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Introduction
Since the introduction of major trauma centres and regional trauma networks in 2012, management of splenic injury has shifted, with non-operative management now favoured. For those requiring intervention, splenic artery embolisation is well established as a first-line treatment in all but the most severely injured. Follow-up is variabl...
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Citations
... However, over recent decades, there has been a shift towards more conservative treatment methods. This change is due to the critical role the spleen plays in immune function; patients without a spleen are at increased risk of opportunistic infections, including overwhelming post-splenectomy infection syndrome [1,2]. Conservative management of splenic trauma typically involves nonoperative measures, such as angiography and embolization, especially for patients who continue to exhibit signs of blood loss [2]. ...
... SAE has demonstrated a success rate exceeding 90% in controlling splenic hemorrhage in trauma settings [1,15,38,42,43,45,51,52]. Complication rates between proximal and distal splenic embolization have shown conflicting results, with some studies indicating higher rates for distal embolization, while others report similar rates for both techniques [11,27,39,42]. ...
... A systematic review analyzing immune function in patients who have undergone SAE showed immune competency and recommended against routine vaccination [36]. Follow-up imaging after embolization for splenic trauma is recommended only in symptomatic cases [1]. ...
The management of traumatic splenic injuries has evolved significantly over the past several decades, with the majority of these injuries now being treated nonoperatively. Patients who exhibit hemodynamic instability upon initial evaluation typically require surgical intervention, while the remainder are managed conservatively. Conservative treatment for traumatic splenic injuries encompasses both medical management and splenic artery angiography, followed by embolization in cases where patients exhibit clinical signs of ongoing splenic hemorrhage. Splenic artery embolization is generally divided into two categories: proximal and distal embolization. The choice of embolization technique is determined by the severity and location of the splenic injury. Patients who retain functioning splenic tissue after trauma do not routinely need immunization. This is in contrast to post-splenectomy patients, who are at increased risk for opportunistic infections.
... Our 95% CI for the effect of protocol implementation was −4.82 to 1.84, indicating a small effect or small possible harm. In our results, surgical procedures decreased in the after-protocol period compared to the before-protocol period, and protocol introduction was associated with an increase in IVR, which was consistent with the results of a previous study [22]. However, a drastic increase in the number of surgical procedures was observed during the protocol development period, while a decline in the number of IVR procedures was observed during the after-protocol period. ...
Background and Objectives: Minimally invasive trauma management, including interventional radiology and non-operative approaches, has proven effective. Consequently, our hospital established a trauma IVR protocol called “Ohta Nishinouchi Hospital trauma protocol (ONH trauma protocol) in 2013, mainly for trunk trauma. However, the efficacy of the ONH trauma protocol has remained unverified. We aimed to assess the protocol’s impact using interrupted time-series analysis (ITSA). Materials and Methods: This retrospective cohort study was conducted at Ohta Nishinouchi hospital, a tertiary emergency hospital, from January 2004 to December 2019. We included patients aged ≥ 18 years who presented to our institution due to severe trauma characterized by an Abbreviated Injury Scale of ≥3 in any region. The primary outcome was the incidence of in-hospital deaths per 100 transported patients with trauma. Multivariable logistic regression analysis was conducted with in-hospital mortality as the outcome, with no exposure before protocol implementation and with exposure after protocol implementation. Results: Overall, 4558 patients were included in the analysis. The ITSA showed no significant change in in-hospital deaths after protocol induction (level change −1.49, 95% confidence interval (CI) −4.82 to 1.84, p = 0.39; trend change −0.044, 95% CI −0.22 to 0.14, p = 0.63). However, the logistic regression analysis revealed a reduced mortality effect following protocol induction (odds ratio: 0.50, 95% CI: 0.37 to 0.66, p < 0.01, average marginal effects: −3.2%, 95% CI: −4.5 to −2.0, p < 0.01). Conclusions: The ITSA showed no association between the protocol and mortality. However, before-and-after testing revealed a positive impact on mortality. A comprehensive analysis, including ITSA, is recommended over before-and-after comparisons to assess the impact of the protocol.
