Splenic Trauma: Rethinking the Classic Approach Through Interventional Radiology

CT Imaging and Management of Blunt Splenic Trauma: Lessons for Today and Tomorrow

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.

Objective The aim of this study was to compare between operative and conservative management of splenic trauma in pediatric patients. Background In the past the management of blunt splenic injuries was carried out using splenectomy. However, the high rate of operative complications caused a paradigm shift from operative to nonoperative management in hemodynamically stable blunt abdominal trauma patients. Patients and methods This prospective study included a total of 40 patients. The patients were managed conservatively or operatively. Nonoperative management criteria included hemodynamic stability and absence of other injuries requiring laparotomy. Unstable patients were operated using splenectomy. Results Road traffic accident was the most common mechanism of trauma in this study (55%) in the patients who were managed conservatively and (60%) in the patients who were managed operatively (χ2 = 1.507; P = 1.000). Computed tomography was performed for stable patients only; grade I and grade II splenic injury comprised 70% of cases. The incidence of complications was 5% in the patients who were managed conservatively and 10% in the patients who were managed operatively (χ2 = 0.360; P = 1.000). The incidence of blood transfusion was less in the patients who were managed conservatively (25%) than in the patients who were managed operatively (100%) (χ2 = 24.000; P < 0.001). There was no mortality in the patients who were managed conservatively, whereas in the patients who were managed operatively the incidence of mortality was 5% (χ2 = 1.026; P = 1.000). All these tests were used as tests of significance at P less than 0.05. Conclusion The nonoperative management is considered the ideal management for blunt splenic injuries in pediatric patients because of fewer complications, lower blood transfusion rate, shorter hospital stay, and less mortality compared with operative management.

Selective nonoperative management of pediatric blunt splenic injury became the standard of care in the late 1980s. The extent to which this practice has been adopted in both trauma centers and nontrauma hospitals has been investigated sporadically. Several studies have demonstrated significant variations in practice patterns; however, most published studies capture only a selective population over a relatively short time interval, often without simultaneous adjustment for confounding variables. The objective of this study was to characterize the variation in operative versus nonoperative management of blunt splenic injury in children in nontrauma hospitals and in trauma centers with varying resources for pediatric care within a regionalized trauma system in the past decade. The study population included all children who were younger than 19 years and had a diagnosis of blunt injury to the spleen (International Classification of Diseases code 865.00-865.09) and were admitted to each of the 175 acute care hospitals in Pennsylvania between 1991 and 2000. The proportion of patients who were treated operatively was stratified by trauma-level certification and adjusted for age and splenic injury severity. Multivariable logistic regression models were used to generate probabilities of splenectomy by age, injury severity, and hospital type. From 1991 through 2000 in Pennsylvania, 3245 children sustained blunt splenic injury that required hospitalization; 752 (23.2%) were treated operatively. Generally, as age and splenic injury severity increased, the proportion of patients who were treated operatively increased. Compared with pediatric trauma centers, the relative risk (with associated 95% confidence interval) of splenectomy was 4.4 (3.0-6.3) for level 1 trauma centers with additional qualifications in pediatrics; 6.2 (4.4-8.7) for level 1 trauma centers, 6.3 (5.3-7.4) for level 2 trauma centers, and 5.0 (4.2-5.9) for nontrauma centers. Significant variation in practice pattern was seen among hospital types and over time even after adjustment for age and injury severity. The operative management of splenic injury in children varied significantly by hospital trauma status and over time during the past decade in Pennsylvania. Given the relative benefits of nonoperative treatment for children with blunt splenic injury, these results highlight the need for more widespread and standardized adoption of this treatment, particularly in hospitals without a large volume of pediatric trauma patients.

