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PURPOSE: Nonoperative management (NOM) for blunt splenic injuries (BSIs) is supported by both international and national guidelines in Germany, with high success rates even for severe organ injuries. Angioembolization (ANGIO) has been recommended for stabilizable patients with BSI requiring intervention since the 2016 German National Trauma Guideline. The objectives were to study treatment modalities in the adult BSI population according to different severity parameters including NOM, ANGIO and splenectomy in Germany. METHODS: Between 2015 and 2020, a retrospective registry-based cohort study was performed on patients with BSIs with an Abbreviated Injury Score ≥ 2 in Germany using registry data from the TraumaRegister DGU® (TR DGU). This registry includes patients which were treated in a resuscitation room and spend more than 24-h in an intensive care unit or died in the resuscitation room. RESULTS: A total of 2,782 patients with BSIs were included in the analysis. ANGIO was used in 28 patients (1.0%). NOM was performed in 57.5% of all patients, predominantly those with less severe organ injuries measured by the American Association for the Surgery of Trauma Organ Injury Scale (AAST) ≤ 2. The splenectomy rate for patients with an AAST ≥ 3 was 58.5%, and the overall mortality associated with BSI was 15%. CONCLUSIONS: In this cohort splenic injuries AAST ≥ 3 were predominantly managed surgically and ANGIO was rarely used to augment NOM. Therefore, clinical reality deviates from guideline recommendations regarding the use of ANGIO and NOM. Local interdisciplinary treatment protocols might close that gap in the future.
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Trauma is one of the leading causes of disability and mortality in working-age population. Abdominal injuries comprise 20-30% of traumas. Uncontrolled bleeding is the main cause of death in 30-40% of patients. Among abdominal organs, spleen is most often damaged due to fragile structure and subcostal localization. In the last two decades, therapeutic management has become preferable in patients with abdominal trauma and stable hemodynamic parameters. In addition to clinical examination, standard laboratory tests and ultrasound, as well as contrast-enhanced CT of the abdomen should be included in diagnostic algorithm to identify all traumatic injuries and assess severity of abdominal damage. Development of interventional radiological technologies improved preservation of damaged organs. Endovascular embolization can be performed selectively according to indications (leakage, false aneurysm, arteriovenous anastomosis) and considered for severe damage to the liver and spleen, hemoperitoneum or severe polytrauma. Embolization is essential in complex treatment of traumatic vascular injuries of parenchymal abdominal organs. We reviewed modern principles and methods of intra-arterial embolization for the treatment of patients with traumatic injuries of the liver and spleen.
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Traumatismos Abdominales , Embolización Terapéutica , Procedimientos Endovasculares , Bazo , Heridas no Penetrantes , Humanos , Traumatismos Abdominales/terapia , Traumatismos Abdominales/diagnóstico , Heridas no Penetrantes/terapia , Embolización Terapéutica/métodos , Bazo/lesiones , Bazo/irrigación sanguínea , Procedimientos Endovasculares/métodos , Hígado/lesiones , Hígado/irrigación sanguínea , Hígado/diagnóstico por imagenRESUMEN
BACKGROUND: The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for the spleen (and other organs) was created in 1989. It has been validated to predict mortality, need for operation, length of stay (LOS), and intensive care unit (ICU) LOS. PURPOSE: We aimed to determine if the Spleen OIS is applied equally to blunt and penetrating trauma. RESEARCH DESIGN/STUDY SAMPLE: We analyzed the Trauma Quality Improvement Program (TQIP) database from 2017-2019, including patients with spleen injuries. DATA COLLECTION: Outcomes included the rates of mortality, operation, spleen-specific operation, splenectomy, and splenic embolization. RESULTS: 60900 patients had a spleen injury with an OIS grade. Mortality rates increased in Grades IV and V for both blunt and penetrating trauma. In blunt trauma, the odds for any operation, spleen-specific operation, and splenectomy increased, for each increase in grade. Penetrating trauma showed similar trends in grades up to grade IV, but were statistically similar between grade IV and V. Splenectomy was higher in penetrating trauma for all grades. Splenic embolization peaked at 25% of grade IV trauma before decreasing in grade V. Rates in penetrating trauma were significantly lower in all grades, peaking at 2.5% of Grade III injuries. CONCLUSIONS: The mechanism of trauma is a significant factor for all outcomes, independent of AAST-OIS. Hemostasis is predominantly surgical in penetrating trauma, achieved with angioembolization more frequently in blunt trauma. Penetrating trauma management is influenced by the potential for injury to peri-splenic organs.
