Nonoperative Management Of Splenic Trauma Research Articles

A Clinical Review and Experience of Splenic Trauma in North India: A Retrospective Observational Study.

The spleen is one of the frequently injured solid organs in abdominal blunt trauma. The standard of care is nonoperative nowadays depending on the hemodynamic stability (World Society of Emergency Surgery (WSES) grade I-III) of the patient due to advancements in treating modalities. Operative interventions are required in hemodynamically unstable patients or failure of nonoperative management. The study was planned to find the clinical spectrum of abdominalblunt trauma, specifically those having splenic trauma, and their subsequent management in an institution. This is a retrospective observational study. All included patients with blunt abdominal injuries were treated in a level 1 trauma center between July 2021 and December 2022. Data regarding demographic profile, blood transfusion, pre- and postoperative findings, and management including the period of hospital stay, morbidity, and mortality were collected and analyzed. One hundred sixty-four patients were analyzed, of which 142 were males and 22 were females. The commonest mechanism of injury was motor vehicle collision, followed by falls. Grade III splenic injury was the most common injury, while the predominantly associated injury was rib fracture. The patients were managed preferably through nonoperative management, followed by angioembolization and operative management. The commonest postoperative complication was pneumonia. Nonoperative management of splenic trauma has evolved as the standard of care replacing operative management in order tosustain its immune function, thereby preventing overwhelming post-splenectomy infection.

Non-Operative Management of Splenic Trauma, A Commentary

Non-Operative Management of Splenic Trauma, A Commentary

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

The spleen is one of the most frequently affected organs in blunt abdominal trauma. Since Upadhyaya, the treatment of splenic trauma has undergone important changes. Currently, the consensus is that every splenic trauma presenting with hemodynamic stability should be initially treated nonoperatively, provided that the hospital has adequate structure and the patient does not present other conditions that indicate abdominal exploration. However, several topics regarding the nonoperative management (NOM) of splenic trauma are still controversial. Splenic angioembolization is a very useful tool for NOM, but there is no consensus on its precise indications. There is no definition in the literature as to how NOM should be conducted, neither about the periodicity of hematimetric control, the transfusion threshold that defines NOM failure, when to start venous thromboembolism prophylaxis, the need for control imaging, the duration of bed rest, and when it is safe to discharge the patient. The aim of this review is to make a critical analysis of the most recent literature on this topic, exposing the state of the art in the NOM of splenic trauma.

Predicting the Outcome of Non-operative Management of Splenic Trauma in South Africa.

We aimed to expand on the global surgical discussion around splenic trauma in order to understand locally and clinically relevant factors for operative (OP) and non-operative management (NOM) of splenic trauma in a South African setting. A retrospective cohort study was performed using 2013-2017 data from the Pietermaritzburg Metropolitan Trauma Service. All adult patients (≥15years) were included. Those managed with OP or NOM for splenic trauma were identified and analyzed descriptively. Multiple logistic regression analysis identified patients and clinical factors associated with management type. There were 127 patients with splenic injury. Median age was 29 [19-35] years with 42 (33%) women and 85 (67%) men. Blunt injuries occurred in the majority (81, 64%). Organ Injury Scale (OIS) grades included I (25, 20%), II (43, 34%), III (36, 28%), IV (15, 11%), and V (8, 6%). Nine patients expired. On univariate analysis, increasing OIS was associated with OP management, need for intensive care unit (ICU) admission, and hospital and ICU duration of stay, but not mortality. In patients with a delayed compared to early presentation, ICU utilization (62% vs. 36%, p = 0.008) and mortality (14% vs. 4%, p = 0.03) were increased. After adjusting for age, sex, presence of shock, and splenic OIS, penetrating trauma (adjusted odds ratio, 5.7; 95%CI, 1.7-9.8) and admission lactate concentration (adjusted odds ratio, 1.4; 95%CI 1.1-1.9) were significantly associated with OP compared to NOM (p = 0.002; area under the curve 0.81). We have identified injury mechanism and admission lactate as factors predictive of OP in South African patients with splenic trauma. Timely presentation to definitive care affects both ICU duration of stay and mortality outcomes. Future global surgical efforts may focus on expanding non-operative management protocols and improving pre-hospital care in patients with splenic trauma.

