Accepted Manuscript Title: The Contemporary management of Penetrating Splenic injury Author: Regan J Berg Kenji Inaba Obi Okoye Jason Pasley Pedro G Teixeira Michael Esparza Demetrios Demetriades PII: DOI: Reference:
S0020-1383(14)00193-4 http://dx.doi.org/doi:10.1016/j.injury.2014.04.025 JINJ 5714
To appear in:
Injury, Int. J. Care Injured
Received date: Revised date: Accepted date:
20-12-2013 20-3-2014 9-4-2014
Please cite this article as: Berg RJ, Inaba K, Okoye O, Pasley J, Teixeira PG, Esparza M, Demetriades D, The Contemporary management of Penetrating Splenic injury, Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.04.025 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Original Scientific Article
Running Head: Penetrating Splenic Injury
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THE CONTEMPORARY MANAGEMENT OF PENETRATING SPLENIC INJURY
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Regan J Berg MD, Kenji Inaba MD, Obi Okoye MD, Jason Pasley DO, Pedro G Teixeira MD, Michael Esparza BS, Demetrios Demetriades MD PhD
an
Los Angeles County Medical Center – University of Southern California Division of Trauma Surgery and Surgical Critical Care Los Angeles, California
M
The authors have no conflict of interest to report and have received no financial or material support related to this manuscript
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d
Presented at the Trauma Association of Canada’s Annual Meeting, Toronto ON, April 2012
Ac ce p
Key words: Splenic injury, penetrating trauma, selective non‐operative management, clinical decision‐ making
Abstract Word Count: 340
Manuscript Word Count: 3031 Correspondence to:
Kenji Inaba, MD, FRCSC, FACS Associate Professor of Surgery Division of Trauma Surgery and Surgical Critical Care LAC+USC Medical Center 2051 Marengo Street Inpatient Tower (C) – Room C5L100 Los Angeles, CA, 90033 T: 323.409.8596 F: 323.441.9907 E: [email protected]
1
Page 1 of 26
Original Scientific Article
Running Head: Penetrating Splenic Injury
cr
ip t
us
THE CONTEMPORARY MANAGEMENT OF PENETRATING SPLENIC INJURY
M
an
Ac ce p
Manuscript Word Count: 3160
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Abstract Word Count: 342
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Key words: Splenic injury, penetrating trauma, selective non‐operative management, clinical decision‐ making
2
Page 2 of 26
Abstract Introduction: Selective non-operative management (NOM) is standard of care for clinically stable patients with blunt splenic trauma and expectant management approaches are
ip t
increasingly utilized in penetrating abdominal trauma, including in the setting of solid
organ injury. Despite this evolution of clinical practice, little is known about the safety and
cr
efficacy of NOM in penetrating splenic injury.
us
Methods: Trauma registry and medical record review identified all consecutive patients presenting to LAC+USC Medical Center with penetrating splenic injury between January
an
2001 and December 2011. Associated injuries, incidence and nature of operative
M
intervention, local and systemic complications and mortality were determined. Results: During the study period, 225 patients experienced penetrating splenic trauma. The
d
majority (187/225, 83%) underwent emergent laparotomy. Thirty-eight clinically stable
te
patients underwent a deliberate trial of NOM and 24/38 (63%) were ultimately managed without laparotomy. Amongst patients failing NOM, 3/14 (21%) underwent splenectomy
Ac ce p
while an additional 6/14 (42%) had splenorrhaphy. Hollow viscus injury (HVI) occurred in 21% of all patients failing NOM. Forty percent of all NOM patients had diaphragmatic injury (DI). All patients undergoing delayed laparotomy for HVI or a splenic procedure presented symptomatically within 24h of the initial injury. No deaths occurred in patients undergoing NOM.
Conclusions: Although the vast majority of penetrating splenic trauma requires urgent operative management, a group of patients does present without hemodynamic instability, peritonitis or radiologic evidence of hollow viscus injury. Management of these patients is complicated as over half may remain clinically stable and can avoid laparotomy, making
3
Page 3 of 26
them potential candidates for a trial of NOM. HVI is responsible for NOM failure in up to a fifth of these cases and typically presents within 24h of injury. Delayed laparotomy, within this limited time period, did not appear to increase mortality nor preclude successful
ip t
splenic salvage. In clinically stable patients, diagnostic laparoscopy remains essential to evaluate and repair occult DI. As NOM for penetrating abdominal trauma becomes more
cr
common, multi-center data is needed to more accurately define the principles of patient
us
selection and the limitations and consequences of this approach in the setting of splenic
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M
an
injury.
