Is non-operative management of severe blunt splenic injury safer than embolization or surgery? Results from a French prospective multicenter study

PURPOSE OF THE STUDY

The management of the severe blunt splenic injuries remains debated. The aim of this study is to evaluate the morbidity and mortality of splenic injury according to severity and management (surgery, embolization, non-operative management [NOM]).

METHODS

A prospective multicenter study was conducted including patients aged 16 years and older with diagnosed splenic injury. We evaluated severity according to the AAST classification, the presence of hemoperitoneum or a contrast blush on initial CT scan. The initial hemodynamic status, patients co-morbidities, the ISS (injury severity score), management and morbidity were also noted.

RESULTS

Between May 2010 and May 2012, 91 patients were included. Thirty-seven patients (41%) had mild splenic injury (AAST I or II and a small hemoperitoneum) while 54 patients (59%) had severe splenic injury (AAST III or greater). The management included 18 splenectomies (20%), 15 embolizations (16%). Among 67 patients undergoing NOM without initial embolization, five (7%) developed secondary bleeding, five required surgery and nine underwent secondary embolization. No patient died and morbidity was 44% (n=40), 13% for mild injuries vs. 65% for severe injuries (P<0.01). For severe injuries, total morbidity was 58% after NOM, 73% after embolization and 70% after surgery. Specific morbidity related to the management was 10% after NOM vs. 47% after embolization (P=0.02). Specific morbidity after surgery was 15%.

CONCLUSION

Embolization, because of its important specific morbidity, should not be performed as a prophylactic measure, but only in presence of clinical or laboratory signs of bleeding.

Splenic injury: management in the Languedoc-Roussillon region

GOAL OF STUDY

Treatment of splenic injury is not standardized. We conducted an inventory of splenic injury treatment modalities of splenic injury in the Languedoc-Roussillon region of France.

METHODS

A questionnaire was sent by e-mail to 33 surgeons practicing in 10 hospitals in that region. Surgeons were asked: how many cases were treated per year (PMSI databank for the last three years), local resources (resuscitation bay or intensive care unit, availability of CT and interventional radiology), indications (surgery, embolization, nonoperative management [NOM]), prognostic criteria, NOM modalities (duration of bed rest, hospital stay, restriction of physical activity, thromboembolic prophylaxis, and imaging schedule).

RESULTS

Thirty-one surgeons replied. An average of 185 patients were treated per year. There was consensus concerning the indication for urgent splenectomy, NOM was practiced in the stable patient (even with diffuse hemoperitoneum) and splenic artery embolization was performed for active bleeding (blush on CT) (for the six centers who have interventional radiology at their disposal). Disparities existed between centers concerning the modalities of NOM excepting imaging monitoring, initial surveillance in resuscitation bay or intensive care and in the therapeutic indications when bleeding persisted.

CONCLUSION

Based on the consensus observed in this study and an analysis of the literature, a uniform treatment policy can be proposed.