Splenic trauma: WSES classification and guidelines for adult and pediatric patients

Robotic assisted splenectomy after failure of splenic angioembolization in blunt abdominal trauma

Traumatic blunt splenic injury in the hemodynamically stable patient is initially managed with a nonoperative strategy that may include angioembolization. If patients continue to have ongoing signs of bleeding after angioembolization, definitive management is surgical splenectomy. We report the case of a patient with a grade IV blunt splenic injury who had ongoing bleeding after angioembolization and was taken for diagnostic robotic surgery. An isolated splenic injury was identified and the patient was treated with robotic splenectomy. On one month follow up the patient was noted to be doing well with minimal pain. To our knowledge, this is the first report of robotic splenectomy after failed non-operative manage in the setting of trauma. This case shows the potential value of robotic surgery to apply the benefits of minimally invasive surgery in hemodynamically stable patients who fail non-operative management after traumatic splenic injury.

Variation in paediatric splenic trauma management in adult and combined major trauma centres in England

AIM

Treatment options for paediatric splenic injuries include conservative management, splenic embolisation, and splenectomy. Within the UK, in addition to standalone paediatric trauma centres, adult and combined (adult and paediatric) major trauma centres (MTCs) receive traumatically injured children. We describe the treatment of paediatric splenic injuries between 2017 and 2021 in the United Kingdom adult and combined MTCs.

MATERIALS AND METHODS

Data were extracted from the Trauma Audit and Research Network (TARN) for all patients <18 years old with splenic injuries admitted between 01/01/17 and 31/12/21 at adult and combined MTCs. The relationship between injury and centre type, treatment, and outcomes was assessed using chi-squared and Fisher's exact tests.

RESULTS

A total of 690 children were included. The median age was 13.9 years (interquartile range: 10.9-16.1), and 78.7% (543/690) of the patients were male. A total of 92.9% (641/690) of patients suffered blunt injuries; 7.1% (49/690) suffered penetrating. Of those known, 69.5% (182/262) were treated in a combined MTC and 30.5% (80/262) at an adult MTC. Treatment included: A total of 90.4% (624/690) received conservative management, 5.5% (38/690) underwent splenic embolisation, and 4.1% (28/690) had a splenectomy. Embolisation and splenectomy rates at adult-only MTCs were 8.8% (7/80) and 10% (8/80), respectively, compared to 4.4% (8/182) and 1.6% (3/182) in combined MTCs (P = 0.002). No embolised patients required a subsequent splenectomy. The mortality rates were 8.8% (7/80) in adult and 3.3% (6/182) in combined centres (P = 0.118).

CONCLUSION

Embolisation is performed more (5.5%) than splenectomy (4.1%). Combined MTCs demonstrate superior outcomes and lower intervention rates than adult-only MTCs. These findings should inform strategies to standardise paediatric trauma care within the UK.

Contemporary management of adult splenic injuries: What you need to know

ABSTRACT

The spleen is a frequently injured organ, with over 40,000 adult splenic injuries occurring yearly. It plays an important role in the body's immune system, so surgeons should make every effort to perform splenic salvage when able. In blunt injury, indications for emergent splenectomy have not recently changed and include hemodynamic instability and peritonitis. A computed tomography (CT) scan with intravenous contrast is the preferred imaging modality for hemodynamically normal patients and should be used to classify the grade of injury and identify active bleeding and its stigmata. Nonoperative management has been successful for all grades of blunt injury (80-95%), but it is the job of the surgeon to carefully select the patient, in the context of their age, other associated injuries, and splenic CT findings, so this success rate remains high. Angioembolization is an important tool for splenic salvage that should be used when an actively bleeding vessel is observed on CT scan. Both proximal and distal embolizations are effective with no data to suggest that one is superior to the other. All patients selected for nonoperative management require close monitoring, which can include interval CT scans for high-grade injuries. Penetrating splenic injuries differ from blunt injuries because they are more likely to be surgically explored on presentation and they have a higher operative splenorrhaphy rate.

Who will be the bastions of pediatric trauma care?

The 2024 American College of Surgeons Point Counterpoint conference held in Baltimore, Maryland included a panel on pediatric trauma. The panelists included pediatric surgeons, a pediatric trauma nurse practitioner, a trauma pharmacist and a trauma surgeon. The discussion focused on unique clinical considerations for pediatric abdominal trauma, pharmacologic best practices and optimizing care models to incorporate pediatric and trauma surgeons. Points raised during panel discussion will be highlighted and expanded on in the following article, which is by no means meant to be a comprehensive review of pediatric trauma management but rather a discussion of important topics within the field.

Management of penetrating splenic trauma; is it different to the management of blunt trauma?

PURPOSE

We compare the treatment and outcomes of penetrating and blunt splenic trauma at Major Trauma Centres (MTC) within the UK.

METHODS

Data obtained from the national Trauma Audit Research Network database identified all eligible splenic injuries admitted to MTC within England between 01/01/17-31/12/21. Demographics, mechanism of injury, splenic injury classification, associated injuries, treatment, and outcomes were compared.

RESULTS

Penetrating injuries accounted for 5.9 % (235/3958) of splenic injuries, compared to blunt at 94.1 % (3723/3958). Most penetrating injuries (91.5 %, 215/235) resulted from stabbing. There was a statistically significant difference in first treatment between penetrating and blunt splenic injuries (p < 0.001), but similar trends between GSW and stab injuries. Most penetrating injuries were managed conservatively (68.9 %,162/235), with 10.6 % (25/235) embolized compared to 13.2 % (491/3723) for blunt splenic injury. More penetrating injuries (20.4 %, 48/235) underwent splenectomy compared to blunt injuries (8.8 %, 326/3723). Those receiving embolization after penetrating trauma had an 8.0 % (2/25) 30-day mortality compared with blunt at 8.6 % (42/491) and compared with 2.1 % (1/48) and 12.3 % (40/326) of those who received splenectomy in the penetrating and blunt groups, respectively. 8 out of the 25 penetrating trauma patients who underwent embolisation (32.0 %) required splenectomy due to embolisation failure compared to 5.3 % (26/491) in the blunt trauma group.

CONCLUSION

A trend is seen towards the use of operative management in penetrating splenic trauma. There is a high splenic embolisation failure rate (32.0 %) in penetrating trauma although mortality for those embolised was similar to the blunt injury group.

Tertiary butylhydroquinone regulates oxidative stress in spleen injury induced by gas explosion via the Nrf2/HO-1 signaling pathway

Gas explosion is a recurrent event in coal mining that cause severe spleen damage. This study aimed to investigate the role and mechanism of oxidative stress in gas explosion-induced spleen injury. 120 male Sprague-Dawley (SD) rats were randomly divided into a control group (NC), a gas explosion-induced spleen injury model group (Model), an Nrf2 inhibitor group (Model + ATRA), and an Nrf2 induction group (Model + TBHQ). After explosion, the rats of the inhibitor group and induction group were immediately given intraperitoneal injection of all-trans-retinoicacid (ATRA, 5 mg/kg) or tertiary butylhydro-quinone (TBHQ, 1 mg/kg) once. Then, the rats were anesthetized with blood taken from the abdominal aorta at 24 h, 72 h and 7 days. The results showed that gas explosion reduced the spleen index. The expression of oxidative stress-related genes and proteins Nrf2, HO-1, COX2 and GPX4 were increased significantly (P < 0.05) after gas explosion. Compared with the model group, TBHQ improved the spleen index, and reduced inflammation. Moreover, the expression of inflammatory factor IL-6 and ROS was decreased (P < 0.05), HMOX1 and the expression of oxidative stress-related genes and proteins were increased (P < 0.05), but the opposite results were observed in the inhibitor group. Taken together, we firstly found that TBHQ may regulate the degree of oxidative stress in spleen injury induced by gas explosion through the Nrf2/HO-1 signaling pathway.

Exploring the topography of the splenic artery: a comprehensive analysis

INTRODUCTION

Comprehensive knowledge of the complete anatomy of the splenic artery (SA) is of utmost importance in various abdominal surgical procedures. The present study aims to present a novel arterial map of the SA, showcasing its origin and course in the abdominal cavity. We hope that our results can be of great value to physicians performing the aforementioned procedures.

METHODS

The research involved the analysis of records from 75 consecutive patients who underwent abdomen and pelvis computed tomography angiography. Morphometric characteristics of the SA and/or its associated anatomical area were evaluated across 42 categories.

RESULTS

The SA was identified to originate from the celiac trunk in 73 cases (98.6%) and in one case from the aorta (1.4%). The most common branching pattern was the left gastric artery, followed by the common trunk of SA and the common hepatic artery occurring in 51 cases (69.9%). The median SA length (in a straight line) was determined to be 74.18 mm (LQ = 64.50; HQ = 87.22). Moreover, the median length of SA (over the surface) was 149.28 mm (LQ = 119.28, HQ = 177.50).

