1
|
Wongweerakit O, Akaraborworn O, Sangthong B, Thongkhao K. Clinical parameters for the early detection of complications in patients with blunt hepatic and/or splenic injury undergoing non-operative management. Eur J Trauma Emerg Surg 2024; 50:847-855. [PMID: 38294693 DOI: 10.1007/s00068-024-02460-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 01/22/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Complications arising during non-operative management (NOM) of blunt hepatic and/or splenic trauma, particularly in cases of severe injury, are associated with significant morbidity and mortality. Abdominal computed tomography (CT) is the gold standard for the initial detection of complications during NOM. Although many institutions advocate routine in-hospital follow-up scans to improve success rates, others recommend a more selective approach. The use of follow-up CT remains a subject of ongoing debate, with no validated guidelines available regarding the timing, effectiveness, or intervals of follow-up imaging. OBJECTIVE We aimed to identify the clinical parameters for the early detection of complications in patients with blunt hepatic and/or splenic injury undergoing NOM. MATERIALS AND METHODS This retrospective cohort study included patients with blunt hepatic and/or splenic trauma treated at Songklanagarind Hospital, a level 1 trauma center, from 2013 to 2022. We assessed all patients indicated for non-operative management and examined their clinical parameters and complications. RESULTS Of 542 patients with blunt hepatic and/or splenic injuries, 315 (58%) were managed non-operatively. High-grade hepatic injuries were significantly associated with complications, as determined through a multivariate logistic regression analysis after adjusting for factors such as contrast blush findings, age, sex, and injury severity score (ISS) (adjusted OR = 7.69, 95% CI 1.59-37.13; p = 0.011). Among the patients with complications (n = 27), 17 (63%) successfully underwent non-operative management. Notably, eight patients presented with clinical symptoms prior to the diagnosis of complications, while only two patients had no clinical symptoms before the diagnosis. Tachycardia, abdominal pain, decreased hematocrit levels, and fever were significant indicators of complications (p < 0.05). CONCLUSION Routine CT to detect complications may not be necessary in patients with asymptomatic low-grade blunt hepatic injuries. By contrast, in those with isolated blunt hepatic injuries that are managed non-operatively, high-grade injuries, the presence of a contrast blush on initial imaging, and the patient's age may warrant consideration for routine follow-up CT scans. Clinical symptoms and laboratory observations during NOM, such as tachycardia, abdominal pain, decreased hematocrit levels, and fever, are significantly associated with complications. These symptoms necessitate further management, regardless of the initial injury severity, in patients with blunt hepatic and/or splenic injuries undergoing NOM.
Collapse
Affiliation(s)
- Onchuda Wongweerakit
- Division of Trauma and Critical Care, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand.
| | - Osaree Akaraborworn
- Division of Trauma and Critical Care, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Burapat Sangthong
- Division of Trauma and Critical Care, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Komet Thongkhao
- Division of Trauma and Critical Care, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| |
Collapse
|
2
|
Huang Z, Sun K, Luo Z, Zhang J, Zhou H, Yin H, Liang Z, You J. Spleen-targeted delivery systems and strategies for spleen-related diseases. J Control Release 2024; 370:773-797. [PMID: 38734313 DOI: 10.1016/j.jconrel.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/25/2024] [Accepted: 05/05/2024] [Indexed: 05/13/2024]
Abstract
The spleen, body's largest secondary lymphoid organ, is also a vital hematopoietic and immunological organ. It is regarded as one of the most significant organs in humans. As more researchers recognize the functions of the spleen, clinical methods for treating splenic diseases and spleen-targeted drug delivery systems to improve the efficacy of spleen-related therapies have gradually developed. Many modification strategies (size, charge, ligand, protein corona) and hitchhiking strategies (erythrocytes, neutrophils) of nanoparticles (NPs) have shown a significant increase in spleen targeting efficiency. However, most of the targeted drug therapy strategies for the spleen are to enhance or inhibit the immune function of the spleen to achieve therapeutic effects, and there are few studies on spleen-related diseases. In this review, we not only provide a detailed summary of the design rules for spleen-targeted drug delivery systems in recent years, but also introduce common spleen diseases (splenic tumors, splenic injuries, and splenomegaly) with the hopes of generating more ideas for future spleen research.
Collapse
Affiliation(s)
- Ziyao Huang
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China
| | - Kedong Sun
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China
| | - Zhenyu Luo
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China
| | - Junlei Zhang
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China
| | - Huanli Zhou
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China
| | - Hang Yin
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China
| | - Zhile Liang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, 639 LongMian road, NanJing, JiangSu 211198, PR China
| | - Jian You
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China; Zhejiang-California International Nanosystems Institute, Zhejiang University, Hangzhou 310058, PR China; Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310058, Zhejiang, PR China.
| |
Collapse
|
3
|
Kumar S, Katiyar V, Sharma S, Srivastava VK, Bhartiya SK, Mishra SP. A Clinical Review and Experience of Splenic Trauma in North India: A Retrospective Observational Study. Cureus 2024; 16:e55384. [PMID: 38562336 PMCID: PMC10984127 DOI: 10.7759/cureus.55384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION 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 abdominal blunt trauma, specifically those having splenic trauma, and their subsequent management in an institution. METHODS 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. RESULTS 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. CONCLUSIONS Nonoperative management of splenic trauma has evolved as the standard of care replacing operative management in order to sustain its immune function, thereby preventing overwhelming post-splenectomy infection.
Collapse
Affiliation(s)
- Sunil Kumar
- Division of Trauma Surgery, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IND
| | - Vivek Katiyar
- Division of Trauma Surgery, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IND
| | - Sumit Sharma
- Division of Trauma Surgery, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IND
| | - Vipul K Srivastava
- Division of Trauma Surgery, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IND
| | - Satyanam K Bhartiya
- Division of Trauma Surgery, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IND
| | - Shashi P Mishra
- Division of Trauma Surgery, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IND
| |
Collapse
|
4
|
Moghimi Z, Sadeghian E, Notash AY, Sobhanian E. Splenic abscess due to non-operative management of splenic injury: a case report. J Med Case Rep 2023; 17:305. [PMID: 37454091 DOI: 10.1186/s13256-023-04026-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 06/06/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Splenic abscess is a rare disease, with incidence of 0.2-0.7% in previous studies. It often appears with left upper quadrant abdominal pain, fever, chills. Splenic abscess often happens because of hematogenous spreading of infections, endocarditis, angioembolization and some other rare reasons. Treatment relies on one of these two methods: percutaneous drainage or surgery. CASE PRESENTATION A 68-year-old diabetic Asian female (Asian woman) presented with generalized abdominal pain, low blood pressure, tachycardia, fever, lethargy and elevated level of blood sugar. She had history of conservative therapy in intensive care unit due to blunt abdominal trauma and splenic injury. She had a huge splenic abscess in ultrasonography and computed tomography scan so she went under splenectomy. Our patient had a splenic abscess without performing any intervention like angioembolization. CONCLUSION Immune compromised patients who are selected for nonoperative management after splenic injury need close follow up and evaluating about abscess formation for at least 2 weeks. Early diagnosis and treatment with two methods including percutaneous drainage or splenectomy should be considered and it depends on patient's risk factors, vital signs, general conditions and presence or absence of sepsis.
Collapse
Affiliation(s)
- Zahra Moghimi
- Department of Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Sadeghian
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Ehsan Sobhanian
- Department of Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
5
|
Podda M, De Simone B, Ceresoli M, Virdis F, Favi F, Wiik Larsen J, Coccolini F, Sartelli M, Pararas N, Beka SG, Bonavina L, Bova R, Pisanu A, Abu-Zidan F, Balogh Z, Chiara O, Wani I, Stahel P, Di Saverio S, Scalea T, Soreide K, Sakakushev B, Amico F, Martino C, Hecker A, de'Angelis N, Chirica M, Galante J, Kirkpatrick A, Pikoulis E, Kluger Y, Bensard D, Ansaloni L, Fraga G, Civil I, Tebala GD, Di Carlo I, Cui Y, Coimbra R, Agnoletti V, Sall I, Tan E, Picetti E, Litvin A, Damaskos D, Inaba K, Leung J, Maier R, Biffl W, Leppaniemi A, Moore E, Gurusamy K, Catena F. Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document. World J Emerg Surg 2022; 17:52. [PMID: 36224617 PMCID: PMC9560023 DOI: 10.1186/s13017-022-00457-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved.
Methods Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.
Results Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications. Conclusion This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.
Collapse
Affiliation(s)
- Mauro Podda
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy.
