Davis K A, Fabian T C, Croce M A, Gavant M L, Flick P A, Minard G, Kudsk K A, Pritchard F E
Department of Surgery, Presley Regional Trauma Center, University of Tennessee Health Science Center, Memphis 38163, USA.
J Trauma. 1998 Jun;44(6):1008-13; discussion 1013-5. doi: 10.1097/00005373-199806000-00013.
By using abdominal computed tomographic scans in the evaluation of blunt splenic trauma, we previously identified the presence of vascular blush as a predictor of failure, with a failure of nonoperative management of 13% in that series. This finding led to an alteration in our management scheme, which now includes the aggressive identification and embolization of splenic artery pseudoaneurysms.
The medical records of 524 consecutive patients with blunt splenic injury managed over a 4.5-year period were reviewed for the following information: age, Injury Severity Score (ISS), American Association for the Surgery of Trauma splenic injury grade (SIG), method and outcome of management.
Of the patients, 66% were male with a mean age of 32 +/- 16, and mean ISS of 25 +/- 13. A total of 180 patients (34%) were managed with urgent operation on admission (81% splenectomy (SIG 4.0), 19% splenorrhaphy (SIG 2.6)). The remaining 344 patients (66%) were hemodynamically stable and underwent computed tomographic scan and planned nonoperative management. Of these patients, 322 patients (94%) were successfully managed nonoperatively (61% of total splenic injuries). In 26 patients (8%), a contrast blush identified on computed tomographic scan was confirmed as a parenchymal pseudoaneurysm on arteriography. Twenty patients (SIG, 2.8) were successfully embolized. In six patients, technical failure precluded embolization; all required splenectomy (SIG, 4.0). A total of 22 patients (6%) failed nonoperative management, including the six with unsuccessful embolization attempts. Sixteen patients (SIG, 3.0) who had no evidence of pseudoaneurysm were explored for a falling hematocrit, hemodynamic instability, or a worsening follow-up computed tomography: 13 patients had splenectomy, and three patients had splenorrhaphy.
Aggressive surveillance for and embolization of posttraumatic splenic artery pseudoaneurysms improved the rate of successful nonoperative management of blunt splenic trauma to 61%, with a nonoperative failure rate of only 6%. In comparison with our previous work, this reduction in failure of nonoperative management is a significant improvement (p < 0.03).
通过腹部计算机断层扫描评估钝性脾外伤时，我们之前发现存在血管造影剂外溢是治疗失败的一个预测指标，在该系列研究中，非手术治疗失败率为13%。这一发现导致我们的治疗方案发生了改变，现在包括积极识别和栓塞脾动脉假性动脉瘤。
回顾了4.5年间连续收治的524例钝性脾损伤患者的病历，以获取以下信息：年龄、损伤严重程度评分（ISS）、美国创伤外科协会脾损伤分级（SIG）、治疗方法及结果。
患者中66%为男性，平均年龄32±16岁，平均ISS为25±13。共有180例患者（34%）入院时接受了紧急手术（81%为脾切除术（SIG 4.0），19%为脾修补术（SIG 2.6））。其余344例患者（66%）血流动力学稳定，接受了计算机断层扫描并计划进行非手术治疗。在这些患者中，322例患者（94%）非手术治疗成功（占脾损伤总数的61%）。在26例患者（8%）中，计算机断层扫描发现的造影剂外溢在动脉造影中被确认为实质内假性动脉瘤。20例患者（SIG，2.8）成功进行了栓塞。6例患者因技术原因未能进行栓塞；均需行脾切除术（SIG，4.0）。共有22例患者（6%）非手术治疗失败，包括6例栓塞尝试未成功的患者。16例无假性动脉瘤证据的患者因血细胞比容下降、血流动力学不稳定或随访计算机断层扫描结果恶化而接受了探查：13例患者行脾切除术，3例患者行脾修补术。
对创伤后脾动脉假性动脉瘤进行积极监测和栓塞，使钝性脾外伤非手术治疗的成功率提高到61%，非手术失败率仅为6%。与我们之前的研究相比，非手术治疗失败率的降低有显著改善（p < 0.03）。