CONCLUSION

The present study demonstrated the high complexity of the arterial blood supply of the spleen. The SA exhibited a significant degree of variability regarding its course, branching pattern, and spatial relationship to the pancreas. By creating a novel arterial heat map, we provided a detailed visualization of the SA's course. These findings aim to improve the pre- and intraoperative identification of the SA, potentially reducing costs and the risk of complications associated with iatrogenic vessel injury during various surgical and endovascular procedures.

Using Interpretable Artificial Intelligence Algorithms in the Management of Blunt Splenic Trauma: Applications of Optimal Policy Trees as a Treatment Prescription Aid to Improve Patient Mortality

BACKGROUND

The identification of the optimal management for blunt splenic trauma-angioembolization (AE), splenectomy, or observation-remains a challenge. This study applies Optimal Policy Trees (OPT), an artificial intelligence (AI) model, to prescribe appropriate management and improve in-hospital mortality.

METHODS

OPTs were trained on patients with blunt splenic injuries in the ACS-TQIP 2013-2019 to prescribe one of the three interventions: splenectomy, angioembolization (AE), or observation. Prescriptive trees were derived in two separate patient cohorts: those who presented with a systolic blood pressure (SBP) < 70 mmHg and those with an SBP ≥ 70 mmHg. Splenic injury severity was graded using the American Association of Surgical Trauma (AAST) grading scale. Counterfactual estimation was used to predict the effects of interventions on overall in-hospital mortality.

RESULTS

Among 54,345 patients, 3.1% underwent splenic AE, 13.1% splenectomy, and 83.8% were managed with observation. In patients with SBP < 70 mmHg, AE was recommended for shock index (SI) < 1.5 or without transfusion, while splenectomy was indicated for SI ≥ 1.5 with transfusion. For patients with SBP ≥ 70 mmHg, AE was recommended for AAST grades 4-5, or grades 1-3 with SI ≥ 1.2; observation was recommended for grades 1-3 with SI < 1.2. Predicted mortality using OPT-prescribed treatments was 18.4% for SBP < 70 mmHg and 4.97% for SBP ≥ 70 mmHg, compared to observed rates of 36.46% and 7.60%, respectively.

CONCLUSIONS

Interpretable AI models may serve as a decision aid to improve mortality in patients presenting with a blunt splenic injury. Our data-driven prescriptive OPT models may aid in prescribing the appropriate management in this patient cohort based on their characteristics.

Long-term follow-up of infection, malignancy, thromboembolism, and all-cause mortality risks after splenic artery embolization for blunt splenic injury: comparison with splenectomy and conservative management

BACKGROUND

Non-operative management, including splenic artery embolization, is preferred for blunt splenic injuries, but its long-term risks need further investigation. Long-term splenic functions were assessed in patients with blunt splenic injuries, hypothesizing that splenic artery embolization would preserve function and reduce long-term risks.

METHODS

This retrospective cohort study used Taiwan's National Health Insurance Research Database to analyse patients with blunt splenic injuries from 2004 to 2019. To balance baseline characteristics across the treatment groups, inverse probability of treatment weighting was used based on propensity scores. Outcomes of main interest included the incidence and cumulative infection, malignancy, thromboembolism, and all-cause mortality risks after one year.

RESULTS

Altogether, 18 771 patients sustained blunt splenic injuries; 8195 were eligible for inclusion. The mean age was 38.4 years, with male predominance (70.5%). Outcomes were compared between splenectomy, splenic artery embolization, and conservative treatment groups. After applying a generalized boosted model with inverse probability of treatment weighting, patients who underwent splenic artery embolizations or conservative treatment had lower infection risks than those in the splenectomy group. The conservative treatment group had a lower malignancy risk than the splenectomy group. Patients with blunt splenic injuries who underwent splenic artery embolizations or conservative treatment had a lower thromboembolism risk than those who underwent splenectomies.

CONCLUSION

Long-term infection, malignancy, thromboembolism, and all-cause mortality risks were not significantly different between the splenic artery embolization and conservative treatment groups. In contrast, patients who underwent splenectomies had increased infection, malignancy, thromboembolism, and all-cause mortality risks. Clinicians must be familiar with the potential long-term complications associated with the different treatment modalities for splenic injuries and provide appropriate prophylactic measures.

Trends of primary health care practitioners toward bleeding management in Saudi Arabia: a cross-sectional analysis

OBJECTIVES

High rates of morbidity and mortality are a result of trauma being a significant health burden in Saudi Arabia. We evaluated the current trends of primary healthcare (PHC) physicians in Saudi Arabia toward patients with bleeding and their referral awareness for percutaneous endovascular arterial embolization (EAE).

METHODS

We formulated a 13-question survey to assess PHC physicians' knowledge regarding decision-making and appropriate approaches to manage patients with traumatic and non-traumatic abdominopelvic and lower limb bleeding. We conducted in-person surveys with various specialists with varying levels of clinical experience in Saudi Arabia.

RESULTS

Overall, 112 PHC physicians were assessed. Of them, 43.75% had ≥ 5 years of independent practice experience, and 72.3% and 27.7% encountered bleeding patients rarely and routinely, respectively. General practitioners scored lower across all questions than other PHC physicians. Physicians with > 10 years of practice had higher median scores in decision-making questions (p = 0.159). Internists and gynecologists (p = 0.046) and physicians (p = 0.050) in tertiary-care settings had significantly higher median scores on decision-making questions. Pediatricians (p = 0.091) and PHC physicians (p = 0.440) at private institutions had higher median scores on approach appropriateness questions.

CONCLUSIONS

PHC physicians in Saudi Arabia require a better understanding of the indications of EAE to avoid referral and triage errors, inefficient use of healthcare resources, and suboptimal patient outcomes.

Retrospective Observational Study of the Management of Blunt Traumatic Splenic Injury 2017-2022 at Major Trauma Centres in England. What is the Current Role of Splenic Artery Embolisation?

BACKGROUND

PURPOSE: To compare the treatment and outcomes of blunt splenic injury (BSI) management strategy within Major Trauma centres in England between 2017 and 2022.

METHODS

Data was extracted from UK TARN (Trauma Audit Research Network) identifying all splenic injuries admitted to English Major Trauma Centres (MTCs) between 01/01/17 and 31/12/21. Mechanism, injuries, treatment and outcomes were compared between management strategies according to American Association of Surgery in Trauma (AAST) grade over the period. The main endpoints of splenic salvage rate, along with mortality and length of stay were compared between the treatment options.

RESULTS

3,723 patients sustained BSI; 2,906 (78.1%) were managed conservatively, 491 (13.2%) underwent embolisation while 326 (8.8%) underwent splenectomy. There were 1895 (50.9%) AAST grade 2 injuries, 1019 (27.4%) grade 3, 592 (15.9%) grade 4 and 247 (6.6%) grade 5. Embolisation was successful (i.e. no subsequent splenectomy) for 465/491 (94.7%). The length of stay of discharged patients in the splenectomy group was longer than in those receiving embolisation (p = 0.001) or conservative management (p < 0.001) (median (IQR) of 12 (7, 27), 10 (6, 19), 10 (6, 20) days, respectively). Mortality at 30 days was not significantly different in those who underwent splenectomy (12.3%) compared to embolisation (8.6%) and conservative management (11.5%) (p = 0.129).

CONCLUSION

Splenic embolisation results in a high rate of splenic salvage.

Chronic Myelomonocytic Leukemia (CMML) as a Rare Cause of Spontaneous Atraumatic Splenic Rupture in a 65-Year-Old Male

This report describes a patient with a history of chronic thrombocytopenia who presented with splenic rupture and hemorrhagic shock in the absence of trauma. Four days earlier, the patient had visited the emergency department with symptoms of sore throat, fever, and myalgia. Due to the relatively benign presentation, further workup was deferred in favor of a presumed infectious etiology. This delay in diagnosis led to the patient presenting with life-threatening injuries, necessitating an emergent splenectomy. Subsequent evaluation revealed an underlying diagnosis of chronic myelomonocytic leukemia (CMML), which ultimately caused the splenic rupture. This case underscores the importance of considering hematologic malignancies, including rare pathologies like CMML, in the differential diagnosis of atraumatic splenic rupture (ASR).

