Fang Jen-Feng, Chen Ray-Jade, Lin Being-Chuan, Hsu Yu-Bau, Kao Jung-Liang, Chen Miin-Fu
Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Kweis-han, Taoyuan, Taiwan.
J Trauma. 2003 Jun;54(6):1131-6; discussion 1136. doi: 10.1097/01.TA.0000066123.32997.BB.
Nonoperative management (NOM) of blunt splenic injury (BSI) is currently a well-accepted treatment modality for hemodynamically stable patients. More than 60% of BSI patients can be successfully treated without operation. Old age, high-grade injury, contrast blush, and multiple associated injuries were reported to have a higher failure rate but not to be exclusive of NOM. The purpose of this study was to review the treatment courses and results of a special group of BSI patients with coexistent liver cirrhosis. Factors leading to poor results were analyzed and treatment strategy was proposed accordingly.
During a 5-year period, 487 patients with BSI were treated following a standard protocol. Twelve of them had underlying liver cirrhosis. The medical records, radiographic findings, laboratory data, and operative variables were retrospectively reviewed.
Eighty-nine (18%) patients had immediate celiotomy for splenic hemorrhage with unstable hemodynamic status, 59 (12%) had non-spleen-related or nontherapeutic laparotomy, and 339 (70%) patients received NOM initially. Failure of NOM was found in 74 patients (22%). Twelve patients with initial NOM had coexistent liver cirrhosis. The amount of blood transfusion within 72 hours after admission for these 12 patients ranged from 4 to 26 units. Patients with coexistent liver cirrhosis and BSI had a significantly higher NOM failure rate (92% vs. 19%). In NOM failure patients, those with liver cirrhosis had lower Injury Severity Scores, lower splenic injury severity grades, more blood transfusions, and a higher mortality rate. Risk factors for mortality in these patients included a higher Injury Severity Score, a severely elevated prothrombin time (PT), a larger transfusion requirement, and a lower serum albumin level.
Liver cirrhosis with subsequent development of portal hypertension, splenomegaly, and coagulopathy makes spontaneous hemostasis of the injured spleen difficult. NOM for BSI patients with coexistent liver cirrhosis carries a high failure and mortality rate. NOM may be successful in only a small group of patients with low-grade single-organ injury and with a normal or mildly elevated PT. Aggressive correction of coagulopathy should be performed in these patients. High-grade splenic injury, multiple associated injuries, and an elevated PT are indicators for early surgery. The mortality rate is high in patients with a severely prolonged PT irrespective of treatment modalities.
钝性脾损伤（BSI）的非手术治疗（NOM）目前是血流动力学稳定患者广泛接受的治疗方式。超过60%的BSI患者无需手术即可成功治疗。据报道，老年、高等级损伤、造影剂外渗和多发合并伤的失败率较高，但并非NOM的绝对禁忌证。本研究旨在回顾一组合并肝硬化的特殊BSI患者的治疗过程和结果。分析导致不良结果的因素，并据此提出治疗策略。
在5年期间，487例BSI患者按照标准方案进行治疗。其中12例合并肝硬化。对病历、影像学检查结果、实验室数据和手术变量进行回顾性分析。
89例（18%）患者因脾出血伴血流动力学不稳定立即行剖腹手术，59例（12%）患者行非脾脏相关或非治疗性剖腹手术，339例（70%）患者最初接受NOM治疗。74例（22%）患者NOM治疗失败。12例最初接受NOM治疗的患者合并肝硬化。这12例患者入院后72小时内的输血量为4至26单位。合并肝硬化和BSI的患者NOM失败率显著更高（92%对19%）。在NOM治疗失败的患者中，合并肝硬化的患者损伤严重程度评分更低、脾损伤严重程度等级更低、输血量更多且死亡率更高。这些患者死亡的危险因素包括更高的损伤严重程度评分、凝血酶原时间（PT）严重升高、更大的输血需求和更低的血清白蛋白水平。
肝硬化继发门静脉高压、脾肿大和凝血功能障碍使受损脾脏难以自发止血。合并肝硬化的BSI患者行NOM治疗失败率和死亡率高。NOM可能仅在一小部分低等级单器官损伤且PT正常或轻度升高的患者中成功。应对这些患者积极纠正凝血功能障碍。高等级脾损伤、多发合并伤和PT升高是早期手术的指征。无论治疗方式如何，PT严重延长的患者死亡率高。
