Brazilian Trauma Society’s (SBAIT) management guidelines of splenic injuries

ABSTRACT

The splenic injuries are frequent among victims of blunt trauma, and the most appropriate approach must be based on the physiological status and anatomical complexity of the lesions balance. The alternatives must balance, in stable patients without peritonitis, the simplicity and prompt resolution of splenectomy and the potential complications and immunobiological consequences, considering modern minimally invasive diagnostic and therapeutic tools. This paper presents the Brazilian Trauma Society’s (SBAIT) management guidelines, based on the most recent evidence and tailored to the reality of Brazilian trauma centers

Keywords:
Multiple Trauma; Splenic Rupture; Splenectomy

RESUMO

As lesões esplênicas são frequentes nas vítimas de trauma fechado e a melhor conduta deve considerar o status fisiológico e complexidade anatômica das lesões. As alternativas devem ponderar, em pacientes estáveis e sem peritonite, a simplicidade e resolutividade da esplenectomia bem como as complicações e consequências imunobiológicas deste procedimento frente às modernas ferramentas diagnósticas e terapêuticas minimamente invasivas. Este artigo apresenta o consenso da Sociedade Brasileira de Atendimento Integrado ao Traumatizado (SBAIT) para manejo destas lesões, baseado na literatura atual e adaptado à realidade dos centros de trauma brasileiros.

Palavras-chave:
Traumatismo Múltiplo; Ruptura Esplênica; Esplenectomia

INTRODUCTION

Advances in minimally invasive diagnostic and treatment technologies have been reshaping the management paradigms of splenic injuries. However, given the realities of Brazilian trauma services that care for polytrauma patients, Nonoperative Management (NOM), including angioembolization or other interventional radiology techniques, is not always performed under ideal conditions. Therefore, in the Brazilian context, the decision to pursue NOM must consider both the inherent risks of splenectomy and the potential lack of optimal infrastructure for nonoperative approaches.

This consensus statement, developed by the Consensus Group of the Brazilian Society for Integrated Trauma Care through a review of the classification and pathophysiology of splenic injuries proposed by the American Association for the Surgery of Trauma (AAST), aims to update and reinterpret established management strategies in light of the Brazilian reality, providing emergency physicians and trauma surgeons with a theoretical framework aligned with local practice conditions.

METHODS

The SBAIT comprises active members with substantial experience in the multidisciplinary management of polytrauma patients, and is coordinated by a senior investigator. A panel of 12 experts was convened, all with over 10 years of experience managing splenic injuries, representing different regions of Brazil to ensure diverse practices. No conflicts of interest were declared.

A search was conducted by a librarian, including articles indexed in the PubMed/MEDLINE, Scopus, and Cochrane platforms and published between January 2010 and August 2024, using the combination of terms “Splenic Injuries”[Mesh] OR splenic injur*[tiab] OR splenic trauma[tiab] AND “Hemorrhagic Shock”[Mesh] OR “Hypotension”[Mesh] OR “Circulatory Shock”[Mesh] OR hemodynamic*[tiab] OR haemodynamic*[tiab] AND “Nonoperative Management”[Mesh] OR “Conservative Treatment”[Mesh] OR nonoperative[tiab] OR non-operative[tiab] OR Conservative management[tiab] OR “Splenectomy”[Mesh] OR “Surgical Procedures, Operative”[Mesh] OR splenectomy[tiab] OR surgery[tiab] OR embolization[tiab] OR angioembolization[tiab]. Articles classified as consensus statements, systematic reviews, meta-analyses, case series, original articles, and clinical trials were accepted; case reports were not accepted as references.

Figure 1
PRISMA flow chart.

The considerations were deemed appropriate when based on the PICO strategy - Patients/Intervention or Exposure/Controls/Outcome - of the selected articles.

The discussion points were defined by the lead author (L.G.A.P.), who brought together the other members’ considerations based on the evidence presented. To standardize terminology, the AAST Organ Injury Scale (OIS) anatomical-clinical classification was used to discuss procedures.

