Severe Splenic Injuries Research Articles

Laparoscopic surgery: An effective alternative for managing severe blunt splenic injuries in patients who are ineligible for transcatheter arterial embolization

BackgroundTranscatheter arterial embolization (TAE) is an effective alternative to nonoperative management (NOM) to improve the spleen salvage rate for patients with blunt splenic injuries (BSIs), but it is not always available at some institutions. Moreover, laparoscopy has also been used to diagnose and treat trauma, including BSIs. MethodsWe present our 11-year experience in performing laparoscopic surgery for spleen salvage in patients with severe BSIs when TAE is infeasible. The outcomes of laparoscopic surgery or TAE for spleen salvage in hemodynamically stable patients with severe BSIs were compared. ResultsFifty-six patients underwent interventions for severe BSIs during this period. Twenty patients underwent laparoscopic surgery, and 36 underwent TAE. There were no significant differences in demographics, preoperative conditions, or clinical characteristics (all p > 0.05). In the laparoscopic surgery group, 15 patients (75%) underwent laparoscopic splenorrhaphy for spleen salvage surgery, and five (25%) required splenectomy. No complications requiring intervention were observed in the laparoscopic surgery group, whereas three patients in the TAE group required a late splenectomy for splenic abscess. No significant differences were detected in the splenic preservation rate, complication rate, or length of hospital stay between the groups (all p > 0.05). ConclusionLaparoscopy is feasible and safe for managing hemodynamically stable patients with severe BSIs, and the outcomes are comparable to those of TAE. When TAE is infeasible, laparoscopy can be considered an alternative to increase the spleen salvage rate.

Surgical Repair vs Splenectomy in Patients With Severe Traumatic Spleen Injuries

The spleen is often removed in laparotomy after traumatic abdominal injury, with little effort made to preserve the spleen. To explore the association of surgical management (splenic repair vs splenectomy) with outcomes in patients with traumatic splenic injuries undergoing laparotomy and to determine whether splenic repair is associated with lower mortality compared with splenectomy. This is a trauma registry-based cohort study using the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2019. Participants included adult patients with severe splenic injuries (Abbreviated Injury Scale [AIS] grades 3-5) undergoing laparotomy after traumatic injury within 6 hours of admission. Data analysis was performed from April to August 2023. Splenic repair vs splenectomy in patients with severe traumatic splenic injury. The primary outcome was in-hospital mortality. Outcomes were compared using different statistical approaches, including 1:1 exact matching with consecutive conditional logistic regression analysis as the primary analysis and multivariable logistic regression, propensity score matching, and inverse-probability weighting as sensitivity analyses. A total of 11 247 patients (median [IQR] age, 35 [24-52] years; 8179 men [72.7%]) with a severe traumatic splenic injury undergoing laparotomy were identified. Of these, 10 820 patients (96.2%) underwent splenectomy, and 427 (3.8%) underwent splenic repair. Among patients who underwent an initial splenic salvage procedure, 23 (5.3%) required a splenectomy during the subsequent hospital stay; 400 patients with splenic preservation were matched with 400 patients who underwent splenectomy (matched for age, sex, hypotension, trauma mechanism, AIS spleen grade, and AIS groups [0-2, 3, and 4-5] for head, face, neck, thorax, spine, and lower and upper extremity). Mortality was significantly lower in the splenic repair group vs the splenectomy group (26 patients [6.5%] vs 51 patients [12.8%]). The association of splenic repair with lower mortality was subsequently verified by conditional regression analysis (adjusted odds ratio, 0.4; 95% CI, 0.2-0.9; P = .03). Multivariable logistic regression, propensity score matching, and inverse-probability weighting confirmed this association. In this retrospective cohort study, splenic repair was independently associated with lower mortality compared with splenectomy during laparotomy after traumatic splenic injury. These findings suggest that efforts to preserve the spleen might be indicated in selected cases of severe splenic injuries.

Laparotomy for Traumatic Splenic Injury: Should we Increase our Efforts to Preserve the Spleen?

