Hepatic Injury, Blunt, Selective Nonoperative Management of

Published 2012
Citation: J Trauma. 73(5):S288-S293, November 2012

Authors

Stassen, Nicole A. MD; Bhullar, Indermeet MD; Cheng, Julius D. MD; Crandall, Marie MD; Friese, Randall MD; Guillamondegui, Oscar MD; Jawa, Randeep MD; Maung, Adrian MD; Rohs, Thomas J. Jr MD; Sangosanya, Ayodele MD; Schuster, Kevin MD; Seamon, Mark MD; Tchorz, Kathryn M. MD; Zarzuar, Ben L. MD; Kerwin, Andrew MD

Author Information

From the Department of Surgery (M.C.), Northwestern University, Chicago, Illinois; Department of Surgery (N.A.S., J.D.C., A.S.), University of Rochester, Rochester, New York; Department of Surgery (R.F.), University of Arizona, Tucson, Arizona; Department of Surgery (O.G.), Vanderbilt University, Nashville; and Department of Surgery (B.L.Z.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (R.J.), University of Nebraska, Omaha, Nebraska; Department of Surgery (A.M., K.S.), Yale University, New Haven, Connecticut; Borgess Trauma Services (T.J.R.), Kalamazoo, Michigan; Department of Surgery (M.S.), Cooper Health System, Camden, New Jersey; Department of Surgery (K.M.T.), Wright State University, Dayton, Ohio; and Department of Surgery (I.B., A.K.), College of Medicine, University of Florida, Jacksonville, Florida.

Address for reprints: Nicole A. Stassen, MD, Department of Surgery, University of Rochester, 601 Elmwood Ave, Box SURG, Rochester, NY 14642; email: nicole_stassen@urmc.rochester.edu.

Statement of the Problem

During the last century, the management of blunt force trauma to the liver has changed from observation and expectant management in the early part of the 1900s to operative intervention, to the current practice of selective operative and nonoperative management. The current nonoperative paradigm in adults was stimulated by the success of nonoperative management of solid organ injuries in hemodynamically stable children. The advantages of nonoperative management include lower hospital cost, earlier discharge, avoiding nontherapeutic celiotomies (and their associated cost and morbidity), fewer intra-abdominal complications, and reduced transfusion rates. Selective nonoperative management of blunt hepatic injury is associated with an improvement in mortality when compared with operative therapy.^[1–3] A 2008 study by Tinkoff et al.^[4] showed that 86.3% of hepatic injuries are now managed without operative intervention. These issues were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the Practice Management Guidelines for Non-operative Management of Blunt Injury to the Liver and Spleen published online in 2003.^[5] Since that time, a large volume of literature on these topics has been published. As a result, the Practice Management Guidelines Committee of EAST set out to develop updated guidelines for the nonoperative management of hepatic and splenic injuries. The practice management guideline update was split into separate recommendations for the nonoperative management of blunt hepatic and splenic injuries in adult trauma patients rather than the amalgamated recommendations included in the 2003 practice management guideline.

Reports of nonoperative management in adults with injuries to the liver continue to support nonoperative management in hemodynamically stable adults, but questions still exist about efficacy, patient selection, and details of management.^[2][6–9] These questions include as follows:

Are the 2003 recommendations still valid?
Is nonoperative management appropriate for all hemodynamically stable adults regardless of the severity of solid-organ injury or presence of associated injuries?
What role should angiography and other adjunctive therapies play in nonoperative management?
Is the risk of missing a hollow viscous injury a deterrent to nonoperative management?
What is the best way to diagnose injury to the liver?
What roles do computed tomographic (CT) scan and/or ultrasound have in the hospital management of the patient being managed nonoperatively?
Should patients be placed on a “bed rest” activity status, and if so, for what duration?
Finally, what period and evaluation is needed before releasing patients back to full activity?

Process

Identification of References

References were identified by research librarians at the University of Rochester—Miner Medical Library. The MEDLINE database in the National Library of Medicine and the National Institutes of Health was searched using Entrez (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year of literature used for the existing guideline) using the keywords: liver injury; and blunt abdominal trauma. The articles were limited to humans, clinical trials, randomized controlled trials, practice guidelines, meta-analyses, and reviews. Two hundred twenty-three articles were identified. Case reports and small case series were excluded. The committee chair and members then reviewed the articles for relevance and excluded any reviews and tangential articles. One hundred seventy-six articles were reviewed, of which 94 were used to create the nonoperative management of blunt hepatic injures recommendations. (Table).

Quality of References

The methodology developed by the Agency for Healthcare Policy and Research of the US Department of Health and Human Services was used to group the references into three classes.^[1]

Class I: Prospective randomized studies (no references).

Class II: Prospective, noncomparative studies and retrospective series with controls (12 references).

Class III: Retrospective analyses (case series, databases or registries, and case reviews) (82 references).

Based on the review and assessment of the selected references, three levels of recommendations are proposed.

Level 1

The recommendation is convincingly justifiable based on the available scientific information alone. This recommendation is usually based on Class I data; however, strong Class II evidence may form the basis for a Level 1 recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, low-quality or contradictory Class I data may not be able to support a Level 1 recommendation.

Level 2

The recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. This recommendation is usually supported by Class II data or a preponderance of Class III evidence.

Level 3

The recommendation is supported by available data, but adequate scientific evidence is lacking. This recommendation is generally supported by Class III data. This type of recommendation is useful for educational purposes and in guiding future clinical research.

Recommendations

Upon review of the updated literature, it was found that most of the recommendations from the 2003 guideline remain valid. The previous guidelines were incorporated into the greatly expanded current recommendations as appropriate. A multitude of unanswered questions remain in the literature for nonoperative management of blunt hepatic injuries.

Level 1

Patients who are hemodynamically unstable or who have diffuse peritonitis after blunt abdominal trauma should be taken urgently for laparotomy.

Level 2

A routine laparotomy is not indicated in the hemodynamically stable patient without peritonitis presenting with an isolated blunt hepatic injury.
In the hemodynamically stable blunt abdominal trauma patient without peritonitis, an abdominal CT scan with intravenous contrast should be performed to identify and assess the severity of injury to the liver.
Angiography with embolization may be considered as a first-line intervention for a patient who is a transient responder to resuscitation as an adjunct to potential operative intervention.
The severity of hepatic injury (as suggested by CT grade or degree of hemoperitoneum), neurologic status, age of more than 55 years, and/or the presence of associated injuries are not absolute contraindications to a trial of nonoperative management in a hemodynamically stable patient.
Angiography with embolization should be considered in a hemodynamically stable patient with evidence of active extravasation (a contrast blush) on abdominal CT scan.
Nonoperative management of hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy.

Level 3

After hepatic injury, clinical factors such as a persistent systemic inflammatory response, increasing persistent abdominal pain, jaundice, or an otherwise unexplained drop in hemoglobin should prompt reevaluation by CT scan.
Interventional modalities including endoscopic retrograde cholangiopancreatography, angiography, laparoscopy, or percutaneous drainage may be required to manage complications (bile leak, biloma, bile peritonitis, hepatic abscess, bilious ascites, and hemobilia) that arise as a result of nonoperative management of blunt hepatic injury.
Pharmacologic prophylaxis to prevent venous thromboembolism can be used for patients with isolated blunt hepatic injuries without increasing the failure rate of nonoperative management, although the optimal timing of safe initiation has not been determined.

There was not enough literature available to make recommendations regarding the following:

Frequency of hemoglobin measurements
Frequency of abdominal examinations
Intensity and duration of monitoring
Time to reinitiating oral intake
Duration and intensity of restricted activity (both in hospital and after discharge)
Optimum length of stay for both the intensive care unit (ICU) and hospital
Timing of initiating chemical deep venous thrombosis (DVT) prophylaxis after hepatic injury

Scientific Foundation

Nonoperative management of blunt hepatic trauma is now the standard of care for hemodynamically stable patients with blunt hepatic trauma at most of the US trauma centers, with reported success rates ranging from 82% to 100%.^[8][10–14] Some have even voiced that operative management of hepatic trauma leads to increased hepatic hemorrhage and may lead to unnecessary interventions with an increased incidence of iatrogenic complications.^[2][3] Factors previously thought to completely preclude nonoperative management of hepatic injuries include hepatic injury grade, head injury, injury severity score, degree of hemoperitoneum, age greater than 55 years, number of transfusions, periportal tracking of blood or pooling of contrast/a blush on CT scan.^[15][16] More recent literature has challenged these findings and the severity of hepatic injury (as suggested by CT grade or degree of hemoperitoneum), neurologic status, presence of a “blush” on CT scan, age greater than 55 years, and/or the presence of associated injuries are no longer considered absolute contraindications to a trial of nonoperative management in the hemodynamic stable patient.^{[3][6][17–19]}

There is no established consensus on how much blood loss or transfusion requirement mandates the decision to intervene, whether operatively or angiographically.^[3][16] A correlation between hepatic injury grade and failure of nonoperative management has not been consistently shown; therefore, the initial management of patients with blunt hepatic trauma should be mandated by their hemodynamic status rather than their grade of hepatic injury.^[7][20][21] Patients who are hemodynamically unstable with evidence of intra-abdominal hemorrhage (a positive FAST or DPL) should undergo operative management of their hepatic bleeding.^[22][23] Patients who have peritonitis should undergo immediate exploratory laparotomy.^[12] Nonoperative management should only be performed in centers capable of diagnosis of hepatic trauma and associated injuries, rapid response to change in patient status if necessary, and delayed interventions if complications arise. Careful and repeated examinations and multidisciplinary consultation are needed to support this management strategy.^[12] Any suspicion of hollow viscous injury or change in abdominal pain pattern indicates a need for operation. In addition, as increasing numbers of solid organ injuries are detected in a patient with blunt trauma, the incidence of hollow viscous injury increases.^[24] The overall incidence of missed injury is quite low and should not influence decisions concerning eligibility for nonoperative management.^[25][26] Adopting a standardized protocol of nonoperative management for isolated liver trauma based on hemodynamics reduces resource use and hospital costs, without any detriment to care.^[27]

A CT scan of the abdomen with intravenous contrast administration is the optimal diagnostic modality for hemodynamically stable patients to aid in both the diagnosis and management of blunt hepatic trauma.^[28] It is also useful in quantifying the amount of hemoperitoneum and identifying other intraperitoneal or retroperitoneal injuries or the presence of pneumoperitoneum.^[29–31] CT scan also offers the advantage of potentially identifying ongoing active bleeding.^[32][33] The finding of a “blush” or pooling of intravenous contrast material within the liver parenchyma on CT scan can be indicative of active hemorrhage.^[32][33] Hemodynamically stable patients with free intraperitoneal extravasation should be considered for immediate angiography if readily available.^[34] Close observation alone with planned angiographic embolization for signs of ongoing bleeding, such as a drop in hematocrit or need for transfusion, is also an option in appropriate facilities.^[33][35] Fang et al.^[28] showed that intraperitoneal contrast extravasation and hemoperitoneum in six compartments on CT scan indicates massive or active hemorrhage and should be regarded as high risk for the need of operation or angiography in hemodynamically stable patients after blunt hepatic injury. Multichannel detector CT scanners have improved sensitivity, and more rapid imaging allows for the visualization of major vascular structures in different phases following contrast enhancement. In addition, reconstruction can be performed in multiple planes without significant loss of image quality.^[36] However, while serious abnormalities on CT scan often predict the need for intervention for blunt liver injuries, clinical findings including shock or peritoneal signs may outweigh findings on CT scan and may lead to operative intervention or the need for angioembolization.^[37] Although routine follow-up CT scans are not necessary, clinical factors such as persistent systemic inflammatory response syndrome, abdominal pain, jaundice, or an unexplained drop in hemoglobin level should prompt reevaluation by CT scan.^[19][30][38] Grossly elevated transaminases after traumatic injury should prompt further evaluation of the liver with CT scan if possible.^[39][40]