Eleven points were defined regarding the surgical and non-surgical management of splenic injuries caused by blunt trauma in adults. Still, these points do not apply to patients with penetrating injuries and a pre- or intraoperative diagnosis of splenic injury, or to pediatric patients (under 14 years of age). The points were divided into stages: (1) Clinical decision for nonoperative management (NOM); (2) strategies and resources for implementing NOM; (3) surgical strategies in blunt splenic trauma; and (4) postoperative management.

The definitions for the discussion points were developed according to the Delphi Protocol, coordinated by the authors L.G.A.P. and P.S.L.A., who were responsible for the final arrangement. Definitions were reached after at least two rounds on the same topic, with the last round validated by the cited authors. In case of disagreement, a third round was proposed, involving a researcher not yet consulted on the topic, with subsequent validation by the lead authors.

The level of evidence for each guideline presented in the consensus was graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, a hierarchical tool that systematically evaluates proposals based on the types of studies included. The results were discussed during the XVI Congress of the Brazilian Society for Integrated Trauma Care, held between August 15 and 17, 2024, and the final version of the consensus is presented in this article

RESULTS

1) Decision for Nonoperative Management (NOM)

1.1) Indications for NOM

• Hemodynamic stability: Patients without clinical signs of tissue hypoperfusion, represented by normal clinical parameters such as capillary refill time, blood pressure, and heart rate, as well as the absence of alterations in arterial blood gas analysis, are the main candidates for NOM - GR 2A^1-11;

• Mild to moderate injuries: Traumas classified as grade I-III on the American Association for the Surgery of Trauma (AAST) scale have lower failure rates in non-invasive surgical management (NOM), with a lower risk of bleeding - GR 2A^1-9,12;

• Absence of lesions in hollow organs: NOM is not indicated in patients with lesions requiring primarily surgical management, whether evisceration or lesions in hollow organs evidenced on contrast-enhanced CT scan - GR 1A^1-11;

• Continuous monitoring capability: Patients eligible for NOM should be continuously monitored, with regular clinical assessments and serial hematocrit and hemoglobin tests - GR 2A^1-11.

Table 1
GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system to evaluate the level of evidence and recommendation.

Grade of recommendation	Clarity of risk/benefit	Quality of supporting evidence	Implications
1A Strong recommendation, high-quality evidence.	Benefits clearly outweigh risks and burdens, or vice versa.	RCTs without important limitations or overwhelming evidence from observational studies.	Strong recommendation, applies to most patients in most circumstances without reservation.
1B Strong recommendation, moderate-quality evidence	Benefits clearly outweigh risks and burdens, or vice versa.	RCTs with important limitations (inconsistent results, methodological flaws, indirect analyses, or imprecise conclusions) or exceptionally strong evidence from observational studies.	Strong recommendation, applies to most patients in most circumstances without reservation.
1C Strong recommendation, low-quality or very low-quality evidence.	Benefits clearly outweigh risks and burdens, or vice versa.	Observational studies or case series.	Strong recommendation, but subject to change when higher-quality evidence becomes available.
2A Weak recommendation, high-quality evidence.	Benefits closely balanced with risks and burden.	RCTs without important limitations or overwhelming evidence from observational studies.	Weak recommendation, best action may differ depending on the patient, treatment circumstances, or social values.
2B moderate-quality evidence.	Benefits closely balanced with risks and burden.	RCTs with important limitations (inconsistent results, methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies.	Weak recommendation, best action may differ depending on the patient, treatment circumstances, or social values.
2C Weak recommendation, low-quality or very low-quality evidence	Uncertainty in the estimates of benefits, risks, and burden; benefits, risks, and burden may be closely balanced.	Observational studies or case series.	Very weak recommendation; alternative treatments may be equally reasonable and merit consideration.

1.2) Contraindications to NOM

• Hemodynamic instability: Patients with ongoing bleeding and signs of shock should be referred for immediate surgery - GR 1A^1-11;

• Presence of peritonitis on clinical examination: Peritonitis on admission is an indirect sign of bowel, intraperitoneal bladder, or other hollow viscera lesions, contraindicating NOM - GR 1A;

• Lack of resources for monitoring: When adequate monitoring or rapid access to emergency surgery is not available, NOM should be avoided - GR 2A7.

