The American Journal of Surgery (2011) 202, 810 816

The Southwestern Surgical Congress

Nonsurgical management of blunt splenic injury: is it cost effective?

Pamela J. P. Bruce, M.D.a, Stephen D. Helmer, Ph.D.a, Paul B. Harrison, M.D.a,b, Tony Sirico, P.A.b, James M. Haan, M.D.a,c,*
a

Department of Surgery, The University of Kansas School of Medicine-Wichita, Wichita, KS, USA; bDepartment of Trauma Services, Wesley Medical Center, Wichita, KS, USA; cDepartment of Trauma Services, Via Christi Hospital on Saint Francis, 929 N. Saint Francis St., Room 2514, Wichita, KS 67214, USA KEYWORDS:
Splenic injury; Splenectomy; Splenic embolization; Cost; Nonsurgical management Abstract BACKGROUND: This study analyzed outcomes and cost of splenic embolization compared with surgery for the management of blunt splenic injury. METHODS: We performed a retrospective chart review of all patients admitted with isolated, blunt splenic injury. An intent-to-treat analysis was initially conducted. Outcomes and cost/charges were compared in patients treated with embolization and surgical treatment. RESULTS: Of 236 patients admitted with isolated, blunt splenic injury, 190 patients were ultimately managed by observation, 31 by splenic embolization, and 15 by surgical management. Comparing outcomes and cost data for splenic embolization versus surgical management, there was no signicant difference in intensive care unit use, hospital stay, complications, or re-admission. Surgical management patients required more blood transfusions and incurred higher procedure charges. Conversely, splenic embolization patients underwent more radiologic evaluations and charges. Total procedurerelated charges were higher for surgical management when compared with splenic embolization ($28,709 vs $19,062; P .016), but total hospital cost and total hospital charges were not signicantly different. CONCLUSIONS: Nonsurgical treatment of blunt splenic injury is safe and cost effective. Angioembolization was statistically similar to surgical therapy regarding cost. 2011 Elsevier Inc. All rights reserved.

Nonsurgical management of blunt splenic injury in hemodynamically stable patients is now the standard of care. The use of splenic embolization, however, remains an area of debate. Some centers advocate embolization as treatment for splenic vascular injury to improve salvage and decrease length of stay, whereas others contend it adds no benet and
Presented at the 63rd Annual Meeting of the Southwestern Surgical Congress, April 3 8, 2011, Ko Olina, HI. * Corresponding author. Tel.: 1-316-268-5538; fax: 1-316-2917892. E-mail address: James.Haan.Research@viachristi.org Manuscript received March 18, 2011; revised manuscript June 28, 2011

incurs procedural risks and increased costs.118 In reviewing the literature, we were unable to identify any studies comparing the cost effectiveness of surgical versus angiographic management of blunt splenic injury. With the current economic environment, the practice of cost-conscious medicine is critical. This requires a balanced assessment of resource use, costs, and patient outcomes; without which, determination of a preferred method of managing patients with higher-grade blunt splenic injuries, or who are stable but failing simple nonsurgical management, is potentially problematic. This study compares angiographic and surgical management in 2 hospitals, within a single community with

0002-9610/$ - see front matter 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2011.06.041

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Blunt splenic injury management cost comparison

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different management algorithms, to measure overall success rates and outcomes of patients with blunt splenic injury.