The role of angioembolization in the management of blunt hepatic injury remains controversial. Poletti et al.^[41] showed that CT injury grade (AAST Grade III or higher), evidence of arterial injury (a contrast “blush”), and evidence of hepatic venous injury are useful indicators of high-risk patients who would benefit from hepatic angiography to limit persistent or delayed bleeding or other delayed complications.^[42] In a study by Hagiwara et al.,^[34] all stable patients with Grade III or higher liver injuries had an angiogram where nearly half of the Grade III injuries and nearly all of the Grade IV injuries had active bleeding on angiography regardless of the presence of CT scan blush. The reported efficacy of angioembolization for the control of bleeding after blunt hepatic injury is as high as 83%, with some patients requiring a repeated angiogram.^[20] Misselbeck et al.^[43] showed that angiography is useful in management of those with patients with a “blush” on CT scan and that these patients are 20 times more likely to require embolization than those without. While angioembolization can be very effective, it remains associated with significant morbidity owing to renal impairment related to the injection of iodinated contrast agents; to arterial dissection or accidents at the arterial puncture site; to localized hepatic necrosis, abscess, and necrosis of the biliary tract; and to cholecystitis, which occurred in up to 58% of patients in some studies.^[43][44]

There is no consensus in the literature regarding predicting the failure of nonoperative management of hepatic injuries. Patients with hepatic injuries who require ongoing fluid resuscitation to maintain hemodynamic stability have multiple solid-organ injuries, a higher Injury Severity Score (ISS), large hemoperitoneum, or contrast extravasation on CT scan are more likely to fail nonoperative management and will likely require additional treatment, either angioembolization and/or laparotomy.^[14][23][45] Malhotra et al. showed that patients with concomitant liver and spleen injuries have higher ISS, mortality, length of stay, and transfusion requirement and are more likely to fail nonoperative management of their injuries than those with single solid-organ injuries.^[46][47] However, other studies have not found that multiple solid-organ injuries to be a great detriment to successful nonoperative management of blunt hepatic injury.^[48]

Hemodynamic instability is responsible for 75% of all failures of nonoperative management.^[7] While the incidence of delayed hemorrhage is low at 2.8% to 3.5% in an appropriately chosen population, it still remains the most common complication and cause of death in nonoperative management.^[2] Angiography with embolization should be considered as a first-line intervention for a patient who is a transient responder to resuscitation before potential operative intervention (if embolization is unsuccessful).^[49] For those patients who are hemodynamically unstable despite continuous resuscitation, laparotomy followed by embolization if needed is likely a safer approach.^[3] The amount of blood transfused and infectious complications were significantly reduced for patients with angioembolization as first-line therapy compared with those who underwent laparotomy followed by embolization.^[44]

Many patients who undergo nonoperative management of hepatic trauma have complications including bile leaks, hemobilia, bile peritonitis, bilious ascites, hemoperitoneum, abdominal compartment syndrome, missed injuries, hepatic necrosis, hepatic abscess, and delayed hemorrhage.^[3][8][25] The complication rate increases with the grade of injury as illustrated in several studies of patients where those with Grade III had a complication rate of 1%, Grade IV at 21%, and Grade V at 63%.^[35][46][47] Minimally invasive endoscopic techniques and interventional radiology therapies are available and more likely to be required for patients being managed conservatively with higher-grade injuries.^[47][50]Typically, biliary complications present in a more delayed fashion for patients with high-grade injuries.^[47] Biliary duct disruptions with associated bilomas, bile peritonitis, biliary leaks, and biliary sepsis occur in approximately 3.2% of all hepatic trauma patients and contribute significantly to the morbidity associated with hepatic injuries.^[3] Biliary leaks are more common in higher-grade injuries, and most patients will develop clinical symptoms such as a systemic inflammatory response, sepsis, an elevation in serum bilirubin levels, or worsening abdominal pain. Hepatobiliary iminodiacetic acid scans have been shown to be nearly 100% sensitive and specific for diagnosing bile duct leaks after liver injury.^[51]Although most peripheral biliary leaks will seal without treatment, continued high-output biliary drainage may warrant adjunctive endoscopic retrograde cholangiopancreatography and stenting.^[39] Continued observation of biliary leaks is necessary because multiple and recurrent late complications occur, which can be dealt with operatively (laparoscopic or open) or through less invasive means such as endoscopic retrograde cholangiopancreatography with stenting or percutaneous drainage.^[20][46]Laparoscopic washout of biliary peritonitis is gaining traction as an adjunctive therapy to the nonoperative management of liver injuries. It is thought that this washout helps to resolve the systemic inflammatory process that is a result of the bile peritonitis.^[52–54] Intrahepatic abscesses occur in up to 4% of nonoperatively managed hepatic trauma, and mortality is approximately 10%.^[31] The treatment may be either surgical drainage (open or laparoscopic) or percutaneous drainage.^[50]

Nonoperative management of hepatic injuries should only be considered for patients who are hemodynamically stable and have an absence of peritoneal signs and in an environment that has the capability for monitoring, serial clinical evaluations, and facilities for urgent laparotomy. Nonoperative management of blunt hepatic injury consists of a period of in-hospital/ICU observation/monitoring, serial abdominal examinations, serial hematocrit measurements, and a period of immobility (bed rest/postdischarge restricted activity). What remains unclear in the literature is the duration and frequency required of all of these interventions.^[1] St Peter et al.^[55] showed that an abbreviated trauma protocol with overnight bed rest for Grades I and II injuries and two nights for higher-grades could be safely used for patients with blunt hepatic injuries. In adults, timing of an in-hospital mobilization did not seem to contribute to delayed hemorrhage in a retrospective study by London et al.;^[56] however, this has not been confirmed in a prospective fashion. Median healing time for hepatic subcapsular hematomas was found to be different from hepatic lacerations in a single study by Tiberio et al.^[57] The median healing time for a Grade I hematoma was found to be 6 days, while it was 16 days for Grade II and 108 days for Grade III hematoma. For lacerations, the median healing time was found to be 29 days for Grade II, 34 days for Grade III, and 78 days for Grade IV. These patients are being discharged earlier now than previous periods without negative consequences.^[7] There is no true consensus about what constitutes an appropriate in-hospital and posthospital management of a patient with blunt hepatic injury once they have been selected for nonoperative management. Frequency of serial hematocrits, abdominal examinations, and monitoring; when a diet should be started; how long should patients be kept at bed rest; the optimum length of stay in both the ICU and hospital; and how long should activities be limited are all questions to which there are no clear-cut answers in the literature.

Chemical DVT prophylaxis can be used for patients with isolated blunt hepatic injuries without increasing the failure rate of nonoperative management. Eberle et al.^[58] showed that chemical DVT prophylaxis may not increase the failure rate of nonoperative management. In their study, early (<3 days) use of low–molecular weight heparin did not seem to increase failure rates or blood transfusion requirements for patients with hepatic injuries. Although the use of chemical DVT prophylaxis has been shown not to negatively impact nonoperative management of hepatic injuries, there is no literature consensus about safe initiation time.

Summary

There has been a plethora of literature regarding nonoperative management of blunt hepatic injuries published since the 2003 EAST practice management guideline was written. Nonoperative management of blunt hepatic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury. Its use is associated with a low overall morbidity and mortality when applied to an appropriate patient population. Nonoperative management of blunt hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast–enhanced CT scan is the diagnostic modality of choice for evaluating blunt hepatic injuries. Repeated imaging should be guided by a patient’s clinical status. Adjunctive therapies such as angiography, percutaneous drainage, endoscopy/ERCP and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt hepatic injuries remain without conclusive answers in the literature.

Disclosure

The authors declare no conflicts of interest.

