A review of the management of blunt splenic trauma in England and Wales: have regional trauma networks influenced management strategies and outcomes?

Major trauma and comorbidity: a scoping review

PURPOSE

Major trauma is a leading cause of acute morbidity and mortality. While injury severity drives much of the associated burden, pre-existing comorbidities may influence both acute management and long-term outcomes. This scoping review examines the impact of comorbidities on trauma outcomes.

METHODS

Embase, Medline, CINAHL, Cochrane Library, and PubMed were systematically searched from inception to 22/04/2021 (update 22/03/2024). Studies investigating comorbidities as risk factors for adverse outcomes in adults (≥ 18 years) with major trauma were included.

RESULTS

Of 5448 studies identified, 33 met inclusion criteria. No studies examined whether comorbidities increases the risk of major trauma, and only two studies investigated the development of comorbidities post-trauma. Among trauma patients with pre-existing comorbidities particularly cardiovascular disease, diabetes, liver disease, and kidney disease were associated with higher case fatality. Comorbidities were also associated with increased morbidity, longer hospital stays and higher complication rates.

CONCLUSIONS

Trauma patients with comorbidities suffer experience worse outcomes, yet limited research explores whether comorbidities contribute to trauma risk or emerge as a consequence. Further research is needed to clarify these relationships and guide targeted interventions.

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.

SPEED (SPlEnic Embolisation Decisions) study-Decision to treat acute traumatic splenic artery injury in the context of trauma protocol

BACKGROUND

The spleen is commonly injured in trauma and this may be managed with a conservative approach, embolisation or splenectomy. There is uncertainty how splenic embolisation fits into the treatment paradigm and the delivery of IR services remains variable.

AIMS AND OBJECTIVES

The primary objectives are to determine if service design significantly affects splenic embolisation (SE) rates in AAST grade 2-5 acute traumatic splenic injuries (ATSI) across the Major Trauma Centres (MTCs) in England and to determine if variation in treatment affects SE outcomes in ATSI.

METHODS

We will include 5 years of data from traumatic splenic injury patients in the MTCs from 01/01/2016 to 31/12/2020 available from the Trauma Audit and Research Network (TARN) database. Inclusion Criteria will be all patients with ATSI registered with TARN. Those without a CT available to grade radiologically will be excluded. Data available from the TARN database and then correlated with data that will be collected at each MTC, where detail as to the embolisation technique, specific injury pattern, imaging based follow up and patient survival will be available. A short service-based questionnaire will be sent to each centre to establish centre-specific details such as on call rota, IR response activation, reporting practices and capture data around routine decision-making at that site. Data will be collected on an anonymised (REDCap) database. This project will evaluate the impact of service design on embolisation rates and outcomes, as well as evaluating the impact of the variation upon treatment selection and outcomes. Logistic regression will be used to identify factors associated with treatment selection and mortality at 30 days.

Clinical Outcomes of Splenic Artery Embolization Versus Splenectomy in the Management of Hemodynamically Stable High-Grade Blunt Splenic Injuries: A National Analysis

INTRODUCTION

This study aims to compare the outcomes of splenic artery embolization (SAE) versus splenectomy in adult trauma patients with high-grade blunt splenic injuries.

METHODS

This retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database (2017-2021) compared SAE versus splenectomy in adults with blunt high-grade splenic injuries (grade ≥ IV). Patients were stratified first by hemodynamic status then splenic injury grade. Outcomes included in-hospital mortality, intensive care unit length of stay (ICU-LOS), and transfusion requirements at four and 24 h from arrival.

RESULTS

Three thousand one hundred nine hemodynamically stable patients were analyzed, with 2975 (95.7%) undergoing splenectomy and 134 (4.3%) with SAE. One thousand eight hundred sixty five patients had grade IV splenic injuries, and 1244 had grade V. Patients managed with SAE had 72% lower odds of in-hospital mortality (odds ratio [OR] 0.28; P = 0.002), significantly shorter ICU-LOS (7 versus 9 d, 95%, P = 0.028), and received a mean of 1606 mL less packed red blood cells at four h compared to those undergoing splenectomy. Patients with grade IV or V injuries both had significantly lower odds of mortality (IV: OR 0.153, P < 0.001; V: OR 0.365, P = 0.041) and were given less packed red blood cells within four h when treated with SAE (2056 mL versus 405 mL, P < 0.001).