Abstract Background In trauma laparotomy the spleen is removed very liberally, and often little effort is made for splenic preservation. Aims The aim of this study was to assess the effect of surgical management (splenic repair vs. splenectomy) on outcomes in patients undergoing trauma laparotomy. Methods This is a trauma registry (TQIP) study (2013–2019), including adult patients with severe splenic injuries (grades III-V) undergoing trauma laparotomy. Characteristics and outcomes of patients who underwent splenic repair vs. splenectomy within 6 hours of admission were compared using different statistical approaches, i.e. 1:1 exact matching with consecutive conditional logistic regression analysis as primary analysis, multivariable logistic regression, propensity score matching and inverse-probability weighting as sensitivity analyses. The primary outcome was in-hospital mortality. Results A total of 11,247 patients with a severe splenic injury undergoing trauma laparotomy within 6 hours of admission were identified. Of these, 10,820 (96.2%) patients underwent splenectomy and 427 (3.8%) patients splenic repair within 6 hours of admission. Among patients who underwent an initial splenic salvage procedure, 23 (5.3%) patients underwent a splenectomy during the subsequent hospital stay. 400 patients with splenic preservation, were matched with 400 patients who underwent splenectomy (matched for age, sex, hypotension, trauma mechanism as well as AIS spleen grades 3,4,5 and AIS groups (AIS 0-2, AIS 3, AIS 4-5) for head, face, neck, thorax, spine, and lower & upper extremity). The mortality was significantly lower in the group of patients with splenic repair (6.5% vs 12.8%, p=0.002). The mortality benefit was subsequently verified by conditional regression analysis (aOR 0.4, CI 95% 0.2; 0.9). Multivariable logistic regression, propensity score matching, and inverse-probability weighting confirmed the lower mortality in the splenic repair group. Conclusion In trauma laparotomy splenic repair was independently associated with lower mortality compared with splenectomy. Splenectomy was required in approximately 5% of the patients after initial splenic repair. The findings provide evidence that efforts for spleen preservation in trauma laparotomy should be considered in selected cases.

An ASER AI/ML expert panel formative user research study for an interpretable interactive splenic AAST grading graphical user interface prototype.

The AAST Organ Injury Scale is widely adopted for splenic injury severity but suffers from only moderate inter-rater agreement. This work assesses SpleenPro, a prototype interactive explainable artificial intelligence/machine learning (AI/ML) diagnostic aid to support AAST grading, for effects on radiologist dwell time, agreement, clinical utility, and user acceptance. Two trauma radiology ad hoc expert panelists independently performed timed AAST grading on 76 admission CT studies with blunt splenic injury, first without AI/ML assistance, and after a 2-month washout period and randomization, with AI/ML assistance. To evaluate user acceptance, three versions of the SpleenPro user interface with increasing explainability were presented to four independent expert panelists with four example cases each. A structured interview consisting of Likert scales and free responses was conducted, with specific questions regarding dimensions of diagnostic utility (DU); mental support (MS); effort, workload, and frustration (EWF); trust and reliability (TR); and likelihood of future use (LFU). SpleenPro significantly decreased interpretation times for both raters. Weighted Cohen's kappa increased from 0.53 to 0.70 with AI/ML assistance. During user acceptance interviews, increasing explainability was associated with improvement in Likert scores for MS, EWF, TR, and LFU. Expert panelists indicated the need for a combined early notification and grading functionality, PACS integration, and report autopopulation to improve DU. SpleenPro was useful for improving objectivity of AAST grading and increasing mental support. Formative user research identified generalizable concepts including the need for a combined detection and grading pipeline and integration with the clinical workflow.

Surgical Treatment versus Conservative Management of Splenic Rupture: Outcomes and Risk Factors.

This study aimed to evaluate the outcome and risk factors in operative and non-operative management of splenic injury. This cross-sectional study was conducted on patients with traumatic splenic injuries who were hospitalized in Kashani Hospital (Isfahan, Iran) from 2017 to 2019. The studied variables were extracted from the medical records of the enrolled participants. The outcomes such as mortality complications and risk factors were compared based on treatment methods. A total of 240 patients were investigated. The mean age of the patients was 29.8±12.2, with 180 (77.5%) patients being men. 154 (64.2%) patients underwent operative treatment. The mortality rate was 18.9% and 4.6% among operative and non-operative groups (p<0.001). Complications were observed in 11.5% and 46.1% of non-operative and operative groups, respectively (p<0.001). Operative treatment inversely correlated with mortality (p<0.001) and complications (p<0.05). Splenic injury severity was correlated positively with mortality (p<0.001) and negatively with complications (p<0.001). Unstable hemodynamic status was positively correlated with complications (p<0.001). Age had a positive correlation with mortality (p<0.001) and complications (p<0.001). Male sex had a negative correlation with complications (p<0.001). GCS score and admission were positively correlated with mortality (p<0.001). There was no statistically significant correlation between correlated injuries and outcomes (p≥0.05). Patients who received surgery had higher rates of mortality and complications. However, after controlling for confounders, operative treatment was found to be inversely correlated with mortality and complications.