The need for red blood cell transfusions in the emergency department as a risk factor for failure of non-operative management of splenic trauma: a multicenter prospective study.

The majority of patients with splenic trauma undergo non-operative management (NOM); around 15% of these cases fail NOM and require surgery. The aim of the current study is to assess whether the hemodynamic status of the patient represents a risk factor for failure of NOM (fNOM) and if this may be considered a relevant factor in the decision-making process, especially in Centers where AE (angioembolization), intensive monitoring and 24-h-operating room are not available. Furthermore, the presence of additional risk factors for fNOM was investigated. This is a multicentre prospective observational study, including patients presenting with blunt splenic trauma older than 17years, managed between 2014 and 2016 in two Italian trauma centres (ASST Papa Giovanni XXIII in Bergamo and Sant'Anna University Hospital in Ferrara-Italy). The risk factors for fNOM were analyzed with univariate and multivariate analyses. In total, 124 patients were included in the study. In univariate analysis, the risk factors for fNOM were AAST grade > 3 (fNOM 37.5% vs 9.1%, p = 0.024), and the need of red blood cell (RBC) transfusion in the emergency department (ED) (fNOM 42.9% vs 8.9%, p = 0.011). Multivariate analysis showed that the only significant risk factor for fNOM was the need for RBC transfusion in the ED (p = 0.049). The current study confirms the contraindication to NOM in case of hemodynamically instability in case of splenic trauma, as indicated by the most recent guidelines; attention should be paid to patients with transient hemodynamic stability, including patients who require transfusion of RBC in the ED. These patients could benefit from AE; in centers where AE, intensive monitoring and an 24-h-operating room are not available, this particular subgroup of patients should probably be treated with operative management.

Independent Risk Factors for Failure of Nonoperative Management in Patients with Splenic Injury

Objective: It is crucial to assess non-operative management (NOM) of risk failures before it is preferred as a management option for treatment of splenic trauma or rupture. The purpose of this study is to investigate the outcome of non-operative management of splenic trauma, and to determine the independent predictive factors effecting NOM failure. Material and Methods: Seventy-seven patients among all of consecutive patients admitted with splenic trauma between January 2005 and June 2015 were included in the study. The patients were divided into two groups. Group 1: Successfully treated with non-operative management, and Group 2: The failure of non-operative management. Data recorded included patient demographics, vital signs, injury mechanism, Injury Severity Score (ISS), splenic trauma grade, hematologic parameters, Glasgow Coma Scale (GCS), transfusion requirements, and length of hospital stay. Results: There were 66 (85.7 %) patients in group 1, while only 11 patients (14.3%) in group 2. Mechanism of injury was blunt in seventy-one patients and, penetrating in 6 patients. ISS [Odds Ratio=1.293; 95% CI=1.045-1.601; p=0.018] and blood transfusion [Odds Ratio=2,739; 95% CI= 1.140-6,581; p=0.024] were detected to be an independent predictive factors for the failure of non-operative management. Group 1 has significantly higher hospitalization period (7.73±2.867 vs 6.67±2.289). Conclusions: Non-operative management failure risk is crucial and higher in patients with high ISS and in patients who require much blood transfusion in first 24 hours. Special attention should be paid to these patients if non-operative management becomes the preferred management option.

Results of non-operative management of splenic trauma and its complications in children.

