1
|
Mahmood I, Younis B, Alabdallat M, Mathradikkal S, Abdelrahman H, El-Menyar A, Asim M, Kasim M, Mollazehi M, Al-Hassani A, Peralta R, Rizoli S, Al-Thani H. Pre- and post-implementation protocol for non-operative management of grade III-V splenic injuries: An observational study. Heliyon 2024; 10:e28447. [PMID: 38560121 PMCID: PMC10979267 DOI: 10.1016/j.heliyon.2024.e28447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/04/2024] Open
Abstract
Background Grade (III-V) blunt splenic injuries (BSI) in hemodynamically stable patients represent clinical challenges for successful non-operative management (NOM). In 2014, Our institution proposed a treatment protocol requiring splenic angiography and embolization for stable, intermediate, and high-grade BSI. It also included a follow-up CT scan for grade III BSI. We sought to assess the success rate of NOM in treating intermediate and high-grade BSI, following a standardized treatment protocol at a level 1 trauma center. Methods An observational retrospective study was conducted. Data of patients with BSI from June 2011 to September 2019 were reviewed using the Qatar National Trauma Registry. Patients' demographics, CT scan and angiographic findings, grade of splenic injuries, and outcomes were analyzed. The pre- and post-implementation of treatment protocol periods were compared. Results During the study period, a total of 552 hemodynamically stable patients with BSI were admitted, of which 240 had BSI with grade III to V. Eighty-one patients (33.8%) were admitted in the pre-protocol implementation period and 159 (66.2%) in the post-protocol implementation period. The NOM rate increased from 50.6% in the pre-protocol group to 65.6% in the post-protocol group (p = 0.02). In addition, failure of the conservative treatment did not significantly differ in the two periods, while the requirement for blood transfusion dropped from 64.2% to 45.9% (p = 0.007). The frequency of CT scan follow-up (55.3% vs. 16.3%, p = 0.001) and splenic arterial embolization (32.7% vs. 2.5%, p = 0.001) in NOM patients increased significantly in the post-protocol group compared to the pre-protocol group. Overall mortality was similar between the two periods. However, hospital and ICU length of stay and ventilatory days were higher in the post-protocol group. Conclusions NOM is an effective and safe treatment option for grade III-V BSI patients. Using standardized treatment guidelines for intermediate-to high-grade splenic injuries could increase the success rate for NOM and limit unnecessary laparotomy. Moreover, angioembolization is a crucial adjunct to NOM that could improve the success rate.
Collapse
Affiliation(s)
- Ismail Mahmood
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Basil Younis
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Mohammad Alabdallat
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Saji Mathradikkal
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Husham Abdelrahman
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Trauma and Vascular Surgery, Clinical Research, HMC, Doha, Qatar
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Mohammad Asim
- Department of Surgery, Trauma and Vascular Surgery, Clinical Research, HMC, Doha, Qatar
| | - Mohammad Kasim
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Monira Mollazehi
- Department of Surgery, Trauma Surgery, National Trauma Registry, HMC, Doha, Qatar
| | - Ammar Al-Hassani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Sandro Rizoli
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma and Vascular Surgery, HMC, Doha, Qatar
| |
Collapse
|
2
|
Sammoud S, Ghelfi J, Barbois S, Beregi JP, Arvieux C, Frandon J. Preventive Proximal Splenic Artery Embolization for High-Grade AAST-OIS Adult Spleen Trauma without Vascular Anomaly on the Initial CT Scan: Technical Aspect, Safety, and Efficacy-An Ancillary Study. J Pers Med 2023; 13:889. [PMID: 37373879 DOI: 10.3390/jpm13060889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/18/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023] Open
Abstract