Angioembolization for Isolated Severe Blunt Splenic Injuries with Hemodynamic Instability: A Propensity Score Matched Analysis.

This study aimed to compare patient outcomes after splenic angioembolization (SAE) or splenectomy for isolated severe blunt splenic injury (BSI) with hemodynamic instability, and to identify potential candidates for SAE. Adult patients with isolated severe BSI (Abbreviated Injury Scale [AIS] 3-5) and hemodynamic instability between 2013 and 2019 were identified from the American College of Surgeons Trauma Quality Improvement (ACS TQIP) database. Hemodynamic instability was defined as an initial systolic blood pressure (SBP) <90mmHg, heart rate (HR) >120bpm, or lowest SBP <90mmHg within 1h after admission, with ≥1 unit of blood transfused within 4h after admission. In-hospital mortality was compared between splenectomy and SAE groups using 2:1 propensity-score matching. The characteristics of unmatched and matched splenectomy patients were also compared. A total of 478 patients met our inclusion criteria (332 splenectomy, 146 SAE). After propensity-score matching, 166 splenectomy and 83 SAE patients were compared. Approximately 85% of propensity-score matched patients sustained AIS 3/4 injuries, and 50% presented with normal SBP and HR before becoming hemodynamically unstable. The median time to intervention (splenectomy or SAE) was 137min (interquartile range 94-183). In-hospital mortality between splenectomy and SAE groups was not significantly different (5.4% vs. 4.8%, p = 1.000). More than half of unmatched patients in the splenectomy group sustained AIS 5 injuries and presented with initially unstable hemodynamics. The median time to splenectomy in such patients was significantly shorter than in matched splenectomy patients (67 vs. 132min, p < 0.001). Splenectomy remains the mainstay of treatment for patients with AIS 5 BSI who present to hospital with hemodynamic instability. However, SAE might be a feasible alternative for patients with AIS 3/4 injuries.

Treatment of Severe Blunt Splenic Injury Varies Across Race and Insurance Type of Pediatric Patients

IntroductionRacial and ethnic disparities in the management of adult patients with blunt splenic injuries (BSIs) have been previously demonstrated. It is unknown if similar disparities exist in pediatric patients with BSIs. Management of BSIs can include operative management, but nonoperative management (NOM) is preferred. This study assesses the association of race and insurance status on use of NOM among pediatric (aged < 18 y) patients following BSI. Materials and methodsData were abstracted from the American College of Surgeons Trauma Quality Improvement Program Participant Use Files for calendar years 2013-2017. Multivariate logistic regression was used to evaluate the associations between race or insurance status and NOM while controlling for injury severity, age, and facility type. Secondary outcomes included blood transfusion within 24 h and hospital length of stay. ResultsWe analyzed 1436 pediatric BSI patients. Black, non-Hispanic patients were less likely (odds ratio: 0.45, 95% confidence interval: 0.21-1.02, P = 0.043) to undergo NOM and stayed 0.6 d longer (P = 0.010) than White, non-Hispanic patients. Uninsured patients were less likely (odds ratio: 0.52, 95% CI: 0.25-1.11, P = 0.080) to undergo NOM and publicly insured patients stayed 0.24 d (P = 0.048) longer than privately insured patients. ConclusionsWe found disparities in use of NOM for Black patients and uninsured patients as well as differences in length of stay. These results extend the literature on racial and socioeconomic disparities in care of trauma patients to pediatric BSI patients. Addressing these disparities requires additional studies aimed at identifying the underlying causes.

