近期穿透性创伤手术探查后的常规计算机断层扫描：我们遗漏了哪些损伤？

Routine computed tomography after recent operative exploration for penetrating trauma: What injuries do we miss?

作者信息

Mendoza April E, Wybourn Christopher A, Charles Anthony G, Campbell Andre R, Cairns Bruce A, Knudson Margaret M

机构信息

From the Division of Trauma and Critical Care, Department of Surgery (A.E.M., C.A.W., A.C., M.M.K.), University of California San Francisco, San Francisco, California; and Department of Surgery (A.G.C., B.A.C.), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

出版信息

J Trauma Acute Care Surg. 2017 Oct;83(4):575-578. doi: 10.1097/TA.0000000000001558.

DOI:10.1097/TA.0000000000001558

PMID:28930951

Abstract

BACKGROUND

Patients with penetrating trauma who cannot be stabilized undergo operative intervention without preoperative imaging. In such cases, postoperative imaging may reveal additional injuries not identified during the initial operative exploration. The purpose of this study is to explore the utility of postoperative CT imaging in the setting of penetrating trauma.

METHODS

This was a retrospective analysis of patients with penetrating trauma treated at an urban Level 1 trauma center between 2010 and 2015. Patients were included if they underwent an emergent laparotomy without preoperative imaging. Patients were excluded if they had prior imaging or concomitant blunt injury. For the purposes of this study, occult injury was defined as a CT scan finding not mentioned in the first operative report. Descriptive statistics were used to compare patient characteristics who had received imaging immediately postoperatively with those who had not.

RESULTS

During the 5-year study period, 328 patients who had a laparotomy for penetrating trauma over the study period, 225 patients met the inclusion criteria. Seventy-three (32%) patients underwent CT scanning immediately postoperatively with occult injuries identified in 38 (52%) patients. The most frequent occult injuries were orthopedic (20 of 43) and genitourinary (9 of 43). Importantly, 10 (26%) of the 38 patients required an intervention for these occult injuries. Those selected for immediate postoperative imaging were more likely to have sustained gunshot wounds and were significantly more severely injured (higher Injury Severity Score and longer length of hospital stay) when compared to patients who did not receive immediate imaging.

CONCLUSION

We recommend the use of immediate postoperative CT after emergent laparotomy especially when there is a high index of suspicion for spine or genitourinary injuries and in patients who have sustained ballistic penetrating injuries.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV; diagnostic tests or criteria, level IV.

摘要

背景

对于无法稳定病情的穿透性创伤患者，在未进行术前影像学检查的情况下即接受手术干预。在此类病例中，术后影像学检查可能会发现初次手术探查时未识别出的其他损伤。本研究的目的是探讨穿透性创伤情况下术后CT成像的效用。

方法

这是一项对2010年至2015年期间在一家城市一级创伤中心接受治疗的穿透性创伤患者的回顾性分析。纳入标准为未进行术前影像学检查即接受急诊剖腹手术的患者。若患者有既往影像学检查或合并钝性损伤则被排除。在本研究中，隐匿性损伤定义为首次手术报告中未提及的CT扫描结果。采用描述性统计方法比较术后立即接受影像学检查的患者与未接受影像学检查的患者的特征。

结果

在5年的研究期间，共有328例在研究期间因穿透性创伤接受剖腹手术的患者，其中225例符合纳入标准。73例（32%）患者术后立即接受了CT扫描，其中38例（52%）患者发现有隐匿性损伤。最常见的隐匿性损伤是骨科损伤（43例中的20例）和泌尿生殖系统损伤（43例中的9例）。重要的是，38例患者中有10例（26%）因这些隐匿性损伤需要进行干预。与未立即接受影像学检查的患者相比，选择术后立即进行影像学检查的患者更有可能遭受枪伤，且损伤程度明显更严重（损伤严重度评分更高，住院时间更长）。