| | - Belinda De Simone
- Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | - Marco Ceresoli
- General and Emergency Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Francesco Virdis
- Trauma and Acute Care Surgery Department, Niguarda Hospital, Milan, Italy
| | - Francesco Favi
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
| | - Johannes Wiik Larsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital University of Bergen, Stavanger, Norway
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | | | - Nikolaos Pararas
- Department of General Surgery, Dr Sulaiman Al Habib/Alfaisal University, Riyadh, Saudi Arabia
| | - Solomon Gurmu Beka
- School of Medicine and Health Science, University of Otago, Wellington Campus, Wellington, New Zealand
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Raffaele Bova
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
| | - Adolfo Pisanu
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy
| | - Fikri Abu-Zidan
- Department of Applied Statistics, The Research Office, College of Medicine and Health Sciences United Arab Emirates University, Abu Dhabi, UAE
| | - Zsolt Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Osvaldo Chiara
- Trauma and Acute Care Surgery Department, Niguarda Hospital, Milan, Italy
| | | | - Philip Stahel
- Department of Surgery, East Carolina University, Brody School of Medicine, Greenville, USA
| | - Salomone Di Saverio
- Department of Surgery, San Benedetto del Tronto Hospital, AV5, San Benedetto del Tronto, Italy
| | - Thomas Scalea
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital University of Bergen, Stavanger, Norway
| | - Boris Sakakushev
- Research Institute of Medical University Plovdiv/University Hospital St George Plovdiv, Plovdiv, Bulgaria
| | - Francesco Amico
- Trauma Service, John Hunter Hospital, Newcastle, Australia.,The University of Newcastle, Newcastle, Australia
| | - Costanza Martino
- Department of Anesthesiology and Acute Care, Umberto I Hospital of Lugo, Ausl della Romagna, Lugo, Italy
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Nicola de'Angelis
- Unit of General Surgery, Henri Mondor Hospital, UPEC, Créteil, France
| | - Mircea Chirica
- Service de Chirurgie Digestive, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Andrew Kirkpatrick
- General, Acute Care and Trauma Surgery Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Emmanouil Pikoulis
- General Surgery, Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Denis Bensard
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Luca Ansaloni
- Unit of General Surgery, San Matteo Hospital, Pavia, Italy
| | - Gustavo Fraga
- Division of Trauma Surgery, University of Campinas, Campinas, SP, Brazil
| | - Ian Civil
- Director of Trauma Services, Auckland City Hospital, Auckland, New Zealand
| | | | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, University of Catania, Catania, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Raul Coimbra
- Riverside University Health System Medical Center, Moreno Valley, CA, USA
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Ibrahima Sall
- Department of General Surgery, Military Teaching Hospital, Hôpital Principal Dakar, Dakar, Senegal
| | - Edward Tan
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Andrey Litvin
- Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
| | | | - Kenji Inaba
- University of Southern California, Los Angeles, USA
| | - Jeffrey Leung
- Division of Surgery and Interventional Science, University College London (UCL), London, UK.,Milton Keynes University Hospital, Milton Keynes, UK
| | | | - Walt Biffl
- Division of Trauma and Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, La Jolla, CA, USA
| | - Ari Leppaniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado School of Medicine, Denver, CO, USA
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Fausto Catena
- Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy
| |
Collapse
|
6
|
Han J, Dudi-Venkata NN, Jolly S, Ting YY, Lu H, Thomas M, Dobbins C. Splenic artery embolization improves outcomes and decreases the length of stay in hemodynamically stable blunt splenic injuries - A level 1 Australian Trauma centre experience. Injury 2022; 53:1620-1626. [PMID: 34991862 DOI: 10.1016/j.injury.2021.12.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 12/06/2021] [Accepted: 12/23/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Splenic injuries are the most common visceral injury following blunt abdominal trauma. Increasingly, non-operative management (NOM) and the use of adjunctive splenic angioembolization (ASE) is favoured over operative management (OM) for the hemodynamically stable patient. However, clinical predictors for successful NOM, particularly the role of ASE as an adjunct, remain poorly defined. This study aims to evaluate the outcomes of patients undergoing ASE vs NOM. METHODS A retrospective clinical audit was performed of all patients admitted with blunt splenic injury (BSI) from January 2005 to January 2018 at the Royal Adelaide Hospital. The primary outcome was ASE or NOM failure rate. Secondary outcomes were grade of splenic injury, Injury Severity Score (ISS), length of hospital stay (LOS), and delayed OM or re-angioembolization rates. RESULTS Of 208 patients with BSI, 60 (29%) underwent OM, 54 (26%) ASE, and 94 (45%) NOM only. Patients were predominantly male 165 (79%), with a median age of 33 (IQR 24-51) years. The median ISS was 29 (20-38). There was no difference in the overall success rates for each modality of primary management (48 (89%) ASE vs 77 (82%) NOM, p = 0.374), though patients managed with ASE were older (38 vs 30 years, p = 0.029), had higher grade of splenic injury (grade ≥ IV 42 (78%) vs 8 (8.5%), p<0.001), with increased rates of haemo-peritoneum (46 (85%) vs 51 (54%), p<0.001) and contrast blush (42 (78%) vs 2 (2%), p<0.001). However, for grade III splenic injury, patients managed with ASE had a trend towards better outcome with no failures when compared to the NOM group (0 (0%) vs 8 (35%), p = 0.070) with a significant reduction in LOS (7.2 vs 10.8 days, p = 0.042). Furthermore, the ASE group overall had a significantly shorter LOS compared to the NOM group (10.0 vs 16.0 days, p<0.001). CONCLUSION ASE as an adjunct to NOM significantly reduces the length of stay in BSI patients and is most successful in managing AAST grade III injuries.
Collapse
Affiliation(s)
- Jennie Han
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Department of Surgery, Austin Hospital, Melbourne, Victoria, Australia
| | | | - Samantha Jolly
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ying Yang Ting
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Ha Lu
- Department of Radiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Meredith Thomas
- Department of Radiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
| | - Christopher Dobbins
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
| |
Collapse
|
7
|
Jeong E, Jo Y, Park Y, Kim J, Jang H, Lee N. Very large haematoma following the nonoperative management of a blunt splenic injury in a patient with preexisting liver cirrhosis: a case report. JOURNAL OF TRAUMA AND INJURY 2022. [DOI: 10.20408/jti.2021.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The spleen is the most commonly injured organ after blunt abdominal trauma. Nonoperative management (NOM) is the standard treatment for blunt splenic injuries in haemodynamically stable patients without peritonitis. Complications of NOM include rebleeding, new pseudoaneurysm formation, splenic abscess, and symptomatic splenic infarction. These complications hinder the NOM of patients with blunt splenic injuries. We report a case in which a large haemorrhagic fluid collection that occurred after angio-embolisation was resolved by percutaneous drainage in a patient with liver cirrhosis who experienced a blunt spleen injury.
Collapse
|
8
|
Tran S, Wilks M, Dawson J. Endovascular Management of Splenic Trauma. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
9
|
Predictors for Failure of Non-operative Management of Splenic Injuries. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02523-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
10
|
Increased hospital treatment volume of splenic injury predicts higher rates of successful non-operative management and reduces hospital length of stay: a Swiss Trauma Registry analysis. Eur J Trauma Emerg Surg 2021; 48:133-140. [PMID: 33484278 PMCID: PMC8825359 DOI: 10.1007/s00068-020-01582-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/27/2020] [Indexed: 11/04/2022]
Abstract
Purpose First time analysis of the epidemiology, management and outcomes of patients with splenic injuries in Switzerland. This study aims to assess the effect of hospital treatment volume on successful non-operative management (NOM) in splenic injuries. Methods A multicentric registry-based study including all patients with splenic injuries entered into the Swiss Trauma Registry from 2015 to 2018 was conducted. Patients were stratified according to the hospitals treatment volume of splenic injuries. Primary outcome was the rate of successful NOM. Results During the 4-year study period, 652 patients with splenic injury were included in the study. Median age of the study population was 42 (IQR 27–59) years, and median ISS was 26 (20–34). The overall rate of successful NOM was 86.5%. Median HLOS was 13 (8–21) days. In-hospital mortality was 7.2% (n = 47). The mean number of patients with splenic injuries per center and year was 14. Five out of 12 Level I trauma centers treating more patients than the mean (≥ 15/year) were defined as high-volume centers. Multivariable analysis adjusting for differences in baseline and injury characteristics revealed treatment in a high-volume center as an independent predictor for successful NOM (OR 2.15, 95% CI 1.28–3.60, p = 0.004) and shorter HLOS (RC − 2.39, 95% CI − 4.91/− 0.48, p = 0.017), however, not for reduced in-hospital mortality (OR 0.92, 95% CI 0.39–2.18, p = 0.845). Conclusion Higher hospital treatment volume was associated with a higher rate of NOM and shorter HLOS, but not lower mortality. These results constitute the basis for further quality improvement in the care of splenic injury patients within the trauma system in Switzerland.
Collapse
|
11
|
Nguyen A, Orlando A, Yon JR, Mentzer CJ, Banton K, Bar-Or D. Predictors of splenectomy after failure of non-operative management: An analysis of the nation trauma database from 2013 to 2014. TRAUMA-ENGLAND 2021. [DOI: 10.1177/1460408620911489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction There is practice variability in non-operative management (NOM) of blunt splenic trauma. This is particularly true for management decisions following failure of NOM, i.e. splenectomy versus angioembolization (AE). The objective of this study was to identify predictors of splenectomy versus AE in patients who failed NOM. Methods We included adult patients from the National Trauma Data Bank for 2013–2014, who had a splenic injury and who were admitted to a Level I Trauma Center (L1TC). Patients undergoing splenectomy after 2 h of emergency department arrival were deemed to have failed NOM. Multivariate logistic regression modeling was used to identify independent predictors of intervention after failed NOM. Results There were 2284 patients admitted for splenic injury between 2013 and 2014 who failed NOM. A total of 1253 patients underwent AE and 1031 patients underwent splenectomy. Seven independent factors were identified that predicted failure of NOM: penetrating injury, community L1TC, hospital bed size, number of trauma surgeons on call, functional dependence, chronic steroid use, and cirrhosis. Conclusions Seven independent variables were identified that predicted failure of NOM. These results contribute to the body of data regarding management of blunt splenic injury. Knowing predictive factors could help personalize management of patients, minimize delay of care, efficient resource allocation, and inform future studies.
Collapse
Affiliation(s)
| | - Alessandro Orlando
- Swedish Medical Center, Englewood, CO, USA
- St. Anthony Hospital, Lakewood, Colorado, USA
- The Medical Center of Plano, Plano, TX, USA
- Penrose Hospital, Colorado Springs, CO, USA
| | | | | | | | - David Bar-Or
- Swedish Medical Center, Englewood, CO, USA
- St. Anthony Hospital, Lakewood, Colorado, USA
- The Medical Center of Plano, Plano, TX, USA
- Penrose Hospital, Colorado Springs, CO, USA
| |
Collapse
|
12
|
Revised AAST scale for splenic injury (2018): does addition of arterial phase on CT have an impact on the grade? Emerg Radiol 2020; 28:47-54. [PMID: 32705369 DOI: 10.1007/s10140-020-01823-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To determine whether an additional arterial phase (AP) leads to a change in the grade of splenic injury according to the 2018 revision of the AAST Organ Injury Scale, which has incorporated vascular injuries into the grading system and also to study its impact on management. METHODS In this retrospective study, 527 patients who sustained blunt abdominal trauma and had underwent dual-phase CT (AP and portal venous phase (PVP)) from December 2014 to October 2016 (23 months) were included. Two experienced radiologists independently graded the splenic injury according to the revised system in 2 blinded ways (AP + PVP and PVP alone). Receiver operator characteristic (ROC) curves were generated for grade of injury on both the phases for all splenic interventions. RESULTS Splenic injuries were detected in 154 patients, and splenic vascular injuries were detected in 52 of them. Of these, 22 vascular injuries were detected only on the AP, leading to a change in the grade of injury according to the new system in 18 patients. The AUC for ROC curves was generated for the grade of injury on AP + PVP vs. PVP alone for angioembolization (0.80 vs. 0.71, p value 0.002), and all splenic interventions (0.89 vs. 0.83, p value 0.003) showed higher AUC for AP + PVP. CONCLUSION Addition of AP leads to a significant change in the grading of splenic injuries according to the revised grading system due to increased detection of vascular injuries. Accurate classification of splenic injuries using additional AP would lead to better triage of patients for splenic interventions or conservative management.
Collapse
|
13
|
Clinical Results of Distal Embolization in Grade V Splenic Injury: Four-Year Experience from a Single Regional Trauma Center. J Vasc Interv Radiol 2020; 31:1570-1577.e2. [PMID: 32340865 DOI: 10.1016/j.jvir.2020.01.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/10/2020] [Accepted: 01/27/2020] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To evaluate the benefits and risks of splenic artery embolization (SAE) in patients with American Association for the Surgery of Trauma (AAST) grade V blunt spleen injury (BSI) MATERIALS AND METHODS: Medical records of 88 patients treated with SAE between April 2013 and May 2017 at a regional trauma care center were reviewed retrospectively. The BSI grade according to the AAST spleen injury scale (revised version 2018) was determined by using computed tomography (CT) images. A total of 42 patients (46.6%) had AAST grade V injury and were included in the analysis. Patient demographics, angiographic findings, embolization techniques, and technical and clinical outcomes, including splenic salvage rate and procedure-related complications, were examined. RESULTS SAE was performed within 2 hours after admission for 78.5% of the patients. All patients underwent selective distal embolization (n = 42). Primary clinical success rate was 80.9% (n = 34), and secondary clinical success rate was 88.1% (n = 37). The clinical failure group consisted of 5 patients. Four patients underwent splenectomy, and 1 patient died due to acute respiratory distress syndrome after embolization. The splenic salvage rate was 85.7% (n = 36). No patient had sepsis at follow-up (median, 247.0 days; interquartile range, 92.0-688.0). Clinical success rates (P = .356) and spleen salvage rates (P = .197) of patients who were hemodynamically stable (n = 19) showed no significant differences from those who were unstable (n = 23). CONCLUSIONS Distal embolization of grade V BSI is a safe and feasible procedure which is effective for successful spleen salvage.
