美国创伤外科学会多机构研究：Ⅰ级创伤中心直肠损伤的当代处理。
Contemporary management of rectal injuries at Level I trauma centers: The results of an American Association for the Surgery of Trauma multi-institutional study.
机构信息
From the Dell Medical School (C.V.R.B., P.G.T., E.F.), University of Texas at Austin, Austin, Texas; University of Tennessee Health Science Center (J.P.S.), Memphis, Tennessee; Baylor College of Medicine (T.M.), Houston, Texas; University of Texas Health Science Center at Houston (J.H.), Houston, Texas; University of California San Francisco-East Bay (E.B.), Oakland, California; R. Adams Cowley Shock Trauma Center (B.B.), Baltimore, Maryland; Vanderbilt University (H.A.H.), Nashville, Tennessee; Methodist Health System (M.S.T.), Dallas, Texas; University of Colorado-Denver Health (C.C.B.), Denver, Colorado; University of Southern California (M.S.), Los Angeles, California; MedStar Washington Hospital Center (J.S.), Washington, DC; Legacy Emmanuel Medical Center (J.V.H.), Portland, Oregon; University of Texas Health Science Center San Antonio (B.E.), San Antonio, Texas; University of Oklahoma (A.M.C.), Oklahoma City, Oklahoma; Harbor-UCLA Medical Center (R.V.), Los Angeles, California; University of Arizona (G.V.), Tucson, Arizona; University of California Davis (E.E.C.), Sacramento, California; Via Christi Health (J.H.), Wichita, Kansas; University of California San Diego (R.C.), San Diego, California; Oregon Health and Science University (P.B.), Portland, Oregon; East Texas Medical Center (S.G.), Tyler, Texas; and Brigham and Women's Hospital (P.G.B.), Boston, Massachusetts.
出版信息
J Trauma Acute Care Surg. 2018 Feb;84(2):225-233. doi: 10.1097/TA.0000000000001739.
INTRODUCTION
Rectal injuries have been historically treated with a combination of modalities including direct repair, resection, proximal diversion, presacral drainage, and distal rectal washout. We hypothesized that intraperitoneal rectal injuries may be selectively managed without diversion and the addition of distal rectal washout and presacral drainage in the management of extraperitoneal injuries are not beneficial.
METHODS
This is an American Association for the Surgery of Trauma multi-institutional retrospective study from 2004 to 2015 of all patients who sustained a traumatic rectal injury and were admitted to one of the 22 participating centers. Demographics, mechanism, location and grade of injury, and management of rectal injury were collected. The primary outcome was abdominal complications (abdominal abscess, pelvic abscess, and fascial dehiscence).
RESULTS
After exclusions, there were 785 patients in the cohort. Rectal injuries were intraperitoneal in 32%, extraperitoneal in 58%, both in 9%, and not documented in 1%. Rectal injury severity included the following grades I, 28%; II, 41%; III, 13%; IV, 12%; and V, 5%. Patients with intraperitoneal injury managed with a proximal diversion developed more abdominal complications (22% vs 10%, p = 0.003). Among patients with extraperitoneal injuries, there were more abdominal complications in patients who received proximal diversion (p = 0.0002), presacral drain (p = 0.004), or distal rectal washout (p = 0.002). After multivariate analysis, distal rectal washout [3.4 (1.4-8.5), p = 0.008] and presacral drain [2.6 (1.1-6.1), p = 0.02] were independent risk factors to develop abdominal complications.
CONCLUSION
Most patients with intraperitoneal injuries undergo direct repair or resection as well as diversion, although diversion is not associated with improved outcomes. While 20% of patients with extraperitoneal injuries still receive a presacral drain and/or distal rectal washout, these additional maneuvers are independently associated with a three-fold increase in abdominal complications and should not be included in the treatment of extraperitoneal rectal injuries.
LEVEL OF EVIDENCE
Therapeutic study, level III.
引言
直肠损伤的传统治疗方法包括多种方式，包括直接修复、切除、近端转流、骶前引流和直肠远端冲洗。我们假设，对于腹腔内直肠损伤，可以选择性地不进行转流，并且在治疗腹膜外损伤时，增加直肠远端冲洗和骶前引流并无益处。
方法
这是美国创伤外科学会（American Association for the Surgery of Trauma）一项多机构回顾性研究，纳入了 2004 年至 2015 年期间在 22 个参与中心之一就诊的所有创伤性直肠损伤患者。收集了患者的人口统计学、损伤机制、部位和分级，以及直肠损伤的治疗方法。主要结局是腹部并发症（腹部脓肿、盆腔脓肿和筋膜裂开）。
结果
排除后，共有 785 例患者纳入研究。直肠损伤为腹腔内 32%，腹膜外 58%，两者均有 9%，未记录 1%。直肠损伤严重程度包括：Ⅰ级，28%；Ⅱ级，41%；Ⅲ级，13%；Ⅳ级，12%；Ⅴ级，5%。接受近端转流的腹腔内直肠损伤患者发生更多的腹部并发症（22%比 10%，p = 0.003）。对于腹膜外损伤患者，接受近端转流（p = 0.0002）、骶前引流（p = 0.004）或直肠远端冲洗（p = 0.002）的患者发生更多的腹部并发症。多因素分析显示，直肠远端冲洗（3.4 [1.4-8.5]，p = 0.008）和骶前引流（2.6 [1.1-6.1]，p = 0.02）是发生腹部并发症的独立危险因素。
结论
大多数腹腔内直肠损伤患者行直接修复或切除加转流，但转流并不能改善预后。虽然 20%的腹膜外直肠损伤患者仍接受骶前引流和/或直肠远端冲洗，但这些额外的操作与腹部并发症增加三倍独立相关，因此不应用于治疗腹膜外直肠损伤。
证据水平
治疗性研究，Ⅲ级。
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