of the spleen, its management, and diagnosis of acute and severe haemorrhage.
Collapse
Affiliation(s)
| | - Omar Abbassi
- General Surgery, Furness General Hospital, Barrow-in-Furness, UK
| | - Ali Warsi
- General Surgery, Furness General Hospital, Barrow-in-Furness, UK
| |
Collapse
|