Department of Surgery, Wake Forest University, Winston-Salem, NC.
Department of Surgery, Wake Forest University, Winston-Salem, NC.
J Am Coll Surg. 2014 Apr;218(4):644-8. doi: 10.1016/j.jamcollsurg.2014.01.040. Epub 2014 Jan 28.
Nonoperative management (NOM) of blunt splenic injury is well accepted. Substantial failure rates in higher injury grades remain common, with one large study reporting rates of 19.6%, 33.3%, and 75% for grades III, IV, and V, respectively. Retrospective data show angiography and embolization can increase salvage rates in these severe injuries. We developed a protocol requiring referral of all blunt splenic injuries, grades III to V, without indication for immediate operation for angiography and embolization. We hypothesized that angiography and embolization of high-grade blunt splenic injury would reduce NOM failure rates in this population.
This was a prospective study at our Level I trauma center as part of a performance-improvement project. Demographics, injury characteristics, and outcomes were compared with historic controls. The protocol required all stable patients with grade III to V splenic injuries be referred for angiography and embolization. In historic controls, referral was based on surgeon preference.
From January 1, 2010 to December 31, 2012, there were 168 patients with grades III to V spleen injuries admitted; NOM was undertaken in 113 (67%) patients. The protocol was followed in 97 patients, with a failure rate of 5%. Failure rate in the 16 protocol deviations was 25% (p = 0.02). Historic controls from January 1, 2007 to December 31, 2009 were compared with the protocol group. One hundred and fifty-three patients with grade III to V injuries were admitted during this period, 80 (52%) patients underwent attempted NOM. Failure rate was significantly higher than for the protocol group (15%, p = 0.04).
Use of a protocol requiring angiography and embolization for all high-grade spleen injuries slated for NOM leads to a significantly decreased failure rate. We recommend angiography and embolization as an adjunct to NOM for all grade III to V splenic injuries.
非手术治疗（NOM）对钝性脾损伤是有效的。在更高的损伤等级中，仍然存在大量治疗失败的情况，一项大型研究报告的 III 级、IV 级和 V 级的失败率分别为 19.6%、33.3%和 75%。回顾性数据表明，血管造影和栓塞术可提高这些严重损伤的抢救成功率。我们制定了一项方案，要求对所有无立即手术指征的 III 至 V 级钝性脾损伤患者进行血管造影和栓塞术。我们假设血管造影和栓塞术可降低该人群中 NOM 治疗失败率。
这是我们的一级创伤中心的一项前瞻性研究，作为绩效改进项目的一部分。比较了人口统计学、损伤特征和结果，并与历史对照进行了比较。该方案要求所有稳定的 III 至 V 级脾损伤患者均转诊进行血管造影和栓塞术。在历史对照中，转诊是根据外科医生的偏好决定的。
从 2010 年 1 月 1 日至 2012 年 12 月 31 日，共有 168 例 III 至 V 级脾损伤患者入院，其中 113 例（67%）患者接受了 NOM 治疗。97 例患者遵循了方案，失败率为 5%。16 例方案偏差的失败率为 25%（p = 0.02）。比较了 2007 年 1 月 1 日至 2009 年 12 月 31 日的历史对照组与方案组。在此期间，共有 153 例 III 至 V 级损伤患者入院，80 例（52%）患者尝试进行 NOM。失败率明显高于方案组（15%，p = 0.04）。
对所有计划进行 NOM 的高等级脾损伤患者使用需要进行血管造影和栓塞术的方案可显著降低失败率。我们建议对所有 III 至 V 级脾损伤患者进行血管造影和栓塞术作为 NOM 的辅助治疗。
