Splenic injuries: factors affecting the outcome of non-operative management

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1 Eur J Trauma Emerg Surg DOI /s ORIGINAL ARTICLE Splenic injuries: factors affecting the outcome of non-operative management A. Böyük M. Gümüş A. Önder M. Kapan İ. Aliosmanoğlu F. Taşkesen Z. Arıkanoğlu E. Gedik Received: 7 June 2011 / Accepted: 23 September 2011 Ó Springer-Verlag 2011 Abstract Purpose The aim of this study was to evaluate the outcome of non-operative management (NOM) in patients with splenic injuries and to determine the predictive factors of NOM failure. Methods Two hundred and six patients with splenic injury were admitted between January 2005 and April Of the 206 patients with splenic injury, 47 patients met the inclusion criteria of NOM. The mechanism of injury, grade of splenic injury, other intra- and extraabdominal injuries, systolic blood pressure on admission, hemoglobin levels, number of transfusions, Injury Severity Score (ISS), Glasgow Coma Scale score, and hospitalization period were recorded. The patients were divided into two groups: those with NOM and those in whom the failure of NOM led to laparotomy. The patients were monitored for vital signs, abdominal findings, and laboratory data. NOM was abandoned in cases of hemodynamic instability, ongoing bleeding, or development of peritonitis. Independent predictive factors of NOM failure were identified. The patients managed non-operatively were compared with the patients for whom NOM failed. Results NOM was successful in 40 of 47 patients. There were differences between the two groups for ISS, hemoglobin levels, need for blood transfusion, and the number of associated extra-abdominal injuries. The grade of splenic injury was determined to be an important and significant independent predictive factor for the success of NOM of splenic injuries. A. Böyük (&) M. Gümüş A. Önder M. Kapan İ. Aliosmanoğlu F. Taşkesen Z. Arıkanoğlu E. Gedik Department of General Surgery, Medical Faculty, Dicle University, Yenişehir 21280, Diyarbakır, Turkey azboyuk@hotmail.com Conclusions The grade of splenic injury is an important and significant independent predictor factor for the success of NOM. NOM is not recommended in patients with highgrade splenic injury. Keywords Non-operative management Splenic injury Predictive factor Introduction The non-operative management (NOM) of spleen injuries has been clearly demonstrated to be an effective therapeutic option. Many studies are made to define the exact criteria for patient selection. The criteria for non-operative selection of the patients that are commonly advocated are the presence of hemodynamic stability and the absence of other intra-abdominal lesions requiring laparotomy [1, 2]. However, trauma patients generally have multi-trauma, and spleen injury must be evaluated as a part of the general evaluation of the patient. Although there are some criteria to select patients for non-operative treatment, most of these criteria focus on the severity of the spleen injury. Therefore, we retrospectively evaluated the outcome of NOM in patients with splenic injuries and determined the predictive factors for NOM failure. Patients and methods From January 2005 to April 2011, all 206 consecutive patients with splenic injury who were admitted to the Department of Surgery, University Hospital of Dicle University, were included in the study. Among 206 patients, 47 patients who met the inclusion criteria for NOM were

2 A. Böyük et al. included this study. All of the patients had been prospectively evaluated with respect to splenic preservation. In general, the following criteria were used to select patients for non-operative treatment: (1) hemodynamic stability ([90 mmhg systolic blood pressure) with or without minimal fluid resuscitation; (2) no demonstrable peritoneal signs on abdominal examination; and (3) the absence of any intraperitoneal or retroperitoneal injuries on computed tomography (CT) scans requiring operative intervention (Fig. 1). Patients whose health conditions had an increased risk of bleeding (coagulopathy, hepatic failure, use of anticoagulants, specific coagulation factor deficiency) were excluded. Only 47 patients met these criteria and were managed non-operatively. The records of all of the patients were retrospectively evaluated and the data were collected. Age, gender, mechanism of injury, grade of splenic injury, other intra- and extra-abdominal injuries, systolic blood pressure on admission, hemoglobin levels, number of transfusions, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, and hospitalization