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Table

Literature Evidentiary Table

Authors	Title	Reference information	Reviewer comments
Anderson SW, Varghese JC, Lucey BC,	Blunt splenic trauma: delayed-phase CT for differentiation of active hemorrhage from contained vascular injury in patients.	Radiology. 2007 Apr;243(1):88-95. Epub 2007 Feb 9	PURPOSE: [1] Use delayed-phase CT to differentiate active extravasation (Blush) vs. contained vascular injuries (pseudoaneurysm); CONCLUSIONS: [1] In blunt splenic trauma delayed phase CT effectively differentiates active splenic hemorrhage (extravasation-Blush) from those with contained vascular injuries (pseudoaneurysm); COMMENTS: [1] Small study size (n=47); [2] Questionable utility since both blush vs pseudoaneurysm would, in this day and age, be treated by the same modality: angio-embolization. In the study however, all the active extravasation patients were treated with surgery and all the pseudoaneurysms were embolized; this magnified the authors point for this CT technology to differentiate between the two.
Archer LP, Rogers FB, Schakford SR	Selective non-operative management of liver and spleen injuries in neurologically impaired adult patients	Arch Surg 1996;131:309-315	Retrospective, single-institution study of 187 patients with blunt splenic and/or hepatic injuries. Of the 87 that were managed nonoperatively, patients with (n=30) and without (n=57) altered mental status (AMS) were compared. Injury severity was higher and GCS was lower in patients with AMS. There was no difference in mortality or FNOM rates between these groups.
Avanoglu A, Ulman I, Ergun O,	Blood transfusion requirements in children with blunt spleen and liver injuries.	Eur J Pediatr Surg. 1998 Dec;8(6):322-5	higher transfusion rate in the operative group (both spleen and liver), longer LOS in surgical group, equal associated injuries in both groups, Increased transfusion may be from pre=op which is what triggered operation
Bain IM, Kirby RM.	10 year experience of splenic injury: an increasing place for conservative management after blunt trauma.	Injury. 1998 Apr;29(3):177-82	Retrospective review over 10 years of spleen and multi-systme injuries that included spleens. Relatively small (111patients), and old, covered the time period of op to non-op mgmt. No recommendations would be made based on this study.
Barone JE, Burns G, Svehlak SA,	Management of blunt splenic truama in patients older than 55 years. Southern Connecticut Regional Trauma Quality Assurance Committee.	J Trauma. 1999 Jan;4691): 87-90	small study, failure rates between the two age groups similar, no contraindication to management
Becker CD, Mentha G, Terrier F.	Blunt abdominal truama in adults: role of CT in the diagnosis and management of visceral injuries. Part 1: liver and spleen.	Eur Radiol. 1998; 8(4): 553-62	Majority of hepatic injuries can be managed non-operatively even with tri-segment injury and hemoperitoneum, delayed complications can be easily diagnosed by repeat CT, Different for spleens because only minor splenic injuries on CT can still have delayed rupture.
Bee, Croce, Miller, Pritchard, Davis, Fabian	Failures of Nonoperative Management: Is the Glass Half Empty of Half Full?	J Trauma. 2001 Feb;50(2): 230-6	age > 55 and major spleen injury (Grade 3-5) were independent predictors of failure of NOM with NO difference in mortality when comparing failed Nom to successful NOM
Bianchi JD, Collin GR.	Management of Splenic trauma at a rural, Level I trauma center	Am Surg. 1997 Jun ; 63(6) : 490-5	CT is most common way to diagnose splenic injury, 50% operation rate, 16% non-op failure rate secondary to underestimatino of degree of injury, also most got transfused
Bouras AF, traunt S, Pruvot FR.	Mangement of blunt hepatic trauma.	J Visc Surg. 2010 Nov 24	non operative management in 80-90% of liver trauma, clinical and hemodynamic changes guide therapy, increased incidence of late complications (bile leaks, fistulas, persisent bleeding, ACS or hepatic abcess) complications can be managed via planned interventions - IR, GI, laparoscopy, OR. A success rate of 80—100% can be anticipated with non-operative management of blunt hepatic trauma. CM is the choice of reference in the management of low-grade liver trauma. When a patient presents with uncompensated shock, abbreviated damage—control laparotomy with pedicular clamping and perihepatic packing is the appropriate response. The principal and most dangerous complication of conservative management is persistent bleeding. The number of units of RBC transfusion before surgical intervention varies. The need for laparotomy may be urgent. The prognosis of abdominal compartment syndrome is very grave if rapid decompression by laparoscopy or laparotomy is not performed. Biliary complications are more benign and typically occur later in the evolution of BHT; they may require additional interventional procedures such as percutaneous drainage or endoscopic sphincterotomy and bile stent placement for decompression, or laparoscopic drainage. The occurrence and the need for management of late complications should no longer be considered a failure of conservative management but rather as an anticipated and integral part thereof.
Bowman SM, Bulger E, Sharar SR,	Variability in pediatric splenic injury care: results of a national survey of general surgeons.	Arch Surg. 2010 Nov;145(11): 1048-53	Mail survey of the knowledge, attitudes and beliefs toward pediatric splenic injury management by non-specialty general surgeons. The study demonstrated a variability in clinical practice as well as awareness of clinical practice guidelines
Brasel KJ, DeLisle CM, Olson CJ,	Trends in the management of hepatic injury.	Am J Surg. 1997 Dec;174(6):674-7	Retrospective studay of evolving methodology, single institution '91-95; Measuring success of CT facilitating nonop management strategies. Conclusuion: Nonop management appears safe in hemodynamically stable patients of all grades of injury with few missed injuries. Nonop LOS shorter with lower transfusion requirements.
Carillo EH, Reed DN, Gordon L, et al	Delayed laparoscopy facilitates the management of biliary peritonitis in patients with complex liver injuries.	Surg Endosc 2001; 15:319–322	case series for lap washout
Carobbi A, Romagnani F, Antonelli G, et al	Laparoscopic splenectomy for severe blunt trauma: initial experience of 10 consecutive cases with a fast hemostatic technique	Surg Endosc. 2010;24:1325-1330	Case series of 12 patients, non-op failures with high ISS, older age and higher grade injuries, treatment portocol based on ISS, GCS, plenic injury grade and volume of hemoperitoneum: Operative intervention if age >55, ISS>25, Spleen>3 and hemoperitoneum in two recesses. Scope if GCS>10 They describe their scope technique. All were primary operative therapy, not failures of non -op therapy who were assumed based on criteria, not hemodynamics that they would bleed. No complications with laparoscopy, skill set is an issue
Carrillo EH, Platz A, Miller FB,	Non-operative management of blunt hepatic trauma	Br J Surg. 1998 Apr;85(4):461-8.	difficult to discern how articles referenced in this review article were selected. Reviews the literature to provide information about surgical anatomy, physiology, diagnosis, and management of liver injury.
Carrillo EH, Spain DA, Wohltmann CD,	Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries.	J Trauma. 1999 Apr;46(4):619-22; discussion 622-4	non operattive management in stable patients, 24% had some complication, interventional procedures were successful in 85%
Cathey Kl, Brady WJ Jr, Butler K,	Blunt splenic trauma: characteristics of patients requiring urgent laparotomy.	Am Surg. 1998 May; 65(5): 450-4	Retrospective ED study -helpful for ED physicians to detemine need for surgery
Chen RJ, Fang JF, Chen MF	Intra-abdominal pressure monitoring as a guideline in the nonoperative management of blunt hepatic trauma	J Trauma. 2001;51:44-50.	case series for intraabdominal pressure monitoring as a guideline for non op liver management, grade 3 to 5 injuries, 25 patients, IAP may help a little, but is not predictive
Christmas AB, Wilson AK, Manning B, et al.	Selective management of blunt hepatic injuries including nonoperative management is safe and effective strategy	Surgery 2005;138:606-11	Selective non-operative management of the hemodynamically normal blunt hepatic trauma regardless of grade presents a low liver-related mortality rate.
Ciraulo DL, Luk S, Palter M,	Selective hepatic arterial embolization of grade IV and V blunt hepatic injuries: an extension of resuscitation in the nonoperative management of traumatic hepatic injuries.	J Trauma. 1998 Aug;45(2):353-8: discussion 358-9	Looked at hepatic arterial emblization as a bridge between non-operative and operative management of hepatic trauma. Small study sample (11 patients).Embolization was definitive therapy for the 7 patients that were included. Patients were "stable" only with continuous resuscitation. Went from ED scan to angiography directly. Resuscitation was slowed once pt. was coiled. If they did not tolerate it, they went to the OR. If they stabilized they went to the ICU for observation. 2 patients had complications (liver necrosis and a biloma). All had injuries of gade IV or greater.
Clancy TV, Ramshaw DG, Maxwell JG,	Management outcomes in splenic injury: a statewide trauma center review	Ann Surg. 1997 Jul; 226(1): 17-24	Retrospective North Carolina trauma registry review over a 6 year period (1988-1993) of adult trauma patients ages 17-64 years was utilized to evaluate splenic injury treatment trends. 2555 patients with splenic injuries (blunt and penetrating) were compared with respect to method of management 1) no operation 2) splenectomy 3) splenorhaphy 4) splenorhaphy followed by splenectomy. Splenic preservation rates increased during the study period, and non-operative prevailed as the most common method of management.
Claridge JA, Young JS.	A successful multimodality strategy for management of liver injuries.	Am Surg. 2000 Oct;66(10):920-5; discussion 925-6
Cloutier DR, Baird TB, Gormley P, et al	Pediatric splenic injuries with a contrast blush: successful non-op management without angio and embolization	J ped surg 2004;39:969-971	Retrospective, single-institution database analysis of 107 pediatric patients with blunt splenic injuries over 6 years. An arterial blush was present on CT in 5/63 patients who were imaged. Only one underwent splenectomy for persistent hypotension. Caveats: length of follow up not reported, very small numbers.
Cocanour CS, Moore FA, Ware DN,	Delayed Complications of nonoperative management of blunt adult splenic truama.	Arch Surg. 1998 Jun; 133(6):619-24; discussion 624-5	Four-year retrospective review of 280 blunt splenic injuries >13yo. Study split into 4 groups: Group 1: all patients, Group 2: all mortalities (n=59), Group 3: all operative patients (n=134), Group 4: all NOM patients (n=87). NOM failed in 7%, requiring splenectomy within 48 hours. 8% (n=7) had delayed complications of NOM, including delayed bleeding (n=4) which occurred between PID #4 and #8, and abscess (n=2) which occurred late (> 30 days postinjury). Of those, 5 required splenectomy. Conclusion: The "complication rate is significant and indiscriminate discharge of patients with blunt splenic injury may be potentially harmful". Study has relatively low numbers, and unlike the Tn. study (Zarzaur), doesn't account for potential loss-to-follow-up. Does indicate the potential for post-discharge problems.
Cocanour CS, Moore FA, Ware DN,	Age should not be a consideration for nonoperative management of blunt splenic in jury.	J Trauma. 2000 Apr;48(4): 606-10; discussion 610-2	PURPOSE: [1] To determine if age affects outcome of NOM of BST by comparing outcomes in patients > 55 to those < 55 years of age; CONCLUSIONS: [1] There was NO DIFFERENCE in the failure rate between the two groups (17 vs 14%) and therefore patients >55 years old can be successfully treated with NOM; [2] Although patients >55 had significantly higher ISS (29 vs. 19) and Mortality(67% vs 4%), the authors claim none of the deaths were due to splenic injury - I disagree somewhat with this claim, as pointed out in the comments by Dr. Kennnedy, the NOM did play a role in the mortality from the pulmonary complications due to bed-rest, poor inspiratory effort, etc.; COMMENTS: [1] Although retrospective, good study highlighting the lack of evidence for operative intervention for age>55 after BST.
Cohn SM, Arango JI, Myers JG,	Computed tomography grading systems poorly predict the need for intervention after spleen and liver injuries.	Am Surg. 2009 Feb;75(2): 133-9	Retrospective study comparing the AAST Liver and Spleen grading systems to novel grading systems for liver and spleen injuries developed at the publishing institution. Five attending trauma surgeons who were blinded to patient outcomes reviewed 300 abdominal CT scans of patients with blunt injuries to the liver, spleen or both. While all the grading systems were found to be specific, neither the AAST grading system nor the novel grading systems was sensitive for predicting the need for operative intervention or the need for angioembolization. Interrater reliability was also moderate or poor for all the grading systems. Conclude that while serious abnormalities on CT scan often predict the need for intervention for blunt spleen and liver injuries, clinical findings including shock or peritoneal signs may outweigh findings on CT scan and may lead to intervention.
