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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.
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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.
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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
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Jabbour G, Al-Hassani A, El-Menyar A, Abdelrahman H, Peralta R, Ellabib M, Al-Jogol H, Asim M, Al-Thani H. Clinical and Radiological Presentations and Management of Blunt Splenic Trauma: A Single Tertiary Hospital Experience. Med Sci Monit 2017; 23:3383-3392. [PMID: 28700540 PMCID: PMC5519223 DOI: 10.12659/msm.902438] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 01/10/2017] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Splenic injury is the leading cause of major bleeding after blunt abdominal trauma. We examined the clinical and radiological presentations, management, and outcome of blunt splenic injuries (BSI) in our institution. MATERIAL AND METHODS A retrospective study of BSI patients between 2011 and 2014 was conducted. We analyzed and compared management and outcome of different splenic injury grades in trauma patients. RESULTS A total of 191 BSI patients were identified with a mean (SD) age of 26.9 years (13.1); 164 (85.9%) were males. Traffic-related accident was the main mechanism of injury. Splenic contusion and hematoma (77.2%) was the most frequent finding on initial computerized tomography (CT) scans, followed by shattered spleen (11.1%), blush (11.1%), and devascularization (0.6%). Repeated CT scan revealed 3 patients with pseudoaneurysm who underwent angioembolization. Nearly a quarter of patients were managed surgically. Non-operative management failed in 1 patient who underwent splenectomy. Patients with grade V injury presented with higher mean ISS and abdominal AIS, required frequent blood transfusion, and were more likely to be FAST-positive (p=0.001). The majority of low-grade (I-III) splenic injuries were treated conservatively, while patients with high-grade (IV and V) BSI frequently required splenectomy (p=0.001). Adults were more likely to have grade I, II, and V BSI, blood transfusion, and prolonged ICU stay as compared to pediatric BSI patients. The overall mortality rate was 7.9%, which is mainly association with traumatic brain injury and hemorrhagic shock; half of the deaths occurred within the first day after injury. CONCLUSIONS Most BSI patients had grade I-III injuries that were successfully treated non-operatively, with a low failure rate. The severity of injury and presence of associated lesions should be carefully considered in developing the management plan. Thorough clinical assessment and CT scan evaluation are crucial for appropriate management of BSI.
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Affiliation(s)
- Gaby Jabbour
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | | | - Ayman El-Menyar
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad Medical Corporation, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | | | - Ruben Peralta
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Ellabib
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Hisham Al-Jogol
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohammad Asim
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad Medical Corporation, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
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Abstract
The treatment of blunt splenic injury has evolved over time from splenectomy in all patients to nonoperative management in stable patients with operation reserved for failures of NOM. While rates of OPSI remain low in trauma patients, splenic salvage in stable patients should be attempted. However, clinical evidence of ongoing blood loss or instability should be addressed with prompt splenectomy. Careful patient selection is of paramount importance in nonoperative management of blunt splenic injury.
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Affiliation(s)
- R M Forsythe
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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5
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Delayed splenic rupture presenting 70 days following blunt abdominal trauma. Clin Imaging 2014; 38:73-4. [DOI: 10.1016/j.clinimag.2013.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 08/14/2013] [Accepted: 09/11/2013] [Indexed: 11/23/2022]
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Bhullar IS, Frykberg ER, Siragusa D, Chesire D, Paul J, Tepas JJ, Kerwin AJ. Age Does Not Affect Outcomes of Nonoperative Management of Blunt Splenic Trauma. J Am Coll Surg 2012; 214:958-64. [DOI: 10.1016/j.jamcollsurg.2012.03.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 03/09/2012] [Accepted: 03/09/2012] [Indexed: 11/29/2022]
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8
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Gedik E, Girgin S, Aldemir M, Keles C, Tuncer MC, Aktas A. Non-traumatic splenic rupture: Report of seven cases and review of the literature. World J Gastroenterol 2008; 14:6711-6. [PMID: 19034976 PMCID: PMC2773315 DOI: 10.3748/wjg.14.6711] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate seven patients with non-traumatic splenic rupture (NSR). NSR is an uncommon dramatic abdominal emergency that requires immediate diagnosis and prompt surgical treatment to ensure the patient’s survival.
METHODS: Within 11 years, seven cases were evaluated for patient characteristics, anamnesis and symptoms, method of diagnosis, findings of laparotomy, and etiology of NSR.
RESULTS: There were six (86%) male and one female (14%) patient, whose mean age was 36 ± 12.8 (17-56) years. We report here four cases of Plasmodium vivax malaria (cases I-IV), one case of hemodialysis (case V), one case of spontaneous splenic rupture (case VI), and one case of hairy cell leukemia (case VII). Splenectomy was performed in all patients. All of them made an uneventful recovery and were discharged in stable condition.
CONCLUSION: NSR is a rare entity that needs a high index of suspicion for diagnosis. Using ultrasonography or computer tomography, and peritoneal aspiration of fresh blood may assist in the diagnosis of NSR. Increased awareness of NSR can enhance early diagnosis and effective treatment.
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Gauer JM, Gerber-Paulet S, Seiler C, Schweizer WP. Twenty Years of Splenic Preservation in Trauma: Lower Early Infection Rate Than in Splenectomy. World J Surg 2008; 32:2730-5. [DOI: 10.1007/s00268-008-9733-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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Tinkoff G, Esposito TJ, Reed J, Kilgo P, Fildes J, Pasquale M, Meredith JW. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg 2008; 207:646-55. [PMID: 18954775 DOI: 10.1016/j.jamcollsurg.2008.06.342] [Citation(s) in RCA: 221] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Revised: 06/12/2008] [Accepted: 06/17/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND This study attempts to validate the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for spleen, liver, and kidney injuries using the National Trauma Data Bank (NTDB). STUDY DESIGN All NTDB entries with Abbreviated Injury Scale codes for spleen, liver, and kidney were classified by OIS grade. Injuries were stratified either as an isolated intraabdominal organ injury or in combination with other abdominal injuries. Isolated abdominal solid organ injuries were additionally stratified by presence of severe head injury and survival past 24 hours. The patients in each grading category were analyzed for mortality, operative rate, hospital length of stay, ICU length of stay, and charges incurred. RESULTS There were 54,148 NTDB entries (2.7%) with Abbreviated Injury Scale-coded injuries to the spleen, liver, or kidney. In 35,897, this was an isolated abdominal solid organ injury. For patients in which the solid organ in question was not the sole abdominal injury, a statistically significant increase (p < or = 0.05) in mortality, organ-specific operative rate, and hospital charges was associated with increasing OIS grade; the exception was grade VI hepatic injuries. Hospital and ICU lengths of stay did not show substantial increase with increasing OIS grade. When isolated organ injuries were examined, there were statistically significant increases (p < or = 0.05) in all outcomes variables corresponding with increasing OIS grade. Severe head injury appears to influence mortality, but none of the other outcomes variables. Patients with other intraabdominal injuries had comparable quantitative outcomes results with the isolated abdominal organ injury groups for all OIS grades. CONCLUSIONS This study validates and quantifies outcomes reflective of increasing injury severity associated with increasing OIS grades for specific solid organ injuries alone, and in combination with other abdominal injuries.
