Non operative management of liver and spleen traumatic injuries: a giant with clay feet

Role of laparoscopic surgery in managing hemodynamically stable abdominal trauma patients: a single level I trauma center, propensity score matching study

BACKGROUND

The role of laparoscopy in the treatment and diagnosis of penetrating thoraco-abdominal injury has been established. However, there is no clear consensus on the role of laparoscopy in blunt injury due to numerous reasons, such as concerns of missed injury and technical problems in treating various abdominal organs. This study aimed to determine the feasibility of laparoscopy and evaluate its safety in managing blunt and penetrating abdominal trauma.

METHODS

The medical records and Korean Trauma Data Base (KTDB) of patients who underwent abdominal surgery from January 2018 to December 2022 at a single level I center were collected. Patients were classified into a laparoscopy group and a laparotomy group. The laparoscopy groups were matched 1:1 with the laparotomy group by using propensity score matching (PSM). Patient demographics, injured organ and its grade, operative procedure, and postoperative outcomes were evaluated and compared between the two groups.

RESULTS

After propensity score matching, 128 patients were included. There was no significant imbalance in demographics between the two groups except sex. Injured organ and its grade showed no significant differences between the two groups except for the incidence of omentum. Small bowel and mesenteric repair were performed most often in both groups. Splenectomy, pancreatic surgery, duodenectomy, and liver resection were performed exclusively in the laparotomy group. Severe postoperative complication rate (3% vs. 20%: p = 0.004), length of stay in ICU (3.3 ± 3.2 days vs. 4.6 ± 3.7; p = 0.046), and operation time (93.9 ± 47.7 min vs. 112.8 ± 57.7; p = 0.046) were significantly lower in the laparoscopy group. The conversion rate was about 16%. There was no missed injury.

CONCLUSIONS

In hemodynamically stable abdominal trauma patients who sustained penetrating or blunt injury, laparoscopy is feasible and safe as a diagnostic and therapeutic modality in selected cohort of abdominal trauma.

Importance of Anatomical Variation of the Hepatic Artery for Complicated Liver and Pancreatic Surgeries: A Review Emphasizing Origin and Branching

Knowledge of anatomical variations of the hepatic artery from its origin to intrahepatic segmentation is of utmost importance for planning upper abdominal surgeries including liver transplantation, pancreatoduodenectomy, and biliary reconstruction. The origin and branching pattern of the hepatic artery was thoroughly described by the classification of Michels and Hiatt. Some rare variations of the hepatic artery were classified by Kobayashi and Koops. By the use of the multidetector computed tomography (MDCT) technique, the branching pattern of the hepatic artery can be visualized quite accurately. Unawareness of these arterial variations may lead to intraoperative injuries such as necrosis, abscess, and failure of the liver and pancreas. The origin and course of the aberrant hepatic arteries are crucial in the surgical planning of carcinoma of the head of the pancreas and hepatobiliary surgeries. In liver transplant surgeries, to minimize intraoperative bleeding complications and postoperative thrombosis, exact anatomy of the branching of the hepatic artery, its variations and intrahepatic course is of utmost importance. This review discusses variations in the anatomy of the hepatic artery from its origin to branching by the use of advanced imaging techniques and its effect on the liver, pancreatic, biliary and gastric surgeries.

Utility of microporous polysaccharide hemospheres in severe hepatic trauma: Experimental study of hemostatic strength and ease of use

BACKGROUND

Animal studies confirm the utility of hemostatics against standard packing following severe liver injury. We investigated the efficacy and ease of use of novel microporous polysaccharide hemosphere (MPH) compounds (Perclot®, Baxter) in the treatment of severe hepatic hemorrhage in pig.

METHODS

Pigs were randomized to one of two equal treatment groups: MPH compounds (n=12) and Standard Packing (n=12). All animals underwent standardized surgical devascularization of the suprahepatic veins (grade V) to induce severe hepatic injury. Measures relating to the hemostatic success were monitored at 12, 60, 120 minutes and 24 hours post injury.

RESULTS

Animals allocated to treatment with MPH compounds were associated with higher survival rates at 24 hours than those undergoing standard packing: 66.7% vs, 0%, respectively (p=0.001). At 120 minutes MPH compounds were also associated with reduced blood loss, median (IQR) 1.16 (0.60) vs. 10.19 (5.77) mL/Kg, respectively: p<0.001) as well as higher invasive mean arterial pressures (iMAP) median (IQR) 39.12 (11.29) vs. 25.75 (14.28) mmHg, respectively: p=0.14) and hemoglobin levels median (IQR) 5.45 (2.50) vs. 6.45 (1.73) g/dL, respectively p=0.127). Overall, the application of MPH compounds required nearly half the time of standard packing median (IQR) 32.92 (6.51) vs. 67.75 (14.66) sec, respectively: p<0.001).

