The role of grade of injury in non-operative management of blunt hepatic and splenic trauma

Abstract

This retrospective study shows the results of a 2 years application of a clinical pathway concerning the indications to NOM based on the patient's hemodynamic answer instead of on the injury grade of the lesions.We conducted a retrospective study applied on a patient's cohort, admitted in “Azienda Ospedaliero-Universitaria Ospedali Riuniti of Ancona” and in the Digestive and Emergency Surgery Department of the Santa Maria of Terni hospital between September 2015 and December 2017, all affected by blunt abdominal trauma, involving liver, spleen or both of them managed conservatively. Patients were divided into 3 main groups according to their hemodynamic response to a fluid administration: stable (group A), transient responder (group B) and unstable (group C). Management of patients was performed according to specific institutional pathway, and only patients from category A and B were treated conservatively regardless of the injury grade of lesions.From October 2015 to December 2017, a total amount of 111 trauma patients were treated with NOM. Each patient underwent CT scan at his admission. No contrast pooling was found in 50 pts. (45.04%). Contrast pooling was found in 61 patients (54.95%). The NOM overall outcome resulted in success in 107 patients (96.4%). NOM was successful in 100% of cases of liver trauma patients and was successful in 94.7% of splenic trauma patients (72/76). NOM failure occurred in 4 patients (5.3%) treated for spleen injuries. All these patients received splenectomy: in 1 case to treat pseudoaneurysm, (AAST, American Association for the Surgery of Trauma, grade of injury II), in 2 cases because of re-bleeding (AAST grade of injury IV) and in the remaining case was necessary to stop monitoring spleen because the patient should undergo to orthopedic procedure to treat pelvis fracture (AAST grade of injury II).Non-operative management for blunt hepatic and splenic lesions in stable or stabilizable patients seems to be the choice of treatment regardless of the grade of lesions according to the AAST Organ Injury Scale.

Künt Karın Travmasına Bağlı Solid Organ Yaralanmalarında Non operatif Tedavi-Dalak Yaralanmaları

“…Conservative treatment has become an important therapeutic option for patients without hemodynamic instability in the management of abdominal solid organ injury caused by blunt trauma (4)(5)(6)(7)(8). Before non-operative treatment, surgical exploration was the treatment modality employed in solid organ injuries caused by blunt trauma.…”

“…The successful use of non-operative treatment in pediatric patients with splenic injury and hemodynamic stability has led the use in adult patients [4,5]. While In recent years, noon-operative treatment is increasingly used with success by advances in imaging modalities, interventional radiology and intensive care therapy, rate of surgical exploration has decreased in recent years.…”

“…In addition, it was reported that non-operative treatment is associated less morbidity and mortality when compared to operative treatment while surgical treatment further increases bleeding in the literature [9][10][11][12][13]. Nonoperative treatment is indispensable in patients with solid organ injury and hemodynamic stability; however, it remains to define its effectiveness and management steps [4,5,9,11,14]. There are also questions regarding patient selection.…”

“…When non-operative treatment was first introduced, factors such as age>55 years, presence of head trauma, higher severity of injury, presence of blood at periportal area, contrast material extravasation on CT scan, trauma score, amount of intraperitoneal blood and amount of blood transfusion were reported as major barriers for non-operative treatment [4,5]. In the literature, there are studies that consider factors including age>55 years, contrast material extravasation on CT scan, neurological status, higher grade of injury on CT scan and amount of intraperitoneal blood as absolute contraindications for non-operative treatment [12,14,15,16].…”

Hepatic Trauma Interventions

“…4 Although the AAST criteria is universally used to express severity of injury, it is typically used in combination with the hemodynamic status to determine operative or nonoperative management (NOM). 5 Treatment options include NOM, angiographic embolization, and operative management (OM). Grade I and II injuries with stable hemodynamic status typically undergo NOM in the intensive care unit (ICU), whereas hemodynamically unstable and/or high-grade grade V injuries require urgent OM.…”