Case report on severe splenic injury following colonoscopy with disproportionately stable presentation: A rural hospital perspective

Detection of splenic injury following routine colonoscopy is slowly on the rise. Mostly presenting as left upper abdominal or shoulder tip pain along with a sharp fall in haemoglobin level and hemodynamic instability, sometimes the presentation and initial workup may be vague and falsely reassuring. This is demonstrated in the case of a 72year old male who presented with vague but severe left lower abdominal pain following colonoscopy, during which one caecal polyp was removed and no intraoperative complications were reported. On emergency presentation, abdominal examination was not particularly concerning with only mild left lower tenderness and minimal guarding. Vital signs remained largely normal and blood counts were reasonable. Close to being discharged, patient demonstrated brief hypotension post ambulation which was easily reversed with a fluid bolus. Upon surgical review, a high index of suspicion prompted further investigation which revealed an unsuspected complication necessitating urgent laparotomy and splenectomy. Splenic injury is slowly becoming an increasingly reported complication following colonoscopy. While many cases present with typical features, others may only display subtle signs of deterioration, and warrant a high degree of suspicion. Rural doctors should be aware of and able to recognise this potentially fatal complication to ensure timely successful management.

Splenic embolisation practices within the UK: a national survey

•There is wide variability in the selection and technique of splenic embolisation. •There is a lack of clear evidence and guidelines on the use of splenic embolisation. •Urgent investment in the provision of 24/7 IR services is still required. AIM To review UK splenic embolisation (SE) practices for traumatic injury. MATERIALS AND METHODS An online survey approved by the British Society of Interventional Radiology (BSIR) Audit and Registry Committee was distributed to BSIR members between 15/11/2021–29/11/2021. Data obtained included the interventional radiology (IR) trauma service response, service design, institutional treatment pathways, and key clinical decision-making factors. Descriptive statistics were carried using Microsoft Excel. RESULTS A total of 62 responses, of which 61.29% (n=38) worked at a major trauma centre (MTC); 70.97% (n=44) had an interventional radiologist on-call 24/7; 77.42% (n=48) had no direct involvement with the trauma team until an eligible case was identified with only 19.35% (n=12) being part of the acute receiving trauma team; 88.71% (n=55) did not have a standard imaging pathway for conservatively managed splenic injury in their institution. In terms of the proportion of respondents considering embolisation based on severity of splenic injury, 51% (n=32) would embolise grade 5 injuries, 66% (n=41) for grade 4, 54% (n=34) for grade 3, and 12.9% (n=8) for grade 2. CONCLUSION Wide variability exists in the SE practice and decision-making within the UK IR community. A UK consensus on management of traumatic splenic injuries is required; however, an improved evidence base is essential to support these guidelines. To review UK splenic embolisation (SE) practices for traumatic injury. An online survey approved by the British Society of Interventional Radiology (BSIR) Audit and Registry Committee was distributed to BSIR members between 15/11/2021–29/11/2021. Data obtained included the interventional radiology (IR) trauma service response, service design, institutional treatment pathways, and key clinical decision-making factors. Descriptive statistics were carried using Microsoft Excel. A total of 62 responses, of which 61.29% (n=38) worked at a major trauma centre (MTC); 70.97% (n=44) had an interventional radiologist on-call 24/7; 77.42% (n=48) had no direct involvement with the trauma team until an eligible case was identified with only 19.35% (n=12) being part of the acute receiving trauma team; 88.71% (n=55) did not have a standard imaging pathway for conservatively managed splenic injury in their institution. In terms of the proportion of respondents considering embolisation based on severity of splenic injury, 51% (n=32) would embolise grade 5 injuries, 66% (n=41) for grade 4, 54% (n=34) for grade 3, and 12.9% (n=8) for grade 2. Wide variability exists in the SE practice and decision-making within the UK IR community. A UK consensus on management of traumatic splenic injuries is required; however, an improved evidence base is essential to support these guidelines.

Severe Splenic Injury Following Colonoscopy With Disproportionately Stable Presentation: A Rural Hospital Perspective

Severe Splenic Injury Following Colonoscopy With Disproportionately Stable Presentation: A Rural Hospital Perspective

Porcine spleen as a model organ for blunt injury impact tests: An experimental and histological study.

