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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 127-130

Comparison of outcomes between non-operative and operative management of blunt splenic trauma in adults


Department of Surgery, Lancaster University, Lancaster, England, UK

Date of Submission10-Aug-2020
Date of Decision14-Sep-2020
Date of Acceptance14-Oct-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Dr. Joseph McAleer
Department of Surgery, Lancaster University, Lancaster, England
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_29_20

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  Abstract 


Treatment for hemodynamically stable patients is mostly nonoperative observation, with increasing use of splenic angioembolization (SAE). There is a lack of consensus on management plan and use of SAE. In this review, relevant recent literature is analyzed to evaluate the failure rates, complications, mortality, and hospital length of stay for each management method. The analysis of 6299 patients from 9 studies showed that SAE decreased failure rates (1.3%) against nonoperative management (NOM) with 9.8%. There was no significant difference in mortality and hospital length of stay between SAE and NOM. There was increased complications with SAE but it is not enough evidence to draw comparisons between NOM and operative management (OM) due to heterogeneity of studies. SAE decreased need for splenectomies, reduced hospital stay, and complications. OM should be used if the patient is hemodynamically unstable or re-bleeds after NOM. It is imperative that clinicians assess each patient individually and follow a center-based protocol, while keeping in mind, the possible complications from NOM and subsequent interventions. Interventional radiologists will also need to approach SAE with care to prevent technical failures and re-intervention.

Keywords: Splenectomy, splenic angioembolization, splenic injury


How to cite this article:
Loh D, McAleer J. Comparison of outcomes between non-operative and operative management of blunt splenic trauma in adults. Kerala Surg J 2020;26:127-30

How to cite this URL:
Loh D, McAleer J. Comparison of outcomes between non-operative and operative management of blunt splenic trauma in adults. Kerala Surg J [serial online] 2020 [cited 2020 Nov 29];26:127-30. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/127/300237




  Introduction Top


Spleen is a highly vascularized organ whose main function is in filtering blood and recycling old erythrocytes in the body. It is the most common injury in abdominal trauma, occurring in almost 45% of all such patients.[1] Historically, the majority of blunt splenic trauma injuries were managed operatively with total or partial splenectomy. However, asplenic patients were found to have a 5% lifetime risk of overwhelming postsplenectomy infection, which while small, carries a high mortality rate of up to 80%.[2] They are at higher risk of pneumonia, meningitis, and septicemia as well as deep venous thrombosis and pulmonary embolism, with poorer prognosis than an average person.[3] There is a shift toward increasing nonoperative management (NOM) methods and splenic conservation to reduce infectious risks.

NOM was first introduced in pediatrics in the 1960s [4] as it was found that many young patients recovered successfully with just bed rest and observations. In the 1980s, with the advent of computed tomography (CT) imaging, NOM became more widely used. A meta-analysis of nine datasets from 1994 to 2009[5] showed that 68.4% of 10,157 patients were managed non-operatively in the USA. It is now considered the gold-standard treatment for hemodynamically stable patients with minor injuries.[6]

Scalfani first used splenic angioembolization (SAE) in splenic trauma in the 1980s. It involves inserting a wire-guided catheter into the splenic artery under radiological guidance to occlude the artery and stop hemorrhage.[4] The occlusion could be done either proximal or distal to the spleen, which is decided by the radiologist involved. Since the first Eastern Association for the Surgery of Trauma guidelines were released in 2003,[7] multiple studies from around the world have shown that SAE improves splenic salvage rates and success of NOM.[8] The current management guidelines published by the World Society of Emergency Surgery in 2017 is the most recent tool used by clinicians [Figure 1].
Figure 1: Management guidelines published by the World Society of Emergency Surgery[6]

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Upon admission, patients who are determined as hemodynamically unstable will be operated on immediately. If stable or responsive to fluids, a CT scan will be done and the severity of injury is assessed. The injury is then graded according to the American Association for the Surgery of Trauma splenic injury scale. There is increasing evidence of significant success using NOM for all hemodynamically stable patients regardless of higher grade injuries. In order to facilitate better treatment outcomes for patients, the evaluation of research around management outcomes and consideration of an appropriate protocol that will improve health-care standards is needed.


