Factors affecting the outcome of patients with splenic trauma

This is a report of 546 consecutive patients with penetrating and blunt splenic trauma seen over a 17 1/2-year period (1980-1997). The etiology of the splenic injuries and the associated mortality rates were: blunt injuries 45 of 298 (15%), gunshot wounds 48 of 199 (24%), and stab wounds four of 49 (8%). The overall mortality rate was 97 of 546 (18%). The most significant risk factors for death were all associated with major blood loss: transfusion requirements > or = 6 units of blood, low initial operating room blood pressure, associated abdominal vascular injuries, and performance of a thoracotomy. The two most important organs injured in conjunction with the spleen that were significant predictors of postoperative infectious complications were colon and pancreas. The need for splenectomy was most significantly correlated with higher grades of splenic injury especially grades IV and V. The evolution in management of blunt splenic trauma has led to a significant improvement in splenic preservation and avoidance of laparotomy for many patients. Operative splenic salvage is reduced in patients subjected to laparotomy who are candidates for nonoperative treatment. Improved results with splenic injury should be obtained by rapid control of bleeding. This may require more liberal criterial in selecting patients with splenic trauma for early operative treatment.     

Pediatric Splenic Injury: Nonoperative Management First!

Abstract Background and Purpose:  In the past splenectomy was the standard procedure for traumatic blunt splenic injury, when bleeding of the spleen occurred. Since the spleen performs important immunological functions the advantage of a spleen-saving approach is preservation of immunological functions. Especially in the pediatric population splenic preservation is an important objective. Spleen-saving treatment, in particular selective nonoperative management, has gained ground in the past 20 years. An 18-year retrospective review was performed to evaluate our cumulative experience with nonoperative management. Endpoints: hemodynamical instability and splenectomy. Methods:  Forty-six patients were identified. Demographics, methods of management, mechanism of injury, injury grade, associated injuries, hemodynamical parameters, bloodtransfusion, complications, ICU and hospital stay were documented and analyzed to determine statistical significance between modes of management. Results:  Initially, 34 patients were managed nonoperatively, while 12 patients underwent laparotomy – with 7 (58.3% of the operative group) of these having splenectomy performed. Three patients (out of 34) failed nonoperative management and required delayed splenorraphy or splenectomy, a 91.2% (3 out of 34 failed) success rate for intended nonoperative management versus 85.7% for intended splenorraphy (1 out of 7 failed). Thus, overall rates of 67.4% nonoperative management and 82.6% splenic conservation were achieved. Analysis of parameters between treatments showed significant differences between nonoperative management and splenorraphy for splenic injury grade II and IV. Conclusion:  We recommend based on our data on children with splenic injury grades II and IV that the standard treatment for children aged 0 to 18 years due to blunt abdominal trauma should be nonoperative management. However management of blunt splenic injury remains a clinical decision, for this reason does not preclude on CT-scan grade V for nonoperative management.     

Prospective study of the early postoperative course of splenic rupture: spleen preservation versus splenectomy]

The haematological and immunological changes after splenectomy have been the subject of intensive research in recent years. As a consequence there has been a clear trend towards splenic salvage. Due to the availability of improved diagnostic investigations (sonography, CT) nonoperative treatment with close observation has become increasingly important in adults. 75 patients with documented splenic injury were prospectively evaluated over a 45-month period with an emphasis upon splenic preservation. Unstable patients had operative exploration with attempt at splenorrhaphy or partial splenic resection. Stable patients were managed nonoperatively, regardless of the degree of splenic injury as determined by sonography and/or computed tomography. In 38 patients the spleen was preserved by operative preservation in 20 and nonoperative treatment in 18 patients. 37 patients required splenectomy. Four patients were managed initially by nonoperative treatment, but required exploration for secondary rupture at 7, 7, 10 and 13 days. Delayed splenectomy was performed in three patients and one patient was treated by splenorrhaphy 7 days after admission. Bleeding complications occurred in one patient after splenorrhaphy (bleeding from the pancreatic tail) and the bleeding vessel could be transfixed during the same anaesthetic. Four patients required reexploration after splenectomy for hemorrhage (2) and evacuation of infected haematomas. The Injury Severity Score (ISS) of the splenectomy and splenic preservation group was determined. Splenectomised patients showed in the postoperative follow-up a significantly increased infection rate (40%, p less than 0.02) when compared to patients with splenic preservation (10%) or nonoperative treatment (11%), even when they were matched in respect of multiple trauma using the Injury Severity Score (ISS).     

