Outcomes of Isolated Severe Blunt Splenic Injury

Importance 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. Objective 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. Exposure Open splenectomy (OS) vs SAE vs observation. Main Outcomes and Measures The primary outcomes were mortality and any complication. Outcomes were compared using multivariable Cox proportional hazards regression analyses. Results 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 lt; .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 lt; .001) and observation (β = −1.41; 95% CI, −1.73 to −1.09; P lt; .001) groups. Compared with initial OS, morbidity was higher for patients in whom SAE (OR, 5.39; 95% CI, 3.39-8.57; P lt; .001) and observation (OR, 1.95; 95% CI, 1.44-2.64; P lt; .001) failed, and hospital length of stay was longer for these groups as well (β = 2.50; 95% CI, 1.27-3.73; P lt; .001 and β = 0.71; 95% CI, 0.07-1.35; P = .03, respectively). Conclusions and Relevance 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.