Hospital level variations in the trends and outcomes of the nonoperative management of splenic injuries – a nationwide cohort study

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Abstract

Background

The long-term treatment trends of splenic injuries can provide guidance when treating trauma patients. The nonoperative management (NOM) of splenic injuries was introduced in early 1989. After decades of development, it has proven to be safe and is now the primary treatment choice worldwide. However, there remains a lack of nationwide registry data to support the feasibility and efficiency of NOM.

Methods

We used the Taiwan National Health Insurance Research Database to conduct a whole population-based cohort study. Patients admitted with blunt splenic injuries from 2002 to 2013 were identified. Demographic data, management methods, associated injuries, comorbidities and outcome parameters were collected. Patients were divided into 2 groups by the type of admitting institution: a tertiary center or a non-center hospital. We also used 4 years as an interval to analyze the changes in epidemiological data and treatment trends. Comparisons of the results of NOM and surgical management were also performed.

Results

A total of 12,455 patients were admitted with blunt splenic injuries between 2002 and 2013. Among the 11,551 patients treated in a single hospital after admission, patients underwent NOM more frequently at tertiary centers than at non-center hospitals (64.6% vs 50.3%). During the 12-year study period, the NOM rate increased from 56 to 73% in tertiary centers, while in noncenter hospitals, the rate only increased from 43 to 58%. The mortality rate decreased in tertiary centers from 8.9 to 7.2%, with no apparent change in noncenter hospitals. Complications occurred more frequently in the surgical management group.

Conclusion

There is a trend toward the use of NOM for blunt splenic injury treatments, and the outcomes from the NOM groups were not inferior to those of the operation group. In addition, tertiary centers performed more NOM than did non-center hospitals and better met the international consensus.

Electronic supplementary material

The online version of this article (10.1186/s13049-018-0578-y) contains supplementary material, which is available to authorized users.

Related collections

Most cited references 23

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Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline.

Oscar D Guillamondegui, D Cheng, Ben Zarzuar … (2012)

During the last century, the management of blunt force trauma to the spleen has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. 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. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the current EAST guideline. The National Library of Medicine and the National Institute of Health MEDLINE database was searched using Pub Med (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords splenic injury and blunt abdominal trauma. One hundred seventy-six articles were reviewed, of which 125 were used to create the current practice management guideline for the selective nonoperative management of blunt splenic injury. There has been a plethora of literature regarding nonoperative management of blunt splenic injuries published since the original EAST practice management guideline was written. Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury, patient age, or the presence of associated injuries. Its use is associated with a low overall morbidity and mortality when applied to an appropriate patient population. Nonoperative management of blunt splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and has an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt splenic injuries. Repeat imaging should be guided by a patient's clinical status. Adjunctive therapies like angiography with embolization are increasingly important adjuncts to nonoperative management of splenic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt splenic injuries remain without conclusive answers in the literature.

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Nonoperative management of blunt splenic injury: a 5-year experience.

James Haan, G Bochicchio, Didier N. Kramer … (2005)

The purpose of this study was to examine the success rate of nonoperative management of blunt splenic injury in an institution using splenic embolization. We conducted a retrospective review of all patients admitted to a Level I trauma center with blunt splenic injury. Data review included patient demographics, computed tomographic (CT) scan results, management technique, and patient outcomes. A total of 648 patients with blunt splenic injury were admitted, 280 of whom underwent immediate surgical management. Three hundred sixty-eight underwent planned nonoperative management, and 70 patients were treated with observation, serial abdominal examination, and follow-up abdominal CT scanning. All were hemodynamically stable, with a 100% salvage rate. One hundred sixty-six patients had a negative angiogram, with a nonoperative salvage rate of 94%, and 132 patients underwent embolization, with a nonoperative salvage rate of 90%. Overall salvage rates decreased with increasing injury grade; however, over 80% of grade 4 and 5 injuries were successfully managed nonoperatively. The salvage rate was similar for main coil embolization versus selective or combined embolization techniques. Admission abdominal CT scan correlated with splenic salvage rates. Significant hemoperitoneum, extravasation, and pseudoaneurysm had acceptable salvage rates, whereas arteriovenous fistula had a high failure rate, even after embolization. Splenic embolization is a valuable adjunct to splenic salvage in our experience, allowing for the increased use of nonoperative management and higher salvage rates for American Association for the Surgery of Trauma splenic injury grades when compared with prior studies. Main coil embolization has a similar salvage rate when compared with other angiographic techniques. An arteriovenous fistula as a CT finding was predictive of a 40% nonoperative failure rate.

