Letoublon Christian, Chen Yao, Arvieux Catherine, Voirin David, Morra Irene, Broux Christophe, Risse Olivier
Departement de chirurgie digestive et de l'urgence, Hopital Michallon, BP 217, 38043, Grenoble, cedex, France.
World J Surg. 2008 Jun;32(6):1189-93. doi: 10.1007/s00268-007-9439-y.
Nonoperative management (NOM) is considered standard treatment for 80% of blunt hepatic trauma (BHT). NOM is associated with some events that may require delayed operation (DO), usually considered a criterion of failure of NOM.
A retrospective case note review was performed on 257 consecutive patients with BHT, with a median age of 32.7 years, admitted from 1994 to 2005. We considered the 186 patients (72%) who had an initial indication of NOM, and focused on the 28 patients who were secondarily operated (DO), mainly on the 22 patients operated on for liver-related indications. Celioscopy was used in five cases.
The severity grade of these 22 patients was: zero grade I, seven grade II, ten grade III, four grade IV, one grade V. The timing of DO varied from day 0 to day 11. Ten patients were operated on for a peritoneal inflammatory syndrome. Death occurred in three patients at days 2, 10, and 125. One was attributed to underestimation of hepatic necrosis, another to a nondiagnosed peritoneal inflammatory syndrome; 27, 3% of the patients had liver-related complications.
Our data suggest that BHT treated by NOM must be frequently reevaluated and that DO is an actual part of the so-called nonoperative treatment. The use of laparoscopic washing has to be proposed as soon as day 3 or 5 in patients with large hemoperitoneum and any sign of inflammatory response (fever, leukocytosis, discomfort, tachycardia).
非手术治疗（NOM）被认为是80%钝性肝外伤（BHT）的标准治疗方法。NOM会伴随一些可能需要延迟手术（DO）的情况，这通常被视为NOM治疗失败的标准。
对1994年至2005年收治的257例连续性BHT患者进行回顾性病例记录审查，患者中位年龄为32.7岁。我们纳入了186例（72%）最初有NOM指征的患者，并重点关注28例接受二次手术（DO）的患者，主要是22例因肝脏相关指征接受手术的患者。5例患者使用了腹腔镜检查。
这22例患者的严重程度分级为：0级1例，Ⅱ级7例，Ⅲ级10例，Ⅳ级4例，Ⅴ级1例。DO的时间从第0天到第11天不等。10例患者因腹膜炎综合征接受手术。3例患者分别在第2天、第10天和第125天死亡。1例归因于肝坏死估计不足，另1例归因于未诊断出的腹膜炎综合征；27.3%的患者出现肝脏相关并发症。
我们的数据表明，接受NOM治疗的BHT患者必须经常重新评估，DO是所谓非手术治疗的实际组成部分。对于有大量血腹和任何炎症反应迹象（发热、白细胞增多、不适、心动过速）的患者，应在第3天或第5天尽早采用腹腔镜冲洗治疗。
