观察优先与血管栓塞优先策略在稳定型钝性肝外伤患者中的应用：一项 WTA 多中心研究。
Observation-first versus angioembolization-first approach in stable patients with blunt liver trauma: A WTA multicenter study.
机构信息
From the Division of Division of Trauma, Burns and Surgical Critical Care, Department of Surgery (P.D.N., J.N., N.A., A.G.), University of California, Irvine, Orange, California; Section of Surgical Sciences (J.M.S.), Vanderbilt University Medical Center, Nashville, TN; Department of Surgery, University of Colorado, Aurora, Colorado (M.C., H.C., R.M., S.U., C.C.B., C.V.); Department of Surgery (S.B., R.C.D.), UCSF-Fresno, Fresno, California; Division of Trauma and Acute Care Surgery (M.C.S.), Mount Carmel East; Trauma, Critical Care and Acute Care Surgery (A.L.), Grant Medical Center, Columbus, Ohio; Department of Surgery (M.S.F.), Lehigh Valley Health Network, Allentown, Pennsylvania; Departments of Emergency Medicine and Surgery, Program in Trauma (D.M.S.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Graduate Medical Education (M.S.T., H.M.G.V.), Methodist Dallas Medical Center, Dallas, Texas; Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery (C.J.M., T.J.M.), Spartanburg Regional Medical Center, Spartanburg, South Carolina; Department of Surgery (C.G.B.), University of Calgary, Calgary, Alberta, Canada; Division of Acute Care Surgery (K.M., G.M.), Loma Linda University Health, Loma Linda, California; Department of Surgery (D.J.H., H.A.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Trauma and Acute Care Surgery (T.J.S., J.R.), UCHealth Memorial Hospital, Colorado Springs, Colorado; Department of General Surgery (M.B.), Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Division of Trauma, Acute Care Surgery and Surgical Critical Care (N.K., M.C.), Banner-University Medical Center Phoenix, Phoenix, Arizona; Division of Trauma and Critical Care, Department of Surgery (N.K.D., E.J.L.), Cedars-Sinai Medical Center, Los Angeles, California; Department of Surgery (T.E., J.W.), Cooper University Hospital, Camden, New Jersey; Department of Surgery and Perioperative Care (T.C.P.C., V.E.), Dell Medical School, University of Texas at Austin, Austin, Texas; Division of Trauma Acute Care Surgery, Department of Surgery (K.P., K.C.), Banner Thunderbird Medical Center, Glendale, Arizona; Division of Trauma and Surgical Critical Care, Department of Surgery (S.B.), Hackensack University Medical Center, Hackensack, New Jersey; Division of Trauma and Surgical Critical Care, Department of Surgery (F.S.E.), Rutgers New Jersey Medical School, Newark, New Jersey; Department of Trauma and Acute Care Surgery (W.D., C.P.), Medical Center of the Rockies, Loveland, Colorado; University of Wisconsin-Madison School of Medicine and Public Health (N.L.W.), Madison, Wisconsin; Department of Trauma (J.M.H., K.L.), Ascension Via Christi Saint Francis, Wichita, Kansas; Department of Surgery (G.S.), Miami Valley Hospital, Wright State University, Dayton, Ohio; Department of Surgery (K.S.), Prisma Health-Upstate, Greenville, South Carolina; and Department of Surgery (L.A.H.), Boulder Community Hospital, Boulder, Colorado.
出版信息
J Trauma Acute Care Surg. 2024 Nov 1;97(5):764-769. doi: 10.1097/TA.0000000000004372. Epub 2024 May 27.
BACKGROUND
Prior studies evaluating observation versus angioembolization (AE) for blunt liver injuries (BLT) with contrast extravasation (CE) on computed tomography imaging have yielded inconsistent conclusions, primarily due to limitations in single-center and/or retrospective study design. Therefore, this multicenter study aims to compare an observation versus AE-first approach for BLT, hypothesizing decreased liver-related complications (LRCs) with observation.