Selective management of blunt splenic trauma

During a recent 8-year period, 235 patients with documented blunt splenic trauma were treated. After exclusion of 39 patients with early deaths (19 dead on arrival, nine died in emergency room, and 11 died in operating room), the 196 remaining patients were treated in accordance with an evolving selective management program. Definitive management included splenectomy in 117 patients (59.7%), repair in 32 (16.3%), and nonoperative treatment in 47 (24%). A spectrum of blunt splenic trauma, as manifested by the degree of associated injuries (Injury Severity Scores), hemodynamic status, and blood transfusion requirements, was identified and permitted application of a rational selective management program that proved safe and effective for all age groups. Comparative analysis of the three methods of treatment demonstrated differences that were more a reflection of the overall magnitude of total bodily injury sustained rather than the specific manner in which any injured spleen was managed. Retrospective analysis of 19 nonoperative management failures enabled establishment of the following selection criteria for nonoperative management: absolute hemodynamic stability; minimal or lack of peritoneal findings; and maximal transfusion requirement of 2 units for the splenic injury. With operative management, splenorrhaphy is preferred, but it was often precluded by associated life-threatening injuries or by technical limitations. Of 42 attempted splenic repairs, ten (24%) were abandoned intraoperatively. There were no late failures of repair. In many cases of blunt splenic trauma, splenectomy still remains the most appropriate course of action.     

Risk factors for splenectomy in children with blunt splenic trauma

Background/Purpose: Nonoperative management and splenic preservation have become standards of care for management of pediatric blunt splenic trauma. However, review of the Pennsylvania Trauma Outcome Study (PTOS) registry found that 15% of children with blunt splenic injury still underwent splenectomy. The authors sought to determine the factors that predisposed to splenectomy in this population. Methods: Between 1993 and 1997, 754 children, ages 0 to 16 years, who sustained blunt splenic trauma were entered in the PTOS database. These patients were stratified into groups according to the mode of management: nonoperative, splenorrhaphy, or splenectomy. Logistic regression was performed to determine factors associated with splenectomy. Results: Overall, 15.1% of patients underwent splenectomy, 7.4% underwent splenorrhaphy, and 77.5% were treated nonoperatively. Spleen injury grade, nonspleen abdominal injuries, Glasgow Coma Scale 3 to 8, and age 15 to 16 years were significant determinants of splenectomy by multivariate analysis. Children treated at pediatric trauma centers (PTC) underwent significantly fewer splenectomies. Conclusions: Injury grade, but not hemodynamic instability, was a significant independent determinant of splenectomy in children with blunt splenic trauma. Children treated at PTC are less likely to undergo splenectomy. Ongoing analysis of the management of blunt pediatric splenic injury and reduction of unnecessary splenectomies are needed to optimize care for injured children.     

Management outcomes in splenic injury: a statewide trauma center review.

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.     

A statewide, population-based time-series analysis of the increasing frequency of nonoperative management of abdominal solid organ injury.

Emergency operative intervention has been one of the cornerstones of the care of the injured patient. Over the past several years, nonoperative management has increasing been recommended for the care of selected blunt abdominal solid organ injuries. The purpose of this study was to utilize a large statewide, population-based data set to perform a time-series analysis of the practice of physicians caring for blunt solid organ injury of the abdomen. The study was designed to assess the changing frequency and the outcomes of operative and nonoperative treatments for blunt hepatic and splenic injuries. METHODS: Data were obtained from the state hospital discharge data base, which tracks information on all hospitalized patients from each of the 157 hospitals in the state of North Carolina. All trauma patients who had sustained injury to a solid abdominal organ (kidney, liver, or spleen) were selected for initial analysis. RESULTS: During the 5 years of the study, 210,256 trauma patients were admitted to the state's hospitals (42,051 +/- 7802 per year). The frequency of nonoperative interventions for hepatic and splenic injuries increased over the period studied. The frequency of nonoperative management of hepatic injuries increased from 55% in 1988 to 79% in 1992 in patients with hepatic injuries and from 34% to 46% in patients with splenic injuries. The rate of nonoperative management of hepatic injuries increased from 54% to 64% in nontrauma centers compared with an increase from 56% to 74% in trauma centers (p = 0.01). In patients with splenic injuries, the rate of nonoperative management increased from 35% to 44% in nontrauma centers compared with an increase from 33% to 49% in trauma centers (p < 0.05). The rate of nonoperative management was associated with the organ injury severity, ranging from 90% for minor injuries to 19%-40% for severe injuries. Finally, in an attempt to compare blood use in operatively and nonoperatively treated patients, the total charges for blood were compared in the two groups. When compared, based on organ injury severity, the total blood used, as measured by charges, was lower for nonoperatively treated patients. CONCLUSIONS: This large, statewide, population-based time-series analysis shows that the management of blunt injury of solid abdominal organs has changed over time. The incidence of nonoperative management for both hepatic and splenic injuries has increased. The study indicates that the rates of nonoperative management vary in relation to the severity of the organ injury. The rates increase in nonoperative management were greater in trauma centers than in nontrauma centers. These findings are consistent with the hypothesis that this newer approach to the care of blunt injury of solid abdominal organs is being led by the state's trauma centers.     

