The role of splenic angioembolization as an adjunct to nonoperative management of blunt splenic injuries: A systematic review and meta-analysis

Journal of Trauma and Acute Care Surgery - Tập 83 Số 5 - Trang 934-943 - 2017
Lennard Funk1,2, Kamil Naidoo1,2, Barbaros Yet1,2, Susan I. Brundage1,2, Zane Perkins1,2
1S.I.B.).
2Zealand

Tóm tắt

BACKGROUND Nonoperative management (NOM) of hemodynamically normal patients with blunt splenic injury (BSI) is the standard of care. Guidelines recommend additional splenic angioembolization (SAE) in patients with American Association for the Surgery of Trauma (AAST) Grade IV and Grade V BSI, but the role of SAE in Grade III injuries is unclear and controversial. The aim of this systematic review was to compare the safety and effectiveness of SAE as an adjunct to NOM versus NOM alone in adults with BSI. METHODS A systematic literature search (Medline, Embase, and CINAHL) was performed to identify original studies that compared outcomes in adult BSI patients treated with SAE or NOM alone. Primary outcome was failure of NOM. Secondary outcomes included morbidity, mortality, hospital length of stay, and transfusion requirements. Bayesian meta-analyses were used to calculate an absolute (risk difference) and relative (risk ratio [RR]) measure of treatment effect for each outcome. RESULTS Twenty-three studies (6,684 patients) were included. For Grades I to V combined, there was no difference in NOM failure rate (SAE, 8.6% vs NOM, 7.7%; RR, 1.09 [0.80–1.51]; p = 0.28), mortality (SAE, 4.8% vs NOM, 5.8%; RR, 0.82 [0.45–1.31]; p = 0.81), hospital length of stay (11.3 vs 9.5 days; p = 0.06), or blood transfusion requirements (1.8 vs 1.7 units; p = 0.47) between patients treated with SAE and those treated with NOM alone. However, morbidity was significantly higher in patients treated with SAE (SAE, 38.1% vs NOM, 18.6%; RR, 1.83 [1.20–2.66]; p < 0.01). When stratified by grade of splenic injury, SAE significantly reduced the failure rate of NOM in patients with Grade IV and Grade V splenic injuries but had minimal effect in those with Grade I to Grade III injuries. CONCLUSION Splenic angioembolization should be strongly considered as an adjunct to NOM in patients with AAST Grade IV and Grade V BSI but should not be routinely recommended in patients with AAST Grade I to Grade III injuries. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.

Từ khóa


Tài liệu tham khảo

1991, Severe late postsplenectomy infection, Br J Surg, 78, 716

1997, Nonoperative management of adult blunt splenic trauma: a 15-year experience, Am Surg, 63, 694

2003, Prospective evaluation of criteria for the nonoperative management of blunt splenic trauma, Am Surg, 69, 238, 10.1177/000313480306900311

2000, Blunt splenic injury in adults: multi-institutional study of the Eastern Association for the Surgery of Trauma, J Trauma, 49, 177, 10.1097/00005373-200008000-00002

2001, Outcome of the current management of splenic injuries, J Trauma, 50, 835, 10.1097/00005373-200105000-00010

2012, Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline, J Trauma Acute Care Surg, 73

2012, Meta-analysis of predictive factors and outcomes for failure of non-operative management of blunt splenic trauma, Injury, 43, 1337, 10.1016/j.injury.2011.09.010

1981, The role of angiographic hemostasis in salvage of the injured spleen, Radiology, 141, 645, 10.1148/radiology.141.3.7029619

1991, Blunt splenic injuries: nonsurgical treatment with CT, arteriography, and transcatheter arterial embolization of the splenic artery, Radiology, 181, 189, 10.1148/radiology.181.1.1887032

1998, Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms, J Trauma, 44, 1008, 10.1097/00005373-199806000-00013

2001, Admission angiography for blunt splenic injury: advantages and pitfalls, J Trauma, 51, 1161

2008, Proximal splenic angioembolization does not improve outcomes in treating blunt splenic injuries compared with splenectomy: a cohort analysis, J Trauma, 65, 1346

