Nonoperative management of the ruptured spleen: a revalidation of criteria

Splenic trauma in the twenty-first century: changing trends in management

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.

Predictors of Mortality in Blunt Multi-Trauma Patients: A Retrospective Review

Purpose

The purpose of this study was to identify risk factors predicting mortality in multiple blunt trauma patients so as to prompt appropriate management during trauma resuscitation.

Method

To assess risk factors potentially related to mortality in multiple blunt trauma patients, we reviewed the medical records of 1419 multiple blunt trauma patients who were admitted to the emergency department. The patients were divided into two groups; the survival group (n=1308) and the death group (n=111). Initial data collected on arrival in the emergency department were analyzed.

Results

In the study, 67.4% (n=956) of 1419 patients were male, 32.6% (n=463) were female. The average age was 21.19±0.50 years (range 1-92). After controlling for the factors significantly related to outcome (all p<0.05), death due to multiple blunt trauma was more likely in patients who were of older age, who had major chest injury, who had intra-abdominal solid organ injury and who had low Glasgow Coma Scale (GCS) score and low Revised Trauma Score (RTS).

Conclusion

We conclude that older age, major chest injury, intra-abdominal solid organ injury, low GCS and low RTS were identified as possible risk factors for mortality in multiple blunt trauma patients.

Surgical Management of Solid Organ Injuries

Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.

Evolution of the treatment of splenic injuries: from surgery to non-operative management

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.

Blunt splenic trauma: Assessment, management and outcomes

BACKGROUND

The approach for diagnosis and management of blunt splenic injury (BSI) has been considerably shifted towards non-operative management (NOM). We aimed to review the current practice for the evaluation, diagnosis and management of BSI.

METHODS

A traditional narrative literature review was carried out using PubMed, MEDLINE and Google scholar search engines. We used the keywords "Traumatic Splenic injury", "Blunt splenic trauma", "management" between December 1954 and November 2014.

RESULTS

Most of the current guidelines support the NOM or minimally approaches in hemodynamically stable patients. Improvement in the diagnostic modalities guide the surgeons to decide the timely management pathway Though, there is an increasing shift from operative management (OM) to NOM of BSI; NOM of high grade injury is associated with a greater rate of failure, prolonged hospital stay, risk of delayed hemorrhage and transfusion-associated infections. Some cases with high grade BSI could be successfully treated conservatively, if clinically feasible, while some patients with lower grade injury might end-up with delayed splenic rupture. Therefore, the selection of treatment modalities for BSI should be governed by patient clinical presentation, surgeon's experience in addition to radiographic findings.

CONCLUSION

About one-fourth of the blunt abdominal trauma accounted for BSI. A high index of clinical suspicion along with radiological diagnosis helps to identify and characterize splenic injuries with high accuracy and is useful for timely decision-making to choose between OM or NOM. Careful selection of NOM is associated with high success rate with a lower rate of morbidity and mortality.

Is non-operative management safe and effective for all splenic blunt trauma? A systematic review

Introduction

The goal of non-operative management (NOM) for blunt splenic trauma (BST) is to preserve the spleen. The advantages of NOM for minor splenic trauma have been extensively reported, whereas its value for the more severe splenic injuries is still debated. The aim of this systematic review was to evaluate the available published evidence on NOM in patients with splenic trauma and to compare it with the operative management (OM) in terms of mortality, morbidity and duration of hospital stay.

Methods

For this systematic review we followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" statement. A systematic search was performed on PubMed for studies published from January 2000 to December 2011, without language restrictions, which compared NOM vs. OM for splenic trauma injuries and which at least 10 patients with BST.

Results

We identified 21 non randomized studies: 1 Clinical Controlled Trial and 20 retrospective cohort studies analyzing a total of 16,940 patients with BST. NOM represents the gold standard treatment for minor splenic trauma and is associated with decreased mortality in severe splenic trauma (4.78% vs. 13.5% in NOM and OM, respectively), according to the literature. Of note, in BST treated operatively, concurrent injuries accounted for the higher mortality. In addition, it was not possible to determine post-treatment morbidity in major splenic trauma. The definition of hemodynamic stability varied greatly in the literature depending on the surgeon and the trauma team, representing a further bias. Moreover, data on the remaining analyzed outcomes (hospital stay, number of blood transfusions, abdominal abscesses, overwhelming post-splenectomy infection) were not reported in all included studies or were not comparable, precluding the possibility to perform a meaningful cumulative analysis and comparison.

Conclusions

NOM of BST, preserving the spleen, is the treatment of choice for the American Association for the Surgery of Trauma grades I and II. Conclusions are more difficult to outline for higher grades of splenic injury, because of the substantial heterogeneity of expertise among different hospitals, and potentially inappropriate comparison groups.

The song remains the same although the instruments are changing: complications following selective non-operative management of blunt spleen trauma: a retrospective review of patients at a level I trauma centre from 1996 to 2007

BACKGROUND

Despite a widespread shift to selective non-operative management (SNOM) for blunt splenic trauma, there remains uncertainty regarding the role of adjuncts such as interventional radiological techniques, the need for follow-up imaging, and the incidence of long-term complications. We evaluated the success of SNOM (including splenic artery embolization, SAE) for the management of blunt splenic injuries in severely injured patients.

METHODS

Retrospective review (1996-2007) of the Alberta Trauma Registry and health records for blunt splenic trauma patients, aged 18 and older, with injury severity scores of 12 or greater, admitted to the Foothills Medical Centre.

RESULTS

Among 538 eligible patients, 150 (26%) underwent early operative intervention. The proportion of patients managed by SNOM rose from 50 to 78% over the study period, with an overall success rate of SNOM of 87%, while injury acuity remained unchanged over time. Among SNOM failures, 65% underwent surgery within 24 hours of admission. Splenic arterial embolization (SAE) was used in only 7% of patients managed non-operatively, although at least 21% of failed SNOM had contrast extravasation potentially amenable to SAE. Among Calgary residents undergoing SNOM, hospital readmission within six months was required in three (2%), all of whom who required emergent intervention (splenectomy 2, SAE 1) and in whom none had post-discharge follow-up imaging. Overall, the use of post-discharge follow-up CT imaging was low following SNOM (10%), and thus no CT images identified occult hemorrhage or pseudoaneurysm. We observed seven cases of delayed splenic rupture in our population which occurred from five days to two months following initial injury. Three of these occurred in the post-discharge period requiring readmission and intervention.

