Goedecke Maximilian, Kühn Florian, Stratos Ioannis, Vasan Robin, Pertschy Annette, Klar Ernst
Department of General, Visceral, Vascular and Transplantation Surgery, University Medical Center Rostock, Rostock, Germany.
Department of Oral and Maxillofacial Surgery, Corporate Member of Freie Universität Berlin, Humboldt-Universitätzu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Innov Surg Sci. 2019 Oct 14;4(3):100-107. doi: 10.1515/iss-2018-0004. eCollection 2019 Sep.
The management of a patient suffering from blunt abdominal trauma (BAT) remains a challenge for the emergency physician. Within the last few years, the standard therapy for hemodynamically stable patients with BAT has transitioned to a non-operative approach. The purpose of this study is to evaluate the outcome of patients with BAT and to determine the reasons for failure of non-operative management (NOM).
Analysis of 176 consecutive patients treated for BAT was conducted in a German level 1 trauma center from 2004 to 2011. Abdominal injuries were classified according to the American Association for the Surgery of Trauma (AAST). Patients included were demonstrated to have objective abdominal trauma with either free fluid on focused assessment with sonography for trauma (FAST) or computed tomography (CT), or proven organ injury.
Patients, 142 of 176 (80.7%), with BAT were initially managed non-operatively, with a success rate of 90%. The rates of NOM success were higher among those with less severe injuries; 100% with Abbreviated Injury Scale (AIS) of 1. In total, 125 patients (71.0%) were managed non-operatively, and 51 (29.0%) required surgical intervention. NOM failure occurred in 9.2% of the patients, the most common reason being initially undiagnosed intestinal perforation (46.2%). Positive correlation was identified (r = 0.512; p < 0.001) between the ISS (injury severity score) and the NACA (National Advisory Committee of Aeronautics) score. The delay in operation in NOM failure was 6 h in patients with underlying hepatic or splenic rupture and 34 h with intestinal perforation. The overall mortality of 5.1% was attributed especially to old age (p = 0.016), high severity of injury (p < 0.001), and greater need for blood transfusion (p < 0.001).
NOM was successful for the vast majority of blunt abdominal trauma patients, especially those with less severe injuries. NOM failure and operative delay were most commonly due to occult hollow viscus injury (HVI), the detection of which was achieved by close clinical observation and abdominal ultrasound in conjunction with monitoring for rising markers of infection and by multidetector computed tomography (MDCT) if additionally indicated. Based on this concept, the delay in operation in patients with NOM failure was short. This study underscores the feasibility and benefit of NOM in BAT.
对于急诊医生而言，钝性腹部创伤（BAT）患者的管理仍然是一项挑战。在过去几年中，血流动力学稳定的BAT患者的标准治疗已转变为非手术治疗方法。本研究的目的是评估BAT患者的治疗结果，并确定非手术治疗（NOM）失败的原因。
对2004年至2011年在德国一级创伤中心接受治疗的176例连续BAT患者进行分析。腹部损伤根据美国创伤外科学会（AAST）进行分类。纳入的患者经证实有客观腹部创伤，即创伤重点超声评估（FAST）或计算机断层扫描（CT）显示有游离液体，或有明确的器官损伤。
176例BAT患者中有142例（80.7%）最初接受非手术治疗，成功率为90%。伤情较轻者非手术治疗成功率较高；简明损伤定级（AIS）为1级的患者成功率为100%。共有125例患者（71.0%）接受了非手术治疗，51例（29.0%）需要手术干预。9.2%的患者非手术治疗失败，最常见的原因是最初未诊断出的肠穿孔（46.2%）。损伤严重度评分（ISS）与美国国家航空咨询委员会（NACA）评分之间存在正相关（r = 0.512；p < 0.001）。非手术治疗失败患者中，潜在肝或脾破裂患者的手术延迟为6小时，肠穿孔患者为34小时。总体死亡率为5.1%，尤其归因于老年（p = 0.016）、损伤严重程度高（p < 0.001）以及输血需求大（p < 0.001）。
对于绝大多数钝性腹部创伤患者，尤其是伤情较轻者，非手术治疗是成功的。非手术治疗失败和手术延迟最常见的原因是隐匿性中空脏器损伤（HVI），通过密切临床观察、腹部超声结合监测感染指标升高以及必要时的多排螺旋计算机断层扫描（MDCT）来发现。基于这一理念，非手术治疗失败患者的手术延迟时间较短。本研究强调了非手术治疗在BAT中的可行性和益处。