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Affiliation(s)
- Glen Tinkoff
- Department of Surgery, Christiana Care Health System, Newark, DE, USA
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Siriratsivawong K, Zenati M, Watson GA, Harbrecht BG. Nonoperative Management of Blunt Splenic Trauma in the Elderly: Does Age Play a Role? Am Surg 2007. [DOI: 10.1177/000313480707300610] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nonoperative management (NOM) of blunt splenic injury has become more frequent in the past several decades. Criteria that predict successful NOM remain poorly defined, and one factor that has been studied previously has been patient age. Previous studies have defined older patients as those greater than 55 years of age, but no studies have compared younger patients (55–75 years) with older patients (75+ years) within this age group. A total of 1008 patients ≥55 years of age who sustained blunt splenic injury between 1993 and 2001 were analyzed from the Pennsylvania Trauma Systems Foundation database. Statistical analysis was performed using regression analysis. Data was expressed as mean ± SD, and a P value of ≤ 0.05 was considered significant. Patients were classified as operative management (OM; 39.9%) or NOM (60.1%) according to their initial plan of treatment. Of the patients in the NOM group, 75.3 per cent were successfully managed nonoperatively (SNOM), whereas 24.7 per cent eventually required surgery. The Injury Severity Score of the OM group was highest (34) compared with the SNOM group (22) and failed NOM (FNOM; 27) groups. The mean splenic injury grade for OM, SNOM, and FNOM was 3.5, 2.4, and 3.3, respectively. The number of pre-existing conditions did not differ among the three groups. An upward trend in the failure rate of NOM was observed with increasing age (19.0%, 27.1%, and 28.3%, respectively) for three age groups, 55–64, 65–74, and 75+, but this trend was not statistically significant. Mortality rate was highest in the OM group (35.6%) compared with the successful (16.7%) and failed NOM (17.9%). Hospital length of stay (LOS) and intensive care unit (ICU) LOS were highest among patients who failed NOM (mean hospital LOS = 20.7 days, mean ICU LOS = 13.2 days) compared with OM (17.2 and 10.4, respectively) and successful NOM (12.4 and 6.9, respectively). The majority of patients ≥55 years with blunt splenic injuries can be managed nonoperatively when carefully selected. In the subset of patients older than 55 years of age, increasing age is associated with a trend toward higher failure rates. Mortality was high regardless of management, and failure of NOM in older patients is associated with significantly longer hospital and ICU LOS.
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Affiliation(s)
| | - Mazen Zenati
- University of Pittsburgh Medical Center, Pittsburgh Pennsylvania; and
| | - Gregory A. Watson
- University of Pittsburgh Medical Center, Pittsburgh Pennsylvania; and
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12
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Abstract
The spleen and liver are the 2 most commonly injured abdominal organs following trauma. Trends in management have changed over the years, and the majority of these injuries are now managed nonoperatively. Splenic injuries can be managed via simple observation or with angiography and embolization. Recent data suggest that there are few true contraindications in the setting of hemodynamic stability. Success rate of nonoperative management may be as high as 95%. Liver injuries can be approached similarly. In the setting of a hemodynamically stable patient, observation with or without angiography and embolization may similarly be used. As many as 80% of patients with liver injury can be successfully managed without laparotomy. This review will discuss current concepts in nonoperative management of liver and spleen, including diagnosis, patient selection, nonoperative management strategies, benefits, risks, and complications.
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Affiliation(s)
- Deborah M Stein
- Division of Critical Care/Program in Trauma, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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13
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Watson GA, Rosengart MR, Zenati MS, Tsung A, Forsythe RM, Peitzman AB, Harbrecht BG. Nonoperative management of severe blunt splenic injury: are we getting better? ACTA ACUST UNITED AC 2006; 61:1113-8; discussion 1118-9. [PMID: 17099516 DOI: 10.1097/01.ta.0000241363.97619.d6] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Most minor splenic injuries are readily treated nonoperatively but controversy exists regarding the role of nonoperative management for higher-grade injuries. The infrequency of these injuries has made evaluation of factors critical to their management difficult. METHODS Through the National Trauma Data Bank, 3,085 adults sustaining severe (Abbreviated Injury Scale score > or = 4) blunt splenic injury from 1997 to 2003 were retrospectively reviewed. Patient management, demographic information, physiologic data, procedures performed, and outcomes were analyzed. RESULTS Nonoperative management was attempted in 40.5% of patients but ultimately failed in 54.6% of those. Failure of nonoperative management was associated with increased age, low admission systolic blood pressure, higher injury severity score, and increased hospital and intensive care unit length of stay. Mortality associated with failure of nonoperative management (12.3%) and successful observation (13.8%) was similar. CONCLUSIONS Nonoperative management of higher-grade splenic injuries is associated with a high rate of failure and prolonged hospital stay. Careful judgment must be exercised in applying nonoperative management to patients with severe splenic injuries.
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Affiliation(s)
- Gregory A Watson
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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14
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Abstract
The management of patients with blunt abdominal trauma has evolved over the past two decades with increasing reliance on a non-operative approach. An in-depth understanding of the clinical and radiographic parameters used to determine those who may be eligible for this form of treatment is an essential component of modern trauma care. This case-based review highlights critical aspects of non-operative management and provides a framework for the role of the emergency medicine provider.
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Affiliation(s)
- Douglas Everett Gibson
- Department of Emergency Medicine, Detroit Receiving Hospital-Emergency Medicine Residency, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
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15
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Brichkov I, Cummings L, Fazylov R, Horovitz J. Nonoperative Management of Spontaneous Splenic Rupture in Infectious Mononucleosis: The Role for Emerging Diagnostic and Treatment Modalities. Am Surg 2006. [DOI: 10.1177/000313480607200507] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Infectious mononucleosis (IM) is a self-limiting lymphoproliferative disorder affecting teenagers and young adults. Splenomegaly is a common manifestation of IM and results in a compromised organ that may rarely rupture spontaneously, with significant morbidity and mortality. The IM spleen should be protected from even minor trauma. Although traditional management of spontaneous splenic rupture in IM has been splenectomy, the role of nonoperative management is evolving. The advent of endovascular interventional modalities has augmented the physician's armamentarium in managing these patients nonoperatively. We report a case of spontaneous splenic rupture in a patient with IM managed conservatively with the aid of splenic angiography. The option of arteriography, with or without embolization, should be considered in the management of all patients with spontaneous splenic rupture in the setting of IM.
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Affiliation(s)
- I. Brichkov
- From the Department of Surgery, Maimonides Medical Center, Brooklyn, New York
| | - L. Cummings
- From the Department of Surgery, Maimonides Medical Center, Brooklyn, New York
| | - R. Fazylov
- From the Department of Surgery, Maimonides Medical Center, Brooklyn, New York
| | - J.H. Horovitz
- From the Department of Surgery, Maimonides Medical Center, Brooklyn, New York
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Cooney R, Ku J, Cherry R, Maish GO, Carney D, Scorza LB, Smith JS. Limitations of Splenic Angioembolization in Treating Blunt Splenic Injury. ACTA ACUST UNITED AC 2005; 59:926-32; discussion 932. [PMID: 16374283 DOI: 10.1097/01.ta.0000188134.32106.89] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Robert Cooney
- Department of Surgery, Penn State Milton S. Hershey Medical Center, 17033, USA.