The role of follow-up radiographic studies in nonoperative management of spleen trauma

The management of splenic injuries has evolved significantly in recent years from an operative to a nonoperative approach in stable patients with blunt abdominal trauma. The management of these patients with serial radiographic studies before hospital discharge remains controversial. We reviewed the management of 90 patients retrospectively who were admitted to our Level II trauma center with splenic injuries secondary to blunt trauma to determine the value of serial radiographic studies. Forty-seven (52%) patients underwent immediate laparotomy. Forty-three (48%) patients were managed conservatively without surgery. All nonoperative patients had an initial CT of the abdomen to evaluate their abdominal injuries. Among the 43 patients managed without surgery 31 had no follow-up radiographic studies. Twelve patients had follow-up studies before discharge. Two of these 12 patients subsequently underwent splenectomy. Both had developed hypotension, tachycardia, and a decreasing hematocrit, which prompted their repeat radiographic studies. Ten patients had no change in their clinical status and showed no significant change in the radiographic injury pattern to the spleen. One patient who was initially managed nonoperatively became hemodynamically unstable with increasing abdominal pain and subsequently underwent splenectomy without follow-up radiographic studies. The remaining 30 patients who had no follow-up studies had no significant change in their clinical abdominal examinations and had no further complications from their splenic injuries. Routine follow-up radiographic evaluations are not necessary in the nonoperative management of stable patients with splenic injuries.     

Management of blunt splenic injury in patients with concurrent infectious mononucleosis

Selective nonoperative management is appropriate for most blunt splenic injuries in adults and children, but the efficacy of this approach is unknown when injury occurs in patients with concurrent infectious mononucleosis. We have reviewed our experience during the past 23 years with the selective nonoperative management of blunt splenic injury in these patients. Medical record review identified nine patients with blunt splenic injury and infectious mononucleosis from 1978 to 2001, representing 3.3 per cent of our total trauma population with blunt splenic injury treated during that interval. Two patients underwent immediate splenectomy because of hemodynamic instability. Seven patients were admitted with the intent to treat nonoperatively. Five patients were successfully managed nonoperatively. Two patients failed nonoperative management and underwent splenectomy, one because of hemodynamic instability and one because of an infected splenic hematoma. Concurrent infectious mononucleosis does not preclude the successful nonoperative management of blunt splenic injury. This small subset of patients may be managed nonoperatively using the same criteria as for patients whose splenic injuries are not complicated by infectious mononucleosis.     

Concomitant blunt enteric injuries with injuries of the liver and spleen: a dilemma for trauma surgeons

