Fang J F, Chen R J, Wong Y C, Lin B C, Hsu Y B, Kao J L, Kao Y C
Department of Surgery, Chang-Gung Memorial Hospital, Chang-Gung University, Taoyuan, Taiwan, Republic of China.
Am J Surg. 1998 Oct;176(4):315-9. doi: 10.1016/s0002-9610(98)00196-2.
Nonoperative management of blunt hepatic injury is currently a widely accepted treatment modality. Computed tomography (CT) is an important imaging study both for diagnosis and follow-up of these patients. There is, however, no reliable predictor of failure of nonoperative treatment other than the ultimate development of hemodynamic instability. Previous reports mostly were based on the data obtained from low-speed dynamic incremental scanners. The purpose of this study is to evaluate the value of a high-speed helical scanner in predicting the outcome of patients managed nonoperatively.
During a 30-month period, 194 patients with blunt hepatic injury were treated, 150 of them were hemodynamically stable after initial resuscitation and underwent abdominal CT examination. All CT scans were performed with the High Speed Advantage Scanner. The CT scans and medical records were reviewed.
Nonoperative management was successfully applied to all patients with grade I and II, 93% of grade III, 87% of grade IV, and 67% of grade V liver injuries. Twelve patients required liver-related celiotomy. Pooling of contrast material was detected on the CT scans of 8 patients. Six (75%) of these patients developed hemodynamic instability and required liver-related celiotomy later. Pooling of contrast material can be detected in 50% of the patients receiving liver-related celiotomy.
The presence of pooling of contrast material within the hepatic parenchyma indicates free extravasation of blood as a result of active bleeding. In patients with blunt hepatic injury, if this sign is detected, nonoperative treatment should be terminated and angiography or celiotomy undertaken promptly. With the increasing use of high-speed spiral CT scanner and improvement in scanning technique, pooling of contrast material may become a sensitive sign for active bleeding and may be used as a guide for the selection of treatment modality.
钝性肝损伤的非手术治疗目前是一种广泛接受的治疗方式。计算机断层扫描（CT）对于这些患者的诊断和随访都是一项重要的影像学检查。然而，除了最终出现血流动力学不稳定外，尚无可靠的非手术治疗失败的预测指标。以往的报告大多基于从低速动态增量扫描仪获得的数据。本研究的目的是评估高速螺旋扫描仪在预测非手术治疗患者结局方面的价值。
在30个月的时间里，对194例钝性肝损伤患者进行了治疗，其中150例在初始复苏后血流动力学稳定，并接受了腹部CT检查。所有CT扫描均使用高速优势扫描仪进行。对CT扫描结果和病历进行了回顾。
非手术治疗成功应用于所有I级和II级肝损伤患者，93%的III级、87%的IV级和67%的V级肝损伤患者。12例患者需要进行与肝脏相关的剖腹手术。8例患者的CT扫描中检测到造影剂外渗。其中6例（75%）患者出现血流动力学不稳定，随后需要进行与肝脏相关的剖腹手术。接受与肝脏相关剖腹手术的患者中有50%可检测到造影剂外渗。
肝实质内造影剂外渗表明存在活动性出血导致的血液自由外渗。在钝性肝损伤患者中，如果检测到该征象，应终止非手术治疗，并立即进行血管造影或剖腹手术。随着高速螺旋CT扫描仪的使用增加和扫描技术的改进，造影剂外渗可能成为活动性出血的敏感征象，并可作为治疗方式选择的指导。