The spleen is the most commonly injured organ in blunt abdominal trauma. Its management depends on hemodynamic stability. According to the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS ≥ 3), stable patients with high-grade splenic injuries may benefit from preventive proximal splenic artery embolization (PPSAE). This ancillary study, using the SPLASH multicenter randomized prospective cohort, evaluated the feasibility, safety, and efficacy of PPSAE in patients with high-grade blunt splenic trauma without vascular anomaly on the initial CT scan. All patients included were over 18 years old, had high-grade splenic trauma (≥AAST-OIS 3 + hemoperitoneum) without vascular anomaly on the initial CT scan, received PPSAE, and had a CT scan at one month. Technical aspects, efficacy, and one-month splenic salvage were studied. Fifty-seven patients were reviewed. Technical efficacy was 94% with only four proximal embolization failures due to distal coil migration. Six patients (10.5%) underwent combined embolization (distal + proximal) due to active bleeding or focal arterial anomaly discovered during embolization. The mean procedure time was 56.5 min (SD = 38.1 min). Embolization was performed with an Amplatzer™ vascular plug in 28 patients (49.1%), a Penumbra occlusion device in 18 patients (31.6%), and microcoils in 11 patients (19.3%). There were two hematomas (3.5%) at the puncture site without clinical consequences. There were no rescue splenectomies. Two patients were re-embolized, one on Day 6 for an active leak and one on Day 30 for a secondary aneurysm. Primary clinical efficacy was, therefore, 96%. There were no splenic abscesses or pancreatic necroses. The splenic salvage rate on Day 30 was 94%, while only three patients (5.2%) had less than 50% vascularized splenic parenchyma. PPSAE is a rapid, efficient, and safe procedure that can prevent splenectomy in high-grade spleen trauma (AAST-OIS) ≥ 3 with high splenic salvage rates.
Collapse
Affiliation(s)
- Skander Sammoud
- Department of Radiology, Nîmes Carémeau University Hospital, 30900 Nimes, France
| | - Julien Ghelfi
- Institute for Advanced Biosciences, Inserm U 1209, CNRS UMR 5309, Université Grenoble Alpes, 38000 Grenoble, France
- Department of Radiology, Grenoble-Alpes University Hospital, 38000 Grenoble, France
| | - Sandrine Barbois
- Department of Digestive Surgery, University Hospital Grenoble Alpes, 38043 Grenoble, France
| | - Jean-Paul Beregi
- Department of Radiology, Nîmes Carémeau University Hospital, 30900 Nimes, France
| | - Catherine Arvieux
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, 38043 Grenoble, France
| | - Julien Frandon
- Department of Radiology, Nîmes Carémeau University Hospital, 30900 Nimes, France
| |
Collapse
|
3
|
Freeman JJ, Yorkgitis BK, Haines K, Koganti D, Patel N, Maine R, Chiu W, Tran TL, Como JJ, Kasotakis G. Vaccination after spleen embolization: A practice management guideline from the Eastern Association for the Surgery of Trauma. Injury 2022; 53:3569-3574. [PMID: 36038390 DOI: 10.1016/j.injury.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Angioembolization is an important adjunct in the non-operative management of adult trauma patients with splenic injury. Multiple studies have shown that angioembolization may increase the non-operative splenic salvage rate for patients with high-grade splenic injuries. We performed a systematic review and developed evidence-based recommendations regarding the need for post-splenectomy vaccinations after splenic embolization in trauma patients. METHODS A systematic review and meta-analysis of currently available evidence were performed utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. RESULTS Nine studies were identified and analyzed. A total of 240 embolization patients were compared to 443 control patients who neither underwent splenectomy nor were embolized. There was no statistical difference between the splenic immune function of embolized and control patients. In addition, a total of 3974 splenectomy patients was compared with 686 embolization patients. Embolization patients had fewer infectious complications and a greater degree of preserved splenic immune function. CONCLUSION In adult trauma patients who have undergone splenic angioembolization, we conditionally recommend against routine post-splenectomy vaccinations. STUDY TYPE systematic review/meta-analysis Level of evidence: level III.
