Effect of Prophylactic Embolization on Patients With Blunt Trauma at High Risk of Splenectomy: A Randomized Clinical Trial.

Importance: Splenic arterial embolization (SAE) improves the rate of spleen rescue, yet the advantage of prophylactic SAE (pSAE) compared with surveillance and then embolization only if necessary (SURV) for patients at high risk of spleen rupture remains controversial. Objective: To determine whether the 1-month spleen salvage rate is better after pSAE or SURV. Design, Setting, and Participants: In this randomized clinical trial conducted between February 6, 2014, and September 1, 2017, at 16 institutions in France, 133 patients with splenic trauma at high risk of rupture were randomized to undergo pSAE or SURV. All analyses were performed on a per-protocol basis, as well as an intention-to-treat analysis for specific events. Interventions: Prophylactic SAE, preferably using an arterial approach via the femoral artery, or SURV. Main Outcomes and Measures: The primary end point was an intact spleen or a spleen with at least 50% vascularized parenchyma detected on an arterial computed tomography scan at 1 month after trauma, assessed by senior radiologists masked to the treatment group. Secondary end points included splenectomy and pseudoaneurysm, secondary SAE after inclusion, complications, length of hospital stay, quality-of-life score, and length of time off work or studies during the 6-month follow-up. Results: A total of 140 patients were randomized, and 133 (105 men [78.9%]; median age, 30 years [interquartile range, 23-47 years]) were retained in the study. For the primary end point, data from 117 patients (57 who underwent pSAE and 60 who underwent SURV) could be analyzed. The number of patients with at least a 50% viable spleen detected on a computed tomography scan at month 1 was not significantly different between the pSAE and SURV groups (56 of 57 [98.2%] vs 56 of 60 [93.3%]; difference, 4.9%; 95% CI, -2.4% to 12.1%; P = .37). By the day 5 visit, there were significantly fewer splenic pseudoaneurysms among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 8 of 65 [12.3%]; difference, -10.8%; 95% CI, -19.3% to -2.1%; P = .03), significantly fewer secondary embolizations among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 19 of 65 [29.2%]; difference, -27.7%; 95% CI, -41.0% to -15.9%; P < .001), and no difference in the overall complication rate between the pSAE and SURV groups (19 of 65 [29.2%] vs 27 of 65 [41.5%]; difference, -12.3%; 95% CI, -28.3% to 4.4%; P = .14). Between the day 5 and month 1 visits, the overall complication rate was not significantly different between the pSAE and SURV groups (11 of 59 [18.6%] vs 12 of 63 [19.0%]; difference, -0.4%; 95% CI, -14.4% to 13.6%; P = .96). The median length of hospitalization was significantly shorter for patients in the pSAE group than for those in the SURV group (9 days [interquartile range, 6-14 days] vs 13 days [interquartile range, 9-17 days]; P = .002). Conclusions and Relevance: Among patients with splenic trauma at high risk of rupture, the 1-month spleen salvage rate was not statistically different between patients undergoing pSAE compared with those receiving SURV. In view of the high proportion of patients in the SURV group needing SAE, both strategies appear defendable. Trial Registration: ClinicalTrials.gov Identifier: NCT02021396.

Splenic Rupture in Children With Portal Hypertension.

INTRODUCTION: Massive splenomegaly from portal hypertension (PHTN) in children raises the specter of splenic rupture; however, the incidence, etiology, and risk of rupture have not been studied, nor have existing practices to reduce risk. We therefore performed an international survey to describe the splenic rupture cases in PHTN and to describe the existing empirical practice among hepatologists. METHODS: A questionnaire was constructed to elicit cases of splenic rupture and collect hepatologists' common practices for prevention of splenic rupture. Pediatric hepatologists working in selected tertiary academic centers in the United States, Canada, and the United Kingdom were contacted. RESULTS: Hepatologists from 30 of 35 centers who met the inclusion criteria replied to the survey. Thirteen cases of splenic rupture were described of which 11 resulted from trauma. In the opinion of the practitioners, high-risk activities were football, hockey, and wrestling. Sixty-one percent recommended total restriction from high-risk activities. Seventy-four percent stated that platelet count had no effect on this decision and 61% advised a spleen guard for certain activities. CONCLUSIONS: Splenic rupture in patients with PHTN and splenomegaly seems to be rare. The reported splenic rupture cases were mostly related to falling (and not to participation in sports). There was general agreement among hepatologists about restricting high impact sports. There was variation in recommendations regarding the use of a spleen guard. The authors recommend use of spleen guards in children with splenomegaly from PHTN for physical activities with risk of fall or blunt abdominal trauma.