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Traumatismos Abdominales , Heridas no Penetrantes , Heridas Penetrantes , Humanos , Estados Unidos/epidemiología , Bazo/cirugía , Bazo/lesiones , Esplenectomía , Heridas no Penetrantes/cirugía , Heridas Penetrantes/diagnóstico , Heridas Penetrantes/cirugía , Estudios Retrospectivos , Traumatismos Abdominales/diagnóstico , Traumatismos Abdominales/cirugía , Puntaje de Gravedad del TraumatismoRESUMEN
INTRODUCTION: Predicting failure of nonoperative management (NOM) in splenic trauma remains elusive. Shock index (SI) is an indicator of physiologic burden in an injury but is not used as a prediction tool. The purpose of this study was to determine if elevated SI would be predictive of failure of NOM in patients with a blunt splenic injury. METHODS: Adult patients admitted to a level-1 trauma center from January 2011 to April 2017 for NOM of splenic injury were reviewed. Patients were excluded if they underwent a procedure (angiography or surgery) prior to admission. The primary outcome was requiring intervention after an initial trial of noninterventional management (NIM). An SI > 0.9 at admission was considered a high risk. Univariate and multivariate analyses were used to identify predicators of the failure of NOM. Findings were subsequently verified on a validation cohort of patients. RESULTS: Five hundred and eighty-five patients met inclusion criteria; 7.4% failed NIM. On an univariate analysis, findings of pseudoaneurysm or extra-arterial contrast on computed tomography did not differentiate successful NIM versus failure (8.1% versus 14.0%, P = 0.18). Age, the American Association for the Surgery of Trauma injury grade, and elevated SI were included in multivariate modeling. Grade of injury (OR 3.49, P = 0.001), age (OR 1.02, P = 0.009), and high SI (OR 3.49, P = 0.001) were each independently significant for NIM failure. The risk-adjusted odds of failure were significantly higher in patients with a high risk SI (OR 2.35, P < 0.001). Validation of these findings was confirmed for high SI on a subsequent 406 patients with a c-statistic of 0.71 (95% CI 0.62-0.80). CONCLUSIONS: Elevated SI is an independent risk factor for failure of NIM in those with splenic injury. SI along with age and computed tomography findings may aid in predicting the failure of NIM. Trauma providers should incorporate SI into decision-making tools for splenic injury management.
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Traumatismos Abdominales , Puntaje de Gravedad del Traumatismo , Choque , Bazo , Heridas no Penetrantes , Traumatismos Abdominales/complicaciones , Traumatismos Abdominales/diagnóstico , Traumatismos Abdominales/diagnóstico por imagen , Traumatismos Abdominales/terapia , Adulto , Humanos , Estudios Retrospectivos , Choque/diagnóstico , Choque/etiología , Choque/terapia , Bazo/diagnóstico por imagen , Bazo/lesiones , Esplenectomía , Centros Traumatológicos , Insuficiencia del Tratamiento , Resultado del Tratamiento , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/diagnóstico , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/terapiaRESUMEN
INTRODUCTION: The majority of patients with splenic trauma undergo non-operative management (NOM); around 15% of these cases fail NOM and require surgery. The aim of the current study is to assess whether the hemodynamic status of the patient represents a risk factor for failure of NOM (fNOM) and if this may be considered a relevant factor in the decision-making process, especially in Centers where AE (angioembolization), intensive monitoring and 24-h-operating room are not available. Furthermore, the presence of additional risk factors for fNOM was investigated. MATERIALS AND METHODS: This is a multicentre prospective observational study, including patients presenting with blunt splenic trauma older than 17 years, managed between 2014 and 2016 in two Italian trauma centres (ASST Papa Giovanni XXIII in Bergamo and Sant'Anna University Hospital in Ferrara-Italy). The risk factors for fNOM were analyzed with univariate and multivariate analyses. RESULTS: In total, 124 patients were included in the study. In univariate analysis, the risk factors for fNOM were AAST grade > 3 (fNOM 37.5% vs 9.1%, p = 0.024), and the need of red blood cell (RBC) transfusion in the emergency department (ED) (fNOM 42.9% vs 8.9%, p = 0.011). Multivariate analysis showed that the only significant risk factor for fNOM was the need for RBC transfusion in the ED (p = 0.049). CONCLUSIONS: The current study confirms the contraindication to NOM in case of hemodynamically instability in case of splenic trauma, as indicated by the most recent guidelines; attention should be paid to patients with transient hemodynamic stability, including patients who require transfusion of RBC in the ED. These patients could benefit from AE; in centers where AE, intensive monitoring and an 24-h-operating room are not available, this particular subgroup of patients should probably be treated with operative management.