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Peitzman AB, Harbrecht BG, Rivera L, Heil B. Failure of Observation of Blunt Splenic Injury in Adults: Variability in Practice and Adverse Consequences. J Am Coll Surg 2005; 201:179-87. [PMID: 16038813 DOI: 10.1016/j.jamcollsurg.2005.03.037] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2004] [Revised: 03/28/2005] [Accepted: 03/30/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND The Eastern Association for the Surgery of Trauma Multiinstitutional Workgroup reported a failure rate for nonoperative management of blunt splenic injury in adults of 10.8%. Sixty percent of the failures occurred within 24 hours of admission. The purpose of this multiinstitutional study by the Eastern Association for the Surgery of Trauma was to determine common variables in failure of nonoperative management of blunt splenic injury in adults. STUDY DESIGN Medical records were reviewed in a blinded fashion on 78 patients in whom nonoperative management failed. Statistical analysis was performed with ANOVA, extended chi-square, and Fisher's exact test; statistical significance was p<0.05. RESULTS The 78 patients were categorized based on hemodynamic status. Forty-four percent were stable; 31% had transient hypotension or tachycardia that resolved with fluid infusion (responders); and 25% were unstable. Two-thirds of the unstable patients required laparotomy within 12 hours of admission; all had laparotomy within 72 hours. Mortality was significantly different when comparing the unstable to the stable and responder groups: stable (3%), responders (8%), and unstable (37%), despite similar age and only modest differences in Injury Severity Score. Eight CT scans were misinterpreted initially. Of 26 Focused Abdominal Sonography for Trauma (FAST) studies, 11 (42.3%) were false negative. Abnormal abdominal findings were noted in 67.7% of patients on admission. Ten patients died (12.8%). Sixty percent of the deaths were caused largely by delayed treatment of splenic or other abdominal injuries; one patient died in the responder group and five unstable patients died. CONCLUSIONS Thirty percent to 40% of the patients who had unsuccessful nonoperative management in this study were selected inappropriately, with hemodynamic instability or initial misinterpretation of diagnostic studies. As a consequence, the majority of the deaths were from delayed treatment of intraabdominal injuries. This article suggests that written protocols, better adherence to sound clinical judgment, and experienced and timely interpretation of radiologic studies would reduce the incidence of failure of nonoperative management of blunt splenic injury in adults.
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Affiliation(s)
- Andrew B Peitzman
- Department of Surgery, University of Pittsburgh, Presbyterian University Hospital, Pittsburgh, PA 15213, USA
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Al-Mulhim AS, Mohammad HAH. Non-operative management of blunt hepatic injury in multiply injured adult patients. Surgeon 2005; 1:81-5. [PMID: 15573625 DOI: 10.1016/s1479-666x(03)80120-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Non-operative management of blunt liver trauma has now evolved into a common practice especially since abdominal CT has enabled a more precise evaluation of these patients. CLINICAL MATERIAL Sixty-three patients, haemodynamically stable, were eligible for the study and enrolled into the protocol of non-operative management of blunt hepatic injury. Fifty-two (82.5%) patients were successfully managed non-operatively (non-operative group). The remaining 11 (17.5%) patients failed the non-operative management and underwent exploratory laparotomy (laparotomy group). RESULTS Patients managed non-operatively tended to be younger than patients managed operatively (p < 0.05). The mean values of ISS were 16.2 +/- 6.1, 26.1 +/- 8.5, p < 0.001, in the non-operative and laparotomy groups, respectively. Stay in the ICU was significantly decreased in the non-operative patients (p < 0.001). Patients who had a laparotomy significantly increased requirement for blood transfusion (p < 0.001). Six (9.5%) patients managed non-operatively developed complications; perihepatic collections were observed in two patients, an urinoma in one patient and chest infection in three patients. Perihepatic collections and urinoma were successfully drained percutaneously by CT guidance and no further treatment was required. The mortality rate of the entire series of patients was 4.8% (three patients); one death could be related to hepatic injury itself and the other two deaths were attributed to non-hepatic causes. No deaths occurred in the non-operative group. CONCLUSION Non-operative management should be the initial approach to all patients with blunt liver injuries if haemodynamic stability can be ensured. When continued bleeding can be safely ruled out, a period of close monitoring in the ICU is warranted.
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Affiliation(s)
- A S Al-Mulhim
- Department of Surgery, King Fahad Hospital, Hofuf, PO Box 1164, Hofuf, Al-Hassa 31982.
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19
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Liu PP, Lee WC, Cheng YF, Hsieh PM, Hsieh YM, Tan BL, Chen FC, Huang TC, Tung CC. Use of splenic artery embolization as an adjunct to nonsurgical management of blunt splenic injury. ACTA ACUST UNITED AC 2004; 56:768-72; discussion 773. [PMID: 15187739 DOI: 10.1097/01.ta.0000129646.14777.ff] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Po Ping Liu
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
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Sekikawa Z, Takebayashi S, Kurihara H, Lee J, Niwa T, Kawamoto M, Yamamoto T, Suzuki J, Sugiyama M, Inoue T. Factors affecting clinical outcome of patients who undergo transcatheter arterial embolisation in splenic injury. Br J Radiol 2004; 77:308-11. [PMID: 15107320 DOI: 10.1259/bjr/21985061] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Z Sekikawa
- Departments of Radiology and Critical and Emergency, Yokohama City University Medical Centre, 4-57 Urafunecho Minamiku, Yokohama-city, Japan
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21
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Mohr AM, Pham AM, Lavery RF, Sifri Z, Bargman V, Livingston DH. Management of trauma to the male external genitalia: the usefulness of American Association for the Surgery of Trauma organ injury scales. J Urol 2004; 170:2311-5. [PMID: 14634403 DOI: 10.1097/01.ju.0000089241.71369.fa] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Injury to the male external genitalia is rare and, therefore, there are little data in the literature regarding the options for nonoperative management and outcome. To assist in defining the indications for nonoperative management the usefulness of the American Association for the Surgery of Trauma (AAST) organ injury scales for these injuries was examined. MATERIALS AND METHODS We retrospectively reviewed the medical records of 116 male patients with trauma to the external genitalia in a 10-year period and classified injuries according to the organ injury severity scales (scrotum, testis, penis and urethra) of the AAST. Based on AAST grading management and outcome was reviewed. RESULTS Mean patient age was 28 years and 79% of the injuries were due to gunshot wounds. A total of 87 patients (75%) underwent surgery, while 27 penile injuries and 8 scrotal/testicular injuries were managed nonoperatively. There were 54 scrotal explorations, 33 testicular injuries and 20 orchiectomies (bilateral in 1) for a testicular salvage rate of 39%. Documented followup by the trauma or genitourinary service was achieved in 47 of 110 survivors. No patient reported impotence or difficulty with fertility. CONCLUSIONS The AAST grading for male external genital trauma readily characterizes patients with high grade injuries that require operative management as well as select patients in whom injury can be safely managed nonoperatively.
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Affiliation(s)
- Alicia M Mohr
- Department of Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark 07103, USA.
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22
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Brasel KJ, Weigelt JA, Christians KK, Somberg LB. The value of process measures in evaluating an evidence-based guideline. Surgery 2003; 134:605-10; discussion 610-12. [PMID: 14605621 DOI: 10.1016/s0039-6060(03)00339-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Linking the process of evidence-based guidelines to outcomes is difficult. We hypothesized that the process of implementing an evidence-based clinical guideline for blunt splenic trauma would reduce resource consumption and improve outcome. METHODS Time periods were divided into period 1 (7/1/96-6/30/99) and period 2 (7/1/99-6/30/01). On 7/1/99 our American College of Surgeons-verified level I trauma center instituted an evidence-based approach for managing splenic trauma incorporating hemodynamic normality as the process measure triggering clinical decisions. Outcomes included the number of hemodynamically normal patients treated without operation, patient death, length of stay, and cost. RESULTS Two hundred thirty-one patients had blunt splenic injury; 115 patients were seen during period 1 and 116 during period 2. Hemodynamically normal patients undergoing splenectomy decreased during period 2 (P<.05). Median length of stay was 8 days in period 1 and 6 days in period 2 (P<.03). Cost per patient was $34,972 US dollars in period 1 and $24,037 US dollars in period 2 (P<.03). The mortality rate was unchanged. CONCLUSIONS Compliance with evidence-based data in the management of blunt splenic injury improved rates of nonoperative management, decreased hospital days, and did not change mortality rates. An evidence-based clinical guideline evaluated with process measures can reduce resource use and improve outcome in a trauma program.