Prompt identification of enteric injuries after blunt trauma remains problematic. With the increased utilization of nonoperative management of blunt abdominal trauma gastrointestinal disruptions may escape timely detection and repair. The purpose of this study was to evaluate blunt enteric injuries requiring operative repair in adult patients and the association of concomitant hepatic and/or splenic injuries. Over a 10-year period (January 1990 through December 1999) 1648 patients suffered blunt liver, spleen, and/or enteric injuries, with 87 (5.3%) of these requiring operative repairs of the enteric injury. These patients had enteric injury only (EI) (60.9%; 53 of 87), concomitant enteric/splenic injury (ESI) (10.3%; 9 of 87), concomitant enteric/hepatic injury (EHI) (13.8%; 12 of 87), and enteric/hepatic/splenic injury (EHSI) 14.9% (13 of 87). A delay in treatment of >8 hours from presentation of EI compared with either EHI or ESI was not significantly different between the two groups. EHSI had exploratory laparotomy more expeditiously related to hemodynamic instability. Mortality rates were higher with EHI related to hemorrhagic shock and/or severe traumatic brain injury. Morbidity was not related to a delay in diagnosis until the period of delay was greater than 24 hours. The nonoperative management of blunt solid organ injury does not delay the detection and treatment of concomitant bowel injuries compared with isolated blunt enteric injuries. Occult enteric injury with solid organ injury has a low incidence and represents a continuing challenge to the clinical acumen of the trauma surgeon.     

Has nonoperative management of solid visceral injuries adversely affected resident operative experience?

The purpose of this study was to assess the impact of increased use of nonoperative management of blunt injuries to the spleen or liver on surgical residents' operative experience with solid visceral injuries. We conducted a 10-year retrospective study of blunt spleen and liver injuries at a state-designated Level I trauma center and a survey of chief residents' operative experience with splenic and hepatic injuries from blunt trauma during the same time period. From 1990 through 1999, 431 patients were admitted with splenic injuries and 634 patients were admitted with liver injuries; 350 splenic injuries (81%) were due to blunt trauma; 317 liver injuries (50%) were caused by blunt mechanisms. In 1990 100 per cent of patients with splenic injuries and 93 per cent of those with liver injuries underwent surgery for those injuries. These rates were 19 and 28 per cent respectively in 1999. The number of patients with blunt solid visceral injuries increased more than fourfold from 1990 through 1999. The number of operations for splenic and hepatic injuries performed by chief residents did not decline significantly during this time period (5.5 cases per chief resident in 1990; 4.6 cases per chief resident in 1999). The increased numbers of patients with solid visceral injuries were due to two factors: increased proportion of blunt trauma admissions especially from motor vehicle collisions and improved recognition of spleen and liver injuries by expanded use of CT scans. We conclude that nonoperative management of blunt solid visceral injuries does not necessarily lead to a diminution of operations nor jeopardize resident education. However, trauma volumes must be high enough to support adequate operative experience.     

Management of spleen injuries in the adult trauma population: a ten-year experience.

BACKGROUND: Increasing awareness of the postoperative risks associated with splenectomies has led physicians and surgeons to use an alternative nonoperative strategy in handling traumatic spleen injuries. Our primary objective was to compare clinical outcomes between operative and nonoperative managements in adult patients with blunt splenic injuries. The secondary objective was to assess the changes in the patterns of managing splenic injuries in the past 10 years. METHODS: We performed a retrospective chart review on 266 adult patients with a spleen injury who were admitted to a tertiary trauma centre in Ontario between 1992 and 2001. We grouped and compared the patients according to the treatment received, either operative or nonoperative. Frequencies and confidence intervals are reported. Categorical variables were compared with chi-square or Fisher's exact tests. Continuous variables were reported as median and quartile (Q) and were compared with the nonparametric Mann-Whitney U test. RESULTS: Of 266 patients, 118 had surgery and 148 were managed nonoperatively. The mortality rate was similar between operative and nonoperative groups (9.3% v. 6.8%, p = 0.49), respectively. The rate of any complication was 47.9% for the operative group and 37.9% for the nonoperative group. The median length of stay in hospital was significantly higher in the operative group than in the nonoperative group (21.0 [Q 11.0-40.5] v. 14.0 [Q 7.0-31.5] d, p < 0.001), respectively. This difference was more likely related to a higher proportion of patients having injury severity scores greater than 25 in the operative group. The rate of nonoperative management of spleen injuries was significantly increased from 48.5% to 63.1% between 1992-1996 and 1997-2001 (p = 0.02). CONCLUSION: The present study has shown that nonoperative management of blunt spleen trauma has increased over time and has acceptable mortality and complication rates in selected patients. Additional prospective studies are needed to assess the feasibility and safety of nonoperative management in adult spleen injuries. Furthermore, the management of traumatic spleen injuries with respect to associated injuries, such as head injuries or intra-abdominal injuries, needs ongoing evaluation.     