Collapse
Affiliation(s)
| | - Brian K Yorkgitis
- Department of Surgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL.
| | - Krista Haines
- Division of Trauma and Critical Care, Department of Surgery, Duke University, Durham, NC.
| | | | - Nimitt Patel
- Division of Trauma, Acute Care Surgery & Surgical Critical Care, Department of Surgery, MetroHealth Medical Center, Cleveland, OH.
| | - Rebecca Maine
- Trauma and Acute Care Surgery, University of North Carolina, Chapel Hill, NC
| | - William Chiu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD.
| | | | - John J Como
- Division of Trauma, Acute Care Surgery & Surgical Critical Care, Department of Surgery, MetroHealth Medical Center, Cleveland, OH.
| | - George Kasotakis
- Division of Trauma and Critical Care, Department of Surgery, Duke University, Durham, NC.
| |
Collapse
|
4
|
Arvieux C, Thony F. Management of splenic trauma in hemodynamically stable patients: Lessons to be drawn from the French SPLASH trial (Splenic Arterial Embolization to Avoid Splenectomy (SPLASH) Study Group). J Visc Surg 2021; 159:43-46. [PMID: 34716120 DOI: 10.1016/j.jviscsurg.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- C Arvieux
- CS 10-232, General and Digestive Surgery Department, Université Grenoble-Alpes, CHU de Grenoble-Alpes, 38043 Grenoble cedex, France.
| | - F Thony
- CS 10-232, University Center of Imaging and Interventional Radiology (CURIM), CHU de Grenoble-Alpes, 38043 Grenoble cedex, France
| |
Collapse
|
5
|
Cretcher M, Panick CEP, Boscanin A, Farsad K. Splenic trauma: endovascular treatment approach. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1194. [PMID: 34430635 PMCID: PMC8350634 DOI: 10.21037/atm-20-4381] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/21/2020] [Indexed: 12/16/2022]
Abstract
The spleen is a commonly injured organ in blunt abdominal trauma. Splenic preservation, however, is important for immune function and prevention of overwhelming infection from encapsulated organisms. Splenic artery embolization (SAE) for high-grade splenic injury has, therefore, increasingly become an important component of non-operative management (NOM). SAE decreases the blood pressure to the spleen to allow healing, but preserves splenic perfusion via robust collateral pathways. SAE can be performed proximally in the main splenic artery, more distally in specific injured branches, or a combination of both proximal and distal embolization. No definitive evidence from available data supports benefits of one strategy over the other. Particles, coils and vascular plugs are the major embolic agents used. Incorporation of SAE in the management of blunt splenic trauma has significantly improved success rates of NOM and spleen salvage. Failure rates generally increase with higher injury severity grades; however, current management results in overall spleen salvage rates of over 85%. Complication rates are low, and primarily consist of rebleeding, parenchymal infarction or abscess. Splenic immune function is felt to be preserved after embolization with no guidelines for prophylactic vaccination against encapsulated bacteria; however, a complete understanding of post-embolization immune changes remains an area in need of further investigation. This review describes the history of SAE from its inception to its current role and indications in the management of splenic trauma. The endovascular approach, technical details, and outcomes are described with relevant examples. SAE is has become an important part of a multidisciplinary strategy for management of complex trauma patients.
Collapse
Affiliation(s)
- Maxwell Cretcher
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, Portland, OR, USA
| | - Catherine E P Panick
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, Portland, OR, USA
| | - Alexander Boscanin
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, Portland, OR, USA
| | - Khashayar Farsad
- Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, Portland, OR, USA
| |
Collapse
|
6
|
Marsh D, Day M, Gupta A, Huang EC, Hou W, Vosswinkel JA, Jawa RS. Trends in Blunt Splenic Injury Management: The Rise of Splenic Artery Embolization. J Surg Res 2021; 265:86-94. [PMID: 33894453 DOI: 10.1016/j.jss.2021.02.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 02/07/2021] [Accepted: 02/27/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Splenic injury is common in blunt trauma. We sought to evaluate the injury characteristics and outcomes of BSI admitted over a 10-y period to an academic trauma center. METHODS A retrospective review of adult blunt splenic injury patients admitted between January 2009 and September 2018. RESULTS The 423 patients meeting inclusion criteria were divided by management: Observational (OBS, n = 261), splenic surgery (n = 114 including 4 splenorrhaphy patients), SAE (n = 43), and multiple treatment modalities (3 had SAE followed by surgery and 2 OBS patients underwent splenic surgery at readmission). The most common mechanism of injury was motor vehicle collision (47.8%). The median ISS (OBS 17, SAE 22, Surgery 34) and spleen AIS (OBS 2, SAE 3, Surgery 4) were significantly different. Complication rates (OBS 21.8%, SAE 9.3%, Surgery 45.6%) rates were significantly different, but mortality (OBS 7.3%, SAE 2.3%, Surgery 13.2%), discharge to home and readmission rates were not. Additional abdominal injuries were identified in 26.3% of the surgery group and 2.7% of OBS group. SAE rate increased from 3.0% to 28%; median spleen AIS remained 2-3. Thirty-five patients expired; 28 had severe head, chest, and/or extremity injuries (AIS ≥4). CONCLUSION SAE rates increased over time. Splenorrhaphy rates were low. SAE was associated with relatively low rates of mortality and complications in appropriately selected patients.
