Schmelzer Thomas M, Mostafa Gamal, Gunter Oliver L, Norton H James, Sing Ronald F
Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina 28203, USA.
J Surg Educ. 2008 Sep-Oct;65(5):340-5. doi: 10.1016/j.jsurg.2008.06.008.
In penetrating abdominal trauma, diagnostic imaging and the application of selective clinical management may avoid negative celiotomy and improve outcome.
We prospectively observed patients with penetrating abdominal trauma over 15 months and recorded demographics, presentation, imaging, surgical procedure, and outcome. Patients who underwent immediate laparotomy were compared with patients who were observed and/or had a computed tomography (CT) scan. Outcomes of negative versus positive and immediate versus delayed celiotomy were compared. Chi-square and Student t tests were used. A p value of less than 0.05 was considered significant.
A level 1 trauma center.
Adult patients who presented with penetrating abdominal injury.
In all, 100 consecutive patients (mean age, 32 years) were included (male:female, 91:9; gunshot wound:stab wound, 65:35). Overall, 60 immediate and 10 delayed laparotomies were performed; 30 patients did not undergo surgery. Predictors of immediate celiotomy were hypotension (p = 0.03), anteriorly located entrance wounds (p = 0.0005), and transaxial wounds (p = 0.03). Overall morbidity and mortality was 32% and 2%, respectively. The negative celiotomy rate was 25%. Patients with a positive celiotomy had higher morbidity (p = 0.006) and longer hospital length of stay (p = 0.003) compared with negative celiotomy. A CT scan was employed in 32% of patients, with 100% sensitivity and 94% specificity. Delayed celiotomy (10%) did not adversely impact morbidity (p = 0.70) and was 100% therapeutic, with no deaths.
Nonselective immediate celiotomy for penetrating abdominal trauma results in a high rate of unnecessary surgery. Hemodynamically stable patients can safely be observed and/or have contrast CT scans and undergo delayed celiotomy, if indicated. This selective treatment had no adverse effect on patient outcomes and can potentially improve overall outcome.
在穿透性腹部创伤中，诊断性影像学检查及选择性临床处理方法的应用可避免不必要的剖腹手术并改善预后。
我们对15个月内的穿透性腹部创伤患者进行前瞻性观察，记录人口统计学资料、临床表现、影像学检查结果、手术过程及预后情况。将立即接受剖腹手术的患者与接受观察和/或计算机断层扫描（CT）的患者进行比较。比较阴性与阳性剖腹手术以及立即与延迟剖腹手术的预后情况。采用卡方检验和学生t检验。p值小于0.05被认为具有统计学意义。
一级创伤中心。
出现穿透性腹部损伤的成年患者。
共纳入100例连续患者（平均年龄32岁）（男:女 = 91:9；枪伤:刺伤 = 65:35）。总体而言，进行了60例立即剖腹手术和10例延迟剖腹手术；30例患者未接受手术。立即剖腹手术的预测因素为低血压（p = 0.03）、伤口位于前方（p = 0.0005）和横向伤口（p = 0.03）。总体发病率和死亡率分别为32%和2%。阴性剖腹手术率为25%。与阴性剖腹手术相比，阳性剖腹手术患者的发病率更高（p = 0.006），住院时间更长（p = 0.003）。32%的患者接受了CT扫描，其敏感性为100%，特异性为94%。延迟剖腹手术（10%）对发病率没有不利影响（p = 0.70），且治疗效果为100%，无死亡病例。
对于穿透性腹部创伤，非选择性立即剖腹手术会导致较高比例的不必要手术。血流动力学稳定的患者如果有指征，可以安全地接受观察和/或进行增强CT扫描，并接受延迟剖腹手术。这种选择性治疗对患者预后没有不良影响，且有可能改善总体预后。
