Clinical Features, Paraclinical Findings, and Treatment Outcomes of Severe Traumatic Splenic Injury in Blunt Abdominal Trauma

Clinical Features, Paraclinical Findings, and Treatment Outcomes of Severe Traumatic Splenic Injury in Blunt Abdominal Trauma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Features, Paraclinical Findings, and Treatment Outcomes of Severe Traumatic Splenic Injury in Blunt Abdominal Trauma Van Tuan La, Minh Nghi Truong, Phuong Quynh Ma, Van Hau Phan, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9630873/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: The spleen is the most frequently injured solid abdominal organ in blunt abdominal trauma and carries a high risk of life-threatening haemorrhage. The World Society of Emergency Surgery (WSES) 2017 classification integrates computed tomography (CT) injury severity grading with haemodynamic status to guide management decisions and has been validated in international multicentre cohorts. This study characterises the clinical presentation, paraclinical findings, and treatment outcomes of severe traumatic splenic injury managed according to WSES criteria at a tertiary trauma centre in southern Vietnam. Methods A retrospective cohort analysis was performed on 31 consecutive patients with severe traumatic splenic injury, defined as American Association for the Surgery of Trauma (AAST) grade IV or V on contrast-enhanced CT or any AAST grade combined with haemodynamic instability (systolic blood pressure below 90 mmHg), treated between January 2018 and June 2021. Variables collected included patient demographics, haemodynamic parameters, imaging findings, treatment modality, blood product transfusion requirements, hospital length of stay, and clinical outcomes. Results Mean patient age was 33.1 ± 10 years and 77.4% of patients were male. Traffic-related accidents accounted for 64.5% of injuries. Haemodynamic instability (systolic blood pressure below 90 mmHg) was present in 74.2% of patients on arrival. CT demonstrated AAST grade IV injury in 74.2% of patients and active contrast extravasation in 48.4%. Nonoperative management (NOM) was successful in 80.7% (25 of 31 patients): medical management without intervention succeeded in 73.7% (14 of 19) and selective angioembolisation in 91.7% (11 of 12). Six patients (19.3%) required emergency splenectomy. No in-hospital deaths occurred. Mean hospital stay was 5.9 ± 2.7 days in NOM successes and 7.5 ± 2.4 days in surgical patients. Blood product transfusion was required by 58.1% of patients. Conclusion NOM of severe traumatic splenic injury classified by WSES criteria is safe and effective, achieving an 80.7% overall success rate with no mortality. Selective splenic artery angioembolisation substantially improves outcomes to 91.7% success and should be routinely offered to haemodynamically responsive patients with CT evidence of active arterial haemorrhage or pseudoaneurysm. CT findings of active contrast extravasation and large-volume free peritoneal fluid demonstrated clinical trends towards NOM failure consistent with the established literature, supporting their use in patient risk stratification. splenic injury blunt abdominal trauma nonoperative management angioembolisation selective embolisation WSES classification haemostasis splenectomy Introduction The spleen is the most commonly injured solid abdominal organ in blunt trauma and represents the leading cause of haemorrhage in patients with closed abdominal injuries.[ 1 , 25 ] Its anatomical position in the left upper abdomen beneath the lower rib cage, combined with its highly vascular parenchyma and large blood volume capacity, renders it particularly susceptible to injury from direct compressive forces and sudden deceleration mechanisms.[ 17 , 25 ] Haemorrhage from splenic injury may be rapid, profuse, and potentially fatal if not identified and treated promptly. Over the past four decades, the paradigm for splenic trauma management has undergone a fundamental transformation driven by increasing recognition of the critical immunological function of the spleen and advances in diagnostic and interventional technology. Whereas operative intervention was historically the default treatment for most splenic injuries, contemporary evidence-based practice prioritises organ preservation through selective NOM in haemodynamically stable patients. Large multicentre studies have demonstrated NOM success rates exceeding 95% in paediatric populations and above 80% in adults managed at experienced trauma centres.[ 4 , 22 ] The introduction of selective splenic artery embolisation has further extended the applicability of NOM to high-grade injuries with angiographic evidence of arterial haemorrhage, achieving haemostatic success rates of 85% to 92% in appropriately selected patients.[ 5 , 24 ] In 2017, the WSES published an evidence-based classification system that represented a significant methodological advance over the earlier AAST CT-grade-only approach by incorporating haemodynamic stability as an independent determinant of injury severity and management strategy.[ 2 ] The WSES system stratifies splenic injury into four groups across three severity levels: minor (WSES class I), moderate (WSES class II), and severe (WSES class III and IV). Severe injury is defined as either AAST grade IV or V on CT with haemodynamic stability (WSES class III) or any AAST grade with haemodynamic instability (WSES class IV), recognising that physiological compromise is at least as important as anatomical injury extent in determining clinical trajectory and treatment urgency.[ 2 , 15 ] The 2019 WSES validation study confirmed the prognostic utility of this classification in an international cohort.[ 15 ] Despite widespread adoption of this framework in high-income settings, published outcome data using WSES criteria from tertiary centres in Southeast Asia remain sparse, and the performance of NOM including angioembolisation in this clinical context has not been well characterised.[ 8 , 11 ] The present study aimed to describe the clinical presentation, paraclinical findings, and treatment outcomes of patients with severe traumatic splenic injury managed according to WSES criteria at a tertiary trauma centre in southern Vietnam. Methods Study Design and Setting A retrospective cohort study was conducted at Nhan Dan Gia Dinh Hospital, a tertiary-level public hospital in Ho Chi Minh City, Vietnam, equipped with a 24-hour emergency department, round-the-clock contrast-enhanced CT capability, a dedicated interventional radiology suite with splenic angiographic facilities, and surgical services for emergency laparotomy. All consecutive patients with severe traumatic splenic injury admitted between January 2018 and June 2021 were eligible for inclusion. Institutional ethics committee approval was obtained prior to data collection (Approval No. 381/HDDD-DHYD, Institutional Ethics Committee of the University of Medicine and Pharmacy at Ho Chi Minh City, dated 15 May 2020). Individual informed consent was waived because of the retrospective study design and absence of patient contact or additional intervention. Eligibility Criteria Patients were eligible for inclusion if they satisfied the WSES definition of severe splenic injury: (1) AAST grade IV or V splenic injury on contrast-enhanced CT imaging with haemodynamic stability (WSES class III); or (2) any AAST grade of splenic injury combined with haemodynamic instability, defined as persistent systolic blood pressure below 90 mmHg despite initial intravenous fluid resuscitation, or shock index (heart rate divided by systolic blood pressure) persistently above 1.0 (WSES class IV). Patients were excluded if they had a penetrating mechanism of injury, were under 15 years of age, had a composite Injury Severity Score above 50 that precluded attribution of clinical outcomes to splenic injury alone, had concurrent intra-abdominal injuries independently necessitating urgent laparotomy, were receiving long-term anticoagulant therapy or had a pre-existing coagulopathy, or had incomplete medical records precluding comprehensive outcome assessment. Data Collection and Variables Eligible patients were identified through a search of hospital coding records using International Classification of Diseases, Tenth Revision (ICD-10) code S36.0 (injury of spleen). A standardised data extraction form was used to collect the following variables: demographics (age, sex); injury mechanism; prehospital factors including alcohol use and time from injury to hospital arrival; haemodynamic parameters on emergency department arrival (systolic and diastolic blood pressure, heart rate, shock index); physical examination findings (abdominal wall injury, pain distribution, distension, peritoneal signs); admission laboratory findings including haemoglobin concentration; bedside ultrasonography findings (presence and estimated volume of free peritoneal fluid, visible splenic lesion morphology); contrast-enhanced CT findings (AAST injury grade, lesion morphology, presence of active contrast extravasation or pseudoaneurysm, peritoneal fluid volume); treatment modality; angiographic findings and intervention details where applicable; blood product transfusion volumes (packed red blood cells and fresh frozen plasma); intraoperative findings and surgical management; postoperative complications; hospital and intensive care unit (ICU) length of stay; and in-hospital mortality. Management decisions were made by the treating trauma surgeon in collaboration with the interventional radiologist according to institutional protocol. Haemodynamically stable patients without CT vascular injury were managed with strict bed rest, continuous vital sign monitoring, serial abdominal examination, repeat imaging as clinically indicated, and blood product transfusion guided by haemoglobin concentration and clinical parameters. Patients with CT evidence of active arterial haemorrhage or pseudoaneurysm were referred urgently for splenic angiography and selective embolisation. Emergency splenectomy was reserved for patients with haemodynamic deterioration unresponsive to resuscitation and blood product support, or for failure of angioembolisation to achieve haemostasis. Statistical Analysis Statistical analysis was performed using IBM SPSS Statistics version 22.0 (IBM Corporation, Armonk, New York, USA). Normally distributed continuous variables are reported as mean ± standard deviation (SD). Non-normally distributed continuous variables are reported as median with interquartile range (IQR). Categorical variables are reported as absolute counts with percentages. Differences in categorical variables between patients with successful NOM and those who failed NOM were compared using the chi-square test or Fisher exact test as appropriate for cell sizes. Odds ratios (OR) with 95% confidence intervals (CI) were calculated to estimate the magnitude of association between clinical and imaging variables and NOM failure. Between-group differences in transfusion volumes and hospital length of stay were assessed using one-way analysis of variance (ANOVA). A two-tailed P value below 0.05 was considered statistically significant. Results Demographics and Injury Characteristics Thirty-one patients with severe traumatic splenic injury were identified during the three-and-a-half-year study period. Patient age ranged from 17 to 58 years (mean 33.1 ± 10 years). The largest age group was 20 to 40 years, comprising 67.7% of the cohort (21 of 31), reflecting the predominant exposure of economically active adults to high-energy traumatic mechanisms. Male patients