Non-operative management of blunt splenic trauma: evolution, results and controversies

Spread and feasibility of non-operative management (NOM) of traumatic splenic injuries in adults: a national survey

In hemodynamically stable adults sustaining a splenic trauma, non-operative management (NOM) represents the standard approach even in high-severity injuries. However, knowledge, structural, and logistic limitations still reduce its wider diffusion. This study aims to identify such issues to promote the safe and effective management of these injuries.A survey was developed using the SurveyMonkey® software and spread nationally in Italy. The survey was structured into: (1) Knowledge of classification systems; (2) Availability to refer patients; (3) Patients monitoring and follow-up; (4) Center-related.The survey was filled in by 327 surgeons, with a completeness rate of 63%. Three responders out of four are used to manage trauma patients. Despite most responders knowing the existing classifications, their use is still limited in daily practice. If a patient needs to be centralized, the concern about possible clinical deterioration represent the main obstacle to achieving a NOM. The lack of protocols does not allow standardization of patient surveillance according to the degree of injury. The imaging follow-up is not standardized as well, varying between computed tomography, ultrasound, and contrast-enhanced ultrasound.The classification systems need to be spread to all the trauma-dedicated physicians, to speak a common language. A more rational centralization of patients should be promoted, ideally through agreements between peripheral and reference centers, both at regional and local level. Standardized protocols need to be shared nationally, as well as the clinical and imaging follow-up criteria should be adapted to the local features.

In Solid Organ Injury Patients Requiring Blood Transfusion, Hemostatic Procedures are Associated with Improved Survival Over Observation

Introduction

Selective nonoperative management (NOM) is the standard of care for blunt solid organ injury (SOI). Hemodynamic instability is a contraindication for NOM, but it is unclear whether the need for blood transfusion should be a criterion for instability. This study looks at the outcome of blood-transfused SOI patients to determine whether NOM is safe for this group.

Methods

This is a retrospective cohort study using the National Trauma Data Bank years 2017 through 2019. We selected patients with blunt liver, spleen, and kidney injuries. Within this group, we compared the mortality for those managed with NOM versus the hemostatic procedures of laparotomy and angioembolization. Significance for univariate analysis is tested with Chi-square for categorical variables. Multivariate analysis is performed with Cox proportional hazards regression with time-dependent covariate.

Results

108,718 (3.5%) patients for the years 2017 through 2019 had a SOI. 20,569 (18.9%) of these received at least one unit of packed red blood cells (PRBCs) within the first 4 h. Of the SOI patients who received blood, 8264 (40.2%) underwent laparotomy only, 2924 (14.2%) underwent embolization only, and 1119 (5.4%) underwent both procedures. The adjusted odds ratios (ORs) of death for transfused SOI patients who underwent laparotomy only, embolization only, and both procedures are 0.93 (P = not significant), 0.27 (P < 0.001), and 0.48 (P < 0.001), respectively. The ORs of death with laparotomy for patients receiving >1 through 4 units are 0.87, 0.78, 0.75, and 0.72, respectively (P ≤ 0.01 for all). For embolization, the ORs are 0.27, 0.30, 0.30, and 0.30, respectively (P < 0.001 for all).

Conclusion

Laparotomy is independently associated with survival for patients who receive >1 unit of PRBCs. Angioembolization is independently associated with survival for the entire cohort, including transfused patients. Given the protective association of laparotomy in the blood-transfused SOI group, need for blood transfusion should be considered a meaningful index of instability and a relative indication for laparotomy. The protective association with angioembolization supports current practices for angioembolization of high-risk patients in the transfused and nontransfused groups.

Clinical features and direct medical cost of splenic injury in China: a cross-sectional study

OBJECTIVES

This study analyses the clinical features and direct medical cost (DMC) of splenic injury during 2000-2013 in China.

DESIGN

This was a cross-sectional study.

METHODS

We used 'The No. 1 Military Medical Project' information system to conduct a retrospective study. Patients' information from 2000 to 2013 were identified. Demographic data, treatment, clinical data and DMC were collected. We performed a generalised linear method (GLM) using gamma distribution to assess the drivers of DMCs.

RESULTS

We included 8083 patients with splenic injury who met the study criteria. Over the 14-year study period, 2782 (34.4%) patients were treated with non-operative management (NOM), 5301 (65.6%) with OM. From 2000 to 2013, the rate of NOM increased from 34.7% to 55.9%, while OM decreased from 65.3% to 44.1%. Mean per-patient DMC in both NOM and OM increased from 2000 to 2013. In GLM analysis, male, old age, length of stay, severe splenic injury grade, OM, intensive care unit, blood transfusion and tertiary hospitals were associated with higher DMC, while female and NOM was associated with lower DMC.

CONCLUSIONS

In China, management of splenic injury was the most important factor impacting the total DMC. Proper management and public policy could curtail the burden of splenic injury.

Non-operative management in blunt splenic trauma: A ten-years-experience at a Level 1 Trauma Center

Trauma; Spleen injuries are among the most frequent trauma-related injuries. The approach for diagnosis and management of Blunt Splenic Injury (BSI) has been considerably shifted towards Non- Operative Management (NOM) in the last few decades. NOM of blunt splenic injuries includes Splenic Angio-Embolization (SAE). Aim of this study was to analyze Pisa Level 1 trauma center (Italy) last 10-years-experience in the management of Blunt Splenic Trauma (BST), and more specifically to evaluate NOM rate and failure. Retrospective analysis of all patients admitted with blunt splenic trauma was done. They were divided into two groups according to the treatment: hemodynamically unstable patients treated operatively (OM group) and patients underwent a nonoperative management (NOM group). The CT scan performed in all NOM group patients. Univariate analysis was performed to identify differences between the two groups. Multivariate analysis adjusting for factors with a p value < 0.05 or with clinical relevance was used to identify possible risk factors for NOM failure. 193 consecutive patients with blunt splenic trauma were admitted. Emergency splenectomies were performed in 53 patients (OM group); 140 were managed non-operatively with or without SAE (NOM group). NOM rate in high grade injuries is 57%. Overall NOM failure rate is 9%, and success rate in high grade splenic injuries is 48%; multivariate analysis showed AAST score ≥3 as a risk factor for NOM failure. Non-operative management currently represents the gold standard management for hemodynamically stable patient with blunt splenic trauma even in high grade splenic injuries. AAST ≥3 spleen lesion is a failure risk factor but not a contraindication to for non-operative management.