Zhang Wen-Bo, Li Ning, Wang Ge-Fei, Li Jie-Shou
Institute of General Surgery, Nanjing General Hospital of Nanjing Military Command, Nanjing 210002, China.
Zhonghua Wai Ke Za Zhi. 2009 Mar 15;47(6):441-5.
To assess the efficacy and safety of damage control surgery with abdominal packing in non-trauma patients with severe abdominal hemorrhage.
A retrospective review of consecutive non-trauma patients who underwent abdominal packing to control severe abdominal hemorrhage between February 2002 and February 2007 were performed. The demographics, physiological parameters, surgical indications and procedures, mortality, morbidity and volumes of resuscitation were retrieved. The observed mortality was compared to those calculated from the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) and Portsmouth Predictor Equation (P-POSSUM) scores.
A total of 26 non-trauma patients were included in this study, with a mean age of (42.6 +/- 15.8) years (range, 18 - 72 years). The most common etiologies associated with the severe hemorrhage was necrotizing pancreatitis (11 cases), intestinal fistula (5 cases) and tumor (4 cases). Of the patients, 24 cases (92.4%) achieved hemostasis by simple packing, 1 achieved hemostasis by using packing and angiographic embolization, and the other one failed and died. The mean intra-operative blood loss during the initial procedure was 1253.8 ml. The physiological parameters which improved significantly after rewarming and resuscitation in ICU phase included: body temperature, systolic blood pressure, heart rate, arterial pH, base excess, hemoglobin, hematocrit, prothrombin time, and international normalized ratio. The mean duration of packing was 4.3 days. The mean length of SICU stay and hospital stay was 40.5 and 67.4 days, respectively. Mortality rate predicted by POSSUM and P-POSSUM was 77.7% and 63.4%, respectively. Seven patients (26.9%) died after operation, brought an observed mortality rate significantly lower than predicted (P = 0.001 and 0.025, respectively). The most common complications included pneumonia (57.7%), bacteremia (50.0%), and re-bleeding (26.9%).
Damage control laparotomy with packing is an effective procedure in the management of severe non-trauma abdominal hemorrhage, it can prevent the aggravation of "lethal triad" characterized by hypothermia, coagulopathy and acidosis. Appropriate application of the technique in strictly selected patients can result in a lower mortality rate.
评估腹部填塞损伤控制手术在非创伤性严重腹部出血患者中的疗效和安全性。
对2002年2月至2007年2月间连续接受腹部填塞以控制严重腹部出血的非创伤性患者进行回顾性研究。收集患者的人口统计学资料、生理参数、手术指征和手术过程、死亡率、发病率及复苏量。将观察到的死亡率与根据生理和手术严重程度评分系统（POSSUM）及朴茨茅斯预测方程（P-POSSUM）评分计算出的死亡率进行比较。
本研究共纳入26例非创伤性患者，平均年龄为（42.6±15.8）岁（范围18 - 72岁）。与严重出血相关的最常见病因是坏死性胰腺炎（11例）、肠瘘（5例）和肿瘤（4例）。其中，24例（92.4%）通过单纯填塞实现止血，1例通过填塞和血管造影栓塞实现止血，另1例失败死亡。初次手术期间的平均术中失血量为1253.8 ml。在重症监护病房（ICU）阶段复温和复苏后显著改善的生理参数包括：体温、收缩压、心率、动脉血pH值、碱剩余、血红蛋白、血细胞比容、凝血酶原时间和国际标准化比值。平均填塞时间为4.3天。外科重症监护病房（SICU）平均住院时间和总住院时间分别为40.5天和67.4天。POSSUM和P-POSSUM预测的死亡率分别为77.7%和63.4%。7例患者（26.9%）术后死亡，观察到的死亡率显著低于预测值（分别为P = 0.001和0.025）。最常见的并发症包括肺炎（57.7%）、菌血症（50.0%）和再次出血（26.9%）。
腹部填塞损伤控制剖腹术是治疗严重非创伤性腹部出血的有效方法，可防止以体温过低、凝血功能障碍和酸中毒为特征的“致死三联征”加重。在严格选择的患者中适当应用该技术可降低死亡率。
