腹部实质脏器损伤的治疗进展

腹部实质脏器损伤的经典治疗原则是剖腹探查,并行确定性的一期手术。随着基础和临床研究的进展,一方面,针对肝、脾、胰的低级别损伤采取非手术治疗已广泛用于临床;另一方面,针对腹部实质脏器严重创伤采取损伤控制性手术受到了应有的重视。一、腹部实质脏器损伤的非手术治疗1.准     

腹部实质脏器损伤的诊断及剖腹探查

腹部实质脏器损伤是外科急腹症中最常见也是最凶险的腹部急症,要求外科医生在最短的时间内做出正确的判断并给予恰当的处理,稍有不慎就有可能导致终生的遗憾。这对外科医生,尤其是低年资的外科医生的判断力、应变力及心理素质都是一种巨大的挑战。本文就自己的临床经验简述对腹部实质脏器损伤诊断及剖腹探查的一点体会。一、腹部实质脏器损伤的诊断确定腹部实质脏器损伤并不困难,在询问病史和查体之后结合简单的实验室及影像学检查就可以完成,但做出一个对治疗有指导意义的诊断却不容易。我们认为恰当地选择下列检查会有帮助。1.B超:可准确…     

超声造影在腹部实质脏器损伤中的诊断价值

目的探讨超声造影在腹部实质脏器损伤中的临床诊断价值。方法回顾性分析笔者所在医院2009年11月～2011年3月收治的27例腹部实质脏器损伤患者的临床资料,比较CEUS与常规超声的敏感度和特异度。结果27例腹部实质脏器损伤患者中共26个病灶,经CEUS检出23个病灶,与手术或增强CT比较,检查的敏感度为95．65％,特异度为66．67％;经常规超声检出17个病灶,与手术或增强CT比较,检查的敏感度为65．22％,特异度为33．33％。两种方法敏感度和特异度比较差异有统计学意义（P〈0．05）。结论CEUS在诊断腹部实质脏器损伤中诊断的敏感度、特异度较高,并且操作简便、创伤性小、费用较低、可重复性好,对于临床上选择合适的治疗方案具有重要的指导和应用价值。     

腹部多脏器损伤的诊断与治疗

腹部多脏器损伤系腹腔２个脏器以上均需治疗的损伤，病情危急，处理复杂，并发症多，病死率高。我院自１９８６．６～２００１．６共收治腹部多脏器损伤８９例，现就诊治体会报告如下。临床资料１．一般资料：本组男６８例，女２１例，年龄１２～６８岁。致伤原因：车祸４８例，塌方１７例，坠落伤１７例，爆炸伤７例。腹部脏器损伤情况：脾破裂５２例，肝破裂４５例，小肠破裂３６例，肾破裂２５例，结肠破裂１８例，胰腺损伤１２例，膀胱损伤８例，腔静脉裂伤６例，胃破裂６例，十二指肠破裂６例，合并伤以胸外伤、脑外伤、四肢骨折居多。…     

腹部脏器损伤首诊临床分析

目的 探讨腹部内脏损伤首诊处理经验。方法 对我院急诊外科从2002年1月～2003年12月处理的173例腹部脏器损伤病例进行回顾性分析。结果 173例中，手术145例，非手术28例。死亡13例，占7．5％。结论 在抢救中，尽早明确诊断，与相关科室取得联系，大出血者以最快速度施行手术。完善专业队伍的建设。     

腹部手术后腹内脏器损伤12例诊治体会

腹部手术后腹内脏器损伤有特殊的损伤机理,临床表现及处理原则。本院自1995年6月至2001年6月共收治12例,分析总结如下。1临床资料1.1一般资料:本组12例中,男8例,女4例;年龄22～74岁;车祸伤6例,坠落伤4例,打击伤2例;均为闭合性损伤。1.2原手术部位与疾病:肝胆手术4例,胃手术3例,阑尾手术3例,结肠手术1例,妇科盆腔手术1例。良性疾病手术9人(急症4例,择期5例),恶性肿瘤手术3人。原手术与受伤时间间隔5月～7年。1.3腹内脏器损伤情况:空回肠破裂7人次,脾破裂3人次,肝破裂2人次,十二指肠破裂1人次,结肠破裂1人次;其他部位合并伤:肋骨骨折1人,肾挫…     

腹部多脏器损伤的诊断与处理

腹部多脏器损伤(abdominal multiorgons trauma,AMOT)是指腹腔内2个脏器以上的损伤。由于损伤脏器出血量大,生理功能紊乱,病情危急,诊治复杂,所以并发症多,病死率高。现在,腹部外伤发生率在不断上升,据柳运海等[1]报道3年中收治158例AMOT患者。车祸及高空坠落伤88例,占55.7%;而马九强等[2]报道193例腹部创伤病例,其中交通事故伤及坠落伤135例,高达74%,腹部多脏器损伤40例占20.7%,死亡率高达16.5%。因此,及时诊断,正确处理,才能显著降低病死率和并发症发生率。迅速正确的伤情判断及救治,及时确立诊断初步判断伤情与抢救生命同步。现场救…     

