Non operative management of liver and spleen traumatic injuries: a giant with clay feet

In fact trauma surgeons realized that in liver trauma, it was safer to pack livers [1] than do finger fracture [2] or resection, and this represented a tangential issue to nonoperative approach.Damage control was not the paradigm shift for spleen and liver, but rather to address coagulopathy that was more commonly associated with penetrating major abdominal vascular injuries [3].The shift to nonoperative care was largely motivated by intraoperative observations that many minor liver [4] and splenic injuries [5] were found no longer bleeding.Then CT arrived in the early 1980s and confirmed that many moderate liver and spleen injuries did not require OR intervention. Pediatric surgeons first lead the shift to nonoperative management for splenic trauma [6,7].In the 90's it became the gold standard for liver injuries in hemodynamically stable patients, regardless of injury grade and degree of hemoperitoneum [8], allowing better outcomes with fewer complications and lesser transfusions [9]. Nevertheless concerns have been raised regarding continuous monitoring required [10], safety in higher grades of injury [11] and general applicability of NOM to all haemodynamically stable patients [12]. Similarly, in the same period and following promising results obtained with splenic salvage [13] with several surgical techniques [14] such as splenorraphy, high intensity ultrasound, haemostatic wraps and staplers [15], NOM became the treatment of choice for blunt splenic injuries [5]. However it was immediately clear that NOM failure in adults was significantly higher than that observed in children (17% vs 2%). The incidence of immune system sequelae, coupled with Overwhelming Post Surgical Infection (OPSI) and their real clinical impact, is difficult to establish in the overall population including children [16].Although recent reports [17] showed that despite a similar incidence and severity of solid organ injuries, Trauma centers with higher risk-adjusted mortality rates are more