Leone R J, Hammond J S
Department of Surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey 08903-0019, USA.
Am Surg. 2001 Feb;67(2):138-42.
The purpose of this study was to examine the effect of operative versus nonoperative management of blunt hepatic trauma in children including transfusion practices. We reviewed the experience at our American College of Surgeons-verified Level I trauma center with pediatric commitment over a 5-year period. Children < or = 16 years of age suffering blunt liver injury as documented on admission CT scan were included in the study. Liver injuries identified on CT scan were classified according to the American Association for the Surgery of Trauma's Organ Injury Scaling system. All data are presented as mean +/- standard error. One case of pediatric liver trauma not identified on CT was excluded (prehospital cardiopulmonary resuscitation). Twenty-seven patients were included [age 9.3 +/- 1.0 years (range 3-16)]. Mechanisms of injury included motor vehicle crash (14), pedestrian struck by motor vehicle (7), bicycle crash (4), fall from height (1), and pedestrian struck by falling object (1). Trauma Score was 11.5 +/- 0.3. Distribution of Liver Injury Grade was as follows: grade I, 13; grade II, 9; grade III, 3; grade IV, 2; and grade V, 0. All five patients who underwent operative management had multiple organ injuries; three had concomitant splenic injury requiring operative repair; the remaining two had small bowel injury requiring repair. Hepatorrhaphy did not correlate with severity of liver injury: grade I, n = 1; II, n = 2; III, n = 1; and IV, n = 1. Three operated patients received blood transfusions. Twenty-two patients were managed with nonoperative treatment, of these only one required blood transfusion. No patients in the study died, three were transferred to subacute rehabilitation, one was transferred to another hospital, and 23 were discharged home. Our findings indicate that a majority of children with blunt hepatic injury as documented on CT scan can be managed with nonoperative treatment, and few require blood transfusions. Patients with multiple organ injury including simultaneous splenic injury are likely ideally managed through operative exploration and repair, whereas those with isolated liver injuries can be successfully managed nonoperatively.
本研究的目的是探讨儿童钝性肝外伤手术治疗与非手术治疗的效果，包括输血情况。我们回顾了美国外科医师学会认证的一级创伤中心在5年期间处理儿童钝性肝外伤的经验。纳入研究的儿童年龄≤16岁，入院时CT扫描证实有钝性肝损伤。CT扫描发现的肝损伤根据美国创伤外科协会的器官损伤分级系统进行分类。所有数据均以平均值±标准误差表示。排除1例CT未发现的儿童肝外伤病例（院前心肺复苏）。纳入27例患者[年龄9.3±1.0岁（范围3 - 16岁）]。损伤机制包括机动车碰撞（14例）、行人被机动车撞击（7例）、自行车碰撞（4例）、高处坠落（1例）和行人被坠落物体撞击（1例）。创伤评分11.5±0.3。肝损伤分级分布如下：Ⅰ级13例；Ⅱ级9例；Ⅲ级3例；Ⅳ级2例；Ⅴ级0例。接受手术治疗的5例患者均有多处器官损伤；3例伴有脾损伤需手术修复；其余2例有小肠损伤需修复。肝缝合术与肝损伤严重程度无关：Ⅰ级，n = 1；Ⅱ级，n = 2；Ⅲ级，n = 1；Ⅳ级，n = 1。3例接受手术的患者接受了输血。22例患者接受非手术治疗，其中仅1例需要输血。研究中无患者死亡，3例转至亚急性康复机构，1例转至另一家医院，23例出院回家。我们的研究结果表明，大多数CT扫描证实有钝性肝损伤的儿童可采用非手术治疗，很少需要输血。包括同时合并脾损伤的多处器官损伤患者可能理想的治疗方法是手术探查和修复，而孤立性肝损伤患者可成功地采用非手术治疗。