Collapse
|
14
|
Salottolo K, Madayag RM, O'Brien M, Yon J, Tanner A, Topham A, Lieser M, Carrick MM, Mains CW, Bar-Or D. Quantity of hemoperitoneum is associated with need for intervention in patients with stable blunt splenic injury. Trauma Surg Acute Care Open 2020; 5:e000406. [PMID: 32154378 PMCID: PMC7046947 DOI: 10.1136/tsaco-2019-000406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/27/2019] [Accepted: 12/23/2019] [Indexed: 11/03/2022] Open
Abstract
Background In patients with hemodynamically stable blunt splenic injury (BSI), there is no consensus on whether quantity of hemoperitoneum (HP) is a predictor for intervention with splenic artery embolization (SAE) or failing nonoperative management (fNOM). We sought to analyze whether the quantity of HP was associated with need for intervention. Methods This retrospective cohort study included adult trauma patients with hemodynamically stable BSI admitted to six trauma centers between 2014 and 2016. Quantity of HP was defined as small (perisplenic blood or blood in Morrison's pouch), moderate (blood in one or both pericolic gutters), or large (additional finding of free blood in the pelvis). Multivariate logistic regression was performed to identify predictors of intervention with SAE or fNOM versus successful observation. Results There were 360 patients: hemoperitoneum was noted in 214 (59%) patients, of which the quantity was small in 92 (43%), moderate in 76 (35.5%), and large in 46 (21.5%). Definitive management was as follows: 272 (76%) were observed and 88 (24%) had intervention (83 SAE, 5 fNOM). The rate of intervention was univariately associated with quantity of HP, even after stratification by American Association for the Surgery of Trauma (AAST) grade. After adjustment, larger quantities of HP significantly increased odds of intervention (p=0.01). Compared with no HP, the odds of intervention were significantly increased for moderate HP (OR=3.51 (1.49 to 8.26)) and large HP (OR=2.89 (1.03 to 8.06)), with similar odds for small HP (OR=1.21 (0.46 to 2.76)). Other independent predictors of intervention were higher AAST grade, older age, and presence of splenic vascular injury. Conclusion Greater quantity of HP was associated with increased odds of intervention, with no difference in risk for moderate versus large HP. These findings suggest quantity of HP should be incorporated in the management algorithm of BSI as a consideration for angiography and/or embolization to maximize splenic preservation and reduce the risk of splenic rupture. Level of evidence III, retrospective epidemiological study.
Collapse
Affiliation(s)
- Kristin Salottolo
- Trauma Research, Swedish Medical Center, Englewood, Colorado, USA.,St. Anthony Hospital, Lakewood, Colorado, USA.,Penrose-St. Francis Health Services, Colorado Springs, Colorado, USA.,Radiology, Wesley Medical Center Trauma Services, Wichita, Kansas, USA.,Trauma Services, Research Medical Center, Kansas City, Missouri, USA.,Medical Center of Plano, Plano, Texas, USA
| | | | - Michael O'Brien
- Penrose-St. Francis Health Services, Colorado Springs, Colorado, USA
| | - James Yon
- Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
| | - Allen Tanner
- Penrose-St. Francis Health Services, Colorado Springs, Colorado, USA
| | - Andrew Topham
- Radiology, Wesley Medical Center Trauma Services, Wichita, Kansas, USA
| | - Mark Lieser
- Trauma Services, Research Medical Center, Kansas City, Missouri, USA
| | | | | | - David Bar-Or
- Trauma Research, Swedish Medical Center, Englewood, Colorado, USA.,St. Anthony Hospital, Lakewood, Colorado, USA.,Penrose-St. Francis Health Services, Colorado Springs, Colorado, USA.,Radiology, Wesley Medical Center Trauma Services, Wichita, Kansas, USA.,Trauma Services, Research Medical Center, Kansas City, Missouri, USA.,Medical Center of Plano, Plano, Texas, USA
| |
Collapse
|
15
|
Lee HJ, Cheng CT, Chen CC, Liao CA, Chen SW, Wang SY, Wu YT, Hsieh CH, Yeh CN, Liao CH. Increased long-term pneumonia risk for the trauma-related splenectomized population - a population-based, propensity score matching study. Surgery 2020; 167:829-835. [PMID: 32143843 DOI: 10.1016/j.surg.2020.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/21/2019] [Accepted: 01/13/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Splenectomy is the life-saving treatment for high-grade spleen trauma. Splenectomized patients are at a significant infection risk. However, the trauma-induced splenectomy results in less incidence of postsplenectomy infection than the hematologic disorder. We conducted a large-scale study to identify the infection rate and management strategy in trauma-related splenic injuries. METHODS We included patients with the diagnosis of spleen injury in Taiwan from January 2003 to December 2013 by using the National Health Insurance Database and divided them into spleen preserved and splenectomized groups. The demographic factors including age, sex, hospital level, year of injury, trauma mechanism, associated injuries, whether injury severity score ≧16, and comorbidities were extracted. A 1:1 propensity score match was performed, and we analyzed the long-term outcome as the presence of infection-related disease (septicemia, pneumonia, and meningitis) after spleen trauma. The multivariate logistic regression analysis was used to identify the risk factor for each outcome. RESULTS During the 11 years included in this study, a total of 8,897 patients with spleen trauma were identified. A total of 3,520 (39.6%) patients were splenectomized, and 5,377 (60.4%) were spleen preserved. After propensity score matching, 3,099 pairs of patients were enrolled for further analysis. In univariate analysis, the incidence of pneumonia is significantly higher in the splenectomized group (8.5% vs 7.0%, P = .037). There was no significant difference in septicemia and meningitis between the 2 groups. In multivariate analysis, splenectomy is an independent risk factor for pneumonia in long-term follow-up. CONCLUSION Compared with the spleen preserved group, splenectomy is related to an increased likelihood of long-term pneumonia onset but not to an increase in the possibility of other infections.
Collapse
Affiliation(s)
- Hou-Ju Lee
- Department of General Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Chi Chen
- Departments of Rehabilitation and Physical Medicine, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Chien-An Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Wei Chen
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Yu Wang
- Department of General Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Tung Wu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Nan Yeh
- Department of General Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan.
| |
Collapse
|
16
|
López Marcano AJ, de la Plaza Llamas R, Latorre Fragua RA, Medina Velasco AA, Ramia Ángel JM. Spontaneous splenic rupture associated with apixaban. Cir Esp 2019; 98:164-165. [PMID: 31395276 DOI: 10.1016/j.ciresp.2019.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/30/2019] [Accepted: 06/27/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Aylhin Joana López Marcano
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, España.
| | - Roberto de la Plaza Llamas
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, España
| | | | | | - José Manuel Ramia Ángel
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, España
| |
Collapse
|
17
|
Lauerman M, Brenner M, Simpson N, Shanmuganathan K, Stein D, Scalea T. Extra-parenchymal splenic abnormalities not vascular injury predict need for primary splenectomy. Eur J Trauma Emerg Surg 2019; 46:1063-1069. [PMID: 30721339 DOI: 10.1007/s00068-019-01085-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/30/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Radiographic indications for primary splenectomy (PS) in blunt splenic injury (BSI) after radiographic diagnosis are unknown. Improved understanding of radiographic characteristics of patients requiring splenectomy will help to appropriately triage patients to PS or non-operative management (NOM). METHODS A retrospective, single-center review was performed of BSI diagnosed with computerized tomography (CT). Patients undergoing splenectomy prior to CT diagnosis were excluded. RESULTS BSI was identified in 195 patients. On logistic regression, only subcapsular hematoma presence (OR 7.521, p = 0.002) and left upper quadrant hemoperitoneum (OR 6.146, p = 0.03) were associated with need for PS, while splenic laceration length, number of pseudoaneurysms (PSA), and active contrast extravasation (NS for all) were not. CONCLUSIONS Need for PS is predicted by extra-parenchymal pathology in subcapsular hematoma and hemoperitoneum. Splenic vascular injuries through PSA and active contrast extravasation do not predict the need for PS and can be considered for NOM.
Collapse
Affiliation(s)
- Margaret Lauerman
- Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene St, Baltimore, MD, 21201, USA.
| | - Megan Brenner
- Department of Surgery, University of California Riverside School of Medicine, Moreno Valley, CA, 92555, USA
| | - Nana Simpson
- Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene St, Baltimore, MD, 21201, USA
| | - Kathirkamanthan Shanmuganathan
- Division of Radiology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Deborah Stein
- Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene St, Baltimore, MD, 21201, USA
| | - Thomas Scalea
- Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene St, Baltimore, MD, 21201, USA
| |
Collapse
|
18
|
Hosseinpour M, Irajpour A, Poorjam N. The effect of splenic hilum ligation on the injured spleen and its function in rat model. ARCHIVES OF TRAUMA RESEARCH 2019. [DOI: 10.4103/atr.atr_49_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
19
|
Frink M, Lechler P, Debus F, Ruchholtz S. Multiple Trauma and Emergency Room Management. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:497-503. [PMID: 28818179 DOI: 10.3238/arztebl.2017.0497] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 10/16/2016] [Accepted: 04/24/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND The care of severely injured patients remains a challenge. Their initial treatment in the emergency room is the essential link between first aid in the field and definitive in-hospital treatment. METHODS We present important elements of the initial in-hospital care of severely injured patients on the basis of pertinent publications retrieved by a selective search in PubMed and the current German S3 guideline on the care of severely and multiply traumatized patients, which was last updated in 2016. RESULTS The goal of initial emergency room care is the rapid recognition and prompt treatment of acutely life-threatening injuries in the order of their priority. The initial assessment includes physical examination and ultrasonography according to the FAST concept (Focused Assessment with Sonography in Trauma) for the recognition of intraperitoneal hemorrhage. Patients with penetrating chest injuries, massive hematothorax, and/or severe injuries of the heart and lungs undergo emergency thoracotomy; those with signs of hollow viscus perforation undergo emergency laparotomy. If the patient is hemo - dynamically stable, the most important diagnostic procedure that must be performed is computerized tomography with contrast medium. Therapeutic decision-making takes the patient's physiological parameters into account, along with the overall severity of trauma and the complexity of the individual injuries. Depending on the severity of trauma, the immediate goal can be either the prompt restoration of organ structure and function or so-called damage control surgery. The latter focuses, in the acute phase, on hemostasis and on the avoidance of secondary damage such as intra-abdominal contamination or compartment syndrome. It also involves the temporary treatment of fractures with external fixation and the planning of definitive care once the patient's organ functions have been securely stabilized. CONCLUSION The care of the severely injured patient should be performed in structured fashion according to the A-B-C-D-E scheme, which involves the securing of the airway, breathing, and circulation, the recognition of neurologic deficits, and whole-body examination by the interdisciplinary team.