CONCLUSIONS

SNOM was the initial treatment strategy for most patients with blunt splenic trauma with 13% requiring subsequent operative intervention intended for the spleen. Cases of delayed splenic rupture occurred up to two months following initial injury. The low use of both follow-up imaging and SAE make assessment of the utility of these adjuncts difficult and adherence to formalized protocols will be required to fully assess the benefit of multi-modality management strategies.

Variation in the use of urgent splenectomy after blunt splenic injury in adults

OBJECTIVE

Recent reports indicate that mortality after trauma center admission may be directly related to the rate of operative intervention after blunt solid organ injury. These findings bring into question the role of urgent splenectomy after blunt splenic injury (BSI). The purpose of this study was to determine the role of urgent splenectomy (defined as splenectomy within 6 hours of admission) in the management of BSI as well as the relationship between urgent splenectomy and in-hospital mortality.

METHODS

The National Trauma Data Bank for 2007 was queried for adults (18-81) who suffered BSI. Patients who died in or were transferred from the emergency department were excluded. Hierarchical multivariate models were used to account for clustering of patients within hospitals and to identify hospital and patient factors associated with urgent splenectomy. Propensity score matching was used to analyze the relationship between urgent splenectomy and mortality.

RESULTS

There were 507,202 total incidents identified. Of those, 11,793 met inclusion criteria. Urgent splenectomy was performed on 1,104 (9.4%). Hierarchical models revealed that age ≥55 years, arrival systolic blood pressure ≤90 mm Hg, no or mild head injury, increasing injury severity, and massive disruption of the spleen were associated with urgent splenectomy. Hospitals level factors associated with urgent splenectomy included hospital region, hospital type, and trauma center level. The propensity-matched cohorts revealed no association between urgent splenectomy and in-hospital mortality (odds ratio, 1.08; 95% confidence interval, 0.82-1.42).

CONCLUSION

Despite ongoing variation in the use of urgent splenectomy after BSI in adults, urgent splenectomy was not associated with in-hospital mortality.

Nonoperative management of adult blunt splenic injury with and without splenic artery embolotherapy: a meta-analysis

BACKGROUND

Observation and splenic artery embolotherapy (SAE) are nonoperative management (NOM) modalities for adult blunt splenic injury; however, they are quite different, inconsistently applied, and controversial. This meta-analysis compares the known outcomes data for observational management versus SAE by splenic injury grade cohort.

METHODS

Thirty-three blunt splenic injury outcomes articles, published between 1994 and 2009, comprising 24 unique data sets are identified. Of these, nine gave outcomes data by splenic injury grade for observational management and SAE separately. Failure rates were collected and analyzed using random effects estimates.

RESULTS

Overall, 68.4% of the 10,157 patients were managed nonoperatively. The overall failure rate estimate of NOM is 8.3% with a 95% confidence interval (CI) of 6.7% to 10.2%. The observational management failure rate estimate without SAE increases from 4.7% to 83.1% in splenic injury grade 1 to 5 patients. The overall failure rate estimate of SAE is 15.7% (95% CI, 10.4-23.2) and did not vary significantly from splenic injury grades 1 to 5 (p=0.413). The failure rate of observational management without SAE is statistically higher than the failure rare estimate of SAE in splenic injury grade 4 and 5 injuries: 43.7% (95% CI, 25.5-63.8) versus 17.3% (95% CI, 7.8-34.1), p=0.035 and 83.1% (95% CI, 45.2-96.7) versus 25.0% (95% CI, 8.7-53.8), p=0.016, respectively.

CONCLUSIONS

This meta-analysis synthesizes NOM outcomes data by modality and splenic injury grade. The failure rate of observational management increases with splenic injury grade, whereas the failure rate of SAE does not change significantly. SAE is associated with significantly higher splenic salvage rates in splenic injury grade 4 and 5 injuries.

The role of arterial embolization in blunt splenic injury

PURPOSE

The aim of study was to evaluate the results of our experience with transarterial embolization based on a modified algorithm in patients with splenic injury.

MATERIALS AND METHODS

We collected data of patients admitted to our hospital from January 2006 to August 2008 for blunt splenic injury. During this period, 46 patients were admitted for splenic trauma, of whom 17 were treated surgically, 15 conservatively and 14 with percutaneous embolisation (13 men, mean age 44.8, mean injury severity score 18.5, six with grade IV and eight with contrast blush). Patients in shock were referred for laparotomy and splenectomy, whereas those who were haemodynamically stable or responsive to fluid resuscitation were further evaluated with computed tomography (CT). In the presence of imaging evidence of splenic injury ranging from grade I to grade III (n=15) a conservative approach was adopted, whereas haemodynamically unstable patients with grade V injury (n=17) were treated with splenectomy. Embolisation was performed in 14 patients with grade IV injury or in the event of contrast extravasation, regardless of injury grade. In patients with diffuse organ damage, we embolised the main splenic artery, whereas in the case of localised injury, embolisation was selective.

RESULTS

Proximal embolization was required in eight cases and distal coil embolization in six. In 13 cases, we placed magnetic-resonance-compatible coils 4-6 mm in diameter; only one patient was treated with gel-foam injection. Immediate technical success was achieved in all cases. In 13/14 patients (92.9%), no periprocedural complications were observed, whereas the remaining patient underwent splenectomy within 24 h due to recurrent bleeding.

CONCLUSIONS

On the basis of our algorithm, it is possible to reach a quick decision on the most appropriate treatment for patients presenting with blunt abdominal trauma, and splenic artery embolization seems to offer a reliable option in those with high-grade splenic injury or active bleeding.