Coimbra R, Hoyt DB, Engelhart S,	Nonoperative management reduces the overall mortality of grades 3 and 4 blunt liver injuries.	Int Surg. 2006 Sep-Oct; 91(5): 251-7	take home is non-op associated with better survival, 22% failed non-op management, 23.5% reduction in mortality with non-op therapy,
Cooney R, Ku J, Cherry R,	Limitations of splenic angioembolization in treating blunt splenic injury.	J Trauma. 2005 Oct;59(4): 926-32; discussion 932	Extremly small serries of 9 patients of 194 undergoing embolizaton for blush (6) or droping Hct (3) with a 33% failure rate. Series too small to draw meaningful conclusions.
Cox, Fabian, Maish, Bee, Pritchard, Russ, Grieger, Winestone, Zarzaur, Croce	Routine Follow-up Imaging is Unneccesary in the Management of Blunt Hepatic Injury	J trauma. 2005 Nov;59(5): 1175-8; discussion 1178-80	routine follow-up CT scan is not indicated as part of NOM of blunt liver injuries, regardless of injury grade; follow-up CT scan can be ordered if clinical signs of hepatic abnormality
Crawford RS, Tabbara M, Sheridan R,	Early discharge after nonoperative management for splenic injuries: increased patient risk caused by late failure?	Surgery. 2007 Sep;142(3): 337-42	Single center retrospective analysis examing the rate and timing of failure of non-operative management of splenic injury. The study identified 499 patients over 13 years who were managed non-operatively. The failure rate was 7% (36 patients). Early, within 3 days, failure occured in 26 patients and late failure in 10 (within 4-8 days in 7 patients and 12-22 in 3). There were no identified differences in age, ISS, grade of splenic injury, admitting hematocrit or rate of blood transfusion between the early and late failure patients. Study's conclusion was that late failure was an unpredictable but infrequent event and therefore in hospital observation beyond the third day was not necessary. The study's conclusion should however be interpreted cautiously as 38% of patients discharged prior to day 3 were lost to follow up and the study has a relative low number of patients.
Cuff RF, Cogbill TH, Lambert PJ.	Nonoperative management of blunt liver trauma: the value of follow-up abdominal computed tomography scans.	Am Surg. 2000 Apr;66(4): 332-6	Routine use of CT FU not helpful for Gr I-III liver lacs. More likely to change treatment for higher grade lacs, and when clinically indicated.
Danelson KA, Hoth JJ, Miller PR,	A semi-automated approach for measuring splenic injury using computed tomography.	Biomed Sci Instrum. 2007; 43:13-7	describes a method for quantifying the amout of injured spleen volume based on CT interpolation, only 5 patients, still had input from radiologist in identifying injured are of the spleen.
Davies DA, Pearl RH, Ein SH,	Management of blunt splenic injury in children: evolution of the nonoperative approach	J Pediatr Surg. 2009 May;44(5):1005-8.	children aged 0-18 years in 4 eras starting in the 1950s. 486 children studied. Purpose: To summarize their institution's experience over the past 50 years. They found that proportion of childern managed nonoperatively increased over time and splenic salvage rate increased significantly. Mortality, length of hospital stay and transfusion rate significantly decreased over time.
Davis Ka, Fabian TC, Croce MA, et al.	Improved success in non-operative management of blunt splenic injuries: embolization of spelnic aretery pseudoaneurysms.	J Trauma 1998;44:1008-15	94% successful non-operative rate in this study compared with a 61% success rate in their earlier study, attributed to embolization of splenic artery pseudoaneurysms. PA were identified by a blush on CT, they did followup CT's at 48-72 hours and did angios based on blushes on those as well. "non-op" if hemodynamically stable. >50% were grade 2 or less, 17% were grade 4 or 5, only 8 patients had PA on initial scan, 23 found on followup CT. mean time to angio was 4 days, 15 failed non-op and did not have a blush, 7 failed and had a blush.
Dent D, Alsabrook G, Erickson BA, et al	Blunt splenic injuries: high non-operative management rate can be achieved with selective embolization	J Trauma 2004;56:1063-1067	Retrospective, comparative, single-institution study of success of nonoperative management (NOM) with high grade splenic injuries by utilizing early angioembolization. Compared with historical controls, the angioembolization group had higher success of NOM (82% vs 65%). Caveats: length of follow up, angio/septic complications not reported
Dissanaike S, Frezza EE.	Laparoscopic splenectomy in blunt trauma.	JSLS. 2006 Oct-Dec;10(4): 499-503	limited case series, can do lap spleen even with bleeding.
Duane TM, Como JJ, Bochicchio GV,	Reevaluating the management and outcomes of severe blunt liver injury.	J trauma. 2004 Sep;57(3):494-500	high grade liver cases (IV/V), compared apples to oranges (op v non-op mgmt) with very poor science/evaluation of the data
Duchesne JC, Simmons, JD, Schmeig RE, et al	Proximal Splenic Angioembolization does not improve outcomes in treating blunt splenic injuries compared with splenectomy	J Trauma. 2008 Dec;65(6):1346-51; discussion 1351-3.	Increased grade injury=splenectomy= increased PRBCs, but decreased ARDS and sepsis
Ekeh AP, McCarthy MC, Woods RJ, Haley E	Complications arising from splenic embolization after blunt splenic trauma	Am J Surg. 2005;189: 335–339	retrospective 26 month review of NOM splenic trauma at a level 1 trauma center. SAE is an adjunct to NOM with hemodynamically normal patients with: a. CT evidence of contrast extravasation b. CT evidence of intrasplenic pseudoaneurysm c. AAST grade >= 3 Post-splenectomy embolization had 23%major and 53% minor complication rates, compared to WTA reported rates of 23% and 20%, respectively.
Eubanks JW, Meier DE, Hicks BA, et al	Significance of "blush" on CT scan in children with liver injury	J Ped Surg 2003;38:363-366	Retrospective, comparative, single-institution study of hepatic arterial blush on CT versus no blush. Patients with a blush had higher injury severity and higher mortality, but mortality was not related to the liver injury, nearly all were due to head injuries. Summary: hepatic arterial blush in pediatric patients is likely a marker of injury severity
Falimirski ME, Provost D.	Nonsurgical management of solid abdominal organ injury in patients over 55 years of age.	Am Surg. 2000 Jul;66(7): 631-5	Retrospective review at 2 urban trauma centers from 1991 to 1996 with solid organ injuries revealed 88 patients. Of 37 patients managed nonoperatively, 24 had hepatic injuries and 12 had splenic injuries while one had both. 97% of these patients were successfully managed nonoperatively. The authors conclude that age >55 years old is not a contraindication to nonoperative management of solid organ injuries.
Fang JF, Chen RJ, Lin BC,	Blunt hepatic injury: minimal intervention is the policy of treatment.	J Trauma. 2000 Oct;49(4): 722-8
Fang JF, Chen RJ, Lin BC, et al	Liver cirrhosis: an unfavorable factor for nonoperative management of blunt splenic injury	J Trauma 2003;54:1131-1136	Retrospective, comparative, single-institution study of patients with blunt splenic injury with and without hepatic cirrhosis. Cirrhosis predicted failure of NOM (92% vs 19%), but was also associated with a higher median ISS and splenic injury score. No multivariate analysis was done, given the small numbers.
Fang JF, Chen RJ, Wong YC,	Classification and treatment of pooling of contrast material on computed tomographic scan of blunt hepatic trauma.	J Trauma. 2000 Dec;49(6): 1083-8	Assessment of patients who have had a liver injury with contrast extravasation. Overall, over 42 months eventual numbers were low (n=15), and split into three types: Type 1: free blush/pooling into peritoneal cavity. Type 2: "contained" blush with blood noted in peritoneal cavity. Type 3: "contained" blush only. All type 1 patients (n=6) required operation Conclusion: intraperitoneal pooling of contrast indicates massive hemorrhage and impending hemodynamic instability. This is a potentially useful classification system if early reads are available to guide therapy. This study has small numbers, and most patients who needed an intervention became unstable prior to possible angiogram, so that utility is unclear.
Fang JF, Wong YC, Lin BC,	The CT risk factors for the need of operative treatment in initially hemodynamically stable patients after blunt hepatic trauma.	J Trauma. 2006 Sep;61(3):547-53; discussion 553-4	PURPOSE: [1] To determine the risk factors from CT scan findings that determine a high liklihood for operative intervention after blunt hepatic trauma (BHT); CONCLUSIONS: [1] Logistic regression identified intraperitoneal contrast extravasation and hemoperitoneum to indipendently contribute to the need of operative intervention; [2] CT can be used to predict need for operation after BHT; COMMENTS: [1] Large series (n=214); conclusions supported by data and logistical regression.
Fata P, Robinson L, Fakhry SM.	A survey of EAST member practices in blunt splenic injury: a description of current trends and opportunities for improvement.	J trauma. 2005 Oct;59(4): 836-41; discussion 841-2	An e-mail survey of the EAST membership was performed regarding current management of blunt splenic injuries. The survey had a 38.4% response rate. The authors found that there was considerable practice variation in the management of blunt splenic injuries in several areas. Nearly a third of respondents admit Grade I injuries to a monitored setting despite evidence the existence of evidence contrary to this practice. Nearly 30% of do not immediately perform angiograph for a contrast blush on CT. For low-grade injuries, activity level recommendations were based on clinical judgment. For high-grade injuries, there was an increasing reliance on CT to support clinical decisions. The length of activity limitation recommendations varied considerably. The authors concluded that prospective trials are needed to better determine management algorithms for patients with blunt splenic injuries.
Federle MP, Courcoulas AP, Powell M,	Blunt splenic injury in adults: clinical and CT criteria for management, with emphasis on active extravasation.	Radiology. 1998 Jan; 206(1): 137-42	Purpose to determine CT and clinical criteria for prediction of outcome in adults with splenic injuries, ISS had the best correlation with outcome, absence of active extravasation on CT can help predict successful non surgical management of splenic injury
Franklin GA, Casos SR.	Current advances in the surgical approach to abdominal trauma.	Injury. 2006 Dec;37(12): 1143-56. Epub 2006 Nov 7	non- op management of the liver is the first choice in all hemodynamically stable patients. Angio first if the patient has issues that you can resuscitate them from, otherwise operative intervention first. the most common complications of non op management of the liver are bleeding and bile leaks, angio for patients that have a contrast blush on initial CT, non op management of the spleen Predictors of failure of NOMSI are amount of haemoperitoneum, blush on initial CT scan, ISS >25, and age greater than 55. Angio for patients with a blush, falling crit or persistent tachycardia
Franklin GA, Richardson JD, Brown AL,	Prevention of bile peritonitis by laparoscopic evacuation and lavage after nonoperative treatment of liver injuries.	Am Surg. 2007 Jun;73(6):611-6; discussion 616-7	Series of 28 patients with retained fluid collections after blunt liver injury managed with laparoscopy. Patients improved post-op but no control group so recomendaiton would be to consider this as a treatment option.
Fu, Wu, Chen, Chen Wang, Huang, Huang, Lu, Lin	Evaluation of Need for Operative Intervention in Blunt Splenic Injury: Intraperitoneal Contrast Extravasation has an increased Probability of Requiring Operative intervention	World J Surg. 2010 Nov;34(11): 2745-51	intraperitoneal contrast extravasation is associated with higher possibility of requiring surgical intervention
Gaunt WT, McCarthy MC, Lambert CS,	Traditional criteria for observation of splenic trauma should be challenged	Am Surg. 1999 Jul;65(7):689-91.	Compared 212 patients (100 successul observation, 108 immediate operation, 4 failed observation). Purpose: to determine if accepted criteria for non-operative mangement should be liberalized. Found no significant difference in age (<55 vs. >55), SBP (<90 or >90), or GCS (<8, 8-12, or >12) between those who were sucessfully managed non-operatively and those requiring initial operation. Take home point: criteria for splenic observation should be liberalized to include these findings.
Giss SR, Dobrilovic N, Brown RL,	Complications of nonoperative management of pediatric blunt hepatic injury: Diagnosis, management, and outcomes.	J Trauma. 2006 Aug;61(2): 334-9	good description of the long-term outcomes of non-op mgmt of the pediatric liver pt-conclusion: MDs should have a low threshold for repeat CT
Goldman R, Zilkoski M, Mullins R,	Delayed celiotomy for the treatment of bile leak, compartment syndrome, and other hazards of nonoperative management of blunt liver injury.	Am J Surg. 2003 May;185(5): 492-7	6-yr Trauma Registry Review-