  Methods Top


The aim of this review was to analyze recent literature around patient outcomes of blunt splenic trauma treated initially with NOM and operative management (OM) including splenectomy and splenorrhaphy. NOM may simply be active observations with bed rest and serial CT scans or involve radiological intervention such as splenic artery angioembolization (SAE). All the studies were analyzed for failure rates of NOM, complications, in-hospital mortality, morbidity, and length of stay in hospital. Failure of NOM is defined as signs of bleeding after initial observation or SAE, which ultimately required surgery. Failure of observation could lead to SAE while failure of SAE could include re-intervention with repeat SAE or surgery. The research question was “Does NOM with angio-embolisation improve patient outcomes as compared to OM?”


  Results Top


Nine studies were analyzed in this review, following a systematic search of databases. There were 6299 patients collectively.[9] The mean ranges from 31 to 47 years [Table 1]. There were more male than female patients across all groups, with an overall 2.2:1 ratio between them. NOM without SAE is still the most utilized initial management, having a majority percentage in eight of the studies, with one study reaching 78.6%.[14] There is a higher uptake of SAE over observation, 35.2% and 24.9%.[16] An average 34.5% of all cases are still managed operatively.
Table 1: Patient characteristics and initial treatment

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All the studies excluded patients who died upon arrival to hospital, patients under 16 years old, penetrating trauma or other causes of splenic injuries.

There is some variability in how studies define management failure. Two studies defined failure as signs of re-bleeding requiring any re-intervention [13],[17] while three of them defined it as requiring splenectomy after initial NOM.[10],[12],[14] [Table 2] summarizes the failure rates from each study according to management method, with NOM failure defined as being the use of OM after initial intervention.[9],[10],[11],[12],[13],[14],[15],[16],[17]
Table 2: Summary of failure rates of each initial management

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Three of the studies compared failure rates of NOM between two time periods,[10],[16],[17] with the earlier cohort utilizing little or no SAE. The study by van der Vlies et al.[18] showed that increased use of SAE from 2002 reduced the need of operation from 23% to 5.7%. This is in line with results by Miller et al. who showed a 7% reduction in failure of NOM from 2010 when a higher SAE-use protocol was implemented. Banerjee et al. compared results from centers with low- and high-SAE use and found failure rates lower in high-use centers (3.5% vs. 7.6%).[14] In contrast, Hsieh et al. reported an increase in overall NOM failure from 9.6% to 11.4% despite increased use of initial SAE (18.1%–47.5%, P < 0.001).[10] In the study by Bhullar et al., there was no significant differences between failure rates of patients undergoing SAE, observation, or overall NOM (4%). All studies reported in-hospital mortality rates and five of them concluded no significant difference in mortality rates [9],[10],[14],[16],[17] between all three management groups.

The most common intervention-related complication for SAE is minor splenic infarcts.[12] Others include pneumonia, wound infection, and dehiscence.


  Discussion Top


SAE proves to be an effective management method in blunt splenic trauma injury that helps reduce the need of invasive OM and increase splenic preservation.[9] Yet, there are some limitations, which reduces reliability of these results. Many of the results were taken from small scale, single-center studies which reviewed data retrospectively from hospital records.[11],[12],[13],[16] While multi-center studies provide bigger population sizes, some trauma centers did not have protocols hence creating heterogeneity in their data.[9]

While failure rates decreased in NOM with increased SAE,[9],[11],[14],[16],[17] it is unclear whether this could be attributed solely to the treatment modality. Studies will need to be done to establish the immunological effects of SAE as this would have a major impact on patients if they had to be treated with preventative prophylaxis and vaccination.


  Conclusion Top


There is inconclusive evidence for SAE in improving outcomes for splenic trauma patients. The studies show that it is invaluable as an adjunct to observations in NOM but it cannot replace operative splenectomies in some high-grade injuries. There are promising findings that angioembolization could be applied to more patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Costa G, Tierno SM, Tomassini F, Venturini L, Frezza B, Cancrini G, et al. The epidemiology and clinical evaluation of abdominal trauma. An analysis of a multidisciplinary trauma registry. Ann Ital Chir 2010;81:95-102.  Back to cited text no. 1
    
2.
Kyaw MH, Holmes EM, Toolis F, Wayne B, Chalmers J, Jones IG, et al. Evaluation of severe infection and survival after splenectomy. Am J Med 2006;119:276.e1-7.  Back to cited text no. 2
    
