Service de chirurgie viscérale, hôpital d'instruction des armées Sainte-Anne, boulevard Sainte-Anne, 83000 Toulon, France.
J Visc Surg. 2011 Oct;148(5):e379-84. doi: 10.1016/j.jviscsurg.2011.09.007. Epub 2011 Oct 22.
The hemodynamically unstable pelvic fracture are a diagnostic and therapeutic challenge. The current management is based on the control of pelvic bleeding by combining pelvic ring stabilization and embolization of pelvic arteries. The mortality of these patients, however, exceeds 30%. Recently the preperitoneal packing, based on the hemostatic tamponade of the pelvic cavity has been described. The objective of this study was to evaluate the interest of this new surgical procedure. The effectiveness of the standard algorithm is evaluated by analysis of pelvic injuries in 200 severe trauma treated at the Sainte-Anne Hospital. The results are then compared with literature data on the preperitoneal packing.
The profile injury, management and morbidity and mortality was evaluated in 200 polytrauma. After an initial phase of resuscitation, unstable pelvic fractures were treated with a circumferential belt followed by the application of an external fixator. Arteriography was performed for all patients with persistent hemodynamic instability.
The mean injury severity score (ISS) was 31 (4-75). The mean trauma-related injury severity score (TRISS) was 74% (3-99). The proportion of hemodynamically unstable patients was 47%. Fifteen patients (41%) had severe bleeding. The median number of blood transfusion was 10 (4-42); eight patients (22%) underwent embolization. For two patients, reducing the pelvic fracture with an external fixator resulted in permanent hemostasis. Two patients underwent a laparotomy first, for the control of a hemoperitoneum. The mortality rate of the group of patients with hemorrhage was 33% (5/15).
This high mortality leads to reconsider the place of pelvic embolization as firstline treatment. Some major drawbacks are noted: its effectiveness in treating venous bleeding, availability and duration of the procedure. The preperitoneal packing is a fast and effective surgical alternative. It seems to improve hemodynamic status of patients and significantly reduce the use of embolization and massive transfusion. Embolization is still indicated for patients not responding to surgery. However survival is not significantly improved.
血流动力学不稳定的骨盆骨折是一个诊断和治疗的挑战。目前的治疗方法是通过骨盆环稳定和栓塞骨盆动脉来控制骨盆出血。然而，这些患者的死亡率超过 30%。最近，基于骨盆腔止血填塞的腹膜前填塞已被描述。本研究的目的是评估这种新手术方法的意义。通过分析在 Sainte-Anne 医院治疗的 200 例严重创伤患者的骨盆损伤，评估标准算法的效果。然后将结果与文献中关于腹膜前填塞的资料进行比较。
评估了 200 例多发伤患者的损伤谱、处理方法、发病率和死亡率。在复苏的初始阶段后，不稳定的骨盆骨折用环形带治疗，然后应用外固定器。所有持续血流动力学不稳定的患者都进行了血管造影。
平均损伤严重程度评分（ISS）为 31（4-75）。平均创伤相关损伤严重程度评分（TRISS）为 74%（3-99）。血流动力学不稳定患者的比例为 47%。15 名患者（41%）有严重出血。中位数输血次数为 10（4-42）；8 名患者（22%）接受了栓塞。对于两名患者，用外固定器减少骨盆骨折导致永久性止血。两名患者首先进行剖腹手术，以控制腹腔积血。出血组患者的死亡率为 33%（5/15）。
这种高死亡率导致重新考虑栓塞作为一线治疗的位置。存在一些主要缺点：其治疗静脉出血的有效性、可用性和持续时间。腹膜前填塞是一种快速有效的手术替代方法。它似乎可以改善患者的血流动力学状态，并显著减少栓塞和大量输血的使用。栓塞仍然适用于对手术无反应的患者。然而，存活率并没有显著提高。