Common questions about infectious mononucleosis.

Epstein-Barr is a ubiquitous virus that infects 95% of the world population at some point in life. Although Epstein-Barr virus (EBV) infections are often asymptomatic, some patients present with the clinical syndrome of infectious mononucleosis (IM). The syndrome most commonly occurs between 15 and 24 years of age. It should be suspected in patients presenting with sore throat, fever, tonsillar enlargement, fatigue, lymphadenopathy, pharyngeal inflammation, and palatal petechiae. A heterophile antibody test is the best initial test for diagnosis of EBV infection, with 71% to 90% accuracy for diagnosing IM. However, the test has a 25% false-negative rate in the first week of illness. IM is unlikely if the lymphocyte count is less than 4,000 mm3. The presence of EBV-specific immunoglobulin M antibodies confirms infection, but the test is more costly and results take longer than the heterophile antibody test. Symptomatic relief is the mainstay of treatment. Glucocorticoids and antivirals do not reduce the length or severity of illness. Splenic rupture is an uncommon complication of IM. Because physical activity within the first three weeks of illness may increase the risk of splenic rupture, athletic participation is not recommended during this time. Children are at the highest risk of airway obstruction, which is the most common cause of hospitalization from IM. Patients with immunosuppression are more likely to have fulminant EBV infection.

Age should be considered in the decision making of prophylactic splenic angioembolization in nonoperative management of blunt splenic trauma: a study of 208 consecutive civilian trauma patients.

BACKGROUND: A strategy of prophylactic splenic angioembolization using observation failure risk (OFR) computed tomographic (CT) scan criteria has been proposed recently. The main aim of the present study was to evaluate the relevance of the criteria in terms of delayed splenic rupture in patients with blunt splenic injury. METHODS: All patients with blunt splenic injuries admitted consecutively between January 2005 and January 2010 to our institution were included. Clinical, CT scan, and angiographic data, initial management, and outcome were noted. Patients managed expectantly were classified according to OFR CT scan criteria (high OFR was defined by at least one of the following CT scan signs: blush, pseudoaneurysm, Organ Injury Scale [OIS] grade III with a large hemoperitoneum, and OIS grade IV or 5). Initial management success was especially studied. RESULTS: Among the 208 patients included, 161 (77%) were treated by observation (35 OIS grade I, 64 OIS grade II, 33 OIS grade III, 18 OIS grade IV, and 11 OIS grade V) and 129 (80%) were men, with a mean (SD) age of 36.1 (18.7) years and a mean (SD) Injury Severity Score of 20.8 (15.4). Forty-nine patients (30%) had high OFR CT scan criteria. Thirteen patients (8%) experienced observation failure. High OFR CT scan criteria (odds ratio, 11; 95% confidence interval, 2.5-47.5) and patients 50 years and older (odds ratio, 33.9; 95% confidence interval, 6.2-185.5) were independent factors related to observation failure. The positive predictive value of OFR CT scan criteria for observation failure was 18%, and the negative predictive value was 96%. The corresponding values were 67% and 90%, respectively, in patients 50 years and older and 3% and 99%, respectively, in patients younger than 50 years. CONCLUSION: OFR CT scan criteria lack specificity to predict observation failure, mainly in patients younger than 50 years. Age should be considered when identifying patients requiring prophylactic splenic angioembolization. LEVEL OF EVIDENCE: Diagnostic study, level III.

