PHILADELPHIA – Delayed splenectomy for delayed splenic rupture is a feared complication of forgoing surgery on a blunt spleen injury, but early results of the Splenic Injury Outcomes Trial show that the vast majority of trauma patients rarely need splenectomy after the first 24 hours, and the use of angiography and CT to monitor healing of the spleen in asymptomatic patients may not be necessary in most cases.
Dr. Ben Zarzaur of Indiana University, Indianapolis, reported on early results from the Splenic Injury Outcomes Trial study of 383 patients from 11 level 1 trauma centers. The aim of the study is to provide a snapshot of how trauma surgeons manage critically injured patients with a spleen injury. He presented the findings at the annual meeting of the American Association for the Surgery of Trauma, which sponsored the trial.
“Out of that cohort, the in-hospital risk of splenectomy after the first 24 hours was about 3.6%, and after discharge the risk out to 6 months was 0.27%,” Dr. Zarzaur reported. In all, 12 patients had their spleens removed within 10 days of injury, and 4 patients died of causes not spleen related. The trial followed 87% of enrolled patients for up to 6 months after treatment.
One goal of the trial was to determine if the use of angiography and follow-up CT were necessary in monitoring the spleen in critically injured patients. The findings may help clarify management of patients with grade 1 injuries, Dr. Zarzaur said. “These patients likely don’t need any further interventions, because no [individuals with] grade 1 injuries had a splenectomy after the first 24 hours,” he said.
“Patients probably need close observation for 10-14 days after blunt spleen injury, and that can occur as an inpatient or can be done as an outpatient with very explicit instructions to return to the hospital if they have signs or symptoms of bleeding,” he said.
The trial also evaluated whether embolization made a difference in salvaging spleens. “There was no statistical difference in splenectomy rates in patients who were embolized versus those who were not,” Dr. Zarzaur said. He noted, however, that in more patients with grade 3 injuries or greater, the incidence of splenectomy was lower after embolization, but it was not statistically significant. “With regard to angiography embolization, it’s likely helpful. There are probably some high-risk patient populations, and we should concentrate on those in order to maximize the benefit and minimize the risk of patients with blunt splenic injury,” he said.
“There are about 39,000 spleen injuries a year, about 35,000 of which will be managed nonoperatively successfully over 24 hours,” Dr. Zarzaur said after his presentation. “So if we do the calculations for all injury grades, if we do angiography in these patients at the rates we saw in the study, we would save 84 additional spleens. If we concentrate on just higher-grade injuries – just grades 3 to 5 – we might save an additional 274 spleens a year. I think we have to ask ourselves, is that worth all the effort and cost and radiation exposure of angiography?”
That’s not a question the trial authors can answer at this point, Dr. Zarzaur said. A larger randomized clinical trial would be in order to get there, so he said the next step for him and the Splenic Injury Outcomes Trial coauthors is to put together a protocol for that.
Dr. Zarzaur reported having no relevant financial disclosures.