Management of blunt splenic injury in a UK major trauma centre and predicting the failure of non-operative management: a retrospective, cross-sectional study

  • Stella R. Smith
  • Louise Morris
  • Stephen Spreadborough
  • Waleed Al-Obaydi
  • Marta D’Auria
  • Hilary White
  • Adam J. Brooks
Original Article
  • 240 Downloads

Abstract

Purpose

To review the management of patients >16 years with blunt splenic injury in a single, UK, major trauma centre and identify whether the following are associated with success or failure of non-operative management with selective use of arterial embolization (NOM ± AE): age, Injury Severity Score (ISS), head injury, haemodynamic instability, massive transfusion, radiological hard signs [contrast extravasation or pseudoaneurysm on the initial computed tomography (CT) scan], grade, and presence of intraparenchymal haematoma or splenic laceration.

Methods

Retrospective, cross-sectional study undertaken between April 2012 and October 2015. Paediatric patients, penetrating splenic trauma, and iatrogenic injuries were excluded. Follow-up was for at least 30 days.

Results

154 patients were included. Median age was 38 years, 77.3% were male, and median ISS was 22. 14/87 (16.1%) patients re-bled following NOM in a median of 2.3 days (IQR 0.8–3.6 days). 8/28 (28.6%) patients re-bled following AE in a median of 2.0 days (IQR 1.3–3.7 days). Grade III–V injuries are a significant predictor of the failure of NOM ± AE (OR 15.6, 95% CI 3.1–78.9, p = 0.001). No grade I injuries and only 3.3% grade II injuries re-bled following NOM ± AE. Age ≥55 years, ISS, radiological hard signs, and haemodynamic instability are not significant predictors of the failure of NOM ± AE, but an intraparenchymal or subcapsular haematoma increases the likelihood of failure 11-fold (OR 10.9, 95% CI 2.2–55.1, p = 0.004).

Conclusions

Higher grade injuries (III–V) and intraparenchymal or subcapsular haematomas are associated with a higher failure rate of NOM ± AE and should be managed more aggressively. Grade I and II injuries can be discharged after 24 h with appropriate advice.

Keywords

Spleen Splenic Blunt Embolization Non-operative management 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare no conflicts of interest.

Ethical approval

For this type of study, formal consent is not required.

Previous presentation of this work

European Society of Trauma and Emergency Surgery Congress, Vienna 2016 oral presentation. Reference 0197: Management of Blunt Splenic Injury: a retrospective review of practice and outcomes at a UK major trauma centre.