The spleen is a large and highly vascularized secondary lymphatic organ. Spleen injuries are among the most frequent trauma-related injuries in the abdominal region. The aims of the study were to assess the volume fractions of the main splenic tissue components (red pulp, white pulp, trabeculae and reticular fibres) and to determine the severity of splenic injury due to the experimental impact test. Porcine spleens (n=17) were compressed by 6.22kg wooden plate using a drop tower technique from three impact heights (50, 100 and 150 mm corresponding to velocities 0.79, 1.24 and 1.58 m/s). The pressure was measured via catheters placed in the splenic vein. The impact velocity was measured using lasers. The severity of induced injuries was analysed on the macroscopic level. The volume fractions of splenic components were assessed microscopically using stereology. The volume fraction of the red pulp was 76.4%, white pulp 21.3% and trabeculae 2.7% respectively. All impact tests, even with the low impact velocities, led to injuries that occurred mostly in the dorsal extremity of the spleen, and were accompanied by bleeding, capsule rupture and parenchyma crushing. Higher impact height (impact velocity and impact energy) caused more severe injury. Porcine spleen had the same volume fraction of tissue components as human spleen, therefore we concluded that the porcine spleen was a suitable organ model for mechanical experiments. Based on our observations, regions around hilum and the diaphragmatic surface of the dorsal extremity, that contained fissures and notches, were the most prone to injury and required considerable attention during splenic examination after injury. The primary mechanical data are now available for the researchers focused on the splenic trauma modelling.

Clinical features and direct medical cost of splenic injury in China: a cross-sectional study

ObjectivesThis study analyses the clinical features and direct medical cost (DMC) of splenic injury during 2000–2013 in China.DesignThis was a cross-sectional study.MethodsWe used ‘The No. 1 Military Medical Project’ information...

Management of Isolated Severe Blunt Splenic Injury in Level I vs Level II Trauma Centers

Management of Isolated Severe Blunt Splenic Injury in Level I vs Level II Trauma Centers

Soccer-related severe blunt splenic injury in a young goalkeeper

Abdominal injuries are rare in sports, but even minor traumas may result in potentially life-threatening injuries. The most frequent abdominal injury is abdominal wall contusion, following by blunt injuries of the kidneys and spleen. The cases of blunt abdominal injuries in soccer are rarely reported in the literature. We present a case of a grade IV splenic laceration in a 10-year-old soccer goalkeeper caused by the blunt abdominal trauma sustained during the gameplay. The trauma was successfully treated with a nonoperative management approach. • The blunt abdominal injuries in soccer are rarely reported in the literature. • A grade IV splenic laceration in a 10-year-old soccer goalkeeper caused by the blunt abdominal trauma is presented. • The trauma was successfully treated with a nonoperative management approach.

English

BACKGROUND The primary objective in the management of splenic injury earlier was to achieve early haemostasis which resulted in splenectomy as the treatment of choice. But after recognising the role of spleen in immune and haematopoietic functions, nonoperative management (NOM) was started. In order to practice non-operative management safely a better way to assess the severity of splenic injury was necessary. Eventually it became possible with the advent of computed tomography. Along with clinical assessment, it enabled us in the selection of appropriate patients for non-operative management. Now this modality is considered as the gold standard for patients who are hemodynamically stable or readily stabilisable. It decreases the duration of hospital stay and prevents postoperative morbidity. We wanted to find out the proportion of cases and predictors for failure of non-operative management among splenic injury patients in VIMSAR, Burla. METHODS This cross-sectional study was done among 35 patients with splenic injury who were hemodynamically stable from November 2018 to October 2020. RESULTS Age, sex, systolic blood pressure, diastolic blood pressure, mechanism of injury, Glasgow Coma Score (GCS), associated injury (if hemodynamically stable) were not found to be significant predictors in deciding the failure of non-operative management. CONCLUSIONS Most important predictor for failure of non-operative management was development of haemodynamic instability. Tachycardia, low mean arterial pressure (MAP), drop in haemoglobin (Hb) and haematocrit were significant parameters in our study and all these parameters ultimately point towards hemodynamic instability. KEYWORDS Non-Operative Management (Successful), Non-Operative Management (Failure), Hemodynamically Stable, Blunt Trauma Abdomen

Splenic Artery Angioembolization is Associated With Increased Venous Thromboembolism