comprised 77.4% of the study population (24 of 31), yielding a male-to-female ratio of 3.4:1. Complete demographic and clinical data are presented in Table 1 . Traffic-related accidents were the most frequent injury mechanism, accounting for 64.5% of cases (20 of 31), followed by occupational injuries in 25.8% (8 of 31) and domestic accidents in 9.7% (3 of 31). Alcohol consumption prior to the injury event was confirmed by blood alcohol testing in 19.4% of patients (6 of 31). The majority of patients (74.4%, 23 of 31) arrived at hospital within six hours of injury, facilitating early comprehensive assessment and management. Haemodynamic compromise on arrival was pronounced. Systolic blood pressure below 90 mmHg was present in 74.2% (23 of 31) and shock index above 1.0 was documented in 77.4% (24 of 31). The correlation between these two haemodynamic parameters was statistically significant (P < 0.05), with 22 of 23 patients with systolic blood pressure below 90 mmHg also demonstrating shock index above 1.0. Heart rate above 100 beats per minute was present in 64.5% (20 of 31). All 31 patients reported abdominal pain on presentation. Abdominal distension was present in 54.8% (17 of 31) and peritoneal signs were elicited in 12.9% (4 of 31), a relatively low frequency consistent with the predominance of haemorrhagic rather than hollow viscus injury. Admission haemoglobin below 10 g/dL was present in 67.7% (21 of 31), though this initial value likely underestimates true haemorrhage volume because of haemoconcentration and incomplete haemodilution at the time of first measurement. Table 1 Demographic, Injury, and Clinical Characteristics of Patients with Severe Traumatic Splenic Injury (n = 31) Characteristic n Value or % Demographic Characteristics Age (years), mean ± SD 33.1 ± 10 Age range (years) 17 to 58 Patients aged 20 to 40 years 21 67.7 Male sex 24 77.4 Mechanism of Injury Traffic-related accident 20 64.5 Occupational injury 8 25.8 Domestic accident 3 9.7 Alcohol consumption prior to injury 6 19.4 Hospital arrival within 6 hours of injury 23 74.4 Clinical Findings on Arrival Systolic blood pressure below 90 mmHg 23 74.2 Shock index above 1.0 24 77.4 Heart rate above 100 beats per minute 20 64.5 Abdominal pain (all patients) 31 100.0 Abdominal distension 17 54.8 Peritoneal signs on abdominal examination 4 12.9 Haemoglobin below 10 g/dL on admission 21 67.7 SD: standard deviation; AAST: American Association for the Surgery of Trauma. Imaging Findings Bedside ultrasonography was performed in all 31 patients on emergency department arrival. Free intraperitoneal fluid was identified in 100% and splenic parenchymal injury was confirmed in 100% of cases (Table 2 ). On ultrasound, parenchymal contusion or intraparenchymal haematoma was the predominant finding (96.8%, 30 of 31), followed by subcapsular haematoma (58.1%, 13 of 31) and parenchymal laceration (38.7%, 12 of 31). Peritoneal fluid volume was classified as small to moderate in 83.9% and large in 16.1% of patients on initial ultrasonography. All 31 patients subsequently underwent contrast-enhanced CT. AAST grade IV injury was the most frequent CT grade, present in 74.2% (23 of 31); the remaining 8 patients had AAST grade II or III injuries that were included in the study cohort on the basis of meeting the haemodynamic instability criterion for WSES class IV. All 31 patients demonstrated parenchymal contusion or intraparenchymal haematoma (100%); parenchymal laceration was present in 87.1% (27 of 31) and subcapsular haematoma in 54.8% (17 of 31). Active contrast extravasation, indicating ongoing arterial haemorrhage, was identified on CT in 48.4% of patients (15 of 31) and constituted the primary indication for angiographic assessment. Of the 15 patients with CT evidence of active arterial haemorrhage, 12 were referred for diagnostic angiography combined with selective embolisation; 3 were transferred directly to operative management because of refractory haemodynamic instability that precluded the time required for an interventional approach. Among the 12 patients who underwent angiography, active arterial extravasation was confirmed angiographically in 66.7% (8 of 12), splenic artery pseudoaneurysm in 8.3% (1 of 12), and no vascular lesion was identified in 25.0% (3 of 12), illustrating the recognised occasional discordance between CT and angiographic findings attributable to spontaneous haemostasis or CT-to-angiography delay. Table 2 Imaging Findings in Patients with Severe Traumatic Splenic Injury (n = 31) Imaging Finding n % Bedside Ultrasonography (n = 31) Free intraperitoneal fluid identified 31 100.0 Splenic parenchymal injury confirmed 31 100.0 Ultrasound Splenic Lesion Morphology (n = 31) Subcapsular haematoma 13 58.1 Parenchymal contusion or intraparenchymal haematoma 30 96.8 Parenchymal laceration 12 38.7 Contrast-Enhanced CT: AAST Injury Grade (n = 31) AAST Grade II (included on haemodynamic instability criterion) 3 9.7 AAST Grade III (included on haemodynamic instability criterion) 5 16.1 AAST Grade IV 23 74.2 Contrast-Enhanced CT: Splenic Lesion Morphology (n = 31) Subcapsular haematoma 17 54.8 Parenchymal contusion or intraparenchymal haematoma 31 100.0 Parenchymal laceration 27 87.1 Active contrast extravasation (arterial blush)¹ 15 48.4 Free peritoneal fluid: small to moderate volume 26 83.9 Free peritoneal fluid: large volume 5 16.1 Splenic Angiography (n = 12)² Active arterial extravasation confirmed angiographically 8 66.7 Splenic artery pseudoaneurysm 1 8.3 No vascular lesion identified on angiography 3 25.0 CT: computed tomography; AAST: American Association for the Surgery of Trauma. ¹ Active contrast extravasation (arterial blush): a focal hyperdensity on contrast-enhanced CT indicating active arterial haemorrhage into the peritoneal cavity or splenic parenchyma. ² Angiography was performed in 12 of the 15 patients with CT extravasation; 3 patients proceeded directly to operative management because of haemodynamic instability unresponsive to resuscitation. Treatment Modalities and Clinical Outcomes Initial management assignment was based on haemodynamic status and CT findings according to institutional protocol. Nineteen patients (61.3%) were assigned to medical management without intervention, comprising strict bed rest, continuous haemodynamic monitoring with hourly vital sign recording, serial abdominal examination, blood product transfusion guided by haemoglobin thresholds and clinical assessment, and serial imaging at clinically indicated intervals. Twelve patients (38.7%) with CT evidence of active arterial haemorrhage or pseudoaneurysm were referred urgently for splenic angiography and selective embolisation. Treatment outcomes are presented in Table 3 . Overall NOM was successful in 25 of 31 patients (80.7%). Among patients assigned to medical management without intervention, 73.7% (14 of 19) achieved haemostasis and were discharged without operative intervention. Selective splenic artery angioembolisation achieved haemostasis and successful NOM in 91.7% (11 of 12) of patients referred for the procedure, representing a markedly superior success rate compared with medical management alone. Six patients (19.3%) required emergency operative intervention, comprising five from the medical management group who experienced progressive haemodynamic deterioration unresponsive to resuscitation, and one patient from the angioembolisation group in whom the procedure failed to achieve durable haemostasis. Operative findings and postoperative details are described separately below and presented in Table 6 . Blood product transfusion was required by 58.1% (18 of 31) of patients overall. Mean transfusion volume was 714.3 ± 418.1 mL (range 250 to 1450 mL) in the medical management group, 791.7 ± 592.8 mL (range 250 to 1550 mL) in the angioembolisation group, and 850.0 ± 519.6 mL (range 500 to 1750 mL) in the operative group. Between-group differences in transfusion volume were not statistically significant (P > 0.05), reflecting the predominant influence of initial haemorrhage severity rather than treatment modality on transfusion requirements. No in-hospital deaths occurred in any treatment group. Detailed transfusion and hospital stay data are presented in Table 5 . Table 3 Treatment Modalities and Outcomes in Patients with Severe Traumatic Splenic Injury (n = 31) Treatment Modality Patients, n (%) NOM Success, n/N (%) Medical management without intervention 19 (61.3) 14/19 (73.7) Selective splenic artery angioembolisation 12 (38.7) 11/12 (91.7) Total NOM successes 25/31 80.7% Operative conversion (total splenectomy) 6 (19.3) Not applicable In-hospital mortality 0 0% NOM: nonoperative management. Indications, Intraoperative Findings, and Postoperative Course in Operative Cases Operative indications, intraoperative findings, and postoperative data for the six patients requiring surgical intervention are presented in Table 6 . All six patients underwent open laparotomy; a laparoscopic approach was not used owing to haemodynamic instability in all cases. Active intraoperative haemorrhage was confirmed in all six patients. Total splenectomy was performed in five patients (83.3%); one patient (16.7%) had a limited parenchymal laceration with controlled haemorrhage amenable to diathermy coagulation and splenic preservation. Mean intraoperative blood loss was 1833.3 ± 467.6 mL. Autologous intraoperative blood salvage using cell-salvage technology was employed in three of six patients, yielding a mean reinfusion volume of 1178.3 ± 714.8 mL and substantially reducing allogeneic transfusion requirements in these cases. Postoperative complications were recorded in three patients: one patient developed postoperative haemorrhage that was managed conservatively with blood product support, haemostatic agents, and serial drain output monitoring, with cessation of haemorrhage confirmed prior to drain removal; two patients developed small-volume pleural effusions that resolved spontaneously without drainage. No surgical site infections or intra-abdominal abscesses were identified. Mean hospital length of stay in the operative group was 7.5 ± 2.4 days (range 5 to 12 days). Variables Associated with Nonoperative Management Failure Clinical and imaging characteristics of patients with successful NOM (n = 25) and those who failed NOM (n = 6) are compared in Table 4 . Examination of the failure group reveals that all six patients who failed NOM had systolic blood pressure below 90 mmHg on arrival (83.3% vs 72.0% in the success group) and AAST grade IV injury on CT (83.3% vs 72.0%). Active contrast extravasation on CT was present in 66.7% of failure patients compared with 44.0% of those who succeeded with NOM. Despite these numerical differences, none of the clinical or imaging variables examined reached statistical significance as an independent predictor of NOM failure (all P > 0.05), with odds ratios and 95% confidence intervals consistent with no statistically demonstrable association at this sample size. Specifically, the odds ratio for NOM failure associated with CT contrast extravasation was 2.57 (95% CI 0.39 to 17.0, P > 0.05), and the odds ratio associated with large-volume free peritoneal fluid was 1.05 (95% CI 0.10 to 11.56, P > 0.05). These findings reflect the inherent limitations of a retrospective single-institution study with a small sample size (n = 31), which is substantially underpowered to detect associations of the magnitude established in larger multicentre series. The clinical direction of association for CT extravasation (higher failure rate in patients with extravasation) is consistent with the