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Nonoperative management for splenic lesions in polytraumatized patients – Case report and literature review

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ABSTRACT

 Introduction. Nonoperative management (NOM) of blunt splenic injuries was first used in the 1970’s for pediatric patients. The high rate of overwhelming post-splenectomy infection (OPSI) in children deter- mined the shift of medical attitude to NOM. In the 1990’s it was seen the beginning of NOM for adults. Nowadays, NOM of blunt injury of the spleen (BST) in adults has become the standard of care in hemodynamically stable patients, and is well established by the 2012 EAST guidelines, along with AAST splen- ic lesion classification. It is highly successful, with an overall failure rates ranging from 2% to 31% (average 10.8%), the majority of failures occurring in the first 24 hours. Currently, NOM for splenic trauma includes splenic artery embolization (SAE).

Case report. We present a case of a 50 year-old woman, brought to the emergency room by ambulance af- ter being involved in a traffic accident as a pedestrian. Initial diagnosis on admission was bilateral hemopneumotorax and pulmonary contusions, with diagnosis of a subcapsular hematoma after admission, during a routine ultrasound checking. A less severe pathology (without pulmonary lesions, for example), associated with initial failure of FAST and CT to discover the presumable but not yet formed splenic lesion, could have been leading to non-admission or very early dis- charging of the patient, with consecutive life-threat- ening evolution. Ultrasound monitoring was the key factor in blunt splenic trauma diagnosis, and finally led to successful nonoperative management (NOM) of the lesion.

Discussion. The association with extra-abdominal lesions initially appeared to complicate the NOM de- cision, but proved actually to be more like a factor in favor of surgical nonintervention. Consecutive ultra- sound evaluations offered important data about integrity of the splenic capsule, by revealing the absence of free fluid in the peritoneal cavity. In our case, the rather slow progressive evolution of hematoma during 72h could have prevented the rupture of splenic capsule and consecutive surgery, leading to a successful NOM at the end.

Conclusion. Nonoperative management of BST, by preserving the spleen, is the treatment of choice in hospitals with trained trauma surgical team, ICU and potential of monitoring by imaging investigation. In patients with NOM for BST, association of extra-abdominal injuries does not have different outcome than in case of unique organ involvement. Angiography with splenic artery embolization (SAE) is an important method for increasing the success rate of NOM, especially in splenic injuries grades IV and V.

Keywords: spleen, blunt trauma, conservative ap- proach.

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Cristian Balalau, Nicolae Bacalbasa, Ion Motofei, Petrisor Banu, Razvan Valentin Scaunasu, Bogdan Popescu, Denisa Balalau and Vlad Denis Constantin

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