Beekley Alec C, Blackbourne Lorne H, Sebesta James A, McMullin Neil, Mullenix Philip S, Holcomb John B
Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431-1100, USA.
J Trauma. 2008 Feb;64(2 Suppl):S108-16; discussion S116-7. doi: 10.1097/TA.0b013e31816093d0.
Historically, military surgical doctrine has mandated exploratory laparotomy for all penetrating fragmentation wounds. We hypothesized that stable patients with abdominal fragmentation injuries whose computerized tomography (CT) scans for intraperitoneal or retroperitoneal penetration disclosed nothing abnormal, can be safely observed without therapeutic laparotomy.
We retrospectively studied all hemodynamically stable patients with penetrating fragmentation wounds to the back, flank, lower chest, abdomen, and pelvis evaluated by abdominal physical examination (PE), CT, or ultrasound treated during a 6-month period at one combat support hospital. Sensitivity, specificity, and positive and negative predictive values were calculated comparing each positive test to laparotomy and each negative test to successful nonoperative management.
One hundred forty-five patients met study criteria. Based on CT scans, 85 (59%) patients were managed nonoperatively; 60 (41%) underwent laparotomy. Forty-five of 60 (75%) of laparotomies were therapeutic. CT scan for intraperitoneal or retroperitoneal penetration that disclosed nothing abnormal was 99% predictive of successful nonoperative management. In detecting intra-abdominal injury requiring laparotomy, sensitivity for each method was 30.2% (PE), 11.7% (ultrasound), and 97.8% (CT) (p < 0.05). Specificity was 94.8% (PE), 100% (ultrasound), and 84.8% (CT). The areas under the receiver operating characteristic (ROC) curves were 0.565 (PE), 0.543 (ultrasound), and 0.929 (CT) (p < 0.0001). All patients with a positive ultrasound (n = 4) underwent therapeutic laparotomy.
PE alone was unreliable in stable patients with abdominal fragmentation injuries. The clinical value of ultrasound results was limited, likely because the majority of these stable patients did not have injuries associated with the large accumulation of peritoneal fluid. CT scan safely and effectively analyzed nonoperative management of penetrating abdominal fragmentation injuries and should be the diagnostic study of choice in all stable patients without peritonitis with abdominal, flank, back, or pelvic combat fragmentation wounds.
从历史上看，军事外科原则要求对所有穿透性碎片伤患者进行剖腹探查术。我们推测，对于腹部碎片伤且病情稳定的患者，如果其计算机断层扫描（CT）显示腹膜内或腹膜后无异常穿透情况，则可以安全地进行观察，而无需进行治疗性剖腹手术。
我们回顾性研究了在一家战斗支援医院接受治疗的所有血流动力学稳定的穿透性碎片伤患者，这些患者的背部、侧腹、下胸部、腹部和骨盆通过腹部体格检查（PE）、CT或超声进行评估，研究为期6个月。计算敏感性、特异性以及阳性和阴性预测值，将每项阳性检查结果与剖腹手术结果进行比较，将每项阴性检查结果与成功的非手术治疗结果进行比较。
145例患者符合研究标准。根据CT扫描结果，85例（59%）患者接受了非手术治疗；60例（41%）患者接受了剖腹手术。60例接受剖腹手术的患者中有45例（75%）是治疗性手术。CT扫描显示腹膜内或腹膜后无异常穿透情况对成功的非手术治疗的预测准确率为99%。在检测需要进行剖腹手术的腹腔内损伤时，每种方法的敏感性分别为30.2%（体格检查）、11.7%（超声）和97.8%（CT）（p<0.05）。特异性分别为94.8%（体格检查）、100%（超声）和84.8%（CT）。受试者操作特征（ROC）曲线下面积分别为0.565（体格检查）、0.543（超声）和0.929（CT）（p<0.0001）。所有超声检查结果为阳性的患者（n=4）均接受了治疗性剖腹手术。
对于腹部碎片伤且病情稳定的患者，仅靠体格检查是不可靠的。超声检查结果的临床价值有限，可能是因为这些病情稳定的患者大多数没有与大量腹腔积液相关的损伤。CT扫描安全有效地分析了穿透性腹部碎片伤的非手术治疗情况，对于所有无腹膜炎的腹部、侧腹、背部或骨盆战斗性碎片伤且病情稳定的患者，CT扫描应作为首选的诊断检查。
