Mauro Podda1, Belinda De Simone2, Marco Ceresoli3, Francesco Virdis4, Francesco Favi5, Johannes Wiik Larsen6, Federico Coccolini7, Massimo Sartelli8, Nikolaos Pararas9, Solomon Gurmu Beka10, Luigi Bonavina11, Raffaele Bova5, Adolfo Pisanu12, Fikri Abu-Zidan13, Zsolt Balogh14, Osvaldo Chiara4, Imtiaz Wani15, Philip Stahel16, Salomone Di Saverio17, Thomas Scalea18, Kjetil Soreide6, Boris Sakakushev19, Francesco Amico20,21, Costanza Martino22, Andreas Hecker23, Nicola de'Angelis24, Mircea Chirica25, Joseph Galante26, Andrew Kirkpatrick27, Emmanouil Pikoulis28, Yoram Kluger29, Denis Bensard30, Luca Ansaloni31, Gustavo Fraga32, Ian Civil33, Giovanni Domenico Tebala34, Isidoro Di Carlo35, Yunfeng Cui36, Raul Coimbra37, Vanni Agnoletti38, Ibrahima Sall39, Edward Tan40, Edoardo Picetti41, Andrey Litvin42, Dimitrios Damaskos43, Kenji Inaba44, Jeffrey Leung45,46, Ronald Maier47, Walt Biffl48, Ari Leppaniemi49, Ernest Moore50, Kurinchi Gurusamy45, Fausto Catena5. 1. Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy. mauropodda@ymail.com. 2. Department of Emergency, Digestive and Metabolic Minimally Invasive Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France. 3. General and Emergency Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy. 4. Trauma and Acute Care Surgery Department, Niguarda Hospital, Milan, Italy. 5. Department of Emergency and Trauma Surgey, Bufalini Trauma Center, Cesena, Italy. 6. Department of Gastrointestinal Surgery, Stavanger University Hospital University of Bergen, Stavanger, Norway. 7. General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy. 8. Department of Surgery, Macerata Hospital, Macerata, Italy. 9. Department of General Surgery, Dr Sulaiman Al Habib/Alfaisal University, Riyadh, Saudi Arabia. 10. School of Medicine and Health Science, University of Otago, Wellington Campus, Wellington, New Zealand. 11. Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy. 12. Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy. 13. Department of Applied Statistics, The Research Office, College of Medicine and Health Sciences United Arab Emirates University, Abu Dhabi, UAE. 14. Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia. 15. Government Gousia Hospital, Srinagar, India. 16. Department of Surgery, East Carolina University, Brody School of Medicine, Greenville, USA. 17. Department of Surgery, San Benedetto del Tronto Hospital, AV5, San Benedetto del Tronto, Italy. 18. Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA. 19. Research Institute of Medical University Plovdiv/University Hospital St George Plovdiv, Plovdiv, Bulgaria. 20. Trauma Service, John Hunter Hospital, Newcastle, Australia. 21. The University of Newcastle, Newcastle, Australia. 22. Department of Anesthesiology and Acute Care, Umberto I Hospital of Lugo, Ausl della Romagna, Lugo, Italy. 23. Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany. 24. Unit of General Surgery, Henri Mondor Hospital, UPEC, Créteil, France. 25. Service de Chirurgie Digestive, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France. 26. Trauma Department, University of California, Davis, Sacramento, CA, USA. 27. General, Acute Care and Trauma Surgery Foothills Medical Centre, University of Calgary, Calgary, AB, Canada. 28. General Surgery, Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece. 29. Division of General Surgery, Rambam Health Care Campus, Haifa, Israel. 30. Department of Surgery, Denver Health Medical Center, Denver, CO, USA. 31. Unit of General Surgery, San Matteo Hospital, Pavia, Italy. 32. Division of Trauma Surgery, University of Campinas, Campinas, SP, Brazil. 33. Director of Trauma Services, Auckland City Hospital, Auckland, New Zealand. 34. UOC Chirurgia Digestiva e d'Urgenza, Azienda Ospedaliera S.Maria, Terni, Italy. 35. Department of Surgical Sciences and Advanced Technologies, University of Catania, Catania, Italy. 36. Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China. 37. Riverside University Health System Medical Center, Moreno Valley, CA, USA. 38. Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy. 39. Department of General Surgery, Military Teaching Hospital, Hôpital Principal Dakar, Dakar, Senegal. 40. Department of Surgery, Radboudumc, Nijmegen, The Netherlands. 41. Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy. 42. Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia. 43. Department of General Surgery, Royal Infirmary Edinburgh, Edinburgh, UK. 44. University of Southern California, Los Angeles, USA. 45. Division of Surgery and Interventional Science, University College London (UCL), London, UK. 46. Milton Keynes University Hospital, Milton Keynes, UK. 47. University of Washington, Seattle, USA. 48. Division of Trauma and Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, La Jolla, CA, USA. 49. Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland. 50. Ernest E. Moore Shock Trauma Center, University of Colorado School of Medicine, Denver, CO, USA.
Abstract
BACKGROUND: In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved. METHODS: Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM. RESULTS: Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I-II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II-III, AAST Grades III-V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries-WSES Class I, AAST Grades I-II) to 3 days (for high-grade splenic injuries-WSES Classes II-III, AAST Grades III-V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48-72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV-V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48-72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications. CONCLUSION: This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.
BACKGROUND: In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved. METHODS: Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM. RESULTS: Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I-II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II-III, AAST Grades III-V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries-WSES Class I, AAST Grades I-II) to 3 days (for high-grade splenic injuries-WSES Classes II-III, AAST Grades III-V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48-72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV-V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48-72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications. CONCLUSION: This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.
Authors: B Wernick; A Cipriano; S R Odom; U MacBean; R N Mubang; T R Wojda; S Liu; S Serres; D C Evans; P G Thomas; C H Cook; S P Stawicki Journal: Eur J Trauma Emerg Surg Date: 2016-05-11 Impact factor: 3.693
Authors: Gregory A Watson; Matthew R Rosengart; Mazen S Zenati; Allan Tsung; Raquel M Forsythe; Andrew B Peitzman; Brian G Harbrecht Journal: J Trauma Date: 2006-11
Authors: Jarrett E Santorelli; Todd W Costantini; Allison E Berndtson; Leslie Kobayashi; Jay J Doucet; Laura N Godat Journal: Surgery Date: 2021-11-29 Impact factor: 3.982