Relative Contraindications:

• Serious injuries or injuries with signs of active bleeding: Grade IV and V lesions have a lower success rate, even when associated with endovascular stratification with selective embolization^8,9,12. Regarding these injuries, NOM should be reserved for large, structured trauma centers - GR 1C;

• Multiple associated lesions - GR 2A;

• Severe TBI - GR 1C;

• Age over 55 years - GR 2B;

• Large hemoperitoneum - GR 2B;

• Femur fracture - GR 2B;

• Limited availability of transfusions: Patients requiring more than four units of packed red blood cells for clinical stabilization - GR 2C;

• Patients with coagulopathy: These individuals have a higher risk of ongoing bleeding and may require surgical intervention - GR 1B¹⁶.

Despite being simple and effective, splenectomy is not a harmless procedure. In addition to intraoperative and postoperative complications, such as pancreatic fistulas and infectious and abdominal wall complications, splenectomy can lead to acquired immunodeficiency, increasing susceptibility to serious infections throughout life^1,3. Thus, in hemodynamically stable patients who have suffered blunt trauma and show no signs of peritonitis, the need for surgical intervention should be based on the presence of associated injuries, the severity of the injury, or signs of active bleeding.

Nonoperative Management (NOM) evolved from the S.O.S. (Save Our Spleens) concept, initially applied to children and later extended to adults. In eligible patients, in addition to the conditions inherent to the patient and the health service for feasibility, a CT scan with intravenous contrast is critical, the gold standard for stratifying the severity of injuries, according to the Organ Injury Scale, proposed by the AAST, as well as for identifying signs of active bleeding and associated injuries, especially those of hollow viscera, which require surgical intervention^1-11. Examination should be performed in different phases; the Portal Venous Phase characterizes the splenic parenchyma and is used to visualize lacerations and subcapsular hematomas; the Arterial Phase is more appropriate for detecting vascular lesions such as contrast extravasation (blush), pseudoaneurysms, and arteriovenous fistulas.

Even with rigorous patient selection, NOM can fail, with late hemorrhage being the main cause. Factors such as injury complexity (AAST grade IV and V)12, volume of hemoperitoneum, subcapsular hematomas involving more than 50% of the splenic surface, and the presence of multiple pseudoaneurysms or contrast extravasation (blush) may be associated with an increased risk of bleeding and the potential need for surgical intervention^4-7. In patients with borderline indications, arteriography can be a useful tool both for diagnosis, risk stratification, and therapy, with embolization of vascular branches^13-18. However, this procedure is not without risks, with a non-negligible chance of extensive splenic necrosis, splenic abscesses, hematomas or pseudocysts, which may lead to infectious complications or late rupture^19-20.

2)Strategies for Implementing the NOM

2.1) Resources Needed for NOM of a Patient With Splenic Trauma

Minimum Resources:

• Full-time surgical capability: NOM is not recommended if the institution is unable to follow up the patient serially and has 24-hour emergency laparotomy availability - GR 1C^1-11;

• Full-time blood bank: The availability of blood components is essential, especially in cases of NOM failure - GR 2A^1-11;

• Easy access to imaging methods (contrast-enhanced CT scan) and laboratory tests around the clock - GR 2A^1-11;

• Intensive care service: patients selected for NOM must remain under continuous observation and monitoring for a minimum period of 24 hours in an intensive care unit, or hospital unit - trauma room, emergency room, semi-intensive care unit - with hemodynamic monitoring capabilities under the care of the surgical team - GR 2A.

Desirable Resources:

• Arteriography: splenic embolization is a tool to reduce cases of NOM failure, especially in high-risk conditions (high-grade splenic lesions, vascular abnormalities, and extensive hemoperitoneum - GR 2A)^14-15;

• Horizontal team responsible for the case - GR 2B.

Despite the advantages, performing NOM means assuming the risks of not surgically addressing a known lesion. The period of greatest risk of bleeding is in the first 72 hours after trauma^21-22, during which the patient should be continuously monitored in an appropriate environment, with periodic recording of vital signs and monitoring of laboratory parameters, especially hematocrit, base deficit, lactate, and pH.