Collapse
Affiliation(s)
- Michael Frink
- Center for Orthopedics and Trauma Surgery, Gießen and Marburg University Hospital, Marburg Campus, Marburg
| | | | | | | |
Collapse
|
20
|
Teuben MPJ, Spijkerman R, Blokhuis TJ, Pfeifer R, Teuber H, Pape HC, Leenen LPH. Safety of selective nonoperative management for blunt splenic trauma: the impact of concomitant injuries. Patient Saf Surg 2018; 12:32. [PMID: 30505349 PMCID: PMC6260576 DOI: 10.1186/s13037-018-0179-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 11/13/2018] [Indexed: 11/10/2022] Open
Abstract
Background Nonoperative management for blunt splenic injury is the preferred treatment. To improve the outcome of selective nonoperative therapy, the current challenge is to identify factors that predict failure. Little is known about the impact of concomitant injury on outcome. Our study has two goals. First, to determine whether concomitant injury affects the safety of selective nonoperative treatment. Secondly we aimed to identify factors that can predict failure. Methods From our prospective trauma registry we selected all nonoperatively treated adult patients with blunt splenic trauma admitted between 01.01.2000 and 12.21.2013. All concurrent injuries with an AIS ≥ 2 were scored. We grouped and compared patients sustaining solitary splenic injuries and patients with concomitant injuries. To identify specific factors that predict failure we used a multivariable regression analysis. Results A total of 79 patients were included. Failure of nonoperative therapy (n = 11) and complications only occurred in patients sustaining concomitant injury. Furthermore, ICU-stay as well as hospitalization time were significantly prolonged in the presence of associated injury (4 versus 13 days,p < 0.05). Mortality was not seen. Multivariable analysis revealed the presence of a femur fracture and higher age as predictors of failure. Conclusions Nonoperative management for hemodynamically normal patients with blunt splenic injury is feasible and safe, even in the presence of concurrent (non-hollow organ) injuries or a contrast blush on CT. However, associated injuries are related to prolonged intensive care unit- and hospital stay, complications, and failure of nonoperative management. Specifically, higher age and the presence of a femur fracture are predictors of failure.
Collapse
Affiliation(s)
- Michel Paul Johan Teuben
- 1Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Roy Spijkerman
- 1Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Taco Johan Blokhuis
- 2Department of Surgery, Maastricht University Medical Center, P. Debyelaan 24, 6229 HX Maastricht, The Netherlands
| | - Roman Pfeifer
- 3Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zürich, Switzerland
| | - Henrik Teuber
- 3Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zürich, Switzerland
| | - Hans-Christoph Pape
- 3Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zürich, Switzerland
| | | |
Collapse
|
21
|
Laparoscopy reduces iatrogenic splenic injuries during colorectal surgery. Tech Coloproctol 2018; 22:767-771. [PMID: 30460619 DOI: 10.1007/s10151-018-1861-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 09/24/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Splenic injury can occur during colorectal surgery especially in cases, where the splenic flexure is mobilized. The aim of this study was to analyze whether the operative approach (laparoscopic vs. open) was associated with an increased risk for splenic injury during colorectal surgery and to compare the outcomes of different management options. METHODS All accidental injuries that occurred during colorectal resections performed in our department between January 2010 and June 2013 were identified from an administrative database. All patients with iatrogenic splenic injuries were classified into two groups according to the operative approach. Only procedures that required splenic flexure mobilization were included. Splenic injury management options and outcomes were compared. RESULTS There were 2336 colorectal resections (1520 open, 816 laparoscopic) performed during the study period. There were 25 (1.1%) iatrogenic splenic injuries. 23 out of 25 splenic injuries occurred during open colorectal surgery. Overall, 16 (64%) patients were managed with topical hemostatic methods, 5 (20%) with splenectomy, and 4 (16%) with splenorrhaphy. It was possible to salvage the spleen in both laparoscopic patients. The laparoscopic approach was associated with a lower splenic injury rate (0.25% vs. 1.5%, p = 0.005) and a lower need for splenectomy/splenorrhaphy (p = 0.03). CONCLUSIONS Our data suggest that laparoscopic colorectal surgery may be associated with a lower risk of iatrogenic splenic injury, and that most splenic injuries can be managed with spleen-preserving approaches.
Collapse
|
22
|
Western Trauma Association Critical Decisions in Trauma: Management of adult blunt splenic trauma-2016 updates. J Trauma Acute Care Surg 2018; 82:787-793. [PMID: 27893644 DOI: 10.1097/ta.0000000000001323] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
|
23
|
Fugazzola P, Morganti L, Coccolini F, Magnone S, Montori G, Ceresoli M, Tomasoni M, Piazzalunga D, Maccatrozzo S, Allievi N, Occhionorelli S, Ansaloni L. 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. Eur J Trauma Emerg Surg 2018; 46:407-412. [PMID: 30324241 DOI: 10.1007/s00068-018-1032-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 10/08/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION 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. MATERIALS AND METHODS This is a multicentre prospective observational study, including patients presenting with blunt splenic trauma older than 17 years, 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. RESULTS 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). CONCLUSIONS 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.
Collapse
Affiliation(s)
- Paola Fugazzola
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy.
| | - Lucia Morganti
- General Surgery Department, Sant'Anna University Hospital, Ferrara, Italy
| | - Federico Coccolini
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | - Stefano Magnone
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | - Giulia Montori
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | - Marco Ceresoli
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | - Matteo Tomasoni
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | - Dario Piazzalunga
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | - Stefano Maccatrozzo
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | - Niccolò Allievi
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| | | | - Luca Ansaloni
- General and Emergency Surgery Department, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo, Italy
| |
Collapse
|
24
|
Moreno P, Von Allmen M, Haltmeier T, Candinas D, Schnüriger B. Long-Term Follow-Up After Non-operative Management of Blunt Splenic and Liver Injuries: A Questionnaire-Based Survey. World J Surg 2018; 42:1358-1363. [PMID: 29138912 DOI: 10.1007/s00268-017-4336-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Non-operative management (NOM) of blunt splenic or liver injuries (solid organ injury, SOI) has become the standard of care in hemodynamically stable patients. However, the incidence of long-term symptoms in these patients is currently not known. The aim of this study was to assess long-term symptoms in patients undergoing successful NOM (sNOM) for SOI. METHODS Long-term posttraumatic outcomes including chronic abdominal pain, irregular bowel movements, and recurrent infections were assessed using a specifically designed questionnaire and analyzed by univariable analysis. RESULTS Eighty out of 138 (58%) patients with SOI undergoing sNOM) responded to the questionnaire. Median (IQR) follow-up time was 48.8 (28) months. Twenty-seven (34%) patients complained of at least one of the following symptoms: 17 (53%) chronic abdominal pain, 13 (41%) irregular bowel movements, and 8 (25%) recurrent infections. One female patient reported secondary infertility. No significant association between the above-mentioned symptoms and the Injury Severity Score, amount of hemoperitoneum, or high-grade SOI was found. Patients with chronic pain were significantly younger than asymptomatic patients (32.1 ± 14.5 vs. 48.3 ± 19.4 years, p = 0.002). Irregular bowel movements were significantly more frequent in patients with severe pelvic fractures (15.4 vs. 0.0%, p = 0.025). A trend toward a higher frequency of recurrent infections was found in patients with splenic injuries (15.9 vs. 2.8%, p = 0.067). CONCLUSION A third of patients with blunt SOI undergoing sNOM reported long-term abdominal symptoms. Younger age was associated with chronic abdominal symptoms. More studies are warranted to investigate long-term outcomes immunologic sequelae in patients after sNOM for SOI.
Collapse
Affiliation(s)
- Peter Moreno
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Matthias Von Allmen
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Tobias Haltmeier
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Beat Schnüriger
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
| |
Collapse
|
25
|
Roy P, Mukherjee R, Parik M. Splenic trauma in the twenty-first century: changing trends in management. Ann R Coll Surg Engl 2018; 100:1-7. [PMID: 30112955 PMCID: PMC6204520 DOI: 10.1308/rcsann.2018.0139] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2018] [Indexed: 12/16/2022] Open
Abstract
Over the past three decades, management of blunt splenic trauma has changed radically. Use of improved diagnostic techniques and proper understanding of disease pathology has led to nonoperative management being chosen as the standard of care in patients who are haemodynamically stable. This review was undertaken to assess available literature regarding changing trends of management of blunt splenic trauma, and to identify the existing lacunae in nonoperative management. The PubMed database was searched for studies published between January 1987 and August 2017, using the keywords 'blunt splenic trauma' and 'nonoperative management'. One hundred and fifty-three articles were reviewed, of which 82 free full texts and free abstracts were used in the current review. There is clear evidence in published literature of the greater success of nonoperative over operative management in patients who are haemodynamically stable and the increasing utility of adjunctive therapies like angiography with embolisation. However, the review revealed a lack of universal guidelines for patient selection criteria and diagnostic and grading procedures needed for nonoperative management. Indications for splenic artery embolisation, the current role of splenectomy and spleen-preserving surgeries, together with the place of minimal access surgery in blunt splenic trauma remain grey areas. Moreover, parameters affecting the outcomes of nonoperative management and its failure and management need to be defined. This shows a need for future studies focused on these shortcomings with the ultimate aim being the formulation and implementation of universally accepted guidelines for safe and efficient management of blunt splenic trauma.
Collapse
Affiliation(s)
- P Roy
- RG Kar Medical College and Hospital, General Surgery, Kolkata, India
| | - R Mukherjee
- RG Kar Medical College and Hospital, General Surgery, Kolkata, India
| | - M Parik
- RG Kar Medical College and Hospital, General Surgery, Kolkata, India
| |
Collapse
|
26
|
Markert K, Haltmeier T, Khatsilouskaya T, Keel MJ, Candinas D, Schnüriger B. Early Surgery in Prone Position for Associated Injuries in Patients Undergoing Non-operative Management for Splenic and Liver Injuries. World J Surg 2018; 42:3947-3953. [DOI: 10.1007/s00268-018-4739-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
27
|
Adibi A, Ferasat F, Baradaran Mahdavi MM, Kazemi K, Sadeghian S. Assessment of blunt splenic trauma: Which imaging scoring system is superior? JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2018; 23:29. [PMID: 29692826 PMCID: PMC5894272 DOI: 10.4103/jrms.jrms_875_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 10/28/2017] [Accepted: 12/04/2017] [Indexed: 11/21/2022]
Abstract
Background: Spleen is the most common viscera that may be hurt in blunt abdominal trauma. Operative or nonoperative management of splenic injury is a dilemma. The American Association for the Surgery of Trauma (AAST) is the most common grading system which has been used for the management of blunt splenic injuries. The new recommended grading system assesses other aspects of splenic injury such as contrast extravasation, pseudoaneurysm, arteriovenous fistula, and severity of hemoperitoneum, as well. The aim of this study is to compare and prioritize the cutoff of AAST grading system with the new recommended one. Materials and Methods: This is a cross-sectional study on patients with splenic injury caused by abdominal blunt trauma referred to Isfahan University of Medical Sciences affiliated Hospitals, Iran, in 2013–2016. All patients underwent abdominopelvic computed tomography scanning with intravenous (IV) contrast. All images were reported by a single expert radiologist, and splenic injury grading was reported based on AAST and the new recommended system. Then, all patients were followed to see if they needed surgical or nonsurgical management. Results: Based on the findings of this study conducted on 68 patients, cutoff point of Grade 2, in AAST system, had 90.3% (95% confidence interval [CI]: 0.73–0.97) specificity, 51.4% (95% CI: 0.34–0.67) sensitivity, 86.4% (95% CI: 0.64–0.95) positive predictive value (PPV), and 60.9% (95% CI: 0.45–0.74) negative predictive value (NPV) for prediction of surgical management requirement, while it was 90.3% (95% CI: 0.73–0.97) specificity, 45.9% (95% CI: 0.29–0.63) sensitivity, 85% (95% CI: 0.61–0.96) PPV, and 58.3% (95% CI: 0.43–0.72) NPV for the new system (P = 0.816). Conclusion: In contrast to the previous studies, the new splenic injury grading method was not superior to AAST. Further studies with larger populations are recommended.