2007, Angiography for blunt splenic trauma does not improve the success rate of nonoperative management, J Trauma, 63, 44

2006, Splenic artery embolization: Have we gone too far?, J Trauma, 61, 541, 10.1097/01.ta.0000235920.92385.2b

2005, Limitations of splenic angioembolization in treating blunt splenic injury, J Trauma, 59, 926

2004, Splenic embolization revisited: a multicenter review, J Trauma, 56, 542, 10.1097/01.TA.0000114069.73054.45

2013, Complications arising from splenic artery embolization: a review of an 11-year experience, Am J Surg, 205, 250, 10.1016/j.amjsurg.2013.01.003

2008, Complications associated with embolization in the treatment of blunt splenic injury, World J Surg, 32, 476, 10.1007/s00268-007-9322-x

2011, Nonoperative management of adult blunt splenic injury with and without splenic artery embolotherapy: a meta-analysis, J Trauma, 71, 898

2015, The splenic injury outcomes trial: an American Association for the Surgery of Trauma multi-institutional study, J Trauma Acute Care Surg, 79, 335, 10.1097/TA.0000000000000782

2009, Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement, PLoS Med, 6

2008, GRADE: an emerging consensus on rating quality of evidence and strength of recommendations, BMJ, 924

2001, Bayesian methods in meta-analysis and evidence synthesis, Stat Methods Med Res, 10, 277, 10.1177/096228020101000404

2002, Bayesian random effects meta-analysis of trials with binary outcomes: methods for the absolute risk difference and relative risk scales, Stat Med, 21, 1601, 10.1002/sim.1189

1998, Clinical significance not statistical significance: a simple Bayesian alternative to p values, J Epidemiol Community Health, 52, 318, 10.1136/jech.52.5.318

2012, Age does not affect outcomes of nonoperative management of blunt splenic trauma, J Am Coll Surg, 214, 958, 10.1016/j.jamcollsurg.2012.03.007

2013, At first blush: absence of computed tomography contrast extravasation in Grade IV or V adult blunt splenic trauma should not preclude angioembolization, J Trauma Acute Care Surg, 74, 105, 10.1097/TA.0b013e3182788cd2

2006, Improved outcome of adult blunt splenic injury: a cohort analysis, Surgery, 140, 625, 10.1016/j.surg.2006.07.005

2013, Trauma center variation in splenic artery embolization and spleen salvage: a multicenter analysis, J Trauma Acute Care Surg, 75, 69, 10.1097/TA.0b013e3182988b3b

2006, Nonoperative management of traumatic splenic injuries: is there a role for proximal splenic artery embolization?, AJR Am J Roentgenol, 186, 779, 10.2214/AJR.04.1800

2012, Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management, J Trauma Acute Care Surg, 72, 1127, 10.1097/TA.0b013e3182569849

2012, Age should be considered in the decision making of prophylactic splenic angioembolization in nonoperative management of blunt splenic trauma: a study of 208 consecutive civilian trauma patients, J Trauma Acute Care Surg, 73, 1213, 10.1097/TA.0b013e318265ccf0

2011, Nonsurgical management of blunt splenic injury: is it cost effective?, Am J Surg, 202, 810, 10.1016/j.amjsurg.2011.06.041

2015, Is non-operative management of severe blunt splenic injury safer than embolization or surgery? Results from a French prospective multicenter study, J Visc Surg, 152, 85, 10.1016/j.jviscsurg.2015.01.003

2012, Blunt splenic trauma: splenectomy increases early infectious complications: a prospective multicenter study, J Trauma Acute Care Surg, 72, 229, 10.1097/TA.0b013e31823fe0b6

2004, Blunt splenic injuries: high nonoperative management rate can be achieved with selective embolization, J Trauma, 56, 1063, 10.1097/01.TA.0000123037.66867.F2

2009, The impact of splenic artery embolization on the management of splenic trauma: an 8-year review, Am J Surg, 197, 337, 10.1016/j.amjsurg.2008.11.017