Return to contact sports following infectious mononucleosis: the role of serial ultrasonography.

Splenic rupture is a rare but potentially fatal complication of infectious mononucleosis. Athletes returning to contact sports following infectious mononucleosis are at potential risk of splenic rupture secondary to abdominal trauma. No clear consensus exists as to when it is safe to allow these athletes to return to contact sports. Suggested periods of abstinence have ranged from 2 weeks to 6 months. We outline our experiences with the use of abdominal ultrasonography at 1 month after the diagnosis of infectious mononucleosis as a means of determining when athletes can safely return to contact sports. Our study group was made up of 19 such patients (mean age: 16.7 yr). We found that 16 of these patients (84%) had normal splenic dimensions on ultrasonography 1 month after diagnosis, and they were therefore allowed to return to contact sports. While the remaining 3 patients had an enlarged spleen at 1 month, their splenic dimensions had all returned to normal when ultrasonographic examination was repeated at 2 months postdiagnosis. We conclude that serial abdominal ultrasonography allows for informed decision making in determining when athletes can safely return to contact sports following infectious mononucleosis.

The significance of pseudoaneurysms in the nonoperative management of pediatric blunt splenic trauma.

PURPOSE: Nonoperative management is the standard of care for hemodynamically stable pediatric and adult blunt splenic injuries. In adults, most centers follow a well-defined protocol involving repeated imaging at 24 to 48 hours, with embolization of splenic pseudoaneurysms (SAPs). In children, the significance of radiologically detected SAP has yet to be clarified. METHODS: A systematic review of the medical literature was conducted to analyze the outcomes of documented posttraumatic SAP in the pediatric population. RESULTS: Sixteen articles, including 1 prospective study, 4 retrospective reviews, and 11 case reports were reviewed. Forty-five SAPs were reported. Ninety-six percent of children were reported as stable. Yet, 82% underwent splenectomy, splenorrhaphy, or embolization. The fear of delayed complications owing to SAP was often cited as the reason for intervention in otherwise stable children. Only one child with a documented pseudoaneurysm experienced a delayed splenic rupture while under observation. No deaths were reported. CONCLUSIONS: There is no evidence to support or dispute the routine use of follow-up imaging and embolization of posttraumatic SAP in the pediatric population. At present, the decision to treat SAP in stable children is at the discretion of the treating physician. A prospective study is needed to clarify this issue.

Traumatic pseudoaneurysms of the liver and spleen in children: is routine screening warranted?

BACKGROUND: Although blunt injury to the spleen and liver can lead to pseudoaneurysm formation, current surgical guidelines do not recommend follow-up imaging. Controversy exists regarding the clinical implications of these traumatic pseudoaneurysms as well as their management. METHODS: Retrospective review of children treated nonoperatively for isolated blunt liver and spleen trauma between 1991 and 2008 was undertaken. Patient demographics, grade of injury, and follow-up Doppler ultrasound results were obtained. RESULTS: Three hundred sixty-two children were identified. One hundred eighty-six of them had splenic injuries, and 10 (5.4%) developed pseudoaneurysms. They were associated with grade III (3/39 [8%]) and grade IV (7/41 [17%]) injuries. In 7 patients, the pseudoaneurysm thrombosed spontaneously. Angiographic embolization was required in 2 children, and one underwent emergency splenectomy for delayed hemorrhage. Of the 176 patients who had liver injuries, 3 (1.7%) developed pseudoaneurysms. All 3 were associated with grade IV injuries (3/11 [27%]). One child underwent early embolization, while 2 developed delayed hemorrhage requiring emergent treatment. CONCLUSIONS: Pseudoaneurysm development after blunt abdominal trauma is associated with high-grade splenic and liver injuries. Routine screening of this group of patients before discharge from hospital may be warranted because of the potential risk of life-threatening hemorrhage.

Early discharge after nonoperative management for splenic injuries: increased patient risk caused by late failure?