Nonoperative Management of Blunt Splenic Trauma: Also Feasible and Safe in Centers with Low Trauma Incidence and in the Presence of Established Risk Factors

BACKGROUND

Treatment of blunt splenic trauma has undergone dramatic changes over the last few decades. Nonoperative management (NOM) is now the preferred treatment of choice, when possible. The outcome of NOM has been evaluated. This study evaluates the results following the management of blunt splenic injury in adults in a Swedish university hospital with a low blunt abdominal trauma incidence.

METHOD

Fifty patients with blunt splenic trauma were treated at the Department of Surgery, Lund University Hospital from January 1994 to December 2003. One patient was excluded due to a diagnostic delay of > 24 h. Charts were reviewed retrospectively to examine demographics, injury severity score (ISS), splenic injury grade, diagnostics, treatment and outcome measures.

RESULTS

Thirty-nine patients (80%) were initially treated nonoperatively (NOM), and ten (20%) patients underwent immediate surgery (operative management, OM). Only one (3%) patient failed NOM and required surgery nine days after admission (failure of NOM, FNOM). The patients in the OM group had higher ISS (p < 0.001), higher grade of splenic injury (p < 0.001), and were hemodynamically unstable to a greater extent (p < 0.001). This was accompanied by increased transfusion requirements (p < 0.001), longer stay in the ICU unit (p < 0.001) and higher costs (p = 0.001). Twenty-seven patients were successfully treated without surgery. No serious complication was found on routine radiological follow-up.

CONCLUSION

Most patients in this study were managed conservatively with a low failure rate of NOM. NOM of blunt splenic trauma could thus be performed in a seemingly safe and effective manner, even in the presence of established risk factors. Routine follow-up with CT scan did not appear to add clinically relevant information affecting patient management.

Recent changes in the management of blunt splenic injury: effect on splenic trauma patients and hospital implications

INTRODUCTION

Management of blunt splenic injury has been controversial with an increasing trend towards splenic conservation. A retrospective study was performed to identify the effect of this changed policy on splenic trauma patients and its implications.

PATIENTS AND METHODS

Data regarding patient demography, mode of splenic injury, CT grading, blood transfusion requirement, operative findings hospital stay and follow-up were collected. Statistical analysis of the data was performed using nonparametric Mann-Whitney tests

RESULTS

Over an 8-year period, only 21 patients were admitted with blunt splenic injury. Ten patients were managed operatively and 11 non-operatively. Non-operative management failed in one patient due to continued bleeding. Using Buntain's CT grading, the majority of grades I and II splenic injuries were managed non-operatively and grades III and IV were managed operatively ( P = 0.008). Blood transfusion requirement was significantly higher among the operative group (P = 0.004) but the non-operative group had a significantly longer hospital stay (P = 0.029). Among those managed non-operatively (median age, 24.5 years), a number of patients were followed up with CT scans with significant radiation exposure and unknown longterm consequences.

CONCLUSIONS

Non-operative management of blunt splenic trauma in adults can be performed with an acceptable outcome. Although CT is classed as the 'gold standard', initial imaging for detection and evaluation of blunt splenic injury, ultrasound can play a major role in follow-up imaging and potentially avoids major radiation exposure.

Emergent transcatheter arterial embolization in hemodynamically unstable patients with blunt splenic injury

RATIONALE AND OBJECTIVES

Splenic preservation is currently the trend for treatment of patients with splenic trauma to avoid complications of splenectomy. This study aimed to evaluate the feasibility of emergent transcatheter arterial embolization (TAE) for hemodynamically unstable patients with blunt splenic injury.

MATERIALS AND METHODS

In a period of 2 years, 65 patients of blunt splenic trauma were studied. Patients with initial systolic blood pressure < 90 mmHg and showed initial response including rapid response and transient response to the emergent fluid resuscitation were included. Angiography and TAE was undertaken if contrast medium extravasation or pseudoaneurysm formation was noted in the computed tomography (CT) images, according to the criteria of American Association for the Surgery of Trauma. All patients who underwent TAE were admitted for observation of the possibility of delayed rupture.

RESULTS

Thirteen hemodynamically unstable patients who were responsive to initial fluid resuscitation received angiography due to abnormal CT findings including contrast agent extravasation in 12 patients, 2 patients with arteriovenous fistula, and 8 patients with pseudoaneurysm formation. TAE was successfully performed in all of these 13 patients, including 2 patients with associated left renal injuries and 1 patient associated with bilateral internal mammary arteries injuries, without complications.

CONCLUSIONS

TAE is a safe and effective procedure for treating blunt splenic injury even in hemodynamically unstable patients who responded to initial fluid resuscitation.

Nonoperative management of traumatic splenic injuries: is there a role for proximal splenic artery embolization?

OBJECTIVE

The objective of our study was to evaluate our experience with transcatheter proximal (i.e., main) splenic artery embolization (TPSAE) in the nonsurgical management of patients with grade III-V splenic injuries, according to the American Association for the Surgery of Trauma (AAST) guidelines, and patients with splenic injuries associated with CT evidence of active contrast extravasation or blush (or cases meeting both criteria).

MATERIALS AND METHODS

The records of patients with traumatic splenic injuries admitted during a 52-month period were retrospectively reviewed for patient age and sex, mechanism of injury, injury severity score (ISS), RBC transfusion requirements, AAST splenic injury CT grade, presence of active contrast extravasation or blush on CT examination, and amount of hemoperitoneum on CT examination. Demographics, CT findings, transfusion requirements, and outcome were compared using the Student's t test or chi-square test in patients undergoing standard nonoperative management and nonoperative management TPSAE-that is, TPSAE followed by nonoperative management.