CONCLUSIONS

The data suggests that the use of MPH works in a severe hemorrhage in the liver of pigs, improving many variables in comparison to standard packing, including survival, blood loss and speed of application and we conclude that this offers a potential alternative for the treatment of hepatic injury. Further work is needed to corroborate these findings.

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

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

Traumatic bruising of the hepatoduodenal ligament can conceal a catastrophic injury to the hepatic artery

We present the case of a 22-year-old man transferred to the regional major trauma centre following a fall of ~15 m. He remained consistently haemodynamically stable for over 10 hours of observation until he deteriorated suddenly with major haemorrhagic shock requiring immediate trauma laparotomy. At laparotomy, 2 L of blood was drained from the abdomen but no source of active bleeding identified. 30 minutes after closure of the abdomen, 500 mL of fresh blood was noted in the drain so he was returned to the theatre where the bleeding source was found to be-after manual compression of a mildly bruised hepatoduodenal ligament-the proper hepatic artery (PHA). This case describes an unusual finding at relaparotomy and shows that even when there is no active bleeding from abdominal organs or classified vessels, it is possible to have isolated injury to PHA.

Contemporary management and prognosis of great vessels trauma

BACKGROUND

Great vessel trauma (GVT), which is defined as trauma to the aorta or vena cava, remains one of the most challenging injuries to treat and has a high mortality rate despite advances in modern medicine. Additionally, the optimal management of GVT is controversial. In this study, we review the incidence, management, and outcome of GVT, identify the current status and prognostic factors of GVT, and compare treatment outcomes.

METHODS

We conducted a retrospective, single-center, cohort study of patients with GVT in a Level I trauma center from August 2008 to December 2013. We retrieved demographic data, physical and imaging findings, injury severity score (ISS), treatment choice, length of hospital stay, and mortality. We analyzed the risks of adverse outcomes and mortality.

RESULTS

The seventy-four patients in this cohort had a mean age of 41.6 (SD 17.7) years and a high mortality rate of 27%. The prognostic factors of survival with GVT included male gender, lower ISS, higher GCS, higher SBP and DBP and vena caval injuries. We also determined that vena caval injury is the main factor that can predict mortality.

CONCLUSION

In conclusion, GVT is relatively rare but often lethal in clinical practice. Patient survival depends on injury severity and the shock status grade. Aggressive resuscitation and treatment play important roles in survival. The coordination of different levels of surgical expertise and the application of novel treatment methods are required to improve clinical outcomes for patients with vena caval injuries.

Liver trauma: What current management?

BACKGROUND

The liver is the most commonly damaged organ in abdominal trauma. The management of liver trauma has experienced many changes over the last two decades. Currently there is a trend toward a non-operative treatment warranted by the successful pediatric experience and better results recorded in many trauma centers worldwide. This study aimed to evaluate outcomes of operative and non-operative management of liver trauma in our institution over the last five years.

METHODS

The patients with a diagnosis of blunt or penetrating liver injuries, admitted and managed in our hospital from January 2012 to December 2016 were retrospectively studied. The patients were divided into 2 groups, operated and non-operated groups, according to the initial management considered appropriate at the time of patient admission. Clinical features and outcomes were analyzed.

RESULTS

The study involved 83 patients, with a mean age of 33 years and a marked male predominance (85.5%). The most common type of lesions was blunt trauma and the main cause was road traffic accidents. Sixty-eight liver injuries (81.9%) were of low severity (grades I, II, III), while 15 (18.1%) were of high severity (grade IV or greater). Fifty-six patients (67.5%) had multiple injuries. Surgical treatment was performed in 26 (31.3%) patients. Non-operative management was undertaken in 57 cases (68.7%). The morbidity and mortality rates were clearly lower in non-operative patients compared to those in the operated group.

CONCLUSIONS

Careful non-operative management is an adequate therapeutic strategy for the patients suffering from liver trauma with stable hemodynamics. Patients with complex hepatic trauma and especially those with other organ injuries continue to have significantly higher mortality.

[Approach to liver, spleen and pancreatic injuries including damage control surgery of terrorist attacks]

BACKGROUND

Terrorist attacks have outreached to Europe with more and more attacks on civilians. Derived from war surgery experience and from lessons learned from major incidents, it seems mandatory for every surgeon to improve understanding of the special circumstances of trauma following a terrorist attack and its' management.

