Cadeddu Margherita, Garnett Anna, Al-Anezi Khaled, Farrokhyar Forough
Surgical Outcomes Research Centre and Department of Surgery, McMaster University and St. Joseph's Healthcare Hamilton, ON.
Can J Surg. 2006 Dec;49(6):386-90.
Increasing awareness of the postoperative risks associated with splenectomies has led physicians and surgeons to use an alternative nonoperative strategy in handling traumatic spleen injuries. Our primary objective was to compare clinical outcomes between operative and nonoperative managements in adult patients with blunt splenic injuries. The secondary objective was to assess the changes in the patterns of managing splenic injuries in the past 10 years.
We performed a retrospective chart review on 266 adult patients with a spleen injury who were admitted to a tertiary trauma centre in Ontario between 1992 and 2001. We grouped and compared the patients according to the treatment received, either operative or nonoperative. Frequencies and confidence intervals are reported. Categorical variables were compared with chi-square or Fisher's exact tests. Continuous variables were reported as median and quartile (Q) and were compared with the nonparametric Mann-Whitney U test.
Of 266 patients, 118 had surgery and 148 were managed nonoperatively. The mortality rate was similar between operative and nonoperative groups (9.3% v. 6.8%, p = 0.49), respectively. The rate of any complication was 47.9% for the operative group and 37.9% for the nonoperative group. The median length of stay in hospital was significantly higher in the operative group than in the nonoperative group (21.0 [Q 11.0-40.5] v. 14.0 [Q 7.0-31.5] d, p < 0.001), respectively. This difference was more likely related to a higher proportion of patients having injury severity scores greater than 25 in the operative group. The rate of nonoperative management of spleen injuries was significantly increased from 48.5% to 63.1% between 1992-1996 and 1997-2001 (p = 0.02).
The present study has shown that nonoperative management of blunt spleen trauma has increased over time and has acceptable mortality and complication rates in selected patients. Additional prospective studies are needed to assess the feasibility and safety of nonoperative management in adult spleen injuries. Furthermore, the management of traumatic spleen injuries with respect to associated injuries, such as head injuries or intra-abdominal injuries, needs ongoing evaluation.
对脾切除术后相关风险的认识不断提高，促使内科医生和外科医生在处理外伤性脾损伤时采用另一种非手术策略。我们的主要目标是比较成年钝性脾损伤患者手术治疗与非手术治疗的临床结果。次要目标是评估过去10年中脾损伤处理模式的变化。
我们对1992年至2001年期间入住安大略省一家三级创伤中心的266例成年脾损伤患者进行了回顾性病历审查。我们根据接受的治疗方式（手术或非手术）对患者进行分组和比较。报告了频率和置信区间。分类变量采用卡方检验或Fisher精确检验进行比较。连续变量以中位数和四分位数（Q）表示，并采用非参数Mann-Whitney U检验进行比较。
266例患者中，118例接受了手术治疗，148例接受了非手术治疗。手术组和非手术组的死亡率相似（分别为9.3%对6.8%，p = 0.49）。手术组任何并发症的发生率为47.9%，非手术组为37.9%。手术组的中位住院时间显著高于非手术组（分别为21.0 [Q 11.0 - 40.5]天对14.0 [Q 7.0 - 31.5]天，p < 0.001）。这种差异更可能与手术组中损伤严重程度评分大于25的患者比例较高有关。1992 - 1996年至1997 - 2001年期间，脾损伤的非手术治疗率从48.5%显著增加到63.1%（p = 0.02）。
本研究表明，随着时间的推移，钝性脾外伤的非手术治疗有所增加，且在特定患者中具有可接受的死亡率和并发症发生率。需要进一步的前瞻性研究来评估成年脾损伤非手术治疗的可行性和安全性。此外，对于伴有头部损伤或腹腔内损伤等相关损伤的外伤性脾损伤的处理，需要持续评估。