Collapse
Affiliation(s)
- Atoosa Adibi
- Department of Radiology and Imaging, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farbod Ferasat
- Department of Radiology and Imaging, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Kimia Kazemi
- Department of Radiology and Imaging, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sina Sadeghian
- Department of Radiology and Imaging, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
28
|
Matos Filho ASDE, Petroianu A, Cardoso VN, Vidigal PVT. Splenic implant preservation after conservation in lactated Ringer´s solution. Rev Col Bras Cir 2018; 45:e1346. [PMID: 29451641 DOI: 10.1590/0100-6991e-20181346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 09/17/2017] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE to evaluate the morphology and function of autogenous splenic tissue implanted in the greater omentum, 24 hours after storage in Ringer-lactate solution. METHODS we divided 35 male rats into seven groups (n=5): Group 1: no splenectomy; Group 2: total splenectomy without implant; Group 3: total splenectomy and immediate autogenous implant; Group 4: total splenectomy, preservation of the spleen in Ringer-lactate at room temperature, then sliced and implanted; Group 5: total splenectomy, spleen sliced and preserved in Ringer-lactate at room temperature before implantation; Group 6: total splenectomy with preservation of the spleen in Ringer-lactate at 4°C and then sliced and implanted; Group 7: total splenectomy and the spleen sliced for preservation in Ringer-lactate at 4°C before implantation. After 90 days, we performed scintigraphic studies with Tc99m-colloidal tin (liver, lung, spleen or implant and clot), haematological exams (erythrogram, leucometry, platelets), biochemical dosages (protein electrophoresis) and anatomopathological studies. RESULTS regeneration of autogenous splenic implants occurred in the animals of the groups with preservation of the spleen at 4ºC. The uptake of colloidal tin was higher in groups 1, 3, 6 and 7 compared with the others. There was no difference in hematimetric values in the seven groups. Protein electrophoresis showed a decrease in the gamma fraction in the group of splenectomized animals in relation to the operated groups. CONCLUSION the splenic tissue preserved in Ringer-lactate solution at 4ºC maintains its morphological structure and allows functional recovery after being implanted on the greater omentum.
Collapse
Affiliation(s)
| | - Andy Petroianu
- Department of Surgery, Medical School, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Valbert Nascimento Cardoso
- Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, UFMG, Belo Horizonte, MG, Brazil
| | | |
Collapse
|
29
|
Mebert RV, SchnÜRiger B, Candinas D, Haltmeier T. Follow-Up Imaging in Patients with Blunt Splenic or Hepatic Injury Managed Nonoperatively. Am Surg 2018. [DOI: 10.1177/000313481808400226] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Nonoperative management of blunt splenic and hepatic injuries has become the standard of care for hemodynamically stable patients. However, nonoperative management may lead to delayed complications and appropriate follow-up is therefore crucial. The aim of this systematic literature review was to assess the role of different imaging modalities in the follow-up assessment of patients with blunt splenic or hepatic injuries using the PubMed database. Eighteen studies were found to be relevant to the topic. A total of 2725 patients were enrolled in the included studies. Both retrospective and prospective studies, but no randomized controlled trials were found. In these studies, CT, ultrasound, and contrast-enhanced ultrasound were discussed. CT was the most commonly used imaging modality. Taking into account all studies included, only one patient underwent intervention due to a complication diagnosed by follow-up CTscan in the absence of clinical signs and symptoms. This equates to a total of 920 CT scans performed to diagnose one clinically nonevident complication that required intervention. Based on the reviewed literature, routine imaging follow-up CT scans may not be indicated in asymptomatic patients with lower grade blunt splenic or hepatic injuries. Contrast-enhanced ultrasound is a promising alternative imaging modality for the follow-up of these patients.
Collapse
Affiliation(s)
- R. Viola Mebert
- Division of Acute Care Surgery, Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Beat SchnÜRiger
- Division of Acute Care Surgery, Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Daniel Candinas
- Division of Acute Care Surgery, Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Tobias Haltmeier
- Division of Acute Care Surgery, Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| |
Collapse
|
30
|
Pothmann CEM, Sprengel K, Alkadhi H, Osterhoff G, Allemann F, Jentzsch T, Jukema G, Pape HC, Simmen HP, Neuhaus V. [Abdominal injuries in polytraumatized adults : Systematic review]. Unfallchirurg 2018; 121:159-173. [PMID: 29350250 DOI: 10.1007/s00113-017-0456-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Abdominal injuries are potentially life-threatening and occur in 20-25% of all polytraumatized patients. Blunt trauma is the main mechanism. The liver and spleen are most commonly injured and much less often the intestines. The clinical evaluation proves equivocal in many cases; therefore, the gold standard is computed tomography (CT), which has been increasingly used even in hemodynamically weakly stable or sometimes even unstable patients because it promptly provides precise diagnostic findings, which present the basis for successful therapy. Hemodynamically unstable patients always need an exploratory laparotomy (EL). An EL should also be carried out with a positive focused assessment with sonography for trauma (FAST) or CT for severe parenchymal lesions, hollow organ lesions, intraperitoneal bladder lesions, peritonitis and organ evisceration, impalement injuries and lesions of the abdominal fascia. Hemodynamically stable patients without signs of peritonitis and a lack of such findings can often be treated conservatively irrespective of the extent of an injury. Angiography (and if needed embolization) can additionally be diagnostically and therapeutically utilized.
Collapse
Affiliation(s)
- C E M Pothmann
- Klinik für Traumatolgie, UniversitätsSpital Zürich, Rämistr. 100, 8091, Zürich, Schweiz
| | - K Sprengel
- Klinik für Traumatolgie, UniversitätsSpital Zürich, Rämistr. 100, 8091, Zürich, Schweiz
| | - H Alkadhi
- Institut für Diagnostische und Interventionelle Radiologie, UniversitätsSpital Zürich, Zürich, Schweiz
| | - G Osterhoff
- Klinik für Traumatolgie, UniversitätsSpital Zürich, Rämistr. 100, 8091, Zürich, Schweiz
| | - F Allemann
- Klinik für Traumatolgie, UniversitätsSpital Zürich, Rämistr. 100, 8091, Zürich, Schweiz
| | - T Jentzsch
- Klinik für Traumatolgie, UniversitätsSpital Zürich, Rämistr. 100, 8091, Zürich, Schweiz
| | - G Jukema
- Klinik für Traumatolgie, UniversitätsSpital Zürich, Rämistr. 100, 8091, Zürich, Schweiz
| | - H C Pape
- Klinik für Traumatolgie, UniversitätsSpital Zürich, Rämistr. 100, 8091, Zürich, Schweiz
| | - H-P Simmen
- Klinik für Traumatolgie, UniversitätsSpital Zürich, Rämistr. 100, 8091, Zürich, Schweiz.
| | - V Neuhaus
- Klinik für Traumatolgie, UniversitätsSpital Zürich, Rämistr. 100, 8091, Zürich, Schweiz
| |
Collapse
|
31
|
A comparison of the management of blunt splenic injury in children and young people-A New South Wales, population-based, retrospective study. Injury 2018; 49:42-50. [PMID: 28867641 DOI: 10.1016/j.injury.2017.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/25/2017] [Accepted: 08/11/2017] [Indexed: 02/02/2023]
Abstract
UNLABELLED The importance and safety of non-operative management (NOM) of Blunt Splenic Injury (BSI) has been established in children and adults over recent decades. However, studies have shown higher operation rates in adults. There is international evidence that when children are managed in adult centres, operation rates are higher while adolescents in paediatric centres, are operated on in line with paediatric guidelines. This difference between children and young adults, and the factors responsible, have not been examined in New South Wales (NSW). OBJECTIVE To use NSW hospital and mortality data to compare the characteristics of BSI in patients aged 0-16 to those aged 17-25, and determine factors related to operative management (OM) and splenic salvage in each group. METHODS Patients age 0-25 between July 2000 and December 2011, with a diagnosis of BSI, were identified in the NSW Admitted Patient Data Collection, and linked to deaths data from Registry of Births Deaths and Marriages and Bureau of Statistics. Operation rate was compared between the two groups. Univariable analysis was used to determine factors associated with OM. Multivariable logistic regression with stepwise elimination was then performed to determine likelihood of OM according to age group, adjusting for potential confounders. RESULTS 1986 cases were identified, with 422 (21.2%) managed operatively - 101/907 children (11.1%) and321/1079 (29.7%)young adults(p<0.001). Of these, 59 (58%) children underwent splenectomy compared with 233 (73%) young adults (p<0.001). OM increased significantly after the age of 12 (p=0.03), and the percentage almost tripled in the teenage years, coinciding with a higher proportion admitted to adult centres. OM doubled again in young adults(p<0.001), all of whom were managed away from paediatric centres. On multivariable analysis, factors significantly associated with operation included age over 16 (OR 2.82, 95%CI 2.10-3.81), splenic injury severity, associated thoracic, liver, pancreatic and hollow viscus injury, and blood transfusion. CONCLUSION While Paediatric Surgeons have wholeheartedly adopted non-operative management, away from paediatric centres, it is possible children and young people in NSW are undergoing operation unnecessarily. Further evaluation of the surgeon attitudes and institutional factors involved in the management of injured children and young people within the broad NSW trauma system is required.