4
Page 4 of 26
The Contemporary Management of Penetrating Splenic Injury Introduction The evolution of non-operative approaches to blunt solid organ injury1 and the expectant
ip t
management of penetrating injuries2 are paradigmatic changes that have significantly
altered contemporary abdominal trauma management. In blunt splenic injury, increasing
cr
awareness of the potential for overwhelming post-splenectomy sepsis prompted a
us
progressive shift from routine splenectomy to intra-operative splenic conservation3 and selective non-operative management (NOM),4 this latter strategy adopted as standard of
an
care for stable patients on the basis of two landmark, multi-center reviews.5,6 Routine
M
exploration of patients with penetrating abdominal trauma is associated with high rates of non-therapeutic exploration and has consequently yielded clinical space to expectant
d
approaches for both stab wounds (SWs)7 and gunshot wounds (GSWs),8-10 a strategy that is
te
feasible even in the presence of solid organ injury.11-14 As experience with NOM of penetrating abdominal trauma increases, so too does willingness to attempt expectant
Ac ce p
management of penetrating splenic injury. 15 Despite increasing experience with NOM, little is known about the safety and efficacy of this approach in splenic injury, as previous studies have largely focused on operative management.16-18 Given the growing trend to attempt NOM of penetrating abdominal trauma, further data is needed to define the risks and benefits of this strategy in the face of splenic injury. The current study examines 11 years of penetrating splenic trauma at a major American College of Surgeons (ACS) level I trauma center to determine whether this is a feasible approach for highly-selected, clinically stable patients. Although we hypothesized that this strategy was likely efficacious in a small select group of patients, we
5
Page 5 of 26
anticipated a need for further data to appropriately determine the incidence and consequences of NOM failure, as well as to define the characteristics that best guide patient selection.
ip t
Methods
All patients arriving alive to Los Angeles County, University of Southern California Medical
cr
Center (LAC+USC) with penetrating splenic injury between January 1, 2001 and December
us
31, 2011 were identified through the institutional trauma registry. Patients were excluded if they: underwent splenectomy as part of another procedure without a primary splenic injury
an
(e.g. distal pancreatectomy); had splenectomy for a proximal splenic artery injury without
M
splenic parenchymal damage; or suffered iatrogenic injury. Demographic details, initial physiologic parameters, mechanism and pattern of injuries, operative procedures, need for
d
massive transfusion (MT), mortality, and intensive care unit (ICU) and hospital length of
te
stay (LOS) and in-hospital and post-discharge complications were determined. Additional data was obtained through medical chart review.
Ac ce p
Once identified, the study population was stratified by clinical management. A clinically “unstable” group was classified as those patients who underwent operative intervention within 2 hours (h) of admission without computed tomographic (CT) imaging. A clinically “stable” group comprised those patients who arrived without persistent hemodynamic derangement or peritonitis and who underwent further CT evaluation, and an additional subgroup that was investigated with x-ray and ultrasound in the emergency department and who subsequently underwent diagnostic laparoscopy after a planned observation period. Amongst patients arriving clinically “stable” was a subset with CT findings leading to emergent surgery. This group combined with the “unstable” group to form an “emergent
6
Page 6 of 26
surgery” population. All other clinically “stable” patients were identified as undergoing NOM. Once identified from the registry, this population was verified by chart review. Demographics, admission physiology, injury patterns, operative repairs and outcomes
ip t
were described for the total population, and the “emergent surgery” and “clinically stable” subgroups were compared. The “clinically stable” group was examined, comparing patients
cr
undergoing successful vs. unsuccessful NOM. Failure of NOM was defined broadly, as need
us
for laparotomy for any reason, but also specifically, as the need for a splenic operative procedure. The entire population was then examined by grade of splenic injury. For those
an
failing NOM, time to failure, transfusion requirements, splenic procedures performed, and
M
associated repair of a solid organ, DI or HVI were described by splenic grade of injury. Finally, the incidence of all complications and duration of follow-up was described for
d
patients undergoing NOM.
te
Statistical analyses were performed using SPSS for Windows, version 17 (Chicago, IL). Continuous variables were occasionally dichotomized using relevant cut-points: age (≥55
Ac ce p
vs.
