The song remains the same although the instruments are changing: complications following selective non-operative management of blunt spleen trauma: a retrospective review of patients at a level I trauma centre from 1996 to 2007

Aisling A Clancy, Corina Tiruta, Dianne Ashman, Chad G Ball, Andrew W Kirkpatrick, Aisling A Clancy, Corina Tiruta, Dianne Ashman, Chad G Ball, Andrew W Kirkpatrick

Abstract

Background: Despite a widespread shift to selective non-operative management (SNOM) for blunt splenic trauma, there remains uncertainty regarding the role of adjuncts such as interventional radiological techniques, the need for follow-up imaging, and the incidence of long-term complications. We evaluated the success of SNOM (including splenic artery embolization, SAE) for the management of blunt splenic injuries in severely injured patients.

Methods: Retrospective review (1996-2007) of the Alberta Trauma Registry and health records for blunt splenic trauma patients, aged 18 and older, with injury severity scores of 12 or greater, admitted to the Foothills Medical Centre.

Results: Among 538 eligible patients, 150 (26%) underwent early operative intervention. The proportion of patients managed by SNOM rose from 50 to 78% over the study period, with an overall success rate of SNOM of 87%, while injury acuity remained unchanged over time. Among SNOM failures, 65% underwent surgery within 24 hours of admission. Splenic arterial embolization (SAE) was used in only 7% of patients managed non-operatively, although at least 21% of failed SNOM had contrast extravasation potentially amenable to SAE. Among Calgary residents undergoing SNOM, hospital readmission within six months was required in three (2%), all of whom who required emergent intervention (splenectomy 2, SAE 1) and in whom none had post-discharge follow-up imaging. Overall, the use of post-discharge follow-up CT imaging was low following SNOM (10%), and thus no CT images identified occult hemorrhage or pseudoaneurysm. We observed seven cases of delayed splenic rupture in our population which occurred from five days to two months following initial injury. Three of these occurred in the post-discharge period requiring readmission and intervention.

Conclusions: SNOM was the initial treatment strategy for most patients with blunt splenic trauma with 13% requiring subsequent operative intervention intended for the spleen. Cases of delayed splenic rupture occurred up to two months following initial injury. The low use of both follow-up imaging and SAE make assessment of the utility of these adjuncts difficult and adherence to formalized protocols will be required to fully assess the benefit of multi-modality management strategies.

Figures

Figure 1
Figure 1
Abdominal CT scan of parenchymal splenic laceration without obvious vascular injury at 01:16 am.
Figure 2
Figure 2
Abdominal CT scan of same patient revealing active contrast extravasation at 08:13 am.
Figure 3
Figure 3
Utilization of splenic artery angiography (SAA) in patients undergoing nonoperative management (NOM) for acute splenic injury at the Foothills Medical Centre 2000-2007.