CONCLUSIONS

SAE may be a safer and more effective management approach for hemodynamically stable adult trauma patients with high-grade blunt splenic injuries, as demonstrated by its association with significantly lower rates of in-hospital mortality, shorter ICU-LOS, and lower transfusion requirements compared to splenectomy.

The Blunt Liver and Spleen Trauma (BLAST) audit: national survey and prospective audit of children with blunt liver and spleen trauma in major trauma centres

PURPOSE

To compare the reported and observed management of UK children with blunt liver or spleen injury (BLSI) to the American Pediatric Surgical Association (APSA) 2019 BLSI guidance.

METHODS

UK Paediatric Major Trauma Centres (pMTCs) undertook 1 year of prospective data collection on children admitted to or discussed with those centres with BLSI and an online questionnaire was distributed to all consultants who care for children with BLSI in those centres.

RESULTS

All 21/21 (100%) pMTCs participated; 131 patients were included and 100/152 (65%) consultants responded to the survey. ICU care was reported and observed to be primarily determined using haemodynamic status or concomitant injuries rather than injury grade, in accordance with APSA guidance. Bed rest was reported to be determined by grade of injury by 63% of survey respondents and observed in a similar proportion of patients. Contrary to APSA guidance, follow-up radiological assessment of the injured spleen or liver was undertaken in 44% of patients before discharge and 32% after discharge, the majority of whom were asymptomatic.

CONCLUSIONS

UK management of BLSI differs from many aspects of APSA guidance. A shift towards using clinical features to determine ICU admission and readiness for discharge is demonstrated, in line with a strong evidence base. However, routine bed rest and re-imaging after BLSI is common, contrary to APSA guidance. This disparity may exist due to concern that evidence around the incidence, presentation and natural history of complications after conservatively managed BLSI, particularly bleeding from pseudoaneurysms, is weak.

Conservative Management of Splenic Injury in Blunt Abdominal Trauma: A Single Center Experience

BACKGROUND

Road traffic accidents are the greatest cause of death worldwide. Most intra-abdominal injuries caused by blunt abdominal trauma have been treated surgically for a very long period. Over the past few decades, conservative care has gained in popularity and effectiveness as a treatment choice for blunt abdominal trauma.

OBJECTIVE

To determine the efficacy of conservative management in patients suffering from splenic injury in blunt abdominal trauma.

METHODS

The study included 62 cases of blunt abdominal trauma treated non-operatively in the general surgery department of the Hayatabad Medical Complex Peshawar between June 2021 and December 2022.

RESULTS

Minimal hemoperitoneum was observed in 47 (75.8%) cases, moderate hemoperitoneum was noted in 11 (17.7%) cases, and 4 (6.4%) patients didn't have free fluid in the abdomen. There was no massive hemoperitoneum among the study patients. No major complications were observed during the study period. Only 7 (11.3%) cases develop minimal pleural effusion while 2 (3.2%) patients developed splenic abscess. Mortality was observed in only 1 (1.6%) case.

CONCLUSIONS

Conservative management is a safe and efficient strategy and should be considered as a first line of treatment for all hemodynamically stable patients who suffered blunt splenic injury.

Splenic Artery Embolization in Conservative Management of Blunt Splenic Injury Graded by 2018 AAST-OIS: Results from a Hospital in Vietnam

Purpose

This study was conducted to evaluate the results of conservative management of blunt splenic trauma according to the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) in 2018 by embolization.

Methods

This observational study included 50 patients (42 men and 8 women) with splenic injury who underwent multidetector computed tomography (MDCT) and embolization.

Results

According to the 2018 AAST-OIS, 27 cases had higher grades than they did according to the 1994 AAST-OIS. The grades of two cases of grade II increased to grade IV; those of 15 cases of grade III increased to grade IV; and four cases of grade IV increased to grade V. As a result, all patients underwent successful splenic embolization and were stable at discharge. No patients required re-embolization or conversion to splenectomy. The mean hospital stay was 11.8±7 days (range, 6-44 days), with no difference in length of hospital stay among grades of splenic injury (p >0.05).

Conclusion

Compared with the AAST-OIS 1994, the AAST-OIS 2018 classification is useful in making embolization decisions, regardless of the degree of blunt splenic injury with vascular lacerations visible on MDCT.