腹部闭合损伤脾破裂危险因素

目的 总结腹部闭合损伤脾破裂的临床规律．进一步提高临床疗效。方法对1980年1月～1995年12月我院收治的腹部闭合性损伤而致的269例脾破裂患者入院时13项指标和预后(并发症的发生率和死亡率)的关系进行了分析。结果患者的年龄、全腹肌紧张、肠麻痹、收缩压≤12kPa(90mmHg)、脉率≥100次／分和同时合并2个以上其它脏器的损伤等6项是腹部闭合损伤脾破裂的危险因素。结论重视老龄人腹部外伤后的病理生理特点、积极防治休克、重视合并伤的治疗是减少腹部闭合损伤脾破裂并发症发生率和死亡率的重要环节。     

多发性腹部脏器损伤65例诊治体会

随着交通工具的发达．由交通工具引起的复合外伤逐年增加．其中多发性腹部外伤同时增加。它病情重．临床表现各不相同．当合并有其它部位损伤时．要求医生以最快的速度作出早期诊断及合理治疗．能提高治愈率．降低死亡率。本院从1994年至2004年．共收治65例多发性腹部脏器损伤病人．其中闭合性腹部脏器损伤58例．开放性腹部脏器损伤7例．治愈63例，死亡2例。现将笔者诊治多发性腹部脏器损伤的体会报告如下．     

伴有腹内脏器伤的胰腺损伤诊治

胰腺损伤是一种严重的腹部外伤,据统计不到2%的腹部外伤患者发生胰腺损伤。胰腺损伤往往伴有腹内其他脏器伤,处理颇为复杂。本院自1992年1月至2002年8月,共收治胰腺损伤51例,其中合并腹内其他脏器损伤33例,现就其诊治经验报告如下。1临床资料1.1一般资料:本组33例,其中男性23例,女性10例;年龄9～60岁。致伤原因:车祸伤25例,坠落伤4例,殴斗伤3例,挤压伤1例。1.2临床表现:33例均有明显腹痛和腹膜刺激症状,15例有失血性休克。诊断性腹腔穿刺32例,30例抽出血性或混浊液体,2例阴性,12例腹腔液淀粉酶测定在512苏氏单位以上。1.3损伤程度和合并伤:…     

Nonoperative Management of Pancreato-Duodenal Injuries

Abstract Following injuries to the pancreas and duodenum (PDI) patients often present in extremis and undergo immediate laparotomy for hemodynamic instability and peritoneal signs. Nonoperative management (NOM) may be offered in selected patients with lowgrade injuries. Precise mapping of the injury, most commonly by computed tomography, is a prerequisite for NOM because clinical symptomatology can be variable and misleading. Additionally, delaying the treatment of PDI that should be corrected surgically may lead to significant complications. Therefore, NOM of PDI presents unique challenges, and the decision-making is not as straightforward as it is with NOM of other solid abdominal organs. Essentially, only duodenal hematomas without fullthickness wall perforation (Grade I and selected II) and pancreatic trauma without major duct involvement (Grade I and selected II) could be offered NOM. In these cases, the reported success rates vary from 74 to 95%. There are also a few severe pancreatic injuries that can be managed by stents with adequate reconstitution of the major pancreatic duct integrity and resolution of symptoms and without the need for operative management. Intensive monitoring and follow-up by clinical examination and repeat CT imaging is essential in these patients, as the risk of complications, and particularly a pseudocyst is high.     

Selective Nonoperative Management of Kidney Gunshot Injuries

Background  Nonoperative management (NOM) of kidney gunshot injuries as an alternative to surgical exploration is rarely reported. The aim of this study was to assess the feasibility and safety of selective NOM of such injuries. Methods  A 4-year prospective study was conducted that included all patients admitted to a Level I trauma center with kidney gunshot injuries. Patients with abdominal gunshot wounds and hematuria with no indications for immediate laparotomy (peritonitis, hemodynamic instability, head or spinal cord injury) underwent intravenous contrast abdominal computed tomography. Patients with confirmed kidney injuries were observed with serial clinical examinations. Outcome parameters included the need for delayed laparotomy, complications, length of hospital stay, and survival. Results  During the study period, 33 patients with kidney gunshot injuries were selected for NOM without laparotomy. The mean Injury Severity Score was 10.5 (range 4–25). Simple kidney injuries (grades I, II) occurred in 15 (45.5%) patients and complex kidney injuries (grades III, IV) in 18 (54.5%) patients. Associated injuries included 14 of the liver (42.4%), 4 (12.1%) of the spleen, and 6 (18.2%) each of the diaphragm, lung (contusion), and hemothorax. Three patients required delayed laparotomy: two for nonrenal indications, and one patient had a delayed nephrectomy for a grade IV injury. The overall successful NOM rate was 90.9%. The mean hospital stay was 5.9 days (range 2–23 days). There were no kidney-related complications and no mortality. Conclusion  Selective NOM of patients with kidney gunshot injuries is a feasible, safe, effective alternative to routine exploration.     