References

  1. 1.
    Costa GI, Tierno SM, Tomassini F, Venturini L, Frezza B, et al. The epidemiology and clinical evaluation of abdominal trauma. An analysis of a multidisciplinary trauma registry. Ann Ital Chir. 2010;81(2):95–102.PubMedGoogle Scholar
  2. 2.
    Moore EE, Cogbill TH, Malangoni M, Jurkovich GJ, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J Trauma. 1995;38(3):323–4.CrossRefPubMedGoogle Scholar
  3. 3.
    Shapiro MJ, Krausz C, Durham RM, Mazuski J, Battistella FD, et al. Overuse of splenic scoring and computed tomographic scans. J Trauma. 1999;47:651–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Scarborough JE, Ingraham AM, Liepert AE, Jung HS, O’Rourke AP, et al. Non-operative management is as effective as immediate splenectomy for adult patients with high-grade blunt splenic injury. J Am Coll Surg. 2016;223(2):249–58.CrossRefPubMedGoogle Scholar
  5. 5.
    Velmahos GC, Zacharias N, Emhoff TA, Feeney JM, Hurst JM, et al. Management of the most severely injured spleen: a multicenter study of the research consortium of new england centers for trauma (ReCONECT). Arch Surg. 2010;145(5):456–60.CrossRefPubMedGoogle Scholar
  6. 6.
    McIntyre LK, Schiff M, Jurkovich GJ. Failure of nonoperative management of splenic injuries: causes and consequences. Arch Surg. 2005;140:563–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Requarth JA, D’Agostino RB, Miller PR. Nonoperative management of adult blunt splenic injury with and without splenic artery embolotherapy: a meta-analysis. J Trauma. 2011;71(4):898–903.CrossRefPubMedGoogle Scholar
  8. 8.
    Haan JM, Bochicchio GV, Kramer N, Scalea TM. Non-operative management of blunt splenic injury: a 5 year experience. J Trauma. 2005;58:492–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Konstantakos AK, Barnoski AL, Plaisier BR, Yowler CJ, Fallon WF Jr, et al. Optimizing the management of blunt splenic injury in adults and children. Surgery. 1999;126:805–12.CrossRefPubMedGoogle Scholar
  10. 10.
    Fu CY, Wu SC, Chen RJ, Chen YF, Wang YC, et al. Evaluation of need for operative intervention in blunt splenic injury: intraperitoneal contrast extravasation has an increased probability of requiring operative intervention. World J Surg. 2010;34(11):2745–51.CrossRefPubMedGoogle Scholar
  11. 11.
    Zarzaur BL, Kozar R, Myers JG, Claridge JA, Scalea TM, et al. The splenic injury outcomes trial: an american association for the surgery of trauma multi-institutional study. J Trauma Acute Care Surg. 2015;79(3):335–42.CrossRefPubMedGoogle Scholar
  12. 12.
    Lopez JM Jr, McGonagill PW, Gross JL, Hoth JJ, Chang MC, et al. Subcapsular hematoma in blunt splenic injury: a significant predictor of failure of nonoperative management. J Trauma Acute Care Surg. 2015;79(6):957–60.CrossRefPubMedGoogle Scholar
  13. 13.
    Olthof DC, Joosse P, van der Vlies CH, de Haan RJ, Goslings JC. Prognostic factors for the failure of non-operative management in adults with blunt splenic injury. J Trauma. 2013;74(2):546–57.CrossRefGoogle Scholar
  14. 14.
    Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS, et al. Selective nonoperative management of blunt splenic injury: an eastern association for the surgery of trauma practice management guideline. J Trauma. 2012;73(5):S294–300.CrossRefGoogle Scholar
  15. 15.
    Lecky Fiona. Twenty-five years of the trauma audit and research network: a continuing evolution to drive improvement. Emerg Med J. 2015;32:906–8.CrossRefPubMedGoogle Scholar
  16. 16.
    The national confidential enquiry into patient outcome and death (NCEPOD) report. Trauma: who cares? London. 2007. http://www.ncepod.org.uk/2007t.html. Accessed 4 Oct 2016.
  17. 17.
    The trauma audit and research network (TARN). Press release on major trauma. 2015. https://www.tarn.ac.uk/Content.aspx?c=3477. Accessed 4 Oct 2016.
  18. 18.
    Yiannoullou P, Hall C, Newton K, Pearce L, Bouamra O, et al. A review of the management of blunt splenic trauma in England and Wales: have regional trauma networks influenced management strategies and outcomes? Ann R Coll Surg Engl. 2017;99:63–9.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Moore FA, Davis JW, Moore EE, Cocanour CS, West MA, et al. Western trauma association (WTA) critical decisions in trauma: management of adult blunt splenic injury. J Trauma. 2008;65:1007–11.CrossRefPubMedGoogle Scholar
  20. 20.