established predictive literature and supports the continued clinical use of this finding in risk stratification. Table 4 Variables Associated with Nonoperative Management Failure in Severe Traumatic Splenic Injury Variable NOM Success (n = 25), n (%) NOM Failure (n = 6), n (%) Systolic blood pressure below 90 mmHg on arrival 18 (72.0) 5 (83.3) AAST grade IV injury on contrast-enhanced CT 18 (72.0) 5 (83.3) Shock index above 1.0 on arrival 19 (76.0) 5 (83.3) Hospital arrival within 6 hours of injury 19 (76.0) 4 (66.7) Active contrast extravasation on CT (arterial blush) 11 (44.0) 4 (66.7) Large-volume free peritoneal fluid on CT 4 (16.0) 1 (16.7) NOM: nonoperative management; CT: computed tomography; AAST: American Association for the Surgery of Trauma. All between-group differences P > 0.05. No variable reached statistical significance as an independent predictor of NOM failure in this series, attributable to limited statistical power with n = 31. Active contrast extravasation: focal arterial hyperdensity on contrast-enhanced CT. Large-volume free peritoneal fluid: haemoperitoneum tracking through more than four peritoneal compartments on CT. Table 5 Blood Product Transfusion Requirements and Hospital Length of Stay by Treatment Group Treatment Group Patients requiring transfusion, n (%) Mean blood product volume transfused (mL), mean ± SD (range) Hospital length of stay (days), mean ± SD (range) Medical management alone (n = 14) 7 (50.0) 714.3 ± 418.1 (250 to 1450) 5.9 ± 2.8 (2 to 13) Angioembolisation (n = 11) 6 (54.5) 791.7 ± 592.8 (250 to 1550) 5.9 ± 2.7 (3 to 12) Operative intervention (n = 6) 5 (83.3) 850.0 ± 519.6 (500 to 1750) 7.5 ± 2.4 (5 to 12) All patients (n = 31) 18 (58.1) 777.8 ± 418.5 (250 to 1750) 6.2 ± 2.7 (2 to 13) SD: standard deviation. Between-group differences for transfusion volume and hospital stay were not statistically significant (P > 0.05, one-way ANOVA). Blood products include packed red blood cells and fresh frozen plasma administered from admission through discharge. Table 6 Operative Indications, Intraoperative Findings, and Postoperative Course in Patients Requiring Surgical Intervention (n = 6) Variable Value Indications for Operative Intervention (n = 6) Haemodynamic deterioration unresponsive to resuscitation 6/6 (100.0%) Failed angioembolisation requiring operative conversion 1/6 (16.7%) Delayed (two-stage) splenic rupture 1/6 (16.7%) Intraoperative Findings and Surgical Management (n = 6) Surgical approach Open laparotomy: 6/6 (100%) Active haemorrhage confirmed at operation 6/6 (100%) Total splenectomy performed 5/6 (83.3%) Splenic preservation by diathermy haemostasis 1/6 (16.7%) Mean intraoperative blood loss (mL), mean ± SD 1833.3 ± 467.6 Autologous intraoperative blood salvage (cell salvage) used 3/6 (50.0%) Mean cell salvage volume reinfused (mL), mean ± SD 1178.3 ± 714.8 Mean operative duration (minutes), mean ± SD (range) 100.0 ± 34.5 (80 to 170) Postoperative Course (n = 6) Abdominal drain placed routinely 6/6 (100%) Drain removal, mean ± SD (days) (range) 4.3 ± 1.0 (3 to 6) Return of bowel function, mean ± SD (days) (range) 2.8 ± 0.8 (2 to 4) Postoperative haemorrhage (managed conservatively) 1/6 (16.7%) Pleural effusion (resolved without intervention) 2/6 (33.3%) Surgical site infection 0/6 (0%) Hospital length of stay, mean ± SD (days) (range) 7.5 ± 2.4 (5 to 12) SD: standard deviation. Cell-salvage technology: intraoperative autologous blood recovery, centrifugation, washing, and reinfusion of the patient's own erythrocytes to minimise allogeneic transfusion requirements. Multiple indications recorded per patient where applicable; total may exceed 100%. Discussion This study demonstrates that NOM of severe traumatic splenic injury, classified using WSES 2017 criteria, is both safe and effective at a tertiary trauma centre in southern Vietnam, achieving an overall NOM success rate of 80.7% with no in-hospital mortality. These outcomes are consistent with the large body of international evidence supporting NOM as the treatment of choice for haemodynamically stable patients with splenic injury, irrespective of CT injury grade. Peitzman and colleagues, in a landmark multicentre study of 1,488 adult patients across 27 North American trauma centres, reported a composite NOM success rate of 89.2%.[ 4 ] Systematic reviews and meta-analyses of NOM in high-grade splenic injuries consistently report success rates ranging from 80% to 90% at experienced centres.[ 5 , 6 , 22 ] The modest difference between our overall success rate and those reported by higher-volume Western centres is likely attributable, at least in part, to our inclusion of all WSES class IV patients, including those with haemodynamic instability on arrival, a higher-risk subgroup that many centres in the published literature manage operatively as a matter of institutional protocol. The demographic profile of our cohort, characterised by a predominance of young adult males injured in traffic-related accidents (64.5%), is consistent with the epidemiology of splenic trauma reported across Southeast Asian and global series.[ 1 , 7 , 25 ] Cadeddu and colleagues reported a male-to-female ratio of 4.3:1 in their Canadian series of 266 patients,[ 7 ] while our cohort demonstrated a ratio of 3.4:1. The notably elevated rate of haemodynamic instability at presentation (74.2% of patients with systolic blood pressure below 90 mmHg) reflects the definitional requirement for haemodynamic compromise in the WSES class IV subgroup, and may additionally reflect longer prehospital transport intervals typical of the regional setting. The statistically significant correlation between systolic blood pressure below 90 mmHg and shock index above 1.0 (P < 0.05) observed in this cohort validates the utility of shock index as a complementary haemodynamic assessment tool and supports its inclusion in clinical triage protocols, consistent with current WSES guideline recommendations. The substantially superior success rate of selective angioembolisation (91.7%) compared with medical management alone (73.7%) in this series is consistent with an extensive and growing body of evidence supporting the integration of interventional radiology into NOM protocols. Bhullar and colleagues, in a study of more than 1,000 adult trauma patients, demonstrated that selective angioembolisation significantly reduced NOM failure rates compared with observation alone.[ 18 ] Wei and colleagues similarly reported that access to embolisation substantially reduced operative conversion rates at their centre.[ 19 ] Meta-analyses and systematic reviews have established embolisation success rates of 85% to 92% in appropriately selected patients with CT evidence of vascular injury.[ 5 , 24 ] The present findings corroborate this evidence and support the recommendation that centres treating significant volumes of severe splenic trauma should develop dedicated interventional radiology capacity for this indication. Notably, the employment of intraoperative autologous blood salvage (cell-salvage technology) in three of the six operative patients yielded a mean reinfusion volume of 1178.3 ± 714.8 mL, substantially offsetting allogeneic transfusion requirements and representing a valuable adjunct in settings with limited blood bank capacity. Although CT contrast extravasation was observed in a higher proportion of NOM failure patients (66.7%) than successes (44.0%), and the calculated odds ratio of 2.57 indicates a clinically plausible direction of association, this finding did not reach statistical significance (P > 0.05) in this series. Similarly, large-volume free peritoneal fluid showed no meaningful association with NOM outcome (OR 1.05, P > 0.05). These results must be interpreted in the context of the study's most important limitation: with only 31 patients and only 6 NOM failures, the study is substantially underpowered to detect associations of the magnitude that prior literature has identified. Federle and colleagues were among the first to characterise active arterial extravasation on CT as a clinically important predictor of NOM failure and ongoing haemorrhage requiring intervention,[ 9 ] a finding subsequently confirmed in multiple independent cohorts and systematic reviews.[ 10 , 21 ] The failure of the present study to reproduce statistical significance for this association is most plausibly attributed to insufficient sample size rather than a true absence of association, as the direction of the numerical difference is consistent with prior literature. Future multicentre prospective studies with adequate statistical power will be required to definitively characterise the predictive value of these CT findings in the Vietnamese and broader Southeast Asian trauma population. Several limitations of this study warrant acknowledgement. First, the retrospective design introduces the possibility of incomplete or inconsistent documentation despite systematic data extraction using a pre-specified form. Second, the small sample size (n = 31) substantially limits statistical power for subgroup analyses and predictor identification, resulting in wide confidence intervals around odds ratio estimates. Third, the single-institution design limits generalisability across centres with different resources, case volumes, and patient demographics. Fourth, follow-up data beyond the index hospital admission were not available, precluding assessment of delayed complications including splenic infarction, pseudocyst formation, late pseudoaneurysm rupture, and long-term immune function in patients who underwent splenectomy. Prospective multicentre studies with extended post-discharge follow-up protocols are required to address these limitations and provide robust evidence to guide clinical practice. Conclusion Nonoperative management of severe traumatic splenic injury classified according to WSES 2017 criteria is safe, effective, and associated with no in-hospital mortality, achieving an overall success rate of 80.7% in this series. Selective splenic artery angioembolisation substantially improves haemostatic outcomes, achieving 91.7% success, and should be routinely offered to haemodynamically responsive patients with CT evidence of active arterial haemorrhage or pseudoaneurysm. CT findings of active contrast extravasation and large-volume free peritoneal fluid demonstrated numerical trends towards NOM failure consistent with the established predictive literature, and their use in clinical risk stratification and management decision-making is supported, notwithstanding the absence of statistical significance in this underpowered series. Intraoperative autologous blood salvage represents a valuable adjunct to operative management in resource-limited settings. These findings support the WSES classification as a practical and evidence-based framework for guiding treatment decisions in severe splenic trauma and provide preliminary outcome data for a Southeast Asian tertiary care context. Declarations Conflict of Interest: The authors declare that there is no conflict of interest. Ethical Approval: This study was approved by the Institutional Ethics Committee of the University of Medicine and Pharmacy at Ho Chi Minh City (Approval No. 381/HDDD-DHYD, dated 15 May 2020). Informed consent was waived owing to the retrospective study design. Contributorship V.T.L. and K.N.P. conceived and designed the study. V.T.L., M.N.T., and P.Q.M. identified eligible patients and extracted data. K.N.P. performed statistical analysis and drafted the initial manuscript. V.H.P. and T.N.N. performed interventional radiology procedures and contributed clinical expertise to data interpretation. P.T.N. assisted with additional data analysis and manuscript revision. All authors reviewed and critically revised the manuscript and approved the final submitted version. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Acknowledgements: The authors thank the Department of General Surgery at Nhan Dan Gia Dinh Hospital, Ho Chi Minh City, Vietnam, for their assistance with patient care and data collection. Data Availability: The data that support the findings of this study are available from the corresponding author (Kim Ngan Phung; [email protected] ) upon reasonable request. References Wiik Larsen J, Soreide K, Soreide JA et al (2022) Epidemiology of abdominal trauma: an age and sex adjusted incidence analysis with mortality patterns. Injury 53(12):3130–3138 Coccolini F, Montori G, Catena F et al (2017) Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg 12:40 Rutledge R, Hunt JP, Lentz CW et al (1995) A statewide, population based time series analysis of the increasing frequency of nonoperative management of abdominal solid organ injury. 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Injury 43(9):1337–1346 Federle MP, Courcoulas AP, Powell M et al (1998) Blunt splenic injury in adults: clinical and CT criteria for management, with emphasis on active extravasation. Radiology 206(1):137–142 Olthof DC, Joosse P, van der Vlies CH et al (2013) Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: a systematic review. J Trauma Acute Care Surg 74(2):546–557 Stassen NA, Bhullar I, Cheng JD et al (2012) Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 73(5 Suppl 4):S294–S300 Ekeh AP, McCarthy MC, Woods RJ et al (2005) Complications arising from splenic embolization after blunt splenic trauma. Am J Surg 189(3):335–339 Cocanour CS, Moore FA, Ware DN et al (1998) Delayed complications of nonoperative management of blunt adult splenic trauma. Arch Surg 133(6):619–624 Kozar RA, Crandall M, Shanmuganathan K et al (2018) Organ injury scaling 2018 update: spleen, liver, and kidney. J Trauma Acute Care Surg 85(6):1119–1122 Coccolini F, Fugazzola P, Morganti L et al (2019) The World Society of Emergency Surgery (WSES) spleen trauma classification: a useful tool in the management of splenic trauma. World J Emerg Surg 14:30 Davis KA, Fabian TC, Croce MA et al (1998) Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms. J Trauma 44(6):1008–1013 Velmahos GC, Toutouzas KG, Radin R et al (2003) Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg 138(8):844–851 Bhullar IS, Frykberg ER, Siragusa D et al (2012) Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management. J Trauma Acute Care Surg 72(5):1127–1134 Wei B, Hemmila MR, Arbabi S et al (2008) Angioembolization reduces operative intervention for blunt splenic injury. J Trauma 64(6):1472–1477 Harbrecht BG, Ko SH, Watson GA et al (2007) Angiography for blunt splenic trauma does not improve the success rate of nonoperative management. J Trauma 63(1):44–49 Gavant ML, Schurr M, Flick PA et al (1997) Predicting clinical outcome of nonsurgical management of blunt splenic injury: using CT to reveal abnormalities of splenic vasculature. AJR Am J Roentgenol 168(1):207–212 Meira JD, Menegozzo CA, Rocha MC et al (2021) Non-operative management of blunt splenic trauma: evolution, results and controversies. Rev Col Bras Cir 48:e20202777 Rowell SE, Biffl WL, Brasel K et al (2017) Western Trauma Association critical decisions in trauma: management of adult blunt splenic trauma, 2016 updates. J Trauma Acute Care Surg 82(5):787–793 Crichton JCI, Naidoo K, Yet B et al (2017) The role of splenic angioembolization as an adjunct to nonoperative management of blunt splenic injuries: a systematic review and meta-analysis. J Trauma Acute Care Surg 83(5):934–943 Forsythe RM, Harbrecht BG, Peitzman AB (2006) Blunt splenic trauma. Scand J Surg 95(3):146–151 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9630873","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":635526636,"identity":"c36fac39-e401-4ff8-8e89-47d26906bcee","order_by":0,"name":"Van Tuan La","email":"","orcid":"","institution":"Department of General Surgery, 175 Military Hospital, Ho Chi Minh City, Vietnam","correspondingAuthor":false,"prefix":"","firstName":"Van","middleName":"Tuan","lastName":"La","suffix":""},{"id":635526637,"identity":"6e581d6e-a846-4a25-b049-1d082e516755","order_by":1,"name":"Minh Nghi Truong","email":"","orcid":"","institution":"Department of General Surgery, 175 Military Hospital, Ho Chi Minh City, Vietnam","correspondingAuthor":false,"prefix":"","firstName":"Minh","middleName":"Nghi","lastName":"Truong","suffix":""},{"id":635526638,"identity":"d9f56cb4-cb23-44b4-9e6e-7a20ab57b639","order_by":2,"name":"Phuong Quynh Ma","email":"","orcid":"","institution":"Department of General Surgery, 175 Military Hospital, Ho Chi Minh City, Vietnam","correspondingAuthor":false,"prefix":"","firstName":"Phuong","middleName":"Quynh","lastName":"Ma","suffix":""},{"id":635526639,"identity":"09940b42-cf0f-4d36-b18b-2d5267675b55","order_by":3,"name":"Van Hau Phan","email":"","orcid":"","institution":"Department of General Surgery, 175 Military Hospital, Ho Chi Minh City, Vietnam","correspondingAuthor":false,"prefix":"","firstName":"Van","middleName":"Hau","lastName":"Phan","suffix":""},{"id":635526640,"identity":"f587248b-4eb5-45ff-ba12-375304cb05d6","order_by":4,"name":"Phu Thong Nguyen","email":"","orcid":"","institution":"Department of General Surgery, 175 Military Hospital, Ho Chi Minh City, Vietnam","correspondingAuthor":false,"prefix":"","firstName":"Phu","middleName":"Thong","lastName":"Nguyen","suffix":""},{"id":635526641,"identity":"95a74f02-2165-40c1-83b5-2fcdbe03e672","order_by":5,"name":"Thanh Nam Nguyen","email":"","orcid":"","institution":"Department of General Surgery, 175 Military Hospital, Ho Chi Minh City, Vietnam","correspondingAuthor":false,"prefix":"","firstName":"Thanh","middleName":"Nam","lastName":"Nguyen","suffix":""},{"id":635526642,"identity":"33bf8428-bbf9-4769-8d72-6998cb304ea3","order_by":6,"name":"Kim Ngan Phung","email":"data:image/png;base64,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","orcid":"https://orcid.org/0009-0001-8074-723X","institution":"Department of Exercise Physiology, Midwestern State University, Wichita Falls, Texas, USA","correspondingAuthor":true,"prefix":"","firstName":"Kim","middleName":"Ngan","lastName":"Phung","suffix":""}],"badges":[],"createdAt":"2026-05-06 12:52:11","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9630873/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9630873/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108675541,"identity":"b6838188-4efa-49dd-8a5d-33e3676d4a0c","added_by":"auto","created_at":"2026-05-07 08:26:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":349708,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9630873/v1/fdb41678-7206-4db3-94dd-4317d1b6d88d.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eClinical Features, Paraclinical Findings, and Treatment Outcomes of Severe Traumatic Splenic Injury in Blunt Abdominal Trauma\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe spleen is the most commonly injured solid abdominal organ in blunt trauma and represents the leading cause of haemorrhage in patients with closed abdominal injuries.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Its anatomical position in the left upper abdomen beneath the lower rib cage, combined with its highly vascular parenchyma and large blood volume capacity, renders it particularly susceptible to injury from direct compressive forces and sudden deceleration mechanisms.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Haemorrhage from splenic injury may be rapid, profuse, and potentially fatal if not identified and treated promptly.\u003c/p\u003e \u003cp\u003eOver the past four decades, the paradigm for splenic trauma management has undergone a fundamental transformation driven by increasing recognition of the critical immunological function of the spleen and advances in diagnostic and interventional technology. Whereas operative intervention was historically the default treatment for most splenic injuries, contemporary evidence-based practice prioritises organ preservation through selective NOM in haemodynamically stable patients. Large multicentre studies have demonstrated NOM success rates exceeding 95% in paediatric populations and above 80% in adults managed at experienced trauma centres.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] The introduction of selective splenic artery embolisation has further extended the applicability of NOM to high-grade injuries with angiographic evidence of arterial haemorrhage, achieving haemostatic success rates of 85% to 92% in appropriately selected patients.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn 2017, the WSES published an evidence-based classification system that represented a significant methodological advance over the earlier AAST CT-grade-only approach by incorporating haemodynamic stability as an independent determinant of injury severity and management strategy.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] The WSES system stratifies splenic injury into four groups across three severity levels: minor (WSES class I), moderate (WSES class II), and severe (WSES class III and IV). Severe injury is defined as either AAST grade IV or V on CT with haemodynamic stability (WSES class III) or any AAST grade with haemodynamic instability (WSES class IV), recognising that physiological compromise is at least as important as anatomical injury extent in determining clinical trajectory and treatment urgency.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] The 2019 WSES validation study confirmed the prognostic utility of this classification in an international cohort.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDespite widespread adoption of this framework in high-income settings, published outcome data using WSES criteria from tertiary centres in Southeast Asia remain sparse, and the performance of NOM including angioembolisation in this clinical context has not been well characterised.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] The present study aimed to describe the clinical presentation, paraclinical findings, and treatment outcomes of patients with severe traumatic splenic injury managed according to WSES criteria at a tertiary trauma centre in southern Vietnam.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eA retrospective cohort study was conducted at Nhan Dan Gia Dinh Hospital, a tertiary-level public hospital in Ho Chi Minh City, Vietnam, equipped with a 24-hour emergency department, round-the-clock contrast-enhanced CT capability, a dedicated interventional radiology suite with splenic angiographic facilities, and surgical services for emergency laparotomy. All consecutive patients with severe traumatic splenic injury admitted between January 2018 and June 2021 were eligible for inclusion. Institutional ethics committee approval was obtained prior to data collection (Approval No. 381/HDDD-DHYD, Institutional Ethics Committee of the University of Medicine and Pharmacy at Ho Chi Minh City, dated 15 May 2020). Individual informed consent was waived because of the retrospective study design and absence of patient contact or additional intervention.