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The effect of trauma center designation and trauma volume on outcome in specific severe injuries.

Linda Chan, Carlos VR Brown, Demetrios Demetriades … (2005)

The objective of this study was to investigate the effect of American College of Surgeons (ACS) trauma center designation and trauma volume on outcome in patients with specific severe injuries. Trauma centers are designated by the ACS into different levels on the basis of resources, trauma volume, and educational and research commitment. The criteria for trauma center designation are arbitrary and have never been validated. The National Trauma Data Bank study, which included patients >14 years of age and had injury severity score (ISS) >15, were alive on admission and had at least one of the following severe injuries: aortic, vena cava, iliac vessels, cardiac, grade IV/V liver injuries, quadriplegia, or complex pelvic fractures. Outcomes (mortality, intensive care unit stay, and severe disability at discharge) were compared among level I and II trauma centers and between centers within the same level designation but different volumes of severe trauma ( or =240 trauma admissions with ISS >15 per year). The outcomes were adjusted for age ( or =65), gender, mechanism of injury, hypotension on admission, and ISS ( 25). A total of 12,254 patients met the inclusion criteria. Overall, level I centers had significantly lower mortality (25.3% vs 29.3%; adjusted odds ratio [OR], 0.81; 95% confidence interval [CI], 0.71-0.94; P = 0.004) and significantly lower severe disability at discharge (20.3% vs 33.8%, adjusted OR, 0.55; 95% CI, 0.44-0.69; P 15 ( or =240 cases per year) had no effect on outcome in either level I or II centers. Level I trauma centers have better outcomes than lower-level centers in patients with specific injuries associated with high mortality and poor functional outcomes. The volume of major trauma admissions does not influence outcome in either level I or II centers. These findings may have significant implications in the planning of trauma systems and the billing of services according to level of accreditation.

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Author and article information

Contributors

Chien-An Liao: victorgoer@gmail.com

Yu-Tung Wu: overwinterwu@gmail.com

Chien-Hung Liao: m7077@cgmh.org.tw

Shang-Yu Wang: shangyuwang@gmail.com

Chih-Yuan Fu: drfu5564@yahoo.com.tw

Chi-Hsun Hsieh: hsieh0818@cgmh.org.tw

Shao-Wei Chen: josephchen0314@gmail.com

Ching-Chang Chen: m8407@gmail.com

An-Hsun Chou: victorgoer@hotmail.com

Chi-Tung Cheng:

ORCID: http://orcid.org/0000-0002-2697-4642

886-3-3281200 , atong89130@gmail.com

Journal

Journal ID (nlm-ta): Scand J Trauma Resusc Emerg Med

Journal ID (iso-abbrev): Scand J Trauma Resusc Emerg Med

Title: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Publisher: BioMed Central (London )

ISSN (Electronic): 1757-7241

Publication date (Electronic): 11 January 2019

Publication date PMC-release: 11 January 2019

Publication date Collection: 2019

Volume: 27

Electronic Location Identifier: 4

Affiliations

[1 ]ISNI 0000 0004 1756 999X, GRID grid.454211.7, Division of Trauma and Emergency Surgery, Department of Surgery, , Chang Gung Memorial Hospital, Linkou, ; Taoyuan City, Taiwan

[2 ]ISNI 0000 0004 1756 1461, GRID grid.454210.6, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, , Chang Gung Memorial Hospital, ; Taoyuan City, Taiwan

[3 ]GRID grid.145695.a, Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, , Chang Gung University, ; Taoyuan City, Taiwan

[4 ]GRID grid.145695.a, Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, , Chang Gung University, ; 5 Fu-Hsing Street, Kwei-Shan Shiang, Taoyuan, Taiwan

[5 ]GRID grid.145695.a, Department of Surgery, Chang Gung Memorial Hospital, , Chang Gung University, ; 5 Fu-Hsing Street, Kwei-Shan Shiang, Taoyuan, Taiwan

[6 ]ISNI 0000 0001 0425 5914, GRID grid.260770.4, Institute of Biomedical Informatics, , National Yang-Ming University, ; Taipei, Taiwan

Author information

Chi-Tung Cheng http://orcid.org/0000-0002-2697-4642

Article

Publisher ID: 578

DOI: 10.1186/s13049-018-0578-y

PMC ID: 6329069

PubMed ID: 30635015

SO-VID: adf7019a-4572-412a-9a75-5678ce1aef72

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.