[Do concomitant urological injuries in severely injured patients lead to poorer outcomes? : A multivariate risk analysis]

BACKGROUND

Severely injured patients with associated genitourinary (GU) injuries have only rarely been investigated in the current literature. If at all, analyses are commonly focussed on renal injuries, marginalising other GU traumas such as ureteral injuries. In this study, we would like to characterise patients with GU injuries and analyse the impact of such injuries on mortality and length of stay.

MATERIALS AND METHODS

The inclusion criteria for this retrospective analysis of TraumaRegister DGU® data were: Injury Severity Score ≥ 16 within the period between 2009 and 2016 with available data on age and length of stay. A descriptive analysis was used to compare patients with and without GU injuries. The impact of GU injuries on mortality and length of hospital stay was evaluated by means of multivariate regression analyses.

RESULTS

In all, 90,962 patients met the inclusion criteria; 5.9% of them had suffered GU injuries (n = 5345). The prevalence in patients with pelvic fractures was up to 19%. On average, patients with GU trauma were 10 years younger (42.9 vs. 52.2 years) and more severely injured (ISS: 31.8 vs. 26.4). The multivariate analyses demonstrated that GU injuries in severely injured patients are no independent risk factor for mortality. However, particularly bladder and genital injuries result in longer hospitalisation.

CONCLUSION

GU injuries do not represent an additional risk factor for mortality. However, after adjusting for established prognosis factors, they can cause prolonged periods of hospitalisation of severely injured patients.

Injured patients who would benefit from expedited major trauma centre care: a consensus-based definition for the United Kingdom

INTRODUCTION

Despite the importance of treating the 'right patient in the right place at the right time', there is no gold standard for defining which patients should receive expedited major trauma centre (MTC) care. This study aimed to define a reference standard applicable to the United Kingdom (UK) National Health Service major trauma networks.

METHODS

A one-day facilitated roundtable expert consensus meeting was conducted at the University of Sheffield, UK, in September 2019. An expert panel of 17 clinicians was purposively sampled, representing all specialities relevant to major trauma management. A consultation process was subsequently held using focus groups with Public and Patient Involvement (PPI) representatives to review and confirm the proposed reference standard.

RESULTS

Four reference standard domains were identified, comprising: need for critical interventions; presence of significant individual anatomical injuries; burden of multiple minor injuries; and important patient attributes. Specific criteria were defined for each domain. PPI consultation confirmed all aspects of the reference standard. A coding algorithm to allow operationalisation in Trauma Audit and Research Network data was also formulated, allowing classification of any case submitted to their database for future research.

CONCLUSIONS

This reference standard defines which patients would benefit from expedited MTC care. It could be used as the target for future pre-hospital injury triage tools, for setting best practice tariffs for trauma care reimbursement and to evaluate trauma network performance. Future research is recommended to compare patient characteristics, management and outcomes of the proposed definition with previously established reference standards.

Laparoscopic splenectomy after trauma: Who, when and how. A systematic review

Importance:

A deep knowledge of the indication for laparoscopic splenectomy (LS) in trauma case can lead trauma surgeon to offer in a wider number of situations a minimally invasive approach to a common injuries.

Objective:

To present and review the advantages and disadvantages of laparoscopic approach for spleen trauma and to identify patient whose can benefit from a minimally invasive approach versus patient that need open surgery to assess the whole severity of trauma.

Evidence Review:

A systematic review was performed according to the PRISMA statement in order to identify articles reporting LS after trauma. A literature search was performed through MEDLINE (through PubMed), Embase and Google Scholar from January 1990 to December 2018. Studies conducted on animals were not considered. All other laparoscopic procedures for spleen trauma were excluded.

Results:

Nineteen articles were included in this study, reporting 212 LS after trauma. The most study includes blunt trauma patient. All LS were performed in haemodynamically stable patient. Post-operative complications were reported in all articles with a median post-operative morbidity rate of 30 patients (14.01%), including 16 (7.5%) post-operative deaths.

Conclusions and Relevance:

This article reports the feasibility and safety of a minimally invasive approach for common trauma injuries which can help non-advanced laparoscopic skill trauma surgeon to develop the best indication to when to adopt this kind of approach.