RESULTS

Of the 79 identified patients with splenic trauma, 67 were managed nonoperatively. Thirty-seven patients (28 men, nine women; mean age, 40 years; mean ISS, 28.8) underwent nonoperative management TPSAE and 30 patients (27 men, three women; mean age, 37 years; mean ISS, 25.1) underwent nonoperative management. Age, sex, and ISS were not significantly different between the two groups. TPSAE was always technically feasible. Splenic injuries were significantly more severe in the nonoperative management TPSAE group than in the nonoperative management group with respect to the mean splenic injury AAST CT grade (3.7 vs 2, respectively; p < 0.0001), active contrast extravasation or blush (38% [14/37] vs 3% [1/30], respectively; p = 0.0005), and hemoperitoneum grade (1.6 vs 0.8, respectively; p = 0.0006). Secondary splenectomy rate was lower in the nonoperative management TPSAE group (2.7% [1/37] vs 10% [3/30]). No procedure-related complications were encountered during early and delayed clinical follow-up.

CONCLUSION

TPSAE is a feasible and safe adjunct to observation in the nonoperative management of severe traumatic splenic injuries. The secondary splenectomy rate using nonoperative management TPSAE (2.7%) is among the lowest reported despite a selection of severe injuries.

Limitations of Splenic Angioembolization in Treating Blunt Splenic Injury

BACKGROUND

When angiography is performed in all hemodynamically normal patients with splenic injury, only 30% require embolization. This study examines the use of selective splenic angioembolization (SAE) as part of a management algorithm for adult splenic injury.

METHODS

Criteria for selective SAE were added to our adult splenic injury protocol in July 1999. SAE was performed in hemodynamically stable patients if computed tomographic (CT) scan revealed injury to the hilum or vascular blush and when nonoperative patients had a gradual decrease in hematocrit. Patients were grouped by management strategy: nonoperative; operative; or SAE. Demographics, injury severity, and outcomes of the different groups were compared. Medical records, CT scans, and registry data were reviewed for all SAE cases, deaths, and treatment failures. Data are means +/- SE. p < 0.05 versus nonoperative management by analysis of variance.

RESULTS

From July 1999 to August 2003, 194 adults were treated for splenic injury. Nine patients underwent SAE, six for CT findings (1 vascular blush) and three for decreasing hematocrit. Three patients failed SAE (33%), one for bleeding and two for delayed splenic infarction. Eleven patients failed nonoperative therapy (8%); splenorrhaphy was performed in three and splenectomy in eight. Operative patients were more seriously injured and had higher Injury Severity Scores and mortality; splenectomy (39 of 48) was more commonly performed than splenorrhaphy (9 of 48) in this group.

CONCLUSION

Use of a splenic injury algorithm is associated with a high success rate for nonoperative management of splenic trauma. Using selective criteria, only 5% of patients were treated with SAE. SAE salvaged six patients with high-grade splenic injury or decreasing hematocrit but had a 33% failure rate. Failure of nonoperative management was most commonly caused by errors in judgment, primarily recognition of "high-risk" injury patterns on CT scan or attempting nonoperative management in anticoagulated or coagulopathic patients.

U-stitching splenorraphy technique: experimental and clinical study

BACKGROUND

The aim of the present study was to describe the laboratory development and the subsequent clinical utility of the U-stitching technique for splenorraphy over the recent years in a general non-trauma hospital. Patients with splenectomies and patients treated conservatively during the same time period, are also presented.

METHODS

In the 15-year period from September 1988 until September 2003, 65 patients were diagnosed with splenic injury following admission to 2nd Department of Surgery, Democritus University Hospital, after blunt abdominal trauma. During the first 3 years, 14 patients were admitted; one of them was treated conservatively and 13 had splenectomies. Because computed tomography (CT) was not available at that time, these 14 patients form a control group. During the remaining 12-year period, 51 patients (39 male and 12 female; age, 4-82 years; mean, 31.1 years; SD, 19.7 years) were treated conservatively or surgically, either with splenectomy or with splenorraphy. Splenorraphy was performed using the U-stitching technique. This alternative splenorraphy technique was first tested on experimental models at 2nd Department of Surgery, Democritus University Hospital, then followed by successful clinical application. The medical records for these patients were reviewed to extract the data for the present study.

RESULTS

Thirty-six patients (70.6% of 51 patients) were treated surgically; of these, 21 (41.2% of 51 patients) had splenectomy and 15 (29.4% of 51 patients) had splenorraphy. Non-operative treatment was initially given to 15 patients (29.4% of 51 patients). Two of them had delayed rupture of the spleen and underwent splenectomy (at 8 and 40 days). The total number of preserved spleens was 28 of 51 (54.9%). None of the patients with conservative treatment or splenorraphy died. One patient with splenectomy died later from overwhelming sepsis.

CONCLUSIONS

Splenic salvage is now a treatment goal. If the patient is haemodynamically unstable and splenorraphy is possible, the U-stitching technique is a promising approach.

Blunt trauma to the spleen: ultrasonographic findings

The spleen is the most frequently injured organ in adults who sustain blunt abdominal trauma. Splenic trauma accounts for approximately 25% to 30% of all intra-abdominal injuries. The management of splenic injury has undergone rapid change over the last decade, with increasing emphasis on splenic salvage and non-operative management. Identifying the presence and degree of splenic injury is critical in triaging the management of patients. Imaging is integral in the identification of splenic injuries, both at the time of injury and during follow-up. Although CT remains the gold standard in blunt abdominal trauma, US continues to play an important role in assessing the traumatized spleen. This pictorial review illustrates the various ultrasonographic appearances of the traumatized spleen. Correlation with other imaging is presented and complications that occur during follow-up are described.

The role of diagnostic algorithms in the management of blunt splenic injury

BACKGROUND

Diagnostic algorithms for patients with blunt abdominal trauma have been in use since 1995. This study investigated the role of diagnostic algorithms in the management of adult patients with blunt splenic injury at our institution.

METHODS

A retrospective review of hospital records was performed to enroll patients with blunt injury of the spleen. Demographic data and information about injury severity, diagnostic methods, management and final outcomes were evaluated. Patients were separated into an early and late group according to the year that diagnostic algorithms were used (1990-1994 or 1995-1999).