At the earliest sign of clinical deterioration, adjunctive diagnostic modalities such as computed tomography (CT scan) or arteriography may reveal active bleeding, warranting interventional management. Likewise, in the presence of hemodynamic instability or peritonitis, emergent surgical exploration is mandatory, and the institution must have an immediately available surgical team and adequate infrastructure to proceed without delay.

Accordingly, Nonoperative Management (NOM) should be undertaken in hospitals equipped with appropriate personnel and resources. In their absence, patient transfer or operative management should be considered.

2.2)When is arteriography indicated in a patient with splenic trauma?

• Patients eligible for NOM who have signs of active bleeding on Computed Tomography (blush, pseudoaneurysm, or arteriovenous fistula) - GR 2A^16-18;

• Patients eligible for NOM with large hemoperitoneum, regardless of the degree of injury - GR 2A^15-18;

• Patients with complex splenic lesions (AAST IV and V), regardless of the presence of blush - GR 1B¹⁷;

• Patients who maintain hemodynamic stability and a decrease in hematocrit, excluding other bleeding sites - GR 1C.

Arteriography with selective angioembolization has become an important tool in the NOM of splenic lesions^13-15, with results varying according to the precision of the indication and the heterogeneity of each service.

Regarding indication, it is performed with two main objectives: therapeutic, when there are tomographic signs of active bleeding, and diagnostic, for stratification.

In a study involving 143 patients with contrast extravasation (blush) on contrast-enhanced imaging, it was suggested that not performing embolization doubles the risk of failure with non-operative management¹⁶. Therefore, when signs of active bleeding are evident, arteriography with angioembolization is the management of choice in hemodynamically stable patients.

Regarding stratification, Grade I and II splenic lesions have a 2% to 10% NOM failure rate; 10% to 20% for Grade III; 40% to 43% for Grade IV; and 70% to 75% for Grade V without splenic artery embolization. Some meta-analyses have shown significant improvement in the success of non-operative management using arteriography and angioembolization (OR 0.26, 95% CI 0.13-0.53, p < 0.002), especially in complex lesions - AAST IV-V (43.7 vs. 17.3%, p = 0.035, and 83.1 vs. 25.0%, p = 0.016). Stratified arteriography can therefore provide additional information, such as identifying pseudoaneurysms not previously visible on CT scans, estimating the degree of necrosis, and assessing the feasibility of embolization. Such information, even in hemodynamically stable patients without other signs of poor outcome, may point to the benefit of surgical management^13-18.

With advancements in materials, the selectivity of splenic vascularization branches during coil embolization has reduced the frequency of complications. However, hematomas, local or retroperitoneal, pseudoaneurysms, arteriovenous fistulas, peripheral nerve injury, thrombosis, and distal embolization, with segmental infarcts and late abscesses, still occur^18-20.

The loss of splenic function after splenic artery embolization is still controversial, with some studies arguing that these patients retain their immunity23. Pancreatic ischemia is rare, but when abdominal pain increases after endovascular management, it should be promptly investigated^19,20.

2.3)When should CT scans be repeated for patients undergoing non-operative management of splenic trauma?

• NOM for Grade I and II Splenic Trauma (AAST) without arterial changes (blush, pseudoaneurysm or arteriovenous fistula), there is no need for follow-up CT scan if the hemodynamic conditions of the patients are maintained - GR 2A^21,22,24;

• NOM for Grade III Splenic Trauma without arterial changes (blush, pseudoaneurysm or arteriovenous fistula), repeat CT scan seven days after the initial CT scan - GR 2A^21,22,24;

• NOM for Grade IV and V Splenic Trauma (AAST) without arterial changes (blush, pseudoaneurysms or arteriovenous fistulas), repeat CT scan 48 to 72 hours after the initial CT scan, as well as a control CT scan after seven days - GR 2A^21,22,24;

• NOM with angioembolization, in any Grade, repeat CT scan seven days after the initial CT scan^21,22,24 - GR 2A;

• NOM with decreased hematocrit or abdominal pain without peritonitis, in any Grade, repeat CT scan immediately - GR 1B^21,22,24.