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Affiliation(s)
- Karen J Brasel
- Department of Surgery, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 52336, USA
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23
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Hughes TMD, Elton C, Hitos K, Perez JV, McDougall PA. Intra-abdominal gastrointestinal tract injuries following blunt trauma: the experience of an Australian trauma centre. Injury 2002; 33:617-26. [PMID: 12208066 DOI: 10.1016/s0020-1383(02)00068-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIMS The aim of the study was to use the extensive experience of an Australian Level I trauma centre to develop guidelines for diagnosis and management of significant gastrointestinal tract injuries (GITIs). METHODS This was a retrospective study of 74 patients admitted to Westmead Hospital between 1985 and 1996 who had sustained major gastrointestinal tract (GIT) injuries following blunt trauma. The patients were identified from the trauma unit database. Clinical information was retrieved from the database and augmented by a review of the medical records. RESULTS Motor vehicle accidents were responsible for 55 (92%) admissions. Laparotomy was performed as a result of a positive diagnostic peritoneal lavage in 26 (35.1%) patients, abdominal signs in 20 (27%), diagnostic findings on computed tomography in 19 (25.7%), haemodynamic instability in eight (10.8%) and a positive contrast study in one (1.4%) patient. There was a total of 95 injuries: one gastric (1.1%), eight duodenal (8.4%), 64 small bowel (67.3%), two appendiceal (2.1%), 19 colonic (20%) and one rectal (1.1%). Thirty day mortality was 23% (17 patients). Seven (9.5%) patients died within 24h of injury, three (4.1%) of which were directly related to the GIT. Ten (13.5%) patients died within 2 weeks of admission, three (4.1%) of which were attributable to the GIT. Thirty day GIT morbidity was 29.7% (22 patients). The development of GIT morbidity was significantly related to a delay to laparotomy of more than 24h (P=0.036) and tachycardia on presentation (P=0.023). Associated injuries, injury severity scores (ISS) and age did not significantly impact on GITI related morbidity and mortality. DISCUSSION Major GITIs are associated with a high mortality due to the severity and complexity of associated injuries. Morbidity from GITIs correlates to delays in diagnosis and management.
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Affiliation(s)
- T M D Hughes
- Department of Trauma, Westmead Hospital, Westmead2145, NSW, Australia.
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24
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Mostafa G, Matthews BD, Sing RF, Prickett D, Heniford BT. Elective laparoscopic splenectomy for grade III splenic injury in an athlete. Surg Laparosc Endosc Percutan Tech 2002; 12:283-6; discussion 286-8. [PMID: 12193827 DOI: 10.1097/00129689-200208000-00017] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The safety and efficacy of laparoscopic splenectomy in the management of benign hematologic diseases is well established. Laparoscopic splenectomy for splenic trauma has been reported infrequently, and most consider a minimally invasive approach to be contraindicated. A heralded, standout college football player who sustained a grade III splenic laceration while playing football was referred for laparoscopic splenectomy so that he could convalesce rapidly, complete his final year of athletic eligibility, and prepare for the National Football League draft. The ethical issues regarding this patient's care were discussed extensively with the patient, his parents, and the hospital administration. After informed consent, the patient underwent a laparoscopic splenectomy with no intraoperative complications. He was discharged 20 hours after surgery. The patient played in a collegiate football game 12 days after surgery, was drafted into the National Football League 9 months later, and was on the opening day roster 12 months after his surgery. We do not advocate laparoscopic splenectomy for injuries to the spleen as the standard of care. This case, however, illustrates the potential for laparoscopic surgery to provide a safe and feasible alternative to traditional surgical approaches.
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Affiliation(s)
- Gamal Mostafa
- Department of Surgery, Carolinas Medical Center, Medical Education Building Suite 601, 1000 Blythe Boulevard, Charlotte, NC 28203, USA
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25
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Wahl WL, Ahrns KS, Brandt MM, Franklin GA, Taheri PA. The need for early angiographic embolization in blunt liver injuries. THE JOURNAL OF TRAUMA 2002; 52:1097-101. [PMID: 12045636 DOI: 10.1097/00005373-200206000-00012] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although nonoperative management of blunt liver injury (BLI) has become standard practice, adjuncts to nonoperative therapy, such as angiographic embolization, have not been well characterized. METHODS Patients with BLI were retrospectively identified at our American College of Surgeons-verified Level I trauma center from January 1997 through February 2001. Patients were stratified into four groups: those who received angiographic embolization (AE) as an early intervention when BLI was initially diagnosed (EARLY-AE); those who underwent AE after liver-related operation or later in the hospital course (LATE-AE); those treated with operation only (OR-ONLY); and nonoperative patients who also did not undergo AE (NO-OR). RESULTS There were 126 patients with BLI, of whom 94 were NO-OR, 20 were OR-ONLY, 6 had LATE-AE, and 6 had EARLY-AE. The NO-OR group had significantly lower liver Abbreviated Injury Scale scores. Liver Abbreviated Injury Scale scores were not different between the EARLY-AE, LATE-AE, and OR-ONLY groups. Liver-related mortality was not lower for those treated with AE. There was a trend toward lower mortality for just the EARLY-AE group compared with the LATE-AE and OR-ONLY groups (0% vs. 50% and 35%). The number of units of packed red blood cells transfused and the number of liver-related operations were lower in the EARLY-AE compared with the LATE-AE group, but liver-related complications were not different between the EARLY-AE, LATE-AE, or OR-ONLY groups. AE was successful in arresting hemorrhage in 83% of the cases. CONCLUSION In this small series, we observed similar morbidity and mortality with AE compared with operative therapy. EARLY-AE did decrease blood use and the number of liver-related operations. AE can be performed on severely injured patients with comparable liver-related mortality and complications. Further study of the timing of and outcomes from AE is needed.
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Affiliation(s)
- Wendy L Wahl
- Division of Trauma Burn and Emergency Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan 48109-0033, USA.
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26
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Affiliation(s)
- T M D Hughes
- Department of Trauma, Westmead Hospital, Westmead NSW 2145, Australia.
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27
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Albrecht RM, Schermer CR, Morris A. Nonoperative Management of Blunt Splenic Injuries: Factors Influencing Success in Age <55 Years. Am Surg 2002. [DOI: 10.1177/000313480206800303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Roxie M. Albrecht
- From the Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Carol R. Schermer
- From the Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Amy Morris
- From the Department of Surgery, University of New Mexico, Albuquerque, New Mexico
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Affiliation(s)
- A B Peitzman
- Section of Trauma/Surgical Critical Care and Division of General Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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29
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Harbrecht BG, Peitzman AB, Rivera L, Heil B, Croce M, Morris JA, Enderson BL, Kurek S, Pasquale M, Frykberg ER, Minei JP, Meredith JW, Young J, Kealey GP, Ross S, Luchette FA, McCarthy M, Davis F, Shatz D, Tinkoff G, Block EF, Cone JB, Jones LM, Chalifoux T, Federle MB, Clancy KD, Ochoa JB, Fakhry SM, Townsend R, Bell RM, Weireter L, Shapiro MB, Rogers F, Dunham CM, McAuley CE. Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma. THE JOURNAL OF TRAUMA 2001; 51:887-95. [PMID: 11706335 DOI: 10.1097/00005373-200111000-00010] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults. METHODS Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively. RESULTS Fifteen percent of patients were 55 years of age or older. A similar proportion of patients > or = 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients > or = 55 was significantly greater than patients < 55 (43% vs. 23%). Patients > or = 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women > or = 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05). CONCLUSION Patients > or = 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > or = 55 had significantly greater mortality and failure of NOM than women < 55.
