Non-operative management of blunt hepatic and splenic injuries–practical aspects and value of radiological scoring systems

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Summary

Background

Non-operative management (NOM) of blunt hepatic and splenic injuries has become popular in haemodynamically stable adult patients, despite uncertainty about efficacy, patient selection, and details of management. Up-to-date strategies and practical recommendations are presented.

Methods

A selective literature search was conducted in PubMed and the Cochrane Library (1989–2016).

Results

No randomized clinical trial was found. Non-randomized controlled trials and large retrospective and prospective series dominate. Few systematic reviews and meta-analyses are available. NOM of selected patients with blunt liver and spleen injuries is associated with low morbidity and mortality. Only data of limited evidence are available on intensity and duration of patient monitoring, repeat imaging, antithrombotic prophylaxis and return to normal activity. There is high-level evidence on early mobilisation and post-splenectomy vaccination.

Conclusion

NOM of blunt liver or spleen injuries is a worldwide trend, but the literature does not provide high-grade evidence for this strategy.

Zusammenfassung

Hintergrund

Das nichtoperative Management (NOM) stumpfer Leber- und Milzverletzungen hat sich zu einem beliebten Verfahren bei hämodynamisch stabilen Patienten entwickelt, trotz der Ungewissheit bezüglich Wirksamkeit, Patientenselektion und Details zum Management. In diesem Beitrag werden aktuelle Verfahren und praktische Empfehlungen vorgestellt.

Methoden

Eine selektive Literaturrecherche in PubMed und Cochrane Library (1989–2016) wurde durchgeführt.

Ergebnisse

Es wurde keine randomisierte klinische Studie gefunden. Nichtrandomisierte kontrollierte Studien und große retrospektive und prospektive Serien dominieren das Ergebnis. Einzelne systematische Reviews und Metaanalysen sind verfügbar. Das NOM bei ausgewählten Patienten mit stumpfen Leber- und Milzverletzungen ist mit einer geringen Morbidität und Mortalität assoziiert. Hinsichtlich der Intensität und Dauer der Patientenüberwachung, der wiederholten Bildgebung, Thromboseprophylaxe und Wiederaufnahme der normalen Aktivitäten stehen nur Daten mit eingeschränkter Evidenz zur Verfügung. Es besteht eine hochgradige Evidenz für die frühe Mobilisation und die Immunisierung nach Splenektomie.

Schlussfolgerung

Das NOM stumpfer Leber- und Milzverletzungen ist ein weltweiter Trend, jedoch bietet die Literatur keine hochgradige Evidenz für dieses Verfahren.

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Most cited references 50

Record: found
Abstract: found
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A prospective study of venous thromboembolism after major trauma.

W H Geerts, K I Code, R Jay … (1994)

Although deep-vein thrombosis and pulmonary embolism are considered common complications after major trauma, their frequency and the associated risk factors have not been carefully quantified. We performed serial impedance plethysmography and lower-extremity contrast venography to detect deep-vein thrombosis in a cohort of 716 patients admitted to a regional trauma unit. Prophylaxis against thromboembolism was not used. Deep-vein thrombosis in the lower extremities was found in 201 of the 349 patients (58 percent) with adequate venographic studies, and proximal-vein thrombosis was found in 63 (18 percent). Three patients died of massive pulmonary embolism before venography could be performed. Before venography, only three of the patients with deep-vein thrombosis had clinical features suggestive of the condition. Deep-vein thrombosis was found in 65 of the 129 patients with major injuries involving the face, chest, or abdomen (50 percent); in 49 of the 91 patients with major head injuries (53.8 percent); in 41 of the 66 with spinal injuries (62 percent); and in 126 of the 182 with lower-extremity orthopedic injuries (69 percent). Thrombi were detected in 61 of the 100 patients with pelvic fractures (61 percent), in 59 of the 74 with femoral fractures (80 percent), and in 66 of the 86 with tibial fractures (77 percent). A multivariate analysis identified five independent risk factors for deep-vein thrombosis: older age (odds ratio, 1.05 per year of age; 95 percent confidence interval, 1.03 to 1.06), blood transfusion (odds ratio, 1.74; 95 percent confidence interval, 1.03 to 2.93), surgery (odds ratio, 2.30; 95 percent confidence interval, 1.08 to 4.89), fracture of the femur or tibia (odds ratio, 4.82; 95 percent confidence interval, 2.79 to 8.33), and spinal cord injury (odds ratio, 8.59; 95 percent confidence interval, 2.92 to 25.28). Venous thromboembolism is a common complication in patients with major trauma, and effective, safe prophylactic regimens are needed.

