Highlights from #AAST2014 - Splenic Injury Outcomes Trial

Interesting paper about splenic outcomes to kick off  the AAST meeting.

Multi-institutional study with nearly 400 patients.

Patients with contrast extravasation on admission are more likely to fail nonoperative management and should be considered for angiography and embolization.

CT to follow healing is not indicated.

THE SPLENIC INJURY OUTCOMES TRIAL: AN AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA MULTI-INSTITUTIONAL STUDY

Ben L. Zarzaur* MD,MPH, Rosemary Kozar* MD,Ph.D., John G. Myers* MD, Jeffrey A. Claridge* MD, MS, Thomas M. Scalea* MD, Todd A. Neideen* MD, Adrian A. Maung* MD, Louis Alarcon* MD, Aaron Scifres* MD, Alain Corcos* MD, Andrew

Kerwin* MD, Raul Coimbra* MD,Ph.D., AAST Multi-Institutional Trials Committee Invited Discussant: Andrew Peitzman, MD

Introduction: Delayed splenic rupture resulting in delayed splenectomy (DS) after attempted non-operative (NON-OP) management of blunt splenic injury (BSI) is a feared complication, particularly in the outpatient setting. Significant healthcare resources, including angiography (ANGIO) and follow-up computed tomography (CT), are utilized in an effort to prevent DS. However, no prospective, long-term data exists to determine the actual risk of DS. Understanding the actual risk of DS could help limit resource utilization and radiation exposure. The purpose of this multi-institutional trial was to ascertain the 180-day risk of DR after 24 hours of successful NON-OP management of BSI and to determine factors related to DS.

Methods: 11 Level I trauma centers participated in this prospective study. Adults ≥ 18 with BSI successfully managed NON-OP for 24 hours were eligible. Patients were followed for 180-days. Demographic, physiologic, radiographic and injury related information was obtained. Any spleen related interventions were recorded. Univiariate and bivariate analyses were used to determine factors associated with DS.

Results: 383 patients were enrolled. 30, 90, and 180-day follow-up were 95%, 88%, and 87% respectively. 12 patients (3.1%) suffered in-hospital splenectomy between 24 hours and 9 days post-injury. 4 patients died (none were spleen related) and 1 withdrew leaving 366 patients discharged with a spleen. 1 (0.27%) required readmission for splenectomy on post-injury day 12. No Grade I injuries suffered DS. High-grade injuries tended to have earlier DS and lower grade injuries had later DS (Figure). Overall splenectomy rate after NON-OP management for 24 hours was 1.5 per 1000 patient-days. Only extravasation from the spleen (ADMIT-BLUSH) at time of admission was associated with DS (OR 3.6;

95% CI 1.4, 12.4). Of patients with ADMIT-BLUSH (n=49), 17 (34.7%) did not have ANGIO with embolization (EMBO) and 2 of those (11.8%) underwent splenectomy; 32 (65.3%) underwent ANGIO with EMBO and 2 of those (6.3%) required splenectomy.

Conclusions: The need for splenectomy after 24 hours of successful NON-OP management is rare. After the initial 24 hours, no additional interventions are warranted

for patients with Grade I injuries. For grade II – V BSI close observation is indicated for 10 – 14 days as this is the time of greatest risk of DS. Extravasation of contrast from the spleen at the time of admission is a strong predictor of DS and may be an area where aggressive use of ANGIO and EMBO is warranted and should be the focus of future prospective studies. Use of CT to follow splenic healing after discharge is not indicated in patients without symptoms.