Introduction:Non-operative management (NOM) of splenic trauma in children is currently the treatment of choice.Purpose:We report a series of 83 cases in order to compare our results with literature data.Patients and Methods:For this, we conducted a retrospective study of 13 years and collected 83 cases of children with splenic trauma contusion, managed at Lapeyronie Montpellier Hospital in Visceral Pediatric Surgery Department. The studied parameters were age, sex, circumstances, the blood pressure (BP), hematology, imaging, associated injuries, transfusion requirements, treatment, duration of hospital stay, physical activity restriction and evolution.Results:NOM was successful in 98.7% of cases. We noted 4 complications including 3 pseudo aneurysms (PSA) of splenic artery and 1 pseudocyst spleen with a good prognosis. There was no mortality in our series.Conclusion:NOM is the treatment of choice for splenic trauma in children with a success rate of over 90%. Complications are rare and are dominated by the PSA of splenic artery.

Splenocolonic fistula following non-operative management of splenic rupture

Non-operative management has become the preferred treatment for splenic trauma in the absence of haemodynamic instability. The reported complications of non-operative management of splenic trauma may include pseudoaneurysm formation, delayed splenic rupture and splenic abscess formation. Splenocolonic fistula is a finding that has only previously been described in association with Crohn’s disease, pancreatitis, malignancy and haematological disorders. We present the case of a 16-year-old male who suffered a blunt traumatic injury to the spleen, was haemodynamically stable and successfully managed non-operatively. He represented 1 month later following a single episode of per-rectum bleeding. A CT scan of his abdomen revealed a pseudoaneurysm within the spleen, a splenic abscess and a splenocolonic fistula. He proceeded to emergency laparotomy for splenectomy and colonic resection and had an uneventful recovery. The history of management of blunt traumatic splenic injury is discussed, along with the associated risks of operative and conservative management. Methods predicting the success of non-operative management are explored, along with their application and relevance to this particular case.

Temporal Assessment of Splenic Function in Patients Who Have Undergone Percutaneous Image-Guided Splenic Artery Embolization in the Setting of Trauma

Purpose The role of transcatheter splenic arterial embolization (SAE) in the nonoperative management of splenic injury is evolving. The purpose of this study is to evaluate patients who have undergone SAE for laboratory markers of hyposplenism in the years after their procedure. Materials and Methods Thirty-four subjects who had undergone SAE as part of nonoperative management of splenic trauma during a period of 10 years were included. A blood sample was collected from each patient for complete blood count and smear analysis for peripheral markers of hyposplenism (as indicated by Howell–Jolly bodies [HJBs]). Sample size and power analysis was performed, and likelihoods for various true prevalences were calculated. Results The average time interval from procedure to follow-up was 4.4 years. No participants had peripheral markers of hyposplenism or abnormalities in cell count on follow-up. Conclusions Phagocytic function of the spleen in patients who have undergone SAE is preserved, as evidenced by the absence of HJBs on follow-up peripheral blood smears.

Controversies in the management of splenic trauma

Background The technologic innovations of the last three decades, coupled with a deeper understanding of the immunologic role of the spleen, have significantly shifted the management of splenic injuries towards non-operative approaches. However, there continuous to be a wide range of practice patterns related to the non-operative management of splenic injuries, from which the authors infer a gap between the best available evidence and its translation into practice. We sought to explore ongoing areas of controversy in the non-operative management of splenic trauma with the aim of further elucidating why these controversies continue to exist. Methods We explored areas of ongoing controversy in the management of splenic injury though a series of iterative surveys. We invited 70 experts in trauma care from ten countries around the world to participate. Areas of controversy explored included: indications and frequency for in-hospital and follow-up imaging, definitions of failure of non-operative management, indications for angioembolisation and non-operative management in special populations (i.e. elderly, concomitant traumatic brain injury, penetrating trauma). Results A 49% response rate was obtained. Even though a wide range of practice patterns were identified, no controversies were identified in areas that do not involve the adoption of new technologies. In areas where practice pattern variation was observed, the strong influence of the local environment was constantly identified as an impediment to changes in practice. Conclusions We have identified that barriers present within local practice environments are the major driving forces behind controversies in the non-operative management of splenic injuries.