Caracterización de pacientes con trauma esplénico atendidos en un hospital de tercer nivel entre enero de 2000 y diciembre de 2017

Introducción. Es frecuente (46 %) que la lesión esplénica se acompañe de otra lesión visceral concomitante, con una alta tasa de morbimortalidad. La evolución de las técnicas para el abordaje de estas lesiones incluye procedimientos quirúrgicos, intervencionistas y de manejo expectante. Métodos. Se trata de un estudio con cohorte única retrospectiva y observacional. Se incluyeron pacientes mayores de 13 años de edad con trauma esplénico, atendidos entre enero de 2000 y diciembre de 2017. Se describieron las características relacionadas con el proceso de atención. Resultados. Se identificaron 116 pacientes con trauma esplénico, el 85,2 % de ellos hombres, con una edad promedio de 26 años. El 75,9 % de los pacientes presentaba lesiones concomitantes; las más frecuentes fueron de diafragma (31,0 %), de hígado (17,2 %) y de riñón (11,2 %). Los mecanismos de lesión más frecuentes fueron por arma corto-punzante (29,3 %), por arma de fuego (22,4 %) y por accidentes de tránsito (22,4 %). La gravedad fue clasificada como de grado V en el 24,1 % de los pacientes y de grado I en el 23,3 %. Se practicó esplenectomía total en el 39,7 % de los pacientes y el 15,2 % fue manejado de forma conservadora. La mortalidad fue del 4,3 %, tres casos en el posoperatorio inmediato (menos de 24 horas) y dos en la primera semana posoperatoria. Discusión. El manejo conservador de las lesiones esplénicas de poca gravedad es una estrategia segura y efectiva, con una tasa de fracaso de menos del 5. El abordaje quirúrgico se reserva para lesiones de mayor gravedad y su relación con otros órganos lesionados, con una mayor morbimortalidad (63 %)

Variations in the management of adolescents with blunt splenic trauma in England and Wales: are we preserving enough?

INTRODUCTION

Management of blunt splenic injury has changed drastically with non-operative management increasingly used in paediatric and adult patients. Studies from America and Australia demonstrate disparities in care of patients treated at paediatric and adult centres. This study assessed management of splenic injuries in UK adolescents.

MATERIALS AND METHODS

Data were acquired from the Trauma Audit and Research Network on isolated blunt splenic injuries reported 2006-2015. Adolescents were divided into age groups of 11-15 years and 16-20 years, and injuries classified as minor (grades 1/2) or major (3+). Primary outcomes were needed for splenectomy and blood transfusion.

RESULTS

A total of 445 adolescents suffered isolated blunt splenic injuries. Road traffic collisions were the most common mechanism. There were no deaths as a result of isolated blunt splenic injuries, but 49 (11%) adolescents needed transfusions and 105 (23.6%) underwent splenectomies. There was no significant difference observed in the management of adolescents with minor trauma. In major trauma, 11-15-year-olds were more likely to have splenectomies when managed at local trauma units compared with major trauma centres (31% vs 4%, odds ratio 11.5; 95% confidence interval 3.82-34.38, p < 0.0001). Within major trauma centres, older adolescents were more likely to have splenectomies than younger adolescents (35.5% vs 3.8%, odds ratio 14; 95% confidence interval 4.55-43.26, p < 0.0001). There were no significant differences in haemodynamic status, transfusion requirement or embolisation rates.

CONCLUSIONS

There appears to be a large variation in the management of isolated blunt splenic injuries in the UK. The reasons for this remain unclear however non-operative management is safe and should be first line management in the haemodynamically stable adolescent, even with major splenic injuries.

Splenic artery embolisation in trauma: A five-year single-centre experience at a UK major trauma centre

Introduction

Since the introduction of major trauma centres and regional trauma networks in 2012, management of splenic injury has shifted, with non-operative management now favoured. For those requiring intervention, splenic artery embolisation is well established as a first-line treatment in all but the most severely injured. Follow-up is variable, with few guidelines, highlighting the paucity of data addressing the need for further imaging and antimicrobial prophylaxis. This review was undertaken to assess practice and outcomes at our centre in the context of the contemporary literature.

Methods

This retrospective study captured splenic embolisations over five years (January 2012–December 2016). CRIS interventional radiology codes were used to retrieve embolisation cases and Trauma Audit and Research Network and hospital event statistics data were used to identify all cases of traumatic splenic injury and to identify splenectomy and non-operative management patients. Outcomes were compared with available standards from different sources.

