Siriratsivawong Kris, Zenati Mazen, Watson Gregory A, Harbrecht Brian G
Department of General Surgery, Naval Medical Center San Diego, San Diego, California 92134-5000, USA.
Am Surg. 2007 Jun;73(6):585-9; discussion 590.
Nonoperative management (NOM) of blunt splenic injury has become more frequent in the past several decades. Criteria that predict successful NOM remain poorly defined, and one factor that has been studied previously has been patient age. Previous studies have defined older patients as those greater than 55 years of age, but no studies have compared younger patients (55-75 years) with older patients (75+ years) within this age group. A total of 1008 patients > or =55 years of age who sustained blunt splenic injury between 1993 and 2001 were analyzed from the Pennsylvania Trauma Systems Foundation database. Statistical analysis was performed using regression analysis. Data was expressed as mean +/- SD, and a P value of < or = 0.05 was considered significant. Patients were classified as operative management (OM; 39.9%) or NOM (60.1%) according to their initial plan of treatment. Of the patients in the NOM group, 75.3 per cent were successfully managed nonoperatively (SNOM), whereas 24.7 per cent eventually required surgery. The Injury Severity Score of the OM group was highest (34) compared with the SNOM group (22) and failed NOM (FNOM; 27) groups. The mean splenic injury grade for OM, SNOM, and FNOM was 3.5, 2.4, and 3.3, respectively. The number of pre-existing conditions did not differ among the three groups. An upward trend in the failure rate of NOM was observed with increasing age (19.0%, 27.1%, and 28.3%, respectively) for three age groups, 55-64, 65-74, and 75+, but this trend was not statistically significant. Mortality rate was highest in the OM group (35.6%) compared with the successful (16.7%) and failed NOM (17.9%). Hospital length of stay (LOS) and intensive care unit (ICU) LOS were highest among patients who failed NOM (mean hospital LOS = 20.7 days, mean ICU LOS = 13.2 days) compared with OM (17.2 and 10.4, respectively) and successful NOM (12.4 and 6.9, respectively). The majority of patients > or = 55 years with blunt splenic injuries can be managed nonoperatively when carefully selected. In the subset of patients older than 55 years of age, increasing age is associated with a trend toward higher failure rates. Mortality was high regardless of management, and failure of NOM in older patients is associated with significantly longer hospital and ICU LOS.
在过去几十年中，钝性脾损伤的非手术治疗（NOM）变得越来越普遍。预测NOM成功的标准仍未明确界定，之前研究过的一个因素是患者年龄。以往研究将老年患者定义为年龄大于55岁，但尚未有研究在该年龄组内比较年轻患者（55 - 75岁）和老年患者（75岁以上）。从宾夕法尼亚创伤系统基金会数据库中分析了1993年至2001年间1008例年龄≥55岁的钝性脾损伤患者。采用回归分析进行统计分析。数据以平均值±标准差表示，P值≤0.05被认为具有统计学意义。根据患者的初始治疗计划，将患者分为手术治疗（OM；39.9%）或非手术治疗（NOM；60.1%）。在NOM组患者中，75.3%通过非手术治疗成功（SNOM），而24.7%最终需要手术。与SNOM组（22分）和非手术治疗失败（FNOM；27分）组相比，OM组的损伤严重程度评分最高（34分）。OM、SNOM和FNOM组的平均脾损伤分级分别为3.5、2.4和3.3。三组患者的既往病史数量无差异。在55 - 64岁、65 - 74岁和75岁以上三个年龄组中，随着年龄增长，NOM失败率呈上升趋势（分别为19.0%、27.1%和28.3%），但这一趋势无统计学意义。与成功的NOM组（16.7%）和失败的NOM组（17.9%）相比，OM组的死亡率最高（35.6%）。与OM组（分别为17.2天和10.4天）和成功的NOM组（分别为12.4天和6.9天）相比，非手术治疗失败的患者住院时间（LOS）和重症监护病房（ICU）住院时间最长（平均住院LOS = 20.7天，平均ICU LOS = 13.2天）。经过仔细筛选，大多数年龄≥55岁的钝性脾损伤患者可以进行非手术治疗。在年龄大于55岁的患者亚组中，年龄增长与失败率升高的趋势相关。无论采用何种治疗方式，死亡率都很高，老年患者非手术治疗失败与显著更长的住院和ICU住院时间相关。