RESULTS

One hundred and twenty-one patients were enrolled. Initially, 71 patients had an operation (OP group), whereas 50 received non-operative management (NOM group). Patients in the OP versus NOM group had lower blood pressure and greater transfusion volumes in the emergency room, higher grade splenic injury, and a greater rate of intra-abdominal-related injury. NOM failed in 7 patients (14%). Early- versus late-group patients were less likely to have NOM and high grade splenic injury; however, the rate of NOM failure was not different between the early and late groups.

CONCLUSION

Diagnostic algorithms using sonograms for screening provide an initial means of selecting patients for NOM. Patients with higher grades of splenic injury can then be managed non-operatively.

Use of splenic artery embolization as an adjunct to nonsurgical management of blunt splenic injury

BACKGROUND

Splenic artery embolization (SAE) has been used as an adjunct to the nonsurgical treatment of blunt splenic injuries since 1981. It is imperative to define the role of SAE in the management of splenic trauma and to establish a guideline for its use.

METHODS

In this study, 39 consecutive patients with blunt splenic ruptures were evaluated. All the patients were treated according to the authors' protocol, which included SAE as an adjunct. Angiographic study was performed for patients with any of the following presentations: recurrent hypotension despite fluid resuscitation, significant hemoperitoneum or extravasation of contrast media on computed tomography, grade 4 or 5 splenic injury, or progressive need for blood transfusion. Laparotomy was reserved for patients with unstable hemodynamics or failure of SAE.

RESULTS

Four patients were excluded from the study, and 6 of the 35 remaining patients (male-to-female ratio, 22:13) received SAE. One of the six SAE patients underwent operation because of persistent hemorrhage after SAE. Nonoperative treatment was successful for 31 patients. Splenic artery embolization increased the success rate for nonsurgical management from 74% (26 of 35 patients) to 89% (31 of 35 patients).

CONCLUSIONS

Judicious use of SAE for patients with blunt splenic injury avoids unnecessary surgery and expands the number of patients who can retain their spleen.

Factors affecting clinical outcome of patients who undergo transcatheter arterial embolisation in splenic injury

Transcatheter arterial embolisation (TAE) offers a less invasive approach to traditional laparotomy for the management of bleeding in the context of blunt splenic injury. This is a retrospective review study to identify clinical factors associated with clinical outcome of the patients who underwent this procedure. Of 65 patients with splenic injuries at our institution, 26 patients underwent TAE for management of bleeding. The following factors were assessed to determine their relationship to procedure outcomes: American Association for the Surgery of Trauma (AAST) grade, complications, age, shock index, injury severity score (ISS), haemoglobin (Hb), haematocrit (Ht), prothrombin time (PT), activated partial thromboplastin time (APTT), systolic blood pressure (BP), BP changes during TAE, blood transfused before TAE and timing of TAE. The overall good clinical outcome rate was 73.1% (19/26). Of the factors we assessed, absence of concomitant pelvic injury, higher Hb, higher Ht, higher BP, greater increases in BP during TAE and a decreased requirement for blood transfusions before TAE were associated with good clinical outcome of the patients who underwent TAE in splenic injury.

Blunt Splenic Injuries: High Nonoperative Management Rate Can Be Achieved with Selective Embolization

BACKGROUND

This retrospective review tests the hypothesis that including selective splenic arteriography and embolization in the algorithm of a previously existing nonoperative management (NOM) strategy will result in higher rates of successful NOM in patients with blunt splenic injury.

METHODS

All patients with blunt splenic injuries documented by computed tomographic scan and/or operative findings over a 24-month period at a Level I trauma center were reviewed. A previously published series from this institution of 251 patients with splenic injury (Group 1) was then compared with the patients that constitute this current review (Group 2). Group 2 was then compared with patients described in a previous publication advocating nonselective arteriography in blunt splenic injuries.

RESULTS

Thirteen patients with blunt splenic injury in Group 2 underwent 14 splenic embolization procedures, with 12 (93%) being successfully treated without operation. Group 2 had a significantly higher NOM rate (82% vs. 65%, p < 0.01) than Group 1. These results are similar to the series published by Sclafani et al. (82.1% vs. 83.1%) in which every patient with splenic injury that was managed non-operatively underwent arteriography with or without embolization.

CONCLUSION

A high rate of NOM can be achieved with observation and selective use of arteriography with or without embolization in the management of blunt splenic injuries.

Nonoperative Management of Blunt Splenic Injuries: Factors Influencing Success in Age <55 Years

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

Outcome of the current management of splenic injuries

BACKGROUND

For patients > 55 years, nonoperative management (NOM) of blunt splenic injury remains controversial. Conflicting reports of excessively high or acceptably low failure rates have discouraged widespread application of NOM in these older patients. However, the small number of patients in these studies limits the impact of their conclusions.

METHODS

We manage splenic injury nonoperatively in all appropriate patients without regard to age. We present the largest series of patients > 55 years who have been managed nonsurgically, in a retrospective review of all patients with blunt splenic injury admitted to our trauma center between 1996 and 1999.

RESULTS

In 4 years, 542 patients were admitted with blunt splenic injury. Eighty-three patients were > 55 years, and 61 of these patients underwent NOM. Seven older patients failed NOM and required delayed splenectomy, yielding a failure rate of 11.4%. This failure rate was statistically equivalent to the 7% failure rate of patients < 55 years. This study has a power of 80% to detect a failure rate change from 7% to 20%. By multivariate analysis, the only factor that significantly increased the risk of NOM failure was splenic injury grade. Patients > 55 years had a higher mortality than younger patients regardless of NOM/operative treatment. Splenic injury did not directly cause any of the deaths in patients > 55 years who had NOM or failure of NOM. High-grade splenic injuries fail NOM in those > 55 years.

CONCLUSION

Nonoperative management of lower grade splenic injuries in patients > 55 years can be accomplished with an acceptably low failure rate. Only grade of splenic injury, not patient age, increases the risk of NOM failure.