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

OBJECTIVE: The recognition that splenectomy renders patients susceptible to lifelong risks of septic complications has led to routine attempts at splenic conservation after trauma. In 1990, the authors reported that over an 11-year study period involving 193 patients, splenorrhaphy was the most common splenic salvage method (66% overall) noted, with nonoperative management employed in only 13% of blunt splenic injuries. This report describes changing patterns of therapy in 190 consecutive patients with splenic injuries seen during a subsequent 6-year period (1990 to 1996). An algorithmic approach for patient management and pitfalls to be avoided to ensure safe nonoperative management are detailed. METHODS: Nonoperative management criteria included hemodynamic stability and computed tomographic examination without shattered spleen or other injuries requiring celiotomy. RESULTS: Of 190 consecutive patients, 102 (54%) were managed nonoperatively: 96 (65%) of 147 patients with blunt splenic injuries, which included 15 patients with intrinsic splenic pathology, and 6 hemodynamically stable patients with isolated stab wounds (24% of all splenic stab wounds). Fifty-six patients underwent splenectomy (29%) and 32 splenorrhaphy (17%). The mean transfusion requirement was 6 units for splenectomy survivors and 0.8 units for nonoperative therapy (85% received no transfusions). Fifteen of the 16 major infectious complications that occurred followed splenectomy. Two patients failed nonoperative therapy (2%) and underwent splenectomy, and one patient required splenectomy after partial splenic resection. There no missed enteric injuries in patients managed nonoperatively. The overall mortality rate was 5.2%, with no deaths following nonoperative management. CONCLUSIONS: Nonoperative management of blunt splenic injuries has replaced splenorrhaphy as the most common method of splenic conservation. The criteria have been extended to include patients previously excluded from this form of therapy. As a result, 65% of all blunt splenic injuries and select stab wounds can be managed with minimal transfusions, morbidity, or mortality, with a success rate of 98%. Splenectomy, when necessary, continues to be associated with excessive transfusion and an inordinately high postoperative sepsis rate.     

Nonoperative management of blunt splenic and hepatic trauma in the pediatric population: significant differences between adult and pediatric surgeons?

Although operative management was the preferred method of treating blunt abdominal trauma in the past, recent literature and practice recommend a nonsurgical approach to most pediatric splenic and hepatic injuries. The majority of data supporting the safety and efficacy of this nonoperative approach are derived from university trauma programs with a pediatric center where care was managed by pediatric surgeons only. To evaluate the applicability of this approach in a regional trauma center where pediatric patients are managed by pediatric and non-pediatric surgeons we reviewed the experience at a Level II community trauma center. Fifty-four children (16 years of age or less) were admitted between April 1992 and April 1998 after sustaining blunt traumatic splenic and/or hepatic injuries. There were 37 (69%) males and 17 (31%) females; the average age was 11 years (range 4 months to 16 years). Of the 54 patients 34 (63%) sustained splenic injuries, 17 (31%) sustained hepatic injuries, and three (6%) sustained both splenic and hepatic injuries. All of these injuries were diagnosed by CT scan or during laparotomy. The average Injury Severity Score was 14.9 with a range from four to 57. Of the 47 patients initially admitted for nonoperative management one patient failed nonoperative management and required operative intervention. In our study 98 per cent (46 of 47 patients) of pediatric patients were successfully managed nonoperatively. Complications of nonoperative management occurred in two patients. Both developed splenic pseudocysts after splenic injury, which required later operative repair. These data are comparable with those from university trauma programs and confirm that nonoperative management is safe in a community trauma center. The majority of children with blunt splenic and hepatic trauma can be successfully treated without surgery, in a regional trauma center treated by nonpediatric trauma surgeons, if the decision is based on careful initial evaluation, aggressive resuscitation, and close observation of their hemodynamic stability.     