Haan J, Obeid NI, Kramer M, Scalea TM	Protocol-Driven Nonoperative Management in Patients with Blunt Splenic Trauma and Minimal Associated Injury Decreases Length of Stay	J Trauma. 2003;55:317–322.	Use of admission screening angiography for higher isolated splenic injuries is cost effective and reduces resource utilization.
Haan JM, Bochicchio GV, Kramer N,	Nonoperative management of blunt splenic injury: a 5-year experience.	J Trauma. 2005 Mar;58(3):492-8	All adult patients with blunt splenic injuries admitted during 1997 and 2002 were reviewed and compared on the basis operative versus nonoperative management. Patients managed nonoperatively were compared with respect to the use of immediate angiography for all hemodynamically normal patients (1997-2000) and selective angiography for AAST grade III-V injuries (2000-2002). 280 patients underwent immediate surgical management and 366 had nonoperative management. Of these, 166 had negative arteriograms with a 94% nonoperative salvage rate while 90% of the 132 who underwent embolization were successfully managed nonoperatively. Splenic embolization appeared to improve splenic salvage rates in advanced AAST grades.
Haan JM, Marmery H, Shanmuganathan K	Experience with splenic main coil embolization and significance of new or persistent pseudoaneurym: reembolize, operate, or observe.	J Trauma. 2007 Sep;63(3):615-9
Hackam DJ, Potoka D, Meza M, et al	Utility of radiographic hepatic injury grade in predicting outcome for children after BAT	J Ped Surg 2002;37:386-389	Retrospective, comparative, single-institution study of pediatric patients with isolated and non-isolated hepatic injuries. Investigators determined that hepatic injury grade did not predict mortality or length of stay. Caveats: numbers were very small, particularly for isolated hepatic injuries.
Hagiwara A, Fukushima H, Murata A,	Blunt splenic injury: usefulness of transcatheter arterial embolization in patients with a transient response to fluid resuscitation.	Radiology. 2005 Apr: 235(1): 57-64. Epub 2005 Mar 4.	Review of transient-responders as subgroup of larger splenic injury angio study. Also low numbers (n=15). Follow-up inclided ICU observation, repeat CT at PID #2, 7 and 21, plus tecnetium scanning as well. Breakdown of patients included 2 grade III, 11 grade IV, and two grade V. 14/15 had CT (+) blush. Post-angio fluid needs decreased and no splenectomies were performed. However, all those who had stopped responding went to primary splenectomy. In addition, no transfusion needs were specified in the study. Study demonstrates feasibility of angiography, but doesn't show if angio is preferable in transient responders, given (retrospective) selection bias for inclusion.
Hagiwara A, Murata A, Matsuda T,	The usefulness of transcatheter arterial embolization for patients with blunt polytrauma showingtransient response to fluid resuscitation.	J Trauma. 2004 Aug;57(2):271-6; discussion 276-7	Retrospective review of a prospective database of 19 blunt trauma patients admitted to a single trauma center in Japan. The patients were transient responders to fluid resuscitation (2L for adults and 20mg/kg for children) and they all underwent angioembolization for a blunt solid organ injury, a pelvic fracture or both. All of the spleen injuries that required angioembolization were grade III or grade IV. The same was true for liver injuries. There were no reported complications from angioembolization, but 2 patients with grade IV splenic injuries and pelvic fractures died. The authors concluded that angioembolization in the setting of transient response of vital signs to fluid was safe as long as the surgical team was ready to intervene if angioembolization failed.
Hagiwara A, Murata A, Matsuda T,	The efficacy and limitations of transartial embolization for severe hepatic injury.	J Truama. 2002 Jun;52(6): 1091-6	PURPOSE: [1] Prospective study evaluating the efficacy of transarterial embolization (TAE) after blunt hepatic trauma (BHT) in patients with Grade 3-5 injuries; CONCLUSIONS: [1] CT grade 4 and 5 injuries that require > 2000 ml/hour fluids to maintain normotension should NOT have TAE and rather should have immediate laparotomy; COMMENTS: [1] Authors indicate that failure after TAE is primarily in patients with juxtahepatic venous injury-these patients require immediate surgery and do poorly if surgery is delayed by TAE. However, the authors do admit that there is no way of knowing on initial CT scan which patients might have these juxahepatic venous injuries, and how to select them out for surgery vs TAE.
Hagiwara A, Yukioka T, Ohta S,	Nonsurgical management of patients with blunt hepatic injury: efficacy of transcatheter arterial embolization.	AJR Am J Roentgenol. 1997 Oct; 169(4):1151-6	Prospective observational study of a protocol for hepatic arteriography for Mirvis grade 3 or greater or active extravastion. Moderrate size (28) series demonstrating good results with no deaths and little morbidity. Old study but angioraphy is safe although the exact indications can not be gleaned from this study other than Mirvis grade I and II may do well without angio-embolization.
Harbrecht BG	Is anything new in adult blunt splenic trauma?	AJS 2005;190:273-278.	Debated topics are who should be observed, ultrasound or ustrasound with CT for monitoring, do you need follow up imaging, what role should angio play;
Harbrecht, Peitzman, Rivera, Heil, Croce, et al.	Contributions of Age and Gender to Outcome of of Blunt Splenic Injury in Adults: Multicenter Study of the Eastern Association for the Surgery of Trauma	J Trauma. 2001 Nov;51(5): 887-95	Patients > 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > 55 had significantly greater mortality and failure of NOM than women < 55.
Hartnett KL, Winchell RJ, Clark DE.	Management of adult splenic injury: a 20-year perspective.	Am Surg. 2003 Jul;69(7): 608-11	Retrospective database review of historical trends for blunt splenic injuries in a single state (Maine) over a 20 year period (1981 to 2000). The authors demonstrate that over the time period the rate of operative intervention decreased from 71% to 47%, the rate of splenorraphy remained constant (~13-15%) and mortality rate remained stable (7.6% to 5.6%). Patients with ISS > 24 or head AIS > 4 had a higher mortality rate.
Holmes JH 4th, Wiebe DJ, Tataria M,	The failure of nonoperative management in pediartic solid organ injury: a multi-institutional experience.	J Trauma. 2005 Dec;59(6):1309-13	Sought to describe the natural history of failure of nonop management. In order to accrue cases defined "failure" as any trip to the OR regardless of original treatment plan. Found "failures" occurred almost entirely within 72 hrs, most less than 4hrs. post admissin. Increased failure liklihood determined by increasing injury grade, ISS associated intra-abdominal injuries and pancreatic injuries.
Hsieh CH.	Comparison of hepatic abscess after operative and nonoperative management of isolated blunt liver trauma.	Int Surg. 202 Jul-Sep;87(3)178-84	compared abcess rate in operative vs. non-op liver management. Higher in operative group.
Hurtuk M, Reed RL 2nd, Esposito TJ	Trauma surgeons practice what they preach: The NTDB story on solid organ injury management.	J Trauma. 2006 Aug;61(2): 243-54; discussion 254-5	NTDB review of all solid organ cases, 10 yrs, good review of change from op to non-op mgmt, non-specific conclusions
Izu BS, Ryan M, Markert RJ,	Impact of splenic injury guidelines on hospital stay and charges in patients with SI.	Surgery. 2009 Oct;146(4): 787-91; discussion 791-3	7 yr study, before and after implementation non-mandatory ICU admit for all spleen injuries-cost analysis ICU vs ward for grade
Jacobs et al	Nonoperative management of Blunt Splenic and Hepatic Trauma in the pediatric population: significant differences between adult and pediatric Surgeons.	Am Surg;2001; 67:149	There is no statistical difference in safety/failure rates of nonoperative management of hemodynamically normal blunt liver/spleen injuries under the supervision of non-pediatric surgeons in a level II trauma center.
Jim J, Leonardi MJ, Cryer HG,	Management of high-grade splenic injury in children.	Am Surg. 2008 Oct;74(10): 988-92	NTDB analysis of 413 children with high-grade blunt splenic injury (AAST grade ≥4) during the 2001-2005 period in an effort to characterize the management of high-grade splenic injury in children. Patients were categorized as either undergoing “early operative management” within 6hrs of presentation, delayed operative management after 6hrs, and nonoperative management. Of 413 patients, 31% had initial operative management and 69% were nonoperative. 16% of nonoperative patients required delayed operations. Nonoperative management is possible and often successful in children with high-grade splenic injuries.
Kaseje N, Agarwal S, Nurch M,	Short-term outcomes of splenectomy avoidance in trauma patients.	Am J Surg. 2008 Aug;196(2): 213-7
Keckler SJ, Tsao K, Sharp SW,	Blood utilization in children manged nonoperatively for blunt solid organ solid injury	J Surg Res. 2008 Jun 15;147(2):237-9. Epub 2008 Apr 9	Observational study of number of units ordered for crossmatch and transfused in pediatric population. Purpose was to determine need for routine crossmatch in blunt injury patients. Overall low numbers (130 pts/7 years), and noted that of those units ordered crossmatched, only 25% were actually transfused - in 17% of the patients that were stable. Conclusion: selective criteria for ordering blood crossmatch should be used as most of the cross-matched blood ordered is not used in that patient. Unclear as to the applicability of this information to the general population at large, but fits with the reduced-transfusion idea of blood product management.
Kiankhooy A, Sartorelli KH, Vane DW,	Angiographic embolization is safe and effective therapy for blunt abdominal solid organ injury in children.	J Trauma. 2010 Mar;68(3):526-31	PURPOSE: [1] Evalute use of Angio-embolization (AE) for control of on-going hemorrhage as defined by decreasing hemoglobin levels in hemodynamically stable children after blunt trauma to liver, spleen or kidney; CONCLUSIONS: [1] AE is safe and an effective technique for controlling on-going hemorrhage from blunt trauma to liver, spleen or kidney in pediatric patients (age<17); COMMENTS: [1] Authors indicate that in review of the literature there is a lack of studies evaluating AE in children. This is one of the largest series with 127 patients with 7 AE (2 spleen, 2 Liver and 3 Kidney). All bleeding stopped after the AE.
Klapheke WP, Franklin GA, Foley DS,	Blunt liver injury in children and adults: is there really a difference?	Am Surg. 2008 Sep;74(9): 798-801	Retrospective review of 399 adult (18 and older) and pediatric (<18) patients managed in a single city at an adult trauma center and a pediatric trauma center, respectively. Differences in management and outcomes between adult and pediatric patients were determined. Twenty-seven (9%) of 299 adults died with no mortality attributed to the liver injury. Six (7%) of 90 pediatric patients died with 50% of the mortality attributable to the presence of liver injury. While pediatric patients only required adjuvant treatment for liver injury in one case, 15% of adult patients required adjuvant management. There were no differences between groups for the need for operative management of liver injury. Conclude that most liver injuries in adult and pediatric patients can be managed non-operatively. But, adults require more adjunctive interventions (such as ERCP or percutaneous drainage of biloma) than pediatric patients. Delay in operative intervention in pediatric patients may lead to increased mortality.
Konstantakos AK, Barnoski AL, Plaisier BR,	Optimizing the management of blunt splenic injury in adults and children.	Surgery. 1999 Oct;126(4):805-12; discussion 812-3	Review of blunt splenic injuries in adults and children in a single center (222 adults/45 children). Determined splenic salvage rate was the same in adults and children for comparable injuries. Recommendation would be criterria for non-op management of blunt splenic trauma should be the same for adults and children.
Kozar RA, Moore FA, Cothren CC,	Risk factors for hepatic morbidity following nonoperative management: multicenter study.	Arch Surg. 2006 May;141(5): 451-8; discussion 458-9	NOM of high grade liver injuries is associated with significant morbidity and mortality.
Kozar RA, Moore FA, Moore EE,	Western Trauma Association critical decisions in trauma: nonoperative mangement of adult blunt hepatic trauma.	J Trauma. 2009 Dec;67(6): 1144-8; discussion 1148-9	Western Trauma Association's algorithm for management of blunt hepatic trauma based on review of available studies including prospective, observational, and retrospective studies as well as expert opinion.
Kozar RA, Moore JB, Niles SE,	Complications of nonoperative management of high-grade blunt hepatic injuries.	J Trauma. 2005 Nov;59(5): 1066-71	Purpose to define hepatic related morbidity in high-grade nonoperatively treated patients. Infrequent complications in Gr 3 injuries. Significant incidence of complications in Gr 4-5 ijuries frequently requires mutidisciplinary treatment approach. Clinical indications guide most manageent, but routine CT screening may be justified in high-grade hilar and "cleft" injuries.
