Delayed Complications of Nonoperative Management of Blunt Adult Splenic Trauma

Cocanour, Christine S.; Moore, Frederick A.; Ware, Drue N.; Marvin, Robert G.; Clark, J. Michael; Duke, James H.

doi:10.1001/archsurg.133.6.619

Cited by 109 publications

(59 citation statements)

References 34 publications

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“…The frequency of missed hollow visceral injuries (HVI) was less than 1% in large patient studies on blunt splenic trauma [21,22]. Delayed bleeding has been reported to occur in 6-15% of nonoperatively managed patients [20,23]. Overall, transfusion rates, mortality and complications have been lower in nonoperatively managed patients than in operated patients [6,22,24], as was also seen in the present study.…”

Section: Discussionsupporting

confidence: 71%

“…The questions that were raised concerned the risks of consistent or delayed bleeding, missed visceral injury, and increased transfusion rate with associated blood-borne diseases [18]. It has also been implied that the ambition to manage patients conservatively has extended too far, thereby increasing the risks of unsafe, nonsurgical treatment of more seriously injured patients too [19,20]. Several recent studies have, however, proven these concerns to be groundless.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Nonoperative Management of Blunt Splenic Trauma: Also Feasible and Safe in Centers with Low Trauma Incidence and in the Presence of Established Risk Factors

Norrman¹,

Tingstedt²,

Ekelund³

et al. 2008

Eur J Trauma Emerg Surg

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Section: Discussionsupporting

confidence: 71%

Section: Discussionmentioning

confidence: 99%

Nonoperative Management of Blunt Splenic Trauma: Also Feasible and Safe in Centers with Low Trauma Incidence and in the Presence of Established Risk Factors

Norrman¹,

Tingstedt²,

Ekelund³

et al. 2008

Eur J Trauma Emerg Surg

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“…Patients with splenic injury, treated either surgically or nonoperatively, have the potential for developing lifethreatening delayed complications such as delayed rebleeding, vascular malformations, parenchymal or subcapsular pseudocysts, and splenic or subphrenic abscesses [12,16,83,84]. After nonoperative management the incidence of these complications is reported to be up to 8% in adults [83,84,85] and from 0 to 7.5% in children [2,16].…”

Section: Spleenmentioning

confidence: 99%

Traumatic injuries: imaging and intervention in post-traumatic complications (delayed intervention)

Goffette

Laterre

2002

Eur Radiol

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The nonoperative management (NOM) of abdominal trauma has gained increasing acceptance over the past decade. This approach has been extended to severe trauma patients previously considered as candidates for surgery. Consequently, the incidence of delayed and uncommonly encountered complications has increased. Causes of delayed complications are multiple and include: (a) abnormal or insufficient injury healing process; (b) retention of necrotic tissue; (c) secondary infection of initially sterile collections; and (d) underestimation of injury severity. The purpose of this review article is to explain the role of various imaging modalities in detecting post-traumatic delayed complications and to highlight the usefulness of minimally invasive techniques, including laparoscopy, biliary endoscopy, therapeutic angiography and image-guided drainage. Subsequent complications, which do not necessarily negatively influence the final outcome, are often predictable, virtually obligatory consequences of the successful NOM of high-grade or complex abdominal injuries. Between 50 and 60% of those patients with grade-IV or grade-V liver or splenic lacerations require some type of interventional treatment; therefore, indiscriminate discharge of patients with solid organ injury managed conservatively may be potentially harmful. As the incidence of complications is higher for more severe grade-IV or grade-V liver, spleen, or kidney injuries, scheduled follow-up CT scans may be rational in this subset of patients to identify potential complications amenable to early application of interventional techniques. Follow-up CT scans are unnecessary in stable adults or children with low-grade injury. Delayed splenic or hepatic rupture is one of the major concerns because this type of complication remains difficult to predict and historically often requires emergent surgery. These ruptures may benefit from NOM, should the same criteria as for primary rupture be respected. Conversely, parenchymatous focal pooling of contrast on initial CT is a good predictor for the development of delayed vascular malformation. In children, as a large part of splenic and hepatic vascular malformations resolve spontaneously, expectant observation may be indicated provided that a strict imaging follow-up is performed until complete disappearance of these lesions. If needed, embolization of parenchymal vascular lesions should be performed as selectively as possible in order to avoid functional parenchyma loss and to reduce the risk of secondary infection of hematoma or ischemic tissue. Technical improvements, such as microcatheter systems and direct percutaneous approach to targeted lesions, have widened the potential for safe endovascular management of acquired vascular malformations. Advantages and disadvantages relative to the different embolic agents are explained. Endoscopic retrograde pancreatography is the chief investigational tool for detecting biliary and pancreatic ducts injuries. The respective roles of endoscopic, percutaneous and surgical approaches...

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“…The length of hospital stay required for observation is unknown. The combination of the increasing popularity of NOMSI and the pressure to discharge patients early may create the ideal setting for delays in recognition and treatment of late splenic ruptures, 10 potentially leading to increased morbidity or mortality. Early identification of patients who are at high risk for failure of NOMSI is essential to prevent this risk.…”

Section: Comparison Between Ct and Operative Grading Of Splenic Injurymentioning

confidence: 99%

“…10 Identificationofpatients at high risk for NOMSI failure may lower the thresholdforoperationorincreasethelength of in-hospital observation. A combination of radiographic and physiologic parameters could identify such patients.…”

mentioning

confidence: 99%