Materials and methods

A retrospective review of the trauma databases of 2 American College of Surgeonsveried Level I trauma centers was conducted to identify all patients admitted with blunt splenic injury between January 1, 2005, and December 31, 2009. Both centers used initial observation of hemodynamically stable patients with blunt splenic injury, but one used angiography for patients with highergrade splenic injury (American Association for the Surgery of Trauma Organ Injury Scale [AAST OIS] score 35), evidence of vascular injury on abdominal computed tomography (CT), or for evidence of continued bleeding in hemodynamically stable patients. The other used surgery in these subgroups, based on attending preference. The review then was narrowed to those patients with an Injury Severity Score that was 20 or less, limiting chart reviews to patients with primarily isolated splenic injuries. Because of limitations in patient accrual, the review then was expanded to include an Injury Severity Score of less than 30 followed by electronic and paper chart review. This was performed to identify those patients who suffered an isolated splenic injury or those who had associated minor injuries in addition to their splenic injury that were deemed to not increase hospital length of stay per the principal investigator. Data collection included the following: patient demographics, injury (mechanism, severity, and details), initial vitals and laboratory values, procedures performed, need for mechanical ventilation or intensive care unit (ICU) admission, mechanical ventilation duration, ICU length of stay, blood products received, complications, hospital length of stay, disposition, mortality, need for re-admission, and hospital costs and charges. Patients were stratied into 3 groups: those admitted for observation, those undergoing immediate splenic embolization, and those undergoing immediate surgery (splenorrhaphy, splenectomy). Patients initially were compared on an intent-to-treat basis. Subsequent analyses were performed specically comparing patients treated with splenic embolization and surgical intervention. If patients were treated with embolization, but subsequently underwent surgical therapy, they were kept in the embolization treatment arm for the purposes of data analysis. Data were initially summarized. Quantitative data were analyzed with one-way analysis of variance. If heterogeneity of variance was identied, the MannWhitney test or the KruskalWallis test was used when comparing 2 or 3 treatment groups, respectively. Similarly, comparisons of ordinal data were analyzed with the MannWhitney test or the KruskalWallis test. Qualitative data were analyzed with

the Pearson chi-square analysis or the Fisher exact test in instances in which cell number was 5 or less observations. Results of statistical tests were considered signicant if the resultant P value was less than .05. This study was approved for implementation by the Institutional Review Boards of Via Christi Hospital and Wesley Medical Center, as well as the Human Subjects Committee of the University of Kansas School of Medicine Wichita.

Results
During the study period, a total of 606 patients were admitted with a diagnosis of blunt splenic injury. Of those, 236 patients were identied as having an isolated splenic injury or a splenic injury with other minor injuries that were deemed not to have increased their hospital length of stay. Of these patients, 195 patients initially were observed with serial abdominal examinations and scheduled blood draws, 30 underwent immediate angiography and splenic embolization (main and/or selective coiling), and 11 underwent immediate surgical treatment (splenorrhaphy, splenectomy) secondary to hemodynamic instability (n 3) or severity of injury (Table 1). Neither trauma center had a protocol in place to manage blunt splenic injuries; therefore, patients were subject to variations in treatments based on the preference of the trauma surgeon on call. Based on those preferences one trauma center treated splenic injuries more aggressively and tended to perform more splenectomies. This trauma center was responsible for care of 156 (64.5%) of the study subjects. The proportion of subjects initially treated by observation, embolization, and surgery was 88.5% (n 138), 7.1% (n 11), and 4.5% (n 7), respectively. The second trauma center took a more conservative approach that favored embolization. This trauma center was responsible for the care of 86 (35.5%) of the study subjects. The proportion of subjects initially treated by observation, embolization, and surgery at this hospital was 73.3% (n 63), 22.1% (n 19), and 4.7% (n 4), respectively. The proportion of subjects initially treated with observation, embolization, or surgery was signicantly different between the trauma centers (P .003). Sex, race, mechanism of injury, trauma activation level, initial systolic blood pressure and heart rate, Injury Severity Score, Glasgow Coma Scale score, AAST splenic injury grade, and proportion of positive focused abdominal sonography for trauma (FAST) results were not signicantly different among the 3 groups (Table 1). Patients in the surgical group were signicantly older than those who were initially observed for their splenic injuries (53.8 vs 31.9 y; P .001). Patients in the surgical group also had lower initial hematocrit values than observation patients (29.2 vs 37.1; P .001). There appeared to be a trend for embolization and surgery patients to have more positive FAST examina-

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The American Journal of Surgery, Vol 202, No 6, December 2011