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cp\u003ePatients were eligible for inclusion if they satisfied the WSES definition of severe splenic injury: (1) AAST grade IV or V splenic injury on contrast-enhanced CT imaging with haemodynamic stability (WSES class III); or (2) any AAST grade of splenic injury combined with haemodynamic instability, defined as persistent systolic blood pressure below 90 mmHg despite initial intravenous fluid resuscitation, or shock index (heart rate divided by systolic blood pressure) persistently above 1.0 (WSES class IV). Patients were excluded if they had a penetrating mechanism of injury, were under 15 years of age, had a composite Injury Severity Score above 50 that precluded attribution of clinical outcomes to splenic injury alone, had concurrent intra-abdominal injuries independently necessitating urgent laparotomy, were receiving long-term anticoagulant therapy or had a pre-existing coagulopathy, or had incomplete medical records precluding comprehensive outcome assessment.\u003c/p\u003e\n\u003ch3\u003eData Collection and Variables\u003c/h3\u003e\n\u003cp\u003eEligible patients were identified through a search of hospital coding records using International Classification of Diseases, Tenth Revision (ICD-10) code S36.0 (injury of spleen). A standardised data extraction form was used to collect the following variables: demographics (age, sex); injury mechanism; prehospital factors including alcohol use and time from injury to hospital arrival; haemodynamic parameters on emergency department arrival (systolic and diastolic blood pressure, heart rate, shock index); physical examination findings (abdominal wall injury, pain distribution, distension, peritoneal signs); admission laboratory findings including haemoglobin concentration; bedside ultrasonography findings (presence and estimated volume of free peritoneal fluid, visible splenic lesion morphology); contrast-enhanced CT findings (AAST injury grade, lesion morphology, presence of active contrast extravasation or pseudoaneurysm, peritoneal fluid volume); treatment modality; angiographic findings and intervention details where applicable; blood product transfusion volumes (packed red blood cells and fresh frozen plasma); intraoperative findings and surgical management; postoperative complications; hospital and intensive care unit (ICU) length of stay; and in-hospital mortality.\u003c/p\u003e \u003cp\u003eManagement decisions were made by the treating trauma surgeon in collaboration with the interventional radiologist according to institutional protocol. Haemodynamically stable patients without CT vascular injury were managed with strict bed rest, continuous vital sign monitoring, serial abdominal examination, repeat imaging as clinically indicated, and blood product transfusion guided by haemoglobin concentration and clinical parameters. Patients with CT evidence of active arterial haemorrhage or pseudoaneurysm were referred urgently for splenic angiography and selective embolisation. Emergency splenectomy was reserved for patients with haemodynamic deterioration unresponsive to resuscitation and blood product support, or for failure of angioembolisation to achieve haemostasis.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using IBM SPSS Statistics version 22.0 (IBM Corporation, Armonk, New York, USA). Normally distributed continuous variables are reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). Non-normally distributed continuous variables are reported as median with interquartile range (IQR). Categorical variables are reported as absolute counts with percentages. Differences in categorical variables between patients with successful NOM and those who failed NOM were compared using the chi-square test or Fisher exact test as appropriate for cell sizes. Odds ratios (OR) with 95% confidence intervals (CI) were calculated to estimate the magnitude of association between clinical and imaging variables and NOM failure. Between-group differences in transfusion volumes and hospital length of stay were assessed using one-way analysis of variance (ANOVA). A two-tailed P value below 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDemographics and Injury Characteristics\u003c/h2\u003e \u003cp\u003eThirty-one patients with severe traumatic splenic injury were identified during the three-and-a-half-year study period. Patient age ranged from 17 to 58 years (mean 33.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10 years). The largest age group was 20 to 40 years, comprising 67.7% of the cohort (21 of 31), reflecting the predominant exposure of economically active adults to high-energy traumatic mechanisms. Male patients comprised 77.4% of the study population (24 of 31), yielding a male-to-female ratio of 3.4:1. Complete demographic and clinical data are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eTraffic-related accidents were the most frequent injury mechanism, accounting for 64.5% of cases (20 of 31), followed by occupational injuries in 25.8% (8 of 31) and domestic accidents in 9.7% (3 of 31). Alcohol consumption prior to the injury event was confirmed by blood alcohol testing in 19.4% of patients (6 of 31). The majority of patients (74.4%, 23 of 31) arrived at hospital within six hours of injury, facilitating early comprehensive assessment and management.\u003c/p\u003e \u003cp\u003eHaemodynamic compromise on arrival was pronounced. Systolic blood pressure below 90 mmHg was present in 74.2% (23 of 31) and shock index above 1.0 was documented in 77.4% (24 of 31). The correlation between these two haemodynamic parameters was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with 22 of 23 patients with systolic blood pressure below 90 mmHg also demonstrating shock index above 1.0. Heart rate above 100 beats per minute was present in 64.5% (20 of 31). All 31 patients reported abdominal pain on presentation. Abdominal distension was present in 54.8% (17 of 31) and peritoneal signs were elicited in 12.9% (4 of 31), a relatively low frequency consistent with the predominance of haemorrhagic rather than hollow viscus injury. Admission haemoglobin below 10 g/dL was present in 67.7% (21 of 31), though this initial value likely underestimates true haemorrhage volume because of haemoconcentration and incomplete haemodilution at the time of first measurement.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic, Injury, and Clinical Characteristics of Patients with Severe Traumatic Splenic Injury (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eValue or %\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographic Characteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge range (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 to 58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients aged 20 to 40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMechanism of Injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraffic-related accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupational injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomestic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlcohol consumption prior to injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital arrival within 6 hours of injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Findings on Arrival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic blood pressure below 90 mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShock index above 1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart rate above 100 beats per minute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal pain (all patients)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal distension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeritoneal signs on abdominal examination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaemoglobin below 10 g/dL on admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eSD: standard deviation; AAST: American Association for the Surgery of Trauma.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImaging Findings\u003c/h3\u003e\n\u003cp\u003eBedside ultrasonography was performed in all 31 patients on emergency department arrival. Free intraperitoneal fluid was identified in 100% and splenic parenchymal injury was confirmed in 100% of cases (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). On ultrasound, parenchymal contusion or intraparenchymal haematoma was the predominant finding (96.8%, 30 of 31), followed by subcapsular haematoma (58.1%, 13 of 31) and parenchymal laceration (38.7%, 12 of 31). Peritoneal fluid volume was classified as small to moderate in 83.9% and large in 16.1% of patients on initial ultrasonography.\u003c/p\u003e \u003cp\u003eAll 31 patients subsequently underwent contrast-enhanced CT. AAST grade IV injury was the most frequent CT grade, present in 74.2% (23 of 31); the remaining 8 patients had AAST grade II or III injuries that were included in the study cohort on the basis of meeting the haemodynamic instability criterion for WSES class IV. All 31 patients demonstrated parenchymal contusion or intraparenchymal haematoma (100%); parenchymal laceration was present in 87.1% (27 of 31) and subcapsular haematoma in 54.8% (17 of 31). Active contrast extravasation, indicating ongoing arterial haemorrhage, was identified on CT in 48.4% of patients (15 of 31) and constituted the primary indication for angiographic assessment.\u003c/p\u003e \u003cp\u003eOf the 15 patients with CT evidence of active arterial haemorrhage, 12 were referred for diagnostic angiography combined with selective embolisation; 3 were transferred directly to operative management because of refractory haemodynamic instability that precluded the time required for an interventional approach. Among the 12 patients who underwent angiography, active arterial extravasation was confirmed angiographically in 66.7% (8 of 12), splenic artery pseudoaneurysm in 8.3% (1 of 12), and no vascular lesion was identified in 25.0% (3 of 12), illustrating the recognised occasional discordance between CT and angiographic findings attributable to spontaneous haemostasis or CT-to-angiography delay.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eImaging Findings in Patients with Severe Traumatic Splenic Injury (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImaging Finding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBedside Ultrasonography (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFree intraperitoneal fluid identified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSplenic parenchymal injury confirmed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUltrasound Splenic Lesion Morphology (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubcapsular haematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParenchymal contusion or intraparenchymal haematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParenchymal laceration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContrast-Enhanced CT: AAST Injury Grade (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAAST Grade II (included on haemodynamic instability criterion)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAAST Grade III (included on haemodynamic instability criterion)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAAST Grade IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContrast-Enhanced CT: Splenic Lesion Morphology (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubcapsular haematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParenchymal contusion or intraparenchymal haematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParenchymal laceration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive contrast extravasation (arterial blush)\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFree peritoneal fluid: small to moderate volume\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFree peritoneal fluid: large volume\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSplenic Angiography (n\u0026thinsp;=\u0026thinsp;12)\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive arterial extravasation confirmed angiographically\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSplenic artery pseudoaneurysm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo vascular lesion identified on angiography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eCT: computed tomography; AAST: American Association for the Surgery of Trauma.