period were recorded. Then, the patients were divided into two groups regarding the type of management; included those who were selected for NOM and included those in whom the failure of NOM led to laparotomy. A standard management protocol that consisted of treating all hemodynamically stable patients non-operatively, irrespective of the injury grade was used, and hemodynamically unstable patients were immediately taken to the operating room after 24 h following hospital admission. All of the patients were evaluated with abdominal ultrasonography and contrast-enhanced tomography. In general, the patients with spleen injury were graded according the American Society for the Study of Trauma (AAST) classification (Table 1), which was reported in the name of the Organ Injury Scaling Group by Moore et al. [3]. Standard NOM included the restriction of oral intake, parenteral fluids, and bed rest. The patients were monitored for vital signs, abdominal findings, and laboratory data Fig. 1 Flow diagram of the patients Recruited patients with splenic injury (n = 206) Including criteria; Hemodynamic stability Negative abdominal examination Absence of contrast extravasation on CT Absence of other clear indication for exploratory laparatomy or associated injuries requiring a surgical intervention Absence of associated health condition that carry an increased risk of bleeding (coagulopathy, hepatic failure, use of anti coagulant, specific coagulation factor deficiency) Patients with non-operative management (NOM) (n = 47) Success of NOM (n = 40) Failure of NOM (n = 7)

3 Non-operative management of splenic injury Table 1 Grade I II III IV V Grading of splenic injuries Finding Subcapsular hematoma of less than 10% of the surface area Capsular tear of less than 1 cm in depth Subcapsular hematoma of 10 50% of the surface area Intraparenchymal hematoma of less than 5 cm in diameter Laceration of 1 3 cm in depth and not involving trabecular vessels Subcapsular hematoma of greater than 50% of the surface area or expanding and ruptured subcapsular or parenchymal hematoma Intraparenchymal hematoma of greater than 5 cm or expanding Laceration of greater than 3 cm in depth or involving trabecular vessels Laceration involving segmental or hilar vessels with devascularization of more than 25% of the spleen Shattered spleen or hilar vascular injury (especially hemoglobin level). NOM of splenic injuries generally consisted of admission to an intensive care unit or monitored setting. NOM was abandoned in cases of hemodynamic instability, ongoing bleeding, or development of peritonitis. Statistical analysis The data were statistically analyzed using SPSS (SPSS for Windows 10.0, SPSS Inc., Chicago, IL) to determine the most significant factors in the failure of non-operative treatment. For comparisons of incidences for univariate analyses, Chi-square or Fisher s exact test was used, while the independent t test or Mann Whitney U test was used to compare the values. To assess the predictive factors for the failure of NOM, multivariable analysis using logistic regression was performed. Candidate variables either of biological importance or with a p \ 0.02 were entered, using an entry approach. Predictor variables were kept in the final model if p \ Table 2 Univariate analysis of predictors for the failure of nonoperative treatment in patients with splenic injury (NOM) (n = 40) (NOM failure) (n = 7) p value Age (years) 30.6 ± ± Male 34 (85%) 6 (85.7%) SBP (mmhg) ± ± ISS 8.2 ± ± 5.7 \ GCS score 13.6 ± ± Grade of splenic injury, n (%) I 15 (37.5) 0 II 21 (52.5) 0 \ III 3 (7.5) 5 (71.4) IV 1 (2.5) 2 (28.6) Hgb (g/dl) 11.8 ± ± Blood transfusion 0.7 ± ± 0.7 \ (IU) a EAI 11 (25%) 4 (71.4%) IAI 28 (70%) 4 (57.1%) HP (days) 7.4 ± ± SBP systolic blood pressure, ISS Injury Severity Score, GCS Glasgow Coma Scale, Hgb hemoglobin, EAI number of associated extraabdominal injuries, IAI number of associated intra-abdominal injuries, HP hospitalization period a Within the first 24 h Grade of Splenic Injury 5,0 4,0 3,0 2,0 1,0 Results During the study period, 206 patients were admitted with splenic injuries. A total of 159 (77.2%) patients did not meet the NOM criteria, and 47 patients (22.8%) were planned for NOM. However, this management failed in 7 patients (14.9%) in the latter group, and splenectomy was done (Fig. 1). The demographic and clinical characteristics of the patients are shown in Table 2. Forty-three patients suffered from blunt and four patients from low-grade (3 patients, grade I; 1 patient, grade II) penetrating injuries. 0,0 Fig. 2 Splenic injury grade in Groups 1 and 2 The grades of splenic injury in Groups 1 and 2 are shown in Fig. 2. Thirty-two patients had additional intra-abdominal (12 liver injuries) and 15 extra-abdominal (9 patients, thoracic injury) injuries. In these cases, indication for operative treatment was hemodynamic instability during