References

    1. Brasel KJ, DeLisle CM, Olson CJ, Borgstrom DC. Splenic injury: trends in evaluation and management. J Trauma-Injury Infect Crit Care. 1998;44:283–286. doi: 10.1097/00005373-199802000-00006.
    1. Peitzman AB, Heil B, Rivera L, Federle MB, Harbrecht BG, Clancy KD, Croce M, Enderson BL, Morris JA, Shatz D. et al.Blunt selenic injury in adults: multi-institutional study of the Eastern association for the surgery of trauma. J Trauma-Injury Infect Crit Care. 2000;49:177–187. doi: 10.1097/00005373-200008000-00002.
    1. Nix JA, Costanza M, Daley BJ, Powell MA, Enderson BL. Outcome of the current management of splenic injuries. J Trauma-Injury Infect Crit Care. 2001;50:835–841. doi: 10.1097/00005373-200105000-00010.
    1. Dent D, Alsabrook G, Erickson BA, Myers J, Wholey M, Stewart R, Root H, Ferral H, Postoak D, Napier D, Pruitt BA. Blunt splenic injuries: High nonoperative management rate can be achieved with selective embolization. J Trauma-Injury Infect Crit Care. 2004;56:1063–1067. doi: 10.1097/01.TA.0000123037.66867.F2.
    1. Haan JM, Biffl W, Knudson MM, Davis KA, Oka T, Majercik S, Dicker R, Marder S, Scalea TM. Splenic embolization revisited: a multicenter review. J Trauma-Injury Infect Crit Care. 2004;56:542–547. doi: 10.1097/01.TA.0000114069.73054.45.
    1. Haan JM, Bochicchio GV, Kramer N, Scalea TM. Nonoperative management of blunt splenic injury: A 5-year experience. J Trauma-Injury Infect Crit Care. 2005;58:492–498. doi: 10.1097/01.TA.0000154575.49388.74.
    1. Smith JS, Cooney RN, Mucha P. Nonoperative management of the ruptured spleen: a revalidation of criteria. Surgery. 1996;120:745–750. doi: 10.1016/S0039-6060(96)80026-2.
    1. Balaa F, Yelle JD, Pagliarello G, Lorimer J, O'Brien JA. Isolated blunt splenic injury: Do we transfuse more in an attempt to operate less? Can J Surg. 2004;47:446–450.
    1. Cocanour CS, Moore FA, Ware DN, Marvin RG, Clark JM, Duke JH. Delayed complications of nonoperative management of blunt adult splenic trauma. Arch Surg. 1998;133:619–624. doi: 10.1001/archsurg.133.6.619.
    1. Haan JM, Marmery H, Shanmuganathan K, Mirvis SE, Scalea TM. Experience with splenic main coil embolization and significance of new or persistent pseudoaneurym: reembolize, operate, or observe. J Trauma-Injury Infect Crit Care. 2007;63:615–619. doi: 10.1097/TA.0b013e318142d244.
    1. Weinberg JA, Magnotti LJ, Croce MA, Edwards NM, Fabian TC. The utility of serial computed tomography imaging of blunt splenic injury: Still worth a second look? J Trauma-Injury Infect Crit Care. 2007;62:1143–1147. doi: 10.1097/TA.0b013e318047b7c2.
    1. Weinberg JA, Lockhart ME, Parmar AD, Griffin RL, Melton SM, Vandromme MJ, McGwin G, Rue LW. Computed tomography identification of latent Pseudoaneurysm after blunt splenic injury: pathology or technology? J Trauma-Injury Infect Crit Care. 2010;68:1112–1116. doi: 10.1097/TA.0b013e3181d769fc.
    1. Schroeppel TJ, Croce MA. Diagnosis and management of blunt abdominal solid organ injury. Curr Opin Crit Care. 2007;13:399–404. doi: 10.1097/MCC.0b013e32825a6a32.
    1. Thaemert BC, Cogbill TH, Lambert PJ. Nonoperative management of splenic injury: are follow-up computed tomographic scans of any value? J Trauma-Injury Infect Crit Care. 1997;43:748–751. doi: 10.1097/00005373-199711000-00003.
    1. Peitzman AB, Harbrecht BG, Rivera L, Heil B. Eastern Assoc Surg Trauma M: failure of observation of blunt splenic injury in adults: Variability in practice and adverse consequences. J Am Coll Surg. 2005;201:179–187. doi: 10.1016/j.jamcollsurg.2005.03.037.