3.
Kristinsson SY, Gridley G, Hoover RN, Check D, Landgren O. Long-term risks after splenectomy among 8,149 cancer-free American veterans: A cohort study with up to 27 years follow-up. Haematologica 2014;99:392-8.  Back to cited text no. 3
    
4.
Hildebrand DR, Ben-Sassi A, Ross NP, Macvicar R, Frizelle FA, Watson AJ. Modern management of splenic trauma. BMJ 2014;348:g1864.  Back to cited text no. 4
    
5.
Requarth JA, D'Agostino RB Jr., Miller PR. Nonoperative management of adult blunt splenic injury with and without splenic artery embolotherapy: A meta-analysis. J Trauma 2011;71:898-903.  Back to cited text no. 5
    
6.
Coccolini F, Montori G, Catena F, Kluger Y, Biffl W, Moore EE, et al. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg 2017;12:40.  Back to cited text no. 6
    
7.
Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS, Guillamondegui OD, et al. Selective nonoperative management of blunt splenic injury: An Eastern Association for the surgery of trauma practice management guideline. J Trauma Acute Care Surg 2012;73:S294-300.  Back to cited text no. 7
    
8.
Gaarder C, Dormagen JB, Eken T, Skaga NO, Klow NE, Pillgram-Larsen J, et al. Nonoperative management of splenic injuries: Improved results with angioembolization. J Trauma 2006;61:192-8.  Back to cited text no. 8
    
9.
Scarborough JE, Ingraham AM, Liepert AE, Jung HS, O'Rourke AP, Agarwal SK. Nonoperative management is as effective as immediate splenectomy for adult patients with high-grade blunt splenic injury. J Am Coll Surg 2016;223:249-58.  Back to cited text no. 9
    
10.
Hsieh TM, Liu CT, Wu BY, Hsieh CH. Is strict adherence to the nonoperative management protocol associated with better outcome in patients with blunt splenic injuries?: A retrospective comparative cross-sectional study. Int J Surg (London, England) 2019;69:116-23.  Back to cited text no. 10
    
11.
Bhullar IS, Frykberg ER, Siragusa D, Chesire D, Paul J, Tepas JJ 3rd, et al. Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management. J Trauma Acute Care Surg 2012;72:1127-34.  Back to cited text no. 11
    
12.
Cinquantini F, Simonini E, Di Saverio S, Cecchelli C, Kwan SH, Ponti F, et al. Non-surgical management of blunt splenic trauma: A comparative analysis of non-operative management and splenic artery embolization-experience from a European trauma center. Cardiovasc Intervent Radiol 2018;41:1324-32.  Back to cited text no. 12
    
13.
Corn S, Reyes J, Helmer SD, Haan JM. Outcomes following blunt traumatic splenic injury treated with conservative or operative management. Kans J Med 2019;12:83-8.  Back to cited text no. 13
    
14.
Banerjee A, Duane TM, Wilson SP, Haney S, O'Neill PJ, Evans HL, et al. Trauma center variation in splenic artery embolization and spleen salvage: A multicenter analysis. J Trauma Acute Care Surg 2013;75:69-74.  Back to cited text no. 14
    
15.
Chastang L, Bège T, Prudhomme M, Simonnet AC, Herrero A, Guillon F, et al. Is non-operative management of severe blunt splenic injury safer than embolization or surgery? Results from a French prospective multicenter study. J Visc Surg 2015;152:85-91.  Back to cited text no. 15
    
16.
Miller PR, Chang MC, Hoth JJ, Mowery NT, Hildreth AN, Martin RS, et al. Prospective trial of angiography and embolization for all grade III to V blunt splenic injuries: Nonoperative management success rate is significantly improved. J Am Coll Surg 2014;218:644-8.  Back to cited text no. 16
    
17.
van der Vlies CH, Hoekstra J, Ponsen KJ, Reekers JA, van Delden OM, Goslings JC. Impact of splenic artery embolization on the success rate of nonoperative management for blunt splenic injury. Cardiovasc Intervent Radiol 2012;35:76-81.  Back to cited text no. 17
    
18.
Van der Cruyssen F, Manzelli A. Splenic artery embolization: Technically feasible but not necessarily advantageous. World J Emerg Surg 2016;11:47.  Back to cited text no. 18
    


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