Krause KR, Howells GA, Bair HA,	Non-operative management of blunt splenic injury in adults 55 years and older: a twenty-year experience	Am Surg. 2000 Jul;66(7):636-40.	33 patients (18 age >55 managed non-operatively compared with 15 age>55 managed operatively) over a 20 year period. Purpose: to review and update non-operative management criteria in adults >55 years. Used a variety of methods to identify splenic injury including liver-spleen scan, ultarsound, and CT scan. None of 18 patients with criteria for non-operative management required surgery. 8/18 required blood transfusions. Take home point: nonoperative management of patients age>55 is indicated if they are hemodynamically stable, do not require significant blood transfusion, & have no other associated abdominal injuries.
Kristoffersen KW, Mooney DP.	Long-term outcome of nonoperative pediatric splenic injury mangement.	J Pediatr Surg. 2007 Jun;42(6): 1038-41; discussion 1041-2	Pt contact after NOM (1-11yrs f/u), minimal long-term issues, 92% returned to full activity
Lee WC, Kuo LC, Cheng YC, et al.	Combination of white blood cell count with liver enzymes in the diagnosis of blunt liver laceration	Am J Emerg Med. 2010; 28: 1024–1029	Retrospective case-controlled study to establish non-radiologic diagnosis of blunt hepatic trauma with a combination of serum biomarkers and WBC with high sensitivity and specificity.
Leone RJ Jr, Hammond JS.	Nonoperative management of pediatric blunt hepatic trauma.	Am Surg. 2001 Feb;67(2): 138-42	Sought to determine the effect that management choice (operative vs. nonoperative) had on 27 pediatric patients with blunt liver injuries. Retrospective, descriptive study in which 5 patients underwent operative management, although all of these patients had concomitant injuries and 4 of these 5 had AAST grade I-III injuries. From this, the authors state that patients with both hepatic and splenic injuries are best managed operatively.
Letoublon C, Chen Y, Arvieux C,	Delayed celiotomy or laparoscopy as part of the nonoperative management of blunt hepatic trauma.	World J Surg. 2008 June32 (6): 1189-93
Lin WC, Chen YF, Lin CH,	Emergent transcatheter arterial embolization in hemodynamically unstable patients with blunt splenic injury.	Acad Radiol. 2008 Feb;15(2): 201-8	Retrospective review over ~18 months evaluating usage of emergent embolization of lacerated spleens. Small number (n=24) sent to angiogram, and only 13 were "meta-stable" (my term) that were included in the study. Of those 7 had grade III, and 6 grade IV splenic injuries. All were embolized, and most (12 of 13) were selective branch embolization vs. splenic artery embolization. All patients stabilized without splenectomy. Conclusion: "Transcatheter Arterial Embolization is a safe and effective procedure for treating blunt splenic injury even in hemodynamically unstable patients who respond to initial fluid resuscitation". Given small numbers in this study, I'm not sure the conclusion is supported, especially with the potential of (retrospective) selection bias, and as their algorithm for patient selection isn't quite clear (page 202 re: blood transfusion); in addition, they did not specify any transfusion needs for the study. NB: paper appears to be translated from Chinese with attendant errors, rather than natively written in English.
London Ja, Parry L, Galante J,	Safety of early mobilization of patients with blunt solid organ injuries.	Arch Surg. 2008 Oct;143(10): 972-6; discussion 977	PURPOSE: [1] To determine if there is an association between the day of mobilization and rates of delayed hemorrhage after blunt trauma to solid organs (Liver, Spleen or Kidney); CONCLUSIONS: [1] The timing of mobilization does not affect delayed hemorrhage rate. for controlling on-going hemorrhage from blunt trauma to liver, spleen or kidney in pediatric patients (age<17); COMMENTS: [1] Retrospective; [2] Timing of mobilization extracted from nursing notes; [3] Multivariate Logistic Regression used to verify that day of mobilization does not have a significant bearing on delayed hemorrhage.
Malhotra AK, Fabian TC, Croce MA,	Blunt hepatic injury: a paradigm shift from operative to nonoperative management in the 1990s.	Ann Surg. 2000 Jun;231(6): 804-13	Large case series divided into thgree time periods (pre non-op mgmt, early non-op mgmt, later non-op mgmt). Take home point: Non-op mgmt is safe in about 80% of patients with liver trauma, especially low grade, few associated injuries, normal hemodynamics, and minimal base deficit. These patients are being discharged earlier now than prior time periods w/o negative cosequences.
Malhotra AK, Latifi R, Fabian TC,	Multiplicity of solid organ injury: influence on management and outcomes after blunt abdominal trauma.	J Trauma. 2003 May;54(5):925-9	concomitant liver and spleen injuries have higher failure rate of NOM. Patients with concomitant liver and spleen injuries have higher ISS, mortality, LOS, and transfusion requirement
Markogiannakis H, Sanidas E, Michalakis I,	Predictive factors of operative or nonoperative management of blunt hepatic trauma.	Minerva Chir. 2008 Jun;63(3):223-8	purpose to predict who you can non op manage with liver injureis. 55 patients examined in series, concominant abdominal trauma, high ISS, and low probability of survival score more likely to result in operative management.
Marmery H, Shanmuganathan K, Alexander MT,	Optimization of selection for nonoperative management of blunt splenic injry: comparison of MDCT grading systems.	AJR Am J Roentgenol. 2007 Dec;189(6):1421-7	Retrospective single center study comparing authors' new proposed CT splenic injury grading system, which included splenic vascular injury, to the AAST Splenic Injury Scale. The main purpose of the study was to evaluate which grading system could better predict which patients need surgery or angioembolization. The study, which reviewed 400 CTs, demonstrates that using active splenic bleeding, pseudoaneurysm or arteriovenous fistula as grading criteria improved slightly but statistically significantly the model's accuracy in predicting the need for arteriography (87% vs 82%) and the need for surgery (82% vs 79%) compared to a model utilizing the AAST injury scale.
Marmery H, Shanmuganathan K, Mirvis SE,	Correlation of multidetector CT findings with splenic arteriography and surgery: prospective study in 392 patients.	J Am Coll Surg. 2008 Apr;206(4):685-93. Epub 2008 Feb 11.	Purpose to correlate the fingings of multidetector CT with later arteriographic study or operative findings. Sensitivity of CT 84%, specificity 89%. Conclusion MDCT valuable in finding and differentiating between pseudoaneurysm and actively bleeding splenic vascular injury. Spenectomy much more likely in bleeding group, embolization increases success of nonop management in non-bleeding vasc injury group.
Mayglothling JA, Haan JM, Scalea TM.	Blunt Splenic Injuries in the Adolescent Trauma Population: The Role of Angiography and Embolization	J Emerg Med. 2009 Jan 30.	97 patients aged 13-17 years; 79 underwent nonoperative management. Purpose: to demonstrate the safety and utility of angiography/embolization in adolescents. Found 87% splenic salvage rate in 23 patients undergoing angiography/embolization as a complement to non-operative management. 100% splenic salvage rate in patients with negative angiography. Take home point: splenic artery embolization is valuable adjunct in adolescents with high grade splenic injury or splenic vascular injury on CT
McVay MR, Kokoska ER, Jackson RJ,	Throwing out the "grade" book: management of isolated spleen and liver injury based on hemodynamic status.	J Pediatr Surg. 2008 Jun;43(6): 1072-6	single institution review of NOM algorithm for pediatric solid organs based upon hemodynamics, not grade-utilized U/S to clear for activity
Meguid AA, Bair HA, Howells GA,	Prospective evaluation of criteria for the nonoperative management of blunt splenic trauma.	Am Surg. 2003 Mar;69(3):238-42; discussion 242-3	6-yr Retrospective trauma review after introduction of NOM splenic injury
Mehall JR, Ennie JS, Saltzzman DA, et al.	Prospective Results of a Standardized Algorithm based on Hemodynamic Status for Managing SOI	J Am Coll Surg.2001;193:347-353	Adopting a standardized protocol of NOM for isolated spleen/liver trauma based on hemodynamics in a pediatric population, reduces resource utilization and hospital costs, without any detriment to care.
Miller K, Kou D, Sivit C,	Pediatric hepatic truama: does clinical course support intensive care unit stay?	J Pediatr Surg. 1998 Oct;33(10): 1459-62	Retrospective review of 36 children with blunt hepatic injuries from 1989 to 1988 in which only one patient underwent operative intervention and 3 died, all due to severe concomitant injuries. While no difference in hepatic injury severity between survivors and nonsurvivors, ISS and GCS correlated. No blood transfusions were required for children with grade I-II injuries and no hepatic complications were reported during their hospitalization. As the authors found no correlation with grade, they conclude that ICU observation is unnecessary for isolated liver injuries.
Miller PR, Croce MA, Bee TK,	Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management.	J Trauma. 2002 Aug;53(2): 238-42; discussion 242-4
Misselbeck TS, Teicher EJ, Cipolle MD,	Hepatic angioembolization in trauma patients: indications and complications.	J Trauma. 2009 Oct;67(4): 769-73	Review of results of (n=79 hepatic angiogram) patients with liver injuries over 8 years. Noted 40% resulted in therapeutic embolization, with 29% hepatic complication rate (n=9 - mostly gallbladder ischemia), and of those, 1 patient died of liver failure. Conclusion: angiography is useful in management of those with CT (+) blush; 20x more likely to require embolization than those without. Good article; angio-embolization also teamed with operative management inseveral of their cases - not an either-or technique.
Moore FA, Davis JW, Moore EE Jr,	Western Trauma Association (WTA) critical decisions in trauma: management of adult blunt splenic trauma.	J Trauma. 2008 Nov;65(5): 1007-11	The most fascinating finding in this entire paper is Table 1 which compares the management stategies from 8 Centers across the US. Univ of maryland in 2005 had 368 patients with BST that underwent NOM, they AE 81% for overall Failure rate of 8%. UT Knoxville in 2001 had 407 patients with BST that underwent NOM, they AE 0% and had an overall failure rate of 8%. Interesting!
Myers JG, Dent DL, Stewart RM, et al	Blunt splenic injuries: dedicated trauma surgeons can achieve a high rate of no-op success in patient of all ages	J Trauma 2000;48(5):801-806	Retrospective, single-institution study that compared NOM rates between pediatric, younger adult, and older adult patients. Approximately 30% of patients underwent immediate laparotomy. Of the remaining patients, 89-94% were successfully managed without an operation.
Nellensteijn DR, Ten Duis HJ, Oldenziel J,	Only moderate intra- and inter-observer agreement between radiologists and surgeonswhen grading blunt paediatric hepatic injury on CT scan.	Eur J Pediatr Surg. 2009 Dec;19(6): 392-4. Epub	27 scans reviewed by radiologist, trauma surgeon, hepatobiliary surgeon, inter and intra observer agreement was pm;y moderate using AAST grading scale
Nix JA, Costanza M, Daley BJ,	Outcomes of the current management of splenic injuries.	J Trauma. 2001 May;50(5):835-42	Retrospective review over 4 years of 542 patients with blunt splenic injury managed using a defined protocol. Seven percent of patients < 55 years old failed non-operative management and 11.4% of patients 55 and older failed non-operative management. There was no statistical difference in failure rates between young and old patients. No deaths were attributed to failure of non-operative management in either age group. The authors also found that non-operative failure was associated with splenic injury grade, independent of patient age. Concluded that the patients 55 and older can be safely managed non-operatively with acceptable failure rates.
Nwomeh BC, Nadler EP, Meza MP, et al	Contrast extravasation predicts the need for operative intervention in children with blunt splenic trauma	J Trauma 2004;56:536-541	Retrospective, single-institution database analysis of 343 pediatric patients with blunt splenic injuries. An arterial blush was present on CT in 27/216 patients who were imaged. These patients were significantly more likely to fail NOM (22% vs 4%).
Ochsner MG.	Factors of failure for nonoperative management of blunt liver and splenic injuries.	World J Surg. 2001 Nov;25(11): 1393-6	Failure risk of non-op mgmt increases with hemodynamic instability, contrast extravasation, and in the case of splenic injury grade of injury
Ohtsuka Y, Iwasaki K, Okazumi S,	Managemnent of blunt hepatic injury in children: usefulness of emergency transcatheter artial embolization.	Pediatr Surg Int. 2003 Apr;19(1-2): 29-34. Epub 2002 Dec 20.	review of emergent angio of peds liver injuries, 21 kids, protocol was stable patients were managed non-operatively, Angio if Ct showed blush, 89% non-op management success, 2 treated with angio
Omert LA, Salyer D, Dunham CM,	Implications of the "contrast blush" finding on computed tomographic scan of the spleen in trauma.	J Trauma. 2001 Aug;51(2): 272-7; discussion 277-8	more than 2 liters and 2 units of PRBCS madated OR or angiography for their splenic injury patients. If they were unstable, OR was the choice
