Malhotra A K, Fabian T C, Croce M A, Gavin T J, Kudsk K A, Minard G, Pritchard F E
Department of Surgery, University of Tennessee-Memphis, Memphis, Tennessee 38163, USA.
Ann Surg. 2000 Jun;231(6):804-13. doi: 10.1097/00000658-200006000-00004.
To analyze the outcome of hemodynamically stable patients with blunt hepatic injury managed nonoperatively, and to examine the impact of this approach on the outcome of all patients with blunt hepatic injury.
Until recently, operative management has been the standard for liver injury. A prospective trial from the authors' institution had shown that nonoperative management could safely be applied to hemodynamically stable patients with blunt hepatic injury. The present study reviewed the authors' institutional experience with blunt hepatic trauma since that trial and compared the results with prior institutional experience.
Six hundred sixty-one patients with blunt hepatic trauma during the 5-year period ending December 1998 were reviewed (NONOP2). The outcomes were compared with two previous studies from this institution: operative 1985 to 1990 (OP) and nonoperative 1993 to 1994 (NONOP1).
All 168 OP patients were managed operatively. Twenty-four (18%) of 136 NONOP1 patients and 101 (15%) of the 661 NONOP2 patients required immediate exploration for hemodynamic instability. Forty-two (7%) patients failed nonoperative management; 20 were liver-related. Liver-related failures of nonoperative management were associated with higher-grade injuries and with larger amounts of hemoperitoneum on computed tomography scanning. Twenty-four-hour transfusions, abdominal infections, and hospital length of stay were all significantly lower in the NONOP1 and NONOP2 groups versus the OP cohort. The liver-related death rate was constant at 4% in the three cohorts over the three time periods.
Although urgent surgery continues to be the standard for hemodynamically compromised patients with blunt hepatic trauma, there has been a paradigm shift in the management of hemodynamically stable patients. Approximately 85% of all patients with blunt hepatic trauma are stable. In this group, nonoperative management significantly improves outcomes over operative management in terms of decreased abdominal infections, decreased transfusions, and decreased lengths of hospital stay.
分析血流动力学稳定的钝性肝损伤患者非手术治疗的结果，并探讨这种治疗方法对所有钝性肝损伤患者治疗结果的影响。
直到最近，手术治疗一直是肝损伤的标准治疗方法。作者所在机构的一项前瞻性试验表明，非手术治疗可安全地应用于血流动力学稳定的钝性肝损伤患者。本研究回顾了自该试验以来作者所在机构钝性肝外伤的治疗经验，并将结果与之前的机构经验进行了比较。
回顾了截至1998年12月的5年期间661例钝性肝外伤患者（NONOP2）。将结果与该机构之前的两项研究进行比较：1985年至1990年手术治疗组（OP）和1993年至1994年非手术治疗组（NONOP1）。
所有168例OP患者均接受了手术治疗。136例NONOP1患者中有24例（18%），661例NONOP2患者中有101例（15%）因血流动力学不稳定需要立即进行探查。42例（7%）患者非手术治疗失败；20例与肝脏相关。非手术治疗的肝脏相关失败与更高级别的损伤以及计算机断层扫描显示的腹腔积血较多有关。NONOP1组和NONOP2组的24小时输血量、腹部感染和住院时间均显著低于OP队列。在三个时间段内，三个队列的肝脏相关死亡率均恒定在4%。
尽管紧急手术仍然是血流动力学不稳定的钝性肝外伤患者的标准治疗方法，但在血流动力学稳定患者的治疗方面已经发生了模式转变。所有钝性肝外伤患者中约85%是稳定的。在这组患者中，非手术治疗在减少腹部感染、减少输血量和缩短住院时间方面比手术治疗显著改善了治疗结果。
