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Military treatment of splenic injury in the era of non-operative management
  1. Somayyeh Mossadegh1,2,
  2. M Midwinter2,
  3. W Sapsford3 and
  4. N Tai2,3
  1. 1Honorary Trauma Fellow, Royal London Hospital, London, UK
  2. 2Academic Department of Military Surgery and Trauma (ADMST), Royal Centre for Defence Medicine (RCDM), Birmingham, UK
  3. 3Royal London Hospital, London, UK
  1. Correspondence to Flt Lt Somayyeh Mossadegh, Academic Department of Military Surgery and Trauma (ADMST), Royal Centre for Defence Medicine (RCDM), ICT Centre, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, UK; Somayyeh.mossadegh{at}doctors.org.uk

Abstract

Objectives Management of blunt splenic injury (BSI) in battlefield casualties is controversial. Splenectomy is the traditional treatment, as setting the conditions for selective non-operative management (SNOM) is difficult in the operational environment. On mature operations, it may be feasible to adopt a more conservative approach and manage the patient according to civilian protocols. The aim of this study was to document the contemporary practice of deployed military surgeons when dealing with BSI and to compare this against a matched cohort of civilian BSI patients.

Method The Joint Theatre Trauma Registry held at the Royal Centre for Defence Medicine, Birmingham, was thoroughly examined to yield patients with BSI. The study encompassed a 55-month period ending September 2009. Data abstracted included patient demographics, injury epidemiology, grade of splenic injury, treatment and outcome. These data were compared with a registry database from a UK civilian major trauma centre.

Result Of 1516 military trauma patients, 16 (1%) had a splenic injury, of which five were excluded either because of fatalities due to overwhelming injury or penetrating trauma. The remaining 11 had a blunt component. Median (IQR) injury severity score (ISS) was 17 (15–21). Nine underwent a splenectomy with median (IQR) ISS of 17 (12–18). Of this group, organ injury grades were documented in 10 patients (four Grade V injuries, three Grade IV and three Grade II). All patients survived surgery. There were no complications in survivors as a result of splenic conservation in the military group. Data from the civilian major trauma centre database showed 160 (2%) patients sustained a splenic injury, of which 131 (82%) had a blunt mechanism, 43/160 (27%) and 9/160 (6%) patients underwent splenectomy and angio-embolisation, respectively.

Conclusions Patients with BSI, an uncommon finding in combat casualties, are occasionally selected for conservative management, contrary to previous military surgical paradigms but in keeping with the civilian shift to SNOM. Guidelines to clarify the place of SNOM are required to assist surgical decision making on deployed operations.

  • Medical Journalism
  • Trauma Management

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Key messages

  • Isolated splenic injury in the military setting is uncommon; however, deployed military specialists, educated in an era of non-operative or conservative therapies, and practising in a context of mature operations, may elect to use selective non-operative management (SNOM) when appropriate.

  • Successful SNOM is predicated on timely imaging, careful monitoring and sequential clinical review in order to observe the patient for signs that predict continued haemorrhage and potential failure requiring angio-embolisation or surgical intervention (laparotomy and splenic preservation or definitive splenectomy).

  • The minimum clinical inventory required to set the conditions for SNOM typically includes access to multi-detector contrast CT, a high dependency ward bed, continuity of specialist surgical review and contingent access to an operating theatre.

Introduction

Selective non-operative management (SNOM) of blunt splenic injury (BSI) in otherwise haemodynamically stable patients is a well-accepted tenet of civilian trauma care.1 ,2 The method first gained ground among paediatric surgeons who recognised that splenectomy placed the injured child at a small but appreciable risk of developing an often fatal overwhelming postsplenectomy infection (OPSI).3 ,4 While OPSI is a much rarer sequelae of adult trauma splenectomy, SNOM has become a standard care pathway in the treatment of haemodynamically stable patients with splenic injury. The potential advantages of SNOM include avoidance of the complications of unnecessary laparotomy and splenectomy, reduced transfusion requirement, and circumvention of the need for postsplenectomy antibiotic prophylaxis.5 ,6 The consequences to military personnel of splenectomy may include occupational restriction in the form of permanent downgrading or barring from deployment to countries where malaria is endemic.7 ,8 Recent surveys of practice among North American trauma centres suggest that 61%–85% of all patients with splenic trauma can be managed non-operatively.9–11

SNOM of BSI has yet to be incorporated into the medical doctrine of UK Defence Medical Services. Successful SNOM is predicated on timely imaging, careful monitoring and sequential clinical review in order to observe the patient for signs that predict continued haemorrhage and potential failure requiring angio-embolisation or surgical intervention (laparotomy and splenic preservation or definitive splenectomy). As such, the minimum clinical inventory required to set the conditions for SNOM typically includes access to multi-detector contrast CT, a high dependency ward bed, continuity of specialist surgical review and contingent access to an operating theatre. In echeloned tiers of military care on deployed operations such infrastructure may not be available, particularly in the acutely resource-constrained conditions of manoeuvre warfare. The view that ‘there is no role for non-operative management in solid organ injury’ has thus been propagated.12

The established and highly specialised trauma system that has been developed in Southern Afghanistan represents a departure from historic 20th century models of military trauma care. The infrastructure that exists in Camp Bastion Role 3 Medical Treatment Facility (MTF) matches or surpasses civilian standards in many domains. Deployed military specialists, educated in an era of non-operative or conservative therapies, and practising in a context of mature operations, may elect to use SNOM when appropriate. The aim of this study was to determine the rate of SNOM in UK casualties from Afghanistan who were treated for BSI and to compare this rate against a matched cohort of civilian patients treated in a Major Trauma Centre.

