Introduction

Nonoperative management (NOM) of abdominal trauma is indicated for patients with abdominal injuries to avoid surgical intervention. The goal of this dynamic management is to reduce the number of non-therapeutic laparotomies and their complications¹.

In blunt abdominal trauma, the spleen is the organ most frequently injured, with an incidence between 30 and 45%². The diagnostic and therapeutic approach for these patients has significantly evolved in recent years. The diagnosis made by physical examination has been replaced by computed tomography (CT) scans². Conservative management is now preferred over planned splenectomy for all patients, regardless of the extent of the lesion. Conservative treatment may be non-invasive (NICT), with observation and monitoring, or invasive (ICT), which includes partial splenectomy, embolization, use of biological glues and splenorrhaphy.

Nowadays, spleen preservation, either through NICT or conservative surgery, seems to be the most accepted therapeutic modality in cases of blunt and penetrating trauma involving this organ¹.

The current evidence suggests that this approach should be carried out in high-complexity centers with trained personnel and appropriate technology. The conditions for indicating NOM are based on patient safety and require access to the operating room 24/7, CT imaging, blood bank, and arteriography-embolization capabilities⁴.

There are currently no established national protocols for managing this condition or publications recommending its implementation in low-complexity centers that lack the necessary human resources and infrastructure to support non-invasive conservative treatment. Additionally, there is a lack of studies with acceptable evidence to support such implementation.

The aim of this publication is to present the outcomes of NICT in patients with blunt abdominal trauma and splenic injury who were treated in a center lacking the infrastructure required for this therapeutic modality as described in the literature.

Material and methods

We conducted a retrospective, descriptive, observational and cross-sectional study of cases admitted with a diagnosis of abdominal trauma and splenic injury, identified through ultrasound and/ or computed tomography images with intravenous contrast agent between 2012 and 2022. Patients with open abdominal trauma and those with blunt abdominal trauma without eFAST (Extended Focused Assessment with Sonography in Trauma) on admission were excluded from this study. The variables recorded were age, sex, time from injury to admission, hemodynamic status on admission, peritoneal signs on admission, initial indication of surgery, lesion severity on CT images, amount of hemoperitoneum, minor associated lesions, length of hospital stay, type of unit of hospitalization, need for transfusions, and reasons to stop NICT.

Hemodynamic instability, peritoneal signs, and severe associated injuries were considered initial indications for surgery. Any hollow viscus injury or vascular injury with indication for initial surgery was considered a severe associated injury, except for severe traumatic brain injury (TBI). Minor associated injuries were those less severe injuries associated with splenic trauma that did not require major surgical treatment and/or did not interfere with monitoring of NOM, except for severe TBI, which was also excluded from this category and was considered as a single category. Hemoperitoneum was classified according to the number of abdominal spaces with free fluid as mild (1-2 spaces), moderate (3-4 spaces) and large (more than 4 spaces).

The severity of splenic injury was categorized with the grading system based on CT scan images developed by the American Association for the Surgery of Trauma (AAST)⁵.

Patients admitted to the general ward were monitored for 24 hours by postgraduate year 1 and 2 residents in general surgery, and by the chief of the general surgery ward from 8:00 am to 2:00 pm. Thereafter, monitoring was taken over by postgraduate year 1 to 4 residents in general surgery on duty and the surgeon on duty. In the intensive care unit, monitoring was carried out by the intensivist, postgraduate year 2 resident in general surgery and the chief of the general surgery ward.

Data was collected from the statistical database of the Department of General Surgery (Access Office®) and the hospital statistical database SISC® (Sistema Integrado de Supervisión de Centrales). All the statistical calculations were performed using IBM SPSS Statistics® software package (International Business Machines - Statistical Package for the Social Sciences).

The association of the severity of splenic injury, associated lesions, amount of hemoperitoneum, severe BTI, and type of unit of hospitalization with successful NOM was analyzed with the Pearson’s chi-square test, and when the expected result was higher than 20%, the Cramer’s V test was used to analyze the association of polytomous variables.