Significance of minimal or no intraperitoneal fluid visible on CT scan associated with blunt liver and splenic injuries: a multicenter analysis

BACKGROUND

The use of ultrasound (U/S) for the evaluation of patients with blunt abdominal trauma is gaining increasing acceptance. Patients who would have undergone computed tomographic (CT) scan may now be evaluated solely with U/S. Solid organ injuries with minimal or no free fluid may be missed by surgeon sonographers.

OBJECTIVE

The purpose of this study was to describe the incidence and clinical importance of liver and splenic injuries with minimal or no free intraperitoneal fluid visible on CT scan. We hypothesized that these solid organ injuries occur infrequently and are of minor clinical significance.

METHODS

Patient records and CT scans were reviewed for the presence of and outcome associated with blunt liver and splenic injuries with minimal (<250 mL) or no free fluid detected by an attending radiologist. Data were collected from six major trauma centers during a 4-year period before the introduction of U/S and included demographics, grade of injury (American Association for the Surgery of Trauma scale), need for operative intervention, and outcome.

RESULTS

A total of 938 patients with liver and splenic injuries were identified. In this group, 11% of liver injuries and 12% of splenic injuries had no free fluid visible on CT scan and could be missed by diagnostic peritoneal lavage or U/S. Of the 938 patients, 267 (28%) met the inclusion criteria; 161 had injury to the spleen and 125 had injury to the liver. In the 267 patients studied, 97% of the injuries were managed nonoperatively. However, 8 patients (3%) required operative intervention for bleeding. Compared with the liver, the spleen was significantly more likely to bleed (p = 0.01), but the grade of splenic injury was not related to the risk for hemorrhage (p = 0.051).

CONCLUSION

Data from this study suggest that injuries to the liver or spleen with minimal or no intraperitoneal fluid visible on CT scan occur more frequently than predicted but usually are of minimal clinical significance. However, patients with splenic injuries may be missed by abdominal U/S. We found a 5% associated risk of bleeding. Therefore, abdominal U/S should not be used as the sole diagnostic modality in all stable patients at risk for blunt abdominal injury.

Nonoperative Management of Blunt Splenic Injury in Adults 55 Years and Older: A Twenty-Year Experience

The nonoperative management of splenic injury secondary to blunt trauma in older patients remains controversial. We have reviewed our experience from January 1978 to December 1997 with selective nonoperative management of blunt splenic injury in adults 55 years and older. Criteria for nonoperative management included hemodynamic stability with any transient hypotension corrected using less than 2000 cm3 crystalloid infusion, a negative abdominal physical examination ruling out associated injuries, and a blood transfusion requirement of no more than 2 units attributable to the splenic injury. During the study period, 18 patients over age 55 with radiographic confirmation of a splenic injury met the above criteria for nonoperative management. Their mean age was 72 years (range 56–86), and 13 of the 18 were female (72%). The mean Injury Severity Score was 15 (range 4–29), with the mechanism of injury equally divided between automobile crashes (9) and falls (9). During a similar time period, 15 patients 55 years or older with splenic injury composed an operative group; these patients did not differ with respect to age (mean 68 years), sex (60% female), or mechanism of injury. CT scans of 8 patients managed nonoperatively were available and graded using the American Association for the Surgery of Trauma classification, with a mean score of 2.3 (range 2–3). Eight of the 18 nonsurgical patients received blood transfusions. None of the 18 patients who met the criteria for nonoperative management “failed” the protocol, and none were taken to the operating room for abdominal exploration. Two patients (11%) died of associated thoracic injuries after lengthy hospital stays, one at 10 days and one at 24 days. We conclude from our data that nonoperative management of blunt splenic injury in patients age 55 years and older is indicated provided they are hemodynamically stable, do not require significant blood transfusion, and have no other associated abdominal injuries.

Nonsurgical Management of Solid Abdominal Organ Injury in Patients over 55 Years of Age

Age greater than 55 is often stated to be a contraindication to nonoperative management of intraperitoneal solid organ injury, based upon failures in early experiences of nonoperative therapy. Refinements in the criteria for nonoperative management of hepatic and splenic injuries have yielded improved success rates compared with those in initial reports, raising questions as to the validity of an age-related contraindication. A retrospective chart review of patients more than 55 years of age sustaining blunt hepatic and/or splenic injury at two urban Level I trauma centers was performed. Patients were stratified into three groups in which selection criteria could not consistently be determined: those managed nonoperatively, those managed operatively, and those who died within 24 hours. The purpose of this review is to identify whether age is a determinant for nonoperative management of abdominal solid organ injury. Eighty-eight patients were identified (mean age, 68.7 ± 9.8), 17 of whom died in the emergency department or after operative intervention. Of the remaining 71 patients, 37 were originally managed nonoperatively (mean age 69.9 ± 9.1, mean Injury Severity Score 19.9), 24 sustained hepatic injuries (grades I–IV), 12 sustained splenic injuries (grades I–III), and one patient sustained both organ injuries. Three patients with multisystem trauma died from complications unrelated to their solid organ injury (one brain death, one septic death, and one respiratory arrest). A single patient, with a grade I liver injury, required delayed exploration (for a persistent, unexplained metabolic acidosis) and underwent a nontherapeutic celiotomy. All but one of the 37 patients were successfully treated nonoperatively, for a 97 per cent success rate. We conclude that hemodynamically stable patients more than 55 years of age sustaining intra-abdominal injury can be observed safely. Age alone should no longer be considered an exclusion criterion for nonoperative management of intraabdominal solid organ injury.

Blunt trauma to the spleen

BACKGROUND

The management of splenic injury resulting from blunt trauma in adults is controversial, with an increasing trend towards non-operative management and conservation of the spleen. A retrospective review was performed on adult patients treated in a single institution for splenic injury resulting from blunt trauma in an attempt to identify factors important in selecting an appropriate management option and predicting the success of that option.