Management of Blunt Splenic Trauma

We read this article on the management of blunt splenic injury with interest. Although their experience is rather limited involving 21 cases in 9 years (January 1997 to December 2005), it reflects, to a great extent, the overall practice in the UK. We would like to comment on three points: Non-operative management of splenic trauma also includes splenic artery embolisation. By making a literature search using PubMed and the Cochrane Library, we were unable to identify any reports from the UK of experience on angio-embolisation for splenic trauma. We recently managed successfully, with proximal splenic artery embolisation, an 85-year-old woman with grade III splenic injury and extensive haemoperitoneum after a fall at home. Nevertheless, there is extensive literature on the topic, mostly North American. Arteriography and embolisation is routinely performed in many trauma centres, and has proved to be a safe and useful investigation and therapeutic intervention.1 Despite this, there is still much to be said as to its precise role. Embolisation for low-grade injuries is probably unnecessary as these patients may do just as well without it. Patients with higher grade splenic injuries may benefit more as embolisation can result in an increased rate of successful non-operative management. Some reports have questioned the value of indiscretionary embolisation, or have suggested that only specific subgroups of patients may benefit.2,3 A multicentre, randomised, controlled trial is necessary to give answers as to which subgroups of non-operative management patients would benefit from embolisation. The reported rarity of blunt splenic trauma is in accordance with the recent report from the Scottish Trauma Audit Group (STAG).4 In 2000, STAG retrieved data for the entire Scottish trauma population resulting in an incidence for Scotland of 1.38 per 100,000 population. Many of these were polytrauma patients and about 15% died soon after arrival in hospital from concomitant injuries. If these numbers are extrapolated for the entire UK, it is apparent that a consultant surgeon in a medium-sized district general hospital (DGH) with five surgeons on the general surgical take and serving a population of 300,000 will see on average less than one case per year. The authors have clearly demonstrated that the modern management of these injuries has shifted towards conservative treatment. They concluded that selection of patients for operative versus non-operative management is difficult. This is true, particularly when taking into consideration the limited experience of individual surgeons. Papers originating mostly from North American high-volume trauma centres have described criteria for the non-operative management of blunt splenic injuries.5 These are: (i) haemodynamic stability on admission or after initial resuscitation with up to 2 l of crystalloid; (ii) no physical findings or any associated injuries necessitating laparotomy; and (iii) a transfusion requirement attributable to the splenic injury of two units or less.5 Even with these criteria, there will still be a small percentage of patients who will fail initial non-operative management and end up having a splenectomy. The 2007 report of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) focused on trauma services.6 One of its recommendations was the designation of level I trauma centres in the UK. Although this may improve the outcome of severely multiple injured patients, we still feel that patients with isolated or predominantly splenic injury can be safely managed in a DGH provided that general surgical, anaesthetical, intensive care and CT scan services are available on demand, as well as an interventional radiologist during working hours.

Need for a National Database for Splenic Trauma?

