急诊外科患者的监测与处理—严重肝脏外伤的处理

严重肝外伤病情复杂，合并伤多，如处理不及时，患者生命将受到严重威胁。目前超声和CT成为诊断监测严重肝外伤的主要手段。对于循环稳定的严重肝外伤患者，可以尝试行非手术治疗。而手术治疗方面，加入了在围手术期对“限制性复苏”（limited fluid resuscitation）或“延迟性复苏”（delayed fluid resuscitation）的讨论，并且“损伤控制”这一新概念为越来越多的外科医生所接受。     

肝脾外伤的微创治疗

肝脏和脾脏是腹部最容易遭受外伤的器官,位列腹部外伤的前两位,活动性出血和并发症是导致死亡的主要原因。近10余年来,随着现代诊疗水平不断提高,肝脾外伤的诊治也取得了显著进展,入院时循环稳定抑或补液治疗后稳定的肝脾外伤超过80％可以通过非手术治疗抑或微创处理获得治愈。现结合国内外文献和我们的经验谈谈肝脾外伤的微创治疗。     

严重肝外伤手术中要点

按美国外科创伤学会(AAST)分类,肝外伤Ⅲ级或以上者都需急诊手术,故Ⅲ级或以上肝外伤为严重肝外伤,不得用非手术治疗。其判断根据是循环不稳定,在排除其它原因后,循环不稳定指经充分复苏后,当输液速度减慢,脉率即上升,持续尿管计量又减少或停止滴出,中心静脉压和血压下降,PaO_2下降。CT虽能确定肝外伤存在,但评估其外伤程度不全确切,有报道仅16％病例手术所见与CT判断相符,其余病例CT评估伤情过高或过低各占半数。此外在循环不稳定需快速输液维持时也不应作CT检查,应急送手术室。实际上除去有延误复苏等因素后,病人所需输液量的多少总是和肝外伤程度相符合的。     

肝外伤的诊治体会(附55例报告)

目的 总结肝外伤的诊断和治疗经验.方法 回顾55例肝外伤患者的临床资料.结果 55例肝外伤中Ⅰ～Ⅱ级18例,Ⅲ级15例,Ⅳ级17例,Ⅴ级5例;采用非手术治疗31例,均痊愈;于术治疗24例,痊愈22例,自动出院2例.结论 肝外伤诊断以伞腹B超和腹腔穿刺为首选检杏,血液动力学稳定时可行腹部CT平扫或加增强扫描对判断是否行于术治疗彳丁帮助.目前,肝外伤的治疗主要考虑两个方面:血液动力学的稳定性和外伤的性质:钝挫伤或贳通伤;在判断是否行保守治疗时,血液动力学稳定性比肝外伤分级相对更重要.对血液动力学稳定的Ⅰ级、Ⅱ级和部分Ⅲ级钝性肝外伤可存严密连续临测下行非于术治疗;根据m液动力学变化和伤情判断及时中转于术;对血液动力学不稳定的部分Ⅲ级、Ⅳ级和Ⅴ级严重肝外伤以下术治疗为宜.早期复苏、有效止血、充分引流和防治术后并发症足降低严重肝外伤病死率的关键.     

严重肝外伤46例诊治体会

目的总结严重肝外伤的手术处理经验。方法回顾性分析我院2000～2010年46例接受手术治疗的严重肝外伤患者的临床资料,手术方式及术后疗效。结果参照AAST对肝脏外伤的分级:Ⅲ级28例,Ⅳ级12例,Ⅴ级6例。痊愈40例,死亡6例。结论手术是治疗严重肝外伤的有效方法,尽快救治失血性休克,术中彻底止血,充分引流以及预防术后并发症是治疗严重肝外伤的有效措施。     

Experience of diagnosis and treatment for severe liver trauma: a report of 46 cases

目的 总结严重肝外伤的手术处理经验.方法 回顾性分析我院2000～2010年46例接受手术治疗的严重肝外伤患者的临床资料,手术方式及术后疗效.结果 参照AAST对肝脏外伤的分级:Ⅲ级28例,Ⅳ级12例,Ⅴ级6例.痊愈40例,死亡6例.结论 手术是治疗严重肝外伤的有效方法,尽快救治失血性休克,术中彻底止血,充分引流以及预防术后并发症是治疗严重肝外伤的有效措施.     

