In patients with high-grade splenic injury, non-operative management (NOM) can be as effective as immediate splenectomy (IS), according to Wisconsin-based researchers.
In an April 22 online paper in the Journal of the American College of Surgeons, Dr. John E. Scarborough and colleagues at the University of Wisconsin School of Medicine and Public Health, Madison, noted that such an approach has become standard in those with low-grade injury. However, routine use in patients with grade IV or V blunt splenic injury, remains controversial.
To investigate further, the team examined data from 2013 and 2014 on more than 2,700 patients with such injury in about half of whom NOM was attempted. Using propensity-matching techniques they identified and compared outcome in 758 NOM and 758 immediate splenectomy patients. In-hospital mortality was 10.0% in the NOM group, not significantly different from the 11.5% in the splenectomy group. However, the splenectomy group had a significantly higher incidence of infectious complications (21.4% versus 16.9%, p=0.02).
Of the 1,489 patients from the overall study sample in whom NOM was attempted, 299 (20.1%) ultimately required splenectomy. The NOM failure rate was 17.8% in grade IV splenic injury, and 29.0% with grade V injury. Among early predictors of failed NOM were early blood transfusion requirement and grade V injury.
Splenic artery embolization (SAE) was associated with a decreased risk of NOM failure. The failure rate in initial NOM patients who underwent SAE was 11.0%, compared to 21.4% in those patients who did not. Although failed NOM patients had a longer median hospital stay than splenectomy patients (13 versus 10 days) their in-hospital mortality was significantly lower (6.4% versus 16.4%).
Overall, the researchers concluded, “NOM is as effective as IS for hemodynamically stable adult patients with grade IV or V blunt splenic injury. The delay in operative intervention that results from failed attempts at NOM does not adversely impact the outcomes of patients who ultimately require splenectomy.”
Commenting on the findings by email, Dr. Andrew L. Warshaw told Reuters Health, “Non-operative management of splenic fractures in hemodynamically stable patients is widely accepted. What is being tested here is the extension of the practice from lesser degrees of injury to the more severe grades IV-V, which are more likely to be in unstable patients who may also have other significant visceral injuries.”
Dr. Warshaw, who is Surgeon-in-Chief Emeritus at Massachusetts General Hospital, Boston, concluded, “The key to successful application of this approach lies in careful selection of the patients to be treated in this manner.”