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Affiliation(s)
- B G Harbrecht
- University of Pittsburgh School of Medicine, Pennsylvania 15213-2582, USA.
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30
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Shanmuganathan K, Mirvis SE, Boyd-Kranis R, Takada T, Scalea TM. Nonsurgical management of blunt splenic injury: use of CT criteria to select patients for splenic arteriography and potential endovascular therapy. Radiology 2000; 217:75-82. [PMID: 11012426 DOI: 10.1148/radiology.217.1.r00oc0875] [Citation(s) in RCA: 168] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine if contrast material-enhanced spiral computed tomography (CT) can be used to select patients with blunt splenic injuries to undergo arteriographic embolization. MATERIALS AND METHODS During a 15-month period, 78 patients who were hemodynamically stable and required no immediate surgery underwent contrast-enhanced spiral CT followed by splenic arteriography. CT scans were assessed for splenic vascular contrast material extravasation or posttraumatic splenic vascular lesions. Medical records were reviewed for splenic arteriographic results and clinical outcome. RESULTS There were 25 grade I, 12 grade II, 27 grade III, 12 grade IV, and two grade V splenic injuries. CT showed active contrast material extravasation in seven patients and splenic vascular lesions in 19 patients. At CT, splenic vascular contrast material extravasation was 100% (seven of seven patients) and a posttraumatic splenic vascular lesion was 83% (10 of 12 patients) sensitive on the basis of arteriographic or surgical outcome in predicting the need for transcatheter embolization or splenic surgery. Overall, CT had a sensitivity of 81% (17 of 21 patients), a specificity of 84% (48 of 57 patients), negative and positive predictive values of 92% (48 of 52 patients) and 65% (17 of 26 patients), respectively, and an accuracy of 83% (65 of 78 patients) in predicting the need for splenic injury treatment. CONCLUSION Contrast-enhanced spiral CT plays a valuable role in selecting hemodynamically stable patients with splenic vascular injury who may be treated with transcatheter therapy and potentially improves the success rate of nonsurgical management.
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Affiliation(s)
- K Shanmuganathan
- Department of Radiology, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201, USA.
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31
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Hunt JP, Cherr GS, Hunter C, Wright MJ, Wang YZ, Steeb G, Buechter KJ, Meyer AA, Baker CC. Accuracy of administrative data in trauma: splenic injuries as an example. THE JOURNAL OF TRAUMA 2000; 49:679-86; discussion 686-8. [PMID: 11038086 DOI: 10.1097/00005373-200010000-00016] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Accurate data are needed to evaluate clinical outcomes, therapeutic modalities, and quality of care in trauma. Administrative data, usually used for billing, have been used to evaluate performance and assess therapy in other medical specialties. This study was performed to determine whether administrative databases are accurate in the recording of information about trauma patients with splenic injuries. METHODS Patients who had blunt splenic injuries were identified using a state trauma registry. The medical records of those patients were reviewed. The data collected by chart review were compared with data in the statewide administrative database of patients who had splenic injuries at the same four Level I and II trauma centers in the same 5-year period. Age, sex, admission date, and hospital were matched to assure comparison of the identical cohort. chi2 analysis was used to compare dichotomous data and Student's t test continuous data. RESULTS The administrative database identified 641 and the trauma registry identified 529 patients with a diagnosis of splenic injury. A total of 401 patients were found in both databases. Of these, 120 (22.7%) patients were not recorded in the administrative database. Injury Severity Score was underreported by the administrative database (25.74 +/- 14.7 vs. 19.52 +/- 11, p < 0.0001). The administrative database underreported orthopedic, chest, and head injuries (317 vs. 215, 325 vs. 228, and 234 vs. 155, respectively; all p < 0.0001). Use of abdominal computed tomographic scan and diagnostic peritoneal lavage were also underreported (260 vs. 56 and 104 vs.17, both p < 0.0001). The number of operations on the spleen and number of orthopedic procedures were underreported (259 vs. 225, p < 0.014 and 147 vs. 94, p < 0.0001). Complications were markedly underreported by the administrative database (200 vs. 47, p < 0.0001) CONCLUSION This study shows that administrative data lack accuracy in the recording of associated injuries, injury severity, diagnostics, procedures, and outcomes data in patients with splenic injuries. Whether these data should be used to evaluate treatment modalities or quality of care in trauma is questionable.
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Affiliation(s)
- J P Hunt
- Department of Surgery, Louisiana State University at New Orleans, 70112, USA.
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Krause KR, Howells GA, Bair HA, Glover JL, Madrazo BL, Wasvary HJ, Bendick PJ. Nonoperative Management of Blunt Splenic Injury in Adults 55 Years and Older: A Twenty-Year Experience. Am Surg 2000. [DOI: 10.1177/000313480006600707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
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.
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Affiliation(s)
- Kevin R. Krause
- Department of Surgery, William Beaumont Hospital, Royal Oak, Michigan
| | - Greg A. Howells
- Division of Trauma Surgery, William Beaumont Hospital, Royal Oak, Michigan
| | - Holly A. Bair
- Division of Trauma Surgery, William Beaumont Hospital, Royal Oak, Michigan
| | - John L. Glover
- Department of Surgery, William Beaumont Hospital, Royal Oak, Michigan
| | | | - Harry J. Wasvary
- Department of Surgery, William Beaumont Hospital, Royal Oak, Michigan
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Sartorelli KH, Frumiento C, Rogers FB, Osler TM. Nonoperative management of hepatic, splenic, and renal injuries in adults with multiple injuries. THE JOURNAL OF TRAUMA 2000; 49:56-61; discussion 61-2. [PMID: 10912858 DOI: 10.1097/00005373-200007000-00008] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Nonoperative management (NOM) of abdominal solid organ (ASO; liver, spleen, kidney) injuries from blunt trauma in adults has gained acceptance, but multisystem trauma remains a relative contraindication to NOM. METHODS We reviewed the charts of 126 adult patients who underwent NOM of an ASO injury for success of NOM, transfusions, and complications. Patients were divided into two groups: group I had isolated ASO injuries (n = 48); group II had an ASO injury and at least one additional injury with an Abbreviated Injury Score > or = 2 (n = 78). RESULTS NOM was successful 89.6% of group I and 93.6% of group II patients (p = 0.55). Group II had higher Injury Severity Scores (20.7 +/- 9.8 vs. 8.3 +/- 4.9 p < 0.05) and transfusion requirements (30.8% vs. 14.6%,p < 0.05) than group I. Complication rates were not different (group I, 20.8% vs. 26.9% group II, p = 0.58). CONCLUSION NOM of ASO injuries may attempted in adult patients with multiple injuries without increased morbidity.
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Affiliation(s)
- K H Sartorelli
- Department of Surgery, University of Vermont College of Medicine, Burlington 05405, USA
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34
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Falimirski ME, Provost D. Nonsurgical Management of Solid Abdominal Organ Injury in Patients over 55 Years of Age. Am Surg 2000. [DOI: 10.1177/000313480006600706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
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.
