Abstract
BackgroundA widespread shift to non-operative management (NOM) for blunt hepatic and splenic injuries has been observed in most centers worldwide. Furthermore, many countries introduced safety measures to systematically reduce severe traffic and leisure sports injuries. This study aims to evaluate the effect of these nationwide implementations on individual patient characteristics and outcomes through a time-trend analysis over 17 years in an Austrian high-volume trauma center.MethodsA retrospective review of all emergency trauma patients admitted to the Medical University of Innsbruck from 2000 to 2016. Injury severity, clinical data on admission, operative and non-operative treatment parameters, complications, and in-hospital mortality were evaluated.ResultsIn total, 731 patients were treated with blunt hepatic and/or splenic injuries. Among these, 368 had a liver injury, 280 splenic injury, and 83 combined hepatic/splenic injury. Initial NOM was performed in 82.6% of all patients (93.5% in hepatic and 71.8% in splenic injuries) with a success rate of 96.7%. The secondary failure rate of NOM was 3.3% and remained consistent over 17 years (p = 0.515). In terms of injury severity, we observed a reduction over time, resulting in an overall mortality rate of 4.8% and 3.5% in the NOM group (decreasing from 7.5 to 1.9% and from 5.6 to 1.3%, respectively). These outcomes confirmed an improved utilization of the NOM approach.ConclusionOur cohort represents one of the largest Central European single-center experiences available in the literature. NOM is the standard of care for blunt hepatic and splenic injuries and successful in > 96% of all patients. This rate was quite constant over 17 years (p = 0.515). Overall, national and regional safety measures resulted in a significantly decreased severity of observed injury patterns and deaths due to blunt hepatic or splenic trauma. Although surgery is nowadays only applied in about one third of splenic injury patients in our center, these numbers might further decrease by intensified application of interventional radiology and modern coagulation management.
Highlights
A widespread shift to non-operative management (NOM) for blunt hepatic and splenic injuries has been observed in most centers worldwide
NOM is the standard of care in hemodynamically stable patients [6], which is associated with an estimated success rate exceeding 80–90% [2]
The rate was 1.9% versus 13.3% in the early period (p < 0.001) compared to 2% versus 7.8% (p = 0.048) in the late period. This analysis is characterized by three main points: (I) the observed cohort represents one of the largest Western European single-center experiences available, reporting clinical presentations, management, and outcomes of blunt liver and splenic injuries over a time span of 17 years; (II) NOM was the option of treatment in more than 80% of cases with only minor changes over time; and (III) injury severity decreased over time accompanied by major improvements in mortality rates
Summary
A widespread shift to non-operative management (NOM) for blunt hepatic and splenic injuries has been observed in most centers worldwide. Blunt abdominal trauma is very common in central European emergency departments The management of these injuries can be complex because of frequent association with a multifaceted picture of trauma, involving head, thoracic, and limb injuries [1]. While NOM carries the risk of missed hollow visceral injuries or delayed bleeding, operative management (OM) is naturally associated with the possible side effects of any surgical intervention, depending on a variety of patient, medical, and technical factors. Strong evidence exists that an age of 40 years or above, Injury Severity Score (ISS) of 25 or greater, associated intra-abdominal injuries and hepatic/ splenic injury grade III or higher are prognostic factors for failure of NOM [6, 7, 9, 13]
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