严重肝外伤的诊治(附28例报告)

目的:探讨严重肝外伤诊断与治疗。方法:对28例严重肝外伤的临床诊断与治疗进行回顾性分析。结果:入院病例均有外伤史,伴失血性休克24例,明显腹膜炎21例,伴有合并伤26例。肝外伤分级(按AAST分级法)Ⅲ级16例,Ⅳ级8例,Ⅴ级3例,Ⅵ级1例。28例均手术治疗,治愈24例(85.7％),死亡3例(10.7％)。结论:早期和及时的诊断是严重肝外伤处理的关键,术前快速复苏是抢救的重要环节,手术仍是治疗严重肝外伤的重要手段。     

肝外伤治疗的新观念

肝外伤是腹部外伤中较为突出的问题,其发生率在腹内脏器伤中仅次于脾、小肠创伤而居第3位。近10多年来,由于现代诊断技术和外科治疗水平的不断提高,国内外学者在对肝外伤特别是严重肝外伤处理方法的不断探索中积累了许多成功的经验,创伤处理新概念的确立和治疗方法的改进已使Ⅲ、Ⅳ级肝损伤的死亡率降至10%以下[1]。肝外伤的伤情评估肝外伤的临床诊断一般不难,然而准确判断伤情从而为治疗决策和预后判断提供依据却并非易事。美国创伤外科学会(AAST)1994年提出的肝外伤分级法是迄今最为详细,被公认为是评估肝外伤严重程度最可靠的分级方法[…     

不规则性肝切除对严重肝外伤的诊治体会

目的探讨不规则性肝切除治疗严重肝外伤的临床价值。方法回顾性分析2003年03月～2009年03月期间在我院行不规则性肝切除术的49例严重肝外伤(Ⅳ、Ⅴ级)患者的临床资料。结果严重肝外伤(Ⅳ、Ⅴ级)49例,均实施不规则性肝切除,其中加行肝后下腔静脉损伤修补1例。治愈43例,死亡6例(12.2%),并发症15例(30.6%)。结论不规则性肝切除是治疗严重肝外伤的有效手段。     

肝外伤的分级标准及处理原则

肝脏是腹内最大的实质脏器,质脆而易受损伤。肝外伤占腹部损伤的15～20％。不同程度的肝外伤所采取的治疗方法以及预后各不相同。严重肝外伤合并肝周大血管损伤,死亡率可高达70％以上。因此,对肝外伤规范地进行分级,为治疗方法的选择建立一个统一标准。     

Selection of Nonoperative Management Candidates

The liver and spleen are the most commonly injured intraabdominal organs and comprise most of the injuries to the solid viscera during blunt abdominal injury. The contrast-enhanced computed tomography (CT) scan has emerged as an accurate, safe diagnostic tool for blunt torso trauma, making nonoperative management of even severe injury to the liver and spleen possible. This review concentrates on the trends, patient selection criteria, and some of the risks of nonoperative management of hemodynamically stable patients with blunt liver and spleen injury.     

The Efficacy of Gauze Packing in Liver Trauma: an Evaluation of the Management and Treatment of Liver Trauma

Background: This study evaluates the management and treatment of liver trauma with emphasis on the efficacy of gauze packing. Material and Methods: 92 patients, diagnosed with liver trauma between 01/1992 and 01/2000, were evaluated retrospectively. For clinical management reasons, a distinction was made between hemodynamically stable and unstable patients. Results: 42 patients were clinically diagnosed as hemodynamically stable and had an average Injury Severity Score (ISS) of 24. 15 of them underwent abdominal surgery. In ten of these patients additional liver treatment was performed. The mortality among the 42 patients was two, both non-liver-related (sepsis and neurologic injury). 50 patients were considered to be hemodynamically unstable and had an average ISS of 35. All patients needed abdominal surgery. The mortality was 22 out of 50, of which seven were liver-related. In 38 of all 92 patients only gauze packing was used as initial therapy. In twelve patients the bleeding was controlled by the first tamponade, and ten patients needed a second tamponade after an average of 2 days. Additional surgery was performed in nine patients, and seven patients died shortly after the first laparotomy. The mortality was 16, of which nine were directly liver-related. Conclusion: Gauze packing as the initial treatment of liver trauma is considered a safe and quick method for controlling ongoing hemorrhage. Nevertheless, severe liver trauma goes with a high mortality rate.     