Spontaneous splenic rupture associated with Q fever and portal hypertension: A case report

Spontaneous splenic rupture (SSR) is an exceptionally rare and life-threatening condition, with its pathophysiology remaining poorly understood. This report describes the first documented case of SSR in a patient with Q fever infection and underlying liver cirrhosis with portal hypertension. The patient was a man in his late 30 s who presented with severe abdominal pain, vomiting and hypovolemic shock who required emergency splenectomy due to unstable splenic hemorrhage. Post-operatively, a diagnosis of Q fever was confirmed through serological testing. To date, there has only been six cases describing splenic rupture precipitated by Q fever, and none in the context of concurrent portal hypertension. Conversely, portal hypertension is an independent risk factor for splenic complications including splenomegaly and hypersplenism. This case underlines the critical need to consider rare etiologies, offers valuable insights into the pathogenesis of SSR, and emphasizes the importance of early recognition and multidisciplinary management. Moreover, a proposed algorithm for the diagnosis and management of SSR has been included for clinicians who face similar complex presentations.

Risk factors of 180-day rebleeding after management of blunt splenic injury without surgery and embolization: a national database study

PURPOSE

This study aimed to identify risk factors for rebleeding within 180 days post-discharge in blunt splenic injury patients managed without splenectomy or embolization.

MATERIALS AND METHODS

A retrospective analysis was conducted using Taiwan's National Health Insurance Research Database. Adult patients aged ≥ 18 years with blunt splenic injury (ICD-9-CM codes 865.01-865.09) from 2000 to 2012 were included. Patients who died, underwent splenectomy (ICD-9-OP codes 41.5, 41.42,41.43, and 41.95) or transcatheter arterial embolization (TAE) (ICD-9-OP codes 39.79 and 99.29) on the first admission were excluded. The primary endpoint was rebleeding, which was identified if patients underwent splenectomy or TAE at 180 days after discharge. Multivariate logistic regression was used to identify risk factors, which were validated in a separate cohort.

RESULTS

Of 6,140 patients, 80 (1.302%) experienced rebleeding within 180 days. Five significant risk factors were identified: age < 54 years (aOR 3.129, p = 0.014), male sex (aOR 2.691, p = 0.010), non-traffic accident-induced injury (aOR 2.459, p = 0.006), ISS ≥ 16 (aOR 2.130, p = 0.021), and congestive heart failure (aOR 6.014, p = 0.006). We generate Delayed Splenic Bleeding System (DSBS). Patients with > 2 points had significantly higher rebleeding rates (risk-identifying cohort: 2.2% vs. 0.6%, OR 3.790, p < 0.001; validation cohort: 2.6% vs. 0.8%, OR 3.129, p = 0.022).

CONCLUSIONS

Age < 54 years, male, non-traffic accident-induced injury, ISS ≥ 16, and congestive heart failure are risk factors of rebleeding within 180 days after discharge from treating blunt splenic injury without splenectomy or embolization. Despite limitations, this study underscores large-scale data's role in identifying risks which can aid clinicians in prioritizing additional interventions during NOM.

Impact of early arterial-phase multidetector CT in blunt spleen injury: a clinical outcomes-oriented study

BACKGROUND

Blunt spleen injuries (BSI) present significant diagnostic and management challenges in trauma care. Current guidelines recommend arterial-phase contrast-enhanced multidetector computed tomography (CT) for a detailed assessment. However, the direct impact of add-on arterial phase CT on clinical outcomes remains unclear. This study investigated the impact of early arterial-phase imaging via multidetector CT on the clinical outcomes of patients with blunt splenic injuries.

METHODS

A retrospective case-control study was conducted to analyze the data of adult patients with BSI treated at a single institution between 2019 and 2022. Patients were divided based on the CT phase performed: portal vein phase only or add-on arterial phase. Management methods were divided according to the initial treatment intent: nonoperative management observation (NOM-Obs), transarterial embolization (TAE), and splenectomy. NOM failure refers to either NOM-Obs or TAE failure leading to splenectomy. NOM-Obs failure refers to cases initially managed with observation only, but later requiring either TAE or splenectomy. Transarterial embolization (TAE) failure refers to cases initially treated with TAE, but subsequently requiring splenectomy. Inverse probability of treatment weighting (IPTW) was used to balance baseline differences and compare outcomes between the two groups.

RESULTS

Of 170 patients assessed, 147 met the inclusion criteria and were divided into two groups: those receiving portal vein phasic-only CT (N = 104) and those receiving add-on arterial phasic CT (N = 43). The overall NOM failure rate was 3.0% (4/132), the NOM-OBS failure rate was 6.7% (4/60), and the TAE failure rate was 4.1% (3/73). After adjusting for covariates using inverse probability of treatment weighting (IPTW), the comparison between the add-on arterial phase and portal phase CT groups revealed similar overall NOM failure rates (3.0% vs. 2.2%, p = 0.721), NOM-OBS failure rates (3.8% vs. 6.2%, p = 0.703), and intra-abdominal bleeding-related mortality rates (4.8% vs. 2.1%, p = 0.335). Among the 43 patients who underwent add-on arterial CT, only one was diagnosed with a tiny pseudoaneurysm (0.7 cm) attributable to the inclusion of the arterial phase.

CONCLUSION

Dual-phase CT within 24 h of presentation offers no added value over single-phase CT in managing blunt splenic injuries in terms of clinical outcomes.

Prophylactic embolization vs observation for high-grade blunt trauma splenic injury: a systematic review with meta-analysis

OBJECTIVE

The objective of this systematic review was to compare the effectiveness of prophylactic angioembolization with observation as primary management strategies for patients with high-grade (grades 3-5) blunt trauma splenic injury.

INTRODUCTION

The spleen is commonly injured in abdominal trauma. Historical management practices involved splenectomy, but more recent evidence suggests an increased risk of severe infections and sepsis associated with this approach. Accordingly, nonoperative management strategies, including prophylactic splenic artery embolization and clinical observation, have gained prominence. This systematic review with meta-analysis directly compared angioembolization with clinical observation for high-grade splenic injuries only, aiming to provide clarity on this matter amid ongoing debates and variations in clinical practice.

INCLUSION CRITERIA

This review included adult patients aged 15 years or older with high-grade splenic injuries (grades 3-5) due to blunt trauma. Outcomes of interest include the need for further intervention (failure of management), mortality, complications, red blood cell transfusion requirements, hospital length of stay, and intensive care unit length of stay.

METHODS

A comprehensive search of PubMed, Embase, and CINAHL (EBSCOhost) was performed, with no restrictions on language or publication date. Gray literature was searched, including trial registries and relevant conference proceedings. After deduplication, 2 reviewers independently assessed titles and abstracts, and, subsequently, full-text articles for eligibility. Methodological quality of the included studies was assessed using standardized instruments from JBI. Data were extracted using predefined templates, and statistical meta-analysis was performed, where possible, using a random-effects model. Heterogeneity was assessed using statistical methods, and potential publication bias was tested with a funnel plot. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the certainty of evidence.

RESULTS

Sixteen studies were included in this review. Methodological quality assessment indicated some risk of bias in most studies, with concerns primarily related to differences in injury severity and potential confounding factors. Meta-analysis revealed that prophylactic angioembolization significantly reduced risk of management failure by 57% (OR 0.43, 95% CI 0.28-0.68, I2 =53%, 15 studies) and decreased patient mortality by 37% (OR 0.63, 95% CI 0.43-0.93, I2 =0%, 9 studies) compared with clinical observation alone. There was a 47% reduction in risk of complications associated with prophylactic embolization compared with clinical observation (OR 0.53, 95% CI 0.29-0.95, I2 =0%, 4 studies). Some statistical heterogeneity was observed, with I2 ranging from 0% to 53%. No significant differences were observed between the 2 management strategies for red blood cell transfusion requirements or hospital length of stay.

CONCLUSIONS

The results of this review support the use of prophylactic embolization for high-grade blunt trauma splenic injuries, indicated by lower rates of management failure, reduced need for additional interventions, lower mortality, and fewer complications.

REVIEW REGISTRATION

PROSPERO CRD42023420220.

Trends of trauma team physicians toward patients with bleeding in Saudi Arabia: a cross-sectional study

OBJECTIVES

Trauma poses a significant health burden in Saudi Arabia, with high rates of morbidity and mortality rates. We evaluated the trends among trauma team (TT) physicians in Saudi Arabia regarding their awareness and referral practices for percutaneous endovascular arterial embolization (EAE) in bleeding patients.

METHODS

A 13-question survey developed by consultants from various specialties assessed the knowledge of TT physicians regarding decision-making and appropriate approaches for managing traumatic bleeding. The surveys were administered in person to 135 TT physicians.