We would agree with the authors that the incidence of blunt splenic injury seen in district general hospitals seems to be decreasing and there is an increasing move towards non-operative management in such cases. We note in their paper that mean in-hospital stay for patients not undergoing surgery was 13 days but this ranged widely from 3–25 days. We have similar experiences in our practice and comparable dilemmas surrounding the management of such patients. We wonder what criteria were used to allow the patients to be safely discharged from hospital and why there was such a wide range of hospital stay. We also wonder what general advice was given to patients following discharge from hospital and specifically what advice was given around resumption of driving, daily activities and contact sports, etc. Several published papers and traditional advice recommend strict bed rest for up to 7 days following non-operative management of splenic trauma, 6 weeks before return to physical activity and 6 months before contact sports should be recommenced.1,2. However, these protocols are based on little evidence. In their large case series, Crawford et al.3 found only a 2% ‘late’ failure rate of a non-operative management strategy (failure occurring 3 days or more after admission) but all of these patients were still in hospital as a result of associated injuries. They concluded, therefore, that ‘in-hospital observation beyond the third day after injury is not necessary for most patients with splenic injury, who have no other reason to remain hospitalised’. However, other authors have reported failure rates of between 5–37%,4–7 Sanders and Civil8 finding the failures occurring on average on the fourth hospitalised day. Advice to remain free from physical activity for 6 weeks is largely based on in vitro experiments that have shown splenic wounds allowed to heal by secondary intention develop a ‘wound break strength’ (the physiological index of wound healing) equal to that of a normal spleen at 6 weeks following initial insult.9 Detrimental effects of an earlier return to physical activity before 6 weeks has yet to be shown in vivo. Advice to remain free from contact sports for 6 months is based on level 3 evidence and professional opinion rather than any scientific evidence. Interestingly, Pachter et al.10 recommended obtaining a follow-up computed tomography (CT) scan at 8 weeks' post-injury in patients keen to return to contact sports, only permitting a return to sport if the CT demonstrated complete resolution. Were there any cases of delayed rupture in the patients from the Royal Glamorgan Hospital? Radiological follow-up following non-operative management of splenic injury remains controversial. In this series, the authors followed up 6 patients with ultrasound and 4 patients with a varying number of CT scans. Although they comment on the significant radiation exposure to these patients, we wonder what criteria were used for determining which imaging modality to use and the timing and number of follow-up imaging in their patients. Follow-up imaging aims to exclude the development of progressive haematomas and pseudo-aneurysms of the splenic hilar vessels. Lyass et al.,11 in their published series, found only 1 patient (3%) whose splenic injury had deteriorated; however, a conservative management strategy in this case was continued and was ultimately successful. They concluded that: ‘follow-up imaging can be omitted in clinically stable patients with blunt splenic trauma of grades 1–3’. These findings correspond with those of Shafi et al.,12 who found a deterioration in radiological findings in 5% of patients, only one of whom required intervention. Sinha and colleagues did not comment on the outcome of the follow-up radiological investigations in their reported series or if there were any cases of late rupture in the non-operative group. Thus the role of follow-up imaging remains controversial. A number of bodies recommend a vaccination programme for asplenic patients and those undergoing elective splenectomy, so as to reduce the risks of sepsis.13 It is recommended that pneumococcal vaccine should be given at least 2 weeks prior to elective splenectomy, if possible, to allow for a peak functional antibody response, as hyposplenic/asplenic patients have been found to have a reduced ability to mount an antibody response to vaccines.14 As rates of failure of non-operative management of splenic trauma vary between 5–40%, we speculate whether all patients admitted with splenic trauma and treated conservatively should undergo routine vaccination immediately, as up to 40% may eventually require a splenectomy. As single-unit experience in the management of splenic trauma is likely to be limited, we wonder if a national database should be established, for patients with splenic injuries managed non-operatively, to allow surgeons both to manage and advise these patients, based on an increasingly established evidence base.

Is Splenectomy after Trauma an Endangered Species?

Nonoperative management of splenic trauma is now the most common treatment modality for splenic injuries and splenectomy has almost disappeared in some trauma centers. Splenectomy for cancer staging is infrequently performed suggesting that the indications for splenectomy continue to evolve. We evaluated a state database to assess a communitywide experience with splenic surgery. International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were used to determine the indication for splenic surgery. Indications for splenic surgery were listed as trauma (injury codes), medical (hematological diseases, neoplasms, or procedures in which the spleen might be removed contiguously like distal pancreatectomy), or incidental (noncontiguous procedures). Splenectomies for medical indications (n = 607, 43%) were more common than splenectomies for trauma (n = 518, 37%) or incidental splenectomies (n = 276, 20%). Splenectomy for medical reasons was associated with hematologic disease in 56 per cent, neoplastic disease in 34 per cent, and other diagnoses in 10 per cent of cases. Incidental splenectomies were most commonly associated with operations on the esophagus/stomach (32%) and colon (30%). Mortality rate and length of stay were greatest for incidental (14.4 +/- 0.9 days, 10.9% mortality) compared with trauma (11.0 +/- 0.5 days, 7.7% mortality) or medical (9.7 +/- 0.4 days, 4.8% mortality) splenectomies (all P < 0.05 versus incidental). Our results suggest that in the era of nonoperative management of splenic injuries, medical indications now represent the most common reason for splenectomy. As laparoscopic techniques for elective splenectomy become more common, the changing indication for splenectomy has important ramifications for surgical education and training.