Table 1 Comparison of demographics, mechanism of injury, initial vitals, and injury severity for patients managed initially by observation, embolization, or surgical intervention* Treatment group Parameter Number of subjects Age, y Male sex Race, white Mechanism Fall Motor vehicle collision Other Trauma level (I) Initial systolic blood pressure, mm Hg Initial systolic blood pressure 90 mm Hg Initial heart rate Initial hematocrit Injury severity score Glasgow coma scale score Splenic injury grade FAST (Pos)
*Means within a row with different superscripts (

Observation 195 31.2 18.5** 69.2 (135) 92.3% (180) 19.5% 62.1% 18.5% 18.9% 123.6 4 95.4 37.1 14.6 14.1 2.5 42.4% (38) (121) (36) (38) 22.7 (3.3%)** 21.4 6.8** 7.2 3.0 1.0** (28/66)

Embolization 30 39.0 19.9**, 73.3 (22) 100.0% (30) 33.3% 43.3% 23.3% 10.0% 126.0 0 92.0 35.1 15.5 14.9 3.6 66.7%
.05.

Surgery 11 53.8 19.7 63.6% (7) 90.9% (10) 45.5% 36.4% 18.2% 36.4% 107.4 3 92.0 29.2 18.5 13.9 3.9 72.7% (5) (4) (2) (4) 46.3 (27.3%) 16.7 9.8 6.7 3.6 .9 (8/11)

P value .001 .837 .781 .082

(10) (13) (7) (3) 20.0 (.0%)** 18.9 7.4**, 6.6 .4 .7 (20/30)

.540 .635 .010 .990 .001 .163 .424 .001 .102

,) are signicantly different, P

tions than the observation patients, but this was not statistically signicant (P .102). There was a signicantly higher incidence of admission hypotension in the surgical versus the embolization and observational groups (P .010). During the 5-year study, 9 patients (3.7%) failed their initial treatment and required further intervention (Table 2). Five patients failed observation (2.5%); 1 patient was treated successfully with embolization and 4 patients required splenectomy. Patient 1 was a 7-year-old boy who was injured during a fall and had a grade 4 splenic injury. He developed acute abdominal pain with decreasing hemoglobin levels. A repeat CT showed a blush and he was treated successfully with splenic embolization. Patient 2 was a 68-year-old man who fell, causing a grade 3 splenic injury. This patient suffered a myocardial infarction with a ventricular aneurysmal clot that necessitated therapeutic anticoagulation; therefore, he underwent subsequent splenectomy. Patient 3 was a 79-year-

Table 2 Comparison of initial treatment plan and nal treatment plan for blunt splenic injury patients Final treatment for data analysis 190 31 15

Treatment group Observation Embolization Surgery

Initial treatment 195 30 11

Failed initial treatment 5 (1 embolization, 4 splenectomy) 3 (3 splenectomy) 1 (1 reoperation)

old female motor vehicle crash victim who suffered a grade 3 splenic injury. She developed hypotension and abdominal pain on hospital day 3 with subsequent splenectomy. Patient 4 was a 48-year-old male motor vehicle crash victim who suffered a grade 2 splenic injury. This patient developed hypotension on his fourth hospital day, with delayed splenic rupture prompting splenectomy. The fth patient was a 62-year-old female fall victim with a grade 3 splenic injury who developed abdominal pain and hypotension on hospital day 4. This patient had a contrast allergy and underwent splenectomy. Three of the 30 patients (10%) initially treated with embolization failed that modality and required subsequent splenectomy. Two of these patients developed splenic abscesses that failed medical management and presented approximately 1 month after embolization. The rst patient, a 51-year-old male bicycle crash victim with a grade 4 splenic injury, underwent a laparoscopic partial splenectomy followed 2 weeks later by a total splenectomy. The second patient, a 31-year-old male fall victim with a grade 3 splenic injury, had a splenic abscess and empyema and was taken directly for splenectomy and thoracotomy/decortication. The third patient, a 62-yearold male motorcycle crash victim with a grade 4 splenic injury, required splenectomy for continued bleeding and hypotension. One patient who was treated initially with emergent splenectomy, required re-exploration 4 hours after surgery for ongoing bleeding from short gastric vessels. Those patients undergoing embolization (successful embolization in addition to those who failed embolization and underwent subsequent splenectomy) were compared with those patients who underwent surgical repair ini-

P.J.P. Bruce et al.

