Surveillance vs Intervention for Spleen Trauma: It’s a Toss-Up

For hemodynamically stable patients with splenic trauma at high risk of rupture, no significant difference in 30-day rates of splenic rescue and complications emerged between immediate prophylactic splenic embolization and wait-and-see surveillance, with embolization performed only when necessary, a randomized trial in France found.

A considerable number of patients assigned to initial surveillance, however, needed embolization within a few days — particularly those with higher-grade splenic injuries — thus increasing the median hospital stay in the surveillance arm, according to investigators in the Splenic Arterial Embolization to Avoid Splenectomy (SPLASH) study.

“In view of the high proportion of patients in the surveillance group needing [embolization], both strategies appear defendable,” Catherine Arvieux, MD, PhD, of Grenoble-Alpes University Hospital in France, and colleagues wrote online in JAMA Surgery.

They noted that the spleen is the organ most frequently affected by blunt abdominal trauma, with an incidence of approximately 40,000 splenic traumas per year in the U.S.

The study randomized patients with grade 3 or higher splenic injury to embolization or surveillance at 16 centers from February 2014 to September 2017.

Of 140 patients randomized, 133 were retained (median age 30 years, 105 men). For the primary endpoint of an intact spleen or at least 50% vascularized parenchyma on computed tomography, data from 117 patients (57 with embolization and 60 with surveillance) were available for analysis.

Among the results:

• The number of patients with at least a 50% viable spleen detected on CT at month 1 was not significantly different between the embolization and surveillance groups: 56 of 57 (98.2%) vs 56 of 60 (93.3%), for a difference of 4.9% (P=0.37)
• By the day 5 visit, there were significantly fewer splenic pseudoaneurysms among patients in the embolization group than in the surveillance group: 1 of 65 (1.5%) versus 8 of 65 (12.3%), for a difference of −10.8% (P=0.03)
• There were also significantly fewer secondary embolizations among patients in the embolization group than in the surveillance group: 1 of 65 (1.5%) versus 19 of 65 (29.2%), for a difference of −27.7% (P<0.001)
• During the entire follow-up period, four splenectomies were performed on days 0, 2, 6, and 44, for an overall rate of splenectomy of 3.3% (4 of 122)
• Overall complication rates were similar in the embolization and surveillance arms: 19 of 65 (29.2%) versus 27 of 65 (41.5%), translating to a difference of −12.3% (P=0.14). Between the day 5 and month 1 visits, the overall complication rate was not significantly different between the embolization and surveillance groups: 11 of 59 (18.6%) versus 12 of 63 (19.0%), difference −0.4% (P=0.96)
• Median length of hospitalization was significantly shorter with the embolization group versus surveillance: 9 days (IQR 6-14) versus 13 days (IQR 9-17; P=0.002)

Arvieux and colleagues concluded that performing control CT scans on or about day 5 and day 30, with subsequent embolization if necessary, would likely provide a good rate of spleen salvage for trauma patients at high risk of splenic rupture. But, they cautioned, such a strategy should be validated in further studies.

In an accompanying editorial, Lillian S. Kao, MD, MS, from the McGovern Medical School at University of Texas Health Science Center in Houston, and two colleagues observed that the SPLASH results do not point to one approach as superior across the board. “However, it does provide a starting point for discussions with patients to engage in shared decision-making,” the commentary indicates.

Patients at high risk for not being followed up (surveillance is challenging) or those with grade 4 or 5 injury might give serious consideration to prophylactic angioembolization, Kao and colleagues wrote. “In the meantime, the SPLASH trial is a refreshing and welcome addition to the observational studies informing the care of patients with blunt trauma.”

They commended the authors for addressing the controversy surrounding routine angioembolization for patients vulnerable to splenic rupture. “The high rate of splenic salvage with nonoperative management, regardless of angioembolization strategy, is reassuring,” they wrote.

They noted that the management of blunt splenic injury has evolved over time, with nonoperative approaches now recommended as an initial strategy for hemodynamically stable adults without peritonitis.

Addressing study limitations, the French investigators said they could not exclude the possibility of imbalances in unknown confounders between evaluable groups. Other limitations were the absence of an individual calculation of the irradiated volume to which patients in the two groups were exposed and the lack of medicoeconomic comparison of the two strategies.

In addition, the data available in 2012 when the study was designed led to an underestimation of the sample size. Another limitation was the possibility that outside of the context of a clinical trial, surveillance of post-trauma patients was not as rigorous as it should have been.