Asensio J A, Ogun O A, Mazzini F N, Perez-Alonso A J, Garcia-Núñez L M, Petrone P
Department of Surgery, Creighton University School of Medicine, Creighton University Medical Center, 601 North 30th Street, Suite 3701, Omaha, NE, 68131-2137, USA.
Eur J Trauma Emerg Surg. 2018 Feb;44(1):55-61. doi: 10.1007/s00068-017-0802-x. Epub 2017 Jun 1.
Operative interventions are uncommonly required for penetrating pulmonary injuries. Similarly, because their incidence is low, few series appear sporadically in the literature. Objectives of this study are to identify predictors of outcome for patients requiring emergent thoracotomy for penetrating pulmonary injuries and evaluate the use of tissue sparing versus resective techniques for their management.
This is a retrospective 169-month study of all patients with penetrating pulmonary injuries requiring thoracotomy. The main outcome measures are: physiologic parameters, AAST-OIS injury grade, surgical procedures and mortality. Statistical analysis includes univariate and stepwise logistic regression.
101 patients required thoracotomy for penetrating pulmonary injuries. Mechanism of injury includes: gunshot wounds (GSW)-73 (72%), stab wounds (SW)-28 (33%). Mean systolic BP 97 ± 47, mean HR 92 ± 47, and mean admission pH 7.22 ± 0.17. Mean RTS 6.25 ± 2.7, mean ISS 36 ± 22. The mean estimated blood loss (EBL) was 5277 ± 4955 mls. Predictors of outcome are: admission pH (p = 0.0014), admission base deficit (p < 0.0001), packed red blood cells (PRBCs) transfused (p = 0.023), whole blood transfused (p < 0.01). A total of 143 procedures were required in 101 patients: tissue sparing 114 (80%) versus resective procedures 29 (20%). Only pneumonectomy (p = 0.024) predicted outcome. Overall survival 64/101-64%. American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) injury grades I-III versus IV-VI predicts survival (p < 0.001). Stepwise logistic regression identified AAST-OIS injury grades IV-VI (p = 0.007; OR 6.38 [95% CI 1.64-24.78]), intraoperative dysrhythmias (p = 0.003; OR 17.38 [95% CI 2.59-116.49]) and associated cardiac injuries (p = 0.02; OR 8.74 [95% CI 1.37-55.79]) as independent predictors of outcome.
Predictors of outcome for penetrating pulmonary injuries requiring thoracotomy are identified and must be taken into account in their operative management. Tissue sparing techniques-stapled pulmonary tractotomy is once again validated, and it remains effective as the mainstay for their management; however, only pneumonectomy predicts outcome. AAST-OIS injury grades IV-VI predict outcome with higher injury grades requiring resective procedures.
穿透性肺损伤很少需要手术干预。同样，由于其发病率低，文献中很少有系列报道。本研究的目的是确定因穿透性肺损伤需要紧急开胸手术患者的预后预测因素，并评估采用保留组织技术与切除技术进行治疗的效果。
这是一项对所有因穿透性肺损伤需要开胸手术的患者进行的为期169个月的回顾性研究。主要观察指标包括：生理参数、美国创伤外科学会器官损伤分级（AAST - OIS）、手术方式和死亡率。统计分析包括单因素分析和逐步逻辑回归分析。
101例患者因穿透性肺损伤需要开胸手术。损伤机制包括：枪伤（GSW）- 73例（72%），刺伤（SW）- 28例（33%）。平均收缩压97 ± 47，平均心率92 ± 47，平均入院时pH值7.22 ± 0.17。平均创伤评分（RTS）6.25 ± 2.7，平均损伤严重度评分（ISS）36 ± 22。平均估计失血量（EBL）为5277 ± 4955毫升。预后的预测因素包括：入院时pH值（p = 0.0014）、入院时碱缺失（p < 0.0001）、输注的浓缩红细胞（PRBCs）（p = 0.023）、输注的全血（p < 0.01）。101例患者共需要进行143次手术：保留组织手术114次（80%），切除性手术29次（20%）。只有肺切除术（p = 0.024）可预测预后。总体生存率为64/101 - 64%。美国创伤外科学会器官损伤分级（AAST - OIS）I - III级与IV - VI级相比可预测生存率（p < 0.001）。逐步逻辑回归分析确定AAST - OIS损伤分级IV - VI级（p = 0.007；比值比[OR] 6.38 [95%可信区间1.64 - 24.78]）、术中心律失常（p = 0.003；OR 17.38 [95%可信区间2.59 - 116.49]）和相关心脏损伤（p = 0.02；OR 8.74 [95%可信区间1.37 - 55.79]）是预后的独立预测因素。
确定了因穿透性肺损伤需要开胸手术患者的预后预测因素，在手术治疗中必须予以考虑。保留组织技术——吻合器肺段切除术再次得到验证，并仍然是其主要治疗方法；然而，只有肺切除术可预测预后。AAST - OIS损伤分级IV - VI级可预测预后，损伤分级越高，越需要进行切除性手术。
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