RESULTS

Among them, 38.52% had five or more years of independent practice, and 87.41% routinely encountered patients with bleeding patients. Physicians who routinely treated patients with bleeding patients exhibited higher median scores, in line with current management standards (p = 0.634). Tertiary care physicians and academic- and military-affiliated physicians exhibited higher median scores (p =  <0.001 and p < 0.006, respectively). Amongst TT physicians, 47.41% preferred EAE for unstable pelvic ring fractures with active bleeding, while 68.15% favored splenectomy for unstable patients with grade V splenic injuries. For traumatic aortic injuries, 67.42% considered TEVAR/EVAR safer options. Notably, 84.44% viewed an INR > 3 as a contraindication for EAE in hemodynamically stable patients. General surgeons scored the highest in management decision-making, followed by neurosurgeons (p = 0.001). Orthopedics, emergency medicine, intensive care (ICU), and anesthesia specialists exhibited similarly high median scores for appropriate management approaches (p = 0.003). Overall, general surgeons, orthopedic surgeons, and ICU specialists exhibited the highest median correct responses, adhering to the current standard of practice (p = 0.001).

CONCLUSIONS

To address the potentially life-threatening condition of traumatic bleeding, raising awareness of the appropriate management and referral patterns for EAE is crucial.

Standard of care for blunt spleen trauma: embracing non-operative management

Non-operative management is the standard of care for blunt spleen trauma in stable patients in the absence of other abdominal injuries. This is a case report of a male patient in his 60s who presented to the emergency room with abdominal pain 2 days after sustaining blunt abdominal trauma. The patient was haemodynamically stable, and CT scan revealed a severe spleen injury. Considering the clinical stability, the patient was admitted for non-operative management and kept under continuous monitoring. A CT angiogram revealed active bleeding, so the patient underwent angioembolisation of the distal splenic artery. Follow-up after angioembolisation was uneventful, and imaging findings were stable, so the patient was discharged after 12 days. Non-operative management is a valid option for stable patients, avoiding surgical complications while preserving spleen function. Being a dynamic process, it should be an option in centres with continuous monitoring capacity and emergency surgery availability, considering the potential failure of this approach.

Endovascular management of haemorrhage and vascular lesions in patients with multiple and/or severe injuries: a systematic review and clinical practice guideline update

PURPOSE

Our aim was to update evidence-based and consensus-based recommendations for the inhospital endovascular management of haemorrhage and vascular lesions in patients with multiple and/or severe injuries based on current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

METHODS

MEDLINE and Embase were systematically searched to June 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared endovascular interventions for bleeding control such as embolisation, stent or stent-graft placement, or balloon occlusion against control interventions in patients with polytrauma and/or severe injuries in the hospital setting. The diagnosis of pelvic haemorrhage was added post-hoc as an additional clinical question. We considered patient-relevant clinical outcomes such as mortality, bleeding control, haemodynamic stability, transfusion requirements, complications, and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.

RESULTS

Forty-three new studies were identified. Interventions covered were resuscitative endovascular balloon occlusion of the aorta (REBOA) (n = 20), thoracic endovascular aortic repair (TEVAR) (n = 9 studies), pelvic trauma (n = 6), endovascular aortic repair (EVAR) of abdominal aortic injuries (n = 3), maxillofacial and carotid artery injuries (n = 2), embolisation for abdominal organ injuries (n = 2), and diagnosis of pelvic haemorrhage (n = 1). Five recommendations were modified, and one additional recommendation was developed. All achieved strong consensus.

CONCLUSION

The following key recommendations are made. Whole-body contrast-enhanced computed tomography should be used to detect bleeding and vascular injuries. Blunt thoracic and abdominal aortic injuries should be managed using TEVAR/EVAR. If possible, endovascular treatment should be delayed beyond 24 h after injury. Bleeding from parenchymatous abdominal organs should be controlled using transarterial catheter embolisation. Splenic injuries that require no immediate intervention can be managed with observation.

Does the AO/OTA fracture classification dictate the anesthesia modality for the surgical management of unstable distal radius fractures? - A retrospective cohort study in 127 patients managed by general vs. regional anesthesia

INTRODUCTION

Regional anesthesia increases in popularity in orthopaedic surgery. It is usually applied in elective surgeries of the extremities. The aim of this study was to assess indication of the use of general anesthesia in the surgical treatment of distal radius fractures.

METHODS

Patients undergoing surgical fixation for distal radius fractures between January 1st, 2020, and December 31st, 2021, were included. Exclusion criteria encompassed incomplete 12-month follow-up, transferred or multiply injured patients, those with prior upper limb fractures, or admission for revision surgeries. Patients were categorized by anesthesia type: GA or plexus block anesthesia (PA). Primary outcomes comprised tourniquet utilization and duration of surgery, while secondary outcomes encompassed complications (e.g., complex regional pain syndrome [CRPS], local wound infection, implant removal necessity) and range of motion at three, six, and twelve months post-surgery. Fractures were classified using the AO/OTA system.

RESULTS

The study enrolled 127 patients, with 90 (70.9%) in Group GA and 37 (29.1%) in Group PA. Mean patient age was 56.95 (± 18.59) years, with comparable demographics and fracture distribution between groups. Group GA exhibited higher tourniquet usage (96.7% vs. 83.8%, p = 0.029) and longer surgery durations (85.17 ± 37.8 min vs. 65.0 ± 23.0 min, p = 0.013). Complication rates were comparable, Group GA 12.2% versus Group PA 5.4% p = 0.407, OR 2.44; 95%CI 0.51 to 11.58, p = 0.343). Short-term functional outcomes favored Group PA at three months (e.g., Pronation: 81.1° ± 13.6 vs. 74.3° ± 17.5, p = 0.046).

CONCLUSION

Solely classifying distal radius fractures does not dictate anesthesia choice. Complexity of injury, anticipated surgery duration, less use of tourniquet, and rehabilitation duration may guide regional anesthesia utilization over GA in distal radius fracture fixation.

Liquid biopsy in organ damage: introduction of an innovative tool for assessing the complexity of blunt splenic injury

Liquid biomarkers are essential in trauma cases and critical care and offer valuable insights into the extent of injury, prognostic predictions, and treatment guidance. They can help assess the severity of organ damage (OD), assist in treatment decisions and forecast patient outcomes. Notably, small extracellular vesicles, particularly those involved in splenic trauma, have been overlooked. Here, we reanalyzed our data and explored whether monocyte-derived small EVs are correlated with AAST score (American Association for the Surgery of Trauma) scoring and are sensitive enough to distinguish the severity of splenic trauma in our explorative study. There was a correlation between monocyte-derived small extracellular vesicles (EVs) and the AAST score (rSp = 0.82, p < 0.001). Specifically, we observed that blood-borne small EVs originating from monocytes (CD9+CD14+ sEVs) were directly correlated with AAST scores. These EVs were found to be significantly elevated in patients with complex spleen injuries (AAST I-IV with hemodynamic instability and need for operative management) in an incremental manner; these patients were typically classified as AAST grade II or higher, which frequently included accompanying solid organ injuries. Our initial discovery shows great promise and warrants further exploration. This could pave a novel future path for a new critical care management approach for splenic injuries. There may also be synergistic effects when combined with extended focused assessment with sonography in trauma (E-FAST) sonography, particularly in triage scenarios, where resource constraints prevent immediate access to a CT scan.

Variation in Outcomes Associated With Blunt Splenic Injury Management

Introduction The management of blunt splenic injury has evolved to include splenic artery embolization in addition to non-surgical management, and splenic surgery. Though research has been conducted examining outcomes between management approaches, the inferential findings are often limited by single-site study designs and small sample sizes. However, results from large-scale prior studies can inform inference if a non-frequentist (Bayesian) framework is used. Therefore, the purpose of this study was to examine mortality and length of stay associated with blunt splenic injury management using both frequentist and Bayesian methods. Methods A total of 56 patients presenting with blunt splenic injury were included in this retrospective, single-center, quantitative study from January 1, 2021 to December 31, 2022 to inform both methodological approaches. Findings from a national retrospective sample of 117,743 patients presenting with blunt splenic injury between 2007 and 2015 were included in the prior distribution for the Bayesian estimates to provide sufficient statistical power and improve internal validity and generalizability of findings. Results Mortality rates and hospital mean length of stay were not significantly different between blunt splenic injury management approaches of non-operative management (n=43), surgery (n=7), and splenic artery embolization (n=6) using a frequentist approach (9.3%, 0%, and 0%, P=.52; and 10.8 (15.8), 10.8 (4.7), and 4.6 (1.8), P=.86, respectively). Bayesian 95% highest density interval (HDI) estimates of the likelihood of mortality ([0.02; 0.18], [-6.4e-23; 0.3], and [-2.2e-22; 0.3]) and hospital mean length of stay ([7.7; 8.3], [11.0; 12.3], and [8.7; 10.2]) provided reduced uncertainty in point and dispersion estimates. Conclusions The inclusion of findings from large high-quality studies provides increased certainty in estimates from smaller studies. Posterior estimates can inform predictive models for testing in future studies.