Blunt splenic injury management cost comparison

Table 4 Comparison of outcomes based on denitive management for patients treated with embolization or surgical intervention Treatment group Parameter Number of subjects Number of blood draws pRBC transfusion, yes Number of pRBC units transfused Number of FFP units transfused Number of cryoprecipitate units transfused Number of platelet units transfused Number of CT scans ICU admission, yes ICU days Mechanical ventilation, yes Ventilation days Hospital length of stay, d Complications, yes Mortality, yes Re-admissions, yes
FFP

813

tially (Table 3). Surgery patients were signicantly older than embolization patients (56.6 vs 38.0 y; P .004), tended to be admitted as Level 1 trauma evaluations more often (33.3% vs 9.7%; P .053), and had a trend toward having lower initial hemoglobin levels (30.5 vs 35.1; P .074) and higher incidence of initial hypotension. Surgery and embolization patients did not differ with regards to sex, race, mechanism of injury, initial systolic blood pressure or heart rate, injury severity, or incidence of positive FAST ndings. In comparing outcomes of patients undergoing splenic embolization versus surgical management (Table 4) there were no signicant differences noted for the number of blood samples drawn, proportion requiring ICU admission or ICU length of stay, number of days of mechanical ventilation required, complications, mortality, or re-admissions. Although hospital length of stay was not signicantly different between the groups, there was a trend toward shorter length of stay for embolization patients (P .109) who were discharged on average 2 days earlier than surgery patients. Signicantly more patients undergoing splenectomy required blood transfusion (93.3% vs 61.3%; P .035) and those surgery patients requiring transfusion required signicantly more units of packed red blood cells than embolization patients requiring transfusion (6.7 vs 2.7 U packed red blood cells; P .007). Surgery patients also required more blood products, including fresh-frozen plasma, cryoprecipitate, and platelets. Patients undergoing embolization had signiTable 3 Comparison of demographics, mechanism of injury, initial vitals, and injury severity based on denitive management for patients treated with embolization or surgical intervention Treatment group Parameter Number of subjects Age, y Male sex Race, white Mechanism Fall Motor vehicle collision Other Trauma Level I Initial systolic blood pressure, mm Hg Initial heart rate Initial hematocrit Injury severity score Glasgow Coma Scale score Splenic injury grade AIS abdomen/pelvis FAST (positive) Embolization 31 38.0 20.4 74.2% (23) 100.0% (31) 35.5% (11) 41.9% (13) 22.6% (7) 9.7% (3) 125.6 19.8 Surgery 15 56.6 18.3 60.0% (9) 93.3% (14) 46.7% (7) 40.0 (6) 13.3% (2) 33.3% (5) 111.0 40.7 P value .004 .327 .326 .781

Embolization 31 13.7 8.7

Surgery 15 13.3 9.5

P value .867 .035 .007 .022 .011

61.3% (19) 2.7 .3 .0 3.8 1.4 .0

93.3% (14) 6.7 1.6 .3 5.9 2.8 .7

.0 2.1

.0 1.2

.3 .8

.7 .7

.040 .001 .244 .748 .003 .345 .109 .311 .101 1.000

96.8% (30) 3.0 6.6 6.5% (2) 3.0 5.7 2.8 3.7

86.7% (13) 2.7 2.8 46.7% (7) 1.6 7.7 1.5 4.1

6.5% (2) .0% (0) 6.5% (2)

20.0% (3) 13.3% (2) .0% (0)

fresh-frozen plasma; pRBC

packed red blood cell.

