Huang Wei, Braschi Caitlyn, Jin Feifei, Lewis Meghan, Demetriades Demetrios
Division of Trauma and Acute Care Surgery, Department of Surgery, Los Angeles General Medical Center, Los Angeles, California.
Peking University People's Hospital, Trauma Center, Beijing, China.
JAMA Netw Open. 2025 Sep 2;8(9):e2533266. doi: 10.1001/jamanetworkopen.2025.33266.
Management of blunt splenic injury is evolving toward wider use of nonoperative approaches for splenic salvage, and splenic angioembolization (SAE) is being considered even in patients with hypotension on admission. Research is needed to understand the outcomes of these evolving management strategies.
To compare outcomes of the 3 major treatments approaches for splenic injury.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was performed using the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database from January 1, 2017, to December 31, 2022. The database collects injury data from more than 815 trauma centers in the US. Adults with isolated, severe (Abbreviated Injury Scale score ≥3) blunt splenic injury were identified. Isolated splenic injury was defined by the absence of other intra-abdominal injury and any other major associated injuries with an Abbreviated Injury Scale score of 3 or higher. Data analysis was performed from September to December 2024.
Open splenectomy (OS) vs SAE vs observation.
The primary outcomes were mortality and any complication. Outcomes were compared using multivariable Cox proportional hazards regression analyses.
A total of 7567 patients (median [IQR] age, 36 [25-55] years; 4901 men [64.8%]) were studied, including 1499 (19.8%) in the OS group, 1547 (20.4%) in the SAE group, and 4521 (59.7%) in the observation group. In multivariable analysis, there was no difference in mortality in the overall cohort or in subgroups. Morbidity was significantly lower in the SAE (odds ratio [OR], 0.61; 95% CI, 0.45-0.81; P < .001) and observation (OR, 0.71; 95% CI, 0.55-0.92; P = .01) groups compared with the OS group. Among patients with hypotension, there was no mortality difference, but shorter hospital length of stay was found in the SAE (β = -1.44; 95% CI, -1.79 to -1.09; P < .001) and observation (β = -1.41; 95% CI, -1.73 to -1.09; P < .001) groups. Compared with initial OS, morbidity was higher for patients in whom SAE (OR, 5.39; 95% CI, 3.39-8.57; P < .001) and observation (OR, 1.95; 95% CI, 1.44-2.64; P < .001) failed, and hospital length of stay was longer for these groups as well (β = 2.50; 95% CI, 1.27-3.73; P < .001 and β = 0.71; 95% CI, 0.07-1.35; P = .03, respectively).
In this retrospective cohort study, nonoperative management (SAE or observation) was associated with favorable outcomes when compared with OS in isolated severe blunt splenic injury, even in patients with hypotension on admission. Failure of nonoperative management, however, risked higher morbidity without associated increase in mortality. With careful patient selection, splenic salvage may be possible and preferred even in severely injured patients.
钝性脾损伤的管理正朝着更广泛地采用非手术方法进行脾脏挽救发展，甚至对于入院时低血压的患者也在考虑进行脾血管栓塞术（SAE）。需要开展研究以了解这些不断演变的管理策略的结果。
比较脾损伤的3种主要治疗方法的结果。
设计、设置和参与者：使用美国外科医师学会创伤质量改进计划（ACS-TQIP）数据库进行了一项回顾性队列研究，时间跨度为2017年1月1日至2022年12月31日。该数据库收集了美国815多个创伤中心的损伤数据。纳入了患有孤立性、严重（简明损伤定级评分≥3）钝性脾损伤的成年人。孤立性脾损伤的定义为不存在其他腹腔内损伤以及任何其他简明损伤定级评分为3或更高的主要相关损伤。数据分析于2024年9月至12月进行。
开放性脾切除术（OS）与SAE与观察。
主要结局为死亡率和任何并发症。使用多变量Cox比例风险回归分析比较结局。
共研究了7567例患者（年龄中位数[四分位间距]为36[25 - 55]岁；4901例男性[64.8%]），其中OS组1499例（19.8%），SAE组1547例（20.4%），观察组4521例（59.7%）。在多变量分析中，总体队列或亚组中的死亡率无差异。SAE组（比值比[OR]，0.61；95%置信区间[CI]，0.45 - 0.81；P < 0.001）和观察组（OR，0.71；95% CI，0.55 - 0.92；P = 0.01）的发病率显著低于OS组。在低血压患者中，死亡率无差异，但SAE组（β = - 1.44；95% CI， - 1.79至 - 1.09；P < 0.001）和观察组（β = - 1.41；95% CI， - 1.73至 - 1.09；P < 0.001）的住院时间较短。与初始OS相比，SAE组（OR，5.39；95% CI，3.39 - 8.57；P < 0.001）和观察组（OR，1.95；95% CI，1.44 - 2.64；P < 0.001）治疗失败的患者发病率更高，且这些组的住院时间也更长（分别为β = 2.50；95% CI，1.27 - 3.73；P < 0.001和β = 0.71；95% CI，0.07 - 1.35；P = 0.03）。
在这项回顾性队列研究中，与OS相比，非手术治疗（SAE或观察）在孤立性严重钝性脾损伤中，即使对于入院时低血压的患者也具有良好的结局。然而，非手术治疗失败会有更高的发病率风险，且死亡率无相关增加。通过仔细选择患者，即使是严重受伤的患者也可能且更倾向于进行脾脏挽救。
