Schellenberg Morgan, Inaba Kenji, Cheng Vincent, Bardes James M, Lam Lydia, Benjamin Elizabeth, Matsushima Kazuhide, Demetriades Demetrios
From the Division of Trauma and Surgical Critical Care (M.S., K.I., V.C., J.M.B., L.L., E.B., K.M., D.D.), LAC+USC Medical Center, University of Southern California, Los Angeles, CA.
J Trauma Acute Care Surg. 2018 Jan;84(1):118-122. doi: 10.1097/TA.0000000000001725.
Traumatic injuries to the distal pancreas are infrequent. Universally accepted recommendations about the need for routine splenectomy with distal pancreatectomy do not exist. The aims of this study were to compare outcomes after distal pancreatectomy and splenectomy versus spleen-preserving distal pancreatectomy, and to define the appropriate patient population for splenic preservation.
All patients who underwent distal pancreatectomy (January 1, 2007, to December 31, 2014) were identified from the National Trauma Data Bank. Patients with concomitant splenic injury and those who underwent partial splenectomy were excluded. Demographics, clinical data, procedures, and outcomes were collected. Study groups were defined by surgical procedure: distal pancreatectomy and splenectomy versus spleen-preserving distal pancreatectomy. Baseline characteristics between groups were compared with univariate analysis. Multivariate analysis was performed with logistic and linear regression to examine differences in outcomes.
Over the 8-year study period, 2,223 patients underwent distal pancreatectomy. After excluding 1,381 patients with concomitant splenic injury (62%) and 8 (<1%) who underwent partial splenectomy, 834 (38%) remained for analysis. Median age was 23 years (range, 0-86 years) and 634 (77%) were male. Mechanism of injury was penetrating in 413 (50%) patients. Of the 834 patients, 469 (56%) underwent splenectomy and 365 (44%) patients did not. Compared with patients who underwent distal pancreatectomy and splenectomy, those who underwent spleen-preserving distal pancreatectomy were younger (p < 0.001), more likely to have sustained blunt trauma (p < 0.001), and had a lower Injury Severity Score (p < 0.001). On multivariate analysis, only hospital length of stay (LOS) was significantly shorter among patients undergoing spleen-preserving distal pancreatectomy (p = 0.017). Complications, mortality, and intensive care unit LOS were not significantly different.
In young patients after blunt trauma who are not severely injured, a spleen-preserving distal pancreatectomy should be considered to allow for conservation of splenic function and a shorter hospital LOS. In all other patients, the surgeon should not hesitate to remove the spleen with the distal pancreas.
Therapy, level IV.
胰腺远端创伤性损伤并不常见。对于远端胰腺切除术常规行脾切除术的必要性，目前尚无普遍接受的建议。本研究的目的是比较远端胰腺切除术联合脾切除术与保留脾脏的远端胰腺切除术的疗效，并确定适合保留脾脏的患者群体。
从国家创伤数据库中识别出所有在2007年1月1日至2014年12月31日期间接受远端胰腺切除术的患者。排除合并脾损伤的患者以及接受部分脾切除术的患者。收集人口统计学、临床数据、手术方式及预后等信息。根据手术方式将研究组分为：远端胰腺切除术联合脾切除术与保留脾脏的远端胰腺切除术。采用单因素分析比较两组间的基线特征。运用逻辑回归和线性回归进行多因素分析，以检验预后差异。
在8年的研究期间，2223例患者接受了远端胰腺切除术。排除1381例合并脾损伤的患者（62%）以及8例（<1%）接受部分脾切除术的患者后，834例（38%）患者纳入分析。患者中位年龄为23岁（范围0 - 86岁），男性634例（77%）。413例（50%）患者的损伤机制为穿透伤。在这834例患者中，469例（56%）接受了脾切除术，365例（44%）未接受。与接受远端胰腺切除术联合脾切除术的患者相比，接受保留脾脏的远端胰腺切除术的患者更年轻（p < 0.001），更可能遭受钝性创伤（p < 0.001），且损伤严重程度评分更低（p < 0.001）。多因素分析显示，仅保留脾脏的远端胰腺切除术患者的住院时间（LOS）显著缩短（p = 0.017）。并发症、死亡率及重症监护病房住院时间无显著差异。
对于钝性创伤后未受重伤的年轻患者，应考虑行保留脾脏的远端胰腺切除术，以保留脾脏功能并缩短住院时间。对于所有其他患者，外科医生应毫不犹豫地在切除远端胰腺时一并切除脾脏。
治疗，四级。