Collapse
Affiliation(s)
- D'Arcy Marsh
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Marilyn Day
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Amit Gupta
- Department of Radiology, Stony Brook University School of Medicine, Stony Brook New York
| | - Emily C Huang
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Wei Hou
- Department of Family, Population and Preventative Medicine, Stony Brook University School of Medicine, Stony Brook, New York
| | - James A Vosswinkel
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Randeep S Jawa
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York.
| |
Collapse
|
7
|
Gill S, Hoff J, Mila A, Sanchez C, McKenney M, Elkbuli A. Post-traumatic Splenic Injury Outcomes for Nonoperative and Operative Management: A Systematic Review. World J Surg 2021; 45:2027-2036. [PMID: 33834284 DOI: 10.1007/s00268-021-06063-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Splenectomies are widely performed, but there exists controversy regarding care for splenic injury patients. The purpose of this study is to provide a comprehensive review of the literature over the last 20 years for operative management (OM) versus nonoperative management (NOM) versus splenic artery embolization (SAE) for traumatic splenic injuries and associated outcomes. METHODS A review of literature was performed following the PRISMA guidelines through a search of PubMed, EMBASE, Cochrane Library, JAMA Network, and SAGE journals from 2000 to 2020 regarding splenic injury in trauma patients and their management. Articles were then selected based on inclusion/exclusion criteria with GRADE criteria used on the included articles to assess quality. RESULTS Twenty retrospective cohorts and one prospective cohort assessed patients who received OM versus NOM or SAE. Multiple studies indicated that NOM, in properly selected patients, provided better outcomes than its operative counterpart. CONCLUSION This review provides additional evidence to support the NOM of splenic injuries for hemodynamically stable patients with benign abdomens as it accounts for consistently shorter hospital length of stay, fewer complications, and lower mortality than OM. For hemodynamically unstable patients, management continues to be intervention with surgery. More studies are needed to further investigate outcomes of post-splenectomy patients based on grade of injury, hemodynamic status, type of procedure (i.e., SAE), and failure of NOM in order to provide additional evidence and improve outcomes for this patient population.
Collapse
Affiliation(s)
- Sabrina Gill
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, 11750 Bird Road, Miami, FL, 33175, USA
| | - John Hoff
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, 11750 Bird Road, Miami, FL, 33175, USA
| | - Ashley Mila
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, 11750 Bird Road, Miami, FL, 33175, USA
| | - Carol Sanchez
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, 11750 Bird Road, Miami, FL, 33175, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, 11750 Bird Road, Miami, FL, 33175, USA
- Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, 11750 Bird Road, Miami, FL, 33175, USA.
| |
Collapse
|
8
|
Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
9
|
Senekjian L, Cuschieri J, Robinson BRH. Splenic artery angioembolization for high-grade splenic injury: Are we wasting money? Am J Surg 2020; 221:204-210. [PMID: 32693942 DOI: 10.1016/j.amjsurg.2020.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Non-operative management (NOM) is accepted treatment of splenic injury, but this may fail leading to splenectomy. Splenic artery embolization (SAE) may improve rate of salvage. The purpose is to determine the cost-utility of the addition of SAE for high-grade splenic injuries. METHODS A cost-utility analysis was developed to compared NOM to SAE in patients with blunt splenic injury. Sensitivity analysis was completed to account for uncertainty. Utility outcome was quality-adjusted life years (QALY). RESULTS For patients with grade III, IV and V injury NOM is the dominant strategy. The probability of NOM being the more cost-effective strategy is 87.5% in patients with grade V splenic injury. SAE is not the favored strategy unless the probability of failure of NOM is greater than 70.0%. CONCLUSION For grade III-V injuries, NOM without SAE yields more quality-adjusted life years. NOM without SAE is the most cost-effective strategy for high-grade splenic injuries.
