The song remains the same although the instruments are changing: complications following selective non-operative management of blunt spleen trauma: a retrospective review of patients at a level I trauma centre from 1996 to 2007

BACKGROUND: Despite a widespread shift to selective non-operative management (SNOM) for blunt splenic trauma, there remains uncertainty regarding the role of adjuncts such as interventional radiological techniques, the need for follow-up imaging, and the incidence of long-term complications. We evaluated the success of SNOM (including splenic artery embolization, SAE) for the management of blunt splenic injuries in severely injured patients. METHODS: Retrospective review (1996-2007) of the Alberta Trauma Registry and health records for blunt splenic trauma patients, aged 18 and older, with injury severity scores of 12 or greater, admitted to the Foothills Medical Centre. RESULTS: Among 538 eligible patients, 150 (26%) underwent early operative intervention. The proportion of patients managed by SNOM rose from 50 to 78% over the study period, with an overall success rate of SNOM of 87%, while injury acuity remained unchanged over time. Among SNOM failures, 65% underwent surgery within 24 hours of admission. Splenic arterial embolization (SAE) was used in only 7% of patients managed non-operatively, although at least 21% of failed SNOM had contrast extravasation potentially amenable to SAE. Among Calgary residents undergoing SNOM, hospital readmission within six months was required in three (2%), all of whom who required emergent intervention (splenectomy 2, SAE 1) and in whom none had post-discharge follow-up imaging. Overall, the use of post-discharge follow-up CT imaging was low following SNOM (10%), and thus no CT images identified occult hemorrhage or pseudoaneurysm. We observed seven cases of delayed splenic rupture in our population which occurred from five days to two months following initial injury. Three of these occurred in the post-discharge period requiring readmission and intervention. CONCLUSIONS: SNOM was the initial treatment strategy for most patients with blunt splenic trauma with 13% requiring subsequent operative intervention intended for the spleen. Cases of delayed splenic rupture occurred up to two months following initial injury. The low use of both follow-up imaging and SAE make assessment of the utility of these adjuncts difficult and adherence to formalized protocols will be required to fully assess the benefit of multi-modality management strategies.