Results

Over the study period 176 splenic injuries were identified, of which 122 underwent non-operative management, 28 were laparotomy first, and 26 undergoing embolisation with an increased trend to an ‘embolisation-first’ approach over this time. In the embolisation group, the age range was 16–79 yr (mean 41), 18 were male and the median time to intervention was 2 h 9 min (range 1.1–171 h), with eight following failed non-operative management. The proportion of proximal versus selective embolisation versus both was 10:14:1 and the predominant mechanism was coiling. One patient was not embolised due to absence of contrast extravasation on initial angiogram and two proceeded to splenectomy due to failure of splenic artery embolisation. There were complications in six patients: five ongoing left upper quadrant pain, one infected haematoma requiring drainage, two chest infections with pleural effusions, one of which required drainage. There were two deaths from other injuries. Fifteen of the 25 patients who underwent splenic artery embolisation had follow-up imaging, seven did not and three were excluded due to splenectomy and/or death; five patients were vaccinated according to the hospital splenectomy protocol, and six received prophylactic antibiotics.

Conclusion

Our data show that non-operative management is the mainstay of treatment for the majority of splenic injury patients. Serious complications are not common but variation does exist in follow-up. The changing management trends are in line with national data. These findings will help to further implement and develop local protocols but more work is required to address splenic function after embolisation and the requirement for antimicrobial prophylaxis.

Evaluation of the impact of the NICE head injury guidelines on inpatient mortality from traumatic brain injury: an interrupted time series analysis

OBJECTIVE

To evaluate the impact of National Institute for Health and Care Excellence (NICE) head injury guidelines on deaths and hospital admissions caused by traumatic brain injury (TBI).

SETTING

All hospitals in England between 1998 and 2017.

PARTICIPANTS

Patients admitted to hospital or who died up to 30 days following hospital admission with International Classification of Diseases (ICD) coding indicating the reason for admission or death was TBI.

INTERVENTION

An interrupted time series analysis was conducted with intervention points when each of the three guidelines was introduced. Analysis was stratified by guideline recommendation specific age groups (0-15, 16-64 and 65+).

OUTCOME MEASURES

The monthly population mortality and admission rates for TBI.

STUDY DESIGN

An interrupted time series analysis using complete Office of National Statistics cause of death data linked to hospital episode statistics for inpatient admissions in England.

RESULTS

The monthly TBI mortality and admission rates in the 65+ age group increased from 0.5 to 1.5 and 10 to 30 per 100 000 population, respectively. The increasing mortality rate was unaffected by the introduction of any of the guidelines.The introduction of the second NICE head injury guideline was associated with a significant reduction in the monthly TBI mortality rate in the 16-64 age group (-0.005; 95% CI: -0.002 to -0.007).In the 0-15 age group the TBI mortality rate fell from around 0.05 to 0.01 per 100 000 population and this trend was unaffected by any guideline.

CONCLUSION

The introduction of NICE head injury guidelines was associated with a reduced admitted TBI mortality rate after specialist care was recommended for severe TBI. The improvement was solely observed in patients aged 16-64 years.The cause of the observed increased admission and mortality rates in those 65+ and potential treatments for TBI in this age group require further investigation.

Non-operative management of blunt splenic injury: is it really so extensively feasible? a critical appraisal of a single-center experience

INTRODUCTION

The spleen is one of the most commonly injured organ following blunt abdominal trauma. Splenic injuries may occur in isolation or in association with other intra-and extra-abdominal injury. Nonoperative management of blunt injury to the spleen has become routine in children. In adult most minor splenic injuries are readily treated nonoperatively but controversy exists regarding the role of nonoperative management for higher grade injuries above all in multi-trauma patients. The aim of this study is the assessment of splenic trauma treatment, with particular attention to conservative treatment, its limits, its efficiency, and its safety in multi-trauma patient or in a severe trauma patient.

METHODS

The present research focused on a retrospective review of patients with splenic injury. The research was performed by analyzing data of the trauma registry of St. Andrea University Hospital in Rome. The St. Andrea University Hospital trauma registry includes 1859. The variables taken into account were spleen injury and general injuries, age, sex, cause and dynamic of trauma, hemoglobin, hematocrit, white blood cells count, INR, number and time blood transfusion, hemodynamic stability, type of treatment provided, hospitalization period, morbidity and mortality. Assessment of splenic injuries was evaluated according to Abbreviated Injury Scale (AIS).

