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Western Trauma Association
Management of Adult Blunt
Splenic Trauma
Historic
Perspective
Management of blunt splenic
trauma has changed drastically
during the past 30 years. In the
mid-1970s, recognition of the
spleen's immunologic importance
and the lifelong risk of
overwhelming postsplenectomy
sepsis provided the rationale
for avoiding splenectomy.
Although the adult surgeons were
focused on perfecting operative
splenic salvage techniques,1-3
the pediatric surgeons provided
convincing evidence that the
best way to salvage the spleen
was not to operate.4-6
Adult trauma surgeons were slow
to adopt nonoperative management
(NOM) because early reports of
its use in adults documented a
30% to 70% failure rate of which
two-thirds underwent total
splenectomy.7-10
There was also a concern about
missing serious concomitant
intra-abdominal injuries.11-13
However, with increasing
experience with NOM, recognition
that negative laparotomies
caused significant morbidity and
the availability of higher
quality computerized tomographic
(CT) scanning, NOM became the
standard of care for adults by
the mid-1990s.14-19
Over the next decade, the
percentage of patients in which
NOM was pursued increased from
30% to 60% to as high as 85% as
previous expert opinion
contra-indications (e.g.
advanced age, fear of missing a
hollow viscus injury (HVI), >2
units of packed red blood cell
transfusion, neurologic
impairment, and high grades
injuries) were refuted.20-26
Additionally, angio-embolization
(AE) was increasingly used as a
NOM adjunct, and the reported
failure rate of 12% to 13%
dropped to as low as 2%.27-36
It is unclear whether this
decrease in the failure rate is
due to the success of AE or more
liberal definitions of failure.
Table 1 lists the most
recent updated series of adult
splenic trauma from US trauma
centers (series with >150 cases
published since 2000).
Variability in management
strategies still exist.
Important factors that drive
management decisions in these
trauma centers include (a)
presence and severity of
hemodynamic instability, (b)
results of the initial workup of
blunt abdominal trauma, which
includes some combination of the
focused abdominal sonography for
trauma (FAST) examination,
abdominal CT scan, and
diagnostic peritoneal aspirate
or diagnostic peritoneal lavage,
(c) availability and indications
for angiography, (d) definition
of failure, and (e) use of
follow-up abdominal CT scanning.
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