Mossadegh Somayyeh, Midwinter M, Sapsford W, Tai N
Honorary Trauma Fellow, Royal London Hospital, London, UK.
J R Army Med Corps. 2013 Jun;159(2):110-3. doi: 10.1136/jramc-2013-000039. Epub 2013 Mar 22.
Management of blunt splenic injury (BSI) in battlefield casualties is controversial. Splenectomy is the traditional treatment, as setting the conditions for selective non-operative management (SNOM) is difficult in the operational environment. On mature operations, it may be feasible to adopt a more conservative approach and manage the patient according to civilian protocols. The aim of this study was to document the contemporary practice of deployed military surgeons when dealing with BSI and to compare this against a matched cohort of civilian BSI patients.
The Joint Theatre Trauma Registry held at the Royal Centre for Defence Medicine, Birmingham, was thoroughly examined to yield patients with BSI. The study encompassed a 55-month period ending September 2009. Data abstracted included patient demographics, injury epidemiology, grade of splenic injury, treatment and outcome. These data were compared with a registry database from a UK civilian major trauma centre.
Of 1516 military trauma patients, 16 (1%) had a splenic injury, of which five were excluded either because of fatalities due to overwhelming injury or penetrating trauma. The remaining 11 had a blunt component. Median (IQR) injury severity score (ISS) was 17 (15-21). Nine underwent a splenectomy with median (IQR) ISS of 17 (12-18). Of this group, organ injury grades were documented in 10 patients (four Grade V injuries, three Grade IV and three Grade II). All patients survived surgery. There were no complications in survivors as a result of splenic conservation in the military group. Data from the civilian major trauma centre database showed 160 (2%) patients sustained a splenic injury, of which 131 (82%) had a blunt mechanism, 43/160 (27%) and 9/160 (6%) patients underwent splenectomy and angio-embolisation, respectively.
Patients with BSI, an uncommon finding in combat casualties, are occasionally selected for conservative management, contrary to previous military surgical paradigms but in keeping with the civilian shift to SNOM. Guidelines to clarify the place of SNOM are required to assist surgical decision making on deployed operations.
战场上伤员钝性脾损伤（BSI）的处理存在争议。脾切除术是传统的治疗方法，因为在作战环境中很难具备选择性非手术治疗（SNOM）的条件。在成熟的行动中，采用更保守的方法并按照 civilian 方案处理患者可能是可行的。本研究的目的是记录部署的军事外科医生处理 BSI 时的当代实践，并将其与匹配的 civilian BSI 患者队列进行比较。
对位于伯明翰皇家国防医学中心的联合战区创伤登记处进行了全面检查，以找出患有 BSI 的患者。该研究涵盖了截至 2009 年 9 月的 55 个月期间。提取的数据包括患者人口统计学、损伤流行病学、脾损伤分级、治疗和结果。这些数据与英国 civilian 主要创伤中心的登记数据库进行了比较。
在 1516 名军事创伤患者中，16 名（1%）有脾损伤，其中 5 名因重伤或穿透伤导致死亡而被排除。其余 11 名有钝性损伤成分。中位（IQR）损伤严重程度评分（ISS）为 17（15 - 21）。9 名患者接受了脾切除术，中位（IQR）ISS 为 17（12 - 18）。在该组中，10 名患者记录了器官损伤分级（4 名 V 级损伤，3 名 IV 级和 3 名 II 级）。所有患者手术存活。军事组中因保留脾脏而存活的患者没有并发症。来自 civilian 主要创伤中心数据库的数据显示，160 名（2%）患者有脾损伤，其中 131 名（82%）有钝性机制，43/160（27%）和 9/160（6%）患者分别接受了脾切除术和血管栓塞术。
BSI 患者在战斗伤员中并不常见，偶尔会被选择进行保守治疗，这与以前的军事外科模式相反，但与 civilian 向 SNOM 的转变一致。需要明确 SNOM 地位的指南来协助部署行动中的手术决策。
