Short-term outcomes of non-operative management of blunt splenic injury: a retrospective study

Abbreviations:

• AAST – American Association for the Surgery of Trauma
• ASA – American Society of Anesthesiologists
• CT – computed tomography
• DSA – digital subtraction angiography
• NOM – non-operative management
• TAE – transcatheter arterial embolization

The spleen is one of the most frequently vulnerable organs, accounting for about 32% of patients with blunt abdominal trauma [1][2]. This injury can lead to severe internal bleeding and hemorrhagic shock with a mortality rate of 7–18% if diagnosis and treatment are delayed [3]. Motor vehicle accidents and falls are the most prevalent causes of splenic injury in blunt abdominal trauma [1][4].

Treatment modalities for blunt splenic injury include surgical interventions (splenorrhaphy and splenectomy) and non-operative management (NOM). Laparotomy is a recommended therapeutic option for blunt splenic injury and splenectomy is often unavoidable in hemodynamically unstable patients [1][5][6]. However, the spleen plays a critical role in the immune defense response, including filtration, blood storage and phagocytosis [3]. Therefore, organ-preserving strategies were proposed with initial studies focusing on pediatric cases [6].

Over the past few decades, because of advances in modern diagnostic tools and medical interventions, the management of splenic trauma has shifted significantly in favor of NOM. For hemodynamically stable patients, NOM may require close monitoring with or without digital subtraction angiography (DSA) or DSA with selective splenic embolization [1][3][6].

The aim of the study is to evaluate the short-term outcomes of NOM for blunt splenic trauma and to identify prognostic factors for its success at a tertiary hospital.

MATERIALS AND METHODS

The retrospective study included patients admitted to People’s Hospital 115 (a tertiary hospital) with a diagnosis of blunt splenic injury according to the classification codes of the International Classification of Disease 10^th revision (ICD-10) between January 2021 and December 2023.

Inclusion criteria were as follows:

• age 16 or older;
• isolated or combined splenic injury due to blunt abdominal trauma;
• conservative therapy or NOM.

Non-inclusion criteria were:

• penetrating injury;
• death before admission to the hospital;
• the need for emergency surgery due to instability or other diagnoses.

Data were collected on demographics, clinical symptoms, trauma causes, radiological injury characteristics, and medical interventions.

The study flowchart is illustrated in Figure. A total of 136 patients with blunt splenic injury were assessed, of whom 91 (66.9%) were included in the study.

All patients admitted for blunt splenic trauma were managed according to the Advanced Trauma Life Support (ATLS^®) guidelines by the American College of Surgeons Committee on Trauma (Chicago, USA) [7]. Fluid resuscitation and blood replacement were administered to maintain hemodynamic stable.

Contrast-enhanced computed tomography (CT) was performed to assess the grade of splenic injury, the extent of haemoperitoneum, presence of peritonitis and other associated injuries. If active splenic arterial bleeding or a pseudoaneurysm was identified using CT, transcatheter arterial embolization (TAE) was performed by interventional radiologists.

When DSA of the celiac artery and splenic artery identified the bleeding site, superselective embolization was performed using embolic materials such as gelatin sponge, Lipiodol, Histoacryl or fibered coil (Boston Scientific, USA).

The primary endpoint was the success of NOM during the current hospitalization.

Statistical data analysis

Data distribution was assessed using the Kolmogorov-Smirnov test. Categorical variables are presented as frequencies (%), continuous variables as mean values ± standard deviation or median (interquartile range) depending on the distribution. For categorical variables, the chi-square test was used. A p-value < 0.05 was considered statistically significant. Statistical analyses were performed using SPSS version 26.0 (IBM Corp., USA).

RESULTS

The median age was 34 (25; 47) years, and the male-to-female ratio was 6:1. Traffic accidents were the leading cause (81.3%), followed by occupational accidents (12.1%). Moreover, 73.6% of patients arrived within 12 hours of trauma. Also, 50 patients (54.9%) received first aid at the healthcare facilities, and 41 patients (45.1%) did not receive first aid or went to the hospital directly. The clinical symptoms, laboratory tests, and diagnostic imaging results are summarized in Table 1.

The severity of the hemoperitoneum correlated with increasing the grade of splenic injury (p = 0.029) (Table 2).

The length of hospital stay ranged from 1 to 26 days, with a median of 5 (4; 6) days. The median blood transfusion volume was 937.5 ± 340.9 mL.

Concerning the interim treatment outcomes, 88 patients (96.7%) were stable and discharged from the hospital following NOM. Of these patients, 74 received medical treatment alone while 14 received a combination of medical therapy and TAE. The distribution of successful NOM rates following Grades I–V of blunt splenic injury was 100%, 100%, 97.1%, 100%, and 60%, respectively (Table 3).

Only three patients experienced persistent intra-abdominal bleeding and hemodynamic instability despite NOM, necessitating urgent open total splenectomy (the characteristics of these cases are summarized in (Table 4). As a result, all three patients achieved postoperative progress and were successfully discharged. There were no mortalities in the study cohort.