Historically poor success rates of nonoperative management of splenic injuries in elderly patients have led to recommendations for operative intervention in patients more than 55 years of age. Recent studies are in opposition to earlier recommendations revealing equal success rates of nonoperative management of splenic injuries in all age groups. A retrospective chart review was performed to assess factors related to the successful management of splenic injuries in patients over 55 years of age at a Level I trauma center. Thirty-seven patients over 55 presented with blunt splenic injuries during the 5-year study period. Thirteen patients were taken immediately to the operating room on the basis of clinical findings and/or abdomen/pelvis CT results. Nonoperative management was attempted in 24 patients on the basis of CT findings. Nonoperative management was successful in 15 patients (62.5%) and failed in eight patients (33.3%). Patients who failed nonoperative management had significantly higher American Association for the Surgery of Trauma splenic injury grade and associated pelvic free fluid. There were no deaths related to complications from failed nonoperative management. We conclude that nonoperative management of blunt splenic injuries in patients over 55 may be attempted. Patients with higher-grade injuries and pelvic free fluid are at greater risk for failure. Patients with these two findings must be monitored closely. The physicians caring for elderly patients with high-grade splenic injuries and free fluid in the pelvis must use clinical judgment regarding the need and timing of operative management.

IntroductionThe goal of non-operative management (NOM) for blunt splenic trauma (BST) is to preserve the spleen. The advantages of NOM for minor splenic trauma have been extensively reported, whereas its value for the more severe splenic injuries is still debated. The aim of this systematic review was to evaluate the available published evidence on NOM in patients with splenic trauma and to compare it with the operative management (OM) in terms of mortality, morbidity and duration of hospital stay.MethodsFor this systematic review we followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" statement. A systematic search was performed on PubMed for studies published from January 2000 to December 2011, without language restrictions, which compared NOM vs. OM for splenic trauma injuries and which at least 10 patients with BST.ResultsWe identified 21 non randomized studies: 1 Clinical Controlled Trial and 20 retrospective cohort studies analyzing a total of 16,940 patients with BST. NOM represents the gold standard treatment for minor splenic trauma and is associated with decreased mortality in severe splenic trauma (4.78% vs. 13.5% in NOM and OM, respectively), according to the literature. Of note, in BST treated operatively, concurrent injuries accounted for the higher mortality. In addition, it was not possible to determine post-treatment morbidity in major splenic trauma. The definition of hemodynamic stability varied greatly in the literature depending on the surgeon and the trauma team, representing a further bias. Moreover, data on the remaining analyzed outcomes (hospital stay, number of blood transfusions, abdominal abscesses, overwhelming post-splenectomy infection) were not reported in all included studies or were not comparable, precluding the possibility to perform a meaningful cumulative analysis and comparison.ConclusionsNOM of BST, preserving the spleen, is the treatment of choice for the American Association for the Surgery of Trauma grades I and II. Conclusions are more difficult to outline for higher grades of splenic injury, because of the substantial heterogeneity of expertise among different hospitals, and potentially inappropriate comparison groups.

BackgroundNon-operative management (NOM) is generally accepted as a treatment method of traumatic paediatric splenic rupture. However, considerable variations in management exist. This study analyses local trends in aetiology and management of paediatric splenic injuries and evaluates the implementation of the guidelines proposed by the American Paediatric Surgical Association (APSA) in a level 1 trauma centre.MethodsThe charts of paediatric patients with blunt splenic injury (BSI) who were admitted or transferred to a level 1 trauma centre between 2003 and 2020 were retrospectively assessed. Information pertaining to demographics, mechanism of injury, injury description, associated injuries, intervention and outcomes were analysed and compared to international literature.ResultsThere were 130 patients with BSI identified (63.1% male), with a mean age of 11.3 ± 4.0 and a mean Injury Severity Score (ISS) of 21.6 ± 13.7. Bicycle accidents were the most common trauma mechanism (23.1%). Sixty-four percent were multi-trauma patients, 25% received blood transfusions, and 31% were haemodynamically unstable. Mean injury grade was 3.0, with 30% of patients having a high-grade injury. In total, 75% of patients underwent NOM with a 100% efficacy rate. Total splenectomy rate was 6.2%. Four patients died due to brain damage.Patients with a high-grade BSI (grades IV–V) had a significantly higher ISS and longer bedrest and more often presented with an active blush on computed tomography (CT) scans than patients with a low-grade BSI (grades I–III). Non-operative management was mainly the choice of treatment in both groups (76.6% and 79.5%, respectively). Haemodynamic instability was a predictor for operative management (OM) (p = 0.001). Predictors for a longer length of stay (LOS) included concomitant injuries, haemodynamic instability and OM (all p < 0.02). Interobserver agreement in the grading of BSI is moderate, with a Cohens Kappa coefficient of 0.493.ConclusionNon-operative management has proven to be a realistic management approach in both low- and high-grade splenic injuries. Consideration for operative management should be based on haemodynamic instability. Compared to the anticipated length of bedrest and hospital stay outlined in the APSA guidelines, the Netherlands can reduce the length of bedrest and hospital stay through their non-operative management.Level of evidenceTherapeutic study, level III