METHOD

A short literature review is followed by outlining the damage control surgery (DCS) principle for each organ system with practical comments from the perspective of a specialized hepatobiliary (HPB) surgery unit.

CONCLUSION

Every surgeon has to become familiar with the new entities of blast injuries and terrorist attack trauma. This concerns not only the medical treatment but also tailoring surgical treatment with a view to a lack of critical resources under these circumstances. For liver and pancreatic trauma, simple treatment strategies are a key to success.

Clinical and Radiological Presentations and Management of Blunt Splenic Trauma: A Single Tertiary Hospital Experience

BACKGROUND Splenic injury is the leading cause of major bleeding after blunt abdominal trauma. We examined the clinical and radiological presentations, management, and outcome of blunt splenic injuries (BSI) in our institution. MATERIAL AND METHODS A retrospective study of BSI patients between 2011 and 2014 was conducted. We analyzed and compared management and outcome of different splenic injury grades in trauma patients. RESULTS A total of 191 BSI patients were identified with a mean (SD) age of 26.9 years (13.1); 164 (85.9%) were males. Traffic-related accident was the main mechanism of injury. Splenic contusion and hematoma (77.2%) was the most frequent finding on initial computerized tomography (CT) scans, followed by shattered spleen (11.1%), blush (11.1%), and devascularization (0.6%). Repeated CT scan revealed 3 patients with pseudoaneurysm who underwent angioembolization. Nearly a quarter of patients were managed surgically. Non-operative management failed in 1 patient who underwent splenectomy. Patients with grade V injury presented with higher mean ISS and abdominal AIS, required frequent blood transfusion, and were more likely to be FAST-positive (p=0.001). The majority of low-grade (I-III) splenic injuries were treated conservatively, while patients with high-grade (IV and V) BSI frequently required splenectomy (p=0.001). Adults were more likely to have grade I, II, and V BSI, blood transfusion, and prolonged ICU stay as compared to pediatric BSI patients. The overall mortality rate was 7.9%, which is mainly association with traumatic brain injury and hemorrhagic shock; half of the deaths occurred within the first day after injury. CONCLUSIONS Most BSI patients had grade I-III injuries that were successfully treated non-operatively, with a low failure rate. The severity of injury and presence of associated lesions should be carefully considered in developing the management plan. Thorough clinical assessment and CT scan evaluation are crucial for appropriate management of BSI.

Current approach to liver traumas

INTRODUCTION

Liver injuries remain major obstacle for successful treatment, due to size and location of the liver. Requirement for surgery should be determined by clinical factors, most notably hemodynamical state. In this present study we tried to declare our approach to liver traumas. We also tried to emphasize the importance of conservative treatment, since surgeries for liver traumas carry high mortality rates.

PRESENTATION OF CASE

Patients admitted to the Department of Emergency Surgery at Kartal Research and Education Hospital, due to liver trauma were retrospectively analyzed between 2003 and 2013. Patient demographics, hepatic panel, APTT (activated partial thromboplastin time), PT (prothrombin time), INR (international normalized ratio), fibrinogen, biochemistry panel were recorded. Hemodynamic instability was the most prominent factor for surgery decision, in the lead of current Advanced Trauma Life Support (ATLS) protocols. Operation records and imaging modalities revealed liver injuries according to the Organ Injury Scale of the American Association for the Surgery of Trauma. 300 patients admitted to emergency department were included in our study (187 males and 113 females). Mean age was 47 years (range, 12-87). The overall mortality rate was 13% (40 out of 300). Major factor responsible for mortality rates and outcome was stability of cases on admission. 188 (% 63) patients were counted as stable, whereas 112 (% 37) cases were found unstable (blood pressure ≤ 90, after massive resuscitation). 192 patients were observed conservatively, whereas 108 cases received abdominal surgery. High levels of AST, ALT, LDH, INR, creatinine and low levels of fibrinogen and low platelet counts on admission were found to be associated with mortality and these cases also had Grade 4 and 5 injuries. Hemodynamic instability on admission and the type and grade of injury played major role in mortality rates). Packing was performed in 35 patients, with Grade 4 and 5 injuries. Mortality rate was %13 (40 out of 300).

