Splenic trauma in the twenty-first century: changing trends in management

Abstract

Over the past three decades, management of blunt splenic trauma has changed radically. Use of improved diagnostic techniques and proper understanding of disease pathology has led to nonoperative management being chosen as the standard of care in patients who are haemodynamically stable. This review was undertaken to assess available literature regarding changing trends of management of blunt splenic trauma, and to identify the existing lacunae in nonoperative management. The PubMed database was searched for studies published between January 1987 and August 2017, using the keywords 'blunt splenic trauma' and 'nonoperative management'. One hundred and fifty-three articles were reviewed, of which 82 free full texts and free abstracts were used in the current review. There is clear evidence in published literature of the greater success of nonoperative over operative management in patients who are haemodynamically stable and the increasing utility of adjunctive therapies like angiography with embolisation. However, the review revealed a lack of universal guidelines for patient selection criteria and diagnostic and grading procedures needed for nonoperative management. Indications for splenic artery embolisation, the current role of splenectomy and spleen-preserving surgeries, together with the place of minimal access surgery in blunt splenic trauma remain grey areas. Moreover, parameters affecting the outcomes of nonoperative management and its failure and management need to be defined. This shows a need for future studies focused on these shortcomings with the ultimate aim being the formulation and implementation of universally accepted guidelines for safe and efficient management of blunt splenic trauma.

Management of a delayed, post-traumatic rupture of splenic artery pseudoaneurysm in a patient with life threatening co-morbidities: A treatment challenge

“…The spleen tops the list of most injured organs in blunt abdominal trauma and if goes undetected or is not managed skillfully results in rapid exsanguination of the patient and hence accounts for immediate explorations in about 40% of cases [ [2] , [3] , [4] ]. The management of splenic trauma may be divided into non operative and operative.…”

“…In the Non-operative management is included conservative management and interventional radiology. In operative management is included splenic preservation and splenectomy [ 1 , 3 ].…”

“…This approach to splenic trauma evolved due to the dreaded complication of extirpative surgery, OPSI (overwhelming post splenectomy infections), that was reported in 0.5% of traumatic splenectomies and up to 20% of non-traumatic causes for splenectomy. OPSI manifests in the first two years after surgery, but results in a lifetime risk of infections and carries a mortality of 50–80% [ 3 ]. Now, non-operative management of splenic trauma has become the standard of therapy in hemodynamically stable patients with 90% success in tertiary centers [ 5 , 6 ].…”

Failure Risk Factor For Non-Operative Treatment of Splenic Trauma

“…CT enables searches for active bleeding or pseudoaneurysm resulting in angioembolization (5, 7-10). However, NOM can fail in multiple ways, leading to secondary splenectomy (5,6,(11)(12)(13)(14).…”

“…This medical management is effective in 62 to 92% of cases, likely because of the increasingly frequent use of splenic angioembolization (5,(7)(8)(9)(10). It is di cult to identify patients who will have NOM failure and require secondary splenectomy (5,6,(11)(12)(13)(14). Many risk factors for NOM failure have been proposed, but none can accurately predict the failure of NOM.…”