.053 .439

92.5 35.1 15.6 14.9

18.8 7.3 6.5 .4

89.9 30.5 15.6 14.2

17.4 9.0 7.5 3.1

.657 .074 .849 .573 .890 .921 .820

3.7 .7 3.6 .8 67.7% (21)

3.6 1.0 3.5 1.1 64.3% (9)

cantly more CT scans performed during their hospitalization and in follow-up evaluation than splenectomy patients (2.1 vs .8; P .001). There was a nonsignicant trend toward increased mortality in the splenectomy group with 2 deaths (13.3%), compared with no deaths in the embolization group (P .101). In evaluating cost and charges, laboratory charges and cost for ICU days were not signicantly different for patients receiving embolization as compared with surgical management (Table 5). Although CT scan charges were signicantly higher in the embolization group ($12,067 vs $4,801; P .001), blood product charges (P .002) operating room charges, surgeon charge, and anesthesia charge all were signicantly higher in surgery patients than for embolization patients (P .001). Similarly, overall procedure-related charges (operating room, surgeon, anesthesia, embolization, and radiology embolization charges) were signicantly higher for surgery patients when compared with embolization patients ($28,709 vs $19,062; P .016). However, both total hospital costs (P .829) and total hospital charges (P .545) were not signicantly different between patients receiving embolization or surgical treatment.

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Table 5 Comparison of cost and charges based on denitive management for patients treated with embolization or surgical intervention Treatment group Parameter Laboratory charges Blood product charges CT scan charges ICU cost Operating room charges Surgeon charge Anesthesia charge Embolization charges Radiology embolization charge Total procedure charges Total hospital charges Total hospital cost
NA not applicable.

Embolization 1141 1684 12,067 4863 4016 189 156 13,680 1021 19,062 41,269 7045 598 2510 6378 10,936 13,014 623 509 653 0 14,025 31,128 11,837

Surgery 1184 5206 4801 3862 26,562 1176 971 0 0 28,709 46,356 6352 602 5666 4057 4468 6430 280 235 0 0 6941 11,334 4644

P value .821 .002 .001 .736 .001 .001 .001 NA NA .016 .545 .829

Comments
Nonsurgical management is the gold standard of treatment in blunt splenic injury in hemodynamically stable patients. This study supports this preference. In evaluating our data, 78% of patients with isolated blunt splenic injury were treated successfully by observation alone, 13% were treated with embolization and 9% were treated with splenectomy. This high percentage of observational patients with a low intent-to-treat failure rate is greater than most studies. The reasons behind this are unclear, but may be related to a signicant number of transfer patients who had time to fail observation before consultation. With the large proportion of patients treated by observation, it is clear that the high success of observation is not related to an overly restrictive selection bias (97.5%). Ten patients (4%) failed their initial treatment and required further evaluation and interventions with an increase in charges incurred. Both angioembolization and surgical therapy had statistically similar outcomes as primary and salvage treatment and are in line with prior literature.118 With limited patient numbers and no unied treatment protocol, it is difcult to comment on treatment efcacy. Despite the groups being statistically similar, except for splenic injury grade, there are some other underlying differences. Although only 3 of the initial surgery group and 4 of the observational group patients were hypotensive on arrival, there were likely elements of instability in the surgical group that we could not detect on retrospective review. The delayed-rupture patients were stabilized before surgery and likely could have been treated by surgery or angioembolization, although preference was given to surgery. Splenic injury grade was signicantly higher for embolization and surgery patients than for observation patients. In prior studies, a higher injury grade was predictive of higher nonsurgical failures, with improved splenic salvage