4 A. Böyük et al. Hospitalization Period (Day) Fig. 3 Hospitalization period in Groups 1 and 2 Table 3 Predictors for the failure of non-operative treatment: binary logistic regression Variable Odds ratio 95% confidence interval (lower upper) the observation period. The mean hospitalization time is shown in Fig. 3. There were no mortalities. Predictors for the failure of non-operative treatment p value Grade of splenic injury ( ) 0.047* Number of associated ( ) extra-abdominal injuries Hgb level ( ) Blood transfusion ( ) ISS ( ) * The grade of splenic injury was a significant independent predictive factor for non-operative management (NOM) Multivariate regression analysis was performed in order to identify independent predictors for the failure of the nonoperative treatment of splenic trauma. In a univariate analysis, there were no significant differences in terms of age, gender, GCS score, blood pressure, and number of intraabdominal injuries between Groups 1 and 2. The grade of splenic injury, ISS, hemoglobin levels, number of extraabdominal injuries, and the need for blood transfusion were entered into a stepwise logistic regression model (Table 3). The grade of splenic injury [odds ratio (OR) = 0.031; 95% confidence interval (CI) = ; p = 0.047] was found to be an independent predictive factor for the failure of NOM. The hospitalization period was significantly longer in compared with that in. Discussion The operative management of splenic injury was the standard treatment until the mid-20th century [4]. However, with increasing emphasis on splenic salvage and NOM, this approach has significantly evolved in recent years [2]. While splenorrhaphy was the most common method of splenic salvage, NOM of blunt splenic injury in adults has been increasingly popular [5, 6]. A literature review shows 80% or higher success rates for NOM of blunt splenic injury in adults [7, 8]. The factors that have been reported to predict the failure of NOM of splenic injuries are hemodynamic stability, need for blood transfusion, blood pressure at admission, ISS, GCS score, age, grade of injury, and degree of hemoperitoneum [1, 5, 8 11]. A correlation was established between the grade of splenic injury and the failure of NOM [1, 12 14]. Velmahos et al. [12] reported a significant difference between patients undergoing successful and failed NOM for the rates of splenic injuries of grade III and higher. Sharma et al. [15] found that a higher grade of injury was not a predictor for the failure of NOM. In our study, the success rate was 85.1% for hemodynamically stable patients. Depending on the grade of splenic injury, the rates of failure were 0% for grade I, 0% for grade II, for grade III, and 66.6% for grade IV. The grade of splenic injury was found to be a predictive factor for the failure of NOM. In the past, NOM was not recommended for patients with splenic injury aged 55 years or older [1, 7, 16]. In their study, Rodrigues et al. [17] reported that, with increasing age, the elasticity of the splenic capsule is reduced, which, in turn, limited the contraction and retraction of intraparenchymal vessels. Restricted splenic distention may contribute to the failure of NOM in the spleens of the elderly. Several recent studies have documented no differences in the risk for failed NOM between patients over age 55 and a younger cohort [18, 19]. Myers et al. [20] reported a success rate of 94% in patients older than 55 years undergoing NOM for splenic injury. In our study, the two groups did not differ in age. In the study by Yanar et al. [8], the GCS score and ISS were significantly higher in the failed-nom group. Bee et al. [21] and Malhotra et al. [22], in almost all of their reports, suggested that the ISS was an independent predictor of failure. According to Shapiro et al. [23], the NOM of neurologically impaired, hemodynamically stable patients with blunt injuries of the liver, spleen, or kidney is a common practice and is successful in more than 90% of cases. No differences were noted in the rates of delayed laparotomy or survival between normal, mild to moderate, and severe head injuries. However, the non-operative

