Nonoperative Management of Splenic Injury in Combat : 2002 – 2012 CPT

Background: Selective nonoperative management of combat-related blunt splenic injury (BSI) is controversial. We evaluated the impact of the November 2008 blunt abdominal trauma clinical practice guideline that permitted selective nonoperative management of some patients with radiological suggestion of hemoperitoneum on implementation of nonoperative management (NOM) of splenic injury in austere environments. Methods: Retrospective evaluation of patients with splenic injuries from November 2002 through January 2012 in Iraq and Afghanistan was performed. International Classification of Diseases, 9th Revision, Clinical Modification procedure codes identified patients as laparotomy with splenectomy, or NOM. Delayed operative management had no operative intervention at earlier North American Treaty Organization (NATO) medical treatment facilities (MTFs), and had a definitive intervention at a latter NATO MTFs. Intra-abdominal complications and overall mortality were juxtaposed. Results: A total of 433 patients had splenic injuries from 2002 to 2012. Initial NOM of BSI from 2002 to 2008 compared to 2009–2012 was 44.1% and 47.2%, respectively ( p = 0.75). Delayed operative management and NOM completion had intra-abdominal complication and mortality rates of 38.1% and 9.1% ( p < 0.01), and 6.3% and 8.1% ( p = 0.77). Conclusions: Despite high-energy explosive injuries, NATO Role II MTFs radiological constraints and limited medical resources, hemodynamically normal patients with BSI and low abdominal abbreviated injury scores underwent NOM in austere environments. INTRODUCTION Management of blunt splenic injury (BSI) in an austere environment continues to evolve. For example, from 1968 to 1970 in Vietnam, Lieutenant Colonel James E. Oglesby describes encountering 126 splenic injuries that resulted in 126 splenectomies. Currently, the preponderance of civilian literature regarding successful management of BSI through selective nonoperative management (SNOM) challenges the old dictum that equates splenic injury with total splenectomy in an austere environment. Formerly, these splenic injuries would have been found intraoperatively during laparotomy. Currently, our utilization of Focused Abdominal Sonography for Trauma (FAST) at North American Treaty Organization (NATO) Role II and III medical treatment facilities (MTFs) facilitates identification of hemoperitoneum, and computed tomography (CT) at NATO Role III MTFs has allowed deployed general surgeons to increase detection of splenic injuries in theater before discovery at exploratory laparotomy. The U.S. Central Command Joint Theater Trauma System (JTTS) in November 2008 changed the blunt abdominal trauma (BAT) clinical practice guideline (CPG); it stated that BAT patients with a positive FAST or CT abdomen/pelvis suggestive of hemoperitoneum, which were hemodynamically normal, could be managed through SNOM at a NATO Role III MTF. This declaration was a bold departure from prior BAT CPGs initially written in December 2004 stating that a positive FAST or CT scan, suggestive of hemoperitoneum, required exploratory laparotomy in patients suffering BAT. The objectives of this retrospective study were to (1) analyze the impact this November 2008 change in the BAT CPG had in the application of nonoperative management (NOM) for BSI in OEF and OEF and (2) evaluate the number of patients who had delayed operative management of their splenic injuries, and their subsequent complications and mortality compared to those who successfully completed NOM. Congruous with these objectives, we hypothesized that (1) this November 2008 change in CPG would increase the utilization of initial NOM overall and (2) patients who underwent delayed operative management of BSI would have higher complications and a higher mortality compared to those who have successfully completed NOM. METHODS This retrospective study evaluated the military medical records, Department of Defense Trauma Registry, Army Medical Protection System, Armed Forces Health Longitudinal Application, Composite Health Care System, and Joint Patient Tracking Application, on all U.S. soldiers in OIF and OEF, with a diagnosis of splenic injury from November 2002 to January 2012; these patients underwent a laparotomy with splenectomy (LWS), laparotomy with splenorraphy (SPL), laparotomy without splenectomy (LWOS) or NOM for their *U.S. Military General Surgery, San Antonio Military Medical Center, 3851 Roger Brooke Drive #3600, San Antonio, TX 78234-7767. †U.S. Army Institute of Surgical Research, 3698 Chambers Pass Suite B, JBSA Fort Sam Houston, TX 78234-7767. This article was presented at the American College of Surgeons Surgical Forum on October 27, 2014. This study was approved by the Brooke Army Medical Center Institutional Review Board under protocol number I.2008.206dt. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. doi: 10.7205/MILMED-D-14-00411 MILITARY MEDICINE, Vol. 180, March Supplement 2015 29 Downloaded from publications.amsus.org: AMSUS Association of Military Surgeons of the U.S. IP: 192.138.057.036 on Mar 16, 2015. Copyright (c) Association of Military Surgeons of the U.S. All rights reserved. Report Documentation Page Form Approved OMB No. 0704-0188 Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.