title: The contemporary management of penetrating splenic injury.
abstract: BACKGROUND
  Selective non-operative management (NOM) is standard of care for clinically stable patients with blunt splenic trauma and expectant management approaches are increasingly utilised in penetrating abdominal trauma, including in the setting of solid organ injury. Despite this evolution of clinical practice, little is known about the safety and efficacy of NOM in penetrating splenic injury.
  
  
  METHODS
  Trauma registry and medical record review identified all consecutive patients presenting to LAC+USC Medical Center with penetrating splenic injury between January 2001 and December 2011. Associated injuries, incidence and nature of operative intervention, local and systemic complications and mortality were determined.
  
  
  RESULTS
  During the study period, 225 patients experienced penetrating splenic trauma. The majority (187/225, 83%) underwent emergent laparotomy. Thirty-eight clinically stable patients underwent a deliberate trial of NOM and 24/38 (63%) were ultimately managed without laparotomy. Amongst patients failing NOM, 3/14 (21%) underwent splenectomy while an additional 6/14 (42%) had splenorrhaphy. Hollow viscus injury (HVI) occurred in 21% of all patients failing NOM. Forty percent of all NOM patients had diaphragmatic injury (DI). All patients undergoing delayed laparotomy for HVI or a splenic procedure presented symptomatically within 24h of the initial injury. No deaths occurred in patients undergoing NOM.
  
  
  CONCLUSIONS
  Although the vast majority of penetrating splenic trauma requires urgent operative management, a group of patients does present without haemodynamic instability, peritonitis or radiologic evidence of hollow viscus injury. Management of these patients is complicated as over half may remain clinically stable and can avoid laparotomy, making them potential candidates for a trial of NOM. HVI is responsible for NOM failure in up to a fifth of these cases and typically presents within 24h of injury. Delayed laparotomy, within this limited time period, did not appear to increase mortality nor preclude successful splenic salvage. In clinically stable patients, diagnostic laparoscopy remains essential to evaluate and repair occult DI. As NOM for penetrating abdominal trauma becomes more common, multi-centre data is needed to more accurately define the principles of patient selection and the limitations and consequences of this approach in the setting of splenic injury.
authors.affiliation: Los Angeles County Medical Center-University of Southern California, Division of Trauma Surgery and Surgical Critical Care, LAC+USC Medical Center, 2051 Marengo Street Inpatient Tower (C)-Room C5L100, Los Angeles, CA, United States.
authors.forename: Regan J
authors.initials: RJ
authors.lastname: Berg
authors.affiliation: Los Angeles County Medical Center-University of Southern California, Division of Trauma Surgery and Surgical Critical Care, LAC+USC Medical Center, 2051 Marengo Street Inpatient Tower (C)-Room C5L100, Los Angeles, CA, United States. Electronic address: kinaba@surgery.usc.edu.
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.affiliation: Los Angeles County Medical Center-University of Southern California, Division of Trauma Surgery and Surgical Critical Care, LAC+USC Medical Center, 2051 Marengo Street Inpatient Tower (C)-Room C5L100, Los Angeles, CA, United States.
authors.forename: Obi
authors.initials: O
authors.lastname: Okoye
authors.affiliation: Los Angeles County Medical Center-University of Southern California, Division of Trauma Surgery and Surgical Critical Care, LAC+USC Medical Center, 2051 Marengo Street Inpatient Tower (C)-Room C5L100, Los Angeles, CA, United States.
authors.forename: Jason
authors.initials: J
authors.lastname: Pasley
authors.affiliation: Los Angeles County Medical Center-University of Southern California, Division of Trauma Surgery and Surgical Critical Care, LAC+USC Medical Center, 2051 Marengo Street Inpatient Tower (C)-Room C5L100, Los Angeles, CA, United States.
authors.forename: Pedro G
authors.initials: PG
authors.lastname: Teixeira
authors.affiliation: Los Angeles County Medical Center-University of Southern California, Division of Trauma Surgery and Surgical Critical Care, LAC+USC Medical Center, 2051 Marengo Street Inpatient Tower (C)-Room C5L100, Los Angeles, CA, United States.
authors.forename: Michael
authors.initials: M
authors.lastname: Esparza
authors.affiliation: Los Angeles County Medical Center-University of Southern California, Division of Trauma Surgery and Surgical Critical Care, LAC+USC Medical Center, 2051 Marengo Street Inpatient Tower (C)-Room C5L100, Los Angeles, CA, United States.
authors.forename: Demetrios
authors.initials: D
authors.lastname: Demetriades
mesh_terms: D000007:Abdominal Injuries / Q000000981:diagnostic imaging* / Q000401:mortality / Q000628:therapy; D000328:Adult; D003657:Decision Making; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D007813:Laparotomy; D007902:Length of Stay / Q000706:statistics & numerical data; D018579:Patient Selection; D011859:Radiography; D012042:Registries; D013154:Spleen / Q000000981:diagnostic imaging / Q000293:injuries*; D013156:Splenectomy / Q000706:statistics & numerical data; D013997:Time Factors; D014193:Trauma Centers; D016896:Treatment Outcome; D014950:Wounds, Penetrating / Q000000981:diagnostic imaging* / Q000401:mortality / Q000628:therapy
keywords: Clinical decision-making; Penetrating trauma; Selective non-operative management; Splenic injury