Splenic trauma: WSES classification and guidelines for adult and pediatric patients
Coccolini et al. World Journal of Emergency Surgery
Splenic trauma: WSES classification and guidelines for adult and pediatric patients
Federico Coccolini 0
Giulia Montori 0
Fausto Catena 19
Yoram Kluger 18
Walter Biffl 24
Ernest E. Moore 23
Viktor Reva 22
Camilla Bing 21
Miklosh Bala 26
Paola Fugazzola 0
Hany Bahouth 18
Ingo Marzi 25
George Velmahos 20
Rao Ivatury 8
Kjetil Soreide 9
Tal Horer 6
Richard ten Broek 7
Bruno M. Pereira 4
Gustavo P. Fraga 4
Kenji Inaba 5
Joseph Kashuk 2
Neil Parry 3
Peter T. Masiakos 1
Konstantinos S. Mylonas 1
Andrew Kirkpatrick 11
Fikri Abu-Zidan 10
Carlos Augusto Gomes 12
Simone Vasilij Benatti 14
Noel Naidoo 15
Francesco Salvetti 0
Stefano Maccatrozzo 0
Vanni Agnoletti 16
Emiliano Gamberini 16
Leonardo Solaini 0
Antonio Costanzo 0
Andrea Celotti 0
Matteo Tomasoni 0
Vladimir Khokha 17
Michele Pisano 0
Stefano Magnone 0
David A. Spain
Marc de Moya 20
Kimberly A. Davis
Nicola De Angelis
Paula Ferrada 20
David Costa Navarro
Ronald V. Maier
Joseph M. Galante
Alain Chichom Mefire
Marco Ceresoli 0
Andrew B. Peitzman
Salomone Di Saverio
Luca Ansaloni 0
0 General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital , P.zza OMS 1, 24128 Bergamo , Italy
1 Pediatric Trauma Service, Massachusetts General Hospital , Boston, MA , USA
2 Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine , Tel Aviv , Israel
3 General and Trauma Surgery Department, London Health Sciences Centre, Victoria Hospital , London, ON , Canada
4 Trauma/Acute Care Surgery and Surgical Critical Care, University of Campinas , Campinas , Brazil
5 Division of Trauma and Critical Care , LAC
6 Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital and Örebro University , Orebro , Sweden
7 Department of Surgery, Radboud University Nijmegen Medical Center , Nijmegen , Netherlands
8 Virginia Commonwealth University , Richmond, VA , USA
9 Department of Gastrointestinal Surgery, Stavanger University Hospital , Stavanger , Norway
10 Department of Surgery, College of Medicine and Health Sciences, UAE University , Al-Ain , United Arab Emirates
11 General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre , Calgary, AB , Canada
12 Universidade Federal de Juiz de Fora , Juiz de Fora , Brazil
13 USC Medical Center , Los Angeles, CA , USA
14 Infectivolgy Department, Papa Giovanni XXIII Hospital , Bergamo , Italy
15 Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
16 Anesthesia Department, Bufalini Hospital , Cesena , Italy
17 General Surgery Department, Mozir City Hospital
18 Division of General Surgery, Rambam Health Care Campus , Haifa , Israel
19 Emergency and Trauma Surgery, Maggiore Hospital , Parma , Italy
20 Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, MA , USA
21 General and Emergency Surgery Department, Empoli Hospital , Empoli , Italy
22 General and Emergency Surgery, Sergei Kirov Military Academy , Saint Petersburg , Russia
23 Trauma Surgery, Denver Health Medical Center , Denver, CO , USA
24 Acute Care Surgery, The Queen's Medical Center , Honolulu, HI , USA
25 Klinik für Unfall-, Handund Wiederherstellungschirurgie Universitätsklinikum Goethe-Universität Frankfurt , Frankfurt , Germany
26 General and Emergency Surgery, Hadassah Medical Center , Jerusalem , Israel
Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.
Spleen; Trauma; Adult; Pediatric; Classification; Guidelines; Embolization; Surgery; Non-operative; Conservative
The management of splenic trauma has changed
considerably in the last few decades especially in favor of
non-operative management (NOM). NOM ranges
from observation and monitoring alone to
angiography/angioembolization (AG/AE) with the aim to
preserve the spleen and its function, especially in
children. These considerations were carried out
considering the immunological function of the spleen and
the high risk of immunological impairment in
splenectomized patients. In contrast with liver traumatic
injuries, splenic injuries can be fatal not only at the
admission of the patient to the Emergency Department
(ED), but also due to delayed subcapsular hematoma
rupture or pseudoaneurism (PSA) rupture. Lastly,
overwhelming post-splenectomy infections (OPSI) are a late
cause of complications due to the lack of the
immunological function of the spleen. For these reasons,
standardized guidelines in the management of splenic
trauma are necessary.
The existing classification of splenic trauma considered
the anatomical lesions (Table 1). However, patients’
conditions may lead to an emergent transfer to the operating
room (OR) without the opportunity to define the grade of
the splenic lesions before the surgical exploration. This
confirms the primary importance of the patient’s overall
clinical condition in these settings. In addition, the
modern tools in bleeding management have helped in
adopting a conservative approach also in severe
lesions. Trauma management must be multidisciplinary
and requires an assessment of both the anatomical
injury and its physiologic effects. The present guidelines
and classification reconsider splenic lesions in the
light of the physiopathologic status of the patient
associated with the anatomic grade of injury and the
other associated lesions.
Notes on the use of the guidelines
The guidelines are evidence-based, with the grade of
recommendation also based on the evidence. The
guidelines present the diagnostic and therapeutic methods for
optimal management of spleen trauma. The practice
guidelines promulgated in this work do not represent a
standard of practice. They are suggested plans of care,
based on best available evidence and the consensus of
experts, but they do not exclude other approaches as
being within the standard of practice. For example, they
should not be used to compel adherence to a given
method of medical management, which method should
be finally determined after taking account of the
conditions at the relevant medical institution (staff levels,
experience, equipment, etc.) and the characteristics of the
individual patient. However, responsibility for the results
of treatment rests with those who are directly engaged
therein, and not with the consensus group.
A computerized search was done by the bibliographer in
different databanks (MEDLINE, Scopus, EMBASE)
citations were included for the period between January 1980
and May 2016 using the primary search strategy: spleen,
injuries, trauma, resuscitation, adult, pediatric, hemodynamic
instability/stability, angioembolization, management,
infection, follow-up, vaccination, and thrombo-prophylaxis
combined with AND/OR. No search restrictions were imposed.
The dates were selected to allow comprehensive
published abstracts of clinical trials, consensus conference,
comparative studies, congresses, guidelines,
government publication, multicenter studies, systematic
reviews, meta-analysis, large case series, original articles,
and randomized controlled trials. Case reports and
small cases series were excluded. Narrative review
articles were also analyzed to determine other possible
studies. Literature selection is reported in the flow
chart (Fig. 1). The Level of evidence (LE) was evaluated
using the GRADE system [
] (Table 2).
A group of experts in the field coordinated by a
central coordinator was contacted to express their
evidence-based opinion on several issues about the
pediatric (< 15 years old) and adult splenic trauma.
Splenic trauma were divided and assessed as type of
injury (blunt and penetrating injury) and management
(conservative and operative management). Through
the Delphi process, the different issues were discussed
in subsequent rounds. The central coordinator
assembled the different answers derived from each round.
Each version was then revised and improved. The
definitive version was discussed during the WSES World
Congress in May 2017 in Campinas, Brazil. The final
version about which the agreement was reached
resulted in present paper.
The WSES position paper suggested to group splenic
injury into minor, moderate, and severe. This classification
has not previously been clearly defined by the literature.
Frequently low-grade AAST lesions (i.e., grades I–III) are
considered as minor or moderate and treated with NOM.
However, hemodynamically stable patients with high-grade
lesions could be successfully treated non-operatively,
especially exploiting the more advanced tools for bleeding
management. On the other hand, “minor” lesions associated
with hemodynamic instability often must be treated with
OM. This demonstrates that the classification of spleen
injuries into minor and major must consider both the
anatomic AAST-OIS classification and the hemodynamic
The WSES classification divides spleen injuries into
Minor spleen injuries:
WSES class I includes hemodynamically stable
AAST-OIS grade I–II blunt and penetrating lesions.
Moderate spleen injuries:
– Minor (WSES class I)
– Moderate (WSES classes II and III)
– Severe (WSES class IV)
The classification considers the AAST-OIS
classification and the hemodynamic status and is the same
for adult and pediatric patients. Table 3 explains the
classification with the different key points of treatment
differentiated within adult and pediatric patients; Table
4 resumes the guidelines statements.
