Asensio J A, Demetriades D, Chahwan S, Gomez H, Hanpeter D, Velmahos G, Murray J, Shoemaker W, Berne T V
Department of Surgery, University of Southern California and the Los Angeles County and University of Southern California Medical Center, 90033-4525, USA.
J Trauma. 2000 Jan;48(1):66-9. doi: 10.1097/00005373-200001000-00011.
Complex hepatic injuries American Association for the Surgery of Trauma Organ Injury Scale grades IV and V incur high mortality rate ranging from 40 to 80%, respectively. The objective of this study is to assess the clinical experience with an aggressive approach to the management of these, the most complex of hepatic injuries.
This is a retrospective 6-year study (1992-1997) at an American College of Surgeons urban Level I trauma center of patients sustaining complex hepatic injuries whose interventions included surgery, angiographic embolization, endoscopic retrograde cholangiopancreatography plus biliary stenting and percutaneous computed tomographic-guided drainage. The main outcome measure was survival.
A total of 22 patients sustaining complex hepatic injuries; mean age of 26 years (range, 10-52 years), mean Revised Trauma Scale score of 9.9, mean Injury Severity Score of 32 (range, 16-75), American Association for the Surgery of Trauma - Organ Injury Scale grade IV (13 cases); grade V (9 cases). Mean estimated blood loss was 4,600 mL; mean number of units of blood transfused was 15. The patients underwent the following interventions: surgery (n = 22), re-operated (n = 13), mean number of operations 1.6 (range, 1-4), extensive hepatotomy and hepatorrhaphy (n = 17), nonanatomic resection (n = 7), formal hepatectomy (n = 4), packing (n = 10), direct approach to hepatic veins (n = 3); angiographic embolization (n = 15); endoscopic retrograde cholangiopancreatography and stenting (n = 5); computed tomographic guided drainage (n = 6). Mean length of stay in the intensive care unit was 21 days (range, 2-134 days), mean hospital length of stay was 40 days (range, 2-147 days). Overall mortality rate was 14% (3 of 22 cases), hepatic mortality rate was 9% (2 of 22 cases), mortality rate by injury grade was 8% grade IV (1 of 13 cases) and 22% grade V (2 of 9 cases).
In this select patient population, improvements in mortality rates can be achieved with an aggressive approach to the management of complex hepatic injuries, including surgery, early packing, angiographic embolization, endoscopic retrograde cholangiopancreatography and stenting of biliary leaks, and drainage of hepatic abscesses.
美国创伤外科协会器官损伤分级IV级和V级的复杂肝损伤死亡率很高，分别为40%至80%。本研究的目的是评估对这些最复杂肝损伤采用积极治疗方法的临床经验。
这是一项在美国外科医师学会城市一级创伤中心进行的回顾性6年研究（1992 - 1997年），研究对象为遭受复杂肝损伤的患者，其干预措施包括手术、血管造影栓塞、内镜逆行胰胆管造影加胆道支架置入术以及经皮计算机断层扫描引导下引流。主要结局指标是生存率。
共有22例患者遭受复杂肝损伤；平均年龄26岁（范围10 - 52岁），平均修订创伤评分9.9分，平均损伤严重程度评分32分（范围16 - 75分），美国创伤外科协会器官损伤分级IV级（13例）；V级（9例）。平均估计失血量为4600毫升；平均输血量为15单位。患者接受了以下干预措施：手术（n = 22），再次手术（n = 13），平均手术次数1.6次（范围1 - 4次），广泛肝切开术和肝缝合术（n = 17），非解剖性切除术（n = 7），正规肝切除术（n = 4），填塞术（n = 10），直接处理肝静脉（n = 3）；血管造影栓塞（n = 15）；内镜逆行胰胆管造影和支架置入术（n = 5）；计算机断层扫描引导下引流（n = 6）。重症监护病房平均住院时间为21天（范围2 - 134天），平均住院时间为40天（范围2 - 147天）。总体死亡率为14%（22例中的3例），肝相关死亡率为9%（22例中的2例），按损伤分级的死亡率为IV级8%（13例中的1例）和V级22%（9例中的2例）。
在这个特定的患者群体中，对复杂肝损伤采用包括手术、早期填塞、血管造影栓塞、内镜逆行胰胆管造影和胆道漏支架置入以及肝脓肿引流在内的积极治疗方法，可提高生存率。