Collapse
Affiliation(s)
- Lara Senekjian
- Division of Trauma and Burns, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359796, Seattle, WA, 98104, USA; Department of Surgery, University of California San Francisco, East Bay - Alameda Health System, 1411 E. 31st Street, Oakland, CA, 94602, USA.
| | - Joseph Cuschieri
- Division of Trauma and Burns, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359796, Seattle, WA, 98104, USA.
| | - Bryce R H Robinson
- Division of Trauma and Burns, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359796, Seattle, WA, 98104, USA.
| |
Collapse
|
10
|
Freeman C, Moran V, Fang A, Isreal H, Ma S, Vyas K. Nonoperative Management of Blunt Splenic Trauma: Outcomes of Gelfoam Embolization of the Splenic Artery. J Emerg Trauma Shock 2018; 11:293-297. [PMID: 30568373 PMCID: PMC6262655 DOI: 10.4103/jets.jets_97_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Context: Nonoperative management (NOM) is the standard of care in hemodynamically stable trauma patients with blunt splenic injury. Gelfoam splenic artery embolization (SAE) is a treatment option used in trauma patients. Aims: The primary aim of this study was to retrospectively examine the use and outcomes of Gelfoam SAE in adult patients with blunt splenic injury. Settings and Design: One hundred and thirty-two adult patients with blunt splenic injury admitted to a Level 1 trauma center between January 2014 and December 2015 were included in the study. Patients treated with Gelfoam SAE, NOM, and splenectomies were reviewed. Descriptive statistics including patient age, Glasgow Coma Scale, Injury Severity Score (ISS), hospital days, Intensive Care Unit (ICU) days, splenic grade, and amount of blood products administered were recorded. Complications, defined as any additional factors that contributed to the patient's overall length of hospital stay, were compared between the three groups. Technical aspects of Gelfoam SAE and associated complications were reviewed. Subjects and Methods: Gelfoam SAE was performed in 25 (18.9%) of the 132 patients. Gelfoam SAE patients had fewer ICU days compared with those patients who had a splenectomy or NOM. There was no statistical difference in complications between patients who underwent Gelfoam SAE and those who did not. Patients who underwent Gelfoam SAE tended to have fewer complications including deep venous thrombosis's, PE, and infections and yielded no complications in 64% of the Gelfoam group. Statistical Analysis: Statistical analysis included descriptives, ANOVA, and nonparametric tests as appropriate. Conclusion: Gelfoam SAE can be used for blunt splenic injury for intermediate ISS and splenic grade as it reduced hospital and ICU days.