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026sup1; Active contrast extravasation (arterial blush): a focal hyperdensity on contrast-enhanced CT indicating active arterial haemorrhage into the peritoneal cavity or splenic parenchyma.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026sup2; Angiography was performed in 12 of the 15 patients with CT extravasation; 3 patients proceeded directly to operative management because of haemodynamic instability unresponsive to resuscitation.\u003c/em\u003e \u003c/p\u003e\n\u003ch3\u003eTreatment Modalities and Clinical Outcomes\u003c/h3\u003e\n\u003cp\u003eInitial management assignment was based on haemodynamic status and CT findings according to institutional protocol. Nineteen patients (61.3%) were assigned to medical management without intervention, comprising strict bed rest, continuous haemodynamic monitoring with hourly vital sign recording, serial abdominal examination, blood product transfusion guided by haemoglobin thresholds and clinical assessment, and serial imaging at clinically indicated intervals. Twelve patients (38.7%) with CT evidence of active arterial haemorrhage or pseudoaneurysm were referred urgently for splenic angiography and selective embolisation. Treatment outcomes are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eOverall NOM was successful in 25 of 31 patients (80.7%). Among patients assigned to medical management without intervention, 73.7% (14 of 19) achieved haemostasis and were discharged without operative intervention. Selective splenic artery angioembolisation achieved haemostasis and successful NOM in 91.7% (11 of 12) of patients referred for the procedure, representing a markedly superior success rate compared with medical management alone. Six patients (19.3%) required emergency operative intervention, comprising five from the medical management group who experienced progressive haemodynamic deterioration unresponsive to resuscitation, and one patient from the angioembolisation group in whom the procedure failed to achieve durable haemostasis. Operative findings and postoperative details are described separately below and presented in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eBlood product transfusion was required by 58.1% (18 of 31) of patients overall. Mean transfusion volume was 714.3\u0026thinsp;\u0026plusmn;\u0026thinsp;418.1 mL (range 250 to 1450 mL) in the medical management group, 791.7\u0026thinsp;\u0026plusmn;\u0026thinsp;592.8 mL (range 250 to 1550 mL) in the angioembolisation group, and 850.0\u0026thinsp;\u0026plusmn;\u0026thinsp;519.6 mL (range 500 to 1750 mL) in the operative group. Between-group differences in transfusion volume were not statistically significant (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), reflecting the predominant influence of initial haemorrhage severity rather than treatment modality on transfusion requirements. No in-hospital deaths occurred in any treatment group. Detailed transfusion and hospital stay data are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTreatment Modalities and Outcomes in Patients with Severe Traumatic Splenic Injury (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment Modality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOM Success, n/N (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical management without intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (61.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14/19 (73.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelective splenic artery angioembolisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (38.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11/12 (91.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal NOM successes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25/31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative conversion (total splenectomy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (19.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eNOM: nonoperative management.\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIndications, Intraoperative Findings, and Postoperative Course in Operative Cases\u003c/h2\u003e \u003cp\u003eOperative indications, intraoperative findings, and postoperative data for the six patients requiring surgical intervention are presented in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. All six patients underwent open laparotomy; a laparoscopic approach was not used owing to haemodynamic instability in all cases. Active intraoperative haemorrhage was confirmed in all six patients. Total splenectomy was performed in five patients (83.3%); one patient (16.7%) had a limited parenchymal laceration with controlled haemorrhage amenable to diathermy coagulation and splenic preservation. Mean intraoperative blood loss was 1833.3\u0026thinsp;\u0026plusmn;\u0026thinsp;467.6 mL. Autologous intraoperative blood salvage using cell-salvage technology was employed in three of six patients, yielding a mean reinfusion volume of 1178.3\u0026thinsp;\u0026plusmn;\u0026thinsp;714.8 mL and substantially reducing allogeneic transfusion requirements in these cases. Postoperative complications were recorded in three patients: one patient developed postoperative haemorrhage that was managed conservatively with blood product support, haemostatic agents, and serial drain output monitoring, with cessation of haemorrhage confirmed prior to drain removal; two patients developed small-volume pleural effusions that resolved spontaneously without drainage. No surgical site infections or intra-abdominal abscesses were identified. Mean hospital length of stay in the operative group was 7.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4 days (range 5 to 12 days).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eVariables Associated with Nonoperative Management Failure\u003c/h2\u003e \u003cp\u003eClinical and imaging characteristics of patients with successful NOM (n\u0026thinsp;=\u0026thinsp;25) and those who failed NOM (n\u0026thinsp;=\u0026thinsp;6) are compared in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Examination of the failure group reveals that all six patients who failed NOM had systolic blood pressure below 90 mmHg on arrival (83.3% vs 72.0% in the success group) and AAST grade IV injury on CT (83.3% vs 72.0%). Active contrast extravasation on CT was present in 66.7% of failure patients compared with 44.0% of those who succeeded with NOM.\u003c/p\u003e \u003cp\u003eDespite these numerical differences, none of the clinical or imaging variables examined reached statistical significance as an independent predictor of NOM failure (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), with odds ratios and 95% confidence intervals consistent with no statistically demonstrable association at this sample size. Specifically, the odds ratio for NOM failure associated with CT contrast extravasation was 2.57 (95% CI 0.39 to 17.0, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), and the odds ratio associated with large-volume free peritoneal fluid was 1.05 (95% CI 0.10 to 11.56, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). These findings reflect the inherent limitations of a retrospective single-institution study with a small sample size (n\u0026thinsp;=\u0026thinsp;31), which is substantially underpowered to detect associations of the magnitude established in larger multicentre series. The clinical direction of association for CT extravasation (higher failure rate in patients with extravasation) is consistent with the established predictive literature and supports the continued clinical use of this finding in risk stratification.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVariables Associated with Nonoperative Management Failure in Severe Traumatic Splenic Injury\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNOM Success (n\u0026thinsp;=\u0026thinsp;25), n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNOM Failure (n\u0026thinsp;=\u0026thinsp;6), n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic blood pressure below 90 mmHg on arrival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (72.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (83.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAAST grade IV injury on contrast-enhanced CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (72.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (83.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShock index above 1.0 on arrival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (76.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (83.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital arrival within 6 hours of injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (76.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive contrast extravasation on CT (arterial blush)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarge-volume free peritoneal fluid on CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eNOM: nonoperative management; CT: computed tomography; AAST: American Association for the Surgery of Trauma.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eAll between-group differences P\u0026thinsp;\u0026gt;\u0026thinsp;0.05. No variable reached statistical significance as an independent predictor of NOM failure in this series, attributable to limited statistical power with n\u0026thinsp;=\u0026thinsp;31.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eActive contrast extravasation: focal arterial hyperdensity on contrast-enhanced CT. Large-volume free peritoneal fluid: haemoperitoneum tracking through more than four peritoneal compartments on CT.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBlood Product Transfusion Requirements and Hospital Length of Stay by Treatment Group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients requiring transfusion, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean blood product volume transfused (mL), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHospital length of stay (days), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical management alone (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e714.3\u0026thinsp;\u0026plusmn;\u0026thinsp;418.1 (250 to 1450)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8 (2 to 13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAngioembolisation (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (54.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e791.7\u0026thinsp;\u0026plusmn;\u0026thinsp;592.8 (250 to 1550)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 (3 to 12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative intervention (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e850.0\u0026thinsp;\u0026plusmn;\u0026thinsp;519.6 (500 to 1750)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4 (5 to 12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll patients (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (58.