Transarterial embolization to treat hemodynamically unstable trauma patients with splenic injuries: A retrospective multicenter observational study

PURPOSE

We described clinical outcomes for patients with blunt splenic injuries treated with transarterial embolization (TAE) based on their hemodynamic status.

MATERIALS AND METHODS

This is a retrospective two-center study of adult patients with splenic injuries who underwent emergency TAE between January 2011 and December 2022. Patients were divided into two groups; hemodynamically unstable (HDU) and hemodynamically stable (HDS) patients. HDU patients were defined as transient- or non-responders to fluid resuscitation and HDS as responders. When immediate laparotomy was not possible for HDU patients, angiography and embolization were performed. The primary outcome was the survival discharge rate. Rebleeding and splenectomy rate was also investigated.

RESULTS

Of 38 patients underwent emergency TAE for splenic trauma, 17 were HDU patients and 21 were HDS patients. The survival discharge rate was 88.2 % (15/17) in the HDU- and 100 % in HDS patients (p = 0.193). Rebleeding rate was 23.5 % (4/17) in HDU- and 5.0 % (1/21) in HDS patients (p = 0.15). Splenectomy was required for one HDU patient (5.9 %) for rebleeding.

CONCLUSION

The survival discharge rate of TAE for splenic trauma in HDU patients was acceptable with a low rate of splenectomy. Further comparative studies of TAE versus operative management in HDU patients are needed to prove the usefulness of TAE.

[Surgical management of severe noncompressible torso and organ hemorrhages]

BACKGROUND

Noncompressible torso hemorrhages (NCTH) are now recognized as the leading cause of preventable death in the context of severe military and civilian injuries. Approximately 20% of all trauma patients still die from uncontrolled bleeding associated with rapidly evolving disorders of blood coagulation function.

OBJECTIVE

Summary of recent advances in the field of nonsurgical and surgical management, presentation of current treatment concepts and future research directions.

MATERIAL AND METHODS

Selective literature review and analysis.

RESULTS

The concepts for the early treatment of NCTH have considerably evolved over the last decade. The updated definition of NCTH includes a combination of high-grade anatomic body trunk injury, hemodynamic instability, urgent need for hemorrhage control, and aggressive hemostatic treatment. The treatment concepts consider the following 3 aspects: controlling the source of bleeding (close the tap), maintaining organ perfusion and restoring hemostasis (fill the tank) and increasing the body's resistance to ischemia (upgrade the armor). New tools, well-established damage control concepts and early and aggressive therapeutic intervention for hemostatic failure have significantly improved the outcomes.

CONCLUSION

Future research needs to refine and validate the current concepts for further clinical application.

Treatment of blunt splenic injury in children in China

Introduction

Nonoperative management (NOM) is recognized as a viable treatment for pediatric closed splenic trauma. However, clinical guidelines are applied inconsistently, resulting in different treatment strategies in different regions. This study aimed to investigate the independent risk factors influencing the length of stay in pediatric closed splenic injuries and to analyze the key determinants in the choice of surgical treatment to optimize inpatient management and patient care and improve outcomes.

Methods

A retrospective evaluation of medical records of pediatric patients with blunt splenic injury (BSI) admitted to Wuhan Children's Hospital from 2020 to 2024 was conducted. The dataset included demographics, mechanism of injury, injury grade, associated injuries, therapeutic measures, and outcomes, which were subjected to statistical analysis. Factors influencing length of hospital stay and treatment regimen were also analyzed.

Results

A total of 88.5% of patients underwent NOM, with 11% requiring splenic embolization due to hemodynamic instability or arterial hemorrhage. Surgery was required in 11.5% of patients, primarily for combined gastrointestinal perforation, or peritonitis. One patient died due to brain injury. Trauma scores and transfusion requirements were higher in the surgical group (37.7 ± 16.1 vs. 17.2 ± 13.1, p < 0.001; 21.7% vs. 100%, p < 0.001). Multivariate logistic regression showed that gastrointestinal complications significantly influenced the decision to operate (p = 0.0087). A generalized additive model showed a corresponding increase in length of stay with increasing injury severity, with the curve flattening in the mid to high ISS range (40-60).

Conclusion

NOM remains an effective and preferred treatment strategy for pediatric BSI, particularly in the setting of stable hemodynamic parameters. This approach reduces the need for surgical intervention and associated complications while preserving splenic function. The study highlights that gastrointestinal complications are important determinants of surgical management. Further research into long-term outcomes and advancements in conservative management are needed.

Splenic artery embolization for trauma: a narrative review

The management of traumatic splenic injuries has evolved significantly over the past several decades, with the majority of these injuries now being treated nonoperatively. Patients who exhibit hemodynamic instability upon initial evaluation typically require surgical intervention, while the remainder are managed conservatively. Conservative treatment for traumatic splenic injuries encompasses both medical management and splenic artery angiography, followed by embolization in cases where patients exhibit clinical signs of ongoing splenic hemorrhage. Splenic artery embolization is generally divided into two categories: proximal and distal embolization. The choice of embolization technique is determined by the severity and location of the splenic injury. Patients who retain functioning splenic tissue after trauma do not routinely need immunization. This is in contrast to post-splenectomy patients, who are at increased risk for opportunistic infections.

Association between nighttime/weekend visits and patient outcomes in children with blunt liver and spleen injuries

PURPOSE

The "out-of-hours effect," which indicates hospital admittance during weekends or nighttime, has poorer outcomes for patients than for those admitted on weekdays and is widely documented in various medical conditions. However, this effect remains understudied in pediatric trauma cases, including blunt liver and spleen injuries (BLSIs).

METHODS

This was a secondary analysis of a nationwide multicenter retrospective study, focusing on pediatric patients with trauma (≤ 16 years old) with BLSI admitted from 2008 to 2019. This study evaluated the association between out-of-hour admissions and outcomes. The primary outcome was the intervention rate and secondary outcomes were 30-day mortality and time from hospital arrival to the first intervention.

RESULTS

This study identified 1414 pediatric patients with BLSI. In total, 681 events occurred during the daytime and 733 during the nighttime, with 927 weekday and 487 weekend events. Out-of-hour admissions did not significantly associate with a higher rate of intervention. This association remained after adjusting for five potential confounders and patient clustering within the hospital. In addition, Out-of-hour admissions did not significantly associated with 30-day mortality, or time from hospital arrival to the first intervention.

CONCLUSIONS

The current study showed no significant difference in treatment strategy and outcomes between weekday and out-of-hour among children with BLSI.

A comparison of adult and pediatric guidelines for the management of blunt splenic trauma

The management of blunt splenic trauma varies between children and adults, with disparate rates of splenectomy and angioembolization. This practice variation can be explained by some of the most recently published guidelines by the American Pediatric Surgical Association (APSA) and the Western Trauma Association (WTA). This narrative review compares these guidelines, and the evidence behind them. A comparison of the guidelines published in 2023 by WTA and APSA was undertaken, supplemented by recommendations in the 2016 WTA & 2015 ATOMAC guidelines. The publications that underpinned the guidelines were also examined. The recommendations from each guideline were summarized and similarities & differences noted, focusing on initial evaluation and resuscitation, the role of imaging, management strategies, hospitalization and follow up. While both guidelines highlight standardized initial resuscitation, subsequent management of both stable and unstable patients is different: guided by CT findings and hemodynamic status in adults and hemodynamic status alone in children. In stable adults, the grade of injury dictates the use of angioembolization, a therapeutic intervention rarely used in children. Differences with regards to ICU admission, follow up investigations and the use of thromoprophylaxis, also underscore the different management strategies in each cohort. It is hoped that this comparison lays the foundation for further exploration of how a unified guideline may be developed, acknowledging the need for nuanced care and resource optimization.

Management and outcomes of splenic injuries secondary to blunt trauma in patients presenting to major trauma hospitals in Aotearoa New Zealand

BACKGROUND

Non-operative management of splenic injuries has significantly increased in the last decade with an increased emphasis on splenic preservation. This shift was assisted by increased availability of angioembolization, however, potential geographical variability in access exists in Aotearoa New Zealand (AoNZ). The aim of this study was to assess the management of splenic injury across AoNZ.

METHOD

Five-year retrospective study of all patients admitted to AoNZ hospitals with blunt major trauma and a splenic injury. Patients were identified using the National Trauma Registry and cross-referenced with the National Minimum Data Set to determine their management. The primary outcome was the non-operative rate.