WSES class II includes hemodynamically stable
AAST-OIS grade III blunt and penetrating lesions.
WSES class III includes hemodynamically stable
AAST-OIS grade IV–V blunt and penetrating
Severe spleen injuries:
WSES class IV includes hemodynamically unstable
AAST-OIS grade I–V blunt and penetrating lesions.
Based on the present classification, WSES suggests
two management algorithms for both adult and pediatric
patients explained in Figs. 2 and 3.
Physiopathology of injuries
Some mechanisms of injuries are similar between
children and adults like motor vehicle crashes and
pedestrian accidents, while others like motorcycle accidents,
sport injuries, gunshot or stab-related injuries, and
assaults are more frequent in adults [
A few authors consider a normal hemodynamic status
in adults when the patient does not require fluids or
blood to maintain blood pressure, without signs of
hypoperfusion; hemodynamic stability in adults as a
counterpart is the condition in which the patient achieve a
constant or an amelioration of blood pressure after
fluids with a blood pressure > 90 mmHg and heart rate
< 100 bpm; hemodynamic instability in adults is the
condition in which the patient has an admission systolic
blood pressure < 90 mmHg, or > 90 mmHg but requiring
bolus infusions/transfusions and/or vasopressor drugs
and/or admission base excess (BE) > −5 mmol/l and/or
shock index > 1 [
] and/or transfusion requirement of
RCTs without important limitations
or overwhelming evidence from
Weak recommendation, best action may
differ depending on the patient, treatment
circumstances, or social values
RCTs with important limitations Weak recommendation, best action may
(inconsistent results, methodological differ depending on the patient, treatment
flaws, indirect or imprecise) or circumstances, or social values
exceptionally strong evidence from
Observational studies or case series Very weak recommendation; alternative
treatments may be equally reasonable and
at least 4–6 units of packed red blood cells within the
first 24 h [
]. The 9th edition of the Advanced Trauma
Life Support (ATLS) definition considers as “unstable” the
patient with the following: blood pressure < 90 mmHg
and heart rate > 120 bpm, with evidence of skin
vasoconstriction (cool, clammy, decreased capillary refill), altered
level of consciousness and/or shortness of breath [
Moreover, transient responder patients (those showing an
initial response to adequate fluid resuscitation and then
signs of ongoing loss and perfusion deficits) and, more
in general, those responding to therapy but not
amenable of sufficient stabilization to be undergone to
interventional radiology treatments, are to be considered as
unstable patients. In the management of severe
bleeding, the early evaluation and correction of the
traumainduced coagulopathy remains a main cornerstone.
Physiologic impairment is frequently associated with
aggressive resuscitation and the activation and
deactivation of several procoagulant and anticoagulant factors
contributes to the insurgence of trauma-induced
coagulopathy. The application of massive transfusion
protocols (MTP) is of paramount importance. The advanced
tailored evaluation of the patient’s coagulative asset is
clearly demonstrated as fundamental in driving the
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-The choice of diagnostic technique at admission must be based
on the hemodynamic status of the patient (GoR 1A).
-E-FAST is effective and rapid to detect free fluid (GoR 1A).
-CT scan with intravenous contrast is the gold standard in
hemodynamically stable or stabilized trauma patients (GoR 1A).
-Doppler US and contrast-enhanced US are useful to evaluate
splenic vascularization and in follow-up (GoR 1B).
-Injury grade on CT scan, extent of free fluid, and the presence
of PSA do not predict NOM failure or the need of OM (GoR 1B).
and need for blood transfusions should be taken into account,
but they are not absolute contraindications for NOM (GoR 2B).
-In WSES class II–III spleen injuries with associated severe traumatic
brain injury, NOM could be considered only if rescue therapy
(OR and/or AG/AE) is rapidly available; otherwise, splenectomy
should be performed (GoR 1C).
-AG/AE may be performed in hemodynamically stable and rapid
responder patients with moderate and severe lesions and in those
with vascular injuries at CT scan (contrast blush, pseudo-aneurysms
and arterio-venous fistula) (GoR 2A).
-In patients with bleeding vascular injuries and in those with
intraperitoneal blush, AG/AE should be performed as part of
NOM only in centers where AG/AE is rapidly available. In other
centers and in case of rapid hemodynamic deterioration, OM
should be considered (GoR 2B).
-In case of absence of blush during angiography, if blush was
previously seen at CT scan, proximal angioembolization could be
considered (GoR 2C).
–AG/AE should be considered in all hemodynamically stable
patients with WSES grade III lesions, regardless with the
presence of CT blush (GoR 1B).
–AG/AE could be considered in patients undergone to NOM,
hemodynamically stable with sings of persistent hemorrhage
regardless with the presence of CT blush once excluded
extrasplenic source of bleeding (GoR 1C).
–Hemodynamically stable patients with WSES grade II lesions
without blush should not underwent routine AG/AE but may be
considered for prophylactic proximal embolization in presence
of risk factors for NOM failure (GoR 2B).
–In the presence of a single vascular abnormality (contrast blush,
pseudo-aneurysms, and artero-venous fistula) in minor and
moderate injuries, the currently available literature is inconclusive
regarding whether proximal or distal embolization should be
used. In the presence of multiple splenic vascular abnormalities
or in the presence of a severe lesion, proximal or combined
AG/AE should be used, after confirming the presence of a
permissive pancreatic vascular anatomy (GoR 1C).
–In performing, AG/AE coils should be preferred to temporary
agents (GoR 1C).
-No sufficient data validating NOM for penetrating
spleen injury in children exist.
-The vast majority of pediatric patients do not
require AG/AE for CT blush or moderate to severe
injuries (GoR 1C).-AG/AE may be considered in
patients undergone to NOM, hemodynamically
stable with sings of persistent hemorrhage not
amenable of NOM, regardless with the presence
of CT blush once excluded extra-splenic source
of bleeding (GoR 1C).
-AG/AE may be considered for the treatment
of post-traumatic splenic pseudo-aneurysms
prior to patient discharge (GoR 2C).
-Patients with more than 15 years old should
be managed according to adults AG/AE-protocols
-OM should be performed in patients with hemodynamic -Patients should undergo to OM in case of
instability and/or with associated lesions like peritonitis or bowel hemodynamic instability, failure of conservative
evisceration or impalement requiring surgical exploration treatments, severe coexisting injuries necessitating
(GoR 2A). intervention and peritonitis, bowel evisceration,
-OM should be performed in moderate and severe lesions even impalement (GoR 2A).
in stable patients in centers where intensive monitoring cannot -Splenic preservation (at least partial) should be
be performed and/or when AG/AE is not rapidly available (GoR 2A). attempted whenever possible (GoR 2B).
-Splenectomy should be performed when NOM with AG/AE
failed, and patient remains hemodynamically unstable or shows
a significant drop in hematocrit levels or continuous transfusion
are required (GoR 2A).
–During OM, salvage of at least a part of the spleen is debated
and could not be suggested (GoR 2B).
–Laparoscopic splenectomy in early trauma scenario in bleeding
patients could not be recommended (GoR 2A).
–Clinical and laboratory observation associated to bed rest in
moderate and severe lesions is the cornerstone in the first 48–72
h follow-up (GoR 1C).
–CT scan repetition during the admission should be considered
in patients with moderate and severe lesions or in decreasing
hematocrit, in presence of vascular anomalies or underlying
splenic pathology or coagulopathy, and in neurologically impaired
patients (GoR 2A).
–In hemodynamic stable children without drop
in hemoglobin levels for 24 h, bed rest should
be suggested (GoR 2B).
–The risk of pseudo-aneurysm after splenic
trauma is low, and in most of cases, it resolves
spontaneously (GoR 2B).
–Angioembolization should be taken into
consideration when a pesudoaneurysm is found
–US (DUS, CEUS) follow-up seems reasonable to
minimize the risk of life-threatening hemorrhage
and associated complications in children (GoR 1B).
–After NOM in moderate and severe injuries,
the reprise of normal activity could be considered
safe after at least 6 weeks (GoR 2B).
–Mechanical prophylaxis is safe and should be considered in all
patients without absolute contraindication to its use (GoR 2A).
– Spleen trauma without ongoing bleeding is not an absolute
contraindication to LMWH-based prophylactic anticoagulation
–LMWH-based prophylactic anticoagulation should be started as
soon as possible from trauma and may be safe in selected patients
with blunt splenic injury undergone to NOM (GoR 2B).