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Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline.

Oscar D Guillamondegui, D Cheng, Ben Zarzuar … (2012)

During the last century, the management of blunt force trauma to the spleen has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the Practice Management Guidelines for Non-operative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the current EAST guideline. The National Library of Medicine and the National Institute of Health MEDLINE database was searched using Pub Med (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords splenic injury and blunt abdominal trauma. One hundred seventy-six articles were reviewed, of which 125 were used to create the current practice management guideline for the selective nonoperative management of blunt splenic injury. There has been a plethora of literature regarding nonoperative management of blunt splenic injuries published since the original EAST practice management guideline was written. Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury, patient age, or the presence of associated injuries. Its use is associated with a low overall morbidity and mortality when applied to an appropriate patient population. Nonoperative management of blunt splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and has an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt splenic injuries. Repeat imaging should be guided by a patient's clinical status. Adjunctive therapies like angiography with embolization are increasingly important adjuncts to nonoperative management of splenic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt splenic injuries remain without conclusive answers in the literature.

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Splenic trauma: WSES classification and guidelines for adult and pediatric patients

Federico Coccolini, Giulia Montori, Fausto Catena … (2017)

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

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Author and article information

Contributors

Dietmar Öfner: +43-512-50422600 , dietmar.oefner@i-med.ac.at

Journal

Journal ID (nlm-ta): Eur Surg

Journal ID (iso-abbrev): Eur Surg

Title: European Surgery

Publisher: Springer Vienna (Vienna )

ISSN (Print): 1682-8631

ISSN (Electronic): 1682-4016

Publication date (Electronic): 20 July 2018

Publication date PMC-release: 20 July 2018

Publication date (Print): 2018

Volume: 50

Issue: 6

Pages: 285-298

Affiliations

[1 ]ISNI 0000 0000 8853 2677, GRID grid.5361.1, Department of Visceral, Transplantation and Thoracic Surgery, , Medical University of Innsbruck, ; Anichstraße 35, 6020 Innsbruck, Austria

[2 ]ISNI 0000 0000 8853 2677, GRID grid.5361.1, Department of Radiology, , Medical University of Innsbruck, ; Anichstraße 35, 6020 Innsbruck, Austria

[3 ]ISNI 0000 0000 8853 2677, GRID grid.5361.1, Department of Trauma Surgery, , Medical University of Innsbruck, ; Anichstraße 35, 6020 Innsbruck, Austria

Article

Publisher ID: 545

DOI: 10.1007/s10353-018-0545-x

PMC ID: 6267420

PubMed ID: 30546386

SO-VID: 9ce72cf8-c25a-4d82-a3b6-fd82387dda4a

License:

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 14 December 2017

Date accepted : 7 June 2018

Funding

Funded by: University of Innsbruck and Medical University of Innsbruck

Open Access :

Open access funding provided by University of Innsbruck and Medical University of Innsbruck.

Custom metadata

Keywords: abdominal trauma,sports,multiple trauma,classification,diagnostic imaging,bauchtrauma,sport,multiple traumata,klassifikation,diagnostische bildgebung

Data availability:

Keywords: abdominal trauma, sports, multiple trauma, classification, diagnostic imaging, bauchtrauma, sport, multiple traumata, klassifikation, diagnostische bildgebung

Non-operative management of blunt hepatic and splenic injuries–practical aspects and value of radiological scoring systems Translated title: Nichtoperatives Management stumpfer Leber- und Milzverletzungen – Praktische Aspekte und Stellenwert radiologischer Scoring-Systeme

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Zusammenfassung

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Chinese Journal of School Health

Most cited references 50

A prospective study of venous thromboembolism after major trauma.

Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline.

Splenic trauma: WSES classification and guidelines for adult and pediatric patients

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