Materials and methods

The Joint Theatre Trauma Registry held at the Royal Centre for Defence Medicine (RCDM), Birmingham, was interrogated to yield UK servicemen or women who had sustained BSI on Operations. Casualties who had splenic trauma due to displacement from blast were categorised as BSI unless they had a fragment injury to the spleen. The study encompassed a 55-month period ending in September 2009. The start date was determined by the introduction of CT scanners on operations. Data abstracted by a trauma nurse specialist included patient demographics, mechanism of injury, injury epidemiology, grade of splenic injury, injury severity score (ISS), management, length of stay, treatment and outcome (complications, mortality). Patients who died shortly after the start of surgery due to overwhelming injuries were excluded from the analysis. The trauma registry of the Trauma Clinical Academic Unit of the Royal London Hospital contains data on all trauma patients requiring trauma team activation since 1 January 2003 and was similarly interrogated. For methodological accuracy data should have been analysed over the same 55-month period in both registries. However, to ensure that the matching process was sound, the entire civilian cohort was used in order to have the widest pool to sample from. In order to make the civilian and military groups comparable, civilian patients who were embolised for treatment were excluded as interventional radiology is not currently available on deployment by the UK. Rates of SNOM in military BSI casualties were compared with a civilian cohort of BSI patients matched for grade of splenic injury, ISS and Glasgow coma score (GCS). Paired and unpaired student t tests as well as Fisher's exact test were used for statistical analysis of data. The diagnosis of splenic injury and grading was confirmed by CT scan or operative notes if the patient did not have a CT prior to theatre. Grades of splenic injury were classified using the organ injury score (Spleen) (Table 1).13

Table 1

Splenic injury scale as devised by the Organ Injury Scaling Committee of the American Association for the surgery of trauma13

Results

Of 1516 military trauma patients in the Joint Theatre Trauma Registry database, 16 (1%) sustained a splenic injury. Two were excluded from the study cohort as they died almost immediately on reception at Role 3 due to overwhelming injuries and three were excluded due to a penetrating mechanism of injury. Of 7388 civilian trauma patients treated at the Royal London Hospital, 160 (2%) sustained splenic injury and 11 patients were matched to the military cohort (Table 3). The causes of their blunt injuries are shown in Table 2. Nearly two-thirds of military patients had an ISS>15 (Table 4).

Table 2

Mechanism of blunt splenic injury

Table 3

Demographics of study group

Both groups were matched exactly for grade of splenic injury (four Grade I/II injuries, one Grade III and five Grade IV/V injuries). One in each group was unclassified (Table 4). Splenectomies were performed in 9/11 (82%) military patients and 4/11 (36%) civilian patients (Table 5).

Table 4

Injury severity score (ISS)

Table 5

Splenectomy versus SNOM

Two military cases (ISS 17 and 22, respectively) had successful splenic preservation (Figure 1), in spite of fractured ribs, vertebrae, pelvis and mainly lower limb injuries. The first spent 4 days of observation at the Role 3 MTF and 6 days on the ward at RCDM while the second spent 13 days on intensive care (the first day at the Role 3 MTF followed by a critical care air support transfer) and 37 days on the ward at RCDM, due to extensive limb injuries.

Figure 1

CT image showing splenic injury (arrow).

Discussion

Since the beginning of modern surgery, splenectomy has been the procedure of choice for splenic injury as before the late 20th century it was believed that the death rate for SNOM exceeded 90%.14 The concept of splenic preservation was introduced in the early 1970s and by 1979 numerous papers reported the safety of SNOM in hundreds of children worldwide and it became the treatment of choice for paediatric blunt splenic trauma.3 ,4 Additional confidence in SNOM was confirmed by the expanding use of CT scanning, opening up new avenues for diagnosis and observations of splenic injuries as well as liver injuries.15 ,16

State-wide and multi-institutional studies have shown that SNOM represented the prevailing method of splenic preservation in both adult and geriatric populations with satisfactory outcome and economic advantages and that grade of splenic injury and quantity of haemoperitoneum is predictive of success of observation.2 ,9 The EAST Multi-institutional Spleen Study showed that of the 10.8% of patients who failed SNOM, 60.9% of the failures occurred in the first 24 h and 86.2% failed within 96 h. Successful SNOM was associated with higher blood pressure and haematocrit and less severe injury based on ISS, GCS, grade of splenic injury and quantity of haemoperitoneum;9 however, there were large variabilities in management and outcome between centres.

