脾血管栓塞术作为钝性脾损伤非手术治疗辅助手段的作用：一项系统评价与荟萃分析。
The role of splenic angioembolization as an adjunct to nonoperative management of blunt splenic injuries: A systematic review and meta-analysis.
作者信息
Crichton James Charles Ian, Naidoo Kamil, Yet Barbaros, Brundage Susan I, Perkins Zane
机构信息
From the Department of General Surgery (J.C.I.C.), Waikato Hospital, Hamilton, New Zealand; Queen Mary University of London, Barts, and The London School of Medicine and Dentistry, London, United Kingdom (K.N., B.Y., Z.P., S.I.B.).
出版信息
J Trauma Acute Care Surg. 2017 Nov;83(5):934-943. doi: 10.1097/TA.0000000000001649.
BACKGROUND
Nonoperative management (NOM) of hemodynamically normal patients with blunt splenic injury (BSI) is the standard of care. Guidelines recommend additional splenic angioembolization (SAE) in patients with American Association for the Surgery of Trauma (AAST) Grade IV and Grade V BSI, but the role of SAE in Grade III injuries is unclear and controversial. The aim of this systematic review was to compare the safety and effectiveness of SAE as an adjunct to NOM versus NOM alone in adults with BSI.
METHODS
A systematic literature search (Medline, Embase, and CINAHL) was performed to identify original studies that compared outcomes in adult BSI patients treated with SAE or NOM alone. Primary outcome was failure of NOM. Secondary outcomes included morbidity, mortality, hospital length of stay, and transfusion requirements. Bayesian meta-analyses were used to calculate an absolute (risk difference) and relative (risk ratio [RR]) measure of treatment effect for each outcome.
RESULTS
Twenty-three studies (6,684 patients) were included. For Grades I to V combined, there was no difference in NOM failure rate (SAE, 8.6% vs NOM, 7.7%; RR, 1.09 [0.80-1.51]; p = 0.28), mortality (SAE, 4.8% vs NOM, 5.8%; RR, 0.82 [0.45-1.31]; p = 0.81), hospital length of stay (11.3 vs 9.5 days; p = 0.06), or blood transfusion requirements (1.8 vs 1.7 units; p = 0.47) between patients treated with SAE and those treated with NOM alone. However, morbidity was significantly higher in patients treated with SAE (SAE, 38.1% vs NOM, 18.6%; RR, 1.83 [1.20-2.66]; p < 0.01). When stratified by grade of splenic injury, SAE significantly reduced the failure rate of NOM in patients with Grade IV and Grade V splenic injuries but had minimal effect in those with Grade I to Grade III injuries.
CONCLUSION
Splenic angioembolization should be strongly considered as an adjunct to NOM in patients with AAST Grade IV and Grade V BSI but should not be routinely recommended in patients with AAST Grade I to Grade III injuries.
LEVEL OF EVIDENCE
Systematic review and meta-analysis, level III.
背景
对于血流动力学稳定的钝性脾损伤（BSI）患者，非手术治疗（NOM）是标准治疗方法。指南建议对美国创伤外科学会（AAST）IV级和V级BSI患者进行额外的脾动脉栓塞术（SAE），但SAE在III级损伤中的作用尚不清楚且存在争议。本系统评价的目的是比较SAE作为NOM辅助治疗与单纯NOM治疗对成人BSI患者的安全性和有效性。
方法
进行系统的文献检索（Medline、Embase和CINAHL），以确定比较单独接受SAE或NOM治疗的成人BSI患者结局的原始研究。主要结局是NOM失败。次要结局包括发病率、死亡率、住院时间和输血需求。采用贝叶斯荟萃分析计算每个结局的绝对（风险差）和相对（风险比[RR]）治疗效果指标。
结果
纳入23项研究（6684例患者）。对于I至V级合并损伤，SAE组与单纯NOM组在NOM失败率（SAE组为8.6%，NOM组为7.7%；RR为1.09[0.80 - 1.51]；p = 0.28）、死亡率（SAE组为4.8%，NOM组为5.8%；RR为0.82[0.45 - 1.31]；p = 0.81）、住院时间（11.3天对9.5天；p = 0.06）或输血需求（1.8单位对1.7单位；p = 0.47）方面无差异。然而，SAE治疗的患者发病率显著更高（SAE组为38.1%，NOM组为18.6%；RR为1.83[1.20 - 2.66]；p < 0.01）。按脾损伤分级分层时，SAE显著降低了IV级和V级脾损伤患者的NOM失败率，但对I至III级损伤患者影响极小。
结论
对于AAST IV级和V级BSI患者，应强烈考虑将脾动脉栓塞术作为NOM的辅助治疗，但对于AAST I至III级损伤患者，不应常规推荐。
证据级别
系统评价和荟萃分析，III级。
Zotero 插件