Cogbill T H, Moore E E, Jurkovich G J, Morris J A, Mucha P, Shackford S R, Stolee R T, Moore F A, Pilcher S, LoCicero R
Department of Surgery, Gundersen/Lutheran Medical Center, La Crosse, WI.
J Trauma. 1989 Oct;29(10):1312-7. doi: 10.1097/00005373-198910000-00002.
The experience of six referral trauma centers with 832 blunt splenic injuries was reviewed to determine the indications, methods, and outcome of nonoperative management. During this 5-year period, 112 splenic injuries were intentionally managed by observation. There were 40 (36%) patients less than 16 years old and 72 adults. The diagnosis was established by computed tomography in 89 (79%) patients, nuclear scan in 23 (21%), ultrasound in four (4%), and arteriography in two (2%). There were 28 Class I, 51 Class II, 31 Class III, two Class IV, and no Class V splenic injuries. Nonoperative management was unsuccessful in one (2%) child and 12 (17%) adults (p less than 0.05). Failure was due to ongoing hemorrhage in 12 patients and delayed recognition of pancreatic injury in one patient. Of the 12 patients ultimately requiring laparotomy for control of hemorrhage, seven (58%) were successfully treated with splenic salvage techniques. Overall mortality was 3%; none of the four deaths was due to splenic or associated abdominal injury. This contemporary multicenter experience suggests that patients with Class I, II, or III splenic injuries after blunt trauma are candidates for nonoperative management if there is: 1) no hemodynamic instability after initial fluid resuscitation; 2) no serious associated abdominal organ injury; and 3) no extra-abdominal condition which precludes assessment of the abdomen. Strict adherence to these principles yielded initial nonoperative success in 98% of children and 83% of adults. Application of standard splenic salvage techniques to treat the patients with persistent hemorrhage resulted in ultimate splenic preservation in 100% of children and 93% of adults.
回顾了六个转诊创伤中心832例钝性脾损伤的经验，以确定非手术治疗的适应症、方法和结果。在这5年期间，112例脾损伤通过观察进行了有意处理。其中有40例（36%）患者年龄小于16岁，72例为成年人。89例（79%）患者通过计算机断层扫描确诊，23例（21%）通过核扫描确诊，4例（4%）通过超声确诊，2例（2%）通过动脉造影确诊。有28例I级、51例II级、31例III级、2例IV级脾损伤，无V级脾损伤。非手术治疗在1例（2%）儿童和12例（17%）成年人中未成功（p<0.05）。失败原因是12例患者持续出血，1例患者胰腺损伤诊断延迟。在最终因控制出血而需要剖腹手术的12例患者中，7例（58%）通过脾保留技术成功治疗。总体死亡率为3%；4例死亡均非由脾或相关腹部损伤所致。这项当代多中心经验表明，钝性创伤后I级、II级或III级脾损伤的患者，如果有以下情况，可作为非手术治疗的候选对象：1）初始液体复苏后无血流动力学不稳定；2）无严重相关腹部器官损伤；3）无排除腹部评估的腹部外情况。严格遵守这些原则在98%的儿童和83%的成年人中取得了初步非手术成功。应用标准脾保留技术治疗持续出血的患者，在100%的儿童和93%的成年人中实现了最终脾保留。