... This study affirms that there is a high rate (97.8%) of splenic salvage in patients who have SAE and is in keeping with rates previously described in the literature. 7,[14][15][16] Patients in this series who ended up with a splenectomy did so while being treated for other injuries that required a laparotomy. Splenic bleeding described as slow in the OR notes was incidentally identified during the laparotomy and it is difficult to know for certain if this bleeding would have been clinically significant in the absence of other injuries. ...
Purpose:
Retrospective review of splenic artery embolization (SAE) outcomes performed for blunt abdominal trauma.
Materials and methods:
11-year retrospective review at a large level-1 Canadian trauma centre. All patients who underwent SAE after blunt trauma were included. Technical success was defined as angiographic occlusion of the target vessel and clinical success was defined as successful non-operative management and splenic salvage on follow-up.
Results:
138 patients were included of which 68.1% were male. The median age was 47 years (interquartile range (IQR) = 32.5 years). The most common mechanisms of injury were motor vehicle accidents (37.0%), mechanical falls (25.4%), and pedestrians hit by motor vehicles (10.9%). 70.3% of patients had American Association for the Surgery of Trauma (AAST) grade 4 injuries. Patients were treated with proximal SAE (n = 97), distal SAE (n = 23) or combined SAE (n = 18), and 68% were embolized with an Amplatzer plug. No significant differences were observed across all measures of hospitalization (Length of hospital stay: x2(2) = .358, P = .836; intensive care unit (ICU) stay: x2(2) = .390, P = .823; ICU stay post-procedure: x2(2) = 1.048, P = .592). Technical success and splenic salvage were achieved in 100% and 97.8% of patients, respectively. 7 patients (5%) had post-embolization complications and 7 patients (5%) died during hospital admission, but death was secondary to other injuries sustained in the trauma rather than complications related to splenic injury or its management.
Conclusion:
We report that SAE as an adjunct to non-operative management of blunt splenic trauma can be performed safely and effectively with a high rate of clinical success.
... The overall rate of complications in this study was low at 5.6% and occurred at a median time of 2.1 days after the treatment. In addition, only 3% of patients proceeded to splenectomy at a median time of 4 days which is low, and in keeping with the rate shown in prior literature (Moore et al. 1989;Schnüriger et al. 2011;Davies and Wells 2019;Hughes et al. 2017). Of the 7 patients requiring splenectomy after embolization, 1 patient was a 30-year-old male who presented after a motor vehicle accident with multiple injuries (ISS 38) including grade V splenic injury, hollow viscus injury, and pelvic bleeding on CT scan. ...
Background
As an adjunct to non-operative management, splenic artery embolization (SAE) has been increasingly utilized throughout the world and is now the standard of care for hemodynamically stable patients. This study aimed to retrospectively assess the rate of splenic salvage and complications after SAE for blunt trauma at a level 1 trauma center using the 2018 update to the AAST criteria, and further sub-stratify the role of angiography in AAST grade III injuries with significant hemoperitoneum.
All patients between 1 January 2009 and 1 January 2019 who underwent blunt trauma and proceeded to embolization were included. Data was collected concerning initial injury grade, location of embolization, type of embolic material used, complications, and need for subsequent splenectomy. Technical success was defined as successful angiographic occlusion of the target artery at the conclusion of embolization. Clinical success was defined as splenic salvage at discharge. Vascular lesions were characterized including those with active bleeding, pseudoaneurysm, and arterio-venous fistula.
Results
Two hundred thirty-two patients were included in the study. Treatments were performed at a median of 0 days (range 0–28 days) and the median AAST grade was IV (range III-V). Technical success was achieved in all patients. There were 13 complications (5.6%) consisting of re-bleed (9, 3.9%), infarction (3, 1.3%), and access site haematoma (1, 0.43%). Clinical success was achieved in 97% of patients with 7 patients requiring splenectomy after SAE (3.0%) at a median time of 4 days (range 0–17 days). Angiography in patients with grade III injuries identified 18 occult vascular injuries not identified at initial CT ( p < 0.0001).
Conclusions
The SPLEEN-IN study shows that treatment of intermediate-high grade blunt force traumatic splenic injuries using SAE resulted in a low rate of complication and splenic salvage in 97% of patients, providing a safe and effective treatment in stable patients. In addition, angiography of grade III injuries identified occult vascular lesions and may warrant treatment of select patients in this cohort.
Level of evidence
Level 3.
