K. K. Atkins1, A. B. Schneider1, A. G. Charles1 1University Of North Carolina At Chapel Hill, Division Of Trauma, Critical Care, And Acute Care Surgery, Chapel Hill, NC, USA
Introduction: Splenic injuries are some of the most frequent and life-threating traumatic injuries given the high vascularity and anatomic location of the spleen. Non-operative management is recommended in hemodynamically stable patients to preserve the immunological function of the spleen. Total splenectomy is the primary operative management and the role for splenorrhaphy is unclear. We aim to evaluate the role of splenorrhaphy in adult splenic injuries to determine the prevalence and the effect on reoperation and mortality outcomes.
Methods: We performed a retrospective review of the National Trauma Data Bank (2007-2019) of adults (≥16 years old) with splenic injuries, excluding patients with an initial GCS ≤8. Operative splenic injury management (total splenectomy vs. splenorrhaphy vs. failed splenorrhaphy) was compared. The primary outcome was mortality. We performed bivariate analysis of potential explanatory variables and multivariable logistic regression to estimate the effect of operative splenic injury management on mortality.
Results:186,643 patients met inclusion criteria. Splenic injury management was stable over time; 79.8% managed non-operatively, 18.3% undergoing total splenectomy and 1.8% splenorrhaphy. Of 37,681 operative patients, 90.7% required a total splenectomy and 9.3% underwent splenorrhaphy with a subsequent 4.1% requiring reoperation for total splenectomy. Splenorrhaphy patients had a lower mean Spleen-AIS (2.6 vs. 3.8,p<0.001), ISS (18.7 vs. 26.0,p<0.001) and crude mortality (2.6% vs. 8.1%,p< 0.001) compared to total splenectomy patients. Failed splenorrhaphy patients had a higher mean Spleen-AIS (3.1 vs. 2.6,p<0.001) and ISS (26.9 vs. 18.7,p<0.001) compared to successful splenorrhaphy patients. Failed splenorrhaphy patients had a higher crude mortality (9.5% vs. 8.1%,p<0.001), longer ICU stay (15.0 vs. 10.5 days,p<0.001) and were less likely to discharge home (48.1% vs. 52.4%,p<0.001) compared to total splenectomy patients. Patients who underwent total splenectomy and patients who failed splenorrhaphy had an adjusted odds ratio of 2.30 (95%CI 1.82-2.92,p<0.001) and 2.36 (95%CI 1.19-4.67,p<0.014) respectively for mortality compared to successful splenorrhaphy patients, adjusted for age, sex, SBP, HR, initial GCS, Charlson comorbidity score, injury mechanism, Spleen-AIS and total injured AIS systems.
Conclusion: Adults with splenic injuries requiring operative intervention have twice the odds of mortality when a total splenectomy is performed or when splenorrhaphy fails compared to successful splenorrhaphy, despite injury severity. Our findings suggest cautious selection of potential splenorrhaphy patients as failure may lead to significant morbidity and mortality.
