Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management

Bhullar, Indermeet S.; Frykberg, Eric R.; Siragusa, Daniel; Chesire, David J.; Paul, Julia; Tepas, Joseph J.; Kerwin, Andrew J.

doi:10.1097/ta.0b013e3182569849

Cited by 92 publications

(65 citation statements)

References 22 publications

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“…The spectrum of approaches has ranged in the literature from routine admission angiography for all patients with blunt splenic injury, 50 to the application of strictly defined selection criteria for angioembolization based on independent risk factors for failure. 53 All of these studies reported an extremely low failure rate for NOM, which is much lower than our base case of 20%.…”

mentioning

confidence: 67%

“…In recent reports, the probability of failure rates of NOM were reduced to below 10% for grade V injuries with the inclusion of angioembolization in the protocol for NOM. 53 In this type of situation, irrespective of the grade of the splenic injury, immediate splenectomy would never result in a better survival benefit than NOM, as the 2 strategies are equivalent only. Therefore, at institutions where the failure rate of NOM is below 20% irrespective of the grade of the splenic injury, all stable patients with blunt splenic injury and severe TBI should undergo a trial of NOM.…”

Section: Sensitivity Analysesmentioning

confidence: 99%

“…[50][51][52][53][54] Although most studies agree that a protocoldriven approach appears to be associated with the lowest rates of failure of NOM, no clear consensus exists on the optimal strategy for its use. The spectrum of approaches has ranged in the literature from routine admission angiography for all patients with blunt splenic injury, 50 to the application of strictly defined selection criteria for angioembolization based on independent risk factors for failure.…”

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confidence: 99%

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Blunt splenic injury and severe brain injury: a decision analysis and implications for care

2015

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Background:The initial nonoperative management (NOM) of blunt splenic injuries in hemodynamically stable patients is common. In soldiers who experience blunt splenic injuries with concomitant severe brain injury while on deployment, however, NOM may put the injured soldier at risk for secondary brain injury from prolonged hypotension. Methods:We conducted a decision analysis using a Markov process to evaluate 2 strategies for managing hemodynamically stable patients with blunt splenic injuries and severe brain injury -immediate splenectomy and NOM -in the setting of a field hospital with surgical capability but no angiography capabilities. We considered the base case of a 40-year-old man with a life expectancy of 78 years who experienced blunt trauma resulting in a severe traumatic brain injury and an isolated splenic injury with an estimated failure rate of NOM of 19.6%. The primary outcome measured was life expectancy. We assumed that failure of NOM would occur in the setting of a prolonged casualty evacuation, where surgical capability was not present. Results:Immediate splenectomy was the slightly more effective strategy, resulting in a very modest increase in overall survival compared with NOM. Immediate splenectomy yielded a survival benefit of only 0.4 years over NOM. Conclusion:In terms of overall survival, we would not recommend splenectomy unless the estimated failure rate of NOM exceeded 20%, which corresponds to an American Association for the Surgery of Trauma grade III splenic injury. For military patients for whom angiography may not be available at the field hospital and who require prolonged evacuation, immediate splenectomy should be considered for grade III-V injuries in the presence of severe brain injury.Contexte : La gestion non chirurgicale (GNC) initiale des traumatismes spléniques fermés chez les patients hémodynamiquement stables est fréquente. Toutefois, dans les cas de traumatismes spléniques fermés accompagnés de graves lésions cérébrales concomitantes durant leur déploiement, la GNC peut exposer les soldats blessés à un risque de lésion cérébrale secondaire par suite d'une hypotension prolongée.Méthodes : Nous avons appliqué un modèle de Markov à l'analyse décisionnelle pour évaluer 2 stratégies de prise en charge des patients hémodynamiquement stables porteurs de traumatismes spléniques fermés et de graves lésions cérébrales, soit la splénectomie immédiate et la GNC, dans le contexte d'un hôpital de campagne doté d'installations chirurgicales mais non d'installations angiographiques. Nous avons étudié le scénario de référence d'un homme de 40 ans ayant une espérance de vie de 78 ans, victime d'un traumatisme fermé entraînant une lésion cérébrale grave et un traumatisme splénique isolé, avec un taux estimé d'échec de la GNC de 19,6 %. Le principal paramètre mesuré était l'espérance de vie. Nous avons présumé que l'échec de la GNC surviendrait dans le contexte d'une évacuation prolongée des blessés en l'absence d'installations chirurgicales.Résultats : La splénectomie immédiate s'est...

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confidence: 67%

Section: Sensitivity Analysesmentioning

confidence: 99%

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confidence: 99%

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Blunt splenic injury and severe brain injury: a decision analysis and implications for care

2015

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“…For example, a recent retrospective review of 1,039 patients, of whom 19% underwent AE, found that the addition of AE to NOM significantly decreased the failure rate of this approach in patients with splenic injury Grades 4 to 5. 29 Although the reason(s) for this difference is obscure, it is conceivable that the significant comorbidities of LC, which have been shown to negatively affect outcome in surgical patients, 7,8,17,30,31 account for this disparity.…”

Section: Discussionmentioning

confidence: 99%

Management and outcome of patients with blunt splenic injury and preexisting liver cirrhosis

Bugaev

Breeze

Daoud

et al. 2014

Journal of Trauma and Acute Care Surgery

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“…Indications to AE include CT evidence of ongoing bleeding with contrast extravasation outside or within the spleen and a concomitant drop in hemoglobin, tachycardia, and hemoperitoneum, as well as formation of pseudoaneurysm. The risk of failure after NOM is reasonably low (1-6 %) in low-grade injuries, and it can be improved with adjunctive angioembolization even in higher grades (0-9 %) [ 11 ]. However, rebleed and delayed spleen rupture are significantly more likely (38-55 % [ 3 , 12 ]) when highergrade injuries (grade IV-V) have been managed nonoperatively.…”

Section: Nonoperative Managementmentioning

confidence: 98%

Surgical Treatment of Spleen Trauma

Saverio¹,

Giorgini²,

Biscardi³

et al. 2013

Trauma Surgery

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Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management

Abstract: III, therapeutic study.

Cited by 92 publications

References 22 publications

Blunt splenic injury and severe brain injury: a decision analysis and implications for care

Blunt splenic injury and severe brain injury: a decision analysis and implications for care

Management and outcome of patients with blunt splenic injury and preexisting liver cirrhosis

Surgical Treatment of Spleen Trauma

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