DISCUSSION

In cases of splenic injury due to blunt abdominal trauma, NOM has emerged as the gold standard for hemodynamically stable patients without signs of peritonitis [2][3][5]. B. Garber et al. reported in a multicentric retrospective analysis that NOM became the preferred therapeutic strategy, followed by splenectomy and splenorrhaphy. The rate of NOM increased from 59% in 1991 to 75% in 1994, while splenectomy rates declined from 35% to 24% during the same period [8].

Recent studies indicate that NOM of blunt splenic injury is feasible in 74–88% of cases [9][10]. Among patients with blunt splenic injury in this study, NOM was possible in 66.9%. There is a male predominance in blunt splenic injury (85%), with motor vehicle and motorbike accidents being the primary cause of such injuries. As reported in other studies, the prevalence among men was about 70–80% [6][11][12]. Since the most common vehicle in Vietnam is the motorcycle, motorcycle accidents are the leading cause of blunt abdominal trauma, especially splenic injury [13].

Abdominal ultrasound and contrast-enhanced CT could allow for assessing hemoperitoneum volume, injury severity, and associated abdominal organ damage. In this study, imaging findings revealed splenic injuries predominantly classified as Grades II–III according to AAST scale, accompanied by mild-to-moderate hemoperitoneum. A. Yildiz et al. reported Grades II and III injuries as the most common (34.1% and 35.4%, respectively). The extent of hemoperitoneum correlated positively with the severity of splenic injury [14]. In the present study, NOM of blunt splenic injury demonstrated a high success rate of 96.7%, and in only three patients (3.3%) did it prove not successful. Currently, NOM has become the primary treatment strategy for splenic injuries, with success rates ranging from 80% to 100% [10][15–18]. A. Brillantino et al. reported a comparable failure rate of 4.6% [18].

The severity of the splenic injury is a critical predictor of NOM failure. Previous studies have classified Grade I-III spleen injuries as low grade, whereas Grade IV–V is considered high grade. If Grade III spleen damage is accompanied by concomitant solid organ injury, it may be reclassified as a high-grade. The incidence of NOM failure increased progressively with the increasing grade of splenic injury.

In this study, the Grade I–V spleen injuries were successfully treated with NOM in 100%, 100%, 97.1%, 100%, and 60% (p = 0.0001), respectively. A. Yildiz et al. demonstrated that the success rates in Grade I-V spleen injuries were 100%, 96.3%, 92.8%, 57.7%, and 0% [14]. In three patients with NOM failure, two patients had Grade V splenic injury and one patient had Grade III splenic injury with an older age (85 years). Moreover, this patient had concomitant Grade III lateral kidney injury. All three patients had contrast extravasation on angiography and required more than three units of blood transfusion.

A. Yildiz et al. suggested that the grade of splenic injury, hemoperitoneum volume, the age being over 55 years old, the presence of contrast extravasation or pseudoaneurysm on CT, and requiring a transfusion of more than four units of blood within the first 24 h were considered risk factors for NOM failure. Additionally, other factors including ASA (American Society of Anesthesiologists) physical status classification, GCS (Glasgow Coma Scale), ISS (Injury Severity Score), and RTS (Revised Trauma Score), comorbidities, and abdominal and extra-abdominal organ injuries, have impacted NOM success [18–21].

NOM failure typically occurs within four days following trauma, with a maximum reported delay of 26 days [11]. A. Peitzman et al. found that 78.9% of failures happened within 48 hours of admission, with the remainder failing between days 7 and 12 [4]. In this study, three cases experienced NOM failure on day 2. CT scanning was frequently performed to monitor hospitalized or discharged patients, but this is controversial. Repeat imaging of low-grade splenic injuries is not necessary unless there is evidence of intra-abdominal hemorrhage. Nonetheless, repeat CT scans in hospitalized patients may detect vascular anomalies such as splenic artery pseudoaneurysms [14].

In the present study, we indicated TAE in patients who had contrast extravasation or artery pseudoaneurysm on CT immediately after admission. In three cases with NOM failure, TAE could enhance the outcomes of blunt splenic injuries and increase the splenic salvage rates. Most studies suggested using TAE only for patients with a contrast hemorrhage or posttraumatic pseudoaneurysm of the splenic artery on CT [11][21].

The limitations of this study are as follows: 1) this is a retrospective study; 2) sample size was limited; 3) this was a single-center study. The failure rate of NOM in the study was low. Therefore, no predictive variables could be provided.

CONCLUSION

Out of all the solid organs, the spleen is one of the most vulnerable to blunt abdominal trauma. NOM is preferred for managing hemodynamically stable patients, demonstrating a relatively high success rate, especially in patients with mild to moderate splenic rupture severity. TAE in combination with medical treatment enhances the rate of splenic salvage.

AUTHORS CONTRIBUTIONS

Quang H. Nguyen and Toan K. Dang conceived and designed the study. They also wrote the article. Song X. Hoang collected and analyzed the data, as well as participated in the drafting of the article. Quang H. Nguyen analyzed and interpreted the data. All of the authors approved the final version of the publication.

ВКЛАД АВТОРОВ

К.Х. Нгуен, Т.К. Данг разработали концепцию и дизайн исследования, написали статью. Ш.С. Хоанг осуществил сбор и анализ данных, участвовал в написании статьи. К.Х. Нгуен проанализировал и интерпретировал данные. Все авторы одобрили окончательную версию публикации.