In relation to “Response to ‘Management of splenic injuries utilizing a multidisciplinary protocol in 110 consecutive patients at a level II hospital’”

To the Editor:

We have read with interest the article by Zurita et al.¹ and the response to it by Sánchez et al.² on their experience with the management of splenic injuries. We agree with the authors of both publications on the indications for non-operative management (NOM) and management of splenic trauma. We would like to add the experience of our center, which is also a level II hospital.

We have compared the results of Zurita et al.¹ with those of our series. From 2007 to 2019, our hospital treated 41 patients with splenic trauma. Out of these, 28 required urgent surgery (27 splenectomies and one spleen-preserving surgery), while NOM was chosen in 13 cases. The indication for urgent surgery was based on the hemodynamic stability of the patient and the classification of the American Association for Surgery of Trauma (AAST).³ Compared with the Zurita et al. group, our caseload is quite smaller because the most serious injuries are transferred to the referral center that is 8 km from ours and has Neurosurgery and Interventional Radiology services available 24 h a day. Three of the 13 cases that received NOM required urgent splenectomy. This represents a failure of NOM of 32%, which is much higher than rates reported in the literature.^1,4 The percentage of patients who required splenectomy was 68%—a result that is also higher than reports in the literature (approximately 50% of the patients would be candidates for NOM⁴).

Reviewing the results, we were surprised by our higher rate of splenectomies and NOM failure, and we reviewed the cases to find an explanation. We think that it was due to the fact that it is a small series that is also biased, as severe polytrauma and patients with injuries treatable with embolization are transferred to the referral center. At our hospital, we treat less serious trauma and patients in situation of hemodynamic instability who are brought in due to proximity. This situation explains why our splenectomy rate is 68%, as surgery was indicated due to the severity of the injuries.

Regarding the failure of NOM, we also think that it is due to the small sample size. Of the three cases requiring urgent surgery, two of them abruptly became unstable in the Intensive Care Unit, which allowed for immediate diagnosis and treatment. The third case presented hemodynamic instability after exertion.

We would like to support the idea of ​​Jiménez et al.⁵ in that a multicenter registry would help us determine the real situation of NOM in splenic trauma injuries. Likewise, we agree that small series should be reviewed with caution because they may demonstrate non-significant results.