Nonoperative management of delayed splenic rupture in a patient with hemophilia B

Nonoperative management of splenic lacerations has become the standard of care in hemodynamically stable patients. The decision to manage a patient nonoperatively is much more difficult when the patient has a known bleeding disorder. There are a few case reports in the literature describing nonoperative management of splenic trauma in children with hemophilia A (factor VIII deficiency), but only one case report of a patient with hemophilia B (factor IX deficiency) and a splenic laceration successfully managed nonoperatively. We present the case of a 13-year-old boy who presented with a grade 4 splenic laceration, acute blood loss anemia, and hypotension that was managed nonoperatively.

Limitations of Splenic Angioembolization in Treating Blunt Splenic Injury

When angiography is performed in all hemodynamically normal patients with splenic injury, only 30% require embolization. This study examines the use of selective splenic angioembolization (SAE) as part of a management algorithm for adult splenic injury. Criteria for selective SAE were added to our adult splenic injury protocol in July 1999. SAE was performed in hemodynamically stable patients if computed tomographic (CT) scan revealed injury to the hilum or vascular blush and when nonoperative patients had a gradual decrease in hematocrit. Patients were grouped by management strategy: nonoperative; operative; or SAE. Demographics, injury severity, and outcomes of the different groups were compared. Medical records, CT scans, and registry data were reviewed for all SAE cases, deaths, and treatment failures. Data are means +/- SE. p < 0.05 versus nonoperative management by analysis of variance. From July 1999 to August 2003, 194 adults were treated for splenic injury. Nine patients underwent SAE, six for CT findings (1 vascular blush) and three for decreasing hematocrit. Three patients failed SAE (33%), one for bleeding and two for delayed splenic infarction. Eleven patients failed nonoperative therapy (8%); splenorrhaphy was performed in three and splenectomy in eight. Operative patients were more seriously injured and had higher Injury Severity Scores and mortality; splenectomy (39 of 48) was more commonly performed than splenorrhaphy (9 of 48) in this group. Use of a splenic injury algorithm is associated with a high success rate for nonoperative management of splenic trauma. Using selective criteria, only 5% of patients were treated with SAE. SAE salvaged six patients with high-grade splenic injury or decreasing hematocrit but had a 33% failure rate. Failure of nonoperative management was most commonly caused by errors in judgment, primarily recognition of "high-risk" injury patterns on CT scan or attempting nonoperative management in anticoagulated or coagulopathic patients.

Management of blunt splenic trauma

ANZ Journal of SurgeryVolume 75, Issue 7 p. 620-621 Management of blunt splenic trauma James Wood MB ChB, FRCS, James Wood MB ChB, FRCS Children's Hospital at Westmead, Westmead, NSWSearch for more papers by this authorErik La Hei MB BS, FRACS, Erik La Hei MB BS, FRACS Children's Hospital at Westmead, Westmead, NSWSearch for more papers by this author James Wood MB ChB, FRCS, James Wood MB ChB, FRCS Children's Hospital at Westmead, Westmead, NSWSearch for more papers by this authorErik La Hei MB BS, FRACS, Erik La Hei MB BS, FRACS Children's Hospital at Westmead, Westmead, NSWSearch for more papers by this author First published: 22 June 2005 https://doi.org/10.1111/j.1445-2197.2005.03449.xCitations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume75, Issue7July 2005Pages 620-621 RelatedInformation

Traitement non opératoire des traumatismes de la rate

Non-operative management of splenic trauma is one of the most notable advances in paediatric surgery. It should be systematically proposed except for cases of hemodynamic instability. Abdominal CT scan without and with contrast injection is essential with initial optimal management. Stay in paediatric surgical intensive care unit with monitoring can prevent rare but serious complications. The time of hospitalisation stay lies between two and three weeks and will be followed by three months without contact activity. The advantages of this treatment are obvious safeguarding of splenic function and absence of postoperative complications. Consequently only one of the 88 children admitted these ten last past years for splenic trauma in our unity was operated.

