Klapheke W Patrick, Franklin Glen A, Foley David S, Casos Steven R, Harbrecht Brian G, Richardson J David
Department of Surgery, University of Louisville, Louisville, Kentucky 40292, USA.
Am Surg. 2008 Sep;74(9):798-801.
Hepatic injuries are increasingly managed nonoperatively with the availability of adjunctive procedures such as angiography, ERCP, and percutaneous drainage. Although extensively discussed in the adult population, little has been reported on outcomes and management of pediatric liver injury. Retrospective review of all patients with blunt liver injuries admitted to an adult Level I trauma center and pediatric trauma center within the same community was performed from 2004 to 2006. The necessity for operation, adjuncts to nonoperative management, and outcome were collected and compared for the pediatric (PED) (<18 years of age) versus the adult (> or = 18 years of age) injured patients. There were 389 liver injuries identified (PED = 90, adult = 299); 25 per cent of adult injuries were greater than or equal to grade III, while 23 per cent of PED injuries were high-grade injuries. Each group of patients had similar rates of primary operative intervention: adult patients (18%) versus PED patients (16%). Adjunctive therapies were rarely used in the PED patients with only one patient requiring a percutaneous drain and one patient undergoing ERCP twice. Conversely, the adult patient group required eight percutaneous drains, 15 angiograms, 6 ERCPs and 14 laparoscopic abdominal washout procedures. ICU and hospital LOS were 25 per cent and 33 per cent lower in the adult population for high-grade injuries. The overall mortality rates were similar at 7 per cent (PED) and 9 per cent (adult). Liver-related mortality was 50 per cent (3/6 deaths) in the PED group with no liver-related deaths in the adult group (27 deaths). Adult patients with blunt liver injury were no more likely to sustain high grade liver injuries than PED patients. Furthermore, adult and PED patients underwent similar rates of operative intervention and primary liver procedures. Adult patients used adjunctive measures as part of their nonoperative management more frequently, but both subsets had similar length of hospital stays and low overall mortality. A higher rate of liver-related mortality was seen in the PED population. Overall, PED patients seemed to sustain fewer liver related complications necessitating invasive procedures despite similar injury patterns.
随着血管造影、内镜逆行胰胆管造影（ERCP）和经皮引流等辅助治疗手段的出现，肝损伤越来越多地采用非手术治疗。虽然在成人患者中对此进行了广泛讨论，但关于小儿肝损伤的治疗结果和管理的报道却很少。对2004年至2006年期间入住同一社区的一家成人一级创伤中心和小儿创伤中心的所有钝性肝损伤患者进行了回顾性研究。收集并比较了小儿（PED）（<18岁）与成人（≥18岁）受伤患者的手术必要性、非手术治疗的辅助手段及治疗结果。共确定了389例肝损伤（PED组90例，成人组299例）；25%的成人损伤为Ⅲ级或以上，而23%的PED损伤为高级别损伤。每组患者的初次手术干预率相似：成人患者（18%）与PED患者（16%）。辅助治疗在PED患者中很少使用，只有一名患者需要经皮引流，一名患者接受了两次ERCP。相反，成人患者组需要8次经皮引流、15次血管造影、6次ERCP和14次腹腔镜腹腔冲洗术。对于高级别损伤，成人患者的重症监护病房（ICU）和住院时间分别缩短了25%和33%。总体死亡率相似，PED组为7%，成人组为9%。PED组肝相关死亡率为50%（6例死亡中有3例），成人组无肝相关死亡（27例死亡）。钝性肝损伤的成人患者并不比PED患者更容易遭受高级别肝损伤。此外，成人和PED患者的手术干预率和初次肝脏手术率相似。成人患者更频繁地使用辅助措施作为非手术治疗的一部分，但两个亚组的住院时间相似，总体死亡率较低。PED人群中肝相关死亡率较高。总体而言，尽管损伤模式相似，但PED患者似乎较少出现需要侵入性治疗的肝相关并发症。