METHODS

Associated injuries (standardized using Injury Severity Scores), clinical signs at presentation, computed tomographic grading of splenic injury, and transfusion requirements were documented. Statistical analysis was performed using non-parametric Mann-Whitney, Chi-squared, Kolmogorov-Smirnov and multivariate logistic regression tests.

RESULTS

Eighty-five patients were identified. Non-operative management was used on 39 patients, splenic conservation on 14 patients, and splenectomy on 32 patients. The mean Injury Severity Score was significantly lower in the non-operative group. Computed tomographic grading of the splenic injury was not found to correlate well with intraoperative findings. Transfusion requirements were lower in the non-operative group. Non-operative management failed in four patients; two had continued splenic bleeding, and two required surgery for other intra-abdominal injuries. Overall mortality was 7%. There was one death in the splenic conservation group, unrelated to the splenic injury, and two patients required a second laparotomy and splenectomy for persistent splenic bleeding. There were five deaths in the splenectomy group, only one of which was related to the splenic surgery.

CONCLUSION

Management of blunt splenic injury remains controversial. The decision to pursue non-operative management rather than splenic conservation or splenectomy depends on the individual merits of each case. There is an increasing trend towards splenic conservation, particularly in younger, stable patients with single organ injury.

[Surgical abstention in closed injuries of the spleen]

Splenic conservation avoids the overwhelming postsplenectomy infection. The high percentage of patients treated by noninvasive procedures would be due to the simple clinical course of splenic trauma and precision of diagnosis, using CT scan. Only clinical evaluation could provide further information on the indications for surgical treatment, as there is no available score regarding the value of CT scan for choosing the therapeutical option. Non-operative management of splenic ruptures should be considered in selected patients in whom hemodynamics is stable and closely monitored.

Nonoperative management of solid organ injuries in children results in decreased blood utilization

BACKGROUND

The administration of blood products to injured children has been recognized as a potential risk of nonoperative management. The purpose of this study was to evaluate blood utilization in the management of solid organ injuries in pediatric blunt abdominal trauma victims.

METHODS

One hundred sixty-one children (< or =16 years old) with solid organ injuries over an 8-year study period (1990 through 1997) were identified from the trauma registries at 2 urban regional trauma centers.

RESULTS

Mean age of the study patients was 7.9+/-0.4 years, 95 (59%) were boys, and their mean injury severity score (ISS) was 17.8+/-1.2. Patients were divided into 4-year study cohorts (1990 through 1993 and 1994 through 1997) to examine changes in operative management and blood utilization. For each time period examined, those treated nonoperatively received fewer blood transfusions (46% v 9% and 44% v 13%, P<.05 by Fisher's Exact test), and the hospital length of stay was shorter (12.3+/-2.1 v 5.0+/-0.7 and 7.8+/-1.9 v 4.2+/-0.4 days, P<.0001 by analysis of variance/Scheffe's) compared with the laparotomy cohort.

CONCLUSIONS

The appropriate nonoperative management of injured children actually reduces the risks of receiving blood transfusion and decreases the length of hospital stay compared with aggressive operative intervention. Blood transfusion should be reserved only for those injured children with solid organ injuries who are hemodynamically unstable.

Comparative study of splenic wound healing in young and adult rats

BACKGROUND

Nonoperative management (NOM) of splenic injuries is a common practice in stable trauma patients. Nevertheless, age-related differences in the success rate of NOM have prompted inclusion of age among the criteria of patient selection. Elucidation of the cellular mechanism of splenic wound healing in the young versus that of adults may explain why age can be related to the success of NOM in splenic injuries.

METHODS

A laceration was made in the splenic antihilar surface of 40 young and 40 adult male rats. Postoperatively, at specified intervals extending until day 21, spleens were removed, fixed, and examined by routine histopathology. In addition, sections were stained histochemically for collagen fibers and immunohistochemically for myofibroblast histomorphometry.

RESULTS

The intense local hemorrhage was resorbed within 48 hours in the young rats, and within 7 days in the adults. Disappearance of germinal centers and other splenic alterations started on the first day in both groups, but regeneration of splenic parenchyma was accomplished after 14 days in the young, whereas in the adults, on day 21 it was still incomplete. Maximal myofibroblast accumulation at the laceration site was seen after two days in the young, whereas in adults only on day 4 (p < 0.0001). Collagen scars were not present in either group. Thickening of the damaged capsule, composed of collagen fibers with yellowish-green polarization colors, was observed only in adult rats.

CONCLUSION

Splenic wounds heal by regeneration and not by collagen scarring. In the young, myofibroblasts accumulate in the site of injury faster than in adults. These cells may enhance contraction and increase the rate of wound healing until parenchymatic regeneration is completed. Our results may indirectly explain the higher success rate of NOM of splenic injury in young patients.

Traditional Criteria for Observation of Splenic Trauma Should be Challenged

Age less than 55 years, normal Glasgow Coma Score (GCS), and absence of hypotension are traditional criteria for the selection of adult patients with blunt splenic trauma for observation. The objective of this study is to challenge these criteria. Two hundred twelve patients who presented with blunt splenic injury between 1992 and 1997 were identified from the Trauma Registry at our Level I trauma center. The patients were divided into three groups: 100 patients (47%) were observed, 108 (51%) underwent immediate splenorrhaphy or splenectomy, and 4 (2%) failed observation. The three groups were compared by participants’ ages, GCSs, and histories of hypotension. No statistical differences were noted between the successfully observed patients and those requiring immediate surgery with respect to these criteria. Of the 4 patients who failed observation, all were younger than 55 years, all had a GCS >12, and all were normotensive. Our findings suggest that traditional criteria used to select patients for splenic trauma observation are not absolute indicators and should be liberalized: patients can be successfully observed despite having criteria that, in the past, would have led to immediate operative intervention.