–In patient with oral anticoagulants the risk-benefit balance of
reversal should be individualized (GoR 1C).
–Patients should receive immunization against the encapsulated
bacteria (S. pneumoniae, H. influenzae, and N. meningitidis) (GoR 1A).
–Vaccination programs should be started no sooner than 14 days
after splenectomy or spleen total vascular exclusion (GoR 2C).
–In patients discharged before 15 days after splenectomy or
angioembolization, where the risk to miss vaccination is deemed
high, the best choice is to vaccinate before discharge (GoR 1B).
–Immunization against seasonal flu is recommended for patients
over 6 months of age (GoR 1C).
–Malaria prophylaxis is strongly recommended for travelers
–Antibiotic therapy should be strongly considered in the event
of any sudden onset of unexplained fever, malaise, chills or
other constitutional symptoms, especially when medical review
is not readily accessible (GoR 2A).
–Primary care providers should be aware of the splenectomy/
angioembolization (GoR 2C).
administration of blood products, coagulation factors,
and drugs [
– The choice of diagnostic technique at admission must
be based on the hemodynamic status of the patient
– E-FAST is effective and rapid to detect free fluid
– CT scan with intravenous contrast is the gold
standard in hemodynamically stable or stabilized
trauma patients (GoR 1A).
– Doppler US and contrast-enhanced US are useful
to evaluate splenic vascularization and in
followup (GoR 1B).
– Injury grade on CT scan, extent of free fluid, and the
presence of PSA do not predict NOM failure or the
need of OM (GoR 1B).
Extended focused assessment sonography for trauma
(E-FAST) and ultrasonography (US) have replaced
diagnostic peritoneal lavage (DPL) management of abdominal
trauma in present days [
5, 10, 11
]. Studies have shown a
sensitivity up to 91% and a specificity up to 96% also for a
small fluid amount [
Nevertheless, 42% of false-negative have been
]. This might be due to the 20% of cases in
which no significant extravasation of blood is present
in splenic trauma or in injuries near the diaphragm
10, 12, 13
Contrast-enhanced US (CEUS) increases the vi
sualization of a variety of splenic injuries and
Doppler US (DUS) has been reported as safe and
effective in evaluating PSA or blush previously found at
CT scan [
Contrast tomography (CT) scan is considered the gold
standard in trauma with a sensitivity and specificity for
splenic injuries near to 96–100% [
10, 15, 16
Carr et al. [
] reported that CT scan can underestimate
splenic injuries at ilum. CT must be rapidly available
and must be performed only in hemodynamically stable
patients or in those responding to fluid resuscitation
]. However, in some centers, there is the
possibility to perform a fast-track CT scan that seems to
permit to expand the criteria for performing CT scan in
trauma patients. Delayed-phase CT helps in
differentiating patients with active bleeding from those with
contained vascular injuries . This is important to
reduce the risk of discrepancy between CT scan images
and angio images (only 47% of patients have a
confirmation of the CT findings at angio) [
]. Active contrast
extravasation is a sign of active hemorrhage [
use of CT helps in surgical procedure and in AG/AE to
be more selective [
]. Contrast blush occurs in
about 17% of cases and has been demonstrated to be an
important predictor of failure of NOM (more than 60%
of patients with blush failed NOM). Its absence on
initial CT scan in high-grade splenic injuries does not
definitively exclude active bleeding and should not preclude
15, 23, 24
]. Federle et al. showed that the
hemoperitoneum quantification is not related to the risk of
NOM failure .
Blunt and penetrating trauma:
– Patients with hemodynamic stability and absence of
other abdominal organ injuries requiring surgery
should undergo an initial attempt of NOM
irrespective of injury grade (GoR 2A).
– NOM of moderate or severe spleen injuries should be
considered only in an environment that provides
capability for patient intensive monitoring, AG/AE, an
immediately available OR and immediate access to
blood and blood product or alternatively in presence of
a rapid centralization system and only in patients with
stable or stabilized hemodynamic and absence of other
internal injuries requiring surgery (GoR 2A).
– NOM in splenic injuries is contraindicated in the
setting of unresponsive hemodynamic instability or
other indicates for laparotomy (peritonitis, hollow
organ injuries, bowel evisceration, impalement)
– In patients being considered for NOM, CT scan with
intravenous contrast should be performed to define
the anatomic spleen injury and identify associated
injuries (GoR 2A).
– AG/AE may be considered the first-line intervention in
patients with hemodynamic stability and arterial blush
on CT scan irrespective from injury grade (GoR 2B).
– Strong evidence exists that age above 55-years old,
high ISS, and moderate to severe splenic injuries are
prognostic factors for NOM failure. These patients
require more intensive monitoring and higher index
of suspicion (GoR 2B).
– Age above 55 years old alone, large hemoperitoneum
alone, hypotension before resuscitation, GCS
< 12, and low hematocrit level at the admission,
associated abdominal injuries, blush at CT
scan, anticoagulation drugs, HIV disease,
drug addiction, cirrhosis, and need for blood
transfusions should be taken into account, but
they are not absolute contraindications for
NOM (GoR 2B).
– In WSES classes II–III spleen injuries with associated
severe traumatic brain injury, NOM could be
considered only if rescue therapy (OR and/or AG/AE) is
rapidly available; otherwise, splenectomy should be
performed (GoR 1C).
NOM is considered the gold standard for the treatment
of patients with blunt splenic trauma (BST) who are
hemodynamically stable after an initial resuscitation, in
the absence of peritonitis and associated injuries
requiring laparotomy [
]. In high-volume centers with
all facilities, the successful rate of attempted NOM is
near 90% [
]. The advantages of NOM over OM were
described as lower hospital costs, avoidance of
nontherapeutic laparotomies, lower rates of intra-abdominal
complications and of blood transfusions, lower mortality
and the maintenance of the immunological function,
and the prevention of OPSI [
27, 30, 31
guidelines have agreed the non-indication of routine
laparotomy in hemodinamically stable patients with blunt
splenic injury [
NOM failure rate is reported to be between 4 and 15%
15, 29, 34–44
]. Several risk factors of NOM failure have
been reported [
15, 29, 34–54
In several studies, hemodynamic status at the
admission has not been considered a significant prognostic
indicator for NOM failure and, for this reason, should not
be considered an absolute contraindication for NOM
15, 29, 36, 40, 41
]. Others reported that the need for
red cell transfusions in ED or during the first 24 h
], hemoglobin and hematocrit levels at
admission , HIV disease, cirrhosis, and drug addiction
] could affect the outcome after NOM.
The presence of a blush at CT scan has been
considered a risk factor for NOM failure only in studies
in which AG/AE was not adopted [
addition, the extension of hemoperitoneum at imaging
alone cannot be considered an absolute
contraindication for NOM [
15, 19, 20, 40, 54
In AAST-OIS injury grades above IV, the failure rate
of NOM reaches 54.6% [
], while according to other
studies, patients with III–V injury grades could achieve a
87% of success rate [
Patients with higher ISS were more likely to fail NOM.
According to the literature, two ISS values which were
significantly associated with the failure of NOM were above
] or 25 [
]. This finding is in agreement with the
increased risk of associated lesions in higher ISS.
NOM failure in case of missed concomitant abdominal
injuries is reported in 1–2.5% of cases [
38, 41, 47, 48, 51, 58
GCS score below 12 alone should not be considered a
contraindication for NOM as these patients can be
successfully managed non-operatively with a reported
overall NOM failure rate near 4.5% [
15, 29, 40, 49
The risk of NOM failure in patients older than 55 years
is still debated. A few studies [
15, 35, 37, 38, 41, 44, 52, 54
found older age to be a significant prognostic factor
for NOM failure . On the other hand, other
29, 39, 43, 45, 50
] did not find significant
differences between patients ≤ 55 and > 55 years. It has
been suggested that age> 55 years could be a risk
factor for NOM failure only in high AAST-OIS injury
36, 38, 49
]. Furthermore, the failure of NOM
in older patients has been found to be associated with
higher mortality rates and longer length of hospital
stay than patients < 55 years [
Some authors suggested a primary OM in the presence
of hypotension in the ED, more than five red blood cell
transfused, GCS < 11, high ISS, abdominal AIS > 3, age
> 55, and spleen AAST-OIS injury grade > 3. However, it
has also been demonstrated that NOM could be
successful also in high-risk patients without an increase in
complications or mortality rates related to delayed operative
According to larger studies on patients with BST [
in level I trauma centers, NOM success rate is higher
than in level II or III centers. Nevertheless, some authors
stated that this might not be associated with the failure
of NOM [
Finally, severe unstable spleen injuries could ideally
benefit from a resuscitation in a hybrid OR with trauma
surgeons, in order to increase the spleen salvage rate [
Laparotomy has been the gold standard in penetrating
abdominal trauma. Several studies demonstrated as the
rate of negative laparotomy ranges between 9 and 14%
]. For the last 20 years, there has been an
increased number of approaches with NOM for gunshot
and stab injuries [
Carlin et al. in a large series compared penetrating
splenic trauma (248 patients) with blunt trauma and
found that mortality was not significantly different [
However, when the authors compared GSW and SW
versus blunt splenic trauma, they found a significant
difference in mortality (24 versus 15%, p = 0.02).