RESULTS

Seven hundred seventy-three patients were included. Four hundred sixty-nine presented to a tertiary major trauma hospital and 304 to a secondary major trauma hospital. A difference was found in the rate of non-operative management between tertiary and secondary hospitals (P = 0.019). The rate of non-operative management was similar in mild (P = 0.814) and moderate (P = 0.825) injuries, however, significantly higher in severe injuries in tertiary hospitals (P = 0.009). No difference in mortality rate was found.

CONCLUSION

This study found a difference in the management of splenic injuries between tertiary and secondary major trauma hospitals; predominantly due to a higher rate of operative management in patients with severe injuries at secondary hospitals. Despite this, no difference in mortality rate was found between tertiary and secondary hospitals.

The Management of Splenic Injuries

Splenic injury is one of the most common abdominal parenchymal organ injuries. Since the spleen is a parenchymal organ with abundant blood flow, its injury can easily result in hemorrhagic shock. Therefore, prompt and appropriate management for hemostasis is critical. Management of splenic injury is determined by the hemodynamic status and the grade of injury. Splenectomy is the primary choice in cases with unstable hemodynamics, but splenic repair or non-operative management, including conservative treatment or transcatheter arterial embolization (TAE), may be chosen to preserve the spleen if time permits. Non-operative management has advantages over operative management in terms of complications and medical economics. TAE also plays a significant role in non-operative management by contributing to the improvement of patient outcomes.

Follow-up strategy for early detection of delayed pseudoaneurysms in patients with blunt traumatic spleen injury: A single-center retrospective study

BACKGROUND

The spleen is the most commonly injured solid organ in blunt abdominal trauma, and splenic pseudoaneurysm rupture is associated with a high risk of mortality. Nonoperative management has become the standard treatment for hemodynamically stable patients with splenic injuries. On the other hand, delayed splenic pseudoaneurysms can develop in any patient, and at present, there are no known risk factors that may reliably predict their occurrence. Furthermore, there is a lack of consensus regarding the most appropriate strategies for monitoring and managing splenic injuries, especially lower-grade (I-III).

AIM

To determine the predictors of pseudo-aneurysm formation following splenic injury and develop follow-up strategies for early detection of pseudoaneurysms.

METHODS

We retrospectively analyzed patients who visited the Level I Trauma Center between January 2013 and December 2022 and were diagnosed with spleen injuries after blunt abdominal trauma.

RESULTS

Using the American Association for the Surgery of Trauma spleen injury scale, the splenic injuries were categorized into the following order based on severity: Grade I (n = 57, 17.6%), grade II (n = 114, 35.3%), grade III (n = 89, 27.6%), grade IV (n = 50, 15.5%), and grade V (n = 13, 4.0%). Of a total of 323 patients, 35 underwent splenectomy and 126 underwent angioembolization. 19 underwent delayed angioembolization, and 5 under-went both initial and delayed angioembolization. In 14 patients who had undergone delayed angioembolization, no extravasation or pseudoaneurysm was observed on the initial computed tomography scan. There are no particular patient-related risk factors for the formation of a delayed splenic pseudoaneurysm, which can occur even in a grade I spleen injury or even 21 days after the injury. The mean detection time for a delayed pseudoaneurysm was 6.26 ± 5.4 (1-21, median: 6, interquartile range: 2-9) days.

CONCLUSION

We recommend regular follow-up computed tomography scans, including an arterial and portal venous phase, at least 1 week and 1 month after injury in any grade of blunt traumatic spleen injury for the timely detection of delayed pseudoaneurysms.

Splenic Rupture Following Extracorporeal Shockwave Lithotripsy: A Case Requiring Emergency Splenectomy

BACKGROUND Extracorporeal shockwave lithotripsy (ESWL) is a common procedure, and splenic rupture is a rare complication of ESWL. Depending on the stage of injury and patient's condition, treatment options include non-operative management (NOM) and emergency splenectomy. Diagnosis is not difficult with symptoms such as deteriorating hemodynamic and hematologic indices, localized physical signs of peritoneal irritation in the left hypochondriac region, and confirmation provided by signs of free fluid (hemoperitoneum) seen on ultrasound or computed tomography (CT). Prompt diagnosis and treatment are essential for patient survival. If NOM is not feasible, emergency laparotomy with splenectomy is standard procedure. CASE REPORT A 72-year-old man with a medical history of arterial hypertension and cardiac arrhythmia was emergently admitted 1 day after undergoing ESWL for bilateral nephrolithiasis. He presented with abdominal pain, nausea, vomiting, and anemia. Urgent CT confirmed a splenic rupture, with intraperitoneal fluid. He underwent emergency splenectomy 24 h after ESWL. Complete splenic rupture (grade IV) was identified, accompanied by significant blood loss of 2000 mL. The postoperative course was uneventful, and he was discharged on postoperative day 7, with primary wound healing. CONCLUSIONS Splenic injury following ESWL is a rare but serious complication. Our case underscores the importance of monitoring for splenic injury following ESWL. Management should be multidisciplinary, considering physiological, anatomical, and immunological aspects. While splenectomy is the standard treatment, NOM can be considered for hemodynamically stable patients to avoid complications following splenectomy. Recent treatment protocols have improved stone breakage and reduced tissue damage, suggesting long-term adverse effects can be minimized or eliminated.

Follow-up strategies after non-operative treatment of traumatic splenic injuries: a systematic review

PURPOSE

Blunt trauma often results in splenic injuries, with non-operative management (NOM) being the preferred approach for stable patients. Following NOM, splenic vascular injuries, such as pseudoaneurysms, may arise, prompting radiological follow-up. However, a consensus on optimal radiological follow-up strategies is lacking. This systematic review evaluates existing evidence on radiological follow-up post-NOM for traumatic splenic injuries.

METHODS

Conducting a systematic review following updated PRISMA guidelines, we searched MEDLINE, Embase, The Cochrane Library, and trial registries from January 2010 to March 2023. Inclusion criteria covered studies on radiological follow-up for blunt splenic injuries.

RESULTS

Out of 5794 studies, 17 were included involving 3392 patients. Various radiological modalities were used, with computed tomography (CT) being the most common. Vascular injuries occurred in 4.5% of patients, with most pseudoaneurysms diagnosed on day 2-6 post-trauma, and leading to intervention in 60% of these cases. Thirteen studies recommended routine follow-up, with six favouring CT, and seven supporting radiation-free modalities. Four studies proposed follow-up based on clinical indications, initial findings, or symptoms. Recommendations for specific timing of radiological follow-up ranged from 48 h to seven days post-injury. Regarding AAST grading, nine studies recommended follow-up for injury grade III and higher.

CONCLUSION

Limited high-quality evidence exists on radiological follow-up in isolated blunt splenic injuries, causing uncertainty in clinical practice. However, our review suggests a reasonable need for follow-up, with contrast-enhanced ultrasound emerging as a promising alternative to CT. Specific timing and criteria for follow-up remain unresolved, highlighting the need for high-quality prospective studies to address these knowledge gaps.

The Diagnosis and Management of Pediatric Blunt Abdominal Trauma-A Comprehensive Review

Blunt abdominal trauma in childhood has always been full of diagnostic and therapeutic challenges that have tested the clinical and radiological skills of pediatric surgeons and radiologists. Despite the guidelines and the studies carried out so far, to this day, there is no absolute consensus on certain points of view. Around the world, a paradigm shift towards non-operative treatment of hemodynamically stable children, with low complication rates, is noticeable. Children with blunt abdominal trauma require a standardized methodology to provide the best possible care with the best possible outcomes. This comprehensive review systematizes knowledge about all aspects of caring for children with blunt abdominal trauma, from pre-hospital to post-hospital care.

Complications and failure rate of splenic artery angioembolization following blunt splenic trauma: A systematic review

BACKGROUND

Over recent decades, splenic angioembolization (SAE) as an adjunct to non-operative management (NOM) has emerged as a prominent intervention for patients with blunt splenic injuries (BSI). SAE improves patient outcomes, salvages the spleen, and averts complications associated with splenectomy. This systematic review aimed to evaluate the failure rate and complications related to SAE in patients with BSI.

METHODS

A systematic literature search (PubMed, SCOPUS, and Cochrane Library) focused on studies detailing splenic angioembolization in blunt trauma cases. Articles that fulfilled the predetermined inclusion criteria were included. This review examined the indications, outcomes, failure rate, and complications of SAE.

