Ochsner M G
Trauma Services and Surgical/Critical Care, Department of Surgical Education, Memorial Health University Medical Center, Mercer University School of Medicine, Savannah, Georgia 31404, USA.
World J Surg. 2001 Nov;25(11):1393-6. doi: 10.1007/s00268-001-0138-9.
A review of the literature describing the management of hepatic and splenic injuries indicates that as many as 67% of exploratory celiotomies for blunt trauma are reported as nontherapeutic. Avoiding unnecessary surgery through nonoperative management offers an attractive alternative. Nonetheless, nonoperative management should not be considered unless the patient meets the following criteria: (1) hemodynamic stability, with or without minimal fluid resuscitation; (2) no demonstrable peritoneal signs on abdominal examination; and (3) the absence on computed tomography (CT) scan of any intraperitoneal or retroperitoneal injuries that require operative intervention. Although a patient may meet these criteria, several additional factors can serve as predictors of failure of nonoperative management. Such predictors among patients with hepatic injuries are hemodynamic instability, liver injury of American Association for the Surgery of Trauma grades IV and V (especially when accompanied by hemodynamic instability), and pooling of contrast on CT scan. Formerly thought to be a predictor of failure of nonoperative management, periportal tracking has not been cited as such in recent reports of hepatic injuries. Among patients with blunt splenic injuries, such predictors include hemodynamic instability, injury of grade IV or higher, large associated hemoperitoneum, and contrast blush on CT scan. Although preexisting splenic disease and age older than 55 years have traditionally been considered predictors of failure, recent reports have shown that these characteristics do not appear to be associated with an increased need for surgical intervention.
一篇关于肝脾损伤处理的文献综述表明，据报道，因钝性创伤而行剖腹探查术的患者中，多达67%的手术被认为是无效的。通过非手术治疗避免不必要的手术是一种有吸引力的替代方法。然而，除非患者符合以下标准，否则不应考虑非手术治疗：（1）血流动力学稳定，无论是否进行了少量液体复苏；（2）腹部检查未发现明显的腹膜刺激征；（3）计算机断层扫描（CT）未显示任何需要手术干预的腹腔内或腹膜后损伤。尽管患者可能符合这些标准，但还有几个额外因素可作为非手术治疗失败的预测指标。肝损伤患者中的此类预测指标包括血流动力学不稳定、美国创伤外科学会分级为IV级和V级的肝损伤（尤其是伴有血流动力学不稳定时）以及CT扫描上的造影剂聚集。门静脉周围造影剂外渗曾被认为是非手术治疗失败的预测指标，但在最近的肝损伤报告中未被提及。在钝性脾损伤患者中，此类预测指标包括血流动力学不稳定、IV级或更高分级的损伤、大量相关的腹腔积血以及CT扫描上的造影剂外溢。尽管既往存在的脾脏疾病和年龄超过55岁传统上被认为是失败的预测指标，但最近的报告显示，这些特征似乎与手术干预需求的增加无关。