Background: In all blunt abdominal injuries splenic injury relates to about 40%. Splenectomy is the preferred treatment choice for blunt splenic injury in hemodynamically unstable patients. The low-grade splenic injuries and stable patients are mostly treated by non-operative management (NOM) at today era. Consensuses have not been yet formulated about the management of high-grade splenic injuries in hemodynamically stable patients. So, this study analyzes the treatment of patients with high-grade splenic injuries in our institution. Methods: This study includes all the patients with splenic injuries presented to our hospital during the 5 years period from 2017 to 2022. The datas regarding primary baseline at emergency, complications and mortality were collected from the patient records at medical record section. Based on splenic injury and the treatment they received, they were grouped accordingly. Results: In a total of 38 cases of spleen injuries, the most common mode of injury was a road traffic accident (RTA) 84% followed by fall injury (10%) spontaneous rupture of the spleen and blast injury 3% each. Sixty-six per cent of the cases underwent operative management out of which 96% cases had a splenectomy and 4% cases had a splenic repair. There was 5% mortality and 95% recovery without residual morbidity. Conclusion: Most of the cases with spleen injury were managed with a favorable outcome. The careful patient selection for non-operative management will result in higher splenic salvage with close monitoring in an intensive care unit.

Background: The spleen is the most frequently injured organ in blunt abdominal trauma, mainly because of its highly vascularized parenchyma and its anatomic location. In the past the management of blunt splenic injuries was splenectomy, but high rate of operative complications caused paradigm shift from operative to non-operative management (NOM) in hemodynamically stable blunt abdominal trauma patients. Now, nonoperative management of hemodynamically stable patients with blunt splenic injuries is the standard of care and has been proven to be safe and successful in the acute setting. The advent of newer imaging techniques with high resolution CT scanners has enabled the clinicians to exactly diagnose the extent of intra-abdominal organ injury. Objective: This work aim to compare between operative and conservative management of splenic trauma. Methodology: Total numbers of patients in this study were 20 patients classified in two groups, the first group contained12 patients and the other group contained 8 patients. The First group was managed conservative and the second was managed operative with splenectomy and splenoraphy. The first group of patients consisted of 9 males (75%) and 3 female (25%). The second group of patients consisted of 6 males (75%) and 2 females (25%). Results: In this study, bunt splenic injury was found to be more common in males because of their risky and hard work. RTA and Falling from a height were found to be the most common causes of blunt abdominal injuries. According to CT, grade one and two of splenic injury are more common than other grades of splenic injury. As regard complication the operative management has more complication as postoperative wound infection and postoperative chest infection. So, NOM of splenic injury is the management of choice in haemodynamically stable patients. Conclusion: The nonoperative management is considered the ideal management for blunt splenic injuries due to less complication, less blood transfusion, less hospital stay and less mortality than operative management.