2015, Blunt splenic injury: are early adverse events related to trauma, nonoperative management, or surgery?, Diagn Interv Radiol, 21, 327, 10.5152/dir.2015.14800

2011, Does splenic embolization and grade of splenic injury impact nonoperative management in patients sustaining blunt splenic trauma?, Am Surg, 77, 215, 10.1177/000313481107700224

2008, Short-term outcomes of splenectomy avoidance in trauma patients, Am J Surg, 196, 213, 10.1016/j.amjsurg.2007.07.037

2004, Use of splenic artery embolization as an adjunct to nonsurgical management of blunt splenic injury, J Trauma, 56, 768, 10.1097/01.TA.0000129646.14777.ff

2013, Role of splenic artery embolization in management of traumatic splenic injuries: a prospective study, Indian J Surg, 75, 361, 10.1007/s12262-012-0505-9

2013, Computed tomography blush and splenic injury: does it always require angioembolization?, Am Surg, 79, 1089, 10.1177/000313481307901027

2015, Management of splenic trauma: A single institution's 8-year experience, Am J Surg, 209, 308, 10.1016/j.amjsurg.2014.06.034

2009, The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16-year experience, J Trauma, 67, 565

2006, Splenic artery embolization: have we gone too far?, J Trauma, 61, 541, 10.1097/01.ta.0000235920.92385.2b

2015, Nonoperative management of blunt splenic injury in adults: there is (still) a long way to go. The results of the Bologna-Maggiore Hospital trauma center experience and development of a clinical algorithm, Surg Today, 45, 1210, 10.1007/s00595-014-1084-0

2012, Impact of splenic artery embolization on the success rate of nonoperative management for blunt splenic injury, Cardiovasc Intervent Radiol, 35, 76, 10.1007/s00270-011-0132-z

2006, Nonoperative management of splenic injuries: improved results with angioembolization, J Trauma, 61, 192, 10.1097/01.ta.0000223466.62589.d9

2014, Prospective trial of angiography and embolization for all Grade III to V blunt splenic injuries: nonoperative management success rate is significantly improved, J Am Coll Surg, 218, 644, 10.1016/j.jamcollsurg.2014.01.040

2010, Management of blunt injuries to the spleen, Br J Surg, 97, 1696, 10.1002/bjs.7203

2007, Early selective angioembolization improves success of nonoperative management of blunt splenic injury, Am Surg, 73, 897, 10.1177/000313480707300915

2017, Western Trauma Association Critical Decisions in Trauma: management of adult blunt splenic trauma—2016 updates, J Trauma Acute Care Surg, 82, 787, 10.1097/TA.0000000000001323

2010, Blunt splenic injury, Curr Opin Crit Care, 16, 575, 10.1097/MCC.0b013e3283402f3a

1995, Management of blunt splenic trauma: computed tomographic contrast blush predicts failure of nonoperative management, J Trauma, 39, 507

2000, Nonsurgical management of blunt splenic injury: use of CT criteria to select patients for splenic arteriography and potential endovascular therapy, Radiology, 217, 75, 10.1148/radiology.217.1.r00oc0875

2005, Nonoperative management of blunt splenic injury: a 5-year experience, J Trauma, 58, 492, 10.1097/01.TA.0000154575.49388.74

2007, Experience with splenic main coil embolization and significance of new or persistent pseudoaneurysm: reembolize, operate, or observe, J Trauma, 63, 615

2010, Preservation of splenic immunocompetence after splenic artery angioembolization for blunt splenic injury, J Trauma, 69, 1126

2009, Does splenic preservation treatment (embolization, splenorrhaphy, and partial splenectomy) improve immunologic function and long-term prognosis after splenic injury?, J Trauma, 67, 557

2011, A survey of American Association for the Surgery of Trauma member practices in the management of blunt splenic injury, J Trauma, 70, 1026

Thông tin
Thông tin xuất bản

Journal of Trauma and Acute Care Surgery

Tập 83 Số 5

934-943

Thông tin tác giả