A p value < 0.05 with a 95% confidence interval was considered statistically significant.

Results

During the 10-year period, 102 patients were admitted with a diagnosis of blunt abdominal trauma with splenic injury. Mean age was 31 years and 90 were men (88.2%).

Time from injury to admission was < 48 hours in 84 patients, between 48 hours and 7 days in 12, and > 7 days in 6 cases. The frequency of kinematics of trauma is described in Table 1. On admission, most patients (94%) were hemodynamically stable and had no peritoneal signs (76.5%). These patients were managed with NICT. There were 30 cases with at least one initial indication for surgery. These patients were not candidates for NOM and underwent surgery. Of the 72 patients who were managed with NICT, treatment was successful in 66.6% (48), while 33.3% required surgery due to treatment failure. The reasons for treatment failure were peritoneal signs in 18 cases, and peritoneal signs with hemodynamic instability in 6 cases. All these patients underwent splenectomy between 24 and 48 hours after admission. Of the patients managed with NICT, 5.9% (6) required blood transfusion.

On admission, all the patients underwent eFAST. Computed tomography scan was not performed in 12 (11.8%) of these patients due to the presence of contraindications or indications for emergency surgery. The remaining 90 (88.2%) patients underwent CT scan with intravenous contrast agent to diagnose and categorize the severity of the injury.

Of these patients, 24 (23.5%) had grade I lesions, 42 (41.2%) grade II, 18 (17.6%) grade III and 6 (5.9%) grade IV. The imaging tests showed that 30 (29.4%) patients had no associated hemoperitoneum, while 30 (29.4%) had mild hemoperitoneum, 24 (23.5%) patients had moderate hemoperitoneum and 18 (17.6%) had large hemoperitoneum.

In 54 cases (52.9%) splenic injury was associated with other minor injuries resulting from the trauma, while in 48 cases (47.1%) the spleen was the only organ injured. Of the cases involving minor injuries, 29.4% (30 cases) were associated with one injury, 11.8% (12 cases) with two injuries, and 11.8% (12 cases) with three injuries. Only 4.9% (5 cases) were associated with severe TBI. Minor injuries included single rib fracture, multiple rib fractures, simple pneumothorax, single limb fracture, open tibial fracture, unilateral hemothorax, soft tissue wounds, facial fractures, and eye trauma.

Mean length of hospital stay in patients with successful NICT was 5 days. Of the total number of patients admitted, 96 (94.1%) were monitored in a general ward, and 6 (5.9%) required admission to the intensive care unit.

The association between the different variables and successful NICT are detailed in Table 2.

Discussion

When analyzing patients with blunt abdominal trauma and splenic injury, we found that most had high-energy injuries⁶, such as those from motorcycleto-car collisions. Our results showed that nonoperative management (NOM) was successful and was directly related to the severity of the injury on CT images and the amount of hemoperitoneum, as described in similar studies^7,9. In contrast, we could not demonstrate that the association of splenic trauma with minor injuries, multiple trauma or severe TBI is a contraindication to conservative treatment, but has a statistically significant association and could contribute to the lack of success of this treatment. On the other hand, we were able to demonstrate the therapeutic success of NICT with minimal care using medium and low complexity resources in a general hospital ward, if patients are closely monitored by a team made up of internists and surgeons.

Our hospital does not have 24/7 catheterization laboratory capabilities, as recommended by the Manual of Trauma Surgery¹ which we base our protocol of care on. However, NICT with monitoring and observation has shown a low failure rate, similar to that reported by Toro et al. in their study, which was carried out in a center with a catheterization laboratory⁷.

For these reasons, we consider the success rate achieved with NICT at our center to be important, despite the lack of human and technological resources that, according to the existing bibliography, are needed to implement this strategy.

This raises the question of the efficacy of NOM with minimally invasive interventions and the published limitations for implementing conservative treatment. These issues are beyond the scope of this study and could be addressed in future research. We also consider providing the basis for establishing standardized protocols for the care of this condition in low and medium complexity centers, which will determine the appropriate conditions for managing these patients.