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e777.8\u0026thinsp;\u0026plusmn;\u0026thinsp;418.5 (250 to 1750)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 (2 to 13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eSD: standard deviation. Between-group differences for transfusion volume and hospital stay were not statistically significant (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05, one-way ANOVA). Blood products include packed red blood cells and fresh frozen plasma administered from admission through discharge.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOperative Indications, Intraoperative Findings, and Postoperative Course in Patients Requiring Surgical Intervention (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndications for Operative Intervention (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaemodynamic deterioration unresponsive to resuscitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/6 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFailed angioembolisation requiring operative conversion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/6 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed (two-stage) splenic rupture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/6 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative Findings and Surgical Management (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpen laparotomy: 6/6 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive haemorrhage confirmed at operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/6 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal splenectomy performed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5/6 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSplenic preservation by diathermy haemostasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/6 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean intraoperative blood loss (mL), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1833.3\u0026thinsp;\u0026plusmn;\u0026thinsp;467.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAutologous intraoperative blood salvage (cell salvage) used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/6 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean cell salvage volume reinfused (mL), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1178.3\u0026thinsp;\u0026plusmn;\u0026thinsp;714.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean operative duration (minutes), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100.0\u0026thinsp;\u0026plusmn;\u0026thinsp;34.5 (80 to 170)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative Course (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal drain placed routinely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/6 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrain removal, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (days) (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 (3 to 6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReturn of bowel function, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (days) (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 (2 to 4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative haemorrhage (managed conservatively)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/6 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleural effusion (resolved without intervention)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/6 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical site infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0/6 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital length of stay, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (days) (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4 (5 to 12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eSD: standard deviation. Cell-salvage technology: intraoperative autologous blood recovery, centrifugation, washing, and reinfusion of the patient's own erythrocytes to minimise allogeneic transfusion requirements. Multiple indications recorded per patient where applicable; total may exceed 100%.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates that NOM of severe traumatic splenic injury, classified using WSES 2017 criteria, is both safe and effective at a tertiary trauma centre in southern Vietnam, achieving an overall NOM success rate of 80.7% with no in-hospital mortality. These outcomes are consistent with the large body of international evidence supporting NOM as the treatment of choice for haemodynamically stable patients with splenic injury, irrespective of CT injury grade. Peitzman and colleagues, in a landmark multicentre study of 1,488 adult patients across 27 North American trauma centres, reported a composite NOM success rate of 89.2%.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Systematic reviews and meta-analyses of NOM in high-grade splenic injuries consistently report success rates ranging from 80% to 90% at experienced centres.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] The modest difference between our overall success rate and those reported by higher-volume Western centres is likely attributable, at least in part, to our inclusion of all WSES class IV patients, including those with haemodynamic instability on arrival, a higher-risk subgroup that many centres in the published literature manage operatively as a matter of institutional protocol.\u003c/p\u003e \u003cp\u003eThe demographic profile of our cohort, characterised by a predominance of young adult males injured in traffic-related accidents (64.5%), is consistent with the epidemiology of splenic trauma reported across Southeast Asian and global series.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Cadeddu and colleagues reported a male-to-female ratio of 4.3:1 in their Canadian series of 266 patients,[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] while our cohort demonstrated a ratio of 3.4:1. The notably elevated rate of haemodynamic instability at presentation (74.2% of patients with systolic blood pressure below 90 mmHg) reflects the definitional requirement for haemodynamic compromise in the WSES class IV subgroup, and may additionally reflect longer prehospital transport intervals typical of the regional setting. The statistically significant correlation between systolic blood pressure below 90 mmHg and shock index above 1.0 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) observed in this cohort validates the utility of shock index as a complementary haemodynamic assessment tool and supports its inclusion in clinical triage protocols, consistent with current WSES guideline recommendations.\u003c/p\u003e \u003cp\u003eThe substantially superior success rate of selective angioembolisation (91.7%) compared with medical management alone (73.7%) in this series is consistent with an extensive and growing body of evidence supporting the integration of interventional radiology into NOM protocols. Bhullar and colleagues, in a study of more than 1,000 adult trauma patients, demonstrated that selective angioembolisation significantly reduced NOM failure rates compared with observation alone.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Wei and colleagues similarly reported that access to embolisation substantially reduced operative conversion rates at their centre.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Meta-analyses and systematic reviews have established embolisation success rates of 85% to 92% in appropriately selected patients with CT evidence of vascular injury.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] The present findings corroborate this evidence and support the recommendation that centres treating significant volumes of severe splenic trauma should develop dedicated interventional radiology capacity for this indication. Notably, the employment of intraoperative autologous blood salvage (cell-salvage technology) in three of the six operative patients yielded a mean reinfusion volume of 1178.3\u0026thinsp;\u0026plusmn;\u0026thinsp;714.8 mL, substantially offsetting allogeneic transfusion requirements and representing a valuable adjunct in settings with limited blood bank capacity.\u003c/p\u003e \u003cp\u003eAlthough CT contrast extravasation was observed in a higher proportion of NOM failure patients (66.7%) than successes (44.0%), and the calculated odds ratio of 2.57 indicates a clinically plausible direction of association, this finding did not reach statistical significance (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) in this series. Similarly, large-volume free peritoneal fluid showed no meaningful association with NOM outcome (OR 1.05, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). These results must be interpreted in the context of the study's most important limitation: with only 31 patients and only 6 NOM failures, the study is substantially underpowered to detect associations of the magnitude that prior literature has identified. Federle and colleagues were among the first to characterise active arterial extravasation on CT as a clinically important predictor of NOM failure and ongoing haemorrhage requiring intervention,[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] a finding subsequently confirmed in multiple independent cohorts and systematic reviews.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] The failure of the present study to reproduce statistical significance for this association is most plausibly attributed to insufficient sample size rather than a true absence of association, as the direction of the numerical difference is consistent with prior literature. Future multicentre prospective studies with adequate statistical power will be required to definitively characterise the predictive value of these CT findings in the Vietnamese and broader Southeast Asian trauma population.\u003c/p\u003e \u003cp\u003eSeveral limitations of this study warrant acknowledgement. First, the retrospective design introduces the possibility of incomplete or inconsistent documentation despite systematic data extraction using a pre-specified form. Second, the small sample size (n\u0026thinsp;=\u0026thinsp;31) substantially limits statistical power for subgroup analyses and predictor identification, resulting in wide confidence intervals around odds ratio estimates. Third, the single-institution design limits generalisability across centres with different resources, case volumes, and patient demographics. Fourth, follow-up data beyond the index hospital admission were not available, precluding assessment of delayed complications including splenic infarction, pseudocyst formation, late pseudoaneurysm rupture, and long-term immune function in patients who underwent splenectomy. Prospective multicentre studies with extended post-discharge follow-up protocols are required to address these limitations and provide robust evidence to guide clinical practice.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNonoperative management of severe traumatic splenic injury classified according to WSES 2017 criteria is safe, effective, and associated with no in-hospital mortality, achieving an overall success rate of 80.7% in this series. Selective splenic artery angioembolisation substantially improves haemostatic outcomes, achieving 91.7% success, and should be routinely offered to haemodynamically responsive patients with CT evidence of active arterial haemorrhage or pseudoaneurysm. CT findings of active contrast extravasation and large-volume free peritoneal fluid demonstrated numerical trends towards NOM failure consistent with the established predictive literature, and their use in clinical risk stratification and management decision-making is supported, notwithstanding the absence of statistical significance in this underpowered series. Intraoperative autologous blood salvage represents a valuable adjunct to operative management in resource-limited settings. These findings support the WSES classification as a practical and evidence-based framework for guiding treatment decisions in severe splenic trauma and provide preliminary outcome data for a Southeast Asian tertiary care context.