of 10% to 15% with embolization.1,3,4 With a signicantly higher grade in the embolized group with a similar failure rate, embolization does appear to improve salvage in this limited study. With most patients being embolized for pseudoaneurysm, not grade, one could question the use of angioembolization. Based on prior data from Davis et al,17 pseudoaneurysm, the most common indication for angioembolization at both facilities, has a failure rate of approximately 50%, with three fourths of pseudoaneurysms being seen on delayed scan. With only one failure in the embolization group secondary to bleeding in the rst 8 hours, the avoidance in delayed failures and improvement in salvage from the predicted 50% to 90%, there appears to be some efcacy. Continued prospective studies regarding the importance of pseudoaneurysm and grade are ongoing, but are outside the scope of this limited study. Therefore, the focus was on overall costs. Cost-conscious medical practice requires that thought be given to real utility before using expensive or limited hospital resources. Conversely, a more aggressive initial approach ultimately may be more cost effective given hospital or ICU stay is minimized. Splenic embolization had an initial success rate similar to prior studies, with a lower complication rate.2 4,8 17 It also had a signicantly lower procedural charge and trend toward decreased length of stay. This was balanced against higher radiographic charges and costs secondary to treatment failures. This could be owing to limited patient numbers. More importantly, there were no management protocols. In a prior work, the implementation of a splenic angioembolization protocol for splenic injury led to a decreased length of stay with a concomitant decrease in costs.2 These similar failure rates and costs are of interest, but do not address a primary concern: does the embolized spleen have adequate immunologic function to protect the patient? Data currently are limited to indirect evidence ex-

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cept for a review of embolized patients in France. Bessoud et al11 checked serum titers on patients and only one was deemed inadequate; this was in a patient with pre-existing cancer. Further study continues to answer this vital clinical, noneconomic question.

17. Davis KA, Fabian TC, Croce MA, et al. Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms. J Trauma 1998;44:1008 15. 18. Harbrecht BG, Ko SH, Watson GA, et al. Angiography for blunt splenic trauma does not improve the success rate of nonoperative management. J Trauma 2007;63:44 9.

Conclusions
Nonsurgical management in hemodynamically stable patients with blunt splenic injury remains preferred and effective from a clinical and cost standpoint. Splenic embolization remains a valuable adjunct to nonsurgical treatment of blunt splenic injury and trended toward being more cost effective with a decreased hospital length of stay, despite similar failure rates.

Discussion
Dr Jeffrey Johnson (East Lansing, MI): Dr. Haan continues his laudable effort to expand the body of literature on the use of embolization in hemodynamically stable patients with splenic injury. This work follows major contributions by the same author with respect to efcacy, complications, and technique. I have the following specic questions. I do apologize for the number of words, and at the risk of being a sesquipedalian, I will spell them out. Question number 1: since splenic embolization was not an option in the surgery group, the cost of surgery is presumably unavoidable. These were unstable patients. In contradistinction, for stable patients embolization is a choice and comparative cost-effectiveness data are lacking. Is the observation group actually the group against which the embolization should be measured? Number 2: it is argued that the three groupsthe observation, embolization, and surgery groupsrepresent isolated spleen injuries that are statistically similar. In that light, the success rate of observation alone appears higher than embolization. How many spleens were actually saved by embolization? What did we get for the money spent? And, parenthetically, why does the success rate of embolization diminish in proportion to geographic distance from Baltimore, with the possible exception of Cleveland? Number 3: a nonoperative approach is founded on the understanding that bleeding from solid organs in stable patients is predominantly self-limited. Todays dynamically contrasted computed tomograms with multidetector acquisition allow us to observe increasingly minor rates of bleeding. Are we now treating CT scans that poorly represent the condition of the patient? Dr Haan: Beginning with number 3 because that is probably the easiest and truly relevant. This has been a matter of debate, certainly at the last Western Trauma Association meeting we brought up the question, Are all blushes the same and are all pseudo-aneurysms the same? I think the answer is no because CT scans have become so sensitive, maybe not all of them need to be embolized. That is a study they are going to look at. There is also an ongoing AAST study regarding splenic management. So, that one I cannot answer, but I can tell you there are splenic vascular injuries that have been treated without embolization. If you believe Kim Davis work,17 they should have a 50% nonoperative failure rate. I did not put the specic injury/ indications for embolization data in the manuscript. Ap-

