Asensio Juan A, Arroyo Hector, Veloz William, Forno Walter, Gambaro Esteban, Roldan Gustavo A, Murray James, Velmahos George, Demetriades Demetrios
Department of Surgery, Division of Trauma and Critical Care, University of Southern California, LAC+USC Medical Center, 1200 N. State Street, Room 10-750, Los Angeles, California 90033-4525, USA.
World J Surg. 2002 May;26(5):539-43. doi: 10.1007/s00268-001-0147-8. Epub 2001 Nov 22.
The aims of this study were to (1) define characteristics for the thoracoabdominal injury patient population; (2) describe sequences of surgical interventions with combined procedures (i.e., thoracotomy and laparotomy); and (3) describe pitfalls leading to inappropriate sequencing of surgical interventions for thoracoabdominal injuries. It was a retrospective 4-year study (January 1995 to December 1998) conducted at an urban level I trauma center. The study population comprised 254 patients who had sustained thoracoabdominal injuries requiring surgical intervention: 187 (73%) gunshot wounds (GSWs), 64 (25%) stab wounds (SWs), and 3 (2%) shotgun wounds (STWs). The mean revised (RTS) was 6.04; the mean Injury Severity Score (ISS) was 27; the mean estimated blood loss (EBL) was 3000 ml. The overall survival was 175 of 254 (69%). Of the 254, 51 (20%) underwent emergency department (ED) thoracotomy. Altogether, 73 (29%) underwent combined thoracotomy and laparotomy: 59 (81%) GSW, 13 (18%) SW, 1 (1%) STW (mean RTS 5.2, mean ISS 34, mean EBL 6800 ml). Overall survival was 30 of these 73 (41%). A total of 21 of the 73 (29%) underwent ED thoracotomy. In group I (laparotomy then thoracotomy: Lap + Thor, n = 34) the initial procedure was interrupted in 18 (53%). In group II (thoracotomy then laparotomy: Thor + Lap, n = 39) the initial procedure was interrupted in 14 (36%). Pitfalls leading to inappropriate surgical sequencing were persistent hypotension (13/73, 18%) and misleading chest tube output (8/73, 10%). It was concluded that penetrating thoracoabdominal injuries incur high mortality (31%), and the mortality doubles for patients who require combined procedures (59%). Inappropriate surgical sequencing occurred in 32 of 73 (44%) patients undergoing combined procedures. Persistent hypotension, indicating that the wrong cavity was accessed, and misleading chest tube output are the leading pitfalls in thoracoabdominal injury management.
（1）明确胸腹联合伤患者群体的特征；（2）描述联合手术（即开胸术和剖腹术）的手术干预顺序；（3）描述导致胸腹联合伤手术干预顺序不当的陷阱。这是一项在城市一级创伤中心进行的为期4年的回顾性研究（1995年1月至1998年12月）。研究人群包括254例遭受胸腹联合伤需要手术干预的患者：187例（73%）为枪伤（GSW），64例（25%）为刺伤（SW），3例（2%）为霰弹枪伤（STW）。平均修正创伤评分（RTS）为6.04；平均损伤严重度评分（ISS）为27；平均估计失血量（EBL）为3000毫升。总体生存率为254例中的175例（69%）。在254例患者中，51例（20%）在急诊科（ED）接受了开胸术。共有73例（29%）接受了开胸术和剖腹术联合手术：59例（81%）为枪伤，13例（18%）为刺伤，1例（1%）为霰弹枪伤（平均RTS 5.2，平均ISS 34，平均EBL 6800毫升）。这73例患者的总体生存率为30例（41%）。73例患者中有21例（29%）在急诊科接受了开胸术。在第一组（先剖腹术再开胸术：剖腹术+开胸术，n = 34）中，18例（53%）的初始手术被中断。在第二组（先开胸术再剖腹术：开胸术+剖腹术，n = 39）中，14例（36%）的初始手术被中断。导致手术顺序不当的陷阱包括持续性低血压（13/73，18%）和胸腔引流管输出误导（(8/73)，10%）。研究得出结论，穿透性胸腹联合伤死亡率很高（31%），需要联合手术的患者死亡率翻倍（59%）。在73例接受联合手术的患者中，32例（44%）出现了手术顺序不当的情况。持续性低血压表明进入了错误的体腔，以及胸腔引流管输出误导是胸腹联合伤治疗中的主要陷阱。
