钝性肝脾损伤后假性动脉瘤的治疗策略：一项儿科人群的多中心队列研究
Therapeutic strategies for pseudoaneurysm following blunt liver and spleen injuries: A multicenter cohort study in the pediatric population.
作者信息
Katsura Morihiro, Kondo Yutaka, Yasuda Hideto, Fukuma Shingo, Matsushima Kazuhide, Shiraishi Atsushi, Tsuchiya Asuka, Kuriyama Akira, Gima Masafumi, Hayashida Kazuyuki, Miura Naoya, Sugiura Kenta, Toma Keiichiro, Yasumatsu Hiroshi, Kushimoto Shigeki
机构信息
From the Department of Surgery (M.K.), Okinawa Chubu Hospital, Okinawa; Human Health Sciences (M.K., S.F.), Kyoto University Graduate School of Medicine, Kyoto; Department of Emergency and Critical Care Medicine (Y.K.), Juntendo University Urayasu Hospital, Chiba; Department of Emergency and Critical Care Medicine (H.Y.), Jichi Medical University Saitama Medical Center, Saitama, Japan; Division of Acute Care Surgery (K.M.), University of Southern California, Los Angeles, CA; Emergency and Trauma Center (A.S.), Kameda Medical Center, Chiba; Department of Emergency Medicine (A.T.), National Hospital Organization Mito Medical Center, Ibaraki; Department of Emergency and Critical Care Medicine (A.T., N.M.), Tokai University Hospital, Kanagawa; Emergency and Critical Care Center (A.K.), Kurashiki Central Hospital, Okayama; Critical Care Medicine (M.G.), National Center for Child Health and Development, Tokyo; KRC Severe Trauma Center/Trauma and Critical Care (K.H.), Japanese Red Cross Kumamoto Hospital, Kumamoto; Division of Pediatric Emergency Medicine (K.S.), Tokyo Metropolitan Children's Medical Center, Tokyo; Department of Pediatric Critical Care Medicine (K.T.), Hyogo Prefectural Kobe Children's Hospital, Hyogo; Shock and Trauma Center (H.Y.), Nippon Medical School Chiba Hokusoh Hospital, Chiba; and Division of Emergency and Critical Care Medicine (S.K.), Tohoku University Graduate School of Medicine, Miyagi, Japan.
出版信息
J Trauma Acute Care Surg. 2023 Mar 1;94(3):433-442. doi: 10.1097/TA.0000000000003813. Epub 2022 Dec 17.
BACKGROUND
Little guidance exists for the treatment of pseudoaneurysm (PA) following pediatric blunt liver and/or spleen injuries (BLSIs). We aimed to describe the incidence of delayed PA development and the subsequent clinical course of PA in pediatric BLSIs.
METHODS
This multicenter retrospective cohort study from Japan included pediatric patients (16 years and younger) who sustained BLSIs from 2008 to 2019. The cohort was divided into four groups based on hemostatic intervention within 48 hours of admission, namely, nonoperative management (NOM), NOM with interventional radiology (IR), operative management (OM), and combined IR/OM. Descriptive statistics were used to describe the incidence of delayed PA among the groups and to characterize the clinical course of any PAs.
RESULTS
A total of 1,407 children (median age, 9 years) from 83 institutions were included. The overall number (incidence) of cases of delayed PA formation was 80 (5.7%), and the number with delayed PA rupture was 16 cases (1.1%) in the entire cohort. Patients treated with NOM (1,056), NOM with IR (276), OM (53), and combined IR/OM (22) developed 43 (4.1%), 32 (12%), 2 (3.8%), and 3 (14%) delayed PAs, respectively. Among patients who developed any PAs, 39% of patients underwent prophylactic IR for unruptured PA, while 13% required emergency angioembolization for delayed PA rupture, with one ruptured case requiring total splenectomy. At least 45% of patients experienced spontaneous resolution of PA without any interventions.
CONCLUSION
Our results suggest that the risk of delayed PA still exists even after acute phase IR as an adjunct to NOM for BLSIs in children, indicating the necessity of a period of further observation. While endovascular interventions are usually successful for PA management, including rupture cases, given the high incidence of spontaneous resolution, the ideal management of PA remains to be investigated in future studies.
LEVEL OF EVIDENCE
Therapeutic/Care Management; Level IV.
背景
小儿钝性肝和/或脾损伤（BLSIs）后假性动脉瘤（PA）的治疗指导较少。我们旨在描述小儿BLSIs中延迟性PA形成的发生率及随后PA的临床病程。
方法
这项来自日本的多中心回顾性队列研究纳入了2008年至2019年期间发生BLSIs的小儿患者（16岁及以下）。根据入院后48小时内的止血干预措施，该队列分为四组，即非手术治疗（NOM）、联合介入放射学（IR）的NOM、手术治疗（OM）以及联合IR/OM。采用描述性统计来描述各组中延迟性PA的发生率，并对所有PA的临床病程进行特征分析。
结果
共纳入了来自83家机构的1407名儿童（中位年龄9岁）。整个队列中延迟性PA形成的病例总数（发生率）为80例（5.7%），延迟性PA破裂的病例数为16例（1.1%）。接受NOM治疗的患者（1056例）、联合IR的NOM治疗的患者（276例）、OM治疗的患者（53例）以及联合IR/OM治疗的患者（22例）分别发生了43例（4.1%）、32例（12%）、2例（3.8%）和3例（14%）延迟性PA。在发生任何PA的患者中，39%的患者因未破裂PA接受了预防性IR，而13%的患者因延迟性PA破裂需要紧急血管栓塞治疗，其中1例破裂病例需要行全脾切除术。至少45%的患者未经任何干预PA即自行消退。
结论
我们的结果表明，即使在急性期IR作为小儿BLSIs的NOM辅助治疗后，延迟性PA的风险仍然存在，这表明有必要进行一段时间的进一步观察。虽然血管内干预通常对PA的治疗有效，包括破裂病例，但鉴于自行消退的发生率较高，PA的理想治疗方法仍有待未来研究探讨。
证据级别
治疗/护理管理；四级。
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