In a study with routine tomographic follow-up for splenic trauma between 0 and 11 days after the initial CT scan, 96.4% of the exams showed no significant changes beyond an increase in free fluid in the abdominal cavity without a change in management of the NOM²¹, demonstrating that follow-up exams have a precise indication.

The literature shows that one of the main complications of NOM is vascular in nature, such as the formation of pseudoaneurysms and arteriovenous fistulas, which usually occur within 48 to 72 hours after trauma^21,22.

For complex lesions, performing a new image during this period is essential for early diagnosis and potential intervention. For grade I-III lesions, however, most pseudoaneurysms resolved spontaneously after eight days, requiring no further action or intervention^21,22,24.

Therefore, a new early image is not necessary in these cases. In cases of clinical worsening, declining hematocrit levels, or laboratory deterioration, repeat imaging is indicated to rule out previously undetected bleeding sources or missed associated injuries.

Follow-up imaging before discharge, approximately seven days after the initial trauma, is recommended for patients with higher-grade injuries (grade III-V) to exclude complications such as abscess formation, fluid collections, splenic infarction, and sequelae related to angioembolization, when performed.

2.4)How long should the patient be monitored from NOM to discharge?

• In splenic injuries grade I and II, the patient should be observed for at least 72 hours and may be discharged if the hematocrit is stable - GR 1C;

• In lesions of grade III or higher, the monitoring period should be at least seven days, provided that a control image is performed before discharge - GR 2A.

The observation times reported after splenic trauma have varied widely in the literature, with most studies reporting average lengths of stay between 4, 10, and 12 days^3-11. Consistent data show that 95% of patients who fail NOM do so within the first three days after injury. Monitoring for an additional two days (five days after the injury) identifies only 1.5% more failures. Therefore, patients with Grade I and II injuries can be discharged within three days, provided their hemoglobin and vital signs remain stable.

Although complex injuries do not appear to alter the average time to NOM failure, the higher incidence of delayed or procedure-related complications supports more prolonged observation in these patients. Based on the observed readmission patterns among patients with complex injuries, which most frequently occur within seven days after discharge, it is recommended that this time frame be used as a standard reference, in conjunction with follow-up imaging before hospital discharge^4-11,21,22.

3) Surgical Strategies in Blunt Splenic Trauma

3.1) When surgical management is indicated, what is the best method?

• Patients presenting with hemodynamic instability or peritonitis should undergo total splenectomy via laparotomy - GR 2A;

• If NOM fails, regardless of the degree of injury, the patient should undergo total splenectomy - GR 2A;

• - Splenorrhaphy and other splenic preservation techniques may be considered in stable patients with AAST grade I to III lesions who do not present with concomitant cavity contamination, according to the surgeon’s expertise - GR 2B;

• The laparoscopic approach may be considered in patients with splenic lesions, in stable patients, both in cases of failure of NOM and to rule out other associated lesions, provided that the service is equipped to perform the procedure safely and the surgical team has the appropriate expertise to perform the procedure - GR 2A.

When surgical management of splenic trauma is indicated, a total splenectomy should be performed via a midline xipho-umbilical laparotomy. If there is no prior certainty of isolated splenic injury, the four quadrants of the cavity are assessed, as recommended in laparotomies for damage control.

Figure 2
Schematic representation of the emergency surgical approach in the context of splenic injuries. Medial mobilization of the spleen is recommended to facilitate anterior exposure of the splenic hilum following division of any adhesions, with en bloc ligation of the splenic vessels to achieve hemostasis (image courtesy of J.P.F.S.).

En bloc ligation of the splenic hilum should be performed, with a clamp placed near the spleen, to avoid accidental ligation of the gastric fundus or pancreatic tail.

Splenic packing, consisting of direct compression with laparotomy pads in the setting of damage control surgery²⁵, lacks robust supporting evidence but may represent a viable option in critically ill patients with multiple bleeding sources who require damage control procedures, particularly when hemorrhage is controlled with packing.

The main indications for laparoscopy in splenic trauma include diagnostic uncertainty following failed nonoperative management in hemodynamically stable patients, as well as the diagnosis and treatment of delayed complications and selected special circumstances. In all cases, the patient must be hemodynamically stable for the laparoscopy procedure^26-28.