Diagnostic imaging in the follow-up of nonoperative management of splenic trauma in children.

The spleen is the most frequently injured organ in blunt abdominal trauma (BAT). Contrast-enhanced computed tomography (CT) is approximately 95% sensitive and specific for detection of splenic injury. In children, nonoperative treatment is well-established. The basic tenet of such management is an obligatory period of rest to prevent recurrent bleeding and allow splenic healing. Splenic preservation prevents post-splenectomy sepsis. At our level I trauma center, pediatric patients (N=54) with BAT between 1993 and 1998 were retrospectively studied. Two (3.7%) died of associated injuries; 2 underwent splenectomy before transfer to our hospital. All had been diagnosed with splenic injury by CT. The mean age was 11.3 years. The mechanisms of injury were motor vehicle accidents (66%), bicycle accidents (26%), and falls (8%). All 50 remaining patients were followed by ultrasound (US) after the initial diagnosis by CT. The mean hospital stay was 6 days. One patient developed the rare complication of an arterio venous (AV) fistula within the damaged spleen; 47 (94%) had normal, homogeneous parenchymal echogenicity at healing (including the patient with the AV fistula). The remaining 3 demonstrated a visible echogenic scar. Imaging documentation of healing blunt splenic trauma should ideally minimize cost and relative risk. Our results add further evidence that US is well-suited to the task. No delayed complications with this approach were recorded in this series.

Computed tomography-assisted management of splenic trauma

Background In patients who have suffered an injury to the spleen, preservation of the organ is of the utmost importance. To assist in management, contrast-enhanced computed tomography (CT) has been used. We reviewed our experience with a protocol for nonoperative management of splenic trauma based on CT grading of the injury. Methods: During the initial period of the study, 50 CT examinations for blunt abdominal trauma in adults were reviewed by staff radiologists for evidence of splenic injury. The radiologists, blinded to clinical management decisions, graded the CT studies as “A” if there was a subcapsular hematoma or capsular disruption, “B” if there was a parenchymal injury not extending into the hilum, or “C” if there was deep laceration of fracture of the hilum. Following confirmation of the accuracy and reproducibility of the grading scale, the splenic trauma management protocol was instituted, in which nonhilar injuries were managed nonoperatively. Results In the initial assessment, patients managed nonoperatively had shorter hospital stays and received fewer blood transfusions than those undergoing operation. Among 30 patients subsequently enrolled in the protocol, those treated nonoperatively remained in the hospital for fewer days than those treated surgically. Again, fewer units of blood and platelets were used in the nonoperative group. Institution of the protocol decreased the incidence of celiotomy. Conclusions The severity of splenic trauma evident on CT staging guides safe nonoperative management. Patients not suffering injury to the splenic hilum (A and B scores) can be managed without operation, resulting in shorter hospital stays and fewer blood products used.

THE MANAGEMENT OF SPLENIC RUPTURE IN INFECTIOUS MONONUCLEOSIS

Non-operative management of splenic trauma is now well established; however, the role of conservative management in spontaneous splenic rupture is undetermined. The leading cause of spontaneous splenic rupture is infectious mononucleosis. We report on the management of four patients with spontaneous rupture, in association with infectious mononucleosis. Three patients eventually required splenectomy, and one was successfully managed non-operatively. The comparative risks of operative and non-operative management are discussed. We believe that when splenic rupture complicates infectious mononucleosis, early splenectomy is the most appropriate management.