Improved Success in Nonoperative Management of Blunt Splenic Injuries

Davis, Kimberly A.; Fabian, Timothy C.; Croce, Martin A.; Gavant, Morris L.; Flick, Pamela; Minard, Gayle; Kudsk, K A; Pritchard, F E

doi:10.1097/00005373-199806000-00013

Cited by 278 publications

(231 citation statements)

References 12 publications

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“…Only 9.8% of patients in NOM and 8% in SAE, had a secondary splenectomy despite a high median ISS at 18.5 and the absence of a clearly defined protocol. This could argue in favor of SAE which seems to be more effective in cases of high-grade spleen injury, large hemoperitoneum, or associated vascular lesions (2,(6)(7)(8)(9)(10).…”

Section: Discussionmentioning

confidence: 99%

Blunt splenic injury: are early adverse events related to trauma, nonoperative management, or surgery?

Frandon¹,

Rodière²,

Arvieux³

et al. 2015

Diagn Interv Radiol

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B lunt splenic injury (BSI) has become more frequently managed nonoperatively over the years, with the results improved by the contribution of embolization, making it possible to treat active hemorrhages as well as prevent hemorrhages in high-grade trauma of the spleen without active bleeding (1-10). Three methods of splenic artery injury management can be defined: operative management (OM), nonoperative management (NOM), and nonoperative management with splenic artery embolization (SAE).The complication rate in relation to different management methods (operative and nonoperative) continues to be debated. The description and prevalence of these complications varies greatly from one series to another (7,(11)(12)(13), resulting from the confusion existing between adverse events related to injury and those related to treatment. The severity of polytrauma is taken into account using the patients' injury severity score (ISS), and several studies have shown that a high ISS was related to more nonsurgical treatment failures (14). Certain authors have taken a specific interest in the parameters of multiple injuries and shown that lesions of associated organs (pancreas, spinal cord, limbs) were related to more complications (15-17). The severity of trauma and associated lesions could therefore be considered confounding factors resulting in treatment failure and complications. A better understanding of these complications could help in preventing them.The objectives of this study were to compare outcomes of the three types of BSI management, determine if there are any complications statistically related to management methods, and demonstrate risk factors taking polytrauma into account. We focused on associated injuries and early adverse events. Multivariate analysis was performed on 23 prognostic factors to find predictors. RESULTSThe total survival rate was 97.1%, with four deaths all occurred in the OM group. The spleen salvage rate was 91% in NOM and SAE. At least one adverse event was observed in 32.8%, 62%, and 96% of patients in NOM, SAE, and OM groups, respectively (P < 0.001). We found significantly more deaths, infectious complications, pleural drainage, acute renal failures, and pancreatitis in OM and more pseudocysts in SAE. Six prognostic factors were statistically significant for one or more adverse events: simplified acute physiology score 2 ≥25 for almost all adverse events, age ≥50 years for acute respiratory syndrome, limb fracture for secondary bleeding, thoracic injury for pleural drainage, and at least one associated injury for pseudocyst. Adverse events were not related to the type of BSI management. CONCLUSIONPatients with BSI present worse outcome and more adverse events in OM, but this is related to the severity of injury. The main predictor of adverse events remains the severity of injury.

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Section: Discussionmentioning

confidence: 99%

Blunt splenic injury: are early adverse events related to trauma, nonoperative management, or surgery?

Frandon¹,

Rodière²,

Arvieux³

et al. 2015

Diagn Interv Radiol

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“…Distal embolisation is often used for the treatment of focal vascular injuries such as pseudoaneurysms or arteriovenous fistulae [4,23]. Subsequent bleeding may occur because some vascular injuries are initially not detected at angiography or CT due to vasospasm [4,23].…”

Section: Discussionmentioning

confidence: 99%

“…Subsequent bleeding may occur because some vascular injuries are initially not detected at angiography or CT due to vasospasm [4,23]. However, a recent meta-analysis found that the only difference in short-term outcomes between the two techniques was a higher rate of splenic infarcts after distal embolisation [10].…”

Section: Discussionmentioning

confidence: 99%

Proximal Versus Distal Splenic Artery Embolisation for Blunt Splenic Trauma: What is the Impact on Splenic Immune Function?