Pancreatic, diaphragmatic, and colic injuries significantly
increase the rate of OM approach and mortality for septic
complications. The associated pancreatic injuries require
frequently spleno-pancreatectomy [
]. Demetriades et
al. showed in a prospective study with 225 patients with
penetrating splenic injury, the direct relationship
between the degree of injury and the possibility of NOM
vs. emergency laparotomy [
]. Emergency laparotomy
rate was 33% in grade I lesions, and it could increase up
to 84% in the grade IV; all splenectomies were in injuries
with grade III or higher.
Indication to angiography and angioembolization:
– AG/AE may be performed in hemodynamically
stable and rapid responder patients with moderate
and severe lesions and in those with vascular injuries
at CT scan (contrast blush, pseudo-aneurysms and
arterio-venous fistula) (GoR 2A).
– In patients with bleeding vascular injuries and in
those with intraperitoneal blush, AG/AE should be
performed as part of NOM only in centers where
AG/AE is rapidly available. In other centers and in
case of rapid hemodynamic deterioration, OM
should be considered (GoR 2B).
– In case of absence of blush during angiography, if
blush was previously seen at CT scan, proximal
angioembolization could be considered (GoR 2C).
– AG/AE should be considered in all hemodynamically
stable patients with WSES class III lesions, regardless
the presence of CT blush (GoR 1B).
– AG/AE could be considered in patients undergone to
NOM, hemodynamically stable with sings of
persistent hemorrhage regardless the presence of CT
blush once excluded extra-splenic source of bleeding
– Hemodynamically stable patients with WSES class II
lesions without blush should not underwent routine
AG/AE but may be considered for prophylactic
proximal embolization in presence of risk factors for
NOM failure (GoR 2B).
– In presence of a single vascular abnormality (contrast
blush, pseudo-aneurysms and artero-venous fistula)
in minor and moderate injuries the currently
available literature is inconclusive regarding whether
proximal or distal embolization should be used. In
presence of multiple splenic vascular abnormalities
or in presence of a severe lesion, proximal or
combined AG/AE should be used, after confirming the
presence of a permissive pancreatic vascular anatomy
– In performing AG/AE coils should be preferred to
temporary agents (GoR 1C).
The reported success rate of NOM with AG/AE ranges
from 86 to 100% with a success rate of AG/AE from 73 to
]. In a large study, Haan et al. suggested that
indications to AG/AE were pseudo-aneurysms (PSA) or
active bleeding at admission CT scan, significant
hemoperitoneum, and high-grade splenic injury [
than 80% of grade IV–V splenic injuries were successfully
managed non-operatively with AG/AE. A large
multicenter study [
] on 10,000 patients found that AG/AE was
associated with a reduced odds of splenectomy and that
the earlier AG/AE was performed; the less number of
patients had splenectomy. A multi-institutional study by
Banerjee et al. demonstrated that level I trauma center
that had AG/AE rates greater than 10% had significantly
higher spleen salvage rates and fewer NOM failure,
especially for AAST-OIS grade III–IV injured spleen. AG/AE
was also found as an independent predictor of spleen
salvage and mortality reduction [
A few meta-analyses showed a significant
improvement in NOM success following introduction of AG/
AE protocols (OR 0.26, 95% CI 0.13–0.53, p < 0.002)
]. The failure rate without AG/AE is
significantly higher than with AG/AE in AAST-OIS grade
IV–V injuries (43.7 vs. 17.3%, p = 0.035, and 83.1 vs.
25.0%, p = 0.016, respectively) .
Specific CT findings can help in the therapeutic
decision, and they are correlated with outcomes. As such,
patients with PSA and arterovenous fistula showed
higher NOM failure rates [
21, 22, 53, 83–90
NOM failure in the presence of contrast blush treated
without AG/AE ranges between 67 and 82% [
Shanmuganathan et al. reported an 83% accuracy of
blush in predicting the need for AG/AE . Marmery
et al. showed a 4% of active bleeding vascular injuries in
AAST-OIS grade I–II splenic injuries [
Intraperitoneal splenic blush exhibited a significantly higher
percentage of hemodynamic deterioration during the time
required for AG/AE than intra-parenchymal bleedings
(p < 0.001), suggesting intraperitoneal blush as an
independent risk factor for OM .
Between 2.3 and 47% CT detected, contrast blush
could not be confirmed at the subsequent angiography
]. The presence of a vascular injury is significantly
associated with the splenic injury grade (p < 0.0001) .
Moreover an analysis on 143 patients with blush at CT
scan suggested that an angiographic procedure without
embolization increases twofold the risk of re-bleeding
and NOM failure [
The indication for routine prophylactic AG/AE in
high-grade splenic injuries is a matter of controversy
23, 68, 70, 74, 85, 91–93
]. Several retrospective and
prospective studies recommended the use of AG/AE in all
hemodynamically stable patients with high-grade splenic
]. NOM failure rates both with and
without prophylactic AG/AE for high-grade injuries are
0–42% vs. 23–67%, respectively, [
23, 68, 70, 74, 85, 91
Controversies exist regarding which kind of lesions
should be considered as “high-grade” (AAST III–V
or IV–V grade) and should undergo routine AG/AE
23, 68, 91, 92
]. It has been reported that NOM
could fail in up to 3% of grade III lesions without blush
with no AG/AE . Furthermore, no outcome
deterioration (in terms of NOM failure, rate of re-bleeding,
complications, and mortality) was detected after excluding
grade III injuries from routine AG/AE protocol [
Therefore, considering the AG/AE-related morbidity of
47% (versus 10% related to NOM without AG/AE) [
and the fact that widening the selection criteria for AG/
AE from grades IV–V to grades III–V may slightly
decrease the overall NOM failure rate, patients with
grade III lesions without blush should not undergo
To date, no randomized comparing proximal and
distal embolization are available [
]. In a meta-analysis
including 15 retrospective studies, proximal and distal
embolization was found to be equivalent with regard to
the incidence of major infarctions, infections, and major
]. However, a significant higher rate of
overall minor complications was found after distal AE
(2.8–11.6% versus 15.9–25.2%) [
Several studies analyzed the morbidity related to AG/
AE, to OM, and to NOM without AG/AE [
23, 68, 70,
]. The AG/AE major morbidity rates range from
3.7 to 28.5% including re-bleeding, total or subtotal
splenic infarction, splenic abscesses, acute renal
insufficiency, pseudocysts, and puncture-related complications.
The rates for minor morbidities range from 23 to 61%,
and they included fever, pleural effusion, coil migration,
and partial splenic infarction [
70, 96, 102, 103
97, 98, 101
], but one  reported significantly
higher complication rates in patients undergone OM
(increased rate of death, infectious complications, pleural
drainage, acute renal failure, and pancreatitis). In
particular, the incidence of infectious complications was
significantly higher in the splenectomy group (observation
4.8%, AG/AE 4.2%, splenorrhaphy 10.5%, splenectomy
32.0%, p = 0.001) [
Some studies analyzed the cost of NOM and AG/AE
]. They observed that NOM is safe and cost
effective, and AG/AE is similar to surgical therapy
with regard to cost.
Lastly, AG/AE does not seem to totally compromise
the splenic function, and even in presence of an elevated
leukocyte and platelet counts, no significant differences
in immunoglobulin titers were found between splenic
artery AG/AE patients and controls [
]. The spleen due
to its intense vascularization could assure the necessary
blood to continue its immunological function.
Blunt trauma and penetrating:
– OM should be performed in patients with
hemodynamic instability and/or with associated
lesions like peritonitis or bowel evisceration or
impalement requiring surgical exploration (GoR 2A).
– OM should be performed in moderate and severe
lesions even in stable patients in centers where
intensive monitoring cannot be performed and/or
when AG/AE is not rapidly available (GoR 2A).
