90th Annual Meeting Abstracts

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Management of the Most Severely Injured Spleen: A Multi-center Study of the Research Consortium of New England Centers for Trauma (ReCONECT)
George C Velmahos, MD, PhD¹, *Nikos Zacharias, MD¹, Timothy Emhoff, MD², *James Feeney, MD³, James Hurst, MD⁴, *Bruce Crookes, MD⁵, *David Harrington, MD⁶, *Gregg Shea, MD⁶, *Sheldon Brotman, MD⁷, Peter Burke, MD⁸, *Kimberly Davis, MD⁹, *Rajan Gupta, MD¹⁰, *Robert Winchell, MD¹¹, *Steven Desjardins, MD¹¹, *Reginald Alouidor, MD¹², Ronald Gross, MD¹², Michael Rosenblatt, MD¹³, *John Schultz, MD^14
1Massachusetts General Hospital, Boston, MA;²University of Massachusetts Memorial Hospital, Worchester, MA;³Hartford Hospital, Hartford, CT;⁴Beth Israel Deaconess Medical Center, Boston, MA;⁵Fletcher Allen Healthcare, Burlington, VT;⁶Rhode Island Hospital, Providence, RI;⁷Berkshires Medical Center, Pittsfield, MA;⁸Boston Medical Center, Boston, MA;⁹Yale New Haven Hospital, New Haven, CT;¹⁰Hitchckock Dartmouth Medical Center, Lebanon, NH;¹¹Maine Medical Center, Portland, ME;¹²Baystate Medical Center, Springfield, MA;¹³Lahey Clinic, Burlington, MA;¹⁴Bridgeport Hospital, Bridgeport, CT

Objective: To determine the rate and risk factors of failure of non-operative management (NOM) in grade IV and V blunt splenic injuries.
Design: Retrospective case series.
Setting: 14 New England trauma centers.
Patients: 389 adult blunt trauma patients with an American Association for the Surgery of Trauma (AAST) grade of IV or V splenic injury on computed tomography (1/1/01 to 8/31/08). Patients who had incomplete data (48), no CT (72), or arrived dead (3) were excluded.
Main outcome measures: Failure of NOM (f-NOM).
Results: 164 (42%) patients were operated on immediately. Of the remaining 225 who were offered a trial of NOM, 92 (41%) eventually required an operation. Overall 66% of the patients underwent a splenectomy. Multiple logistic regression identified 2 predictors of f-NOM that achieved and 2 that approached statistical significance:

Predictor	Odds Ratio	95% Confidence Interval	p-value
Male gender	2.31	1.23 - 4.36	0.009
Grade V (vs. grade IV)	2.93	1.24 - 6.95	0.014
Assault (vs. MCV or fall)	4.07	0.91 - 18.26	0.067
Age > 55 years	1.92	0.91 - 4.05	0.085

The likelihood of f-NOM was 100% if all predictors were present but remained 29% even when all predictors were absent. Of f-NOM patients 63% developed a complication and 6.5% died. Their average length of hospital stay was 18+28 days (median: 8).
Conclusions: Two thirds of patients with grade IV/V blunt splenic injury require an operation. Among those who are initially treated by NOM, the presence of certain simple clinical factors predicts failure with a likelihood of 100%. This data must be taken into account when generalizations are made about the overall high success rates of NOM, which usually do not reflect severe splenic injuries.

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