Liver injuries

The liver is the most commonly injured abdominal organ. Severe hepatic trauma continue to be associated with high mortality. Management of liver injuries has changed significantly over the last two decades. Nonoperative management of hemodynamically stable patients has become the first treatment of choice. In unstable patients immediate control of bleeding is critical. In the management of severe injuries of the liver, particularly for patients who had developed a metabolic insult (hypothermia, coagulopathy, and acidosis), perihepatic packing has emerged as the key to effective damage control (DCS). The surgical aim is control of hemorrhage, preservation of sufficient hepatic function and prevention of secondary complications. Currently available surgical methods include hepatorrhaphy, resectional debridement, anatomical/nonanatomical resection, selective hepatic artery ligation, Pringle maneuver, total vascular exclusion, liver transplatation. This review discusses available diagnostic modalities and the best management options for liver injury, based on literature search and authors experience.     

A systematic review of the safety and efficacy of non-operative management in patients with high grade liver injury

IntroductionThe liver is the most frequently damaged organ in blunt abdominal trauma. It is widely accepted that hemodynamically stable patients with low-grade liver trauma should be treated with non-operative management, however there is controversy surrounding its safety and efficacy in high-grade trauma. The purpose of this review is to investigate the role of non-operative management in patients with high-grade liver trauma.MethodsPubMed and reference lists of PubMed articles were searched to find studies that examined the efficacy of non-operative management in high-grade liver injury patients, and compare it to operative management. Non-operative management was considered successful if rescue surgery was avoided. Outcomes considered were success, mortality, and complication rates.ResultsThe electronic search revealed 2662 records, 8 of which met the inclusion criteria. All 8 studies contained results suggesting that non-operative management was safe and effective in hemodynamically stable patients with high-grade liver trauma. By combining the outcomes of the different studies, non-operative management had a high success rate of 92.4% (194/210) in high-grade liver trauma patients, which was near the overall 95.0% non-operative management success rate. Non-operative management also had mortality and complication rates of 4.6% (9/194) and 9.7% (7/72) in high-grade injury patients, respectively, compared to operative management's 17.6% (26/148) and 45.5% (5/11).ConclusionNon-operative management of liver trauma is safe and effective in hemodynamically stable patients with high-grade liver injury. It is associated with significantly lower mortality compared with operative management. More studies are required to evaluate complications of non-operative management in high-grade liver injury.     

Contusions of the liver in adults. Initial non-operative management with computerized tomography follow-up is a reasonable therapeutic option. Report of 16 cases

Nonoperative management of blunt liver injury in adults still remains controversial. From February 1985 through September 1989, 27 patients were treated for blunt hepatic trauma: 11 required immediate operation and 16 (59%) were initially managed nonoperatively after evaluation of intraabdominal injury by computerized tomography. All of these 16 patients were hemodynamically stable and had no significant peritoneal signs. CT criteria for nonoperative management included subcapsular and intrahepatic hematoma, capsular tear or unilobar fracture, absence of large hemoperitoneum, absence of large devitalized liver and absence of other intraabdominal organ injuries. Clinical follow-up, repeated radiologic examinations and surgery confirmed the accuracy of CT. Only 2 patients required delayed operation (12.5%). Serial abdominal CT studies are an integral part of the conservative treatment of blunt hepatic injuries and showed complete resolution of hepatic injuries in the fourteen nonoperated patients in less than six months. No death and no delayed septic or biliary complications were noted. Mean hospital stay was seventeen days for all of the patients (multiple injuries or not) and only ten days for isolated blunt liver injury. These good results depend on identification of candidates for nonoperative management on strict clinical and CT criteria. Nonoperative management of adult blunt liver injury based on these findings is a useful alternative in a selected group of hemodynamically stable patients and decreases the rate of non-therapeutic coeliotomy.     

Study of blunt hepatic injury by ultrasonography

Sixty five consecutive patients with blunt hepatic injury were evaluated retrospectively to assess the clinical usefulness of emergency ultrasonography (US). In 30 patients before introduction of US, five patients (16.7%) were treated nonoperatively since they were hemodynamically stable with negative paracentesis. Another four hemodynamically stable patients were surgically treated due to positive paracentesis. After introduction of US, on the other hand, 17 out of 35 patients (48%) were successfully managed nonoperatively. Furthermore, US revealed small intraperitoneal bleeding and enabled conservative treatment of four hemodynamically unstable patients. There was no change in the management of central liver rupture or Makiya's type III injury. The number of nonoperatively managed cases of Makiya's types I and II increased from 1 to 7 after using US, and that of operative cases decreased from 21 to 12. Thus US was helpful to exactly assess the amount of intraperitoneal bleeding and successfully reduce the number of unnecessary laparotomy. We conclude that US provides useful information to decide early management of blunt hepatic injury.     