– Splenectomy should be performed when NOM with
AG/AE failed and patient remains hemodynamicaly
unstable or shows a significant drop in hematocrit
levels or continuous transfusion are required
– During OM, salvage of at least a part of the spleen is
debated and could not be suggested (GoR 2B)
– Laparoscopic splenectomy in early trauma scenario
in bleeding patients could not be recommended
Operative management (OM) of splenic injuries
should be performed in non-responder hemodynamic
instable patients. This condition is frequently observed
in high-ISS trauma, in high-grade lesions, and in patients
with associated lesions. However, it can be also required
in low volume trauma centers or peripheral centers where
no intensive care unit or intensive monitoring can be
13, 105, 106
]. It has been reported that isolated
splenic injury is about 42% of all abdominal trauma [
Multiple injuries are reported near 20–30% [
sufficient data are available about concomitant vascular
and splenic injuries. Associated hollow viscus injuries
could be found in 5% of cases; the severity of splenic
injury seems to be related to the incidence of hollow viscus
injury (1.9, 2.4, 4.9, and 11.6% in minor, moderate, major,
and massive injuries, respectively) [
The use of splenectomy is decreasing, and the use of
splenorrhaphy is rarely adopted (35–24% and 6–1%,
]. The attempt to perform a partial
splenic salvage is reported in 50–78% of cases, but
when NOM fails, splenectomy is the preferred
Laparoscopic splenectomy for trauma is reported only
in some cases of hemodynamically stable low-moderate
grade splenic injuries [
The use of splenic autologous transplantation (i.e.,
voluntarily leaving pieces of spleen inside the abdomen),
to avoid infective risk from splenectomy, has been
investigated, but no reduction of morbidity or mortality has
been demonstrated [
The reported overall hospital mortality of splenectomy
in trauma is near 2%, and the incidence of
postoperative bleeding after splenectomy, ranges from 1.6 to
3%, but with mortality near to 20% [
Spleen injuries with concomitant spinal and brain injuries
Particular attention should be posed in managing
hemodynamically stable patients with blunt spinal
trauma (BST) and severe traumatic brain injury (STBI).
A recent study in patients with concomitant spinal and/
or brain associated to AAST-OIS grade IV–V spleen
injuries reported a general survival benefit of immediate
splenectomy over NOM [
]. However, in centers
where AG/AE is available (having therefore a lower
NOM failure rate of high-grade splenic injuries),
immediate splenectomy in patients with severe brain injury
does not seem to be associated with an improved
survival benefit regardless the grade of injury [
]. It must
be highlighted that the differences in definition of
hemodynamic instability may represent a bias in this
cohort of patients as a few “unstable” patients might have
undergone NOM. This data strongly emphasizes the
dangers related to poor patient selection for NOM in
BST and STBI [
Thrombo-prophylaxis in splenic trauma:
– Mechanical prophylaxis is safe and should be
considered in all patients without absolute
contraindication to its use (GoR 2A).
– Spleen trauma without ongoing bleeding is not an
absolute contraindication to LMWH-based
prophylactic anticoagulation (GoR 2A).
– LMWH-based prophylactic anticoagulation should
be started as soon as possible from trauma and may
be safe in selected patients with blunt splenic injury
undergone to NOM (GoR 2B).
– In patient with oral anticoagulants the risk-benefit
balance of reversal should be individualized
Trauma patients are at high risk of venous
thromboembolism (VTE); the transition to a hyper-coagulation
state occurs within 48 h from injury [
any prophylaxis, more than 50% may experience deep
vein thrombosis (DVT)which substantially increases the
risk of pulmonary embolism (PE) whose mortality is
about 50% [
]. In trauma patients surviving
beyond the first 24 h, PE is the third leading cause of
death. Even with chemical prophylaxis, DVT can be
detected in 15% of patients. There are currently no
standards for the initiation of prophylactic anticoagulation in
trauma patients with blunt spleen injuries. A
surveybased analysis from ASST reported a growing use of
heparin according to the increasing grade of the splenic
lesion, and on the contrary, an increasing use of
lowmolecular-weight heparin (LMWH) in low-grade lesions
. Heparin and LMWH can be combined with
mechanical prophylaxis; however, mechanical
prophylaxis alone in high-grade lesions seems to be preferred
by surgeons compared with heparin. Eberle et al. [
and Alejandro et al. [
] demonstrated no differences
between VTE prophylaxis administered within and after
72 and 48 h from trauma respectively, with highest rate of
failure in patients with high-grade splenic injury. Bellal et
] found no difference in hemorrhagic complication
and NOM failure rate in patients with early (< 48 h),
intermediate (48–72 h), and late (> 72 h) VTE prophylaxis.
These considerations are referred to selected patients,
particularly those without significant head and spinal injuries.
As a counterpart, Rostas et al. [
] show that VTE rates
were over fourfold greater when LMWH was
administered after 72 h from admission.
When trauma occurs in patients under anticoagulants,
it is important to consider, if it is necessary, the reversal
of their effects in order to avoid thrombotic
complication. However, failing to resume anticoagulation in a
timely fashion is associated with poor outcomes [
Short- and long-term follow-up in NOM (blunt and
– Clinical and laboratory observation associated to bed
rest in moderate and severe lesions is the cornerstone
in the first 48–72 h follow-up (GoR 1C).
– CT scan repetition during the admission should be
considered in patients with moderate and severe
lesions or in decreasing hematocrit, in the presence of
vascular anomalies or underlying splenic pathology
or coagulopathy, and in neurologically impaired
patients (GoR 2A).
– In the presence of underlying splenic pathology or
coagulopathy and in neurologically impaired patients
CT follow-up is to be considered after the discharge
– Activity restriction may be suggested for 4–6 weeks in
minor injuries and up to 2–4 months in moderate
and severe injuries (GoR 2C).
Splenic complications after blunt splenic trauma range
between 0 and 7.5% with a mortality of 7–18% in adults
]. In children, these incidences are lower [
The 19% of splenic-delayed ruptures happen within the
first 48 h, more frequently between 4 and 10 days after
trauma. The risk of splenectomy after discharge ranges
between 3 and 146 days after injury, and the rate of
readmission for splenectomy was 1.4% . Savage et al.
] showed that approximately 2% of patients
discharged with a non-healed spleen required late
intervention. Savage et al. [
] found an average of healing in
grades I–II of 12.5 days with a complete healing after
50 days while in grades III–V, 37.2 and 75 days,
respectively. In 2–2.5 months, regardless of severity of spleen
injury, the 84% of patients presented a complete healing
]. As a counterpart, Crawford et al. suggested that
an early discharge is safe because late failure occurs
]. Mortality of late rupture ranges
from 5 to 15% compared with 1% mortality in case of
acute rupture [
]. In any case, patients undergone
NOM should be counseled to not remain alone or in
isolated places for the first weeks after the discharge and
they should be warned regarding the alert symptoms.
Radiological follow-up is used, but there are not clear
information regarding the timing and type of imaging
(CT vs. US); thus, imaging follow-up is usually based on
clinical judgment and has been widely debated [
40, 125, 132–134
]. Management strategies that use
patient education are more cost effective than to undergo
imaging all patients until splenic complete healing.
In the short course (first 24–72 h), observation
remains an essential part of low-grade splenic injury
(AAST I–II grade); after the admission CT scan, serial
abdominal examinations, and hematocrit determination
every 6 h are necessary [
]. Clancy et al. [
as PSA were found in patients with grade II, even
months after trauma, so they recommended CT scan at
36–72 h in all injuries [
129, 131, 132
]. Some authors
suggest to repeat CT scan only in patients with
decreasing hematocrit, in AAST grades III–IV, in patients with
subcapsular hematoma, or underlying splenic pathology
or coagulopathy, as also in neurologically impaired
In the intermediate-long course recent reports
recommended that routine post-discharge follow-up abdominal
CT is not necessary in low-grade (AAST grade I or II)
More than 50% of patients present a healing at CT
scan after 6 weeks, and subsequent image follow-up
seems to have no clinical utility [
healing of almost all grades is observed 3 months after
injury. Lynch et al. , in a prospective study, showed
that mean time to US healing in AAST grade I, II, Ill,
and IV injuries was 3.1, 8.2, 12.1, and 20.7 weeks,
respectively. Soffer D. et al. [
] suggest a DUS for splenic
lesion follow-up. Some authors have suggested the use
of magnetic resonance images [
The role of radiological follow-up before returning to
normal activity remains controversial. According to
some authors, the return to normal activity can occur
3 weeks after splenectomy, and after 2.5–3 months after
126, 134, 136, 137
]. Other authors suggested
activity restriction of 2 weeks for mild injuries with a
return to full activity after 6 weeks, and up to 4–6 months
for patients with more severe injuries [
Pediatric splenic trauma
The spleen is the most commonly injured solid organ in
pediatric blunt trauma patients (25–30%) [
age limit for pediatric patients is considered for present
guidelines to be < 15 years old. While non-operative
management of splenic trauma is the mainstay in
children, the available clinical guidelines are not
universally applied. In urban pediatric hospitals where
resources facilitate the non-operative approach, the
likelihood of splenic preservation with NOM ranges
from 95 to 100% .