BACKGROUND: With increasing experience and knowledge about nonoperative management of splenic injury (NOMSI), patients are being discharged early and possibly placed at risk for late failure of NOMSI and its associated complications. To evaluate if blunt trauma patients managed by NOMSI can be safely discharged early, because failure after the third day from injury occurs infrequently and is not associated with added morbidity. METHODS: The medical records of patients who failed NOMSI from January 1993 to December 2005 in an academic level 1 trauma center were reviewed. Patients who failed NOMSI within 3 days (early failure) were compared with patients who failed it after 3 days (late failure) to identify characteristics that may help predict late failure. Primary outcomes were complications and death related to late failure. RESULTS: Of 691 patients admitted with blunt trauma to the spleen, 499 (72%) had NOMSI and 36 (7%) failed it. Early failure was recorded in 26 patients (5%) and late failure in 10 (2%). Late bleeding was the cause of failure in all patients with late failure and occurred in 8 +/- 6 (mean +/- SD) days after admission (4-8 days in 7 patients and 12-22 days in 3). When comparing age, Injury Severity Score, hemotocrit on admission, preoperative blood transfusions, and grade of splenic injury, no differences were found between patients with early and late failure. All but 1 patient with late failure were still in the hospital for associated injuries at the time of failure. No patient died, had delayed diagnosis, or suffered added morbidity because of late failure. CONCLUSION: Late failure occurs infrequently, unpredictably, and almost always in patients who are still in the hospital for associated injuries. In-hospital observation beyond the third day after injury is not necessary for most patients with splenic injury, who have no other reason to remain hospitalized.

[Prophylactic splenectomy to prevent complications of splenomegaly in children with sickle cell anemia?]. / Peut-on envisager une splénectomie préventive des complications des splénomagalies chez l'enfant drépanocytaire?

OBJECTIVE: To assess the effects of splenectomy in children with sickle cell anemia and to propose a therapeutic approach to splenomegaly in sickle cell anemia. MATERIAL AND METHOD: This retrospective study, conducted in the pediatric surgery department of the Tokoin Teaching Hospital in Lomé, included 8 children followed for sickle cell anemia (hetero- and homozygous) and who were admitted from January 1987 through December 2004 for splenic rupture or referred for prophylactic splenectomy. RESULTS: The patients' mean age at splenectomy was 9 years 6 months. Five were homozygous and three heterozygous; on Hackett's scale, spleen size was 4 for four patients and 5 for the other four. All had episodes of pain of the left hypochondrium before surgery and were averaging one blood transfusion a year. Five splenectomies were for traumatic rupture of splenomegaly and three for other splenic complications. Splenectomy made it possible to decrease the frequency of blood transfusions. Pre- and postoperative prophylaxis against infection included penicillin and vaccinations. CONCLUSION: The review of literature shows a frequent loss of immune function in the enlarged spleens of children with sickle cell anemia. The authors propose prophylactic splenectomy in children with splenomegaly, to prevent the risk of splenic rupture and other complications. Preventive measures after the splenectomy are necessary to control infections.

Pediatric splenic injuries with a contrast blush: successful nonoperative management without angiography and embolization.

BACKGROUND: The presence of a contrast blush on computed tomography (CT) in adult splenic trauma is a risk factor for failure of nonoperative management. Arterial embolization is believed to reduce this failure rate. The significance of a blush in pediatric trauma is unknown. The authors evaluated the outcome of children with blunt splenic trauma and contrast extravasation. METHODS: The trauma registry was queried for all pediatric patients with blunt splenic injuries. Admission CT was reviewed for injury grade and presence of an arterial blush by a radiologist blinded to patient outcome. Hospital and office charts were reviewed for success of nonoperative management, late splenic rupture, and other complications. RESULTS: One hundred seven children with blunt splenic trauma were identified over a 6-year period. Mean injury grade was 2.9. Six patients required emergency splenectomy. An additional 7 patients met hemodynamic criteria for surgical intervention (3 splenectomies, 4 splenorrhaphies). Admission CT was available in 63 patients. An arterial blush was identified in 5 (9.7%). Four remained stable and were treated conservatively. One underwent splenectomy for hemodynamic instability. There were no cases of delayed splenic rupture, failed nonoperative treatment, or long-term complications. CONCLUSIONS: Contrast blush in children with blunt splenic trauma is rare, and its presence alone does not appear to predict delayed rupture or failure of nonoperative treatment. Based on this limited series, splenic artery embolization does not have a place in the management of splenic injuries in children.