Collapse
Affiliation(s)
- Carl Freeman
- Department of Surgery-Trauma, Saint Louis University, USA
| | - Vicki Moran
- Department of Trauma, Saint Louis University, USA
| | - Adam Fang
- Department of Radiology-Interventional Radiology, Saint Louis University, USA
| | - Heidi Isreal
- Department of Orthopaedic Surgery, Saint Louis University, USA
| | - Shuran Ma
- Department of Anesthesiology, Stony Brook, New York, NY, USA
| | - Kena Vyas
- Department of Anesthesiology, Stony Brook, New York, NY, USA
| |
Collapse
|
11
|
Crichton JCI, Naidoo K, Yet B, Brundage SI, Perkins Z. The role of splenic angioembolization as an adjunct to nonoperative management of blunt splenic injuries: A systematic review and meta-analysis. J Trauma Acute Care Surg 2017; 83:934-943. [PMID: 29068875 DOI: 10.1097/ta.0000000000001649] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Nonoperative management (NOM) of hemodynamically normal patients with blunt splenic injury (BSI) is the standard of care. Guidelines recommend additional splenic angioembolization (SAE) in patients with American Association for the Surgery of Trauma (AAST) Grade IV and Grade V BSI, but the role of SAE in Grade III injuries is unclear and controversial. The aim of this systematic review was to compare the safety and effectiveness of SAE as an adjunct to NOM versus NOM alone in adults with BSI. METHODS A systematic literature search (Medline, Embase, and CINAHL) was performed to identify original studies that compared outcomes in adult BSI patients treated with SAE or NOM alone. Primary outcome was failure of NOM. Secondary outcomes included morbidity, mortality, hospital length of stay, and transfusion requirements. Bayesian meta-analyses were used to calculate an absolute (risk difference) and relative (risk ratio [RR]) measure of treatment effect for each outcome. RESULTS Twenty-three studies (6,684 patients) were included. For Grades I to V combined, there was no difference in NOM failure rate (SAE, 8.6% vs NOM, 7.7%; RR, 1.09 [0.80-1.51]; p = 0.28), mortality (SAE, 4.8% vs NOM, 5.8%; RR, 0.82 [0.45-1.31]; p = 0.81), hospital length of stay (11.3 vs 9.5 days; p = 0.06), or blood transfusion requirements (1.8 vs 1.7 units; p = 0.47) between patients treated with SAE and those treated with NOM alone. However, morbidity was significantly higher in patients treated with SAE (SAE, 38.1% vs NOM, 18.6%; RR, 1.83 [1.20-2.66]; p < 0.01). When stratified by grade of splenic injury, SAE significantly reduced the failure rate of NOM in patients with Grade IV and Grade V splenic injuries but had minimal effect in those with Grade I to Grade III injuries. CONCLUSION Splenic angioembolization should be strongly considered as an adjunct to NOM in patients with AAST Grade IV and Grade V BSI but should not be routinely recommended in patients with AAST Grade I to Grade III injuries. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
Collapse
Affiliation(s)
- James Charles Ian Crichton
- From the Department of General Surgery (J.C.I.C.), Waikato Hospital, Hamilton, New Zealand; Queen Mary University of London, Barts, and The London School of Medicine and Dentistry, London, United Kingdom (K.N., B.Y., Z.P., S.I.B.)
| | | | | | | | | |
Collapse
|
12
|
Coccolini F, Montori G, Catena F, Kluger Y, Biffl W, Moore EE, Reva V, Bing C, Bala M, Fugazzola P, Bahouth H, Marzi I, Velmahos G, Ivatury R, Soreide K, Horer T, Ten Broek R, Pereira BM, Fraga GP, Inaba K, Kashuk J, Parry N, Masiakos PT, Mylonas KS, Kirkpatrick A, Abu-Zidan F, Gomes CA, Benatti SV, Naidoo N, Salvetti F, Maccatrozzo S, Agnoletti V, Gamberini E, Solaini L, Costanzo A, Celotti A, Tomasoni M, Khokha V, Arvieux C, Napolitano L, Handolin L, Pisano M, Magnone S, Spain DA, de Moya M, Davis KA, De Angelis N, Leppaniemi A, Ferrada P, Latifi R, Navarro DC, Otomo Y, Coimbra R, Maier RV, Moore F, Rizoli S, Sakakushev B, Galante JM, Chiara O, Cimbanassi S, Mefire AC, Weber D, Ceresoli M, Peitzman AB, Wehlie L, Sartelli M, Di Saverio S, Ansaloni L. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg 2017; 12:40. [PMID: 28828034 PMCID: PMC5562999 DOI: 10.1186/s13017-017-0151-4] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 08/04/2017] [Indexed: 11/25/2022] Open
Abstract
Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.
