Controversies in the management of splenic trauma.
BACKGROUND
The technologic innovations of the last three decades, coupled with a deeper understanding of the immunologic role of the spleen, have significantly shifted the management of splenic injuries towards non-operative approaches. However, there continuous to be a wide range of practice patterns related to the non-operative management of splenic injuries, from which the authors infer a gap between the best available evidence and its translation into practice. We sought to explore ongoing areas of controversy in the non-operative management of splenic trauma with the aim of further elucidating why these controversies continue to exist.


METHODS
We explored areas of ongoing controversy in the management of splenic injury though a series of iterative surveys. We invited 70 experts in trauma care from ten countries around the world to participate. Areas of controversy explored included: indications and frequency for in-hospital and follow-up imaging, definitions of failure of non-operative management, indications for angioembolisation and non-operative management in special populations (i.e. elderly, concomitant traumatic brain injury, penetrating trauma).


RESULTS
A 49% response rate was obtained. Even though a wide range of practice patterns were identified, no controversies were identified in areas that do not involve the adoption of new technologies. In areas where practice pattern variation was observed, the strong influence of the local environment was constantly identified as an impediment to changes in practice.


CONCLUSIONS
We have identified that barriers present within local practice environments are the major driving forces behind controversies in the non-operative management of splenic injuries.
Division of Trauma, Department of Surgery and the Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Ontario, Canada. GomezJaramiD@smh.ca
David
D
Gomez
Barbara
B
Haas
Kaes
K
Al-Ali
Olivier
O
Monneuse
Avery B
AB
Nathens
Najma
N
Ahmed
D000007:Abdominal Injuries / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000601:surgery*; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data* / Q000639:trends; D013154:Spleen / Q000000981:diagnostic imaging / Q000293:injuries / Q000601:surgery*; D013156:Splenectomy / Q000379:methods* / Q000639:trends; D011795:Surveys and Questionnaires; D014057:Tomography, X-Ray Computed; D014194:Traumatology / Q000639:trends