Upper respiratory tract infections: who plays, who sits?

In athletes with upper respiratory infections (URIs), the question of who plays and who sits can be difficult to answer. Acute exercise suppresses several aspects of the immune system. None of these immunologic changes, however, consistently correlate with the incidence of URIs in athletes. The risk of infection with exercise seems to follow a J-curve relationship, with regular, moderate exercisers having a lower risk than sedentary people, and regular, strenuous exercisers having the highest risk of all. The decision to allow an athlete to play or not can be guided by the "neck check" rules, and can also take into account nonmedical factors. The athlete with infectious mononucleosis warrants more careful attention, as there are strict guidelines for return-to-play in these individuals, to avoid the possibility of splenic rupture.

[Hemoglobinopathy C and splenomegaly in an Ivory Coast patient. Value of splenectomy]. / Hémoglobinopathie C et splénomégalie chez un patient ivoirien. Intérêt de la splénectomie.

We report the case of a young patient native of the Ivory Coast who suffered from homozygous hemoglobin C disease. He presented with the usual findings of this hemoglobinopathy: a moderate hemolytic anemia and a massive, painful and even disabling splenomegaly. Pain completely disappeared following splenectomy. However, postoperative course was complicated by portal venous thrombosis, which was medically treated. No deficiency of natural coagulation inhibitors could be demonstrated, so splenectomy was the only factor predisposing to thrombosis. We consider that in only very few cases of hemoglobin C disease, splenectomy (preceded by prophylactic antipneumococcic vaccine) may be indicated from pain and risk of spontaneous splenic rupture.

Splenic injury in side impact motor vehicle collisions: effect of occupant restraints.

BACKGROUND: Side impact motor vehicle collisions (MVCs) are associated with higher morbidity and mortality compared with other types of MVCs. The stiffness of the lateral aspect of the vehicle and restraint use may play a role. The purpose of this study was to evaluate the role of restraint use, vehicle size, and compartment intrusion on the incidence of splenic injury in side impact MVCs. METHODS: The National Automotive Sampling System was used to identify drivers involved in side impact collisions for the years 1996 to 1998. The incidence of splenic injury in these collisions was compared according to restraint use, vehicle size, and magnitude of vehicle crush. Information on the perceived cause of splenic injuries sustained in the MVC was also obtained from National Automotive Sampling System investigator records. RESULTS: Overall, among drivers involved in side impact MVCs, restraint use was associated with a significantly reduced rate of mortality (odds ratio [OR], 0.40; p < 0.0001) and splenic injury (OR, 0.76; p < 0.0001). Restrained drivers of small vehicles (<2,500 lb), however, had a higher incidence of splenic injury in both minimal (lateral intrusion < 30 cm) (OR, 60.1; p < 0.0001) and severe (lateral intrusion > 30 cm) (OR, 4.0; p < 0.0001) magnitudes of vehicle crush on the driver's side of the vehicle. For both midsize (2,500-3,000 lb) and large (>3,000 lb) vehicles, restraint use was associated with a lower risk of splenic injury regardless of the magnitude of crush. In nearly all cases of splenic injury, the left vehicle interior was the source of injury. CONCLUSION: Overall, restraint use is associated with lower rates of splenic injury and mortality in side impacts. Despite this fact, restrained drivers of small vehicles have a higher risk of splenic injury after lateral impact MVCs when compared with unrestrained drivers. Evaluation of the combined role of restraint use, crash, and injury patterns may provide novel insight regarding vehicle safety design features.