Non-operative management of blunt abdominal injuries

Over the past three decades, non-operative management has been shown to be an effective therapeutic option in hemodynamically stable patients. We retrospectively reviewed the last 7 years of our experience with the non-operative management of blunt abdominal traumas. From January 1998 to July 2005, 123 patients with blunt abdominal traumas and injuries to the spleen, liver and pancreas were admitted to our hospital. Fifty-eight of them (47.2%) were submitted to non-operative management; 5 (8.6%) presented associated splenic and hepatic injuries. We performed non-operative treatment for 27 splenic injuries (33.7% of all splenic injuries), 32 hepatic injuries (62.7% of all hepatic injuries) and 3 pancreatic injuries (75% of all pancreatic injuries). There was no mortality and no complications. We submitted one haemodynamically stable patient who presented a grade V hepatic injury and "contrast pooling" at abdominal CT scan to angiography and transarterial embolisation; this patient was successfully managed non-operatively. The overall success rate of non-operative management was 98.5%. The only non-operative management failure was a patient with both splenic and hepatic injuries. The success rate for injuries to the spleen was 96.3%, to the liver 96.9% and to the pancreas 100%. We conclude that hemodynamically stable patients suffering intra-abdominal injury can be safely managed non-operatively.     

Early-onset liver abscess after blunt liver trauma: report of a case

A 23-year-old male patient underwent nonoperative management for his blunt liver trauma as he was hemodynamically stable without any signs of peritonitis initially after injury. A fever of 39.5°C and severe right upper quadrant abdominal pain developed on the second day, and an abdominal computed tomography (CT) scan showed the formation of a gas-containing liver abscess in the traumatized liver. An emergency laparotomy revealed a foul-smelling liver abscess at the traumatized site, which was finally disclosed to be the result of a Clostridium species infection. A liver abscess is a rare complication following the nonoperative management of liver injury, and such an occurrence is even more rare within 1 day after injury. A Clostridium species infection is responsible for the fulminant progressing nature of the disease because the devitalized, ischemic liver parenchyma is ideal for such growth, and this is the first time that a such condition has been shown by CT images. Close observation with a high degree of suspicion is required for the successful treatment of such abscesses. Received: March 28, 2002 / Accepted: July 2, 2002 Reprint requests to: C.-H. Hsieh     

Blunt hepatic injury: a paradigm shift from operative to nonoperative management in the 1990s

OBJECTIVE: To analyze the outcome of hemodynamically stable patients with blunt hepatic injury managed nonoperatively, and to examine the impact of this approach on the outcome of all patients with blunt hepatic injury. SUMMARY BACKGROUND DATA: Until recently, operative management has been the standard for liver injury. A prospective trial from the authors' institution had shown that nonoperative management could safely be applied to hemodynamically stable patients with blunt hepatic injury. The present study reviewed the authors' institutional experience with blunt hepatic trauma since that trial and compared the results with prior institutional experience. METHODS: Six hundred sixty-one patients with blunt hepatic trauma during the 5-year period ending December 1998 were reviewed (NONOP2). The outcomes were compared with two previous studies from this institution: operative 1985 to 1990 (OP) and nonoperative 1993 to 1994 (NONOP1). RESULTS: All 168 OP patients were managed operatively. Twenty-four (18%) of 136 NONOP1 patients and 101 (15%) of the 661 NONOP2 patients required immediate exploration for hemodynamic instability. Forty-two (7%) patients failed nonoperative management; 20 were liver-related. Liver-related failures of nonoperative management were associated with higher-grade injuries and with larger amounts of hemoperitoneum on computed tomography scanning. Twenty-four-hour transfusions, abdominal infections, and hospital length of stay were all significantly lower in the NONOP1 and NONOP2 groups versus the OP cohort. The liver-related death rate was constant at 4% in the three cohorts over the three time periods. CONCLUSIONS: Although urgent surgery continues to be the standard for hemodynamically compromised patients with blunt hepatic trauma, there has been a paradigm shift in the management of hemodynamically stable patients. Approximately 85% of all patients with blunt hepatic trauma are stable. In this group, nonoperative management significantly improves outcomes over operative management in terms of decreased abdominal infections, decreased transfusions, and decreased lengths of hospital stay.