Collapse
|
32
|
Crichton JCI, Naidoo K, Yet B, Brundage SI, Perkins Z. The role of splenic angioembolization as an adjunct to nonoperative management of blunt splenic injuries: A systematic review and meta-analysis. J Trauma Acute Care Surg 2017; 83:934-943. [PMID: 29068875 DOI: 10.1097/ta.0000000000001649] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Nonoperative management (NOM) of hemodynamically normal patients with blunt splenic injury (BSI) is the standard of care. Guidelines recommend additional splenic angioembolization (SAE) in patients with American Association for the Surgery of Trauma (AAST) Grade IV and Grade V BSI, but the role of SAE in Grade III injuries is unclear and controversial. The aim of this systematic review was to compare the safety and effectiveness of SAE as an adjunct to NOM versus NOM alone in adults with BSI. METHODS A systematic literature search (Medline, Embase, and CINAHL) was performed to identify original studies that compared outcomes in adult BSI patients treated with SAE or NOM alone. Primary outcome was failure of NOM. Secondary outcomes included morbidity, mortality, hospital length of stay, and transfusion requirements. Bayesian meta-analyses were used to calculate an absolute (risk difference) and relative (risk ratio [RR]) measure of treatment effect for each outcome. RESULTS Twenty-three studies (6,684 patients) were included. For Grades I to V combined, there was no difference in NOM failure rate (SAE, 8.6% vs NOM, 7.7%; RR, 1.09 [0.80-1.51]; p = 0.28), mortality (SAE, 4.8% vs NOM, 5.8%; RR, 0.82 [0.45-1.31]; p = 0.81), hospital length of stay (11.3 vs 9.5 days; p = 0.06), or blood transfusion requirements (1.8 vs 1.7 units; p = 0.47) between patients treated with SAE and those treated with NOM alone. However, morbidity was significantly higher in patients treated with SAE (SAE, 38.1% vs NOM, 18.6%; RR, 1.83 [1.20-2.66]; p < 0.01). When stratified by grade of splenic injury, SAE significantly reduced the failure rate of NOM in patients with Grade IV and Grade V splenic injuries but had minimal effect in those with Grade I to Grade III injuries. CONCLUSION Splenic angioembolization should be strongly considered as an adjunct to NOM in patients with AAST Grade IV and Grade V BSI but should not be routinely recommended in patients with AAST Grade I to Grade III injuries. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
Collapse
Affiliation(s)
- James Charles Ian Crichton
- From the Department of General Surgery (J.C.I.C.), Waikato Hospital, Hamilton, New Zealand; Queen Mary University of London, Barts, and The London School of Medicine and Dentistry, London, United Kingdom (K.N., B.Y., Z.P., S.I.B.)
| | | | | | | | | |
Collapse
|
33
|
Role of Interventional Radiology in Solid Organ Trauma. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0091-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
34
|
Coccolini F, Montori G, Catena F, Kluger Y, Biffl W, Moore EE, Reva V, Bing C, Bala M, Fugazzola P, Bahouth H, Marzi I, Velmahos G, Ivatury R, Soreide K, Horer T, Ten Broek R, Pereira BM, Fraga GP, Inaba K, Kashuk J, Parry N, Masiakos PT, Mylonas KS, Kirkpatrick A, Abu-Zidan F, Gomes CA, Benatti SV, Naidoo N, Salvetti F, Maccatrozzo S, Agnoletti V, Gamberini E, Solaini L, Costanzo A, Celotti A, Tomasoni M, Khokha V, Arvieux C, Napolitano L, Handolin L, Pisano M, Magnone S, Spain DA, de Moya M, Davis KA, De Angelis N, Leppaniemi A, Ferrada P, Latifi R, Navarro DC, Otomo Y, Coimbra R, Maier RV, Moore F, Rizoli S, Sakakushev B, Galante JM, Chiara O, Cimbanassi S, Mefire AC, Weber D, Ceresoli M, Peitzman AB, Wehlie L, Sartelli M, Di Saverio S, Ansaloni L. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg 2017; 12:40. [PMID: 28828034 PMCID: PMC5562999 DOI: 10.1186/s13017-017-0151-4] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 08/04/2017] [Indexed: 11/25/2022] Open
Abstract
Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.
Collapse
Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Giulia Montori
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, HI USA
| | - Ernest E Moore
- Trauma Surgery, Denver Health Medical Center, Denver, CO USA
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Camilla Bing
- General and Emergency Surgery Department, Empoli Hospital, Empoli, Italy
| | - Miklosh Bala
- General and Emergency Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Paola Fugazzola
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Hany Bahouth
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ingo Marzi
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie Universitätsklinikum Goethe-Universität Frankfurt, Frankfurt, Germany
| | - George Velmahos
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA USA
| | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA USA
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital and Örebro University, Orebro, Sweden.,Department of Surgery, Örebro University Hospital and Örebro University, Obreo, Sweden
| | - Richard Ten Broek
- Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
| | - Bruno M Pereira
- Trauma/Acute Care Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Trauma/Acute Care Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Kenji Inaba
- Division of Trauma and Critical Care, LAC+USC Medical Center, Los Angeles, CA USA
| | - Joseph Kashuk
- Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Neil Parry
- General and Trauma Surgery Department, London Health Sciences Centre, Victoria Hospital, London, ON Canada
| | - Peter T Masiakos
- Pediatric Trauma Service, Massachusetts General Hospital, Boston, MA USA
| | | | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | | | - Noel Naidoo
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Francesco Salvetti
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Stefano Maccatrozzo
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | | | | | - Leonardo Solaini
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Antonio Costanzo
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Andrea Celotti
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Matteo Tomasoni
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mozir, Belarus
| | - Catherine Arvieux
- Clin. Univ. de Chirurgie Digestive et de l'Urgence, CHUGA-CHU Grenoble Alpes UGA-Université Grenoble Alpes, Grenoble, France
| | - Lena Napolitano
- Trauma and Surgical Critical Care, University of Michigan Health System, East Medical Center Drive, Ann Arbor, MI USA
| | - Lauri Handolin
- Trauma Unit, Helsinki University Hospital, Helsinki, Finland
| | - Michele Pisano
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Stefano Magnone
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, CA USA
| | - Marc de Moya
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA USA
| | - Kimberly A Davis
- General Surgery, Trauma, and Surgical Critical Care, Yale-New Haven Hospital, New Haven, CT USA
| | | | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Paula Ferrada
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA USA
| | - Rifat Latifi
- General Surgery Department, Westchester Medical Center, Westchester, NY USA
| | - David Costa Navarro
- Colorectal Surgery Unit, Trauma Care Committee, Alicante General University Hospital, Alicante, Spain
| | - Yashuiro Otomo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, USA
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | | | - Sandro Rizoli
- Trauma and Acute Care Service, St Michael's Hospital, Toronto, ON Canada
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, University of California, Davis Medical Center, Davis, CA USA
| | | | | | - Alain Chichom Mefire
- Department of Surgery and Obstetric and Gynecology, University of Buea, Buea, Cameroon
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Marco Ceresoli
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Andrew B Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, Pensylvania USA
| | - Liban Wehlie
- General Surgery Department, Ayaan Hospital, Mogadisho, Somalia
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Salomone Di Saverio
- General, Emergency and Trauma Surgery Department, Maggiore Hospital, Bologna, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| |
Collapse
|
35
|
Petrone P, Anduaga Peña MF, Servide Staffolani MJ, Brathwaite C, Axelrad A, Ceballos Esparragón J. Evolution of the treatment of splenic injuries: from surgery to non-operative management. Cir Esp 2017; 95:420-427. [PMID: 28779968 DOI: 10.1016/j.ciresp.2017.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/07/2017] [Accepted: 07/10/2017] [Indexed: 11/15/2022]
Abstract
The spleen is one of the most frequently injured organs in blunt abdominal trauma. In the past decades, the treatment of patients with blunt splenic injury has shifted from operative to non-operative management. The knowledge of physiology and immunology of the spleen have been the main reasons to develop techniques for splenic salvage. The advances in high-resolution imaging techniques, as well as less invasive procedures, including angiography and angioembolization, have allowed a higher rate of success in the non-operative management. Non-operative management has showed a decrease in overall mortality and morbidity. The aim of this article is to analyze the current management of splenic injury based on a literature review of the last 30 years, from we have identified 63,205 patients. This would enable the surgeons to provide the best care possible in every case.
Collapse
Affiliation(s)
- Patrizio Petrone
- Department of Surgery, NYU Winthrop Hospital, Mineola (Nueva York), Estados Unidos; Universidad de Las Palmas, Las Palmas de Gran Canaria, España.
| | - María Fernanda Anduaga Peña
- Department of Surgery, NYU Winthrop Hospital, Mineola (Nueva York), Estados Unidos; Hospital Universitario de Salamanca, Salamanca, España
| | - María José Servide Staffolani
- Department of Surgery, NYU Winthrop Hospital, Mineola (Nueva York), Estados Unidos; Hospital Universitario de Cruces, Barakaldo (Vizcaya), España
| | - Collin Brathwaite
- Department of Surgery, NYU Winthrop Hospital, Mineola (Nueva York), Estados Unidos
| | - Alexander Axelrad
- Department of Surgery, NYU Winthrop Hospital, Mineola (Nueva York), Estados Unidos
| | - José Ceballos Esparragón
- Department of Surgery, NYU Winthrop Hospital, Mineola (Nueva York), Estados Unidos; Hospital Vithas Santa Catalina, Las Palmas de Gran Canaria, España
| |
Collapse
|
36
|
Khatsilouskaya T, Haltmeier T, Cathomas M, Eberle B, Candinas D, Schnüriger B. Thromboembolic Prophylaxis with Heparin in Patients with Blunt Solid Organ Injuries Undergoing Non-operative Treatment. World J Surg 2017; 41:1193-1200. [PMID: 27942848 DOI: 10.1007/s00268-016-3820-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with blunt solid organ injuries (SOI) are at risk for venous thromboembolism (VTE), and VTE prophylaxis is crucial. However, little is known about the safety of early prophylactic administration of heparin in these patients. METHODS This is a retrospective study including adult trauma patients with SOI (liver, spleen, kidney) undergoing non-operative management (NOM) from 01/01/2009 to 31/12/2014. Three groups were distinguished: prophylactic heparin (low molecular weight heparin or low-dose unfractionated heparin) ≤72 h after admission ('early heparin group'), >72 h after admission ('late heparin group'), and no heparin ('no heparin group'). Patient and injury characteristics, transfusion requirements, and outcomes (failed NOM, VTE, and mortality) were compared between the three groups. RESULTS Overall, 179 patients were included; 44.7% in the 'early heparin group,' 34.6% in the 'late heparin group,' and 20.8% in the 'no heparin group.' In the 'late heparin group,' the ISS was significantly higher than in the 'early' and 'no heparin groups' (median 29.0 vs. 17.0 vs. 19.0; p < 0.001). The overall NOM failure rate was 3.9%. Failed NOM was significantly more frequent in the 'no heparin group' compared to the 'early' and 'late heparin groups' (10.8 vs. 3.2 vs. 1.3%; p = 0.043). In the 'early heparin group' 27.5% patients suffered from a high-grade SOI; none of these patients failed NOM. Mortality did not differ significantly. Although not statistically significant, VTE were more frequent in the 'no heparin group' compared to the 'early' and 'late heparin groups' (10.8 vs. 4.8 vs. 1.3%; p = 0.066). CONCLUSION In patients with SOI, heparin was administered early in a high percentage of patients and was not associated with an increased NOM failure rate or higher in-hospital mortality.
