严重开放性骨盆骨折损害控制手术策略探讨

目的探讨严重开放性骨盆骨折合并毗邻脏器损伤的术中损害控制外科（DCS）程序。方法回顾性分析2002年1月～2011年12月收治的21例严重开放性骨盆骨折的临床资料。初期行髂内动脉结扎19例，选择性髂内动脉造影栓塞2例；伤道和腹膜后填塞止血11例；膀胱造瘘7例，膀胱修补加尿道会师2例；腹膜内结直肠伤I期修补4例，造瘘1例；腹膜外直肠伤结肠造口13例，远近端钳夹留待Ⅱ期手术3例；骨盆外固定支架固定14例；其他合并伤予相应处理。确定性骨盆整复内固定及结直肠和后尿道重建术留待后期。结果死亡6例（29％），死因为大出血致严重休克5例，腹腔盆底严重感染致多器官功能衰竭（MODS）1例。并发症7例次：直肠膀胱瘘3例，腹腔间隙综合征（ACS）2例，髂血管血栓形成截肢1例，截瘫1例；除截瘫外，其余均非手术治疗临床治愈。结论髂内动脉结扎加填塞是治疗严重开放骨盆骨折出血的重要手段；合并膀胱结直肠损伤时应完成初期改道术；应常规安置骨盆外固定支架。

Discussion of damage control procedures for treating severe open pelvic fractures

Objective To discuss the damage control procedures during the surgical process of severe open pelvic fractures combined with the adjacent organ injuries. Methods Clinical data of 21 cases of severe open pel vic fractures admitted from Jan. 2002 to Dec. 2011 were retrospectively analyzed. Early internal iliac artery ligation was performed in 19 cases, selective internal iliae artery embolization in 2 cases;abdominal packing in 11 cases; bladder stoma in 7 cases, bladder repair plus urethral realignment in 2 cases ; primary repair of intraperitoneal color ectal wound in 4 cases;stoma in 1 case; extraperitoneal rectal injury and colostomy in 13 cases,proximal and distal clamps were applied in the 11 period in 3 cases ;external fixation of pelvis in 14 cases. Definitive reconstructive fix ation and coloreetal and posterior urethral reconstruction were performed at late stage. Results The overall mortali ty rate was 29% （6/21 } ：hemorrhagic shock in 5 cases,MODS in 1 case. Complications occurred in 7 cases ： recto vesical fistula in 3 cases, abdominal compartment syndrome （ ACS ） in 2 cases, iliac vascular thrombosis in 1 case and paraplegia in 1 case. Except for the patients with paraplegia,the rest were cured via nonsurgical treatment. Con clusion Ligation of internal iliac arteries and abdominal packing are important means for bleeding due to severe open pelvic fractures;initial diversion should be performed in patients with cystostomy and colostomy. External fixa tion of pelvis should be olaced.