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eConflict of Interest:\u003c/strong\u003e \u003cp\u003eThe authors declare that there is no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthical Approval:\u003c/h2\u003e \u003cp\u003e This study was approved by the Institutional Ethics Committee of the University of Medicine and Pharmacy at Ho Chi Minh City (Approval No. 381/HDDD-DHYD, dated 15 May 2020). Informed consent was waived owing to the retrospective study design.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eContributorship\u003c/h2\u003e \u003cp\u003eV.T.L. and K.N.P. conceived and designed the study. V.T.L., M.N.T., and P.Q.M. identified eligible patients and extracted data. K.N.P. performed statistical analysis and drafted the initial manuscript. V.H.P. and T.N.N. performed interventional radiology procedures and contributed clinical expertise to data interpretation. P.T.N. assisted with additional data analysis and manuscript revision. All authors reviewed and critically revised the manuscript and approved the final submitted version.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003e The authors thank the Department of General Surgery at Nhan Dan Gia Dinh Hospital, Ho Chi Minh City, Vietnam, for their assistance with patient care and data collection.\u003c/p\u003e\u003ch2\u003eData Availability:\u003c/h2\u003e \u003cp\u003eThe data that support the findings of this study are available from the corresponding author (Kim Ngan Phung; [email protected]) upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWiik Larsen J, Soreide K, Soreide JA et al (2022) Epidemiology of abdominal trauma: an age and sex adjusted incidence analysis with mortality patterns. Injury 53(12):3130\u0026ndash;3138\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoccolini F, Montori G, Catena F et al (2017) Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg 12:40\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRutledge R, Hunt JP, Lentz CW et al (1995) A statewide, population based time series analysis of the increasing frequency of nonoperative management of abdominal solid organ injury. Ann Surg 222(3):311\u0026ndash;326\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeitzman AB, Heil B, Rivera L et al (2000) Blunt splenic injury in adults: multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma 49(2):177\u0026ndash;189\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRequarth JA, D'Agostino RB Jr, Miller PR (2011) Nonoperative management of adult blunt splenic injury with and without splenic artery embolotherapy: a meta-analysis. J Trauma 71(4):898\u0026ndash;903\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaan JM, Bochicchio GV, Kramer N et al (2005) Nonoperative management of blunt splenic injury: a 5-year experience. J Trauma 58(3):492\u0026ndash;498\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCadeddu M, Garnett A, Al-Anezi K et al (2006) Management of spleen injuries in the adult trauma population: a ten-year experience. Can J Surg 49(6):386\u0026ndash;390\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhangu A, Nepogodiev D, Lal N et al (2012) Meta-analysis of predictive factors and outcomes for failure of nonoperative management of blunt splenic trauma. Injury 43(9):1337\u0026ndash;1346\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFederle MP, Courcoulas AP, Powell M et al (1998) Blunt splenic injury in adults: clinical and CT criteria for management, with emphasis on active extravasation. Radiology 206(1):137\u0026ndash;142\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlthof DC, Joosse P, van der Vlies CH et al (2013) Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: a systematic review. J Trauma Acute Care Surg 74(2):546\u0026ndash;557\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStassen NA, Bhullar I, Cheng JD et al (2012) Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 73(5 Suppl 4):S294\u0026ndash;S300\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEkeh AP, McCarthy MC, Woods RJ et al (2005) Complications arising from splenic embolization after blunt splenic trauma. Am J Surg 189(3):335\u0026ndash;339\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCocanour CS, Moore FA, Ware DN et al (1998) Delayed complications of nonoperative management of blunt adult splenic trauma. Arch Surg 133(6):619\u0026ndash;624\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKozar RA, Crandall M, Shanmuganathan K et al (2018) Organ injury scaling 2018 update: spleen, liver, and kidney. J Trauma Acute Care Surg 85(6):1119\u0026ndash;1122\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoccolini F, Fugazzola P, Morganti L et al (2019) The World Society of Emergency Surgery (WSES) spleen trauma classification: a useful tool in the management of splenic trauma. World J Emerg Surg 14:30\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavis KA, Fabian TC, Croce MA et al (1998) Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms. J Trauma 44(6):1008\u0026ndash;1013\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVelmahos GC, Toutouzas KG, Radin R et al (2003) Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg 138(8):844\u0026ndash;851\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhullar IS, Frykberg ER, Siragusa D et al (2012) Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management. J Trauma Acute Care Surg 72(5):1127\u0026ndash;1134\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWei B, Hemmila MR, Arbabi S et al (2008) Angioembolization reduces operative intervention for blunt splenic injury. J Trauma 64(6):1472\u0026ndash;1477\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarbrecht BG, Ko SH, Watson GA et al (2007) Angiography for blunt splenic trauma does not improve the success rate of nonoperative management. J Trauma 63(1):44\u0026ndash;49\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGavant ML, Schurr M, Flick PA et al (1997) Predicting clinical outcome of nonsurgical management of blunt splenic injury: using CT to reveal abnormalities of splenic vasculature. AJR Am J Roentgenol 168(1):207\u0026ndash;212\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeira JD, Menegozzo CA, Rocha MC et al (2021) Non-operative management of blunt splenic trauma: evolution, results and controversies. Rev Col Bras Cir 48:e20202777\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRowell SE, Biffl WL, Brasel K et al (2017) Western Trauma Association critical decisions in trauma: management of adult blunt splenic trauma, 2016 updates. J Trauma Acute Care Surg 82(5):787\u0026ndash;793\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrichton JCI, Naidoo K, Yet B et al (2017) The role of splenic angioembolization as an adjunct to nonoperative management of blunt splenic injuries: a systematic review and meta-analysis. J Trauma Acute Care Surg 83(5):934\u0026ndash;943\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForsythe RM, Harbrecht BG, Peitzman AB (2006) Blunt splenic trauma. Scand J Surg 95(3):146\u0026ndash;151\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Ho Chi Minh City Medicine and Pharmacy University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"splenic injury, blunt abdominal trauma, nonoperative management, angioembolisation, selective embolisation, WSES classification, haemostasis, splenectomy","lastPublishedDoi":"10.21203/rs.3.rs-9630873/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9630873/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eThe spleen is the most frequently injured solid abdominal organ in blunt abdominal trauma and carries a high risk of life-threatening haemorrhage. The World Society of Emergency Surgery (WSES) 2017 classification integrates computed tomography (CT) injury severity grading with haemodynamic status to guide management decisions and has been validated in international multicentre cohorts. This study characterises the clinical presentation, paraclinical findings, and treatment outcomes of severe traumatic splenic injury managed according to WSES criteria at a tertiary trauma centre in southern Vietnam.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective cohort analysis was performed on 31 consecutive patients with severe traumatic splenic injury, defined as American Association for the Surgery of Trauma (AAST) grade IV or V on contrast-enhanced CT or any AAST grade combined with haemodynamic instability (systolic blood pressure below 90 mmHg), treated between January 2018 and June 2021. Variables collected included patient demographics, haemodynamic parameters, imaging findings, treatment modality, blood product transfusion requirements, hospital length of stay, and clinical outcomes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMean patient age was 33.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10 years and 77.4% of patients were male. Traffic-related accidents accounted for 64.5% of injuries. Haemodynamic instability (systolic blood pressure below 90 mmHg) was present in 74.2% of patients on arrival. CT demonstrated AAST grade IV injury in 74.2% of patients and active contrast extravasation in 48.4%. Nonoperative management (NOM) was successful in 80.7% (25 of 31 patients): medical management without intervention succeeded in 73.7% (14 of 19) and selective angioembolisation in 91.7% (11 of 12). Six patients (19.3%) required emergency splenectomy. No in-hospital deaths occurred. Mean hospital stay was 5.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 days in NOM successes and 7.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4 days in surgical patients. Blood product transfusion was required by 58.1% of patients.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eNOM of severe traumatic splenic injury classified by WSES criteria is safe and effective, achieving an 80.7% overall success rate with no mortality. Selective splenic artery angioembolisation substantially improves outcomes to 91.7% success and should be routinely offered to haemodynamically responsive patients with CT evidence of active arterial haemorrhage or pseudoaneurysm. CT findings of active contrast extravasation and large-volume free peritoneal fluid demonstrated clinical trends towards NOM failure consistent with the established literature, supporting their use in patient risk stratification.\u003c/p\u003e","manuscriptTitle":"Clinical Features, Paraclinical Findings, and Treatment Outcomes of Severe Traumatic Splenic Injury in Blunt Abdominal Trauma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-07 08:25:45","doi":"10.21203/rs.3.rs-9630873/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1a3ea1d7-702b-4a92-a6ff-a727ab702654","owner":[],"postedDate":"May 7th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T08:25:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-07 08:25:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9630873","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9630873","identity":"rs-9630873","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}