Paddock HN, Tepas JJ 3rd, Ramenofsky ML,	Management of blunt pediatric hepatic and splenic injury: similar process, different outcome.	Am Surg. 2004 Dec;70(12): 1068-72	Retrospective large database review comparing mortality rates of pediatric patients with splenic, hepatic and combined injuries. Their findings demonstrate mortality rate of 2.5% for hepatic, 0.7% and a significantly increased mortality rate of 8.6% for combined splenic and hepatic injuries.
Parks RW, Chrysos E, Diamond T.	Management of liver truama.	Br J Surg. 1999 Sep;86(9): 1121-35	Discusses nonop management as safe in general language without specific protocols nor with much primary source data used. Citations all at least prior to 1995, some fairly dated.
Patrick DA, Bensard DD, Moore EE,	Nonoperative Management of Solid Organ Injuries in Children Results in Decreased Blood Utilization	J Pediatr Surg. 1999 Nov;34(11):1695-9.	116 children aged less than or equal to age 16. Includes patients with spleen, liver, and/or kidney injury. Purpose: evaluate blood utilization in management of solid organ injury in children. Examined 2 cohorts (1990-1993 and 1994-1997). Found less laparotomies in 2nd time period. Found significantly less blood transfusions in non-operatively managed children. Take home point: nonoperative management reduces risk of receiving blood transfusion.
Peitzman AB, harbrecht BG, Rivera L,	Eastern Association for the Surgery of Trauma Multi-institutional Trials Workgroup. Failure of observation of blunt splenic injury in adults: variability in practice and adverse consequences.	J Am Coll Surg. 2005 Aug;201(2): 179-87	Prospectively collected data using uniform NOM protocols. Blinded review of patient who failed NOM
Peitzman et al	Blunt Splenic Injury in the Adult Multi-institutional study of the Eastern Association for the Surgery of Trauma		Multi-institutional retrospective study that confirmed that: a. patients with increased ISS fail NOM of blunt splenic trauma with increased frequency b. failure rates of NOM of blunt splenic trauma increase with AAST splenic grades c. amount of hemoperitoneum correlates with AAST grades, and failure of NOM for blunt splenic trauma.
Plurad DS, Green DJ, Inaba K, et al	Blunt assault is associated with failure of nonoperative management of the spleen independent of organ injury grade and despite lower overall ISS	J Trauma 2009;66:630-635	incidence of success of non-op management is 54-94%, contraindications for non-op management are hemodynamic instability, blush /massive hemoperitoneum on CT, transfusion triggers, higher rate of failure with blunt assualt, take home is consider mechanism when thinking about non-operative management
Poletti Pa, Mirvis SE, Shanmuganathan K,	CT criteria for management of blunt liver trauma: correlation with angiographic and surgical findings.	Radiology. 2000 Aug;216(2):418-27	A retrospective review performed from 1995 to 1999 at a single institution evaluated 72 patients who underwent both hepatic CT and angiography. The authors sought to determine the value of admission CT scan in predicting the need for hepatic angiography. In a detailed statistical analysis of a select study population, the authors determined that CT injury grade, evidence of arterial injury and hepatic venous injury are useful indicators of high-risk patients which would benefit from hepatic angiography to limit persistent or delayed bleeding or other delayed complications.
Powell M, Courcoulas A, Gardner M,	Management of blunt splenic trauma: significant differences between adults and children.	Surgery. 1997 Oct;122(4): 654-60
Rajani RR, Claridge Ja, Yowler CJ,	Improved outcome of adult blunt splenic injury: a cohort analysis.	Surgery. 2006 Oct;140(4) : 625-31; discussion 631-2	PURPOSE: [1] Compare Blunt Splenic Trauma (BST) management and outcomes from 1991-1998 vs. 1998-2005. To determine role of AE on outcome; CONCLUSIONS: [1] The overall sucess of NOM after BST improved signifcantly over time (77% vs. 96%, p<0.001); [2] The rate of AE signifcantly increased (2.7% vs. 26%, p<0.001); [3] Hospital mortality significantly decreased (12% vs. 6%, p<0.001); [4] Mean length of hospital stay went down (15 days vs. 9 days, p<0.001). Therefore success of NOM improved over time and correlated with a greater use of AE; COMMENTS: [1] One of the best papers. Comaprison really highlights the effective change in multiple endpoints secondary to AE.
Ransom KJ, Kavic MS.	Laparoscopic splenectomy for blunt trauma: a safe operation following embolization.	Surg Endosc. 2009 Feb;23(2):352-5. Epub 2008 May 7	Retrospective review of 11 patients who required splenectomy for hemorrhage control or infarction and abscess formation following angioembolization. Four patients had laparoscopic splenectomy and 7 had open splenectomy. In the bleeding patients, open surgery required less blood and less operative time compared to laparoscopic surgery. However, laparoscopic splenectomy patients required shorter post-operative hospital stays compared to the open splenectomy patients. For patients who required splenectomy for splenic infarction and abscess, laparoscopic management required significantly longer operating room time but the patients had shorter postoperative stay compared to patients treated with open splenectomy. Conclude that laparoscopic splenectomy is possible in the setting of hemorrhage or splenic infarction following angioembolization procedures.
Renzulli P, Gross T, Schnuriger B,	Management of blunt injuries to the spleen.	Br J Surg. 2010 Nov;97(11): 1696-703	159 non-op spleens only risk factor for failure was age with and possibly higher splenic injury grade. Also a suggestion that availability of angio-embolization makes surgeons more likely to pursue non-op mgmt without increased failure of NOM
Robinson WP 3rd, Ahn J, Stiffler A,	Blood transfusion is an independent predictor of increased mortality in nonoperatively managed blunt hepatic and splenic injuries.	J Trauma. 2005 Mar;58(3): 437-44; discussion 444-5
Rose AT, Newman MI, Debelak J,	The incidence of splenectomy is decreasing: lessons learned from trauma experience.	Am Surg. 2000 May:66(5): 481-6	Retrospective single center database review examining the incidence and indications for all splenectomies performed over a 10 year period (1986 to 1995). The study demonstrates that trauma accounted for 41% of all splenectomies performed. Compared to the first half, during the second half of the time period, the overall incidence of splenectomies decreased by 36.9% for all indications and 32.9% for trauma.
Sabe AA, Claridge JA, Rosenblum DI,	The effects of splenic artery embolization on nonoperative mangement of blunt splenic injury: a 16-year experience.	J Trauma. 2009 Sep;67(3): 565-72; discussion 571-2	Historical comparison of groups of nonop splenic lac patients between period of no embolization, period of selective emboization and period of protocol driven embolization. Clear difference in nonop success with both selective and protocol driven embolization compared to no embo. Differences small between selective and protocol groups, except embo utilized more frequently with protocols.
Sarihan H, Abes M.	Nonoperative management of intra-abdominal bleeding due to blunt trauma in children: the risk of missed associated intestinal injuries.	Pediatr Surg Int. 1998 Mar; 13 (2-3): 108-11	peritonitis developed in 3 of 120 patients, no morbidity or mortality with delayed treatment
Sartorelli KH, Frumiento C, Rogers FB,	Nonoperative Management of Hepatic, Splenic, and Renal Injuries in Adults with Multiple Injuries	J Trauma. 2000 Jul;49(1):56-61.	126 patients aged greater than or equal to 17 years. Purpose: evaluate role of non-operative mangagment in patients with multi-system trauma. Compared patients with isolated abdominal solid organ injury and patients with at least one other injury with AIS>2. Found no significant difference in percent of patients who were successfully managed nonoperativley (90% vs. 94%) and in development of complications (21% vs. 27%) amongst 2 groups (isolated abdominal injury and patients with addditional injury). Take home point: non-operative management of solid organ injury in patients with multiple injuries can be performed without increased morbidity.
Savage SA, Zarzaur BL, Magnotti LJ,	The evolution of blunt splenic injury: resolution and progression.	J Trauma. 2008 Apr;64(4): 1085-91; discussion 1091-2	time to healing-lower grade injury heals faster
Schnuriger B, Inderbitzin D, Schafer M,	Concomitant injuries are an important determinant of outcome of high-grade blunt hepatic trauma.	Br J Surg. 2009 Jan;96(1): 104-10
Sekikawa Z, Takebayasji S, Kurihara H,	Factors affecting clinical outcome of patients who undergo transcatheter arterial embolisation in splenic injury.	Br J radiol. 2004 Apr;77(916):308-11
Shanmuganathan k, Mirvis SE, Boyd-Kranis R, et al	Nonsurgical management of blunt splenic injury: use of CT criteria to select patients for splenic artiography and potential endovascular therapy	Radiology 200;217:75-82	Retrospective, single-institution study of 78 patients with blunt splenic injury. All patients underwent CT; contrast extravasation predicted either surgical or transcatheter interventions 100% of the time. Caveats: no physiologic data are provided and it is unclear if contrast extravasation was part of a treatment decision-making pathway.
Shapiro MJ, Krausz C, Durham RM,	Overuse of splenic scoring and computed tomographic scans.	J Truama. 1999 Oct;47(4):651-8	an in depth analysis of done to evaluate which patients need emergency surgery and which patiens will fail non-operative management of the spleen. Looked at ulstrasounds and CT scans both inpatient and out patient. 133 non-operative, 11% failure rate (half for other reasons than spleen), No need for follow up CT scans. The protocol was to re-CT in 1 week and if abnormal, follow it up with an ultrasound, Ultrasonds were then repeated at 1,3 and 6 months, or until the injury was no longer visible, 96% of ultrasounds at a month showed improvement, the operative and CT grades were different, operative decisions were made on clinical matters rather than repeat CT findings, Admit grade 2 and above to the ICU, serial crits q4 then q6 then q8 before moving out of ICU (48 hours or so), those who failed non-op management had higher ISS, more transfusions, etc.
Sharma OP, Oswanski MF, Singer D,	Role of repeat computerized tomography in nonoperative management of solid organ trauma.	Am Surg. 2005 Mar;71(3): 244-9	Review of results with repeat inpatient CT scanning of (n=82) patients over 8 years with NOM. Noted follow-up imaging "was helpful in 6% of patients to alter therapy". However all of those who had deterioration on CT also had clinical changes - hemodynamic changes of signs of peritonitis. Conclusion: "repeat CT scanning has a limited role in the management of NOM solid-organ injury". Small numbers and no protocol, but fits with general bias re: indications of failure of NOM.
Sharma OP, Oswanski MF, Singer D,	Assessment of nonoperative management of blunt spleen and liver trauma.	Am Surg. 2005 May;71(5):379-86	PURPOSE: [1] Eight year retrospective analysis of NOM of spleen and Liver injuries in adults and children; CONCLUSIONS: [1] NOM should be attempted in hemodynamically stable patients; [2] Female gender, age>55, high grade injuries, and large hemoperitonuem were NOT predictors of failure of NOM; [3] Highest rate of failure of NOM was seen in patients with combined liver and spleen trauma; COMMENTS: [1] Nothing new.
Shilyansky J, Navarro O, Superina RA,	Delayed hemorrhage after nonoperative management of blunt hepatic trauma in children: a rare but significant event.	J Pediatr Surg. 1999 Jan;34(1):60-4	Retrospective review of 75 children with blunt hepatic injury managed non-operatively. 74 patients were successfully managed non-operatively. Of the 74 managed successfully, 2 required operative management after discharge from the hospital and 1 of the 2 patients died. Both patients complained of right shoulder and abdominal pain. The authors concluded that significant hemorrhage can occur after discharge following non-operative management of blunt hepatic injury and may be heralded by right-sided shoulder and/or abdominal pain.
Shin H, Tepas JJ, Ismail N, et al	Blunt Hepatic injury in adolescents: age makes a difference	Am Surg 1997Jan;63(1):29-36	individualized management of patients based on patient status is best approach to liver injuries.
Sims CA, Wiebe DJ, Nance ML.	Blunt solid organ injury: do adult and pediatric surgeons treat children differently?	J Trauma. 2008 Sep;65(3): 698-703	not a clinical study no real data other than adult trauma surgeons are more likely to operate or embolize than pediatric surgeons
Sinha S, Raja SVV, Lewis MH	Recent changes in the management of blunt splenic injury:effect on splenic trauma patients and hospital implications	Ann R Coll Surg Engl 2008;90:109-112	retrospective review, 21 patients10 operative, grade 3 and 4 managed operatively, one non-op failure (day3),
Siplovich L, Kawar B.	Changes in management of pediatric blunt splenic and hepatic injury.	J Pediatr Surg. 1997 Oct;32(10):1464-5