The Eastern Association for the Surgery of Trauma
(EAST) recommends NOM in blunt splenic trauma in all
hemodynamically stable children irrespective of the AAST
injury grade [
]. The same guidelines recommend
a “less is more” approach with respect to imaging studies
during admission and follow-up, aiming to reduce the use
of CT scan and radiation exposure [
NOM seems to be more effective in children, and
therefore, it is more commonly used in these patients
compared to adults NOM of pediatric splenic trauma
which is also associated with reduced cost and lengths of
hospital stay, less need for blood transfusions,
vaccinations, and antibiotic therapy, as well as higher immunity
and reduced rate of infections [
Even though it is not clear why NOM outcomes are
superior in children compared with adults, this phenomenon
may be related to certain unique pediatric characteristics
(e.g., thicker splenic capsule, higher proportion of
myoepithelial cells, more efficient contraction, and retraction of
the splenic arterioles [
Clinical presentation in splenic pediatric trauma
The mechanisms of trauma are similar in children and
adults. These include motor vehicle and pedestrian
injuries as well as sports-related injuries, bicycle injuries,
and child abuse [
Pediatric injuries differ from adult trauma as the
elastic pediatric rib cage may cause a transmission of force
into the abdominal compartment [
Trauma in neonates represents a rare but unique
diagnostic challenge since shock and abdominal rigidity or
altered mental status may be the only indications of
underlying abdominal injury [
In adolescents, the signs of splenic trauma may
include the left upper quadrant pain associated with
referred left shoulder pain hypovolemic shock or
generalized abdominal pain [
Definition of the hemodynamic status in children
According to ATLS, the normal systolic blood pressure
in children is 90 mmHg plus twice the child’s age in
years (the lower limit is inferior to 70 mmHg plus twice
the child’s age in years, or inferior to 50 mmHg in some
]. Severe blood loss is defined as blood loss
greater than 45% of the circulating volume and results
in hemodynamic instability. Nevertheless, clinical
judgment remains the most important factor in diagnosing
an ongoing bleeding [
For fluid resuscitation, three boluses of 20 mL/kg of
crystalloid replacement should be administered before
blood replacement [
]. Massive transfusion protocol
in children should be applied with a ratio of 1:1:1 .
Transfusion triggers have been debated, and although,
there are no class I data to support a specific
numerical threshold, it is generally agreed that transfusion
should be considered when hemoglobin is less than
7 g/dL [
Effective resuscitation is classically indicated by
reduction of the heart rate, improved mental status, return of
peripheral pulses and normal skin color, increase in
blood pressure, and urinary output, as well as increase
in extremity warmth [
Even though the benefit of tromboelastography (TEG)
has not been confirmed in children, recent ATOMAC
guidelines suggested that it may be useful in these
patients as well (based on adult data) [
– The role of E-FAST in the diagnosis of pediatric
spleen injury is still unclear (GoR 1A).
– A positive E-FAST examination in children should be
followed by an urgent CT in stable patients
– Complete abdominal US may avoid the use of CT in
stable patients (GoR 1B).
– Contrast-enhanced CT scan is the gold standard in
pediatric splenic trauma (GoR 1A).
– Doppler US and contrast-enhanced US are useful to
evaluate splenic vascularization (GoR 1B).
– CT scan is suggested in children at risk for head and
thoracic injuries, need for surgery, recurrent bleeding,
and if other abdominal injuries are suspected
– Injury grade on CT scan, free fluid amount, contrast
blush, and the presence of pseudo-aneurysm do not
predict NOM failure or the need for OM (GoR 1B).
Thoracic X-ray at the admission is recommended in
the ATLS guidelines [
Ultrasonography (US) is the less invasive and is
considered the gold standard in trauma, according to the
ATLS guidelines especially in Europe [
additional use of DUS or CEUS is helpful and can increase
sensitivity for the evaluation of splenic flow and injuries
. In patients with low clinical suspicion for splenic
trauma, US and CEUS may allow to avoid CT scan
]. The routine use of CEUS can improve the search
of PSA [
FAST (Focused Assessment with Sonography for Trauma):
The role of FAST for the diagnosis of spleen injury in
children is still unclear. Recent Pediatric Emergency Care
Applied Research Network (PECARN) data suggest that
only 13.7% of pediatric trauma patients with a suspicion of
intra-abdominal injuries undergo FAST examination [
The sensitivity of this imaging modality in children ranges
from 50 to 92%, with a comprehensive meta-analysis
suggesting the sensitivity to be around 66% [
The specificity of this exam is also quite low, and
therefore, in a hemodynamically stable patient, a positive
FAST examination should be followed by an urgent CT.
Bedside FAST may have utility in hemodynamically
unstable patients to rapidly identify or rule out
intraperitoneal hemorrhage when patients cannot undergo CT.
Contrast-enhanced computer tomography (CT) is the
gold standard for the evaluation of blunt abdominal
]. However, patients should be
hemodynamically stable, as well as cooperative or sedated. Of
note, surgeons should interpret CT findings cautiously
before opting for OM because more than 50% of children
present with grade III–IV lesions [
]. Taking into
account the radiation risk in children, low-dose protocols
are preferred (3–6 mSv instead of 11–24 mSv) [
APSA guidelines recommend CT scanning in children at
risk for injuries that might be missed by FAST, need for
surgery, recurrent bleeding, and when other abdominal
injuries (such as pancreatic or hollow viscous injury) are
Non-operative management in splenic injury:
– NOM is recommended as first-line treatment for
hemodynamically stable pediatric patients with blunt
splenic trauma (GoR 2A).
– Patients with moderate-severe blunt and all
penetrating splenic injuries should be considered for
transfer to dedicated pediatric trauma centers after
hemodynamic stabilization (GoR2A).
– NOM of spleen injuries in children should be
considered only in an environment that provides
capability for patient continuous monitoring,
angiography, trained surgeons, an immediately
available OR and immediate access to blood and
blood products or alternatively in the presence of a
rapid centralization system in those patients
amenable to be transferred (GoR 2A).
– NOM should be attempted even in the setting of
concomitant head trauma; unless the patient is
unstable, and this might be due to intra-abdominal
bleeding (GoR 2B).
Blunt splenic injury:
– Blunt splenic injuries with hemodynamic stability
and absence of other internal injuries requiring
surgery should undergo an initial attempt of NOM
irrespective of injury grade (GoR 2A).
– In hemodynamically stable children with isolated
splenic injury splenectomy should be avoided
– NOM is contraindicated in the presence of
peritonitis, bowel evisceration, impalement, or other
indications to laparotomy (GoR 2A).
– The presence of contrast blush at CT scan is not an
absolute indication for splenectomy or AG/AE in
children (GoR 2B).
– Intensive care unit admission in isolated splenic
injury may be required only for moderate and severe
lesions (GoR 2B).
Penetrating splenic injury:
– No sufficient data validating NOM for penetrating
spleen injury in children exist.
NOM is successful in 95–100% of blunt pediatric
trauma patients and has therefore become the gold
standard of treatment in children who have sustained an
isolated blunt splenic injury and are hemodynamically stable
at the time of presentation [
]. AG/AE at present
is considered among NOM tools by several authors.
APSA trauma committee recommendations have
resulted in reduced ICU stay, hospital LOS, and
resource utilization, while achieving superior outcomes
142, 162, 163
]. In isolated spleen injuries, ICU stay
should be considered in moderate-severe lesions [
The CT-based solid organ grading system has not only
been used to triage patients but also to administer the
most appropriate treatment and to predict outcomes.
However, the latter remains controversial [
The CT-based solid organ grading system has not only
been used to triage patients but also to administer the
most appropriate treatment and to predict outcomes.
