Nonoperative management of blunt splenic injury in adults: there is (still) a long way to go. The results of the Bologna-Maggiore Hospital trauma center experience and development of a clinical algorithm.

Abstract

Non-operative management (NOM) of hemodynamically stable patients with blunt splenic injury (BSI) is the standard of care, although it is associated with a potential risk of failure. Hemodynamically unstable patients should always undergo immediate surgery and avoid unnecessary CT scans. Angioembolization might help to increase the NOM rates, as well as NOM success rates. The aim of this study was to review and critically analyze the data from BSI cases managed at the Maggiore Hospital Trauma Center during the past 5 years, with a focus on NOM, its success rates and outcomes. A further aim was to develop a proposed clinical practical algorithm for the management of BSI derived from Clinical Audit experience. During the period between January 1, 2009 and December 31, 2013 we managed 293 patients with splenic lesions at the Trauma Center of Maggiore Hospital of Bologna. The data analyzed included the demographics, clinical parameters and characteristics, diagnostic and therapeutic data, as well as the outcomes and follow-up data. A retrospective evaluation of the clinical outcomes through a clinical audit has been used to design a practical clinical algorithm. During the five-year period, 293 patients with BSI were admitted, 77 of whom underwent immediate surgical management. The majority (216) of the patients was initially managed non-operatively and 207 of these patients experienced a successful NOM, with an overall rate of successful NOM of 70 % among all BSI cases. The success rate of NOM was 95.8 % in this series. All patients presenting with stable hemodynamics underwent an immediate CT-scan; angiography with embolization was performed in 54 cases for active contrast extravasation or in cases with grade V lesions even in absence of active bleeding. Proximal embolization was preferentially used for high-grade injuries. After a critical review of the cases treated during the past 5 years during a monthly clinical audit meeting, a clinical algorithm has been developed with the aim of standardizing the clinical management of BSI by a multidisciplinary team to include every patient within the correct diagnostic and therapeutic pathway, in order to improve the outcomes by potentially decreasing the NOM failure rates and to optimize the utilization of resources.