    1. Crawford RS, Tabbara M, Sheridan R, Spaniolas K, Velmahos GC. Early discharge after nonoperative management for splenic injuries: increased patient risk caused by late failure? Surgery. 2007;142:337–342. doi: 10.1016/j.surg.2007.05.003.
    1. Smith J, Armen S, Cook CH, Martin LC. Blunt splenic injuries: have we watched long enough? J Trauma-Injury Infect Crit Care. 2008;64:656–663. doi: 10.1097/TA.0b013e3181650fb4.
    1. Cocanour CS, Moore FA, Ware DN, Marvin RG, Duke JH. Age should not be a consideration for nonoperative management of blunt splenic injury. J Trauma-Injury Infect Crit Care. 2000;48:606–610. doi: 10.1097/00005373-200004000-00005.
    1. 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-Injury Infect Crit Care. 2009;66:1531–1538. doi: 10.1097/TA.0b013e3181a4ed11.
    1. Association for the Advancement of Automotive Medicine Committee on Injury Scaling. The Abbreviated Injury Scale--1998 Revision (AIS-98) Medicine. AftAoA ed. Des Plaines, IL.; 1998.
    1. National Center for Health Statistics, International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM)
    1. Cadeddu M, Garnett A, Al-Anezi K, Farrokhyar F. Management of spleen injuries in the adult trauma population: a ten-year experience. Can J Surg. 2006;49:386–390.
    1. Haan J, Scott J, Boyd-Kranis RL, Kramer M, Scalea TM. Admission angiography for blunt splenic injury: advantages and pitfalls. J Trauma-Injury Infect Crit Care. 2001;51:1161–1165. doi: 10.1097/00005373-200112000-00023.
    1. Harbrecht BG, Zenati MS, Ochoa JB, Puyana JC, Alarcon LH, Peitzman AB. Evaluation of a 15-year experience with splenic injuries in a state trauma system. Surgery. 2007;141:229–238. doi: 10.1016/j.surg.2006.06.032.
    1. Harbrecht BG, Ko SH, Watson GA, Forsythe RM, Rosengart MR, Peitzman AB. Angiography for blunt splenic trauma does not improve the success rate of nonoperative management. J Trauma-Injury Infect Crit Care. 2007;63:44–49. doi: 10.1097/TA.0b013e3180686531.
    1. Liu PP, Lee WC, Cheng YF, Hsieh PM, Hsieh YM, Tan BL, Chen FC, Huang TC, Tung CC. Use of splenic artery embolization as an adjunct to nonsurgical management of blunt splenic injury. J Trauma-Injury Infect Crit Care. 2004;56:768–772. doi: 10.1097/01.TA.0000129646.14777.ff.
    1. Cooney R, Ku J, Cherry R, Maish GO, Carney D, Scorza LB, Smith JS. Limitations of splenic angioembolization in treating blunt splenic injury. J Trauma-Injury Infect Crit Care. 2005;59:926–932. doi: 10.1097/01.ta.0000188134.32106.89.
    1. Smith HE, Biffl WL, Majercik SD, Jednacz J, Lambiase R, Cioffi WG. Splenic artery embolization: have we gone too far? J Trauma-Injury Infect Crit Care. 2006;61:541–544. doi: 10.1097/01.ta.0000235920.92385.2b.
    1. Ball C, Kirkpatrick A, D'Amours S. The RAPTOR: resuscitation with angiography, percutaneous techniques and operative repair. Transforming the discipline of trauma surgery. Canadian J Surgery. 2011;54:E3–E4.
    1. Sclafani SJA, Shaftan GW, Scalea TM, Patterson LA, Kohl L, Kantor A, Herskowitz MM, Hoffer EK, Henry S, Dresner LS, Wetzel W. Nonoperative salvage of computed Tomography-diagnosed splenic injuries - utilization of angiography for triage and embolization for hemostasis. J Trauma-Injury Infect Crit Care. 1995;39:818–827. doi: 10.1097/00005373-199511000-00004.
    1. Wu SC, Chen RJ, Yang AD, Tung CC, Lee KH. Complications associated with embolization in the treatment of blunt splenic injury. World J Surgery. 2008;32:476–482. doi: 10.1007/s00268-007-9322-x.
    1. Ekeh AP, McCarthy MC, Woods RJ, Haley E. Complications arising from splenic embolization after blunt splenic trauma. Am J Surg. 2005;189:335–339. doi: 10.1016/j.amjsurg.2004.11.033.