5 Non-operative management of splenic injury approach was initiated less frequently in patients with more impaired mental status: GCS score: 15, 71%; GCS score: 8 14, 62%; and GCS score B 7, 50%. In our study, the lowest GCS score was 12, and the two groups did not differ for the GCS score. The ISS was statistically significantly higher in than in, but it was not determined as an independent risk factor for failure in NOM by logistic regression analysis. The available data on the timing of and indications for blood transfusion in patients with splenic injury are controversial [9]. No definite and clear limit for transfusion has been defined to date. According to some authors, in cases with splenic trauma requiring more than 1 IU RBC, NOM is likely to fail. Still, others suggest that, especially for nonsplenic trauma, 4 IU is the limit [8]. Maull [24] suggested that blood transfusion should be limited to 4 IU in order to achieve a stable hematocrit. In the study by Velmahos et al. [12], it has been shown that, in patients with high-grade splenic injuries who require a transfusion of more than 1 IU of blood, NOM is very likely to fail. In our study, NOM failed in the patients who required blood transfusion of more than 2 IU in 24 h. NOM is usually used in blunt trauma cases with a high success rate. Currently, selective NOM of penetrating abdominal solid-organ injuries has also been applied with a high success rate and a low complication rate. According to Demetriades et al. [25], 28.4% of all liver, 14.9% of all kidney, and 3.5% of all splenic injuries were successfully managed non-operatively in selected patients with penetrating injuries in abdominal solid organs. In our study, 4 patients with penetrating injuries (3 patients, grade I; 1 patient, grade II) were non-operatively treated. This shows that non-operative treatment is successful in splenic injuries of low grade caused by penetrating trauma. While NOM of blunt splenic injuries has been the standard of care, it can be used for selected low-grade penetrating splenic injuries. Bala et al. [16] showed that extra-abdominal injury is an important and significant predictor for the success of NOM. McCray et al. [26] reported a success rate of 100% for NOM applied in patients with isolated splenic injuries. In our study, the incidence rate of co-existing extra-abdominal injury was higher in than in, while the incidence rates of intra-abdominal injuries of the two groups were not different. Failure of NOM for splenic injury leads to increased hospitalization time and increased mortality in selected subsets of patients, which is the greatest concern [13, 16]. In some studies, the failure of NOM of blunt splenic injuries was found to be associated with a significant increase in the hospital length of stay and, in selected subsets of patients, with increased mortality [12, 27]. Accordingly, the nonoperative treatment of patients with isolated solid-organ injuries yielded a significantly shorter hospital stay than operative treatment, although the NOM group suffered more severe injuries [25]. Likewise, in our study, the hospitalization time of (failed NOM) was longer. The patients need some restrictions both in hospital and at home. We recommend that strict bed rest for h and then limited bed rest (e.g., the patient may go to the bathroom) for 1 week. The limitation on patients activities were arranged depending on their injuries and status after 1 week. Conclusion Non-operative treatment is the gold standard for the management of hemodynamically stable splenic injured patients without additional intra-abdominal organ traumas that require laparotomy. However, it should be kept in mind that, during the follow-up of the patients, new clinical findings that require operation may arise. In many of the earlier studies, parameters such as the Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, the number of associated extra-abdominal organ injuries, and blood transfusion were reported to be the factors that play a role in the failure of non-operative treatment. These are the parameters that show the severity of the trauma to the body. Computed tomography (CT), interventional radiology, and improvements in intensive care have facilitated the determination and treatment of accompanying system and organ traumas. In the light of these, we believe the grade of injury that shows the severity of trauma to the spleen is a predictive factor for the failure of non-operative management (NOM). Thus, in the NOM of high-grade splenic injuries, special attention should be paid. Thus, low-grade splenic injured patients can be treated easily with NOM, but in the NOM of highgrade splenic injuries, special attention should be paid. Conflict of interest References None. 1. 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