Collapse
Affiliation(s)
- Tatsiana Khatsilouskaya
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Haltmeier
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marionna Cathomas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Barbara Eberle
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Schnüriger
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| |
Collapse
|
37
|
Frandon J, Rodiere M, Arvieux C, Vendrell A, Boussat B, Sengel C, Broux C, Bricault I, Ferretti G, Thony F. Blunt splenic injury: are early adverse events related to trauma, nonoperative management, or surgery? Diagn Interv Radiol 2016; 21:327-33. [PMID: 26081719 DOI: 10.5152/dir.2015.14800] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE We aimed to compare clinical outcomes and early adverse events of operative management (OM), nonoperative management (NOM), and NOM with splenic artery embolization (SAE) in blunt splenic injury (BSI) and identify the prognostic factors. METHODS Medical records of 136 consecutive patients with BSI admitted to a trauma center from 2005 to 2010 were retrospectively reviewed. Patients were separated into three groups: OM, NOM, and SAE. We focused on associated injuries and early adverse events. Multivariate analysis was performed on 23 prognostic factors to find predictors. RESULTS The total survival rate was 97.1%, with four deaths all occurred in the OM group. The spleen salvage rate was 91% in NOM and SAE. At least one adverse event was observed in 32.8%, 62%, and 96% of patients in NOM, SAE, and OM groups, respectively (P < 0.001). We found significantly more deaths, infectious complications, pleural drainage, acute renal failures, and pancreatitis in OM and more pseudocysts in SAE. Six prognostic factors were statistically significant for one or more adverse events: simplified acute physiology score 2 ≥25 for almost all adverse events, age ≥50 years for acute respiratory syndrome, limb fracture for secondary bleeding, thoracic injury for pleural drainage, and at least one associated injury for pseudocyst. Adverse events were not related to the type of BSI management. CONCLUSION Patients with BSI present worse outcome and more adverse events in OM, but this is related to the severity of injury. The main predictor of adverse events remains the severity of injury.
Collapse
Affiliation(s)
- Julien Frandon
- Clinique Universitaire de Radiologie et d'Imagerie Médicale, Grenoble University Hospital, Grenoble, France.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Olthof DC, Joosse P, Bossuyt PMM, de Rooij PP, Leenen LPH, Wendt KW, Bloemers FW, Goslings JC. Observation Versus Embolization in Patients with Blunt Splenic Injury After Trauma: A Propensity Score Analysis. World J Surg 2016; 40:1264-71. [PMID: 26718838 PMCID: PMC4820474 DOI: 10.1007/s00268-015-3387-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background Non-operative management (NOM) is the standard of care in hemodynamically stable patients with blunt splenic injury after trauma. Splenic artery embolization (SAE) is reported to increase observation success rate. Studies demonstrating improved splenic salvage rates with SAE primarily compared SAE with historical controls. The aim of this study was to investigate whether SAE improves success rate compared to observation alone in contemporaneous patients with blunt splenic injury. Methods We included adult patients with blunt splenic injury admitted to five Level 1 Trauma Centers between January 2009 and December 2012 and selected for NOM. Successful treatment was defined as splenic salvage and no splenic re-intervention. We calculated propensity scores, expressing the probability of undergoing SAE, using multivariable logistic regression and created five strata based on the quintiles of the propensity score distribution. A weighted relative risk (RR) was calculated across strata to express the chances of success with SAE. Results Two hundred and six patients were included in the study. Treatment was successful in 180 patients: 134/146 (92 %) patients treated with observation and 48/57 (84 %) patients treated with SAE. The weighted RR for success with SAE was 1.17 (0.94–1.45); for complications, the weighted RR was 0.71 (0.41–1.22). The mean number of transfused blood products was 4.4 (SD 9.9) in the observation group versus 9.1 (SD 17.2) in the SAE group. Conclusions After correction for confounders with propensity score stratification technique, there was no significant difference between embolization and observation alone with regard to successful treatment in patients with blunt splenic injury after trauma.
Collapse
Affiliation(s)
- Dominique C Olthof
- Trauma Unit Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Pieter Joosse
- Surgical Department, Medisch Centrum Alkmaar, Alkmaar, The Netherlands
| | | | - Philippe P de Rooij
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Loek P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Klaus W Wendt
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - J Carel Goslings
- Trauma Unit Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| |
Collapse
|
39
|
Abstract
Better understanding of the dual functionality of the spleen has led to a conservative approach to splenic trauma. With accurate assessment and vigilant clinical examination up to two thirds of splenic injuries can be managed expectantly; when surgery is unavoidable, splenic preserving techniques may be used to maintain function.
Collapse
Affiliation(s)
- Jml Williamson
- Specialty Registrar in the Department of Surgery, Bristol Royal Infirmary, Bristol BS2 8HW
| |
Collapse
|
40
|
Ong AW, Eilertson KE, Reilly EF, Geng TA, Madbak F, McNicholas A, Fernandez FB. Nonoperative management of splenic injuries: significance of age. J Surg Res 2015; 201:134-40. [PMID: 26850194 DOI: 10.1016/j.jss.2015.10.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 09/20/2015] [Accepted: 10/07/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND In the nonoperative management (NOM) of blunt splenic injuries (BSI), the clinical relevance of age as a risk factor has not been well studied. METHODS Using the 2011 National Trauma Data Bank data set, age was analyzed both as a continuous variable and a categorical variable (group 1 [13-54 y], group 2 [55-74 y], and group 3 [≥75 y]). BSI severity was stratified by abbreviated injury scale (AIS): group 1 (AIS ≤2), group 2 (AIS 3), and group 3 (AIS ≥4). A semiparametric proportional odds model was used to model NOM outcomes and effects due to age and BSI severity. RESULTS Of 15,113 subjects, 15.3% failed NOM. The odds of failure increased by a factor of 1.014 for each year of age, or factor of 1.5 for groups 2 and 3 each. BSI severity groups 2 and 3 had increases in the odds of failure by factors of 3.9 and 13, respectively, compared with those of group 1. Most failures occurred by 48 h irrespective of age. The effect of age was most pronounced in age groups 2 and 3 with the most severe BSI, where a NOM failure rate of >50% was seen. Both age and failure of NOM were independent predictors of mortality. CONCLUSIONS Age is associated with failure of NOM but its effect seems more clinically relevant only in high-grade BSI. Factors that could influence NOM success in elderly patients with high-grade injuries deserve further study.
Collapse
Affiliation(s)
- Adrian W Ong
- Department of Surgery, Section of Trauma, Reading Hospital and the University of Pennsylvania Perelman School of Medicine, Reading, Pennsylvania.
| | - Kirsten E Eilertson
- Department of Statistics, Eberly College of Science, Pennsylvania State University, Reading, Pennsylvania
| | - Eugene F Reilly
- Department of Surgery, Section of Trauma, Reading Hospital and the University of Pennsylvania Perelman School of Medicine, Reading, Pennsylvania
| | - Thomas A Geng
- Department of Surgery, Section of Trauma, Reading Hospital and the University of Pennsylvania Perelman School of Medicine, Reading, Pennsylvania
| | - Firas Madbak
- Department of Surgery, Section of Trauma, Reading Hospital and the University of Pennsylvania Perelman School of Medicine, Reading, Pennsylvania
| | - Amanda McNicholas
- Section of Trauma, Department of Surgery, Reading Hospital, State College, Pennsylvania
| | - Forrest B Fernandez
- Department of Surgery, Section of Trauma, Reading Hospital and the University of Pennsylvania Perelman School of Medicine, Reading, Pennsylvania
| |
Collapse
|
41
|
Spleen function after preservation in a physiological solution. J Surg Res 2015; 199:586-91. [PMID: 26119270 DOI: 10.1016/j.jss.2015.05.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 05/26/2015] [Accepted: 05/29/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the morphology and function of implanted autogenous spleen tissue after 24 h of preservation in a physiological solution. MATERIAL AND METHODS Thirty-five male rats were divided into seven groups (n = 5): group 1, without surgical procedure; group 2, total splenectomy; group 3, total splenectomy and immediate implant of autogenous spleen tissue; group 4, total splenectomy and preservation of the entire spleen in lactated Ringer solution at room temperature for 24 h, followed by spleen sectioning and implantation; group 5, total splenectomy, followed by spleen sectioning and preservation in lactated Ringer solution at room temperature for 24 h and subsequent implantation of the slices; group 6, total splenectomy and preservation of the entire spleen in lactated Ringer solution at 4°C for 24 h, followed by spleen sectioning and implantation; and group 7, total splenectomy, the spleen was sliced and preserved in lactate Ringer solution at 4°C for 24 h, followed by implantation of the slices. After 90 d, scintigraphic studies using sulfur colloid labeled with 99mTc of the liver, lungs, spleen, implants, and a blood clot were performed. Hematological (erythrogram, leukogram, and platelets) and histologic studies were carried out. RESULTS The autogenous splenic implants regenerated in all animals that received those implants preserved at 4°C and immediately after excision. The scintigraphic study showed a better phagocytic function in groups 1, 3, 6, and 7. No difference was observed in the hematological study. CONCLUSIONS Spleen tissue preserved in lactated Ringer solution at 4°C for 24 h maintains its vitality and capacity to recover hematological and phagocytic functions.
Collapse
|
42
|
Abstract
Abdominal trauma represents the leading cause of haemorrhagic shock in the severely injured patient and is associated with high mortality and morbidity rates. The trauma surgeon has a central role in the multidisciplinary team addressing the specific diagnostic and therapeutic needs of patients with abdominal trauma. The management of blunt and penetrating abdominal trauma has undergone substantial changes in recent decades. Major innovations have been established in the field of diagnostic imaging and of nonoperative interventions such as angioembolization and endoscopic procedures. Another key development is the introduction of the damage control concept for the care of patients with abdominal trauma. The present manuscript comprises a review of the current management of abdominal trauma with an emphasis on diagnostic and therapeutic innovations.
Collapse
|
43
|
Literature review of non-operative management of patients with blunt splenic injury: impact of splenic artery embolization. Wideochir Inne Tech Maloinwazyjne 2014; 9:309-14. [PMID: 25337151 PMCID: PMC4198651 DOI: 10.5114/wiitm.2014.44251] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 04/13/2014] [Accepted: 06/23/2014] [Indexed: 11/17/2022] Open
Abstract
Splenic injuries constitute the most common injuries accompanying blunt abdominal traumas. Non-operative treatment is currently the standard for treating hemodynamically stable patients with blunt splenic injuries. The introduction of splenic angiography has increased the possibility of non-operative treatment for patients who, in the past, would have qualified for surgery. This cohort includes mainly patients with severe splenic injuries and with active bleeding. The results have indicated that applying splenic angioembolization reduces the frequency of non-operative treatment failure, especially in severe splenic injuries; however, it is still necessary to perform prospective, randomized clinical investigations.
