Is non-operative management of severe blunt splenic injury safer than embolization or surgery? Results from a French prospective multicenter study

Abstract

Embolization, because of its important specific morbidity, should not be performed as a prophylactic measure, but only in presence of clinical or laboratory signs of bleeding.

Splenic trauma: Save patients in shock and save the spleen in stable patients!

“…Surgical splenic salvage maneuvers are useful for only a minimum of patients who, in the end, frequently undergo total splenectomy during attempts at splenic preservation. In our series of 336 splenic injuries, we were able to find only two successful surgeries for splenic preservation out of 48 laparotomies performed for splenic trauma and this was the case for only one out of 17 laparotomies in the series of Chastang et al [3]. Editorial Tabulated salvage rates, including immediate and secondary splenectomies, have been noted to be as high as 60% in historical series [8].…”

“…SAE seems to be very effective in controlling bleeding with success rates exceeding 90% [12,13]. However, as pointed out by Chastang et al [3], SAE is not without complications. Determination of the exact prevalence of complications is problematic however, especially for pancreatic tail involvement.…”

“…Editorial Tabulated salvage rates, including immediate and secondary splenectomies, have been noted to be as high as 60% in historical series [8]. In the report by Chastang et al published in this issue [3], the 80% salvage rate has to be analyzed taking into account the referral bias, since this study did not include patients in severe shock who were admitted directly to the operating room and criteria of splenic injury for inclusion were based on computed tomography findings (mortality was 0%).…”

“…Initially, 10-15% of patients with splenic trauma undergo immediate laparotomy because of hemodynamic instability or signs of rupture [1]: of these, 10-15% require immediate splenectomy that can be called ''unavoidable'' (14% in our experience of 336 splenic injuries managed in the last 10 years). Post-splenectomy complications are not rare (10-20%) and are potentially severe [2] (pancreatitis, bleeding, intra-abdominal collections) occurring in as many as 14% of patients in the series reported by Chastang et al [3]. Because of the immunologic role of the spleen [4], splenectomized patients have an increased risk of severe infection (''overwhelming post-splenectomy syndrome'') that appears early post-operatively, reaches its peak during the first two years postsplenectomy, but persists lifelong.…”

“…The post-SAE complication rate is less than 10% in experienced centers (so-called in the US when SAE is performed for more than 10% of splenic trauma) [9,[15][16][17]. In the series published by Chastang et al [3], splenic infarction of more than 50% of the spleen occurred in 26% of patients, a much higher rate than the 0-5% published in the literature [9,13,16]. This may be explained by inappropriateness of management or by interventional radiology performed under sub-optimal technical conditions, since SAE is not indicated in the hemodynamically unstable patient and some of the embolization patients in this series underwent laparotomy for hemorrhagic shock.…”