Management of splenic trauma: a single institution’s 8-year experience

• Nonoperative management of blunt splenic trauma has supplanted surgical therapy.
• Patients undergoing immediate splenectomy have higher injury severity scores as well as morbidity and mortality rates compared with patients successfully managed nonoperatively suggesting that these are 2 very different groups of patients.
• Patients with high-grade injuries, significant-associated visceral injuries, and comorbidities associated with coagulopathy should be considered for early aggressive embolization.
• Patients who have persistent shock should not be considered candidates for nonoperative management and risk a high rate of treatment failure.
• In the properly selected patients, splenic embolization may improve the success rates of nonoperative management of blunt splenic injuries in adult trauma patients.

BackgroundManagement of splenic trauma has evolved, with current practice favoring selective angiographic embolization and non-operative treatment over immediate splenectomy. Defining the optimal selection criteria for the appropriate management strategy remains an important question.MethodsThis retrospective registry review was conducted at a Level I trauma center. The patient population consisted of 20,561 patients in the State Trauma Registry from April 2004 to May 2012. Splenectomy, angiography, splenic embolization, nonoperative, and noninterventional (NI) observation were the management strategies under study. Morbidity and mortality were the outcome measures. Morbidity and mortality by management strategy.ResultsDuring the 8-year study period, 926 (4.5%) patients sustained splenic injury. Observational management increased over time despite the similar distribution of splenic injury grade over the study period: grade I/II (50%), grade III (24.2%), and grade IV/V (25.8%). Mortality rates associated with each management strategy were the following: immediate splenectomy (IS; 25%), splenic embolization (SE; 3.9%), and angiography only or observation, that is, NI (6.5%) management. Injury severity score (ISS) was highest in IS (36.1 ± 1.3) compared with SE (29.1 ± 1.0, P = .001) and NI (21.6, P < .001). Splenectomy was required in 5 of the 129 (3.9%) patients managed with SE and 9 of the 677 (1.3%) patients managed by NI. Mortality was significantly lower among those managed by SE (odds ratio .12, 95% confidence interval: .05 to .32) or NI (odds ratio .21, 95% confidence interval: .12 to .35). This survival benefit was explained by the association of IS with systolic blood pressure <90, high ISS, low GCS at presentation, ISS, development of shock, need for transfusion, and multiorgan failure.ConclusionsIn this large 8-year single institution study, we observed an increase in nonoperative management by an increased application of angiography and embolization. An aggressive utilization of SE in patients with appropriate indications will result in low failure rates and improved mortality.