Clemente Nicola, Di Saverio Salomone, Giorgini Eleonora, Biscardi Andrea, Villani Silvia, Senatore Gianluca, Filicori Filippo, Antonacci Nicola, Baldoni Franco, Tugnoli Gregorio
Trauma Surgery Unit, Trauma Center (Head Dr. G. Tugnoli), Department of Emergency, Maggiore Hospital, Bologna, Italy.
Ann Ital Chir. 2011 Sep-Oct;82(5):351-9.
Management of Liver Trauma may vary widely from NOM +/- angioembolization to Damage Control Surgery. Multidisciplinary management is essential for achieving better outcomes.
During 2000-2009 period 308 patients with liver injury were admitted to level 1 trauma center and recorded in Trauma Registry. Collected data are demographics, AAST grade, initial treatment (operative or non-operative treatment) and outcome (failure of NOM), death. All patients were initially assessed according to ATLS guidelines. In case of haemodynamic instability and FAST evidence of intra-abdominal free fluid, the patients underwent immediate laparotomy. Hemodynamically stable patients, underwent CT scan and were admitted in ICU for NOM.
Two hundred fourteen patients (69.5%) were initially managed with NOM. In 185 patients this was successful. Within the other 29 patients, failure of NOM was due to liver-related causes in 12 patients and non-liver-related causes in 17 Greater the grade of liver injury, fewer patients could be enrolled for NOM (85.8% in I-II and 83.3% in III against 39.8% in IV-V). Of those initially treated non-operatively, the likelihood of failure was greater in more severely injured patients (24.4% liver-related failure rate in IV-V against the 1.3% and 1.0% in I-II and III respectively). One hundred twenty-three patients (40% of the whole population study--308 patients) underwent laparotomy: 94 immediately after admission, because no eligible for NOM; 29 after NOM failure . In the 81 patients in which liver bleeding was still going on at laparotomy, hemostasis was attempted in two different ways: in the patients affected by hypothermia, coagulopathy and acidosis, perihepatic packing was the treatment of choice. In the other cases a "direct repair" technique was preferred. "Early mortality" which was expected to be worse in patients with such metabolic derangements, was surprisingly the same of the other group. This proves efficacy of the packing technique in interrupting the "vicious cicle" of hypothermia, coagulopathy and acidosis, therefore avoiding death ("early death" in particular) from uncontrollable bleeding.
NOM +/- angioembolization is safe and effective in any grade of liver injury provided hemodynamic stability. DCS is Gold Standard for hemodynamically unstable patients.
肝外伤的治疗方法差异很大，从非手术治疗（NOM）±血管栓塞到损伤控制手术。多学科管理对于取得更好的治疗效果至关重要。
2000年至2009年期间，308例肝损伤患者被收治于一级创伤中心，并记录于创伤登记册。收集的数据包括人口统计学资料、美国创伤外科学会（AAST）分级、初始治疗（手术或非手术治疗）以及治疗结果（非手术治疗失败）、死亡情况。所有患者最初均按照高级创伤生命支持（ATLS）指南进行评估。对于血流动力学不稳定且腹部超声检查（FAST）提示腹腔内有游离液体的患者，立即进行剖腹手术。血流动力学稳定的患者接受CT扫描，并入住重症监护病房（ICU）进行非手术治疗。
214例患者（69.5%）最初采用非手术治疗。其中185例治疗成功。在另外29例患者中，非手术治疗失败的原因中，12例为肝脏相关原因，17例为非肝脏相关原因。肝损伤分级越高，能够采用非手术治疗的患者越少（I-II级为85.8%，III级为83.3%，而IV-V级为39.8%）。在那些最初接受非手术治疗的患者中，损伤越严重的患者治疗失败的可能性越大（IV-V级患者肝脏相关治疗失败率为24.4%，而I-II级和III级分别为1.3%和1.0%）。123例患者（占整个研究人群的40% - 308例患者）接受了剖腹手术：94例在入院后立即进行，因为不符合非手术治疗的条件；29例在非手术治疗失败后进行。在剖腹手术时仍有肝脏出血的81例患者中，尝试了两种不同的止血方法：对于体温过低、凝血功能障碍和酸中毒的患者，肝周填塞是首选治疗方法。在其他情况下，更倾向于采用“直接修复”技术。预期这种代谢紊乱患者的“早期死亡率”会更高，但令人惊讶的是，该组与另一组相同。这证明了填塞技术在中断体温过低、凝血功能障碍和酸中毒的“恶性循环”方面的有效性，从而避免因无法控制的出血导致死亡（尤其是“早期死亡”）。
只要血流动力学稳定，非手术治疗（NOM）±血管栓塞对于任何级别的肝损伤都是安全有效的。对于血流动力学不稳定的患者，损伤控制手术（DCS）是金标准。
