A review of the management of blunt splenic trauma in England and Wales: have regional trauma networks influenced management strategies and outcomes?

Abstract

INTRODUCTION The spleen remains one of the most frequently injured organs following blunt abdominal trauma. In 2012, regional trauma networks were launched across England and Wales with the aim of improving outcomes following trauma. This retrospective cohort study investigated the management and outcomes of blunt splenic injuries before and after the establishment of regional trauma networks. METHODS A dataset was drawn from the Trauma Audit Research Network database of all splenic injuries admitted to English and Welsh hospitals from 1 April 2010 to 31 March 2014. Demographic data, injury severity, treatment modalities and outcomes were collected. Management and outcomes were compared before and after the launch of regional trauma networks. RESULTS There were 1457 blunt splenic injuries: 575 between 2010 and 2012 and 882 in 2012-14. Following the introduction of the regional trauma networks, use of splenic artery embolotherapy increased from 3.5% to 7.6% (P = 0.001) and splenectomy rates decreased from 20% to 14.85% (P = 0.012). Significantly more patients with polytrauma and blunt splenic injury were treated with splenic embolotherapy following 2012 (61.2% vs. 30%, P < 0.0001). Increasing age, injury severity score, polytrauma and Charlson Comorbidity Index above 10 were predictors of increased mortality (P < 0.001). Increasing systolic blood pressure (odds ratio, OR, 0.757, 95% confidence interval, CI, 0.716-0.8) and Glasgow Coma Scale (OR 0.988, 95% CI 0.982-0.995) were protective. CONCLUSIONS This study demonstrates a reduction in splenectomy rate and an increased use of splenic artery embolotherapy since the introduction of the regional trauma networks. This may have resulted from improved access to specialist services and reduced practice variation since the establishment of these networks.

Non-operative management of blunt splenic injury: is it really so extensively feasible? a critical appraisal of a single-center experience

“…In our experience, in line with the literature, no patient with an Abbreviated Injury Scale >3 has undergone a conservative management [22-26]. In many published case-series, about 60% of patients with splenic injuries are treated conservatively; this number is higher compared to our study (about 40%), although with a very low rate of failure [27-31]. This difference can be explained with the different severity splenic injuries seen at our center, which occurred more frequently in the context of complex general traumas, as demonstrated from the statistically significant difference between splenic AIS values and medium ISS in our two groups of patients; nevertheless, these differences are reported also in the literature.…”

“…This difference can be explained with the different severity splenic injuries seen at our center, which occurred more frequently in the context of complex general traumas, as demonstrated from the statistically significant difference between splenic AIS values and medium ISS in our two groups of patients; nevertheless, these differences are reported also in the literature. Another elements influencing the treatment choice are related to the referral hospital, with its organizing and structural abilities, in order to access the operating room in the shortest time and to utilize the most modern diagnostic instruments or to offer non-operative options such as the splenic artery embolization We, therefore, evaluated the limits of a conservative management in terms of feasibility efficacy and safety [27, 32-36]. The choice of treating conservatively a patient depends mostly on hemodynamic status on arrival at the Emergency Room [1, 37-39].…”

Splenic artery embolisation in trauma: A five-year single-centre experience at a UK major trauma centre

“…In 2012, all patients with splenic injury proceeded to laparotomy, but by 2016, only one did -the other nine patients were embolised, which complements the results of a national review of TARN data by Yiannoullou et al In 1457 splenic injuries from 2010 to 2014 SAE use increased from 3.5 to 7.6% (P ¼ 0.001) and in polytrauma from 30 to 61.2% (p < 0.001) following the introduction of major trauma networks in 2012; splenectomy rates decreased from 20 to 14.85% over this time. 17 They attributed these results to improved access to centralised services, following the introduction of major trauma networks, which reduced regional practice variation and increased the awareness of IR. The growing awareness of IR across all hospital specialities was also part of the change in practice at our centre.…”

Non-surgical follow-up success in blunt abdominal trauma. Can we protect patients with blunt abdominal trauma from surgery?

“…The American Association for the Surgery of Trauma developed a grading system for spleen injuries. The literature studies show that a significant mortality rate (22.7%) is present in grade V laceration (12)(13)(14). This grading system assists surgeons in choosing the treatment method of the patient.…”