Elsevier

Injury

Volume 43, Issue 1, January 2012, Pages 55-61
Injury

Controversies in the management of splenic trauma

https://doi.org/10.1016/j.injury.2010.09.007Get rights and content

Abstract

Background

The technologic innovations of the last three decades, coupled with a deeper understanding of the immunologic role of the spleen, have significantly shifted the management of splenic injuries towards non-operative approaches. However, there continuous to be a wide range of practice patterns related to the non-operative management of splenic injuries, from which the authors infer a gap between the best available evidence and its translation into practice. 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.

Methods

We explored areas of ongoing controversy in the management of splenic injury though a series of iterative surveys. We invited 70 experts in trauma care from ten countries around the world to participate. Areas of controversy explored included: indications and frequency for in-hospital and follow-up imaging, definitions of failure of non-operative management, indications for angioembolisation and non-operative management in special populations (i.e. elderly, concomitant traumatic brain injury, penetrating trauma).

Results

A 49% response rate was obtained. Even though a wide range of practice patterns were identified, no controversies were identified in areas that do not involve the adoption of new technologies. In areas where practice pattern variation was observed, the strong influence of the local environment was constantly identified as an impediment to changes in practice.

Conclusions

We have identified that barriers present within local practice environments are the major driving forces behind controversies in the non-operative management of splenic injuries.

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.

References (21)

There are more references available in the full text version of this article.

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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.

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