However, the latter remains controversial [
]. Therefore, CT scan should not be the only
factor guiding the diagnostic process; and some authors
use this argument to avoid imaging in a stable patient
altogether. Surprisingly, several studies have shown that
adherence to APSA guidelines is low in non-pediatric
trauma centers [
145, 162, 168–172
]. Pediatric trauma
patients treated in dedicated centers were demonstrated
to have higher probability to undergo NOM than those
treated in adult trauma centers [
145, 162, 168–170
Mooney et al. and Todd et al. demonstrated that
children with splenic injury have a greater chance to
undergo splenectomy or laparotomy in general if treated
in an adult trauma center [
NOM failure rates for pediatric splenic trauma have
been shown to range from 2 to 5% [
]. Of note,
there is evidence suggesting that the rate of NOM failure
peaks at 4 h and then declines over 36 h from admission
. Overall, the majority (72.5%) of NOM failures
seem to occur during the first week after trauma, with
50% of them happening within the first 3–5 days [
Finally, there are no granular data validating NOM for
penetrating spleen injury in children. However, reports
on successful non-operative management of isolated
penetrating spleen injuries in hemodynamically stable
pediatric patients do exist [
The role of angiography/angioembolization (AG/AE):
– The vast majority of pediatric patients do not require
AG/AE for CT blush or moderate to severe injuries
– AG/AE may be considered in patients undergone to
NOM, hemodynamically stable with sings of
persistent hemorrhage not amenable of NOM,
regardless the presence of CT blush once excluded
extra-splenic source of bleeding (GoR 1C).
– AG/AE may be considered for the treatment of
post-traumatic splenic pseudo-aneurysms prior to
patient discharge (GoR 2C).
– Patients with more than 15 years old should be managed
according to adults AG/AE-protocols (GoR 1C).
The role of AG/AE in the management of pediatric
splenic trauma is controversial, and its use varies widely
among institutions [
164, 179, 180
Even though AG/AE appears to be a safe intervention,
the vast majority of retrospective observational data
show that very few pediatric patients with contrast
extravasation may benefit from embolization [
Therefore, AG/AE may only be considered in
carefully selected patients, such as those with high-grade
injuries, transient response to resuscitation, and/or
persistent blood requirements [
]. Similarly, the role of
embolization in the management of pediatric splenic
pseudo-aneurysms is also unclear. Of note, PSAs often
undergo spontaneous thrombosis and could resolve
without any interventions [
133, 144, 155, 180, 183
Some authors proposed a distinction between
adolescent of more than 13–15 years old, for which should be
applied the adult protocol for AG/AE, and children of
less than 13–15 years old that are more vulnerable to
]. Moreover, Skattum et al. suggested
that if a patient aged less than 15 years old is found
to have a PSA on admission CT, contrast-enhanced
ultrasound should be performed prior to discharge. If
at that time PSA is still present, embolization should
be considered .
Mortality and major complications are rarely reported
following AG/AE [
180, 184, 186, 187
]. Nevertheless, a
post-embolization syndrome (PES), consisting of
abdominal pain, nausea, ileus, and fever, seems to occur in 90%
of children undergoing AG/AE. This syndrome is usually
self-limited and tends to resolve spontaneously in 6 to
9 days . In addition, pleural effusion (9%),
pneumonia (9%), and coil migration (4.5%) can also be seen after
splenic embolization [
Overall, AG/AE seems to preserve splenic function
without lasting complications, but most children do not
need this intervention [
179, 189, 190
Operative management in blunt and penetrating injuries:
– Patients should undergo to OM in case of
hemodynamic instability, failure of conservative
treatments, severe coexisting injuries necessitating
intervention and peritonitis, bowel evisceration,
impalement (GoR 2A).
– Splenic preservation (at least partial) should be
attempted whenever possible (GoR 2B).
Indications for laparotomy include hemodynamic
instability, ongoing blood loss, or evidence of hollow
viscous injury [
153, 161, 191–194
]. Of note, ATOMAC
guidelines recommend surgery if transfusion of
40 mL/kg of all blood products within 24 h (or more
than 4 units of blood) fails to stabilize the patient
]. One percent (1%) of
pediatric patients who undergo immediate OM are
readmitted for intestinal obstruction within a year [
In most cases of OM, splenic partial preservation is
possible. Indeed, partial (subtotal) splenectomy or
splenorrhaphy are safe and viable alternatives to total
splenectomy and can be performed even in high-grade
Splenic trauma associated with head injuries
Head injury is an important cause of morbidity and
mortality in trauma patients of all ages (50–60%).
Importantly, head injuries can also result in altered mental
status, which can complicate the process of clinical
]. Especially in the setting of concurrent
head injury, blood pressure and heart rate are poor
markers of hemorrhagic shock in pediatric patients
]. Nevertheless, an analysis of the National
Pediatric Trauma Registry suggested that the
association of altered mental status from head injury with
spleen injuries should not impact the decision for
observational management in pediatric patients (< 19 years
Short- and long-term follow-up in splenic trauma
(blunt and penetrating):
– In hemodynamic stable children without drop in
hemoglobin levels for 24 h, bed rest should be
suggested (GoR 2B).
– The risk of pseudo-aneurysm after splenic trauma is
low, and in most of cases, it resolves spontaneously
– Angioembolization should be taken into
consideration when a pesudoaneurysm is found
– US (DUS, CEUS) follow-up seems reasonable to
minimize the risk of life-threatening hemorrhage and
associated complications in children (GoR 1B).
– After NOM in moderate and severe injuries, the
reprise of normal activity could be considered safe
after at least 6 weeks (GoR 2B).
No definitive data exist regarding complication rate and
short- and long-term follow-up, and no clear indications
regarding the most cost-effective imaging technique (US,
DUS, CEUS, CT scan). Initial APSA guidelines [
recommended bed rest for a number of days equal to the
grade of injury plus 1 day [
]. However, recent studies
suggest a shorter bed rest of one night in solitary grade I–
II splenic trauma and two nights for patients with more
severe injuries (grade ≥ III) and stable hemoglobin level
]. Longer admission should be considered in patients
with lower hemoglobin levels on admission, higher injury
grade, suspicious of other abdominal injuries (as
pancreatic or small bowel injuries), blush on the CT scan, bicycle
handlebar injuries, recurrent bleeding, or patients at risk
for missed injuries [
US or CEUS or DUS follow-up seems reasonable to
minimize the risk of life-threatening hemorrhage and its
associated complications [
]. General surgeons tend to
perform routinely imaging follow-up for children
differently from pediatric surgeons that only in 5% of cases
suggest imaging follow-up [
145, 165, 201
The APSA guidelines [
] recommended 2–5 months
of “light” activity before restart with normal activities
and recommended 3 week–3 months of limited activity
at home. Some authors suggested the reprise of normal
activity even after 4 weeks after III–IV grade injuries. In
fact, the risks of delayed splenic rupture and
posttraumatic pseudocysts seem to be increase within the
first 3 weeks (incidence 0.2 and 0.3%, respectively)
]. Canadian guidelines suggested a discharge
at home after reprise and good toleration of oral intake,
able mobilization, and analgesia with oral medications
without images before discharge . They reported a
32% of children that did not have any images follow-up
without any complications and a restriction of activity
no more than 6–8 weeks with a length of activity
restriction modulated on the grade of injury [
use of CEUS can improve the diagnosis of PSA that can
be found in all grades of injury [
Patients and parents psychological involvement after
trauma can be related with abdominal pain; for this
reason, family and patient education post-discharge
should be considered to reduce readmission rate [
Infection prophylaxis in asplenic and hyposplenic adult
and pediatric patients:
– Patients should receive immunization against the
encapsulated bacteria (Streptococcus pneumoniae,
Haemophilus influenzae, and Neisseria meningitidis)
– Vaccination programs should be started no sooner
than 14 days after splenectomy or spleen total
vascular exclusion (GoR 2C).
– In patients discharged before 15 days after
splenectomy or angioembolization, where the risk to
miss vaccination is deemed high, the best choice is to
vaccinate before discharge (GoR 1B).
– Annual immunization against seasonal flu is
recommended for all patients over 6 months of age
– Malaria prophylaxis is strongly recommended for
travelers (GoR 2C).
– Antibiotic therapy should be strongly considered in
the event of any sudden onset of unexplained fever,
malaise, chills, or other constitutional symptoms,
especially when medical review is not readily
accessible (GoR 2A).
– Primary care providers should be aware of the
splenectomy/angioembolization (GoR 2C).