    1. Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D. Nonoperative treatment of blunt injury to solid abdominal organs - A prospective study. Arch Surg. 2003;138:844–849. doi: 10.1001/archsurg.138.8.844.
    1. Wu SC, Chow KC, Lee KH, Tung CC, Yang AD, Lo CJ. Early selective angioembolization improves success of nonoperative management of blunt splenic injury. Am Surg. 2007;73:897–902.
    1. Bala M, Edden Y, Mintz Y, Kisselgoff D, Gercenstein I, Rivkind AI, Farugy M, Almogy G. Blunt splenic trauma: predictors for successful non-operative management. Israel Med Assoc J. 2007;9:857–861.
    1. Meguid AA, Bair HA, Howells GA, Bendick PJ, Kerr HH, Villalba MR. Prospective evaluation of criteria for the nonoperative management of blunt splenic trauma. Am Surg. 2003;69:238–242.
    1. Savage SA, Zarzaur BL, Magnotti LJ, Weinberg JA, Maish GO, Bee TK, Minard G, Schroeppel T, Croce MA, Fabian TC. The evolution of blunt splenic injury: resolution and progression. J Trauma-Injury Infect Crit Care. 2008;64:1085–1091. doi: 10.1097/TA.0b013e31816920f1.
    1. Schurr MJ, Fabian TC, Gavant M, Croce MA, Kudsk KA, Minard G, Woodman G, Pritchard FE. Management of blunt splenic trauma - computed tomographic contrast blush predicts failure of nonoperative management. J Trauma-Injury Infect Crit Care. 1995;39:507–513.
    1. Lawson DE, Jacobson JA, Spizarny DL, Pranikoff T. Splenic trauma - value of follow-up ct. Radiology. 1995;194:97–100.
    1. Norrman G, Tingstedt B, Ekelund M, Andersson R. Nonoperative management of blunt splenic trauma: also feasible and safe in centers with low trauma incidence and in the presence of established risk factors. Eur J Trauma Emergency Surgery. 2009;35:102–107. doi: 10.1007/s00068-008-8108-7.
    1. Trunkey DD. Trauma. Sci Am. 1983;249:28–35. doi: 10.1038/scientificamerican0883-28.
    1. Houtchens BA. Major trauma in the rural mountain west. Ann Emerg Med. 1977;6:343–50.
    1. Peitzman AB, Heil B, Rivera L, Federle MB, Harbrecht BG, Clancy KD. et al.Blunt splenic injury in adults: Multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma. 2000;49:177–189. doi: 10.1097/00005373-200008000-00002.
    1. Haan J, Scott J, Boyd-Kranis RL, Ho S, Kramer M, Scalea TM. Admission angiography for blunt splenic injury: advantages and pitfalls. J Trauma. 2001;51:1161–1165. doi: 10.1097/00005373-200112000-00023.
    1. Brasel K, Delisle C, Olson C, Borgstrom O. Splenic injury: trends in evaluation and management. J Trauma. 1998;44:283–285. doi: 10.1097/00005373-199802000-00006.
    1. Kirkpatrick AW. Clinician-performed focused sonography for the resuscitation of trauma. Crit Care Med. 2007;35:S162–S172. doi: 10.1097/01.CCM.0000260627.97284.5D.
    1. Kirkpatrick AW, Sirois M, Laupland KB, Goldstein L, Brown DR, Simons RK. et al.The hand-held FAST exam for blunt trauma. Can J Surg. 2005;48:453–460.
    1. Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malagoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision) J Trauma. 1995;38:323–324. doi: 10.1097/00005373-199503000-00001.
    1. Haan JM, Bochicchio GV, Kramer N, Scalea TM. Nonoperative management of blunt splenic injury: a 5-year experience. J Trauma. 2005;58:492–498. doi: 10.1097/01.TA.0000154575.49388.74.
    1. Haan JM, Boswell S, Stein D, Scalea TM. Follow-up abdominal CT is not necessary in low-grade splenic injury. Am Surg. 2007;73:13–18.
    1. Weinberg JA, Magnotti LJ, Croce MA, Edwards NM, Fabian TC. The utility of serial computed tomography imaging of blunt splenic injury: Still worth a second look? J Trauma. 2007;62:1143–1148. doi: 10.1097/TA.0b013e318047b7c2.

Source: PubMed

Спонсоры и соавторы

Заболевания

Медикаментозные вмешательства

Подписаться