Trauma Center, Department of Emergency and Trauma Surgery, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China.
Department of Emergency Surgery, Wuhan Pu'ai Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China.
J Surg Res. 2019 Oct;242:223-230. doi: 10.1016/j.jss.2019.04.005. Epub 2019 May 14.
Flail chest (FC) is known to account for high mortality and morbidity and is typically treated with conservative care. Operative fixation of FC has been advocated as an alternative treatment choice. This prospective randomized controlled trial aims to compare surgical and nonsurgical management of FC in patients with severe polytrauma.
Severe polytrauma patients with FC admitted between January 2015 and July 2017 to our trauma center were investigated. The enrolled patients were randomly assigned to the surgical or nonsurgical group. Basic characteristics of injury and clinical outcomes were compared.
Fifty patients entered final analysis, with 25 patients in each group. Operative rib fixation was associated with shorter duration of mechanical ventilation (7 d [interquartile range {IQR} 6-10] versus 9 d [IQR 7-12], P = 0.012), shorter ICU stay (10 d [IQR 7-12] versus 12 d [IQR 9-15], P = 0.032), lower risk of adult respiratory distress syndrome (28% versus 60%, P = 0.045), pneumonia (48% versus 80%, P = 0.038), and thoracic deformity (8% versus 36%, P = 0.037) and less pain while coughing (pain score 6 [IQR 3-8] versus 8 [IQR 4-9], P = 0.029) and deep breathing (pain score 5 [IQR 3-9] versus 7 [IQR 3-9], P = 0.038). Subgroup analysis was conducted by presence of pulmonary contusion. Shorter time on the ventilator use and ICU stay associated with rib surgery was not observed in patients with pulmonary contusion.
This study reveals that surgical rib fixation may provide some critical care benefits for severe polytrauma patients with FC, including less medical resource use and lower risk of complications. Further studies should be designed to optimally identify patients who are most likely to benefit from this surgery.
连枷胸（FC）死亡率和发病率高，通常采用保守治疗。手术固定 FC 已被提倡作为替代治疗选择。本前瞻性随机对照试验旨在比较 FC 严重多发伤患者的手术和非手术治疗。
对 2015 年 1 月至 2017 年 7 月期间我院创伤中心收治的 FC 严重多发伤患者进行调查。纳入的患者被随机分配到手术组或非手术组。比较两组患者的基本损伤特征和临床结局。
50 例患者最终进入分析，每组 25 例。手术肋骨固定与机械通气时间更短（7 天[四分位距（IQR）6-10]与 9 天[IQR 7-12]，P=0.012）、住 ICU 时间更短（10 天[IQR 7-12]与 12 天[IQR 9-15]，P=0.032）、成人呼吸窘迫综合征风险较低（28%与 60%，P=0.045）、肺炎（48%与 80%，P=0.038）和胸壁畸形（8%与 36%，P=0.037）以及咳嗽时疼痛减轻（疼痛评分 6[IQR 3-8]与 8[IQR 4-9]，P=0.029）和深呼吸（疼痛评分 5[IQR 3-9]与 7[IQR 3-9]，P=0.038）。对存在肺挫伤的患者进行了亚组分析。在有肺挫伤的患者中，使用呼吸机和 ICU 停留时间较短与肋骨手术无关。
本研究表明，对于 FC 严重多发伤患者，手术肋骨固定可能提供一些重症监护益处，包括减少医疗资源的使用和降低并发症的风险。应设计进一步的研究，以最佳地确定最有可能从这种手术中受益的患者。