OPSI are defined as fulminant sepsis, meningitis, or
pneumonia triggered mainly by Streptococcus
pneumoniae (50% of cases) [
] followed by H.
influenzae type B and N. meningitidis. OPSI is a medical
emergency. The risks of OPSI and associated death are
highest in the first year after splenectomy, at least
among young children, but remain elevated for more
than 10 years and probably for life. The incidence of
OPSI is 0.5–2%; the mortality rate is from 30 to 70%,
and most death occurs within the first 24 h. Only
prompt diagnosis and immediate treatment can reduce
2, 204, 206, 207
children younger than 5 years old have a greater overall
risk of OPSI with an increased death compared with
]. The risk is more than 30% in
neonates . Evidence exist regarding the possible
maintaining of the function by the embolized spleen
(hyposplenic patients) however is reasonable to
consider it as less effective and proceed with vaccination
as well [
179, 189, 190
Vaccination against flu is recommended annually for
asplenic/hyposplenic patients over 6 months of age.
Prevention of influenza may decrease the risk of secondary
bacterial infection, including pneumococcal infection
Ideally, the vaccinations against S. pneumoniae, H.
influenzae type B, and N. meningitidis should be given at
least 2 weeks before splenectomy [
]. Patients should be
informed that immunization can only reduce the
incidence of OPSI (vaccines so far available do not allow an
exhaustive coverage neither for S. pneumoniae—23 of 90
serotypes are included—nor for N. meningitidis—5 of 6
serotypes) (Table 5).
In traumatic patients, the correct time for
vaccination should be not less than 14 days after
splenectomy; in fact, before 14 days, the antibody response is
supposed to be suboptimal [
204, 206, 209
]; after that
interval, the earlier the better. In asplenic/hyposplenic
patients discharged before 15 days, where the risk to
miss the vaccination is deemed high, the first vaccines
should be given before discharge [
Centre for Disease Control in 2016 proposed the last
updated recommendations . Most episodes of
severe infections occur within the first 2 years after
splenectomy, and for this reason, some authors
recommend at least 2 years of prophylactic antibiotics
after splenectomy. However, the duration of antibiotic
prophylaxis is controversial.
Community physicians should be aware of the
asplenic/hyposplenic condition, in order to provide them with
the most appropriate level of care.
Asplenic/hyposplenic patients should be given an
antibiotic supply in the event of any sudden onset of
unexplained fever, malaise, chills, or other constitutional
symptoms, especially when medical review is not readily
accessible. The recommended options for emergency
standby in adults include the following: (a) Amoxycillin,
3 g starting dose followed by 1 g, every 8 h; (b)
Levofloxacin 500 mg every 24 h or Moxifloxacin 400 mg every
24 h (for beta-lactam allergic patients).
The recommended emergency standby treatment in
children is Amoxycillin 50 mg/Kg in three divided daily
doses. For beta-lactam allergic patients, an alternative
should be proposed by a specialist (fluoroquinolones are
generally contraindicated in children, but due to the
possible severity of OPSI, they might still be considered).
Antibiotic prophylaxis is necessary in patients with
asplenia/hyposplenia who are bitten by dogs and other
animals because of increased risk of severe sepsis
(Amoxycillin/Clavulanic acid for 5 days) [
205, 207, 208
If the patient is being treated in an outpatient setting,
he/she should be referred immediately to the nearest
emergency department. Clinical deterioration can be
rapid even after antibiotic administration. Antibiotics
should be modified once blood culture results become
]. Failures of antibiotic prophylaxis have
been reported, so patients should be warned that
prophylaxis reduces but does not abolish the risk of
Due to the increased risk of severe malaria, asplenic/
hyposplenic travelers to endemic areas should receive an
adequate pre-departure counseling, regarding both
measures aimed at reducing the exposure to mosquitos’ bites
The management of spleen trauma must be
multidisciplinary and must keep into consideration the physiological
and anatomical derangement together with the
immunological effects. Critical and operative decisions can be
taken more effectively if both anatomy of injury and its
physiological effects, and the associated lesions are
considered especially considering the modern tools for
integrated bleeding management. The treatment
algorithm must differ within adults, and children these lasts
should always be treated in dedicated trauma centers.
AAST: American Association for Surgery for Trauma; AG/AE: Angiography/
angioembolization; AIS: Abbreviated injury score; AMX: Amoxicillin; AMX/
CLA: Amoxicillin/clavulanic; APSA: American Pediatric Surgical Association;
ATLS: Advanced Trauma Life Support; BE: Base excess; BST: Blunt spinal
trauma; CEUS: Contrast-enhanced US; CT: Computerized tomography;
DPL: Diagnostic peritoneal lavage; DUS: Doppler US; DVT: Deep venous
trombosis; EAST: Eastern Association for the Surgery of Trauma;
ED: Emergency Department; E-FAST: Extended focused assessment
sonography for trauma; GCS: Glasgow Coma Scale; ICU: Intensive Care Unit;
ISS: Injury severity score; LE: Level of evidence; LMWH:
Low-molecularweight heparin; LOS: Length of hospital stay; MTP: Massive transfusion
protocols; NOM: Non-operative management; OIS: Organ Injury Scale;
OM: Operative management; OPSI: Overwhelming post-splenectomy
infections; OR: Operating room; PE: Pulmonary embolism; PES:
Postembolization syndrome; PSA: Pseudoaneurism; TBI: Traumatic brain injury;
TEG: Thrombo-elastography; TMP/SMX: Cotrimoxazole;
US: Ultrasonography; VTE: Venous thromboembolism; WSES: World Society
of Emergency Surgery
Special thanks to Ms. Franca Boschini (Bibliographer, Medical Library, Papa
Giovanni XXIII Hospital, Bergamo, Italy) for the precious bibliographical work.
FC, GM, FCa, YK, WB, EEM, VR, CB, MB, PF, HB, IM, GV, RI, KS, TH, RB, BMP, GPF,
KI, JK, NP, KSM, PTM, AK, FAZ, CAG, SVB, NN, FS, SM, MS, VA, EG, LS, AC, AC,
MT, VK, CA, LN, LH, MP, SM, DAS, MM, KAD, NDA, AL, PF, RL, DCN, YO, RC,
RVM, FM, SR, BS, JMG, OC, SC, ACM, DW, MC, AH, ABP, LW, MS, SDS, and LA
contributed to manuscript conception and draft, critically revised the
manuscript, contributed important scientific knowledge, and gave final
approval of the manuscript.
There is no funding received in this study.
Availability of data and materials
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Mozir, Belarus. 27Clin. Univ. de Chirurgie Digestive et de l’Urgence,
CHUGA-CHU Grenoble Alpes UGA-Université Grenoble Alpes, Grenoble,
France. 28Trauma and Surgical Critical Care, University of Michigan Health
System, East Medical Center Drive, Ann Arbor, MI, USA. 29Trauma Unit,
Helsinki University Hospital, Helsinki, Finland. 30Department of Surgery,
Stanford University, Stanford, CA, USA. 31General Surgery, Trauma, and
Surgical Critical Care, Yale-New Haven Hospital, New Haven, CT, USA.
32Hopital Heri Mondor, Paris, France. 33General Surgery Department, Mehilati
Hospital, Helsinki, Finland. 34General Surgery Department, Westchester
Medical Center, Westchester, NY, USA. 35Colorectal Surgery Unit, Trauma Care
Committee, Alicante General University Hospital, Alicante, Spain. 36Trauma
and Acute Critical Care Center, Tokyo Medical and Dental University, Tokyo,
Japan. 37Department of Surgery, UC San Diego Health System, San Diego,
USA. 38Department of Surgery, University of Washington, Seattle, WA, USA.
39Department of Surgery, Gainesville, FL, USA. 40Trauma and Acute Care
Service, St Michael’s Hospital, Toronto, ON, Canada. 41General Surgery
Department, Medical University, University Hospital St George, Plovdiv,
Bulgaria. 42Division of Trauma and Acute Care Surgery, University of
California, Davis Medical Center, Davis, CA, USA. 43Trauma Team, Ospedale
Niguarda, Milan, Italy. 44Department of Surgery and Obstetric and
Gynecology, University of Buea, Buea, Cameroon. 45Department of General
Surgery, Royal Perth Hospital, Perth, Australia. 46Surgery Department,
University of Pittsburgh, Pittsburgh, Pensylvania, USA. 47General Surgery
Department, Ayaan Hospital, Mogadisho, Somalia. 48General and Emergency
Surgery, Macerata Hospital, Macerata, Italy. 49General, Emergency and Trauma
Surgery Department, Maggiore Hospital, Bologna, Italy. 50Department of
Surgery, Örebro University Hospital and Örebro University, Obreo, Sweden.
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