RESULTS

The analysis among the general population of spleen trauma patients identified 68 patients with a splenic injury representing the 41.2% of all abdomen injury. The Average age was of 37.01 ± 17.18 years. The Average ISS value was of 22.88 ± 12.85; mediana of 24.50 (range 4-66). The average Spleen AIS value was of 3.13 ± 0.88; mediana 3.00 (range 2-5). The overall mortality ratio was of 19.1% (13 patients). The average ISS value in patients who died was of 41.92 ± 12.48, whereas in patients who survided was of 23.33 ± 10.15. The difference was considered to be statistically significant (p <0.001). The relashionship between the ISS and AIS values in patients who died was considered directly proportional but not statistically significant (Pearson test AIS/ISS = 0.132, p = n.s.). The initial management was a conservative treatment in 27 patients (39.7%) of them 4 patients (15%) failed, in the other 41 cases urgent splenectomies were performed. The average spleen AIS in all the patients who underwent splenectomy was 3.61 ± 0.63 whereas in the patients who were not treated surgically was 2.42 ± 0.69. The difference was deemed statistically significant (p <0.001).

CONCLUSION

Splenic injury, as reported in our statistic as well as in literature, is the most common injury in closed abdominal trauma. Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The preference of a conservative treatment must be based on the hemodynamic stability indices as well as on the spleen lesion severity and on the general trauma severity. The conservative treatment represent a feasible and safe therapeutic alternative even in case of severe lesions in politrauma patients, but the choice of the treatment form requires an assessment for each singular case.

The elusive spleen

INTRODUCTION

The aim of this study was to review the experience of general surgeons performing splenectomy in a district general hospital. The outcomes are discussed together with potential reasons for the increasing rarity of the procedure.

METHODS

A retrospective cohort study was carried out of all patients undergoing splenectomy (as identified by a single trust pathology department on receipt of splenic samples) between 1 January 2000 and 1 May 2017. Case notes and computer systems were interrogated for data on operating surgeon, patient demographics, diagnosis, surgical approach (laparoscopic/open/converted to open), critical care admission and 30-day mortality.

RESULTS

During the study period, 170 consecutive splenectomies were undertaken by 24 different operating surgeons. There were on average 5.8 planned and 4.2 unplanned splenectomies per year. The 30-day mortality rate for all splenectomies was 8.8%, with an elective 30-day mortality rate of 2.0%. Only 3 of the current consultant surgeons had undertaken more than 6 cases over the 17-year study period. Some senior consultants had not performed any splenectomies (either planned or unplanned) during the 17-year study period.

CONCLUSIONS

Splenectomy is required ever more rarely and experience as a district general hospital consultant is limited. Possible reasons for this include improvements in medical management of haematological diseases, the increasing use of conservative and radiological management for traumatic splenic injury, and a reduction in trauma cases and diversion of such cases to major trauma centres. Trainees and consultants must seek experience during specialty training or via cadaveric training in order to demonstrate competence.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Management of blunt splenic injury in a UK major trauma centre and predicting the failure of non-operative management: a retrospective, cross-sectional study

PURPOSE

To review the management of patients >16 years with blunt splenic injury in a single, UK, major trauma centre and identify whether the following are associated with success or failure of non-operative management with selective use of arterial embolization (NOM ± AE): age, Injury Severity Score (ISS), head injury, haemodynamic instability, massive transfusion, radiological hard signs [contrast extravasation or pseudoaneurysm on the initial computed tomography (CT) scan], grade, and presence of intraparenchymal haematoma or splenic laceration.

METHODS

Retrospective, cross-sectional study undertaken between April 2012 and October 2015. Paediatric patients, penetrating splenic trauma, and iatrogenic injuries were excluded. Follow-up was for at least 30 days.

RESULTS

154 patients were included. Median age was 38 years, 77.3% were male, and median ISS was 22. 14/87 (16.1%) patients re-bled following NOM in a median of 2.3 days (IQR 0.8-3.6 days). 8/28 (28.6%) patients re-bled following AE in a median of 2.0 days (IQR 1.3-3.7 days). Grade III-V injuries are a significant predictor of the failure of NOM ± AE (OR 15.6, 95% CI 3.1-78.9, p = 0.001). No grade I injuries and only 3.3% grade II injuries re-bled following NOM ± AE. Age ≥55 years, ISS, radiological hard signs, and haemodynamic instability are not significant predictors of the failure of NOM ± AE, but an intraparenchymal or subcapsular haematoma increases the likelihood of failure 11-fold (OR 10.9, 95% CI 2.2-55.1, p = 0.004).

CONCLUSIONS

Higher grade injuries (III-V) and intraparenchymal or subcapsular haematomas are associated with a higher failure rate of NOM ± AE and should be managed more aggressively. Grade I and II injuries can be discharged after 24 h with appropriate advice.