Nonoperative management of blunt splenic injuries: factors influencing success in age >55 years

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

Blunt splenic injuries: high nonoperative management rate can be achieved with selective embolization

BACKGROUND: This retrospective review tests the hypothesis that including selective splenic arteriography and embolization in the algorithm of a previously existing nonoperative management (NOM) strategy will result in higher rates of successful NOM in patients with blunt splenic injury. METHODS: All patients with blunt splenic injuries documented by computed tomographic scan and/or operative findings over a 24-month period at a Level I trauma center were reviewed. A previously published series from this institution of 251 patients with splenic injury (Group 1) was then compared with the patients that constitute this current review (Group 2). Group 2 was then compared with patients described in a previous publication advocating nonselective arteriography in blunt splenic injuries. RESULTS: Thirteen patients with blunt splenic injury in Group 2 underwent 14 splenic embolization procedures, with 12 (93%) being successfully treated without operation. Group 2 had a significantly higher NOM rate (82% vs. 65%, p < 0.01) than Group 1. These results are similar to the series published by Sclafani et al. (82.1% vs. 83.1%) in which every patient with splenic injury that was managed non-operatively underwent arteriography with or without embolization. CONCLUSION: A high rate of NOM can be achieved with observation and selective use of arteriography with or without embolization in the management of blunt splenic injuries.     

Blunt splenic trauma.

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.     

BLUNT TRAUMA TO THE SPLEEN

Background : The management of splenic injury resulting from blunt trauma in adults is controversial, with an increasing trend towards non‐operative management and conservation of the spleen. A retrospective review was performed on adult patients treated in a single institution for splenic injury resulting from blunt trauma in an attempt to identify factors important in selecting an appropriate management option and predicting the success of that option. Methods : Associated injuries (standardized using Injury Severity Scores), clinical signs at presentation, computed tomographic grading of splenic injury, and transfusion requirements were documented. Statistical analysis was performed using non‐parametric Mann–Whitney, Chi‐squared, Kolmogorov–Smirnov and multivariate logistic regression tests. Results : Eighty‐five patients were identified. Non‐operative management was used on 39 patients, splenic conservation on 14 patients, and splenectomy on 32 patients. The mean Injury Severity Score was significantly lower in the non‐operative group. Computed tomographic grading of the splenic injury was not found to correlate well with intraoperative findings. Transfusion requirements were lower in the non‐operative group. Non‐operative management failed in four patients; two had continued splenic bleeding, and two required surgery for other intra‐abdominal injuries. Overall mortality was 7%. There was one death in the splenic conservation group, unrelated to the splenic injury, and two patients required a second laparotomy and splenectomy for persistent splenic bleeding. There were five deaths in the splenectomy group, only one of which was related to the splenic surgery. Conclusion : Management of blunt splenic injury remains controversial. The decision to pursue non‐operative management rather than splenic conservation or splenectomy depends on the individual merits of each case. There is an increasing trend towards splenic conservation, particularly in younger, stable patients with single organ injury.     

Splenic artery embolization: Have we gone too far?

BACKGROUND: Splenic artery angioembolization (EMBO) has been promoted to increase the success rate of nonoperative management of splenic injuries. Our institutional clinical pathway calls for EMBO in the setting of ongoing splenic bleeding or contrast blush on computed tomography scan. We perceived a higher rate of failure than that reported in the literature. The purpose of this study was to review our experience with splenic EMBO to identify predictors of failure of nonoperative/EMBO management. METHODS: The trauma registry and interventional radiology database of a Level I trauma center were reviewed for patients with splenic injuries from January 2000 through June 2004. Charts and films of patients undergoing EMBO were reviewed. RESULTS: There were 221 patients admitted with blunt splenic injuries. Of these, 165 (75%) were selected for nonoperative management; 41 (25%) of them underwent splenic EMBO. Of the 41, 11 patients (27%) failed nonoperative/EMBO management. Of nine patients with low-grade injury (I, II) and small or no hemoperitoneum, none failed EMBO, whereas 10 of 23 (43%) with high-grade injury (III, IV, V) and moderate or large hemoperitoneum failed. EMBO was more likely to fail if extravasation was seen on angiography (59% vs. 4%). Coils (vs. particles) and main (vs. selective) artery EMBO were more often successful. Of EMBO patients who experienced transient hypotension, 57% required splenectomy. CONCLUSIONS: EMBO may have salvaged many spleens, but splenectomy was required in 27% of EMBO patients. Patient selection is critical to successful management. Any hypotension in the face of a contrast blush probably warrants laparotomy. The combination of high grade injury and significant hemoperitoneum, or extravasation on angiogram, predict a high risk of failure and thus warrant a low threshold for splenectomy if bleeding persists. Technical EMBO considerations may impact success, but this requires further investigation.