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Affiliation(s)
- Mark E. Falimirski
- Allegheny General Hospital, and Allegheny University Hospitals, Pittsburgh, Pennsylvania
| | - David Provost
- Parkland Memorial Hospital, University of Southwestern at Dallas, Dallas, Texas
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35
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Myers JG, Dent DL, Stewart RM, Gray GA, Smith DS, Rhodes JE, Root HD, Pruitt BA, Strodel WE. Blunt splenic injuries: dedicated trauma surgeons can achieve a high rate of nonoperative success in patients of all ages. THE JOURNAL OF TRAUMA 2000; 48:801-5; discussion 805-6. [PMID: 10823522 DOI: 10.1097/00005373-200005000-00002] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Selective nonoperative management (NOM) of blunt splenic injuries is becoming a more prevalent practice. Inclusion criteria for NOM, which have been a source of controversy, continue to evolve. Age > or = 55 years has been proposed as a predictor for failure of and even a contraindication to NOM of blunt splenic trauma. Additionally, the high rate of NOM in children (up to 79%) has been attributed to their management by pediatric surgeons. We evaluated our experience with NOM of blunt splenic injury with special attention to these age groups. METHODS By using our trauma registry, all patients with blunt splenic injuries (documented by computed tomography, operative findings, or both) cared for over a 36-month period, at a single American College of Surgeons verified Level I trauma center were reviewed. Detailed chart reviews were performed to examine admission demographics, laboratory data, radiologic findings, outcome measures, and patient management strategy. All patients were managed by nonpediatric trauma surgeons. We then compared our adult data with that in the recent literature and our pediatric data with that of the National Pediatric Trauma Registry over the same time period. RESULTS We identified 251 consecutive patients with blunt splenic injuries. Eighteen patients who expired in the immediate postinjury period were excluded from statistical evaluation. No deaths occurred as a result of splenic injury. Of the remaining 233 patients, 73 patients (31%) required early celiotomy, 160 patients (69%) were selected for NOM, with 151 patients (94%) being successfully managed without operation. Blunt splenic injury occurred in 23 patients age 55 years or older. Eighteen patients (78%) were selected for NOM and 17 patients (94%) were successfully treated without operation. Blunt splenic injury occurred in 35 patients less than 16 years of age. Thirty-two patients (91%) were selected for NOM. Thirty-one patients (89% of all pediatric patients) were successfully treated without operation. CONCLUSION Age > or = 55 years is not a contraindication to nonoperative management of blunt splenic injuries. Children with blunt splenic injuries can be successfully managed nonoperatively by nonpediatric trauma surgeons.
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Affiliation(s)
- J G Myers
- Department of Surgery, University of Texas Health Science Center at San Antonio, 78284-7842, USA
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Cocanour CS, Moore FA, Ware DN, Marvin RG, Duke JH. Age should not be a consideration for nonoperative management of blunt splenic injury. THE JOURNAL OF TRAUMA 2000; 48:606-10; discussion 610-2. [PMID: 10780591 DOI: 10.1097/00005373-200004000-00005] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Operative management of blunt splenic injury is recommended for adults > or = 55 years. Because this is not our practice, we did a retrospective review to compare outcomes of patients > or = 55 years old versus patients < 55 years old. METHODS During a 5-year period ending in July of 1998, 461 patients (3%) admitted to our Level I trauma center had a blunt splenic injury. Eighty-six patients (19%) died within 24 hours of massive injuries, leaving 375 patients for evaluation. Data were obtained from our trauma registry and medical records. RESULTS A total of 29 patients (8%) were > or = 55 years old (mean age, 67 +/- 2 years; mean injury severity score [ISS] 25 +/- 2). Of these, 18 patients (62%) underwent nonoperative management (NOM). A total of 346 patients (92%) were < 55 years old (mean age, 28 +/- 0.6; mean ISS, 20 +/- 1). Of these, 198 patients (57%) underwent NOM. The failure rate was not different between the two age groups (17% vs. 14%). However, the ISS and mortality rate were significantly higher in the older age group that failed (ISS, 29.3 +/- 2.6 vs. 19.5 +/- 2.1; mortality: 67% vs. 4%). None of the deaths could be attributed to splenic injury. CONCLUSION Adults > or = 55 years old with blunt splenic injury are successfully treated by NOM. Although older adults had significantly greater injuries, they had similar failure rates of NOM when compared with younger adults. Older adults had significantly higher mortality, but this was not a result of their splenic injury. Therefore, age should not be a criteria for NOM of blunt splenic injury.
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Tulikoura I, Lassus J, Konttinen YT, Juutilainen T, Santavirta S. A safe surgical technique for the partial resection of the ruptured spleen. A clinical report. Injury 1999; 30:693-7. [PMID: 10707245 DOI: 10.1016/s0020-1383(99)00186-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A consecutive series of 11 patients with an acute blunt splenic injury were treated with a 'safe resection' technique. 57% of the injured spleens (range 35-100%) were saved. None of the patients had any signs of secondary bleeding in control CT scan and the mortality was zero. No second-look laparotomies were performed. Follow-up time was at least two months (range 2 month-6 yr). Operation time was in average 120 min. Total mean peroperative bleeding was 1400 ml. Partial resection may offer patient a change for normal function of the injured spleen. However, it is not yet known what is the critical mass of spleen tissue needed for humans. The follow-up time of the present study is still too short to estimate this fact, but further studies may show the benefit of the present method in avoiding serious long term immunological complications of splenectomy. This present study introduces a novel technique for partial resection of injured spleen. Operation can be performed safely and quickly with a complication risk comparable to splenectomy. Resection is applicable even for multi-trauma patients.
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Affiliation(s)
- I Tulikoura
- Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, Finland
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Hughes TM. The diagnosis of gastrointestinal tract injuries resulting from blunt trauma. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1999; 69:770-7. [PMID: 10553964 DOI: 10.1046/j.1440-1622.1999.01693.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND This review studies the efficacy of the methods of assessment of the abdomen in blunt trauma for the detection of gastrointestinal tract injuries (GITI). METHODS MEDLINE searches of English language publications on the subjects of diagnostic peritoneal lavage, abdominal computed tomography (CT) in blunt trauma and gastrointestinal tract injuries between 1980 and 1998 were used to identify relevant material. Earlier publications were identified from reference lists. The methodology, data and conclusions of all studies were examined in detail. The contemporary roles of clinical assessment, diagnostic peritoneal lavage, CT and other diagnostic modalities in detection of significant GITI were determined based on the best available evidence. CONCLUSIONS The most accurate and safest methods of assessment of the abdomen in haemodynamically unstable patients with suspected abdominal injuries following blunt trauma are immediate laparotomy or diagnostic peritoneal lavage (DPL). The goal of assessment of the abdomen in stable patients is to accurately define the site and extent of intra-abdominal injury, in order that further management may be tailored to the specific injuries. The most recent evidence suggests that CT of the abdomen fulfils these criteria better than the other modalities of assessment available. The risk of overlooking a significant GITI on CT scan is minimal provided that unexplained free fluid, bowel wall thickening or enhancement, mesenteric fat streaking and bowel dilatation are taken as evidence of GITI. When scan quality is suboptimal or expert interpretation is unavailable, DPL is recommended. Fully cooperative patients with negligible abdominal signs can be safely observed clinically.
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Affiliation(s)
- T M Hughes
- University of Sydney Department of Surgery, Westmead Hospital, New South Wales, Australia
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Kluger Y, Rabau M, Rub R, Weinbroum A, Chaushu G, Ben-Avraham R, Dayan D. Comparative study of splenic wound healing in young and adult rats. THE JOURNAL OF TRAUMA 1999; 47:261-4. [PMID: 10452459 DOI: 10.1097/00005373-199908000-00007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Y Kluger
- Rabin Trauma Center, Department of Surgery, Tel-Aviv Medical Center, Israel
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Gaunt WT, Mccarthy MC, Lambert CS, Anderson GL, Barney LM, Dunn MM, Lemmon GW, Paul DB, Peoples JB. Traditional Criteria for Observation of Splenic Trauma Should be Challenged. Am Surg 1999. [DOI: 10.1177/000313489906500716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
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.