RESULTS

Among 599 identified articles, 33 met the inclusion criteria. These comprised 29 retrospective studies, three prospective studies, and one randomized control trial. The analysis encompassed 25,521 patients admitted with BSI and 3,835 patients who underwent SAE. The overall failure rate of SAE was 5.3 %. Major complications predominantly were rebleeding (4.8 %), infarction (4.6 %), and abscess formation (4 %). Minor complications were fever (18.4 %), pleural effusion (13.1 %), and coil migration (3.9 %). Other complications included splenic atrophy, splenic cyst, hematoma, and access site complications such as splenic/femoral dissection. Overall, post embolization mortality was 0.08 %.

CONCLUSION

SAE is a valuable adjunct in managing BSI, with a low failure rate. However, this treatment modality is not without the risk of potentially serious complications.

Contrast-enhanced Ultrasound as a Method of Splenic Injury Assessment

Splenic injuries are common in abdominal trauma, as the spleen is one of the most often harmed organs. The treatment of splenic injuries underwent major changes during the past decades, shifting from a surgical approach to nonoperative management. This change of the proceedings results from a constantly growing awareness of the spleen's crucial hematological and immunological function and was possible owing to the advances in radiological techniques. In a setting of high-energy trauma in hemodynamically stable patients, computed tomography (CT) remains the gold standard. Where ultrasonography (US) is of major importance is in cases of unstable patients undergone high-energy trauma or in patients after low-energy trauma. Nevertheless, baseline US's sensitivity is not sufficient to detect splenic traumatic injuries; hence, a new method was developed involving ultrasound contrast agents (UCAs), called contrast-enhanced ultrasound (CEUS). In a low-energy trauma setting, it facilitates the diagnosis of abdominal lesions with a sensitivity close to that of CT, without the disadvantages of the latter. In addition, CEUS can be used in the follow-up of abdominal traumatic injuries. The fact that CEUS preserves CT's sensitivity while not carrying the risk of radiation-induced cancer makes it feasible for children and pregnant women. This review aims to discuss the technical aspects of CEUS, the limitations, and possibilities regarding this modality, present the appearance of both a healthy and injured spleen, and compare CEUS's effectiveness to that of CT through an analysis of retrievable studies.

Laparoscopic surgery: An effective alternative for managing severe blunt splenic injuries in patients who are ineligible for transcatheter arterial embolization

BACKGROUND

Transcatheter arterial embolization (TAE) is an effective alternative to nonoperative management (NOM) to improve the spleen salvage rate for patients with blunt splenic injuries (BSIs), but it is not always available at some institutions. Moreover, laparoscopy has also been used to diagnose and treat trauma, including BSIs.

METHODS

We present our 11-year experience in performing laparoscopic surgery for spleen salvage in patients with severe BSIs when TAE is infeasible. The outcomes of laparoscopic surgery or TAE for spleen salvage in hemodynamically stable patients with severe BSIs were compared.

RESULTS

Fifty-six patients underwent interventions for severe BSIs during this period. Twenty patients underwent laparoscopic surgery, and 36 underwent TAE. There were no significant differences in demographics, preoperative conditions, or clinical characteristics (all p > 0.05). In the laparoscopic surgery group, 15 patients (75 %) underwent laparoscopic splenorrhaphy for spleen salvage surgery, and five (25 %) required splenectomy. No complications requiring intervention were observed in the laparoscopic surgery group, whereas three patients in the TAE group required a late splenectomy for splenic abscess. No significant differences were detected in the splenic preservation rate, complication rate, or length of hospital stay between the groups (all p > 0.05).

CONCLUSION

Laparoscopy is feasible and safe for managing hemodynamically stable patients with severe BSIs, and the outcomes are comparable to those of TAE. When TAE is infeasible, laparoscopy can be considered an alternative to increase the spleen salvage rate.

Contemporary Management of Blunt Splenic Trauma in Adults: An Analysis of the Trauma Quality Improvement Program Registry

PURPOSE

The aim of this study was to evaluate the effectiveness of management strategies for blunt splenic injuries in adult patients.

METHODS

Patients 18 years and older with blunt splenic injuries registered via the Trauma Quality Improvement Program (2013-2019) were identified. Management strategies initiated within 24 hours of hospital presentation were classified as watchful waiting, embolization, surgery, or combination therapy. Patients were stratified by injury grade. Linear models estimated each strategy's effect on hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality.

RESULTS

Of 81,033 included patients, 86.3%, 10.9%, 2.5%, and 0.3% of patients received watchful waiting, surgery, embolization, and combination therapy, respectively. Among patients with low-grade injuries and compared with surgery, embolization was associated with shorter hospital LOS (9.4 days, Q < .001, Cohen's d = .30) and ICU LOS (5.0 days, Q < .001, Cohen's d = .44). Among patients with high-grade injuries and compared with surgery, embolization was associated with shorter hospital LOS (8.7 days, Q < .001, Cohen's d = .12) and ICU LOS (4.5 days, Q < .001, Cohen's d = .23). Among patients with low- and high-grade injuries, the odds ratios for in-hospital mortality associated with surgery compared with embolization were 4.02 (Q < .001) and 4.38 (Q < .001), respectively.

CONCLUSIONS

Among patients presenting with blunt splenic injuries and compared with surgery, embolization was associated with shorter hospital LOS, shorter ICU LOS, and lower risk for mortality.

Level III Trauma Centers Achieve Comparable Outcomes in Blunt Splenic Injury as Level I Centers

INTRODUCTION

Identifying patients who can be safely managed in lower-level trauma centers is critical to avoid overburdening level I centers. This study examines the transfer patterns and outcomes of blunt splenic injury (BSI) patients cared for at 2 regional level III trauma centers as compared to an associated level I center.

METHODS

A retrospective cohort study was conducted including all trauma patients with BSI admitted to 2 level III trauma centers (TC3) and a level I center (TC1) between 2012 and 2022. Patients were broken into 3 categories: TC1, TC3, and transfer patients (transferred from TC3 to TC1).

RESULTS

A total of 1480 patients were admitted to TC1, 208 patients to TC3, and 128 were transferred. 22.7% of transfer patients were children. No difference in splenic injury grade was seen between patients managed at TC1 and TC3. Patients presenting to TC1 had more severe concomitant injuries. Patients underwent urgent splenectomy at similar rates at TC1 and TC3 (15.1 vs 18.7%, P = .1). Successful nonoperative management was achieved at similar rates (81.3 vs 75.5%, P = .1). When controlling for ISS and ED disposition, there was no significant difference in length of stay (LOS), ICU LOS, and inpatient mortality between TC1 and TC3.

CONCLUSION

Level III centers effectively managed BSI achieving comparable outcomes to the level 1 center. Transfers commonly occurred in pediatric and multisystem trauma patients, though high-grade splenic injuries were not predictive of transfer. High-grade BSI can be safely managed at level III centers without need for transfer.

Surgical Repair vs Splenectomy in Patients With Severe Traumatic Spleen Injuries

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Adrenal gland injury in trauma patients and its impact on clinical outcomes

BACKGROUND

Adrenal gland injury (AGI) associated with trauma is an uncommon and often overlooked condition. This study aimed to evaluate the frequency of AGI in individuals with severe trauma injuries and investigate the outcomes of patients with AGI.

METHODS

All patients admitted to a tertiary trauma referral center under the trauma protocol who had a computed tomography (CT) scan between January 2012 and January 2023 were analyzed retrospectively. Patients who were dead on arrival and patients with incomplete data were excluded. They were classified into two main groups, adult and pediatric, and further subcategorized by the presence or absence of radiologically evident AGI. Demographic data, mechanism of injury, injury severity scores (ISS), presence of concurrent abdominal injury, and 30-day mortality rates were compared. A separate analysis was performed for factors affecting mortality rates.

RESULTS

A total of 1,253 patients were included: 950 adults and 303 pediatric patients. In the adult group, AGI was detected in 45 (4.7%) patients and was more commonly associated with the following mechanisms of injury: motor vehicle accidents (26.7% vs. 14.3%) and pedestrian accidents (37.8% vs. 15.5%). Injury to the right side was more common (55.6%). Patients with AGI had higher rates of concurrent liver (17.8% vs. 3.9%), spleen (11.1% vs. 3.6%), and kidney injuries (15.6% vs. 1.3%). In the pediatric population, AGI was detected in 30 patients (14.8%), a significantly higher rate compared to the adult group. Similar to the adult group, AGI was more commonly associated with concurrent abdominal injuries and had a right-sided dominance (60%), but the rate of concurrent abdominal injuries was higher in the pediatric group (80% vs. 46%). The 30-day mortality was significantly higher in both adult and pediatric AGI groups compared to patients without AGI (adult: 15.6% vs. 2.9%, pediatric: 10% vs. 1.8%). In patients with AGI, major head and neck injuries and chest injuries were associated with mortality.