    Tugnoli G, Bianchi E, Biscardi A, Coniglio C, Isceri S, et al. Nonoperative management of blunt splenic injury in adults: there is (still) a long way to go. The results of the Bologna-Maggiore hospital trauma center experience and development of a clinical algorithm. Surg Today. 2015;45(10):1210–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Bhullar I, Frykberg ER, Tepas JJ III, Siragusa D, Loper T, et al. At first blush: absence of computed tomography contrast extravasation in Grade IV or V adult blunt splenic trauma should not preclude angioembolization. J Trauma Acute Care Surg. 2013;74(1):105–12.CrossRefPubMedGoogle Scholar
  22. 22.
    Banerjee A, Duane TM, Wilson SP, Haney S, O’Neill PJ, et al. Trauma center variation in splenic artery embolization and spleen salvage: a multicenter analysis. EAST plenary paper. J Trauma Acute Care Surg. 2013;75(1):69–75.CrossRefPubMedGoogle Scholar
  23. 23.
    Sabe AA, Claridge JA, Rosenblum DI, Lie K, Malangoni MA. The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16-year experience. J Trauma. 2009;67(3):565–72.CrossRefPubMedGoogle Scholar
  24. 24.
    Falimirski ME, Provost D. Nonsurgical management of solid abdominal organ injury in patients over 55 years of age. Am Surg. 2000;66(7):631–5.PubMedGoogle Scholar
  25. 25.
    Sharma OP, Oswanski MF, Singer D, Raj SS, Daoud YA. Assessment of nonoperative management of blunt spleen and liver trauma. Am Surg. 2005;71(5):379–86.PubMedGoogle Scholar
  26. 26.
    Alabbasi T, Nathens AB, Tien H. Blunt splenic injury and severe brain injury: a decision analysis and implications for care. J can chir. 2015;58(3):S108–17.Google Scholar
  27. 27.
    Watson GA, Rosengart MR, Zenati MS, Tsung A, Forsythe RM, et al. Nonoperative management of severe blunt splenic injury: are we getting better? J Trauma. 2006;61(5):1113–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Peitzman A, Heil B, Rivera L, Federle MB, Harbrecht BG, et al. Blunt splenic injury in adults: multi-institutional study of the eastern association for the surgery of trauma. J Trauma. 2000;49(2):177–87.CrossRefPubMedGoogle Scholar
  29. 29.
    Smith J, Armen S, Cook CH, Martin LC. Blunt splenic injuries: have we watched long enough? J Trauma. 2008;64(3):656–63.CrossRefPubMedGoogle Scholar
  30. 30.
    Velmahos GC, Chan LS, Kamel E, Murray JA, Yassa N, et al. Non-operative management of splenic injuries—have we gone too far? Arch Surg. 2000;135:674–9.CrossRefPubMedGoogle Scholar
  31. 31.
    Sartorelli KH, Frumiento C, Rogers FB, Osler TM. Nonoperative management of hepatic, splenic, and renal injuries in adults with multiple injuries. J Trauma. 2000;49(1):56–61.CrossRefPubMedGoogle Scholar
  32. 32.
    London JA, Parry L, Galante J, Battistella F. Safety of early mobilization of patients with blunt solid organ injuries. Arch Surg. 2008;143(10):972–6.CrossRefPubMedGoogle Scholar
  33. 33.
    Duchesne JC, Simmons JD, Schmieg RE Jr, McSwain NE Jr, Bellows CF. Proximal splenic angioembolization does not improve outcomes in treating blunt splenic injuries compared with splenectomy: a cohort analysis. J Trauma. 2008;65(6):1346–51.CrossRefPubMedGoogle Scholar
  34. 34.
    Peitzman AB, Harbrecht BG, Rivera L, Heil B. Eastern association for the surgery of trauma multiinstitutional trials workgroup. Failure of observation of blunt splenic injury in adults: variability in practice and adverse consequences. J Am Coll Surg. 2005;201:179–87.CrossRefPubMedGoogle Scholar
  35. 35.
    Zarzaur BL, Vashi S, Magnotti LJ, Croce MA, Fabian TC. The real risk of splenectomy after discharge home following nonoperative management of blunt splenic injury. J Trauma. 2009;66(6):1531–6.CrossRefPubMedGoogle Scholar
  36. 36.
    Fata P, Robinson L, Fakhry SM. A survey of EAST member practices in blunt splenic injury: a description of current trends and opportunities for improvement. J Trauma. 2005;59(4):836–41.CrossRefPubMedGoogle Scholar
  37. 37.
    Alarhayem AQ, Myers JG, Dent D, Lamus D, Lopera J, et al. Blush at first sight: significance of computed tomographic and angiographic discrepancy in patients with blunt abdominal trauma. Am J Surg. 2015;210(6):1104–10.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  1. 1.East Midlands Major Trauma CentreQueens Medical CentreNottinghamUK
  2. 2.University Hospital South ManchesterWythenshaweUK

Personalised recommendations