Associated injuries, such as certain musculoskeletal traumas, traumatic brain injury, or spinal cord injury, can make laparoscopy difficult, either due to difficulty in mobilizing the patient or due to hemodynamic changes induced by pneumoperitoneum.

Finally, special situations arise when non-surgical management is indicated. Still, the patient requests a splenectomy, such as a professional athlete, or when the patient lacks the socioeconomic means to undergo follow-up care. In these situations, after individualized assessment, considering risks, benefits, and alternatives, laparoscopy may be adopted^26,27.

There are no consistent studies on the use of robotic surgery in splenic trauma. The indications may be similar to laparoscopic surgery²⁸, but this is not a reality for services that treat polytrauma patients in Brazil.

3.2 When is splenic preservation indicated in surgical management?

• Splenorrhaphy, use of hemostatic agents, partial splenectomy, and use of splenic compression garments should not be used in the acute management of splenic trauma - GR 2B.

Adjuvants and preservation techniques were options used before the widespread adoption of non-operative management for splenic trauma; currently, they have very little relevance. Studies evaluating these methods included patients who would currently be candidates for non-operative management²⁸.

A controlled partial splenectomy is contraindicated in emergency settings, especially in hemodynamically unstable patients. Increased surgical time and bleeding volume are factors that preclude this approach, even considering the potential benefits of spared parenchyma. The use of hemostatic agents follows the same guidelines as for splenorrhaphy, with fibrin glues being the main agents. Both splenorrhaphy and partial splenectomy, as well as the use of hemostatic agents, can only be used in patients who are completely hemodynamically stable and in whom there is no concern regarding concomitant injuries.

3.3) What is the role of cavity drainage in a patient undergoing splenectomy?

• There is currently no evidence to support the routine use of drainage after splenectomy - GR 1C;

• If associated pancreatic trauma is suspected, drainage after splenectomy may be performed - GR 2C;

• Draining the cavity to monitor for pancreatic fistula may be an option when pancreatic involvement is suspected during splenectomy - GR 2C.

Since the advent of the ERAS/ACERTO project, there has been a trend towards limiting the use of abdominal drains. The ACERTO project suggests the rational use of abdominal drains, concluding, with a high level of evidence, that prophylactic drains are unnecessary and, ultimately, harmful, with increased rates of infectious complications and drain migration^31,32.

The primary indication for cavity drainage in splenic trauma is the suspicion of associated pancreatic involvement. Pancreatic traumas up to grade 2 in the AAST (American Association for the Surgery of Trauma) classification or class I in the WSES (World Society of Emergency Surgery) classification are preferably treated with wide drainage of the cavity³³. Similarly, suspected or confirmed pancreatic injury during splenic hilum ligation, especially in the context of hemodynamic instability, can be mitigated by draining the splenic fossa.

Therefore, when pancreatic injury is identified or suspected during surgery, drainage of the cavity to monitor for pancreatic fistula may be an option, especially in the context of limited availability of resources for radiologically guided intervention.

4) Post-operative Management

4.1) When and how should vaccination be performed after splenectomy?

• There is no indication for vaccination in cases treated by embolization - GR 2B²³;

• Patients undergoing splenectomy should receive polyvalent pneumococcal vaccine, meningococcal vaccine, conjugated Haemophilus influenzae type B vaccine, varicella vaccine, and hepatitis A vaccine - GR 1A^34-37;

• Vaccination should ideally occur two weeks after splenectomy - GR 2C.

Individuals who have undergone splenectomy are particularly vulnerable to invasive infections caused by encapsulated organisms (mainly S. pneumoniae, N. meningitidis, and type b H. influenzae). These infections have a sudden onset and can have a fulminant evolution, characterizing Fulminant Post-Splenectomy Infections (FPSI)³². A 1982 study followed 193 splenectomized patients and reported an incidence of FPSI of 0.18%³³. In 1991, an Australian retrospective study analyzed 1490 splenectomies, 628 of which were due to trauma, with an incidence of FPSI of 0.42% and a mortality rate of 0.08%. In the subgroup of patients who underwent splenectomy due to trauma, the incidence of FPSI was 0.03%. The study also assessed the incidence of severe non-fulminant infections and concluded that there is a 12.6 times increase in infection risk among splenectomized patients. In the subgroup of splenectomy due to trauma, the risk is 8.6 times higher³⁵.