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Traumatismos Abdominales/terapia , Tratamiento Conservador , Transfusión de Eritrocitos/estadística & datos numéricos , Choque Traumático/terapia , Bazo/lesiones , Esplenectomía/estadística & datos numéricos , Heridas no Penetrantes/terapia , Traumatismos Abdominales/complicaciones , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Embolización Terapéutica/estadística & datos numéricos , Servicio de Urgencia en Hospital , Femenino , Hemodinámica , Hemostasis Quirúrgica/estadística & datos numéricos , Humanos , Puntaje de Gravedad del Traumatismo , Italia , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Choque Traumático/complicaciones , Bazo/cirugía , Insuficiencia del Tratamiento , Heridas no Penetrantes/complicaciones , Adulto JovenRESUMEN
BACKGROUND: Treatment of blunt splenic injury has changed over the past decades. Nonoperative management (NOM) is the treatment of choice. Adequate patient selection is a prerequisite for successful NOM. Impaired mental status is considered as a relative contra indication for NOM. However, the impact of altered consciousness in well-equipped trauma institutes is unclear. We hypothesized that impaired mental status does not affect outcome in patients with splenic trauma. METHODS: Our prospectively composed trauma database was used and adult patients with blunt splenic injury were included during a 14-year time period. Treatment guidelines remained unaltered over time. Patients were grouped based on the presence (Group GCS: < 14) or absence (Group GCS: 14-15) of impaired mental status. Outcome was compared. RESULTS: A total of 161 patients were included, of whom 82 were selected for NOM. 36% of patients had a GCS-score < 14 (N = 20). The median GCS-score in patients with reduced consciousness was 9 (range 6-12). Groups were comparable except for significantly higher injury severity scores in the impaired mental status group (19 vs. 17, p = 0.007). Length of stay (28 vs. 9 days, p < 0.001) and ICU-stay (8 vs. 0 days, p = 0.005) were longer in patients with decreased GCS-scores. Failure of NOM, total splenectomy rates, complications and mortality did not differ between both study groups. CONCLUSION: This study shows that NOM for blunt splenic trauma is a viable treatment modality in well-equipped institutions, regardless of the patients mental status. However, the presence of neurologic impairment is associated with prolonged ICU-stay and hospitalization. We recommend, in institutions with adequate monitoring facilities, to attempt nonoperative management for blunt splenic injury, in all hemodynamically stable patients without hollow organ injuries, also in the case of reduced consciousness.
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Trastornos de la Conciencia , Monitoreo Fisiológico , Bazo/lesiones , Heridas no Penetrantes/terapia , Adulto , Bases de Datos Factuales , Estudios de Factibilidad , Femenino , Hospitalización , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
Background: The World Society of Emergency Surgery (WSES) spleen trauma classification meets the need of an evolution of the current anatomical spleen injury scale considering both the anatomical lesions and their physiologic effect. The aim of the present study is to evaluate the efficacy and trustfulness of the WSES classification as a tool in the decision-making process during spleen trauma management. Methods: Multicenter prospective observational study on adult patients with blunt splenic trauma managed between 2014 and 2016 in two Italian trauma centers (ASST Papa Giovanni XXIII in Bergamo and Sant'Anna University Hospital in Ferrara). Risk factors for operative management at the arrival of the patient and as a definitive treatment were analyzed. Moreover, the association between the different WSES grades of injury and the definitive management was analyzed. Results: One hundred twenty-four patients were included. At multivariate analysis, a WSES splenic injury grade IV is a risk factor for the operative management both at the arrival of the patients and as a definitive treatment. WSES splenic injury grade III is a risk factor for angioembolization. Conclusions: The WSES classification is a good and reliable tool in the decision-making process in splenic trauma management.
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Bazo/lesiones , Heridas y Lesiones/clasificación , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Manejo de la Enfermedad , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Bazo/anomalías , Bazo/fisiopatología , Esplenectomía/métodos , Cirujanos/organización & administración , Cirujanos/estadística & datos numéricosRESUMEN
Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.
