Jacobs I A, Kelly K, Valenziano C, Pawar J, Jones C
Department of Surgery, Morristown Memorial Hospital, New Jersey 07962, USA.
Am Surg. 2001 Feb;67(2):149-54.
Although operative management was the preferred method of treating blunt abdominal trauma in the past, recent literature and practice recommend a nonsurgical approach to most pediatric splenic and hepatic injuries. The majority of data supporting the safety and efficacy of this nonoperative approach are derived from university trauma programs with a pediatric center where care was managed by pediatric surgeons only. To evaluate the applicability of this approach in a regional trauma center where pediatric patients are managed by pediatric and non-pediatric surgeons we reviewed the experience at a Level II community trauma center. Fifty-four children (16 years of age or less) were admitted between April 1992 and April 1998 after sustaining blunt traumatic splenic and/or hepatic injuries. There were 37 (69%) males and 17 (31%) females; the average age was 11 years (range 4 months to 16 years). Of the 54 patients 34 (63%) sustained splenic injuries, 17 (31%) sustained hepatic injuries, and three (6%) sustained both splenic and hepatic injuries. All of these injuries were diagnosed by CT scan or during laparotomy. The average Injury Severity Score was 14.9 with a range from four to 57. Of the 47 patients initially admitted for nonoperative management one patient failed nonoperative management and required operative intervention. In our study 98 per cent (46 of 47 patients) of pediatric patients were successfully managed nonoperatively. Complications of nonoperative management occurred in two patients. Both developed splenic pseudocysts after splenic injury, which required later operative repair. These data are comparable with those from university trauma programs and confirm that nonoperative management is safe in a community trauma center. The majority of children with blunt splenic and hepatic trauma can be successfully treated without surgery, in a regional trauma center treated by nonpediatric trauma surgeons, if the decision is based on careful initial evaluation, aggressive resuscitation, and close observation of their hemodynamic stability.
虽然手术治疗曾是过去处理钝性腹部创伤的首选方法，但最近的文献和实践建议对大多数小儿脾损伤和肝损伤采用非手术方法。支持这种非手术方法安全性和有效性的大多数数据来自设有儿科中心的大学创伤项目，在这些项目中，治疗仅由小儿外科医生负责。为了评估这种方法在一个小儿患者由小儿外科医生和非小儿外科医生共同管理的区域创伤中心的适用性，我们回顾了一家二级社区创伤中心的经验。1992年4月至1998年4月期间，54名16岁及以下儿童在遭受钝性脾和/或肝损伤后入院。其中男性37名（69%），女性17名（31%）；平均年龄为11岁（范围为4个月至16岁）。54例患者中，34例（63%）为脾损伤，17例（31%）为肝损伤，3例（6%）同时有脾损伤和肝损伤。所有这些损伤均通过CT扫描或剖腹手术诊断。平均损伤严重度评分为14.9，范围为4至57。在最初因非手术治疗入院的47例患者中，1例非手术治疗失败，需要手术干预。在我们的研究中，98%（47例患者中的46例）的小儿患者通过非手术治疗成功治愈。非手术治疗的并发症发生在2例患者中。两人在脾损伤后均出现脾假性囊肿，后来需要手术修复。这些数据与大学创伤项目的数据相当，并证实非手术治疗在社区创伤中心是安全的。如果基于仔细的初始评估、积极的复苏以及对血流动力学稳定性的密切观察做出决定，那么在由非小儿创伤外科医生治疗的区域创伤中心，大多数钝性脾和肝创伤的儿童无需手术即可成功治疗。
