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Moderate and High-Grade Blunt Liver and Spleen Injuries Warrant Repeat Imaging to Identify Treatable Complications: Results of the Radiographic Evaluation of Delayed Solid Organ Complications (REDSOC) Multicenter Trial
*Lindsey L. Perea¹, *Kelsey L. Fletcher², *Madison E. Morgan¹, *Allison G. McNickle³, *Douglas Fraser³, *Martin Rosenthal⁴, *Ethan Wang⁴, *Anna Goldenberg⁵, *Emily Hancin⁵, *Alison A. Smith⁶, *Jack A. Leoni⁶, *Jonathan Meizoso⁷, *Christopher F. O'Neil⁷, *Matthew Noorbakhsh⁸, *Khalid Almahmoud⁹, *David Lapham¹⁰, *Erica Sais¹⁰, *Daniel Cullinane¹¹, *Carolyne Falank¹¹, *Adrian A. Maung¹², *Bishwajit Bhattacharya¹², *Paul Bjordahl¹³, *Jenny Guido¹³, *Alexandra Dixon¹⁴, *Amanda Carlson¹⁴, *Pascal Udekwu¹⁵, *Chloe Shell¹⁵, *Jaroslaw Bilaniuk¹⁶, *Zoltan Nemeth¹⁶, *Christopher A. Butts¹⁷, *Julia Zorn¹⁷, *Kellie Bresz¹⁸, *Michael Horst¹⁸, Andrew Bernard¹⁹, *Joshua P. Hazelton^20
1Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA; ²Department of Surgery, Penn State Health, Hershey, PA; ³Department of Surgery, University of Nevada, Las Vegas, NV; ⁴Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA; ⁵Department of Surgery, Cooper University Hospital, Camden, NJ; ⁶Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA; ⁷DeWitt Daughtry Family Department of Surgery, University of Miami; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL; ⁸Department of Surgery, University of Virginia Health University Hospital, Charlottesville, VA; ⁹Department of Surgery, Allegheny General Hospital, Pittsburgh, PA; ¹⁰Department of Surgery, Jefferson University, Philadelphia, PA; ¹¹Department of Surgery, Maine Medical Center, Portland, ME; ¹²Department of Surgery, Yale New Haven Hospital, New Haven, CT; ¹³Department of Surgery, Sanford USD Medical Center Sioux Falls, Sioux Falls, SD; ¹⁴Department of Surgery, Legacy Emanuel Medical Center, Portland, OR; ¹⁵Department of Surgery, Wake Med Health and Hospitals, Raleigh, NC; ¹⁶Department of Surgery, Atlantic Health Morristown Medical Center, Morristown, NJ; ¹⁷Department of Surgery, Reading Hospital, Reading, PA; ¹⁸Data and Analytics, Penn Medicine, Philadelphia, PA; ¹⁹Department of Surgery, University of Kentucky Healthcare, Louisville, KY; ²⁰Department of Surgery, Wellspan York Hospital, York, PA

OBJECTIVES: In appropriate patients, non-operative management (NOM) for blunt liver (BLI) and blunt spleen (BSI) injuries is accepted as standard of care. No guidelines exist as to the necessity of or optimal timing for repeat imaging in these patients to identify complications. We hypothesize that scheduled repeat imaging of patients undergoing NOM for BLI and BSI would result in identification of treatable complications related to their solid organ injury. This scheduled imaging may allow clinicians to identify complications earlier than if repeat imaging is performed only after the patient manifests a change in clinical condition. METHODS: We performed a four-year (11/2020-10/2024), 43-center, multinational, prospective observational study of adult trauma patients undergoing initial NOM of BLI and/or BSI. Injury grading was based on the 2018 American Association for the Surgery of Trauma Liver and Spleen injury grading systems. Patients were grouped by reason for repeat imaging: scheduled imaging (SI) or imaging performed in response to a patient’s clinical change (CC). Timing of SI was at the discretion of each center. Complications identified on repeat imaging were characterized by whether procedural or operative intervention was performed. RESULTS: We identified 2,341 BLI and 2,718 BSI patients (528 with concomitant BLI/BSI). Repeat imaging was performed in 821 (35.1%) BLI patients [SI:456 (55.5%), CC:365 (44.5%)] and 758 (27.9%) BSI patients [SI:478 (63.1%), CC:280 (37.0%)]. Complications identified on repeat imaging were as follows, BLI: 166 (7.1%) [SI:71 (42.8%), CC:95 (57.2%)] and in BSI: 203 (7.5%) [SI:91 (44.8%), CC:112 (55.2%)]. Of patients with BLI complications, 96 (57.8%) [SI:37 (38.5%), CC:59 (61.5%)] underwent an intervention. Of patients with BSI complications, 133 (65.5%) [SI:56 (42.1%), CC:77 (57.9%)] underwent an intervention. BLI Grade 4 and 5 had complications identified via SI in 27 (20.6%) and 15 (34.1%) patients, with interventions in 16 (12.2%) and 12 (27.3%) patients, respectively. BSI Grade 3, 4 and 5 had complications identified via SI in 40 (24.8%), 29 (26.1%), and 12 (26.7%) patients, with interventions in 26 (16.1%), 16 (14.4%), and 8 (17.8%) patients, respectively. Complications identified due to CC v SI were associated with increased mortality in BLI Grade 3 (9.1% v 2.2%, p=0.018), BLI Grade 4 (10% v 3.1%, p=0.035) and BLI Grade 5 (20.7% v 4.5%, p=0.031) and BSI Grade 3 [7.6% v 1.9% (p=0.028)]. Density plots for BLI and BSI demonstrate most complications were identified within 36–72 hours (Fig 1 and 2). CONCLUSIONS: We present results from the largest prospective study on blunt solid organ injury patients to date. Scheduled repeat imaging for asymptomatic patients with BLI Grade 4-5 and BSI Grade 3-5 within 36-72 hours from time of presentation will allow for identification of complications. This may allow interventions to occur prior to a change in the patient’s clinical condition.
Figure 1. Density Graph of all Liver Complications by AAST Grade. (SI- Scheduled imaging; CC- Clinical Change).