Collapse
|
44
|
Spence R, Spence R. Surgery of the troubles: lessons for the future. J Am Coll Surg 2014; 219:171-80. [PMID: 24974264 DOI: 10.1016/j.jamcollsurg.2014.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 04/07/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Roy Spence
- Department of Surgery, Queen's University Belfast, Northern Ireland.
| | - Robert Spence
- Department of Surgery, Queen's University Belfast, Northern Ireland
| |
Collapse
|
45
|
Stone TJ, Norbet C, Rhoades P, Bhalla S, Menias CO. Computed tomography of adult blunt abdominal and pelvic trauma: implications for treatment and interventions. Semin Roentgenol 2014; 49:186-201. [PMID: 24836493 DOI: 10.1053/j.ro.2014.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Taylor J Stone
- Mallinckrodt Institute of Radiology, Washington University of St. Louis, St. Louis, MO.
| | - Christopher Norbet
- Mallinckrodt Institute of Radiology, Washington University of St. Louis, St. Louis, MO
| | - Patrick Rhoades
- Mallinckrodt Institute of Radiology, Washington University of St. Louis, St. Louis, MO
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, Washington University of St. Louis, St. Louis, MO
| | - Christine O Menias
- Mallinckrodt Institute of Radiology, Washington University of St. Louis, St. Louis, MO
| |
Collapse
|
46
|
Trauma center variation in splenic artery embolization and spleen salvage: a multicenter analysis. J Trauma Acute Care Surg 2013; 75:69-74; discussion 74-5. [PMID: 23778441 DOI: 10.1097/ta.0b013e3182988b3b] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to evaluate if variation in management of blunt splenic injury (BSI) among Level I trauma centers is associated with different outcomes related to the use of splenic artery embolization (SAE). METHODS All adult patients admitted for BSI from 2008 to 2010 at 4 Level I trauma centers were reviewed. Use of SAE was determined, and outcomes of spleen salvage and nonoperative management (NOM) failure were evaluated. A priori, a 10% SAE rate was used to group centers into high- or low-use groups. RESULTS There were 1,275 BSI patients. There were intercenter differences in age, injury severity, and grade of spleen injury (Spleen Injury Scale [SIS]). Mortality was similar by center; however, BSI treatment varied significantly by center. Overall, SAE use was highest at center A compared with B, C, and D (19%, 11%, 1%, and 4%, respectively; p < 0.01). High SAE use centers had significantly higher spleen salvage rates and fewer NOM failures. Differences in the use of SAE (25% vs. 2%, p < 0.01) and salvage rate (67% vs. 56%, p = 0.03) were most dramatic between high- and low-use SAE centers for Grade 3 and 4 injured spleens. In patients who received initial NOM, multivariate logistic regression analysis showed that SAE was an independent predictor of spleen salvage (odds ratio, 5; 95% confidence interval, 1.8-13.5; p < 0.01) as were lower age, lower SIS, and Injury Severity Score (ISS). Patients treated at high SAE use centers were more likely to leave the hospital with their spleen in situ (odds ratio, 3; 95% confidence interval, 1.7-6.3; p < 0.01). CONCLUSION Significant practice variation exists in the use of SAE in treating BSI at Level I trauma centers. Centers with higher rates of SAE use have higher spleen salvage and less NOM failure. SAE was shown to be an independent predictor of spleen salvage. LEVEL OF EVIDENCE Therapeutic study, level IV.
Collapse
|
47
|
Bège T, Chaumoître K, Léone M, Mancini J, Berdah SV, Brunet C. Blunt bowel and mesenteric injuries detected on CT scan: who is really eligible for surgery? Eur J Trauma Emerg Surg 2013; 40:75-81. [PMID: 26815780 DOI: 10.1007/s00068-013-0318-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 07/24/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND There is no consensually accepted approach to the management of blunt bowel and mesenteric injuries. Surgery is required urgently in the case of bowel perforation or haemodynamic instability, but several patients can be treated non-operatively. This study aimed to identify the risk factors for surgery in an initial assessment. METHODS We retrospectively reviewed the medical charts and computed tomography (CT) scans of adult patients presenting with a blunt abdominal trauma to our centre between the years 2004 and 2011. We included only patients with a CT scan showing suspected injury to the mesentery or bowel. RESULTS There were 43 patients (33 males and 10 females), with a mean Injury Severity Score (ISS) of 22. The most frequently suspected injuries based on a CT scan were mesenteric infiltrations in 40 (93 %) patients and bowel wall thickening in 22 (51 %) patients. Surgical therapy was required for 23 (54 %) patients. Four factors were independently associated with surgical treatment: a free-fluid peritoneal effusion without solid organ injury [adjusted odds ratio (OR) = 14.4, 95 % confidence interval (CI) [1.9-111]; p = 0.015], a beaded appearance of the mesenteric vessels (OR = 9 [1.3-63]; p = 0.027), female gender (OR = 14.2 [1.3-159]; p = 0.031) and ISS >15 (OR = 6.9 [1.1-44]; p = 0.041). Surgery was prescribed immediately for 11 (26 %) patients and with delay, after the failure of initially conservative treatment, for 12 (28 %) patients. The presence of a free-fluid peritoneal effusion without solid organ injury was also an independent risk factor for delayed surgery (OR = 9.8 [1-95]; p = 0.048). CONCLUSIONS In blunt abdominal trauma, the association of a bowel and/or mesenteric injury with a peritoneal effusion without solid organ injury on an initial CT scan should raise the suspicion of an injury requiring surgical treatment. Additionally, this finding should lead to a clinical discussion of the benefit of explorative laparotomy to prevent delayed surgery. However, these findings need validation by larger studies.
Collapse
Affiliation(s)
- T Bège
- Department of General and Digestive Surgery, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France. .,Laboratoire de Biomécanique Appliquée UMR 24, Aix-Marseille University, Boulevard Pierre Dramard, 13015, Marseille, France.
| | - K Chaumoître
- Department of Radiology, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - M Léone
- Department of Anesthesia and Resuscitation, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - J Mancini
- Department of Public Health and Medical Information, APHM Timone, Aix-Marseille University, 13006, Marseille, France
| | - S V Berdah
- Department of General and Digestive Surgery, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France.,Laboratoire de Biomécanique Appliquée UMR 24, Aix-Marseille University, Boulevard Pierre Dramard, 13015, Marseille, France
| | - C Brunet
- Department of General and Digestive Surgery, APHM North Hospital, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France.,Laboratoire de Biomécanique Appliquée UMR 24, Aix-Marseille University, Boulevard Pierre Dramard, 13015, Marseille, France
| |
Collapse
|
48
|
Consensus strategies for the nonoperative management of patients with blunt splenic injury: a Delphi study. J Trauma Acute Care Surg 2013; 74:1567-74. [PMID: 23694889 DOI: 10.1097/ta.0b013e3182921627] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Nonoperative management is the standard of care in hemodynamically stable patients with blunt splenic injury. However, a number of issues regarding the management of these patients are still unresolved. The aim of this study was to reach consensus among experts concerning optimal treatment and follow-up strategies. METHODS The Delphi method was used to reach consensus among 30 expert trauma surgeons and interventional radiologists from around the world. An online survey was used in the two study rounds. Consensus was defined as an agreement of 80% or greater. RESULTS Response rates of the first and second rounds were 90% and 80%, respectively. Consensus was reached for 43% of the (sub)questions. The American Association for the Surgery of Trauma organ injury scale for grading splenic injury is used by 93% of the experts. In hemodynamically stable patients, observation or splenic artery embolization (SAE) can be applied in the presence of a small or no hemoperitoneum combined with an intraparenchymal contrast extravasation or no contrast extravasation, regardless of the presence of an arteriovenous (AV) fistula/pseudoaneurysm. Hemodynamic instability is an indication for operative management, irrespective of computed tomographic characteristics and grade of splenic injury (≥82% of the experts). Operative management is also indicated in the presence of associated intra-abdominal injuries and/or the need for five or more packed red blood cell transfusions (22 of 27 experts, 82%). Recommended time span to start SAE in a stable patient with an intraparenchymal contrast extravasation is 60 minutes (19 of 24 experts). Patients should be admitted 1 to 3 days to a monitored setting (27 of 27 experts, 100%). Serial hemoglobin checks are performed by all experts, every 4 to 6 hours in the first 24 hours and once or twice a day after that (21 of 24 experts, 88%), in nonoperative management as well as after SAE. Routine postdischarge imaging is not indicated (21 of 24 experts, 88%). CONCLUSION Although treatment should always be adjusted to the specific patient, the results of this study may serve as general guidelines.
Collapse
|
49
|
Leinwand JC, Arroyo JP, Solomon D, Kaplan LJ. Babesia microti infection presenting as acute splenic laceration. Surg Infect (Larchmt) 2013; 14:412-4. [PMID: 23859679 DOI: 10.1089/sur.2012.137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Blunt abdominal trauma leading to splenic injury can cause substantial morbidity, particularly in patients with established splenic pathology. In such cases, the extant pathology may increase a patient's susceptibility to blunt injury, most notably by inducing hypersplenism; Babesia microti may create such a condition. METHODS Case report and English language-based literature review. RESULTS Obtaining an appropriate travel history and understanding endemic infectious conditions will better enable the clinician to establish readily treatable concomitant diagnoses in the setting of injury. CONCLUSIONS Failure to treat such infections may delay solid organ healing, leading to the patient being released to unrestricted and therefore risky activity with persistently abnormal splenic architecture.
Collapse
Affiliation(s)
- Joshua C Leinwand
- Yale School of Medicine, Surgical Critical Care, and Surgical Emergencies, New Haven, Connecticut, USA
| | | | | | | |
Collapse
|
50
|
Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: a systematic review. J Trauma Acute Care Surg 2013; 74:546-57. [PMID: 23354249 DOI: 10.1097/ta.0b013e31827d5e3a] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Contradictory findings are reported in the literature concerning prognostic factors for failure of nonoperative management (NOM) in the treatment of adults with blunt splenic injury. The objective of this systematic review was to identify prognostic factors for failure of NOM, with or without angiography and embolization. METHODS MEDLINE, Embase, and the Cochrane Library databases were searched. Prospective or retrospective cohort studies addressing failure of nonoperative treatment, with and/or without angiography and embolization, of blunt abdominal injuries were included. Methodological quality of the studies was assessed. RESULTS A total of 335 titles and abstracts were screened, of which 31 fulfilled the inclusion criteria. No randomized controlled trials were found. Ten articles were qualified as high-quality articles and used for data extraction (best-evidence synthesis). A total of 25 prognostic factors were investigated, of which 14 were statistically significant in one or more studies. Strong evidence exists that age of 40 years or above, Injury Severity Score (ISS) of 25 or greater, and splenic injury grade of 3 or greater are prognostic factors for failure of NOM. Moderate evidence was found for a splenic Abbreviated Injury Scale score of 3 or greater, trauma and ISS of less than 0.80, the presence of an intraparenchymal contrast blush, as well as transfusion of 1 unit of packed red blood cells or more. Limited evidence was found for large hemoperitoneum, lower Revised Trauma Score, lower Glasgow Coma Scale score, lower systolic blood pressure, male sex, the presence of traumatic brain injury, and splenic embolization as protective factor for failure of NOM. CONCLUSION Awareness for failure of NOM is required in patients aged 40 years or older, in patients with an ISS of 25 or higher or those with splenic injury grade 3 or higher. The prognostic factors for failure that we identified should be confirmed in future prospective cohort studies or meta-analyses using individual patient data. LEVEL OF EVIDENCE Systematic review, level III.
Collapse
|