S0020-1383(14)00193-4 http://dx.doi.org/doi:10.1016/j.injury.2014.04.025 JINJ 5714
To appear in:
Injury, Int. J. Care Injured
Received date: Revised date: Accepted date:
20-12-2013 20-3-2014 9-4-2014
Please cite this article as: Berg RJ, Inaba K, Okoye O, Pasley J, Teixeira PG, Esparza M, Demetriades D, The Contemporary management of Penetrating Splenic injury, Injury (2014), http://dx.doi.org/10.1016/j.injury.2014.04.025 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Original Scientific Article
Running Head: Penetrating Splenic Injury
ip t
THE CONTEMPORARY MANAGEMENT OF PENETRATING SPLENIC INJURY
cr
us
Regan J Berg MD, Kenji Inaba MD, Obi Okoye MD, Jason Pasley DO, Pedro G Teixeira MD, Michael Esparza BS, Demetrios Demetriades MD PhD
an
Los Angeles County Medical Center – University of Southern California Division of Trauma Surgery and Surgical Critical Care Los Angeles, California
M
The authors have no conflict of interest to report and have received no financial or material support related to this manuscript
te
d
Presented at the Trauma Association of Canada’s Annual Meeting, Toronto ON, April 2012
Ac ce p
Key words: Splenic injury, penetrating trauma, selective non‐operative management, clinical decision‐ making
Abstract Word Count: 340
Manuscript Word Count: 3031 Correspondence to:
Kenji Inaba, MD, FRCSC, FACS Associate Professor of Surgery Division of Trauma Surgery and Surgical Critical Care LAC+USC Medical Center 2051 Marengo Street Inpatient Tower (C) – Room C5L100 Los Angeles, CA, 90033 T: 323.409.8596 F: 323.441.9907 E: [email protected]
1
Page 1 of 26
Original Scientific Article
Running Head: Penetrating Splenic Injury
cr
ip t
us
THE CONTEMPORARY MANAGEMENT OF PENETRATING SPLENIC INJURY
M
an
Ac ce p
Manuscript Word Count: 3160
te
Abstract Word Count: 342
d
Key words: Splenic injury, penetrating trauma, selective non‐operative management, clinical decision‐ making
2
Page 2 of 26
Abstract Introduction: Selective non-operative management (NOM) is standard of care for clinically stable patients with blunt splenic trauma and expectant management approaches are
ip t
increasingly utilized in penetrating abdominal trauma, including in the setting of solid
organ injury. Despite this evolution of clinical practice, little is known about the safety and
cr
efficacy of NOM in penetrating splenic injury.
us
Methods: Trauma registry and medical record review identified all consecutive patients presenting to LAC+USC Medical Center with penetrating splenic injury between January
an
2001 and December 2011. Associated injuries, incidence and nature of operative
M
intervention, local and systemic complications and mortality were determined. Results: During the study period, 225 patients experienced penetrating splenic trauma. The
d
majority (187/225, 83%) underwent emergent laparotomy. Thirty-eight clinically stable
te
patients underwent a deliberate trial of NOM and 24/38 (63%) were ultimately managed without laparotomy. Amongst patients failing NOM, 3/14 (21%) underwent splenectomy
Ac ce p
while an additional 6/14 (42%) had splenorrhaphy. Hollow viscus injury (HVI) occurred in 21% of all patients failing NOM. Forty percent of all NOM patients had diaphragmatic injury (DI). All patients undergoing delayed laparotomy for HVI or a splenic procedure presented symptomatically within 24h of the initial injury. No deaths occurred in patients undergoing NOM.
Conclusions: Although the vast majority of penetrating splenic trauma requires urgent operative management, a group of patients does present without hemodynamic instability, peritonitis or radiologic evidence of hollow viscus injury. Management of these patients is complicated as over half may remain clinically stable and can avoid laparotomy, making
3
Page 3 of 26
them potential candidates for a trial of NOM. HVI is responsible for NOM failure in up to a fifth of these cases and typically presents within 24h of injury. Delayed laparotomy, within this limited time period, did not appear to increase mortality nor preclude successful
ip t
splenic salvage. In clinically stable patients, diagnostic laparoscopy remains essential to evaluate and repair occult DI. As NOM for penetrating abdominal trauma becomes more
cr
common, multi-center data is needed to more accurately define the principles of patient
us
selection and the limitations and consequences of this approach in the setting of splenic
Ac ce p
te
d
M
an
injury.