Background:Nonoperative management for hemodynamically stable splenic injury has been accepted as appropriate treatment. Objectives: This study aimed to investigate the changes in management and clinical outcomes of splenic injury by introducing a protocol for splenic injury at a newly established regional trauma center.Methods:From January 2005 to December 2016, we reviewed the outcomes of all 257 patients who sustained blunt trauma to the spleen at the first regional trauma center in South Korea. This 11‐year period was divided into two intervals, before 1 January 2014 (period I, n = 189 patients) and after 1 January 2014 (period II, n = 68 patients), when the trauma center was established and a formal management protocol was followed for patients with blunt traumatic splenic injuries.Results:The proportion of emergency operations performed for patients with more serious (grades 3–5) splenic injuries was lower in period II than in period I (29% vs 22%, respectively, p &lt; 0.001) whereas the rate of angioembolization was higher (89% vs 39.0%, respectively, p &lt; 0.001). The time to intervention, irrespective of whether emergency operation or angioembolization was performed, was shorter in period II than in period I (312.8 min vs 129 min, respectively, p = 0.001). A greater proportion of patients was managed non‐operatively in period II (78% vs 71%), and the non‐operative management success rate was higher in period II than it was in period I (100% vs 83%; p = 0.014). Similarly, the splenic salvage rate was higher in period II (78% vs 59%, p = 0.03).Conclusion:After establishing a regional trauma center and introducing a protocol for the management of blunt splenic injuries, the rates of non‐operative management and splenic salvage improved significantly. The reasons for this may be multifactorial, being related to the early involvement of a trauma surgeon, expansion of angiographic facilities and resources, and the introduction and application of a protocol for managing blunt splenic injury.

For patients > 55 years, nonoperative management (NOM) of blunt splenic injury remains controversial. Conflicting reports of excessively high or acceptably low failure rates have discouraged widespread application of NOM in these older patients. However, the small number of patients in these studies limits the impact of their conclusions. We manage splenic injury nonoperatively in all appropriate patients without regard to age. We present the largest series of patients > 55 years who have been managed nonsurgically, in a retrospective review of all patients with blunt splenic injury admitted to our trauma center between 1996 and 1999. In 4 years, 542 patients were admitted with blunt splenic injury. Eighty-three patients were > 55 years, and 61 of these patients underwent NOM. Seven older patients failed NOM and required delayed splenectomy, yielding a failure rate of 11.4%. This failure rate was statistically equivalent to the 7% failure rate of patients < 55 years. This study has a power of 80% to detect a failure rate change from 7% to 20%. By multivariate analysis, the only factor that significantly increased the risk of NOM failure was splenic injury grade. Patients > 55 years had a higher mortality than younger patients regardless of NOM/operative treatment. Splenic injury did not directly cause any of the deaths in patients > 55 years who had NOM or failure of NOM. High-grade splenic injuries fail NOM in those > 55 years. Nonoperative management of lower grade splenic injuries in patients > 55 years can be accomplished with an acceptably low failure rate. Only grade of splenic injury, not patient age, increases the risk of NOM failure.

BackgroundGrade (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. MethodsAn 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. ResultsDuring 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. ConclusionsNOM 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.

Although operative management was the preferred method of treating blunt abdominal trauma in the past, recent literature and practice recommend a nonsurgical approach to most pediatric splenic and hepatic injuries. The majority of data supporting the safety and efficacy of this nonoperative approach are derived from university trauma programs with a pediatric center where care was managed by pediatric surgeons only. To evaluate the applicability of this approach in a regional trauma center where pediatric patients are managed by pediatric and non-pediatric surgeons we reviewed the experience at a Level II community trauma center. Fifty-four children (16 years of age or less) were admitted between April 1992 and April 1998 after sustaining blunt traumatic splenic and/or hepatic injuries. There were 37 (69%) males and 17 (31%) females; the average age was 11 years (range 4 months to 16 years). Of the 54 patients 34 (63%) sustained splenic injuries, 17 (31%) sustained hepatic injuries, and three (6%) sustained both splenic and hepatic injuries. All of these injuries were diagnosed by CT scan or during laparotomy. The average Injury Severity Score was 14.9 with a range from four to 57. Of the 47 patients initially admitted for nonoperative management one patient failed nonoperative management and required operative intervention. In our study 98 per cent (46 of 47 patients) of pediatric patients were successfully managed nonoperatively. Complications of nonoperative management occurred in two patients. Both developed splenic pseudocysts after splenic injury, which required later operative repair. These data are comparable with those from university trauma programs and confirm that nonoperative management is safe in a community trauma center. The majority of children with blunt splenic and hepatic trauma can be successfully treated without surgery, in a regional trauma center treated by nonpediatric trauma surgeons, if the decision is based on careful initial evaluation, aggressive resuscitation, and close observation of their hemodynamic stability.

Blunt splenic trauma: Assessment, management and outcomes

Population-based analysis of blunt splenic injury management in children: Operative rate is an informative quality of care indicator