Kozar Rosemary A, Moore John B, Niles Sarah E, Holcomb John B, Moore Ernest E, Cothren C Clay, Hartwell Elizabeth, Moore Frederick A
Department of Surgery, University of Texas-Houston, Houston, TX 77030, USA.
J Trauma. 2005 Nov;59(5):1066-71. doi: 10.1097/01.ta.0000188937.75879.ab.
Nonoperative management of blunt hepatic injuries is highly successful. Complications associated with high-grade injuries, however, have not been well characterized. The purpose of the present study was therefore to define hepatic-related complications and associated treatment modalities in patients undergoing nonoperative management of high-grade blunt hepatic injuries.
Three hundred thirty-seven patients from two regional Level I trauma centers with grade 3 to 5 blunt hepatic injuries during a 40-month period were reviewed. Complications and treatment of hepatic-related complications in patients not requiring laparotomy in the first 24 hours were identified.
Of 337 patients with a grade 3 to 5 injury, 230 (68%) were managed nonoperatively. There were 37 hepatic-related complications in 25 patients (11%); 63% (5 of 8) of patients with grade 5 injuries developed complications, 21% (19 of 92) of patients with grade 4 injuries, but only 1% (1 of 130) of patients with grade 3 injuries. Complications included bleeding in 13 patients managed by angioembolization (n = 12) and laparotomy (n = 1), liver abscesses in 2 patients managed with computed tomography-guided drainage (n = 2) and subsequent laparotomy (n = 1). In one patient with bleeding, hepatic necrosis followed surgical ligation of the right hepatic artery and required delayed hepatic lobectomy. Sixteen biliary complications were managed with endoscopic retrograde cholangiopancreatography and stenting (n = 7), drainage (n = 5), and laparoscopy (n = 4). Three patients had suspected abdominal sepsis and underwent a negative laparotomy, whereas an additional three patients underwent laparotomy for abdominal compartment syndrome.
Nonoperative management of high-grade liver injuries can be safely accomplished. Mortality is low; however, complications in grade 4 and 5 injuries should be anticipated and may require a combination of operative and nonoperative management strategies.
钝性肝损伤的非手术治疗非常成功。然而，与高级别损伤相关的并发症尚未得到充分描述。因此，本研究的目的是确定接受高级别钝性肝损伤非手术治疗患者的肝脏相关并发症及相关治疗方式。
回顾了两个地区一级创伤中心在40个月期间收治的337例3至5级钝性肝损伤患者。确定了在最初24小时内不需要剖腹手术的患者的肝脏相关并发症及治疗情况。
在337例3至5级损伤患者中，230例（68%）接受了非手术治疗。25例患者（11%）出现37例肝脏相关并发症；5级损伤患者中有63%（8例中的5例）出现并发症，4级损伤患者中有21%（92例中的19例）出现并发症，而3级损伤患者中只有1%（130例中的1例）出现并发症。并发症包括13例出血，其中12例通过血管栓塞治疗，1例通过剖腹手术治疗；2例肝脓肿，其中2例通过计算机断层扫描引导下引流治疗，1例随后接受剖腹手术。1例出血患者在右肝动脉手术结扎后发生肝坏死，需要延迟进行肝叶切除术。16例胆道并发症通过内镜逆行胰胆管造影和支架置入术（7例）、引流术（5例）和腹腔镜检查（4例）进行处理。3例患者疑似腹腔感染，接受了阴性剖腹探查术，另外3例患者因腹腔间隔室综合征接受了剖腹手术。
高级别肝损伤的非手术治疗可以安全完成。死亡率较低；然而，4级和5级损伤的并发症应予以预期，并可能需要手术和非手术治疗策略相结合。