Table 2
Post-splenectomy vaccination strategy.

Vaccine	1st dose	2nd dose	Reinforcement
Polyvalent pneumococcal	14 days after the trauma	-	every 5 years
Meningococcal C and ACWY conjugate vaccines	14 days after the trauma	After 8 weeks	ACWY: every 5 years
Haemophilus Influenzae type b vaccine	14 days after the trauma - single dose	-	-
Influenza virus	-	-	Annual
Hepatitis A	14 days after the trauma	After 6 months	-
Varicella	14 days after the trauma	After 3 months	-

Vaccination is therefore recommended within two weeks of splenectomy. A study published in 1998 randomized 59 vaccinated patients and evaluated post-vaccination serum immunoglobulin concentration on the first, seventh, and fourteenth days after splenectomy for trauma. Although the concentrations were not statistically different, the most functional humoral response occurred in the vaccinated group at 14 days³⁶. The same group of researchers, in 2002, randomized 40 patients who had undergone splenectomy due to trauma to receive vaccinations 14 and 28 days post-surgery. No difference in humoral response was identified between the groups. Therefore, the current recommendation is that patients undergoing splenectomy for trauma be vaccinated within 14 days post-operatively³⁷.

Regarding patients treated with endovascular strategies, the Eastern Association for the Surgery of Trauma (EAST) published a 2022 systematic review analyzing 9 studies that reported 3974 splenectomies, 686 embolizations, and 240 embolizations compared with 443 healthy controls. Patients who underwent embolization had a lower rate of complications and preserved splenic immune function³³. Therefore, vaccination is not recommended for patients undergoing splenic embolization^23,33,38.

4.2) When should the patient be cleared for physical activity?

• Low-impact activities, in patients undergoing NOM, can be allowed after two weeks for Grade I and II injuries, 4 to 6 weeks for Grade III, and after six weeks for complex injuries (AAST Grade IV and V) - GR 2C;

• Vigorous activities, in patients undergoing NOM, after three to five weeks for Grade I and II injuries and 2 to 6 months for Grade III, IV and V injuries - GR 2C.

Recommendations vary from three weeks to six months, depending on the severity of the splenic injury39. Each HCP’s personal clinical assessment usually guides this decision. Fata et al. assessed, through a survey among active members of the Eastern Association for the Surgery of Trauma (EAST), that most of these professionals authorize a return to low-impact activities after two weeks for mild trauma (AAST Grade I and II), four to six weeks for moderate trauma (AAST Grade III) and after 6 weeks for severe trauma (AAST Grade IV and V)40.

The 2022 World Society of Emergency Surgery consensus recommends that patients with non-operative management of splenic trauma return to vigorous activities after three to five weeks for mild injuries (AAST Grades I and II) and two to four months for more severe injuries (AAST Grades III, IV and V), with this clearance only after a CT scan has been performed to confirm complete healing of the organ and reduce the risk of late splenic rupture7. However, Terrell et al., in a case series, reported that athletes undergoing splenectomy tend to return to contact sports earlier, generally after approximately three weeks of recovery41..

CONCLUSION

Although NOM offers significant advantages, including splenic preservation and reduced surgical morbidity, it is essential to recognize its limitations and remain prepared to modify the treatment strategy when clinically indicated.

The management recommendations presented herein guide the treatment of traumatic splenic injuries within the Brazilian context and should not be interpreted as rigid standards or as precluding alternative therapeutic strategies.

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• Data availability
  Datasets related to this article will be available upon request to the corresponding author.
• Funding source:
  none.

Edited by

• Editor
  Daniel Cacione

Data availability

Datasets related to this article will be available upon request to the corresponding author.

Publication Dates

• Publication in this collection
  03 Aug 2026
• Date of issue
  2026

History

• Received
  09 Nov 2025
• Accepted
  05 May 2026