Grade III blunt splenic injury without contrast extravasation - WSES 2019
Executive Summary
The management of blunt splenic injury has undergone a significant paradigm shift over the last 30 years, moving from surgical intervention toward non-operative management (NOM). Current data indicates that up to 90% of patients can be treated non-operatively, with an 80% success rate in avoiding surgery. While guidelines generally support NOM for Grade III injuries without contrast extravasation ("blush") on computed tomography (CT), these recommendations frequently rely on low-quality evidence, leading to significant practice variation.
To address this, the World Society of Emergency Surgery (WSES) conducted a modified Delphi consensus study during its 2019 congress in Nijmegen. Using a mobile-based questionnaire, 53 acute care surgery experts evaluated 11 clinical factors. The study established a clear consensus (defined as ≥80% agreement) that NOM remains the preferred approach for eight of these factors, including advanced age and comorbidities. However, three critical areas of discrepancy remain: the presence of multiple injuries (overall injury severity), associated intra-abdominal injuries, and non-reversible bleeding diathesis. Clinicians are advised to exercise additional caution when these three factors are present, as they represent areas where expert opinion remains divided.
Background and Research Context
The spleen is the most frequently injured solid organ in blunt abdominal trauma and is a primary contributor to trauma-related morbidity and mortality. The transition toward splenic preservation and NOM has been facilitated by advancements in:
Hemostatic resuscitation.
Enhanced diagnostic and monitoring facilities.
Interventional radiology, specifically selective and non-selective splenic artery angioembolization.
Despite these advances, high-level evidence for managing specific injury patterns is lacking. While Grade IV-V injuries and those with CT blush are well-documented in large databases, Grade III injuries without blush lack similar support. The WSES guidelines generally suggest these injuries do not require angiography or angioembolization, yet practice variation persists due to factors such as patient age, comorbidities, and associated injuries.
Methodology: The Nijmegen Consensus Practice
The 2019 WSES Nijmegen study utilized a live, mobile-application-based questionnaire to capture the real-time decision-making of 53 trauma and acute care experts.
Clinical Scenario for Assessment
Participants were presented with a hypothetical adult patient involved in a car crash one hour prior, arriving with the following clinical profile:
Vitals: BP 120/80 mmHg, HR 90 bpm, SaO2 100% (on 15L O2).
Labs: Lactate <2.0 mmol/L, Base Excess -1.5 mmol/L, pH 7.34.
Imaging: CT identifying an AAST Grade III splenic injury without blush.
Consensus Threshold
Consensus was defined as 80% agreement among respondents regarding whether a specific variable independently influenced the management plan toward angiography/angioembolization or operative management, or if standard NOM should be maintained.
Analysis of Clinical Factors and Consensus Results
The experts evaluated 11 factors, categorized into injury-related and patient-related variables.
Areas of Established Consensus
The following table outlines the factors where experts reached an 80% or greater agreement that standard non-operative management (NOM) was indicated.
Areas of Discrepancy (No Consensus)
Disagreement occurred regarding three specific variables. In these cases, respondents were split between NOM, angiography/angioembolization (AG/AE), and operative management (OM).
Critical Insights into Expert Discrepancies
The study identified specific rationales and potential biases contributing to the lack of consensus in the three disputed areas:
1. Overall Injury Severity
The role of multiple injuries remains ambiguous in existing literature. While some studies suggest a correlation between high injury severity and NOM failure, others do not. The study noted a potential bias where respondents' perceptions of injury severity in the emergency department may differ from the final calculated Injury Severity Score (ISS).
2. Bleeding Diathesis (Congenital or Acquired)
The failure to reach consensus on coagulopathy may be due to the varied etiology of bleeding disorders. However, it is well-established that coagulopathy negatively impacts outcomes in splenic injury patients, making this a critical area for future research.
3. Associated Intra-abdominal Injury
Disagreement here may be linked to terminology. The presence of concurrent solid organ injuries is known to correlate with prolonged hospital stays and ICU requirements. The study authors noted that clarifying the term "solid organs" versus "hollow viscus" injury might have altered the responses.
Conclusion and Future Directions
The WSES consensus indicates that while non-operative management is the standard of care for the majority of Grade III blunt splenic injuries without blush, the presence of polytrauma, coagulopathy, or associated intra-abdominal injuries creates clinical uncertainty.
The use of real-time, application-based assessment tools at professional meetings proved effective for gathering expert opinions quickly and anonymously. This methodology overcomes the low response rates of traditional paper or email surveys. Future research should specifically target the identified areas of discrepancy—injury severity, bleeding diathesis, and associated intra-abdominal trauma—to refine management protocols and improve splenic salvage rates.