Siriratsivawong K, Zenati M, Watson GA, et al.	Non-operative mangement of blunt splenic trauma in the elderly: does age play a role?	Am Surg 2007;73:585-590	Retrospective, single institution database analysis of 1008 patients age 55+ who sustained a splenic injury. Trend toward increased failure of nonoperative management (NOM) with increasing age. Overall, 25% of patients failed nonoperative management (FNOM). NOM may be safely pursued in carefully selected elderly patients, but FNOM is also associated with longer LOS and ICU LOS.
Sjovall A, Hirsch K.	Blunt abdominal truama in children: risks of nonoperative treatment.	J Pediatr Surg. 1997 Aug; 32(8): 1169-74	Retrospective single center descriptive review and case reports of the hospital courses of 203 children treated over a 15 year period with various abdominal injuries secondary to blunt trauma.
Sola JE, Cheung MC, Yang R,	Pediatric FAST and elevated liver transaminases: An effective screening tool in blunt abdominal trauma.	J Surg Res. 2009 Nov;157(1):103-7. Epub 2009 May 3	Compares retrospective groupt of 400 patients CT scans to FAST findings plus transaminase measurement. Finds neg predicitve value to be 96% and concludes neg patients can safely be observed rather than subjected to CT radiation.
St Peter SD, Keckler SJ, Spilde TL,	Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children	J Pediatr Surg. 2008 Jan;43(1):191-3.	243 children. Purpose: to provide justification for an abbreviated hospitalization protocol in children with blunt spleen or liver injury. Using retrospective data, as only 1 patient bled, requiring transfusion and splenectomy after HD #2, they suggest that shorter duration of bed rest may be appropriate
Starnes S, Klein P, Magagna L,	Computed tomographic grading is useful in the selection of patients for nonoperative management of blunt injury to the spleen.	Am Surg. 1998 Aug;64(8):743-8; discussion 748-9	Early article utilizing case-series comparison of op v non-op splenic mgmt:, bringing the CT scan into the Grading system to identfy pts appropriately-(out-dated technologically)
Tan KK, Bang SL, Vijayan A,	Hepatic enzymes have a role in the diagnosis of hepatic injury after blunt abdominal trauma.	Injury. 2009 Sep;40(9):978-83. Epub 2009 Jun 16.	worldwide, CT is not always available. Retrospective review of only 90 patients, ALT and AST of twice normal are concerning. Should CT those patients if possible. Did not predict need for operation.
Tataria M, Nance ML, Holmes JH 4th,	Pediatric blunt abdominal injury: age is irrelevent and delayed operation is not detrimental.	J Trauma. 2007 Sep;63(3): 608-14	Retrospective multicenter review of pediatric patients with blunt splenic, hepatic, renal, or pancreatic injuries from 1993 to 2002. Two patient cohorts were compared: those that underwent immediate operation (n=81) <3hrs after arrival, and those that underwent operation (n=59) >3hrs after arrival. No difference in measured outcomes including ICU LOS, hospital LOS, blood transfusion, or mortality was appreciated between those who underwent immediate operation and those who failed nonoperative management. These results suggest that fear of adverse sequelae after failure of nonoperative management is unjustified.
Tiberio Ga, Portolani N, Coniglio A,	Evaluation of the healing time of non-operatively manged liver injuries.	Hepatogastroenterology. 2008 My-Jun;55(84): 1010-2	purpose of study to detailo the evolution of liver injuries considering their AAST grade, 79 patients, median healing time for grade 1 hematoma 6 days, 2 16 days, 3 108 days; for lacerations grade 2 29 days, grade 3 34 days, grade 4 78 days
Tsugawa K, Koyanagi A, Hashizume M,	New insight for management of blunt splenic trauma: significant differences between young and elderly.	Hepatogastroenterlogy. 2002 Jul-Aug;49(46):1144-9	are patterns of injury different in the over 60 and the under 60? Overall failure of non-op management was higher in elderly patients (10% Vs 5%), for persistent hemodynamic instability or unresolved concerns for other conditions, operative intervention was indicated; The need for operative intervention was an ISS>20, >grade 3 splenic injury in older patients, large hemoperitoneum on 1st Ct scan, active extrav on first scan, and high enegery mechanisms.
Uranus S, Pfeifer J.	Nonoperative treatment of blunt splenic injury.	World J Surg. 2001 Nov;25(11):1405-7
Van der Vlies CH, Saltzherr TP, Wilde JC,	The failure rate of nonoperative management in children with splenic or liver injury with contrast blush on computed tomography: a systematic review.	J Pediatr Surg. 2010 May;45(5):1044-9	Systematic review and meta-analysis of articles re: NOM of liver/spleen injuries - sum of 9 papers met inclusion criteria of solid-organ injury w/ contrast blush. All were observational studies, and noted a pooled failure rate of 28.2% in those without angio-embolization. Two studies with angio-embolization (n=46) noted a failure rate of 6.5%. Conclusion: "management of splenic and hepatic injury in children should not only be based on the physiologic response but include consideration of the presence of a contrast blush". Overall, even this pooled study has a low sample size (n=71), with wildly varying individual failure rates (4.5 to 100%).
Velmahos GC, Chan LS, Kamel E,	Nonoperative management of splenic injuries: have we gone too far?	Arch Surg. 2000 Jun;135(6): 674-9; discussion 679-81	PURPOSE: [1] Examine outcome of Non-operative management (NOM) after blunt splenic trauma (BST); [2] Risk factors that predict failure NOM; [3] Compare CT Grade to Operative Grade. CONCLUSIONS: [1] 52% failure NOM rate; [2] Splenic Grade III or higher, transfusion of >1 U blood, and AIS >2 were the three indipendent risk factors for failure of NOM; [3] In 80% patients the CT grade was same as Operative Grade. COMMENTS: [1] Small study size (n=105); [2] High Failure of NOM (52%); [3] Retrospective study; [4] Went to OR too soon, did not really allow time to observe patients with NOM. As Dr. Hoyt points out in comments, non-operative failure was defined at 3 hours - a bit early in the management.
Velmahos GC, Toutouzas K, Radin R,	Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study.	Arch Surg. 2003 Aug;138(8): 844-51	combined prospective observational study of 149 liver/spleen/kidney blunt injuries. Non-op failure predicted by positive FAST, >300cc blood on CT, splenic injury, other intra-abd injury, >grd III splenic injury. Age was not predictive however cohort was very young
Velmahos GC, Toutouzas K, Radin R,	High Success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ.	Arch Surg. 2003 May;138(5):475-80; discussion 480-1	Prospective cohort of 75 unselected, consecutive patients admitted to a Level I trauma center. Twelve patients (15%) required emergency operation for liver bleeding and 11 patients (12%) required operative intervention for an injury other than the liver. Patients managed operatively had higher ISS, required more fluid and blood, and stayed longer in the hospital than patients managed non-operatively. Four patients managed operatively developed liver related complications. Of the 55 patients selected for non-operative management none required operative intervention for the liver injury, but 8 patients required operative intervention for other reasons. Twelve patients managed non-operatively required angiography and 7 of those required embolization. The authors concluded that non-operative management of blunt hepatic injuries is safe and operative intervention should only be considered for patients with peritonitis or evidence of ongoing hemorrhage.
Velmahos, Zacharias, Emhoff, Feeney, Hurst, Crrokes, Harrington, Gregg, Brotman, Burke, Davis, Gupta, Winchell, Desjardins, Alouidor, Gross, Rosenblatt, Schulz, Chang	Management of the Most Severely Injured Spleen	Arch Surg. 2010 May;145(5): 456-60	nearly 2/3 of grade 4 and 5 spleens require surgery. Grade 5 injury and TBI are independent predictors of failure.
Wahl WL, Brandt MM, Hemmila MR,	Diagnosis and management of bile leaks after blunt liver injury.	Surgery. 2005 Oct;138(4): 742-7; discussion 747-8	Retrospective review of a single center's 8 year experience with bile leaks after blunt liver injury. The study identified 24 bile leaks in 258 patients and demonstrated that all the bile leaks occurred in patients with liver AIS ≥ 4 and that the rate of bile leak was 71% in patients managed with operation, 50% of patients who undergone angioembolization and 17% in observed patients. HIDA scan detected all the leaks with sensitivity and specificity of 100%. Early detection of a bile leak was associated with a shorter lenght of stay. Based on their results, the authors recommend routine HIDA scan for all patients with liver AIS ≥ 4 on post injury 2-3.
Wallis A, Kelly MD, Jones L	Angiography and ambolisation for solid abdominal organ injury in adults - a current perspective	World J of Emerg Surg 2010;5:18	Emergency laparotomy is the standard treatment for hemodynamically unstable patients with intra-abdominal injury. Principles allowing the safe use of embolization and non-operative management in blunt abdominal trauma include the absence of of associated hollow viscous injuries, and the lack of peritoneal findings on abdominal examination. Accuracy of CT diagnosis depends on technique
Wang YC, Fu CY, Chen YF,	Role if arterial embolization on blunt hepatic trauma patients with type I contrast extravasation.	Am J Emerg Med. 2010 Sep 24.	Attempts to evluated the utility of transarterial embolization of hepatic a. extravasation in liver injury. Used as adjunct to successfully maintain 50% of patients in nonop group. Poor selection could affect results, very small numbers.
Wasvary H, Howell G, Villalba M,	Nonoperative management of adult blunt splenic trauma: a 15-year experience.	Am Surg. 1997 Aug; 63(8): 694-9	35% immediate OR rate for hemodynamics, non-op management (bed rest, ICU, serial crits, serial exams) 4 failed (clinical deterioration for 3/4)operative spleens average grade 3, non average grade 2, Stable patiens with without other abdominal findings mandating a laparotomy can be safely managed non operatively (90%).
Watson GA, Rosengart MR, Zenati MS,	Nonoperative Management of Severe Blunt Splenic Injury: Are We Getting Better?	J Trauma. 2006 Nov;61(5):1113-8.	3085 patients in NTDB registry. Purpose: evaluate role of non-operative mangement in patients with higher grade (AIS>4) injury. Includes patients with multi-system injury, and high ISS. Mean ISS for failed non-operative management was 37 vs. 33 in successful non-operatively managed patients. Non-operative management attempted in 41% of patients, but failed in 55% of these. Similar mortality rate (12% vs 14%) in patients who failed vs. patients with successful non-operative managment.
Wei B, Hemmila MR, Arbabi S,	Angioembolization reduces operative intervention for blunt splenic injury.	J Trauma. 2008 Jun;64(6):1472-7	Angioembolizaiton is effective in cutting down on complications of NOM-good article
Weinberg JA, Magnotti LJ, Croce MA,	The utility of serial computed tomography imaging of blunt splenic injury: still worth a second look?	J Trauma. 2007 May;62(5): 1143-7; discussion 1147-8	Retrospective review of new protocol for angio of PSA on initial and/ord F/U CTs
Wu et al	Early Selective Angioembolization Improves Success of Nonoperative Management of Blunt Splenic Injury	Am Surg. 2007;73:897-902	For similarly matched patients, SAE showed significantly improved NOM success rates in the cohort of patients with large hemoperitoneum.
Yanar H, Ertekin C, Taviloglu K,	Nonoperative treatment of multiple intra-abdominal solid organ injry blunt abdominal trauma.	J Trauma. 2008 Apr;64(4):943-8	Prospective observational study involving 46 patients admitted during 1999 to 2005 with multiple solid organ injuries after blunt abdominal trauma. The authors sought to determine whether the presence of multiple injuries affects nonoperative management (NOM) by defining the rate, causes, and predictors of NOM failure. 15 of 46 patients underwent emergency laparotomy for shock unresponsive to resuscitation, while 8 of 31 (25%) who initially underwent NOM failed. Admission hypotension and PRBC transfusion within 6 hours were independently predictive of NOM failure. The authors conclude that NOM should still be considered in select cases of multiple solid organ injuries, albeit with extra caution due to a higher NOM failure rate.
Yang JC, Sharp SW, Ostlie DJ,	Natural history of nonoperative mangement for grade 4 and 5 liver and spleen injuries in children.	J Pediatr Surg. 2008 Dec;43(12): 2264-7
Zarzaur BL, Vashi S, Magnotti LJ,	The real risk of splenectomy after discharge home following nonoperative management of blunt splenic injury.	J Trauma. 2009 Jun;66(6): 1531-6; discussion 1536-8	Review of large state-wide administrative (hospital) database through admission diagnosis. N=4103 for splenic injuries over 5-year span. Noted overall post-discharge risk of splenectomy with NOM at 1.4%. Almost 82% of splenectomy readmissions were within 3 weeks of injury. Conclusion: "early discharge should be accompanied by education to counter rupture risk". Overall, good method to quantify failure rate and counter issue of lack of long-term follow-up/lost to follow-up with a single-center study.

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Blunt Liver and Spleen Injuries, Non-Operative Management (2003)

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