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Affiliation(s)
- W. Trevor Gaunt
- Department of Surgery, Wright State University School of Medicine, Dayton, Ohio
| | - Mary C. Mccarthy
- Department of Surgery, Wright State University School of Medicine, Dayton, Ohio
| | - Carie S. Lambert
- Department of Surgery, Wright State University School of Medicine, Dayton, Ohio
| | - Gary L. Anderson
- Department of Surgery, Wright State University School of Medicine, Dayton, Ohio
| | - Linda M. Barney
- Department of Surgery, Wright State University School of Medicine, Dayton, Ohio
| | - Margaret M. Dunn
- Department of Surgery, Wright State University School of Medicine, Dayton, Ohio
| | - Gary W. Lemmon
- Department of Surgery, Wright State University School of Medicine, Dayton, Ohio
| | - Doug B. Paul
- Department of Surgery, Wright State University School of Medicine, Dayton, Ohio
| | - James B. Peoples
- Department of Surgery, Wright State University School of Medicine, Dayton, Ohio
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Sanders MN, Civil I. Adult splenic injuries: treatment patterns and predictive indicators. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1999; 69:430-2. [PMID: 10392886 DOI: 10.1046/j.1440-1622.1999.01594.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND With the trend towards conservation in splenic trauma, the ability to identify a group of patients for whom we can safely offer conservative treatment becomes an important factor. METHODS Data were reviewed from the trauma register at the Auckland Hospital, Auckland, New Zealand, in an attempt to isolate any predictive factors that may allow more appropriate allocation of treatment modalities in the future. Methods of treatment were determined and the success or failure of conservative management noted. Differences in the demographics, Injury Severity Score (ISS) and computed tomographic (CT) findings were particularly sought. RESULTS Over a period of 111 weeks 48 patients were admitted with splenic injuries. Fifteen (31.2%) had immediate splenectomy, 27 (56.2%) were initially treated non-operatively and six (10.1%) died pre-operatively. Of the non-operative group eight (29.6%) failed this management at an average of 4.125 days into their hospital stay. No differences were found in age, mechanism, gender or ISS between the failed and successfully treated group. Using the Buntain classification of CT-graded splenic injury, 13 (87%) who had successful non-operative treatment had a grade II or III compared with six (86%) who failed this management being grade IV. CONCLUSION Although these results did not reach statistical significance, by coupling the trends seen together with other work, CT grading of splenic injury is a predictive indicator and does appear to have a role in the early allocation of patients to appropriate treatment plans.
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Affiliation(s)
- M N Sanders
- Trauma Services, Auckland Hospital, New Zealand.
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Shafi S, Gilbert JC, Irish MS, Glick PL, Caty MG, Azizkhan RG. Follow-up imaging studies in children with splenic injuries. Clin Pediatr (Phila) 1999; 38:273-7. [PMID: 10349524 DOI: 10.1177/000992289903800504] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We undertook a retrospective study of pediatric blunt splenic injuries treated nonoperatively at our institution from 1990 to 1995 (n = 72) to assess the impact of serial computed tomography (CT) scans on the outcome. Median number of studies per child was three. The result showed that the appearance of the splenic injury remained unchanged or improved in 95% of the imaging studies obtained (116 of 122). Only one of five patients with an image suggesting a worsening splenic injury required operative intervention. There were no instances of missed injuries, delayed ruptures, or readmissions. We conclude that serial CT scans have limited follow-up value and should be used selectively.
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Affiliation(s)
- S Shafi
- Department of Surgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA
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Barone JE, Burns G, Svehlak SA, Tucker JB, Bell T, Korwin S, Atweh N, Donnelly V. Management of blunt splenic trauma in patients older than 55 years. Southern Connecticut Regional Trauma Quality Assurance Committee. THE JOURNAL OF TRAUMA 1999; 46:87-90. [PMID: 9932688 DOI: 10.1097/00005373-199901000-00014] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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%.
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Schreiber MA, Pusateri AE, Veit BC, Smiley RA, Morrison CA, Harris RA. Timing of vaccination does not affect antibody response or survival after pneumococcal challenge in splenectomized rats. THE JOURNAL OF TRAUMA 1998; 45:692-7; discussion 697-9. [PMID: 9783606 DOI: 10.1097/00005373-199810000-00009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pneumococcal vaccination after splenectomy for trauma decreases the incidence of overwhelming postsplenectomy infection. The optimal timing of vaccination has not been established. This study was conducted to determine whether timing of vaccination after splenectomy affects antibody response or survival after pneumococcal challenge. METHODS Sprague-Dawley rats were used for all experiments. Control rats (n=30) were divided into three equal groups and underwent splenectomy followed by sham vaccination 1, 7, or 42 days after splenectomy. Treated rats (n=66) were divided into three equal groups and underwent splenectomy followed by vaccination with polyvalent pneumococcal vaccine 1, 7, or 42 days after splenectomy. All rats then underwent intraperitoneal Streptococcus pneumoniae inoculation with the predetermined lethal dose for 50% of the population 10 days after vaccination. Rats were observed for a 72-hour period after inoculation, and mortality was recorded. Immunoglobulin G and immunoglobulin M antibody titers were determined before vaccination and before inoculation to determine antibody response. RESULTS Mortality was greater in the control group than in the treatment group (21 of 30 [70%] vs. 2 of 64 [3%]; p < 0.01). There were no differences in mortality within either the control group (1 day, 6 of 10; 7 days, 7 of 10; 42 days, 8 of 10; p=0.62) or the treatment group (1 day, 0 of 21; 7 days, 0 of 21; 42 days, 2 of 22; p=0.14). Immunoglobulin G and immunoglobulin M antibody responses were greater in vaccinated than in nonvaccinated rats. There was no effect of timing of vaccination on antibody response. CONCLUSION Pneumococcal vaccine reduces mortality from postsplenectomy infection. Timing of vaccination after splenectomy does not affect survival from a pneumococcal challenge or antibody response in rats. This study supports the practice of administering vaccine within 24 hours of splenectomy when vaccine cannot be administered before surgery.
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Affiliation(s)
- M A Schreiber
- Department of Surgery, William Beaumont Army Medical Center, El Paso, Texas 79920-5001, USA.
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Goan YG, Huang MS, Lin JM. Nonoperative management for extensive hepatic and splenic injuries with significant hemoperitoneum in adults. THE JOURNAL OF TRAUMA 1998; 45:360-4; discussion 365. [PMID: 9715196 DOI: 10.1097/00005373-199808000-00026] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although several retrospective studies have been published concerning nonoperative management of minor liver and spleen injuries, few studies have prospectively analyzed the results of nonoperative management for higher-grade liver and spleen injuries. Is it possible to manage extensive hepatic or splenic injuries with hemoperitoneum nonoperatively? The current study was conducted to evaluate the safety of nonoperative management of blunt hepatic and splenic trauma with significant hemoperitoneum in hemodynamically stable patients regardless of injury severity. METHODS We used the nonoperative methods prospectively to treat consecutive patients with blunt spleen or liver injury during a 35-month period. Patients with unstable conditions underwent emergency laparotomies, and those who were stable underwent abdominal computed tomography for further evaluation. We analyzed the clinical characteristics and the success rate of this method thoroughly. RESULTS Twenty-four patients with severe hepatic or splenic injuries treated nonoperatively were included in this study. Among these 24 patients, 18 (75%) with hepatic or splenic injuries had grades of III or greater on the Organ Injury Scale. Twenty patients (83.3%) had moderate to large amounts of hemoperitoneum. Four patients (16.7%) failed at observation and underwent emergency celiotomy, two for liver-related and two for spleen-related causes. There were no differences between the nonoperative and operative management groups in terms of mean age, initial systolic blood pressure, initial heart rate, emergency room fluid requirement except emergency blood transfusion, abdominal complications, and hospital length of stay. CONCLUSION We suggest that nonoperative management may be undertaken successfully in appropriately designed areas with close observation for the hemodynamic stable patient.