CONCLUSION

A multidisciplinary approach to the management of hepatic injuries has evolved over the last few decades, but the basic principles of trauma continue to be observed. Diagnostic and therapeutic endeavors are chosen based mainly on the stability of the patient. Stable patients with reliable examinations and available resources can be managed nonoperatively. Unstable patients require surgery. Our current approach to liver traumas is non operative technique, if possible.

Liver trauma: WSES position paper

The liver is the most injured organ in abdominal trauma. Road traffic crashes and antisocial, violent behavior account for the majority of liver injuries. The present position paper represents the position of the World Society of Emergency Surgery (WSES) about the management of liver injuries.

Alcohol-related hospitalizations of adult motorcycle riders

OBJECTIVE

To provide an overview of the demographic characteristics of adult motorcycle riders with alcohol-related hospitalizations.

METHODS

Data obtained from the Trauma Registry System were retrospectively reviewed for trauma admissions at a level I trauma center between January 1, 2009 and December 31, 2013. Out of 16,548 registered patients, detailed information was retrieved regarding 1,430 (8.64%) adult motorcycle riders who underwent a blood alcohol concentration (BAC) test. A BAC level of 50 mg/dL was defined as the cut-off value for alcohol intoxication.

RESULTS

In this study, alcohol consumption was more frequently noted among male motorcycle riders, those aged 30-49 years, those who had arrived at the hospital in the evening or during the night, and those who did not wear a helmet. Alcohol consumption was associated with a lower percentage of sustained severe injury (injury severity score ≥25) and lower frequencies of specific body injuries, including cerebral contusion (0.6; 95% confidence interval [CI] = 0.42-0.80), lung contusion (0.5; 95% CI = 0.24-0.90), lumbar vertebral fracture (0.1; 95% CI = 0.01-0.80), humeral fracture (0.5; 95% CI = 0.27-0.90), and radial fracture (0.6; 95% CI = 0.40-0.89). In addition, alcohol-intoxicated motorcycle riders who wore helmets had significantly lower frequencies of cranial fracture (0.4; 95% CI = 0.29-0.67), epidural hematoma (0.5; 95% CI = 0.29-0.79), subdural hematoma (0.4; 95% CI = 0.28-0.64), subarachnoid hemorrhage (0.5; 95% CI = 0.32-0.72), and cerebral contusion (0.4; 95% CI = 0.25-0.78).

CONCLUSIONS

Motorcycle riders who consumed alcohol presented different characteristics and bodily injury patterns relative to sober patients, suggesting the importance of helmet use to decrease head injuries in alcohol-intoxicated riders.

Nonoperative management of blunt splenic injury in adults: there is (still) a long way to go. The results of the Bologna-Maggiore Hospital trauma center experience and development of a clinical algorithm

Non-operative management (NOM) of hemodynamically stable patients with blunt splenic injury (BSI) is the standard of care, although it is associated with a potential risk of failure. Hemodynamically unstable patients should always undergo immediate surgery and avoid unnecessary CT scans. Angioembolization might help to increase the NOM rates, as well as NOM success rates. The aim of this study was to review and critically analyze the data from BSI cases managed at the Maggiore Hospital Trauma Center during the past 5 years, with a focus on NOM, its success rates and outcomes. A further aim was to develop a proposed clinical practical algorithm for the management of BSI derived from Clinical Audit experience. During the period between January 1, 2009 and December 31, 2013 we managed 293 patients with splenic lesions at the Trauma Center of Maggiore Hospital of Bologna. The data analyzed included the demographics, clinical parameters and characteristics, diagnostic and therapeutic data, as well as the outcomes and follow-up data. A retrospective evaluation of the clinical outcomes through a clinical audit has been used to design a practical clinical algorithm. During the five-year period, 293 patients with BSI were admitted, 77 of whom underwent immediate surgical management. The majority (216) of the patients was initially managed non-operatively and 207 of these patients experienced a successful NOM, with an overall rate of successful NOM of 70 % among all BSI cases. The success rate of NOM was 95.8 % in this series. All patients presenting with stable hemodynamics underwent an immediate CT-scan; angiography with embolization was performed in 54 cases for active contrast extravasation or in cases with grade V lesions even in absence of active bleeding. Proximal embolization was preferentially used for high-grade injuries. After a critical review of the cases treated during the past 5 years during a monthly clinical audit meeting, a clinical algorithm has been developed with the aim of standardizing the clinical management of BSI by a multidisciplinary team to include every patient within the correct diagnostic and therapeutic pathway, in order to improve the outcomes by potentially decreasing the NOM failure rates and to optimize the utilization of resources.

