成人钝性脾创伤选择性血管造影栓塞术可降低非手术治疗的失败率。
Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management.
机构信息
Division of Acute Care Surgery (I.S.B.), Department of Surgery, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida 32209, USA.
出版信息
J Trauma Acute Care Surg. 2012 May;72(5):1127-34. doi: 10.1097/TA.0b013e3182569849.
BACKGROUND
To determine whether angioembolization (AE) in hemodynamically stable adult patients with blunt splenic trauma (BST) at high risk for failure of nonoperative management (NOM) (contrast blush [CB] on computed tomography, high-grade IV-V injuries, or decreasing hemoglobin) results in lower failure rates than reported.
METHODS
The records of patients with BST from July 2000 to December 2010 at a Level I trauma center were retrospectively reviewed using National Trauma Registry of the American College of Surgeons. Failure of NOM (FNOM) occurred if splenic surgery was required after attempted NOM. Logistic regression analysis was used to identify factors associated with FNOM.
RESULTS
A total of 1,039 patients with BST were found. Pediatric patients (age <17 years), those who died in the emergency department, and those requiring immediate surgery for hemodynamic instability were excluded. Of the 539 (64% of all BST) hemodynamically stable patients who underwent NOM, 104 (19%) underwent AE and 435 (81%) were observed without AE (NO-AE). FNOM for the various groups were as follows: overall NOM (4%), NO-AE (4%), and AE (4%). There was no significant difference in FNOM for NO-AE versus AE for grades I to III: grade I (1% vs. 0%, p = 1), grade II (2% vs. 0%, p = 0.318), and grade III (5% vs. 0%, p = 0.562); however, a significant decrease in FNOM was noted with the addition of AE for grades IV to V: grade IV (23% vs. 3%, p = 0.04) and grade V (63% vs. 9%, p = 0.03). Statistically significant independent risk factors for FNOM were grade IV to V injuries and CB.
CONCLUSION
Application of strictly defined selection criteria for NOM and AE in patients with BST resulted in one of the lowest overall FNOM rates (4%). Hemodynamically stable BST patients are candidates for NOM with selective AE for high-risk patients with grade IV to V injuries, CB on initial computed tomography, and/or decreasing hemoglobin levels.
LEVEL OF EVIDENCE
III, therapeutic study.
背景
本研究旨在确定在高风险非手术治疗（NOM）失败的血流动力学稳定的成人钝性脾外伤（BST）患者中，血管内栓塞（AE）是否比报道的结果具有更低的失败率。
方法
使用美国外科医师学院国家创伤登记处对 2000 年 7 月至 2010 年 12 月期间在一级创伤中心治疗的 BST 患者的病历进行回顾性分析。如果在尝试 NOM 后需要进行脾手术，则认为 NOM 失败（FNOM）。采用逻辑回归分析确定与 FNOM 相关的因素。
结果
共发现 1039 例 BST 患者。排除儿科患者（年龄 <17 岁）、在急诊科死亡的患者以及因血流动力学不稳定而需要立即手术的患者。在接受 NOM 的 539 例（所有 BST 的 64%）血流动力学稳定的患者中，104 例（19%）接受了 AE，435 例（81%）未接受 AE（无 AE）。不同组的 FNOM 如下：整体 NOM（4%）、无 AE（4%）和 AE（4%）。无 AE 与 AE 在 I 至 III 级的 FNOM 无显著差异：I 级（1%与 0%，p=1）、II 级（2%与 0%，p=0.318）和 III 级（5%与 0%，p=0.562）；然而，对于 IV 至 V 级，添加 AE 可显著降低 FNOM：IV 级（23%与 3%，p=0.04）和 V 级（63%与 9%，p=0.03）。FNOM 的统计学显著独立危险因素为 IV 至 V 级损伤和 CB。
结论
对 BST 患者严格定义 NOM 和 AE 的选择标准，并以此为指导进行应用，可使总体 FNOM 率（4%）达到最低之一。血流动力学稳定的 BST 患者适合接受 NOM，对于高风险患者，选择性应用 AE 治疗 IV 至 V 级损伤、初始 CT 上的 CB 以及/或血红蛋白水平下降的患者。
证据水平
III 级，治疗性研究。
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