Foley

Kavnoudias

Cameron

et al. 2015

Cardiovasc Intervent Radiol

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Purpose To compare the impact of proximal or distal splenic artery embolisation versus that of splenectomy on splenic immune function as measured by IgM memory B cell levels. Materials and Methods Patients with splenic trauma who were treated by splenic artery embolisation (SAE) were enrolled. After 6 months splenic volume was assessed by CT, and IgM memory B cells in peripheral blood were measured and compared to a local normal reference population and to a post-splenectomy population. Results Of the 71 patients who underwent embolisation, 38 underwent proximal embolisation, 11 underwent distal embolisation, 22 patients were excluded, 1 had both proximal and distal embolisation, 5 did not survive and 16 did not return for evaluation. There was a significant difference between splenectomy and proximal or distal embolisation and a trend towards greater preservation of IgM memory B cell number in those with distal embolisation-a difference that could not be attributed to differences in age, grade of injury or residual splenic volume. Conclusion IgM memory B cell levels are significantly higher in those treated with SAE compared to splenectomy. Our data provide evidence that splenic embolisation should reduce immunological complications of spleen trauma and suggest that distal embolisation may maintain better function.

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“…Previously published papers describing these delayed events are almost all limited to splenic pseudoaneurysm. Davis et al 5. and Weinberg et al 6.…”

Section: Discussionmentioning

confidence: 98%

“…Some reports5, 6 have described the incidence and timing of splenic pseudoaneurysm formation, but there is no global consensus for repetitive imaging with computed tomography (CT), especially for injuries classified as low grade on the Trauma Organ Injury Scale of the American Association for the Surgery of Trauma (AAST), and there are no recommendations for the appropriate duration of hospital admission 7, 8…”

Section: Aimmentioning

confidence: 99%

Can we predict delayed undesirable events after blunt injury to the torso visceral organs?

Uchida

Mizobata

Hagawa

et al. 2018

Acute Medicine & Surgery

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AimBlunt injuries to visceral organs have the potential to lead to delayed pseudoaneurysm formation or organ rupture, but current trauma and surgical guidelines do not recommend repetitive imaging. This study examined the incidence and timing of delayed undesirable events and established advisable timing for follow‐up imaging and appropriate observational admission.MethodsPatients with blunt splenic (S), liver (L), or kidney (K) injury treated with non‐operative management (NOM) in our institution were included and retrospectively reviewed.ResultsFrom January 2013 to January 2017, 57 patients were admitted with documented blunt visceral organ injuries and 22 patients were excluded. Of 35 patients (L, 10; S, 17; K, 6; L & S, 1; S & K, 1) treated with NOM, 14 (L, 4; S, 9; K, 1) patients underwent transcatheter arterial embolization. Delayed undesirable events occurred in four patients: three patients with splenic pseudoaneurysm on hospital day 6–7 and one patient with splenic delayed rupture on hospital day 7. The second follow‐up computed tomography scan carried out 1–2 days after admission did not show any significant findings that could help predict undesirable results of delayed events. The patients with delayed events had longer continuous abdominal pain than that of event‐free patients (P = 0.04).ConclusionsUndesirable delayed events were recognized on follow‐up computed tomography scans in 11.4% of NOM patients at hospital day 6–7 and tended to be associated with high‐grade splenic injuries and continuous symptoms. Repetitive screening of these patients 6–7 days after injury might be warranted because of the potential risk of delayed events.

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Improved Success in Nonoperative Management of Blunt Splenic Injuries

Cited by 278 publications

References 12 publications

Blunt splenic injury: are early adverse events related to trauma, nonoperative management, or surgery?

Blunt splenic injury: are early adverse events related to trauma, nonoperative management, or surgery?

Proximal Versus Distal Splenic Artery Embolisation for Blunt Splenic Trauma: What is the Impact on Splenic Immune Function?

Can we predict delayed undesirable events after blunt injury to the torso visceral organs?

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