Non-operative management attempted for selective high grade blunt hepatosplenic trauma is a feasible strategy

Background

There is growing evidence of clinical data recently for successful outcomes of non-operative management (NOM) for blunt hepatic and spleen injuries (BHSI). However, the effectiveness of NOM for high-grade BHSI remains undefined. The aim of the present study was to review our experience with NOM in high-grade BHSI and compare results with the existing related data worldwide.

Methods

In this retrospectively protocol-driven study, 150 patients with grade 3–5 BHSI were enrolled during a 3-year period. Patients were divided into immediate laparotomy (immediate OP) and initial non-operative (initial NOM) groups according to hemodynamic status judged by duty trauma surgeon. Patients who received initial NOM were divided into successful NOM (s-NOM) and failed NOM (f-NOM) subgroups according to conservative treatment failure. We analyzed the clinical characteristics and the outcomes of patients.

Results

Twenty-eight (18.7%) patients underwent immediate operations, and the remaining 122 (81.3%) were initially treated with NOM. Compared with the initial NOM group, the immediate OP group had significantly lower hemoglobin levels, a higher incidence of tube thoracostomy, contrast extravasation and large hemoperitoneum on computed tomography, a higher injury severity score, increased need for transfusions, and longer length of stay (LOS) in the intensive care unit (ICU) and hospitalization. Further analysis of the initial NOM group indicated that NOM had failed in 6 (4.9%) cases. Compared with the s-NOM subgroup, f-NOM patients had significantly lower hemoglobin levels, more hospitalized transfusions, and longer ICU LOS.

Conclusions

NOM of high-grade BHSI in selected patients is a feasible strategy. Notwithstanding, patients with initial low hemoglobin level and a high number of blood transfusions in the ICU are associated with a high risk for NOM failure.

Management of liver trauma in Kuwait

OBJECTIVES

The aim of this study was to introduce the concept of non-operative management (NOM) for blunt liver trauma by establishing a protocol and a prospective Liver Trauma Registry in Kuwait.

SUBJECTS AND METHODS

A prospective Liver Trauma Registry was started in 4 hospitals and it included 117 patients who had sustained blunt liver trauma (94 men and 23 women). Unstable patients were taken to surgery while stable patients were managed conservatively regardless of the grade of liver injury. High-grade (III-VI) liver injuries were managed in collaboration with the liver surgery specialist.

RESULTS

The mean age of the 117 patients was 29.02 ± 11.18 years (range 7-63). NOM was successful in 94 (96%) patients and failed in 4 (4%) (these 4 then underwent successful surgery). Nineteen (16.2%) were unstable and underwent surgery immediately; 15 (79%) of them survived (they had had grade III-V injuries) and 4 died (2 with grade V injuries and 2 with grade VI injuries). Perihepatic packing was necessary in 8/19 (42%) patients. The overall mortality was 3.4% (4/117).

CONCLUSIONS

This study showed that NOM was successful in a majority of patients with blunt liver trauma. In addition, it confirmed that the magnitude of liver injury and haemoperitoneum did not preclude NOM as long as the patient was haemodynamically stable.

Conservative management of major liver necrosis after angioembolization in a patient with blunt trauma

Management of liver injury is challenging particularly for the advanced grades. Increased utility of nonoperative management strategies increases the risk of developing massive liver necrosis (MLN). We reported a case of a 19-year-old male who presented with a history of motor vehicle crash. Abdominal computerized tomography (CT) scan revealed large liver laceration (Grade 4) with blush and moderate free hemoperitoneum in 3 quadrants. Patient was managed nonoperatively by angioembolization. Two anomalies in hepatic arteries origin were reported and both vessels were selectively cannulated and bilateral gel foam embolization was achieved successfully. The patient developed MLN which was successfully treated conservatively. The follow-up CT showed progressive resolution of necrotic areas with fluid replacement and showed remarkable regeneration of liver tissues. We assume that patients with high-grade liver injuries could be managed successfully with a carefully designed protocol. Special attention should be given to the potential major associated complications. A tailored multidisciplinary approach to manage the subsequent complications would represent the best recommended strategy for favorable outcomes.

The swinging pendulum: a national perspective of nonoperative management in severe blunt liver injury

BACKGROUND

Despite a shift toward nonoperative management (NOM) of blunt liver trauma, severe injuries continue to require operative management. Our objective was to examine current trends of NOM for severe blunt liver injury from a national perspective.

