Date Published: January 30, 2018
Publisher: John Wiley and Sons Inc.
Author(s): Kenichiro Uchida, Yasumitsu Mizobata, Naohiro Hagawa, Tomonori Yamamoto, Shinichiro Kaga, Tomohiro Noda, Naoki Shinyama, Tetsuro Nishimura, Hiromasa Yamamoto.
Blunt injuries to visceral organs have the potential to lead to delayed pseudoaneurysm formation or organ rupture, but current trauma and surgical guidelines do not recommend repetitive imaging. This study examined the incidence and timing of delayed undesirable events and established advisable timing for follow‐up imaging and appropriate observational admission.
Patients with blunt splenic (S), liver (L), or kidney (K) injury treated with non‐operative management (NOM) in our institution were included and retrospectively reviewed.
From January 2013 to January 2017, 57 patients were admitted with documented blunt visceral organ injuries and 22 patients were excluded. Of 35 patients (L, 10; S, 17; K, 6; L & S, 1; S & K, 1) treated with NOM, 14 (L, 4; S, 9; K, 1) patients underwent transcatheter arterial embolization. Delayed undesirable events occurred in four patients: three patients with splenic pseudoaneurysm on hospital day 6–7 and one patient with splenic delayed rupture on hospital day 7. The second follow‐up computed tomography scan carried out 1–2 days after admission did not show any significant findings that could help predict undesirable results of delayed events. The patients with delayed events had longer continuous abdominal pain than that of event‐free patients (P = 0.04).
Undesirable delayed events were recognized on follow‐up computed tomography scans in 11.4% of NOM patients at hospital day 6–7 and tended to be associated with high‐grade splenic injuries and continuous symptoms. Repetitive screening of these patients 6–7 days after injury might be warranted because of the potential risk of delayed events.
Recently, as the quality of non‐operative management (NOM) has developed, blunt injuries to visceral organs such as spleen, liver, or kidney are tending to be managed non‐operatively with a high rate of success.1, 2, 3 However, NOM of these injuries sometimes leads to critical delayed complications and the possibility of lethal damage for the patients.4 Pseudoaneurysm formation and delayed rupture are two of the most critical complications that can occur suddenly and unexpectedly.
This study was undertaken retrospectively in the Department of Trauma and Critical Care of Osaka City University Hospital (Osaka, Japan). During the period January 2013–January 2017, all patients aged 16 years or older who were admitted to our institution because of blunt liver, kidney, or splenic injuries were included. We reviewed the patients’ demographics, injury descriptions, values of laboratory data on admission, volume of blood products used in the 24 h after admission, timing of follow‐up CT scans, management techniques, and outcomes obtained from the patients’ medical records.
During the period January 2013–January 2017, 57 patients with documented blunt splenic (S), liver (L), or kidney (K) injury were admitted in our hospital. Twenty‐two patients were excluded described as above, and 35 patients (L, 10; S, 17; K, 6; L & S, 1; S & K, 1) treated with NOM were included (Fig. 1). Of the 35 patients, 14 patients (L, 4; S, 9; K, 1) were treated with TAE. The patient characteristics, mechanism of injury, and injury descriptions are shown in Table 1.
The patients treated with NOM for their visceral organ injuries have been increasing, hence the incidence of delayed events should be predicted as much as possible. In this study, delayed events were detected in 11.4% of the patients within 7 days after injury. Previously published papers describing these delayed events are almost all limited to splenic pseudoaneurysm. Davis et al.5 and Weinberg et al.6 reported the incidence of splenic delayed events of 7.7% and 7.1%, respectively, in patients with blunt splenic injury treated with NOM. Compared to these reports, the incidence rate of splenic delayed events in this study tended to be high (21.1%). We consider that this is resulted from differences in the severity of injury. As Table 1 shows, 57.9% of the patients with splenic injury had AIS grade III injury, and thus the incidence rate of delayed undesirable events turned out to be high percentage of total splenic injury. The other possibilities that should be considered were technical issues with transcatheter embolization. We always have to be careful about preserving organs, especially in young patients, but selective embolization under the status of relatively low blood pressure carries high risks of incomplete embolization because of arterial spasm or unidentified injured arteries, and following delayed events like pseudoaneurysm formation. Describing the timing of delayed splenic events, Leeper et al.9 recently reported their experience of 12 years with the management of hemodynamically stable blunt splenic injuries. Delayed development of pseudoaneurysm or arterial extravasation occurred in only 6% of the patients on follow‐up CT scan 48 h after injury. The delayed events occurring in our four patients were detected approximately 7 days after injury. Muroya et al.10 also reported that the detection of delayed events by follow‐up CT scan were mostly at an interval of 1–8 hospital days after injury.
The present single‐center study is a small preliminary report, and we will definitely have to plan further multi‐institutional, prospective, randomized trials on the basis of this study to assess the appropriate timing of follow‐up CT scans.
Delayed undesirable events were recognized to occur during hospital days 6–7 by follow‐up CT in 11.4% of patients treated with NOM. These events tended to be associated with high‐grade splenic injuries and continuous symptoms. We conclude that repeated screening of these patients approximately 6–7 days after injury may be warranted because of the potential risk of delayed events occurring within this time.
Conflict of interest: None declared.