Controversies in the management of splenic trauma☆
Introduction
The technologic innovations of the last three decades such as rapid access to multi-slice CT imaging, blood banking and angioembolisation, along with the identification of syndromes such as overwhelming post-splenectomy syndrome have significantly shifted the management of splenic injuries towards non-operative approaches.
In the 1970s, physical examination and diagnostic peritoneal lavage were the only tools available for the diagnosis of splenic injury. The main focus of treatment was hemorrhage control, and splenectomy was the treatment for virtually all splenic injuries, regardless of how minor. In the 1980s, increased awareness of the immunologic importance of the spleen, prompted efforts towards splenic salvage and led to the development of techniques such as splenorraphy and partial resection [15], [21]. Expanding on the groundbreaking approaches of paediatric trauma surgeons, it became clear that non-operative management of splenic injuries was also a therapeutic option [6], [14]. In the 1990s, CT scans became the gold standard for the diagnosis of solid organ injuries; this modality permitted identification of concomitant injuries, grading of splenic injuries and broad quantification and imaging based comparisons of degrees of hemoperitoneum [9], [10]. Further, the introduction of angioembolisation increased the options available for splenic salvage [20]. More recently, focused ultrasonography has become an extension of the physical examination, permitting identification of blood in the peritoneal cavity and prompt triage of unstable patients to the operating room [4], [5]. With the introduction of damage control surgery, the current foci of treatment in unstable patients include hemorrhage and contamination control as well as metabolic resuscitation as an equally important goal [19].
Trauma surgeons have adopted many diagnostic and therapeutic options introduced over the last three decades to the extent that the vast majority of splenic injuries are now managed non-operatively, with a significant decrease in morbidity and no change in mortality [18]. However, there appears to be a gap between the available evidence and management strategies of patients with splenic injuries which can be inferred from the wide range of practice patterns observed [8], [18]. This gap, between evidence and action, may be due to a lack of high quality evidence which allows for different interpretation and thus practice variation, or alternatively it may be a lack of research utilisation that is to blame.
We sought to explore ongoing areas of controversy in the non-operative management of splenic trauma with the aim of further elucidating why these controversies continue to exist.
Section snippets
Study design
We used a series of iterative surveys to collect experts’ opinions about areas of ongoing consensus and controversy in the management of splenic injuries. In this study we used a combination of conventional mailing and electronic surveys in the first two rounds. The third and final round of the study consisted of a discussion centred on dominant areas of controversy identified in the previous two rounds and was conducted using teleconferences. The objective of this study was to identify the
Results
We invited 70 experts from ten countries to participate. Overall, 43 (61%) experts initially invited to participate completed round 1 and 34 (79%) of these participated in the second round process. Respondent and facility characteristics are described in Table 1. The majority of experts were male, more than two thirds had formal trauma fellowship training and half have practiced for 15 years or less. Almost two thirds of experts dedicate 50% or more of their practice to the care of injured
Discussion
The past 30 years of technological innovation have significantly contributed to the evolution in the care of injured patients. The introduction of new imaging methods have permitted the identification and characterisation of solid organ injuries and have streamlined the management of the multiply injured patient. The introduction of angioembolisation has expanded the therapeutic options previously limited to operative procedures or observation. Patients with splenic injuries have significantly
Conflict of interest
None of the authors have anything to disclose.
Acknowledgment
The authors would like to thank Sharon E. Strauss MD MSc for her critical revision of the manuscript.
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The Impact of Race and Socioeconomic Status on Treatment and Outcomes of Blunt Splenic Injury
2019, Journal of Surgical ResearchCitation Excerpt :Operative management with splenectomy not only carries the usual postoperative risks associated with an emergent laparotomy but also may put patients at risk for significant life-threatening infections including overwhelming postsplenectomy infection.1 NOM is associated with decrease complications, hospital costs, rates of blood product transfusion, decreased morbidity, and decreased mortality.3 As a result, NOM is now considered the standard of care in hemodynamically stable patients, regardless of injury grade.4
Evolution of the treatment of splenic injuries: from surgery to non-operative management
2017, Cirugia EspanolaDelayed splenic vascular injury after nonoperative management of blunt splenic trauma
2017, Journal of Surgical ResearchCitation Excerpt :The detection of splenic vascular injuries on CT scan predicts failure of nonoperative management and leads to further interventions such as angioembolization or surgery.2,5,6 However, there is no consensus on the role of follow-up CT scan in patients managed with observation for the detection of delayed splenic vascular injury (DSVI)7–10—defined as vascular injury visible at follow-up CT scan study but not present on admission imaging (commonly described as pseudoaneurysm or “contrast blush”). The variation in practices on the use of follow-up CT scan is mainly because of the limited data available on this topic and on the lack of information on the natural history and mechanisms responsible for DSVI.
Management of paediatric splenic injury in the New South Wales trauma system
2017, InjuryCitation Excerpt :While most surgeons agree NOM is preferable in theory [33], in North America, operation rates have been found to be higher under adult trauma surgeons compared with paediatric surgeons, and conversely lower when management is by trauma surgeons with paediatric experience. Barriers surgeons identify include lack of paediatric resources and infrastructure, limited paediatric experience and educational updates, lack of appropriate surgical cover, lack of familiarity with clinical practice guidelines, use of adult algorithms, entrenched practices, concern about splenic injury grade, contrast blush on CT and other injuries, and low volumes of trauma [23,30–34,52,53]. In the absence of paediatric trauma triage criteria and clinical practice guidelines in NSW, it is likely that individual surgical decision making played a role in the OM rates identified in this study.
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This work was a podium presentation at the Combined Annual Scientific Meeting of the Australasian Trauma Society and the Trauma Association of Canada, March, 2009, Auckland New Zealand.