Bhullar Indermeet S, Tepas Joseph J, Siragusa Daniel, Loper Todd, Kerwin Andrew, Frykberg Eric R
From the Orlando Regional Medical Center (I.S.B.), Orlando, Florida; Division of Pediatric Surgery (J.T.P.), University of Florida College of Medicine-Jacksonville, Jacksonville, Florida; Division of Vascular and Interventional Radiology (D.S.), University of Florida College of Medicine, Jacksonville, Florida; Division of Vascular and Interventional Radiology (T.L.), University of Florida College of Medicine, Jacksonville, Florida; University of Florida College of Medicine (A.K.), Jacksonville, Florida; and University of Florida College of Medicine (E.R.F.), Jacksonville, Florida.
J Trauma Acute Care Surg. 2017 Apr;82(4):657-664. doi: 10.1097/TA.0000000000001366.
Nonoperative management (NOM) of hemodynamically stable high-grade (IV-V) blunt splenic trauma remains controversial given the high failure rates (19%) that persist despite angioembolization (AE) protocols. The NOM protocol was modified in 2011 to include mandatory AE of all grade (IV-V) injuries without contrast blush (CB) along with selective AE of grade (I-V) with CB. The purpose of this study was to determine if this new AE (NAE) protocol significantly lowered the failure rates for grade (IV-V) injuries allowing for safe observation without surgery and if the exclusion of grade III injuries allowed for the prevention of unnecessary angiograms without affecting the overall failure rates.
The records of patients with blunt splenic trauma from January 2000 to October 2014 at a Level I trauma center were retrospectively reviewed. Patients were divided into two groups and failure of NOM (FNOM) rates compared: NAE protocol (2011-2014) with mandatory AE for all grade (IV-V) injuries without CB and selective AE for grade (I-V) with CB versus old AE (OAE) protocol (2000-2010) with selective AE for grade (I-V) with CB.
Seven hundred twelve patients underwent NOM with 522 (73%) in the OAE group and 190 (27%) in the NAE group. Evolving from the OAE to the NAE strategy resulted in a significantly lower FNOM rate for the overall group (grade I-V) (OAE vs. NAE, 4% to 1%, p = 0.04) and the grade (IV-V) group (OAE vs. NAE, 19% vs. 3%, p = 0.01). Angiograms were avoided in 113 grade (I-III) injuries with no CB; these patients had NOM with observation alone and none failed.
A protocol using mandatory AE of all high-grade (IV-V) injuries without CB and selective AE of grade (I-V) with CB may provide for optimum salvage with safe NOM of the high-grade injuries (IV-V) and limited unnecessary angiograms.
Therapeutic study, level IV.
鉴于尽管采用了血管栓塞（AE）方案，但血流动力学稳定的高级别（IV - V级）钝性脾损伤的非手术治疗（NOM）失败率仍高达19%，其仍存在争议。2011年对NOM方案进行了修改，包括对所有无对比剂外渗（CB）的（IV - V级）损伤进行强制性AE，以及对有CB的（I - V级）损伤进行选择性AE。本研究的目的是确定这种新的AE（NAE）方案是否能显著降低（IV - V级）损伤的失败率，从而允许在不进行手术的情况下进行安全观察，以及排除III级损伤是否能在不影响总体失败率的情况下避免不必要的血管造影。
回顾性分析2000年1月至2014年10月在一级创伤中心接受钝性脾损伤治疗的患者记录。将患者分为两组并比较NOM失败（FNOM）率：NAE方案（2011 - 2014年），对所有无CB的（IV - V级）损伤进行强制性AE，对有CB的（I - V级）损伤进行选择性AE，与旧的AE（OAE）方案（2000 - 2010年），对有CB的（I - V级）损伤进行选择性AE。
712例患者接受了NOM，其中OAE组522例（73%），NAE组190例（27%）。从OAE策略转变为NAE策略后，总体组（I - V级）的FNOM率显著降低（OAE组与NAE组，4%对1%，p = 0.04），（IV - V级）组的FNOM率也显著降低（OAE组与NAE组，19%对3%，p = 0.01）。113例无CB的（I - III级）损伤患者避免了血管造影；这些患者仅通过观察进行NOM，无一例失败。
一种对所有无CB的高级别（IV - V级）损伤进行强制性AE，对有CB的（I - V级）损伤进行选择性AE的方案，可能为高级别损伤（IV - V级）提供最佳挽救效果，并在安全的NOM情况下减少不必要的血管造影。
治疗性研究，IV级。