References
1. Peitzman AB, Heil B, Rivera L, et al. Blunt splenic injury in adults: multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma 2000;49:177 89. 2. Haan J, Ilahi ON, Kramer M, et al. Protocol-driven nonoperative management in patients with blunt splenic trauma and minimal associated injury decreases length of stay. J Trauma 2003;55:31722. 3. Haan JM, Bochicchio GV, Kramer N, et al. Nonoperative management of blunt splenic injury: a 5-year experience. J Trauma 2005;58:492 8. 4. Haan JM, Bif W, Knudson MM, et al. Splenic embolization revisited: a multicenter review. J Trauma 2004;56:5427. 5. Savage SA, Zarzaur BL, Magnotti LJ, et al. The evolution of blunt splenic injury: resolution and progression. J Trauma 2008;64:108592. 6. McCray VW, Davis JW, Lemaster D, et al. Observation for nonoperative management of the spleen: how long is long enough? J Trauma 2008;65:1354 8. 7. Smith J, Armen S, Cook CH, et al. Blunt splenic injuries: have we watched long enough? J Trauma 2008;64:656 65. 8. Wei B, Hemmila MR, Arbabi S, et al. Angioembolization reduces operative intervention for blunt splenic injury. J Trauma 2008;64: 14727. 9. Wahl WL, Ahrns KS, Chen S, et al. Blunt splenic injury: operation versus angiographic embolization. Surgery 2004;136:8919. 10. Raikhlin A, Baerlocher MO, Asch MR, et al. Imaging and transcatheter arterial embolization for traumatic splenic injuries: review of the literature. Can J Surg 2008;51:464 72. 11. Bessoud B, Duchosal MA, Siegrist CA, et al. Proximal splenic artery embolization for blunt splenic injury: clinical, immunologic, and ultrasound-Doppler follow-up. J Trauma 2007;62:1481 6. 12. Smith HE, Bif WL, Majercik SD, et al. Splenic artery embolization: have we gone too far? J Trauma 2006;61:541 6. 13. Cooney R, Ku J, Cherry R, et al. Limitations of splenic angioembolization in treating blunt splenic injury. J Trauma 2005;59:926 32. 14. Naess PA, Gaarder C, Dormagen JB. Nonoperative management of pediatric splenic injury with angiographic embolization. J Pediatr Surg 2005;40:E63 4. 15. Liu PP, Lee WC, Cheng YF, et al. Use of splenic artery embolization as an adjunct to nonsurgical management of blunt splenic injury. J Trauma 2004;56:768 73. 16. Firstenberg MS, Plaisier B, Newman JS, et al. Successful treatment of delayed splenic rupture with splenic artery embolization. Surgery 1998;123:584 6.

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The American Journal of Surgery, Vol 202, No 6, December 2011 lactates. As I was not responsible for either trauma facility during these periods and they were not done routinely, I have very, very limited data. However, going back, we are talking about less than one fth of the surgery people being unstable based on having a systolic blood pressure less than 90. So most of them did not get rushed off to the operating room because they are hypotensive in the operative group. This is as close as I have ever seen, in our country at least, of having the same patient population being treated in completely different ways. You have over two-thirds undergoing surgery at one trauma center based on softer markers of angiographic failure: they have a head injury, elderly, or large hemoperitoneum versus patients with similar indications undergoing angioembolization for their splenic injuries at the other institution.

proximately 75% of the people who got embolized, were embolized for pseudoaneurysms, a few were for active extravasation, and a few for massive hemoperitoneum. So, that is where I have a problem answering your question regarding how many spleens were saved by embolization because how many of those little pseudoaneurysms would have bled is unclear. As far as the observation being the comparison to embolization, I disagree. In the observation group, the splenic injury grade was only 2.5 versus 3.6 injury; hemoperitoneum was 40% versus 70% gross hemoperitoneum. In retrospect, it would have been great to go back and say how much hemoperitoneum; however, many in the operative group did not get a CT scan and the operative notes did not quantify the degree or quantity of hemoperitoneum. Similarly, I would also have liked to have had base excess and