Angioembolization has become an increasingly utilized adjunct for splenic preservation after trauma. Embolization of the splenic artery may produce a transient systemic hypercoagulable state. This study was designed to determine the risk of venous thromboembolism (VTE) in blunt trauma patients managed nonoperatively with splenic angioembolization, relative to those managed without. Retrospective review of the American College of Surgeons Trauma Quality Improvement Performance (TQIP) Database from 2013 to 2016. Adult (>16 years) patients with isolated, severe (Grades III–V) blunt splenic injuries managed nonoperatively who received pharmacological VTE prophylaxis formed the study population. Outcomes included deep venous thrombosis (DVT), pulmonary embolism (PE), or any VTE. A total of 2643 patients met inclusion criteria (69.1% Grade III, 26.5% Grade IV, 4.5% Grade V). The incidence of DVT was 4.5% in patients who underwent angioembolization, compared to 1.4% in patients who did not (p<0.001). Multivariable analysis showed that angioembolization was an independent risk factor for both DVT (OR 2.65, p = 0.006) and any VTE (OR 2.04, p = 0.01). Analysis according to splenic injury Grades showed that angioembolization remained an independent risk factor for DVT (p = 0.004) in the Grade IV-V injury group, and for VTE (p<0.01) in the Grade III injury group. Initiation of pharmacological VTE prophylaxis 48 h after admission was associated with increased VTE rates in comparison to early initiation (OR 1.75, p = 0.02) Splenic artery angioembolization may be an independent risk factor for VTE events in isolated, severe blunt splenic trauma managed nonoperatively. Early prophylaxis with LMWH after intervention should be strongly considered.

Management of Splenic Trauma in Contemporary Clinical Practice: A National Trauma Data Bank Study

To evaluate the utilization and efficacy of various treatments for management of adult patients with splenic trauma, highlighting the evolving role of splenic artery embolization. The National Trauma Data Bank (NTDB) was queried for patients who sustained splenic trauma between 2007 and 2015, excluding those with death on arrival and selected nonsplenic high-grade injuries. Patients were categorized into (1) nonoperative management (NOM), (2) embolization, (3) splenectomy, (4) splenic repair, and (5) combined treatment groups. Evaluated outcomes included hospital length of stay (LOS), intensive care unit LOS, mortality, and NOM and embolization failures. Overall, 117,743 patients with splenic predominant trauma were included in this study. Over the 9-year study period, 85,793 (72.9%) were treated with NOM, 21,999 (18.9%) with splenectomy, 3895 (3.3%) with embolization, and 2131 (1.8%) with splenic repair. From 2007 to 2015, mortality rates declined from 7.6% to 4.7%. The rate of NOM did not significantly change over time, while embolization increased 369% (1.3%-4.8%). Failure of NOM was 4.4% in 2007 and decreased to 3.4% in 2015. Across all injury grades, NOM had the shortest LOS (8.3 days), followed by splenic repair (12.3), embolization (12.6), and splenectomy (13.8) (p < 0.001). When adjusted for various clinical factors including severity of splenic injury, mortality rates were 7.1% for splenectomy, 3.2% for embolization, and 2.5% for NOM. Most patients with splenic-dominant blunt trauma are managed with NOM. Over time, the use of embolization has increased while open surgery has declined, and mortality has improved for all treatment methods. Compared to splenectomy, embolization is associated with shorter hospital LOS but is still used relatively infrequently.

Splenic Artery Angioembolization is Associated with Increased Venous Thromboembolism.

Angioembolization has become an increasingly utilized adjunct for splenic preservation after trauma. Embolization of the splenic artery may produce a transient systemic hypercoagulable state. This study was designed to determine the risk of venous thromboembolism (VTE) in blunt trauma patients managed nonoperatively with splenic angioembolization, relative to those managed without. Retrospective review of the American College of Surgeons Trauma Quality Improvement Performance (TQIP) Database from 2013 to 2016. Adult (>16years) patients with isolated, severe (Grades III-V) blunt splenic injuries managed nonoperatively who received pharmacological VTE prophylaxis formed the study population. Outcomes included deep venous thrombosis (DVT), pulmonary embolism (PE), or any VTE. A total of 2643 patients met inclusion criteria (69.1% Grade III, 26.5% Grade IV, 4.5% Grade V). The incidence of DVT was 4.5% in patients who underwent angioembolization, compared to 1.4% in patients who did not (p<0.001). Multivariable analysis showed that angioembolization was an independent risk factor for both DVT (OR 2.65, p = 0.006) and any VTE (OR 2.04, p = 0.01). Analysis according to splenic injury Grades showed that angioembolization remained an independent risk factor for DVT (p = 0.004) in the Grade IV-V injury group, and for VTE (p<0.01) in the Grade III injury group. Initiation of pharmacological VTE prophylaxis 48h after admission was associated with increased VTE rates in comparison to early initiation (OR 1.75, p = 0.02) CONCLUSIONS: Splenic artery angioembolization may be an independent risk factor for VTE events in isolated, severe blunt splenic trauma managed nonoperatively. Early prophylaxis with LMWH after intervention should be strongly considered.