METHODS

Patients with blunt liver injury with Abbreviated Injury Scale (AIS) score of 4 or greater and no other major solid organ injury or pelvic fracture were identified in the National Trauma Data Bank 2002 to 2008. Attempted NOM was defined as no surgery in 6 hours or less. Failed NOM was defined as surgery in greater than 6 hours. Cox regression evaluated the association of NOM outcome with 30-day mortality after controlling for injury severity and center. Logistic regression was used to define independent predictors of failed NOM. Annual attempted and failed NOM rates were compared during the study period.

RESULTS

A total of 3,627 patients were identified with a median Injury Severity Score (ISS) of 29 (interquartile range, 20-38) and 20% mortality. Early operative management occurred in 20%, while initial NOM occurred in 73% of the patients. Of these, 93% had successful NOM, and 7% had failed NOM. Failed NOM was an independent predictor of mortality (hazard ratio, 1.7; 95% confidence interval, 1.1-2.6; p = 0.01). Increasing age, male sex, increasing ISS, decreasing Glasgow Coma Scale (GCS) score, hypotension, and hepatic angioembolization were independent predictors of failed NOM. The rate of attempted and failed NOM increased during the study period (p < 0.01).

CONCLUSION

NOM for isolated severe blunt liver injury is increasing nationally with similar increment in failure. Failed NOM was associated with higher mortality. Several predictors of failed NOM were identified including age, sex, ISS, GCS, and hypotension. These factors may allow for better patient selection and improved outcomes.

LEVEL OF EVIDENCE

Therapeutic study, level IV; prognostic/epidemiologic study, level III.

Is non-operative management safe and effective for all splenic blunt trauma? A systematic review

Introduction

The goal of non-operative management (NOM) for blunt splenic trauma (BST) is to preserve the spleen. The advantages of NOM for minor splenic trauma have been extensively reported, whereas its value for the more severe splenic injuries is still debated. The aim of this systematic review was to evaluate the available published evidence on NOM in patients with splenic trauma and to compare it with the operative management (OM) in terms of mortality, morbidity and duration of hospital stay.

Methods

For this systematic review we followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" statement. A systematic search was performed on PubMed for studies published from January 2000 to December 2011, without language restrictions, which compared NOM vs. OM for splenic trauma injuries and which at least 10 patients with BST.

Results

We identified 21 non randomized studies: 1 Clinical Controlled Trial and 20 retrospective cohort studies analyzing a total of 16,940 patients with BST. NOM represents the gold standard treatment for minor splenic trauma and is associated with decreased mortality in severe splenic trauma (4.78% vs. 13.5% in NOM and OM, respectively), according to the literature. Of note, in BST treated operatively, concurrent injuries accounted for the higher mortality. In addition, it was not possible to determine post-treatment morbidity in major splenic trauma. The definition of hemodynamic stability varied greatly in the literature depending on the surgeon and the trauma team, representing a further bias. Moreover, data on the remaining analyzed outcomes (hospital stay, number of blood transfusions, abdominal abscesses, overwhelming post-splenectomy infection) were not reported in all included studies or were not comparable, precluding the possibility to perform a meaningful cumulative analysis and comparison.

Conclusions

NOM of BST, preserving the spleen, is the treatment of choice for the American Association for the Surgery of Trauma grades I and II. Conclusions are more difficult to outline for higher grades of splenic injury, because of the substantial heterogeneity of expertise among different hospitals, and potentially inappropriate comparison groups.

Left thoracotomy utilizing splenectomy in blunt thoracic injury: An alternative surgical approach

INTRODUCTION

Posterolateral thoracotomy could be an alternative surgical approach in selected cases coexistence of abdominal injuries with ipsilateral thoracic injury.

PRESENTATION OF CASE

A 65-year-old male with left sided chest injury was initially admitted to a regional health center after a crawler overthrow accident. He underwent chest tube drainage of left hemithorax and he was transferred immediately to our hospital. A CT scan showed a large spleen which was injured by a wedged splint of the 10th rib into its parenchyma. Lung parenchyma was also lacerated by chest tube misplacement with associated hemothorax. He underwent a lower left lateral thoracotomy. Splenectomy was performed via a phrenotomy and subsequently the injured lung was repaired. His postoperative course was uneventful.

DISCUSSION

Incisions in the diaphragm are commonly made to provide adequate exposure during a variety of thoracic and abdominal operations. Thoracic approach could potentially be advantageous for thoracic and abdominal injuries.

CONCLUSION

Thoracic approach is a safe alternative, providing excellent exposure of upper abdominal organs, and should be considered in selected cases of abdominal trauma, especially when an ipsilateral thoracic injury coexists.