CONCLUSION

Adrenal gland injuries due to trauma are not uncommon. They are usually associated with blunt trauma and other concurrent abdominal organ injuries. The major contributors to mortality in patients with AGI were major head and neck injuries and chest injuries.

Operative and non-operative treatment of injury to solid abdominal organs in adult patients: a single center experience

BACKGROUND

In major trauma, lesions of the parenchymatous organs are subject of a controversy as regards the choice between an operative management (OM) in the operating room and a non-operative management (NOM) associated or not with angiography/angioembolization (AG/AE).

METHODS

Retrospective study of all consecutive data of patients coded as "traumatic pathology" in the period between 2011 and 2021. Were enrolled 13740 entries of adult patients with abdominal injuries, including at least: either hepatic or splenic or renal injury of AAST-OIS I. The primary outcome was to establish the rate of efficacy, respectively of OM and NOM. The secondary outcome is to analyze General (CG) and Specific (CS) complications, mean ward and intensive care unit (ICU) hospital stays.

RESULTS

One hundred sixty-two patients were included with 89 splenic injuries, 70 hepatic and 50 renal lesions; 35 treated with OM and 127 with NOM±AG/AE. The CGs registered in OM patients are seven (20%); seven SCs (20%); four GCs+SCs (11.4%). The average hospital stay was 24.91 days; mean ICU hospital stay of 10.74; five deaths. The CGs registered are 22 (17%); 12 SCs (9.4%); three GCs+SCs (2.3%). Average hospital stays 18 days; mean ICU hospital stay of 3.15; 6 deaths. Failure of the NOM strategy was recorded in nine patients with a success rate of 92.91%.

CONCLUSIONS

In OM the presence of numerous high-grade lesions leads to a rapid stabilization. The NOM has reduced the hospital stay and UTI hospitalization in a feasible and safe way in selected CT.

[Management of Injuries to the Parenchymal Abdominal Organs]

The most common organs affected by abdominal trauma are the spleen and the liver, often in combination. Pancreatic injuries are rare. In the case of blunt abdominal trauma, which is much more common, a clinical and laboratory examination as well as sonography should be performed. In the initial assessment, the circulatory situation must be screened. If there is haemodynamic instability and presentation of free fluid, an emergency laparotomy is indicated. If the situation is stable or stabilised and a pathological sonography is present, it is essential to perform triphasic contrast enhanced computed tomography, which is also mandatory in polytraumatised patients. If a renal injury is suspected, a late venous phase should be attached. In addition to the classification of the injury, attention should be paid to possible vascular injury or active bleeding. In this case, angiography with the possibility of intervention should be performed. Endoscopic treatment is possible for injuries of the pancreatic duct. If the imaging does not reveal any intervention target and a circulation is stable, a conservative approach is possible with continuous monitoring using clinical, laboratory and sonographic controls. Most injuries can be successfully treated by non-operative management (NOM).There are various surgical options for treating the injury, such as local and resecting procedures. There is also the option of "damage control surgery" with acute bleeding control and second look. Complex surgical procedures should be performed at centres. Postoperative complications arise out of elective surgery.In the less common case of penetrating abdominal trauma, the actual extent of the injury cannot be estimated from the visible wound. Here again, the circulatory situation determines the next steps. An emergency laparotomy should be carried out in case of instability. If the condition is stable, further diagnostics should be performed using contrast enhanced computed tomography. If penetration through the peritoneum cannot be clearly excluded, diagnostic laparoscopy should be performed.

Perineal laceration treated with negative pressure wound therapy following colostomy

A male in his early 30s was transported to the emergency room after being hit by a vehicle while inebriated and lying in the street. His general condition was stable; however, he had a perineal laceration that extended to the coccyx. Due to the proximity of the wound margin to the anus, we were concerned regarding the potential contamination and opted not to suture it. Therefore, we refrained from suturing the wound and kept the wound open after irrigation and debridement. Additionally, we performed a transverse colostomy. On day 4, we initiated negative pressure wound therapy for 40 days, during which sufficient wound granulation occurred. The patient was discharged, and the colostomy was closed approximately 4 months after the injury. Our case illustrates the effectiveness of negative pressure wound therapy in managing perineal lacerations.

Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper

Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient's values and target the best outcome possible given the patient's desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes.

Clinical factors and outcomes of spleen-conserving surgery versus total splenectomy in splenic injuries: A nationwide database study

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.

Delayed presentation of splenic artery pseudoaneurysm: A critical outcome of blunt abdominal trauma; A case report

INTRODUCTION AND IMPORTANCE

Blunt abdominal trauma is one of the most common reasons for emergency department visits, and spleen and splenic vasculature is involved variably in those cases. Splenic artery pseudoaneurysm formation is one complication with potentially devastating consequences. Early detection and management are of paramount importance given its potential fatality. Management includes open repair with or without splenectomy, and endovascular approach. The minimally invasive endovascular treatment offers earlier recovery, preserved splenic function, and positive outcomes. We report a case of delayed presentation of a large splenic artery pseudoaneurysm after blunt abdominal trauma, managed using endovascular intervention.

CASE PRESENTATION

A 45-year-old male presented 10 days after being involved in a pedestrian accident with blunt abdominal trauma resulting in a large splenic artery pseudoaneurysm. After multidisciplinary discussion, the decision was to take him for endovascular treatment. The patient recovered very well and was discharged two days later and followed up in an outpatient setting. Over a year, he became symptom free, and demonstrated radiological finding of shrinking pseudoaneurysm.

CLINICAL DISCUSSION

Pseudoaneurysms of visceral arteries are repaired regardless of their size per society of vascular surgery guidelines. Larger ones are at higher risk of rupture and are associated with high mortality. When discovered, treatment plans should be readily discussed, and undertaken. In our case, the patient had a 6.5 cm splenic artery pseudoaneurysm, and a multidisciplinary meeting was conducted and concluded that endovascular treatment would be the best modality to start with, with surgical option as a backup in a hybrid room setting.

CONCLUSION

Blunt abdominal trauma can present with overt symptoms of internal organ injury; however, some might be missed and need high index of suspicion and therefore further testing and imaging. Splenic artery pseudoaneurysms can expand and rupture in delayed presentation, early detection and management is of paramount importance. Endovascular treatment represents an excellent modality, with minimal invasive nature, faster recovery, and early return to daily activity with preserved splenic function.

Clinical parameters for the early detection of complications in patients with blunt hepatic and/or splenic injury undergoing non-operative management

BACKGROUND

Complications arising during non-operative management (NOM) of blunt hepatic and/or splenic trauma, particularly in cases of severe injury, are associated with significant morbidity and mortality. Abdominal computed tomography (CT) is the gold standard for the initial detection of complications during NOM. Although many institutions advocate routine in-hospital follow-up scans to improve success rates, others recommend a more selective approach. The use of follow-up CT remains a subject of ongoing debate, with no validated guidelines available regarding the timing, effectiveness, or intervals of follow-up imaging.

OBJECTIVE

We aimed to identify the clinical parameters for the early detection of complications in patients with blunt hepatic and/or splenic injury undergoing NOM.

MATERIALS AND METHODS

This retrospective cohort study included patients with blunt hepatic and/or splenic trauma treated at Songklanagarind Hospital, a level 1 trauma center, from 2013 to 2022. We assessed all patients indicated for non-operative management and examined their clinical parameters and complications.

RESULTS

Of 542 patients with blunt hepatic and/or splenic injuries, 315 (58%) were managed non-operatively. High-grade hepatic injuries were significantly associated with complications, as determined through a multivariate logistic regression analysis after adjusting for factors such as contrast blush findings, age, sex, and injury severity score (ISS) (adjusted OR = 7.69, 95% CI 1.59-37.13; p = 0.011). Among the patients with complications (n = 27), 17 (63%) successfully underwent non-operative management. Notably, eight patients presented with clinical symptoms prior to the diagnosis of complications, while only two patients had no clinical symptoms before the diagnosis. Tachycardia, abdominal pain, decreased hematocrit levels, and fever were significant indicators of complications (p < 0.05).

CONCLUSION

Routine CT to detect complications may not be necessary in patients with asymptomatic low-grade blunt hepatic injuries. By contrast, in those with isolated blunt hepatic injuries that are managed non-operatively, high-grade injuries, the presence of a contrast blush on initial imaging, and the patient's age may warrant consideration for routine follow-up CT scans. Clinical symptoms and laboratory observations during NOM, such as tachycardia, abdominal pain, decreased hematocrit levels, and fever, are significantly associated with complications. These symptoms necessitate further management, regardless of the initial injury severity, in patients with blunt hepatic and/or splenic injuries undergoing NOM.