Collapse
Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Giulia Montori
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, HI USA
| | - Ernest E Moore
- Trauma Surgery, Denver Health Medical Center, Denver, CO USA
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Camilla Bing
- General and Emergency Surgery Department, Empoli Hospital, Empoli, Italy
| | - Miklosh Bala
- General and Emergency Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Paola Fugazzola
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Hany Bahouth
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ingo Marzi
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie Universitätsklinikum Goethe-Universität Frankfurt, Frankfurt, Germany
| | - George Velmahos
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA USA
| | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA USA
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital and Örebro University, Orebro, Sweden.,Department of Surgery, Örebro University Hospital and Örebro University, Obreo, Sweden
| | - Richard Ten Broek
- Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
| | - Bruno M Pereira
- Trauma/Acute Care Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Trauma/Acute Care Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Kenji Inaba
- Division of Trauma and Critical Care, LAC+USC Medical Center, Los Angeles, CA USA
| | - Joseph Kashuk
- Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Neil Parry
- General and Trauma Surgery Department, London Health Sciences Centre, Victoria Hospital, London, ON Canada
| | - Peter T Masiakos
- Pediatric Trauma Service, Massachusetts General Hospital, Boston, MA USA
| | | | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | | | - Noel Naidoo
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Francesco Salvetti
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Stefano Maccatrozzo
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | | | | | - Leonardo Solaini
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Antonio Costanzo
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Andrea Celotti
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Matteo Tomasoni
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mozir, Belarus
| | - Catherine Arvieux
- Clin. Univ. de Chirurgie Digestive et de l'Urgence, CHUGA-CHU Grenoble Alpes UGA-Université Grenoble Alpes, Grenoble, France
| | - Lena Napolitano
- Trauma and Surgical Critical Care, University of Michigan Health System, East Medical Center Drive, Ann Arbor, MI USA
| | - Lauri Handolin
- Trauma Unit, Helsinki University Hospital, Helsinki, Finland
| | - Michele Pisano
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Stefano Magnone
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, CA USA
| | - Marc de Moya
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA USA
| | - Kimberly A Davis
- General Surgery, Trauma, and Surgical Critical Care, Yale-New Haven Hospital, New Haven, CT USA
| | | | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Paula Ferrada
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA USA
| | - Rifat Latifi
- General Surgery Department, Westchester Medical Center, Westchester, NY USA
| | - David Costa Navarro
- Colorectal Surgery Unit, Trauma Care Committee, Alicante General University Hospital, Alicante, Spain
| | - Yashuiro Otomo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, USA
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | | | - Sandro Rizoli
- Trauma and Acute Care Service, St Michael's Hospital, Toronto, ON Canada
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, University of California, Davis Medical Center, Davis, CA USA
| | | | | | - Alain Chichom Mefire
- Department of Surgery and Obstetric and Gynecology, University of Buea, Buea, Cameroon
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Marco Ceresoli
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Andrew B Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, Pensylvania USA
| | - Liban Wehlie
- General Surgery Department, Ayaan Hospital, Mogadisho, Somalia
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Salomone Di Saverio
- General, Emergency and Trauma Surgery Department, Maggiore Hospital, Bologna, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| |
Collapse
|
13
|
Jabbour G, Al-Hassani A, El-Menyar A, Abdelrahman H, Peralta R, Ellabib M, Al-Jogol H, Asim M, Al-Thani H. Clinical and Radiological Presentations and Management of Blunt Splenic Trauma: A Single Tertiary Hospital Experience. Med Sci Monit 2017; 23:3383-3392. [PMID: 28700540 PMCID: PMC5519223 DOI: 10.12659/msm.902438] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 01/10/2017] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Splenic injury is the leading cause of major bleeding after blunt abdominal trauma. We examined the clinical and radiological presentations, management, and outcome of blunt splenic injuries (BSI) in our institution. MATERIAL AND METHODS A retrospective study of BSI patients between 2011 and 2014 was conducted. We analyzed and compared management and outcome of different splenic injury grades in trauma patients. RESULTS A total of 191 BSI patients were identified with a mean (SD) age of 26.9 years (13.1); 164 (85.9%) were males. Traffic-related accident was the main mechanism of injury. Splenic contusion and hematoma (77.2%) was the most frequent finding on initial computerized tomography (CT) scans, followed by shattered spleen (11.1%), blush (11.1%), and devascularization (0.6%). Repeated CT scan revealed 3 patients with pseudoaneurysm who underwent angioembolization. Nearly a quarter of patients were managed surgically. Non-operative management failed in 1 patient who underwent splenectomy. Patients with grade V injury presented with higher mean ISS and abdominal AIS, required frequent blood transfusion, and were more likely to be FAST-positive (p=0.001). The majority of low-grade (I-III) splenic injuries were treated conservatively, while patients with high-grade (IV and V) BSI frequently required splenectomy (p=0.001). Adults were more likely to have grade I, II, and V BSI, blood transfusion, and prolonged ICU stay as compared to pediatric BSI patients. The overall mortality rate was 7.9%, which is mainly association with traumatic brain injury and hemorrhagic shock; half of the deaths occurred within the first day after injury. CONCLUSIONS Most BSI patients had grade I-III injuries that were successfully treated non-operatively, with a low failure rate. The severity of injury and presence of associated lesions should be carefully considered in developing the management plan. Thorough clinical assessment and CT scan evaluation are crucial for appropriate management of BSI.