4
Page 4 of 26
The Contemporary Management of Penetrating Splenic Injury Introduction The evolution of non-operative approaches to blunt solid organ injury1 and the expectant
ip t
management of penetrating injuries2 are paradigmatic changes that have significantly
altered contemporary abdominal trauma management. In blunt splenic injury, increasing
cr
awareness of the potential for overwhelming post-splenectomy sepsis prompted a
us
progressive shift from routine splenectomy to intra-operative splenic conservation3 and selective non-operative management (NOM),4 this latter strategy adopted as standard of
an
care for stable patients on the basis of two landmark, multi-center reviews.5,6 Routine
M
exploration of patients with penetrating abdominal trauma is associated with high rates of non-therapeutic exploration and has consequently yielded clinical space to expectant
d
approaches for both stab wounds (SWs)7 and gunshot wounds (GSWs),8-10 a strategy that is
te
feasible even in the presence of solid organ injury.11-14 As experience with NOM of penetrating abdominal trauma increases, so too does willingness to attempt expectant
Ac ce p
management of penetrating splenic injury. 15 Despite increasing experience with NOM, little is known about the safety and efficacy of this approach in splenic injury, as previous studies have largely focused on operative management.16-18 Given the growing trend to attempt NOM of penetrating abdominal trauma, further data is needed to define the risks and benefits of this strategy in the face of splenic injury. The current study examines 11 years of penetrating splenic trauma at a major American College of Surgeons (ACS) level I trauma center to determine whether this is a feasible approach for highly-selected, clinically stable patients. Although we hypothesized that this strategy was likely efficacious in a small select group of patients, we
5
Page 5 of 26
anticipated a need for further data to appropriately determine the incidence and consequences of NOM failure, as well as to define the characteristics that best guide patient selection.
ip t
Methods
All patients arriving alive to Los Angeles County, University of Southern California Medical
cr
Center (LAC+USC) with penetrating splenic injury between January 1, 2001 and December
us
31, 2011 were identified through the institutional trauma registry. Patients were excluded if they: underwent splenectomy as part of another procedure without a primary splenic injury
an
(e.g. distal pancreatectomy); had splenectomy for a proximal splenic artery injury without
M
splenic parenchymal damage; or suffered iatrogenic injury. Demographic details, initial physiologic parameters, mechanism and pattern of injuries, operative procedures, need for
d
massive transfusion (MT), mortality, and intensive care unit (ICU) and hospital length of
te
stay (LOS) and in-hospital and post-discharge complications were determined. Additional data was obtained through medical chart review.
Ac ce p
Once identified, the study population was stratified by clinical management. A clinically “unstable” group was classified as those patients who underwent operative intervention within 2 hours (h) of admission without computed tomographic (CT) imaging. A clinically “stable” group comprised those patients who arrived without persistent hemodynamic derangement or peritonitis and who underwent further CT evaluation, and an additional subgroup that was investigated with x-ray and ultrasound in the emergency department and who subsequently underwent diagnostic laparoscopy after a planned observation period. Amongst patients arriving clinically “stable” was a subset with CT findings leading to emergent surgery. This group combined with the “unstable” group to form an “emergent
6
Page 6 of 26
surgery” population. All other clinically “stable” patients were identified as undergoing NOM. Once identified from the registry, this population was verified by chart review. Demographics, admission physiology, injury patterns, operative repairs and outcomes
ip t
were described for the total population, and the “emergent surgery” and “clinically stable” subgroups were compared. The “clinically stable” group was examined, comparing patients
cr
undergoing successful vs. unsuccessful NOM. Failure of NOM was defined broadly, as need
us
for laparotomy for any reason, but also specifically, as the need for a splenic operative procedure. The entire population was then examined by grade of splenic injury. For those
an
failing NOM, time to failure, transfusion requirements, splenic procedures performed, and
M
associated repair of a solid organ, DI or HVI were described by splenic grade of injury. Finally, the incidence of all complications and duration of follow-up was described for
d
patients undergoing NOM.
te
Statistical analyses were performed using SPSS for Windows, version 17 (Chicago, IL). Continuous variables were occasionally dichotomized using relevant cut-points: age (≥55
Ac ce p
vs.