Current Status of Nonoperative Management of Liver Injuries

The successful use of nonoperative management of liver injuries requires a hemodynamically stable patient and early access to computed tomography (CT). Extensive intraperitoneal blood and extravasation of contrast on CT predict potential clinical failures. The CT appearance of the liver injury has poor correlation with clinical outcome. Angiographic embolization complements nonoperative management in the stable patient with an ongoing blood requirement. The follow-up CT scan is not required provided the hematocrit and the patient's clinical status remain stable. Common errors in nonoperative management include attributing evidence of blood loss to nonhepatic sources and continuing transfusions in anticipation that the bleeding will stop without intervention.     

Nonoperative Management of Tracheobronchial Injuries in Severely Injured Patients

Purpose A rupture of the airway due to blunt chest trauma is rare, and treatment can prove challenging. Many surgeons suggest operative management for these kinds of injuries. Nonoperative therapy is reported only in exceptional cases. But there is still a lack of evidence from which to recommend surgical repair of these injuries as the first choice procedure.Methods We retrospectively analyzed the records of 92 multiple injured patients admitted to our trauma department between July 2002 and July 2003 for the incidence and management of tracheobronchial rupture (TBR).Results Five (5.4%) of 92 patients suffered from tracheobronchial injuries. The mean injury severity score was 38. There were three male and two female patients, with a mean age of 23 years. All patients had lesions <2 cm in size and were treated nonoperatively. One patient died from multiorgan failure, but the others recovered from TBR uneventfully. One patient developed acute pneumonia as a result of respirator therapy, but none of the patients had mediastinitis or tracheal stenosis within 3 months after injury.Conclusion We believe that surgical treatment is not mandatory in patients with small to moderate ruptures, and such aggressive treatment may even have adverse effects, especially in patients with multiple injuries.     

Nonoperative Management of Intraabdominal Hypertension and Abdominal Compartment Syndrome

Intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have detrimental effects on all organ systems and are associated with significant morbidity and mortality. In recent years, the diagnosis and management of these syndromes has evolved tremendously, and the importance of comprehensive strategies to reduce intraabdominal pressure (IAP) has been recognized. All clinicians should be aware of the risk factors that predict the development of IAH/ACS, the appropriate measurement of IAP, and the current resuscitation options for managing these highly morbid syndromes. The nonoperative management of IAH/ACS can be summarized using five therapeutic goals: evacuate intraluminal contents, evacuate intraabdominal space-occupying lesions, improve abdominal wall compliance, optimize fluid administration, and optimize systemic and regional tissue perfusion. Surgical intervention through open abdominal decompression should immediately be pursued for patients with progressive IAH, end-organ dysfunction, and failure that is refractory to these nonoperative therapies. This comprehensive management strategy has been demonstrated to improve patient survival and long-term outcome.     

Single Versus Multiple Solid Organ Injuries Following Blunt Abdominal Trauma

Background

We aimed to describe the pattern of solid organ injuries (SOIs) and analyze the characteristics, management and outcomes based on the multiplicity of SOIs.

Methods

A retrospective study in a Level 1 trauma center was conducted and included patients admitted with blunt abdominal trauma between 2011 and 2014. Data were analyzed and compared for patients with single versus multiple SOIs.

Results

A total of 504 patients with SOIs were identified with a mean age of 28 ± 13 years. The most frequently injured organ was liver (45%) followed by spleen (30%) and kidney (18%). One-fifth of patients had multiple SOIs, of that 87% had two injured organs. Patients with multiple SOIs had higher frequency of head injury and injury severity scores (p < 0.05). The majority of SOIs were treated nonoperatively, whereas operative management was required in a quarter of patients, mostly in patients with multiple SOIs (p = 0.01). Blood transfusion, sepsis and hospital stay were greater in multiple than single SOIs (p < 0.05). The overall mortality was 11% which was comparable between the two groups. In patients with single SOIs, the mortality was significantly higher in those who had pancreatic (28.6%) or hepatic injuries (13%) than the other SOIs.

Conclusion

SOIs represent one-tenth of trauma admissions in Qatar. Although liver was the most frequently injured organ, the rate of mortality was higher in pancreatic injury. Patients with multiple SOIs had higher morbidity which required frequent operative management. Further prospective studies are needed to develop management algorithm based on the multiplicity of SOIs.