Collapse
Affiliation(s)
- Gaby Jabbour
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | | | - Ayman El-Menyar
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | | | - Ruben Peralta
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Ellabib
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Hisham Al-Jogol
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohammad Asim
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad Medical Corporation, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| |
Collapse
|
14
|
Chen Y, Qiu J, Yang A, Yuan D, Zhou J. Epidemiology and management of splenic injury: An analysis of a Chinese military registry. Exp Ther Med 2017; 13:2102-2108. [PMID: 28565815 DOI: 10.3892/etm.2017.4208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 12/23/2016] [Indexed: 01/24/2023] Open
Abstract
In China, there have been few meta-analyses of the epidemiology and management of splenic injury. Due to the success of Chinese military hospitals in the domestic treatment of splenic injury, the present study conducted a systematic review of such cases, identifying a high occurrence rate of splenic trauma, as well as a number of strategies of managing splenic injury in China. Data were collected from sixteen Chinese military hospitals between July 2000 and March 2009, and retrospectively reviewed. It was observed that between July 2000 and March 2009 a total of 7,807 patients (84.32% male and 15.68% female) with splenic injury were admitted to hospital. The mean duration of hospital stay was 17.9±18.6 days and the gender distribution of splenic injury over the successive years did not differ significantly (P>0.05, c=0.034). However, there was a significant difference in the gender distribution of splenic injury patients in different months (P<0.05, c=0.063). In addition, admission numbers for splenic injury were highest in September, October and November. It was also found that splenic injury may occur at all ages, though patients of working age (20-50 years), which comprises 85.59% of patients, the highest proportion of all recorded cases. Associations between mortality rate and each management strategy were as follows: Operative management, 0.11% and non-operative management, 0.15%. Furthermore, multivariate analysis demonstrated that transfusion, New Injury Severity Score and management strategies were all correlated with mortality rate. Thus, despite a lack of data for inpatients from civilian hospitals, the present study has, in part, identified the epidemiology and management strategies of splenic injury in China. These findings may supplement those from previous analyses of splenic injury in other countries and regions.
Collapse
Affiliation(s)
- Yong Chen
- State Key Laboratory of Trauma, Burns and Combined Injury, Department 4, Research Institute of Surgery, Daping Hospital, The Third Military Medical University, Chongqing 400042, P.R. China
| | - Jun Qiu
- State Key Laboratory of Trauma, Burns and Combined Injury, Department 4, Research Institute of Surgery, Daping Hospital, The Third Military Medical University, Chongqing 400042, P.R. China
| | - Ao Yang
- State Key Laboratory of Trauma, Burns and Combined Injury, Department 4, Research Institute of Surgery, Daping Hospital, The Third Military Medical University, Chongqing 400042, P.R. China
| | - Danfeng Yuan
- State Key Laboratory of Trauma, Burns and Combined Injury, Department 4, Research Institute of Surgery, Daping Hospital, The Third Military Medical University, Chongqing 400042, P.R. China
| | - Jihong Zhou
- State Key Laboratory of Trauma, Burns and Combined Injury, Department 4, Research Institute of Surgery, Daping Hospital, The Third Military Medical University, Chongqing 400042, P.R. China
| |
Collapse
|