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Affiliation(s)
- Y G Goan
- Emergency Department, Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
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Davis KA, Fabian TC, Croce MA, Gavant ML, Flick PA, Minard G, Kudsk KA, Pritchard FE. Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms. THE JOURNAL OF TRAUMA 1998; 44:1008-13; discussion 1013-5. [PMID: 9637156 DOI: 10.1097/00005373-199806000-00013] [Citation(s) in RCA: 207] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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).
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Affiliation(s)
- K A Davis
- Department of Surgery, Presley Regional Trauma Center, University of Tennessee Health Science Center, Memphis 38163, USA
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Brasel KJ, DeLisle CM, Olson CJ, Borgstrom DC. Splenic injury: trends in evaluation and management. THE JOURNAL OF TRAUMA 1998; 44:283-6. [PMID: 9498498 DOI: 10.1097/00005373-199802000-00006] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Changing methods of evaluating blunt abdominal trauma and expanding selection criteria for nonoperative management (NOM) of splenic injury can increase the number of patients managed nonoperatively without affecting success rates. METHODS The charts of 164 patients with blunt splenic injuries from July 1, 1991, to June 30, 1996, were reviewed. Thirty-eight patients were excluded because of immediate laparotomy without adjunctive tests or expiration in the resuscitative period. Injuries were graded according to the Organ Injury Scale. RESULTS Overall, successful NOM occurred in 84% of patients (73 of 87). NOM was successful in 5 of 7 patients > 55 years old and in 14 of 15 patients with Glasgow Coma Scale scores < 13. CONCLUSION Use of computed tomography increased NOM of splenic trauma from 11 to 71% during the 5-year period for injuries of equivalent severity. Age > 55 years or abnormal neurologic status should not preclude NOM, because success was related only to injury grade.
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Affiliation(s)
- K J Brasel
- Department of Surgery, St. Paul-Ramsey Medical Center, University of Minnesota, St. Paul 55101, USA
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Powell M, Courcoulas A, Gardner M, Lynch J, Harbrecht BG, Udekwu AO, Billiar TR, Federle M, Ferris J, Meza MP, Peitzman AB. Management of blunt splenic trauma: significant differences between adults and children. Surgery 1997; 122:654-60. [PMID: 9347839 DOI: 10.1016/s0039-6060(97)90070-2] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although highly successful in children, nonoperative management of blunt splenic injury in adults is less defined. The purpose of this study was to determine whether mechanism of injury, grade of splenic injury, associated injuries, and pattern of injury differ between adults and children (younger than 15 years of age). METHODS Four hundred eleven patients (293 adults and 118 pediatric patients) with blunt splenic injury were admitted to an affiliated adult/pediatric trauma program from 1989 to 1994. Computed tomography (CT) scans were interpreted in a blinded fashion. Mechanism of injury was significantly different for adults versus children (p < 0.05): motor vehicle crash (66.9% versus 23.7%), motorcycle (8.8% versus 0.8%), sports (2.4% versus 16.9%), falls (8.8% versus 25.4%), pedestrian/automobile (4.4% versus 11.0%), bicycle (1.4% versus 9.3%), and other (7.3% versus 12.7%). RESULTS Higher injury severity scores, lower Glasgow Coma Scales, and higher mortality indicated that the adults were more severely injured than the children. Fifty-nine percent of the adults and 7% of the children required immediate laparotomy for splenic injury. Both CT grade and quantity of blood on CT predicted the need for exploration in adults but not in children. An injury severity score above 15 and high-energy mechanisms correlated with the need for operative intervention. CONCLUSIONS Rather than children simply being physically different, they are injured differently than adults, hence the high rate of nonoperative management.
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Affiliation(s)
- M Powell
- Department of Surgery, University of Pittsburgh, Pa., USA
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Abstract
Based upon the anatomicosurgical segments of the spleen, suggested by DiDio and demonstrated in cadavers, classified and named by Neder (1958) and Zappalá (1958, 1959, 1963), the normal segmental organization was anatomically and radiologically confirmed in 51 human spleens, after studying corrosion casts and radiograms of intraparenchymal vessels (Christo, 1959 a, b, 1960, 1962, 1963, 1993). From 1958 to 1965, pioneer segmental resections were performed successfully in 34 dogs and in 9 patients to safely remove traumatic injured splenic segments. At the same time, the overwhelming postsplenectomy infection (OPSI) became well identified. Consequently, to save normally functioning splenic parenchyma became the most important issue in the management of splenic injuries. The anatomical basis for partial splenectomy and splenic segmentectomy is discussed. The term "splenorrhaphy" was employed to designate all conservative or parenchyma saving operations of spleen based upon its vascular supply: from topical packings to splenic sutures including "cappings" and partial splenectomies. From analysis of 38 consecutive reports in 20 years, covering 4,076 patients, it was concluded that "splenorrhaphies" had been electively employed in 46% of the injuries and partial splenectomies were identified in 8.6% of these surgical interventions. However, the critical minimal mass of splenic tissue to be preserved after partial splenectomies is still to be defined. Postoperative complications directly related to "splenorrhaphies" are rare. Uncommonly performed after splenectomies, the heterotopical splenic autotransplantation has presented dubious results. Trials with nonoperative management of splenic blunt trauma injuries have been safer among children, whose spleens are predominantly transversally disrupted and have a higher relationship "capsular resistance/parenchymal bulk". Splenectomies have been most frequently the ultimate result of delayed laparotomy and underlying risks of growing blood requirements may surpass the advantages of preventing OPSI.
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Affiliation(s)
- M C Christo
- Department of Surgery, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brasil
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Clancy TV, Ramshaw DG, Maxwell JG, Covington DL, Churchill MP, Rutledge R, Oller DW, Cunningham PR, Meredith JW, Thomason MH, Baker CC. Management outcomes in splenic injury: a statewide trauma center review. Ann Surg 1997; 226:17-24. [PMID: 9242333 PMCID: PMC1190902 DOI: 10.1097/00000658-199707000-00003] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Clinical pathways now highlight both observation and operation as acceptable initial therapeutic options for the management of patients with splenic injury. The purpose of this study was to evaluate treatment trends for splenic injury in all North Carolina trauma centers over a 6-year period. METHODS Splenic injuries in adults over a 6-year period (January 1988-December 1993) were identified in the North Carolina Trauma Registry using ICD-9-CM codes. Patients were divided into four groups by method of management: 1) no spleen operation, 2) splenectomy, 3) definitive splenorrhaphy, and 4) splenorrhaphy failure followed by splenectomy. The authors examined age, mechanism of injury, admitting blood pressure, and severity of injury by trauma score and injury severity score. SUMMARY BACKGROUND DATA Comparisons were made between adult (17-64 years of age) and geriatric (older than 65 years of age) patients and between patients with blunt and penetrating injury. Resource utilization (length of stay, hospital charges) and outcome (mortality) were compared. RESULTS One thousand two hundred fifty-five patients were identified with splenic injury. Rate of splenic preservation increased over time and was achieved in more than 50% of patients through nonoperative management (40%) and splenorrhaphy (12%). Splenorrhaphy was not used commonly in either blunt or penetrating injury. Overall mortality was 13%. Geriatric patients had a higher mortality and resource utilization regardless of their mechanism of injury or method of management. CONCLUSIONS Nonoperative management represents the prevailing method of splenic preservation in both the adult and geriatric population in North Carolina trauma center hospitals. Satisfactory outcomes and economic advantages accompany nonoperative management in this adult population.
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Affiliation(s)
- T V Clancy
- University of North Carolina at Chapel Hill, 28402-9025, USA
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