METHODS
We conducted a post hoc analysis of a multicenter, prospective observational study (2019-2021) across 23 centers. Adult patients with BLT + CE undergoing observation or AE within 8 hours of arrival were included. The primary outcome was LRCs, defined as perihepatic fluid collection, bile leak/biloma, pseudoaneurysm, hepatic necrosis, and/or hepatic abscess. A multivariable logistic regression analysis was used to evaluate risk factors associated with LRCs.
RESULTS
From 128 patients presenting with BLT + CE on imaging, 71 (55.5%) underwent observation-first and 57 (45.5%) AE-first management. Both groups were comparable in age, vitals, mechanism of injury, and shock index (all p > 0.05), however the AE group had increased frequency of American Association for the Surgery of Trauma Grade IV injuries (51.0% vs. 22.0%, p = 0.002). The AE cohort demonstrated increased rates of in-hospital LRCs (36.8% vs. 12.7%, p = 0.038), emergency department representation (25.0% vs. 10.0%, p = 0.025), and hospital readmission for LRCs (12.3% vs. 1.4%, p = 0.012). However, the two cohorts had similar mortality rates (5.7% vs. 5.3%, p = 0.912). After adjusting for age, ISS, and grade of liver injury, an AE-first approach had a similar associated risk of LRCs compared with observation-first management (odds ratio, 1.949; 95% confidence interval, 0.673-5.643; p = 0.219).
CONCLUSION
Patients with blunt liver injury and CE undergoing an observation-first approach were associated with a similar adjusted risk of LRCs and rate of mortality compared with AE-first approach. Overall, this calls for reevaluation of the role of routine AE in blunt liver trauma patients with CE. Future prospective randomized trials are needed to confirm these findings.
LEVEL OF EVIDENCE
Therapeutic/Care Management, Level IV.
背景
先前评估 CT 成像显示有对比剂外渗的钝性肝损伤（BLT）采用观察与血管栓塞（AE）治疗的研究得出的结论不一致，主要原因是单中心和/或回顾性研究设计的局限性。因此，这项多中心研究旨在比较观察与 AE 优先治疗 BLT 的方法，假设观察可降低肝相关并发症（LRCs）。
方法
我们对一项多中心前瞻性观察研究（2019-2021 年）进行了事后分析，该研究在 23 个中心进行。纳入的患者为 BLT+CE 并在到达后 8 小时内行观察或 AE 治疗的成年患者。主要结局是 LRCs，定义为肝周积液、胆漏/胆汁瘤、假性动脉瘤、肝坏死和/或肝脓肿。采用多变量逻辑回归分析评估与 LRCs 相关的危险因素。
结果
在影像学上显示 BLT+CE 的 128 名患者中，71 名（55.5%）接受了观察优先治疗，57 名（45.5%）接受了 AE 优先治疗。两组在年龄、生命体征、损伤机制和休克指数方面无差异（均 p＞0.05），但 AE 组的美国创伤外科学会分级 IV 级损伤发生率更高（51.0% vs. 22.0%，p=0.002）。AE 组的院内 LRCs 发生率更高（36.8% vs. 12.7%，p=0.038），急诊就诊率更高（25.0% vs. 10.0%，p=0.025），因 LRCs 再次住院率更高（12.3% vs. 1.4%，p=0.012）。然而，两组的死亡率相似（5.7% vs. 5.3%，p=0.912）。在调整年龄、ISS 和肝损伤分级后，AE 优先治疗与观察优先治疗相比，LRCs 的风险比相似（比值比，1.949；95%置信区间，0.673-5.643；p=0.219）。
结论
接受观察优先治疗的 BLT+CE 患者与接受 AE 优先治疗的患者相比，LRCs 发生风险和死亡率相似。总体而言，这呼吁重新评估常规 AE 在有 CE 的钝性肝外伤患者中的作用。需要前瞻性随机试验来证实这些发现。
证据水平
治疗/护理管理，IV 级。
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