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Traumatismos Abdominales/cirugía , Traumatismos Abdominales/complicaciones , Traumatismos Abdominales/diagnóstico por imagen , Angiografía , Humanos , Riñón/lesiones , Hígado/lesiones , Páncreas/lesiones , Peritonitis/etiología , Peritonitis/cirugía , Bazo/lesionesRESUMEN
The spleen is one of the organs most frequently injured in blunt abdominal trauma. Computed tomography (CT) scanning can accurately detect splenic injury and is currently the imaging modality of choice in assessing clinically stable patients with blunt abdominal trauma. The CT features of spleen injury include lacerations, subcapsular or parenchymal haematomas, active haemorrhage, and vascular injuries. We present a pictorial review of the spectrum of CT findings for blunt splenic injuries. This article will be a useful reference for radiologists and surgeons as CT scan is widely used for the assessment of splenic injuries and contributes to the current trend towards nonsurgical management of this injury.
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BACKGROUND: Intra-abdominal organs, most commonly the spleen and liver, are injured in 40-50% of polytraumatized patients. Because of its important immunological functions, preservation of the injured spleen is of paramount importance. METHODS: There are both conservative and surgical approaches to preservation of the spleen in trauma cases. Of the techniques available for this purpose, tissue adhesives, coagulation, partial resection, and mesh splenorrhapy are the most suitable. RESULTS: Nonoperative management is a worthwhile option in hemodynamically stable patients. The decisive factor for successful conservative management is the degree of injury. We find that the manner in which heparin is administered plays an important role. Tissue adhesives are commonly used with good success with superficial lacerations. Coagulation techniques are also suitable for organ conservation with grade I and II injuries. Splenorraphy with resorbablemesh is the method of choice with the deep lacerations as it permits rapid and permanenthemostasis. If an injury only involves one pole or one half of the spleen, resection of that part of the organ is an option. Partial resection with a stapler is advisable for speed and effectiveness. Total fragmentation or separation of the hilus is treated with an immediate splenectomy, saving the tail of the pancreas. CONCLUSION: In trauma cases, every attempt should be made to save the spleen. If splenectomy cannot be avoided, the splenectomized patient should be immunized against pneumococcus and be informed of his/ her resultant immune deficiency.
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Reporte de caso de un paciente con abdomen agudo posterior a un trauma contuso en el cuál se encontró al examen de laboratorio paludismo a vivax +++. En este artículo nos permitimos demostrar el manejo clínico-quirúrgico realizado en un paciente con trauma esplénico grado 4 y paludismo vivax +++, en el hospital cantonal León Becerra de Milagro haciendo hincapié en la importancia del diagnóstico clínico y semiología quirúrgica a pesar de los limitantes en los exámenes complementarios que tenemos en nuestro centro hospitalario, en el cual TAC no está al alcance de nuestro servicio de emergencia.
This is a report about a patient with acute abdomen posterior to a blunt trauma. In the laboratory exam done to the patient it was positive for P. vivax malaria. In this article we demonstrate the clinical-surgical management on a patient with fourth degree spleen trauma and positive for P. vivax malaria at Leon Becerra Hospital in Milagro. In spite of the limitations for complementary exams such as TAC which is out of our reach at our hospital we put special emphasis on the importance of a surgical - clinical diagnosis
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Masculino , Persona de Mediana Edad , Traumatismos Abdominales , Malaria , Malaria Vivax , Esplenectomía , Plasmodium vivax , BazoRESUMEN
PURPOSE: To evaluate the efficacy of transcatheter arterial embolization(TAE) in children with blunt splenicinjury. MATERIALS AND METHODS: The results of transcatheter splenic arterial embolization in nine children whosuffered splenic injury after blunt abdominal trauma were retrospectively studied. This injury was demonstrated byCT, and the findings were evaluated according to the classification of Mirvis et al. ; two patients were grade 3and seven were grade 4. All were carefully observed in intensive care before embolization. TAE was performed if apatient satisfied the following criteria : (1) transfusion and/or fluid replacement required to maintainhemodynamic stability ; or (2) rapid Hb/Hct decrease ; or (3) both. Splenic function was subsequently estimatedaccording to the results of 99mTc-sulfur colloid scintigraphy and/or CT scanning. RESULT: TAE was suscessful inall nine children. Two were embolized with a coil only, three with gelfoam, and four with gelfoam and a coil.Seven were embolized in the main trunk of the splenic artery and others in both the main trunk and its branches.Splenic function was preserved in all nine children, during follow-up, none suffered rebleeding. CONCLUSION: TAEof the splenic artery can be a safe and effective nonsurgical approach to the management of blunt splenic injuryin children, and can preserve splenic function.