Management of blunt splenic trauma in patients older than 55 years. Southern Connecticut Regional Trauma Quality Assurance Committee

BACKGROUND

Many experts have suggested that blunt splenic trauma in patients older than 55 years should not be managed by observation because of supposed increased fragility of the spleen and decreased physiologic reserve in elderly patients. We sought to determine the outcome of nonoperative management of blunt splenic trauma in patients older than 55 years.

METHODS

For the years 1994 through 1996, data for patients with splenic injury older than 55 years from seven trauma centers in a single state were reviewed.

RESULTS

Blunt splenic trauma occurred in 41 patients older than 55 years. Eight patients were excluded from further analysis because of death from massive associated injuries within 24 hours of admission. The remaining 33 patients (mean age, 72+/-10 years) were divided into two groups: immediate exploration (10 patients) and observation (23 patients). Observation of blunt splenic injury failed in 4 of 23 patients (17%). No patient deaths were related to the method of management of the splenic injury.

CONCLUSIONS

Observation of the elderly patient with blunt splenic trauma has an acceptable failure rate of 17%.

Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms

OBJECTIVES

By using abdominal computed tomographic scans in the evaluation of blunt splenic trauma, we previously identified the presence of vascular blush as a predictor of failure, with a failure of nonoperative management of 13% in that series. This finding led to an alteration in our management scheme, which now includes the aggressive identification and embolization of splenic artery pseudoaneurysms.

METHODS

The medical records of 524 consecutive patients with blunt splenic injury managed over a 4.5-year period were reviewed for the following information: age, Injury Severity Score (ISS), American Association for the Surgery of Trauma splenic injury grade (SIG), method and outcome of management.

RESULTS

Of the patients, 66% were male with a mean age of 32 +/- 16, and mean ISS of 25 +/- 13. A total of 180 patients (34%) were managed with urgent operation on admission (81% splenectomy (SIG 4.0), 19% splenorrhaphy (SIG 2.6)). The remaining 344 patients (66%) were hemodynamically stable and underwent computed tomographic scan and planned nonoperative management. Of these patients, 322 patients (94%) were successfully managed nonoperatively (61% of total splenic injuries). In 26 patients (8%), a contrast blush identified on computed tomographic scan was confirmed as a parenchymal pseudoaneurysm on arteriography. Twenty patients (SIG, 2.8) were successfully embolized. In six patients, technical failure precluded embolization; all required splenectomy (SIG, 4.0). A total of 22 patients (6%) failed nonoperative management, including the six with unsuccessful embolization attempts. Sixteen patients (SIG, 3.0) who had no evidence of pseudoaneurysm were explored for a falling hematocrit, hemodynamic instability, or a worsening follow-up computed tomography: 13 patients had splenectomy, and three patients had splenorrhaphy.

CONCLUSIONS

Aggressive surveillance for and embolization of posttraumatic splenic artery pseudoaneurysms improved the rate of successful nonoperative management of blunt splenic trauma to 61%, with a nonoperative failure rate of only 6%. In comparison with our previous work, this reduction in failure of nonoperative management is a significant improvement (p < 0.03).

Changing patterns in the management of splenic trauma: the impact of nonoperative management

OBJECTIVE

The recognition that splenectomy renders patients susceptible to lifelong risks of septic complications has led to routine attempts at splenic conservation after trauma. In 1990, the authors reported that over an 11-year study period involving 193 patients, splenorrhaphy was the most common splenic salvage method (66% overall) noted, with nonoperative management employed in only 13% of blunt splenic injuries. This report describes changing patterns of therapy in 190 consecutive patients with splenic injuries seen during a subsequent 6-year period (1990 to 1996). An algorithmic approach for patient management and pitfalls to be avoided to ensure safe nonoperative management are detailed.

METHODS

Nonoperative management criteria included hemodynamic stability and computed tomographic examination without shattered spleen or other injuries requiring celiotomy.

RESULTS

Of 190 consecutive patients, 102 (54%) were managed nonoperatively: 96 (65%) of 147 patients with blunt splenic injuries, which included 15 patients with intrinsic splenic pathology, and 6 hemodynamically stable patients with isolated stab wounds (24% of all splenic stab wounds). Fifty-six patients underwent splenectomy (29%) and 32 splenorrhaphy (17%). The mean transfusion requirement was 6 units for splenectomy survivors and 0.8 units for nonoperative therapy (85% received no transfusions). Fifteen of the 16 major infectious complications that occurred followed splenectomy. Two patients failed nonoperative therapy (2%) and underwent splenectomy, and one patient required splenectomy after partial splenic resection. There no missed enteric injuries in patients managed nonoperatively. The overall mortality rate was 5.2%, with no deaths following nonoperative management.

CONCLUSIONS

Nonoperative management of blunt splenic injuries has replaced splenorrhaphy as the most common method of splenic conservation. The criteria have been extended to include patients previously excluded from this form of therapy. As a result, 65% of all blunt splenic injuries and select stab wounds can be managed with minimal transfusions, morbidity, or mortality, with a success rate of 98%. Splenectomy, when necessary, continues to be associated with excessive transfusion and an inordinately high postoperative sepsis rate.

Nonoperative management of splenic injury: are follow-up computed tomographic scans of any value?

OBJECTIVE

To determine the value of follow-up abdominal computed tomography in patients with splenic trauma managed nonoperatively.

DESIGN

Retrospective chart review.

MATERIALS AND METHODS

A total of 108 consecutive patients with splenic injuries treated at a single institution from 1990 to 1996 were studied. All admission and follow-up computed tomographic (CT) scans were reviewed by the authors.

RESULTS

Initial management was surgical in 35 patients (32%) and intentionally nonoperative in 73 patients (68%). Nonoperative management was successful in 45 of 49 adults (92%) and 21 of 24 children(88%). Sixty-two follow-up abdominal CT scans were obtained in 49 patients. Information that affected management was evident on only one follow-up CT scan performed in the absence of clinical indications. Potential savings in hospital and physician charges for routine follow-up CT scans in this study were $54,302.00.

CONCLUSIONS

Follow-up abdominal CT scans are not routinely necessary in patients with splenic injuries managed nonoperatively.