From
StayCurrentMD
History Of Non Operative Management for Splenic Injury with Dr. Wesson
With Dr. David Wesson · hosted by Dr. Em Gootee
Part of
Splenic Injury 3 items
Chapter 1 of 5 · Fundamentals
Current practice
Modern non-operative management and historical context
Cued at 2:05 · press play
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
In 1909, Dr. Coker wrote that if the spleen is injured it should be removed, and that was the only treatment.
In 1968, Dr. Jimmy Simpson published the first series of non-operative management of splenic injuries in what is now the Journal of the American College of Surgeons; it was a case series of only 50 patients with a small percentage managed non-operatively.
In the 1960s and 1970s there was no way to prove splenic injury because imaging was not available, so skeptics didn't believe Dr. Simpson's experience and didn't change their practice.
In 1980, Dr. Wesson presented a case series titled 'Ruptured Spleen, when to operate' at the American Academy of Pediatrics pediatric surgical section in Detroit, and all patients had diagnostic imaging, the majority being radionuclide spleen scans.
Non-believers said the radionuclide scans in Dr. Wesson's 1980 series were congenital anomalies, so Dr. Wesson's team did follow-up radionuclide scans showing healing and resolution of the defect as proof of traumatic injury.
At an American College of Surgeons meeting in Florida, Dr. William Blaisdell told Dr. Wesson that if you believe surgery aggravates bleeding you shouldn't be in surgery, and that adult trauma surgeons have more experience managing kids than any pediatric surgeon will ever see because pediatric surgeons don't see that much.
Adult trauma surgeons thought non-operative management of splenic injuries was complete baloney, but pediatric surgeons were more open-minded to the practice change.
After the 1980 presentation, all the talk was about resource utilization and length of stay, and the hook was that these patients would have better outcomes if managed non-operatively, which got the attention of the rest of the surgical world.
Non-operative management of the spleen put pediatric surgeons in the limelight, and adult trauma surgeons at adult trauma meetings credit pediatric surgeons for starting this trend that is now the norm.
APSA made standardized guidelines so institutions could manage splenic injuries in a similar way and group outcomes across the country to assess results.
CT scans became more prevalent, leading to a grading system for splenic injuries and a treatment algorithm based on CT gradings, but in the last 10 years the approach has flipped to prioritize clinical assessment over CT grade.
ATOMAC guidelines state that grade doesn't matter for splenic injury management; decision-making is based on clinical concern, and if hemodynamically normal and stable, admit to the floor with regular diet and out of bed as tolerated, then discharge after two stable hemoglobins.
In 1909 there were no ICUs, no blood available, no way to maintain an IV, no monitored beds, no oxygen delivery, and no imaging, so surgeons only had clinical grounds to work with.
In the late 1940s, Tim Wandsworth at Toronto Sick Kids had a patient with an abdominal injury who recovered, went home, then came back with another injury that caused death; at autopsy the spleen was found in two pieces that had healed, giving the notion that the spleen doesn't necessarily need to be removed and the patient won't exsanguinate.
After Wandsworth's observation, in select patients at Sick Kids surgeons wouldn't operate on splenic injuries, and this became practice among general surgeons there throughout the 1950s and 1960s, but they didn't publish or talk about it because it went against common wisdom.
Approximately 70% of patients in Dr. Wesson's 1980 study were managed non-operatively and did well.
In 1989, Dr. Wesson published a 5-year follow-up series where almost all patients had CT scans documenting the splenic injury, again showing good outcomes with non-operative management.
The 1989 series plus the 1980 series combined made the first treatment algorithm for when to operate and when not to operate on a pediatric splenic injury.
In pediatric surgery, acceptance of non-operative splenic injury management wasn't very long at all after the initial presentations.
The ATOMAC guidelines boil down to: if hemodynamically stable, go to the floor with diet the next morning and hemoglobin check and go home; if hemodynamically unstable, get fluids and blood and decide whether to go to the OR, using clinical judgment rather than just CT grade.
The updated APSA blunt liver spleen injury guidelines (update from 1990 guidelines) cover: A for admission (ICU vs ward orders), P for procedures (transfusion, angioembolization, OR indications), S for set free (discharge criteria including eating), and A for aftercare (activity restriction and follow-up imaging recommendations).