Risk factors associated with splenectomy following a blunt splenic injury in pediatric patients.

The purpose of the study was to identify the factors associated with splenectomy in pediatric trauma patients. Pediatric Trauma quality improvement program (P-TQIP) database calendar year 2014-2016 was accessed for the study. All patients, age ≤ 18years old, who sustained splenic injury due to blunt mechanism, were included in the study. The primary outcome of the study was to identify the risk factors associated with splenectomy. Univariate followed by multivariate analyses were performed. A p value of < 0.05 was considered an indication of statistical significance. Of 1297 trauma victims, who fulfilled the inclusion criteria, 57 (4.4%) patients underwent total splenectomy. In Univariate analysis, there were significant differences found, in many variables, between the groups who underwent splenectomy versus those who did not have splenectomy. A multivariate logistic regression analysis showed use of blood transfusion within 4h and severity of splenic injury were the two variables associated with splenectomy. The area under the curve (AUC) value was 0.892 and the 95% confidence intervals were [0.859, 0.923]. Blood transfusion within 4h of patient's arrival to the hospital and high-grade splenic injury were main factors for splenectomy in the pediatric population.

Validation of the revised 2018 AAST-OIS classification and the CT severity index for prediction of operative management and survival in patients with blunt spleen and liver injuries

ObjectivesNon-operative management (NOM) is increasingly utilised in blunt abdominal trauma. The 1994 American Association of Surgery of Trauma grading (1994-AAST) is applied for clinical decision-making in many institutions. Recently, classifications incorporating contrast extravasation such as the CT severity index (CTSI) and 2018 update of the liver and spleen AAST were proposed to predict outcome and guide treatment, but validation is pending.MethodsCT images of patients admitted 2000–2016 with blunt splenic and hepatic injury were systematically re-evaluated for 1994/2018-AAST and CTSI grading. Diagnostic accuracy, diagnostic odds ratio (DOR), and positive and negative predictive values were calculated for prediction of in-hospital mortality. Correlation with treatment strategy was assessed by Cramer V statistics.ResultsSeven hundred and three patients were analysed, 271 with splenic, 352 with hepatic and 80 with hepatosplenic injury. Primary NOM was applied in 83% of patients; mortality was 4.8%. Comparing prediction of mortality in mild and severe splenic injuries, the CTSI (3.1% vs. 10.3%; diagnostic accuracy = 75.4%; DOR = 3.66; p = 0.006) and 1994-AAST (3.3% vs. 10.5%; diagnostic accuracy = 77.9%; DOR = 3.45; p = 0.010) were more accurate compared with the 2018-AAST (3.4% vs. 8%; diagnostic accuracy = 68.2%; DOR = 2.50; p = 0.059). In hepatic injuries, the CTSI was superior to both AAST classifications in terms of diagnostic accuracy (88.7% vs. 77.1% and 77.3%, respectively). CTSI and 2018-AAST correlated better with the need for surgery in severe vs. mild hepatic (Cramer V = 0.464 and 0.498) and splenic injuries (Cramer V = 0.273 and 0.293) compared with 1994-AAST (Cramer V = 0.389 and 0.255; all p < 0.001).ConclusionsThe 2018-AAST and CTSI are superior to the 1994-AAST in correlation with operative treatment in splenic and hepatic trauma. The CTSI outperforms the 2018-AAST in mortality prediction.Key Points• Non-operative management of blunt abdominal trauma is increasingly applied and correct patient stratification is crucial.• CT-based scoring systems are used to assess injury severity and guide clinical decision-making, whereby the 1994 version of the American Association of Surgery of Trauma Organ Injury Scale (AAST-OIS) is currently most commonly utilised.• Including contrast media extravasation in CT-based grading improves management and outcome prediction. While the 2018-AAST classification and the CT-severity-index (CTSI) better correlate with need for surgery compared to the 1994-AAST, the CTSI is superior in outcome-prediction to the 2018-AAST.