The correlation between grade of injury and success of SNOM is not strong enough to be used to predict outcome in individual patients.11 Certain criteria have to be met prior to following a SNOM pathway: haemodynamic stability, with or without minimal fluid resuscitation, no demonstrable peritoneal signs on abdominal examination and the absence on CT scan of any intraperitoneal or retroperitoneal injuries that require operative intervention. There is a need for careful monitoring and sequential clinical review in order to observe the patient for signs that predict continued haemorrhage and potential failure requiring angio-embolisation or surgical intervention. As such, the minimum clinical inventory required to set the conditions for SNOM typically includes access to multi-detector contrast CT, a high dependency ward bed, continuity of specialist surgical review and contingent access to an operating theatre.17 Delayed complications of SNOM of blunt adult splenic trauma requiring intervention have been reported between 2% and 10.8% including haemorrhage, pseudoaneurysm and splenic abscess.1 ,9 ,11 ,18 ,19 While CT scanning is a prerequisite for SNOM in the civilian or military arenas, to reduce the rate of non-therapeutic laparotomies and failed SNOM11 it is not the grade of injury on CT however that is solely responsible for outcome, as a high ISS has been shown to significantly increase the risk of SNOM failure and the decision to undergo SNOM is based on clinical criteria including age and associated injuries as well as CT appearances.9 ,20 Angiography has been used to predict successful non-operative therapy of splenic injury as lack of contrast extravasation is a reliable predictor of successful SNOM is the absence of contrast extravasation on splenic arteriography.21 ,22

Despite the small numbers, this study demonstrates that although SNOM is widely accepted for BSI in the civilian setting, it remains uncommon in the military. While military patients have a different mechanism of injury, the degree of trauma insult—as represented by ISS, grade of splenic injury, GCS and systolic blood pressure—did not differ between cohorts, suggesting that haemodynamic stability does not account for the variance in splenectomy rate. In fact, more of the civilian cohort had an ISS≥16 yet progressed to a SNOM strategy.

Traditional rationales for splenectomy in a military environment such as lack of CT, inability to maintain the casualty in a high dependency area or to undertake the degree of vigilant observation required to detect failure of SNOM are not applicable to this period as a mature, static and well-manned Role 3 MTF with multiple high dependency unit (HDU) beds and ready access to CT has rendered SNOM a feasible concept. We are unable to define whether an alternative conservative pathway could have been pursued in the splenectomised casualties, or draw conclusions as to the cost–benefit effect of alternate SNOM or splenectomy strategies (for SNOM eligible casualties) on the medical logistic and evacuation chain without knowing the pressures on the strategic evacuation chain at the time. Nonetheless, SNOM should be considered when conditions allow this choice for BSI patients.

The military evidence for SNOM is scarce. Zonies and Eastridge23 recently presented their preliminary findings of splenic SNOM among US casualties from the conflict in Afghanistan. In a retrospective study of 393 splenic injured patients (70.7% from blunt mechanisms) more than half underwent splenectomy (52.7%). The remaining 47% were managed with SNOM or splenic salvage surgery with a SNOM failure rate of 6% and overall mortality of 9%.

Five cases of successful SNOM of ballistic abdominal solid organ injuries in local national patients have been reported, though none had splenic injury and follow-up was limited; it was concluded that this method was suitable for carefully selected patients.24 This was also the conclusion of the Academic Department of Military Surgery and Trauma Torso Trauma Working Group which produced guidelines on this topic after examination of the published evidence, much of it civilian, and discussion of personnel deployed.25

We accept the limitations of this study, namely, its small size and the disparity of the ages of the two cohorts, although they were well matched for all other parameters. The exclusion of those civilians undergoing embolisation may also have skewed the civilian data, but as this technique is not available in the deployed military setting we feel this exclusion is justified. Nonetheless, in haemodynamically stable patients, who can be observed for 3–4 days without becoming a military operational burden, SNOM is a feasible strategy. We acknowledge that one of the military patients was transferred back to the UK via critical care air support teams (CCAST) and had a lengthy stay due to the nature of the complex injuries.

Conclusions

BSI is an uncommon finding in combat casualties but identification of suitable patients, in keeping with the civilian practices, and in the context of suitable operational circumstances, will allow splenic preservation and avoidance of the consequences of laparotomy and occupational downgrading. It is concluded that, while SNOM has been practised by military surgeons managing patients with BSI, rates of splenectomy remain higher than for a civilian cohort with equivalent injuries. Guidelines to clarify the place of SNOM are required to assist surgical decision making on deployed operations.

Acknowledgments

We would like to thank the Academic Department of Military Emergency Medicine (ADMEM) and the Centre for Defence Radiology for their help with this work. The views expressed in this paper are those of the authors and should not be construed as those of the Ministry of Defence.

References

Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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