穿透性腹部创伤管理模式的变化：万变不离其宗。

Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same.

作者信息

Nicholas Jeffrey M, Rix Emily Parker, Easley Kerr Anthony, Feliciano David V, Cava Raymond A, Ingram Walter L, Parry Neil G, Rozycki Grace S, Salomone Jeffrey P, Tremblay Lorraine N

机构信息

Emory University Department of Surgery/Grady Memorial Hospital and Rollins School of Public Health, Atlanta, Georgia 03030, USA.

出版信息

J Trauma. 2003 Dec;55(6):1095-108; discussion 1108-10. doi: 10.1097/01.TA.0000101067.52018.42.

DOI:10.1097/01.TA.0000101067.52018.42

PMID:14676657

Abstract

BACKGROUND

Damage control surgery (DCS) and treatment of abdominal compartment syndrome have had major impacts on care of the severely injured. The objective of this study was to see whether advances in critical care, DCS, and recognition of abdominal compartment syndrome have improved survival from penetrating abdominal injury (PAI).

METHODS

The care of 250 consecutive patients requiring laparotomy for PAI (1997-2000) was reviewed retrospectively. Organ injury patterns, survival, and use of DCS and its impact on outcome were compared with a similar experience reported in 1988.

RESULTS

Two hundred fifty patients had a positive laparotomy for PAI. Twenty-seven (10.8%) required abdominal packing and 45 (17.9%) did not have fascial closure. Seven (2.8%) required emergency department thoracotomy and 21 (8.4%) required operating room thoracotomy. Two hundred seventeen (86.8%) survived overall. Small bowel (47.2%), colon (36.4%), and liver (34.4%) were most often injured. Mortality was associated with the number of organs injured (odds ratio, 1.98; 95% confidence interval, 1.65-2.37; p < 0.001). Vascular injury was a risk factor for mortality (p < 0.001), as was need for DCS (p < 0.001), emergency department thoracotomy (p < 0.001), and operating room thoracotomy (p < 0.001). Seventy-nine percent of deaths occurred within 24 hours from refractory hemorrhagic shock. DCS was used in 17.9% (n = 45) versus 7.0% (n = 21) in 1988, with a higher survival rate (73.3% vs. 23.8%, p < 0.001). DCS was associated with significant morbidity including sepsis (42.4%, p < 0.001), intra-abdominal abscess (18.2%, p = 0.009), and gastrointestinal fistula (18.2%, p < 0.001).

CONCLUSION

Penetrating abdominal organ injury patterns and survival from PAI have remained similar over the past decade. Death from refractory hemorrhagic shock in the first 24 hours remains the most common cause of mortality. DCS and the open abdomen are being used more frequently with improved survival but result in significant morbidity.

摘要

背景

损伤控制手术（DCS）及腹腔间隔室综合征的治疗对严重创伤患者的救治产生了重大影响。本研究的目的是观察重症监护、DCS及腹腔间隔室综合征认识方面的进展是否改善了穿透性腹部损伤（PAI）患者的生存率。

方法

回顾性分析1997 - 2000年连续250例因PAI需行剖腹手术患者的治疗情况。将器官损伤模式、生存率、DCS的使用及其对预后的影响与1988年报道的类似经验进行比较。

结果

250例患者因PAI行剖腹手术结果为阳性。27例（10.8%）需要腹部填塞，45例（17.9%）未进行筋膜缝合。7例（2.8%）需要在急诊科行开胸手术，21例（8.4%）需要在手术室行开胸手术。217例（86.8%）总体存活。小肠（47.2%）、结肠（36.4%）和肝脏（34.4%）是最常受伤的器官。死亡率与受伤器官数量相关（比值比，1.98；95%置信区间，1.65 - 2.37；p < 0.001）。血管损伤是死亡的危险因素（p < 0.001），DCS的需求（p < 0.001）、急诊科开胸手术（p < 0.001）和手术室开胸手术（p < 0.001）也是如此。79%的死亡发生在难治性失血性休克后的24小时内。1988年DCS的使用比例为7.0%（n = 21），而本研究中为17.9%（n = 45），本研究生存率更高（73.3%对23.8%，p < 0.001）。DCS与显著的并发症相关，包括脓毒症（42.4%，p < 0.001）、腹腔内脓肿（18.2%，p = 0.009）和胃肠瘘（18.2%，p < 0.001）。