Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document
Authors: Podda Mauro , De Simone Belinda , Ceresoli Marco , Virdis Francesco , Favi Francesco , Wiik Larsen Johannes , Coccolini Federico , Sartelli Massimo , Pararas Nikolaos , Beka Solomon Gurmu , Bonavina Luigi , Bova Raffaele , Pisanu Adolfo , Abu-Zidan Fikri , Balogh Zsolt , Chiara Osvaldo , Wani Imtiaz , Stahel Philip , Di Saverio Salomone , Scalea Thomas , Soreide Kjetil , Sakakushev Boris , Amico Francesco , Martino Costanza , Hecker Andreas , de’Angelis Nicola , Chirica Mircea , Galante Joseph , Kirkpatrick Andrew , Pikoulis Emmanouil , Kluger Yoram , Bensard Denis , Ansaloni Luca , Fraga Gustavo , Civil Ian , Tebala Giovanni Domenico , Di Carlo Isidoro , Cui Yunfeng , Coimbra Raul , Agnoletti Vanni , Sall Ibrahima , Tan Edward , Picetti Edoardo , Litvin Andrey , Damaskos Dimitrios , Inaba Kenji , Leung Jeffrey , Maier Ronald , Biffl Walt , Leppaniemi Ari , Moore Ernest , Gurusamy Kurinchi , Catena Fausto 
Published: October 2022

Background

In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved.

Methods

Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.

Results

Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications.

Conclusion

This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.