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

After years of initial aggressive surgical treatment and a subsequent shift to Damage Control Surgery, NOM has be shown to be safe and effective and in the 90's it became the gold standard for liver injuries in hemodynamically stable patients, regardless of injury grade and degree of hemoperitoneum, allowing better outcomes with fewer complications and lesser transfusions. Nevertheless concerns have been raised regarding continuous monitoring need, safety in higher grades and general applicability of NOM to all hemodynamically stable patients. Similarly, in the same period and following promising results obtained with splenic salvage by using several surgical techniques such as splenorraphy, high intensity ultrasound, hemostatic wraps and staplers, NOM became the treatment of choice for blunt splenic injuries. 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 and OPSI, and their real clinical impact in the overall population including children, is perhaps difficult to establish.