外伤性脾破裂保留脾脏手术治疗的探讨

目的探讨外伤性脾破裂行保脾手术的临床价值。方法48例外伤性脾破裂分别施行单纯修补6例,脾部分切除术8例．薇乔网脾脏包裹术18例、自体脾片腹膜后移植术16例等保脾手术治疗。结果48例均顺利完成了保脾手术。单纯缝合修补术后1例出现脾血肿,经非手术治疗治愈。薇乔网包脾术后2例再次出现大出血,行再次手术切除脾脏。本组病例均康复出院,出院前全组46病例复查B超保留脾脏存活良好。术后对保脾成功的46例随访3月～5年（平均2．5年）。粘连性肠梗阻、腹腔感染及全身严重感染等并发症发生。薇乔网包脾者术后6个月复查B超示：脾脏形态完整,密度均匀,网片纹理完全消失。自体脾移植者B超、CT扫描证实：6个月移植脾整体形态显像清晰,脾片有增大及生长情况。结论只要掌握好手术适应症,手术技术处理恰当仔细,部分脾脏损伤可行保脾手术治疗。     

选择性保脾术治疗小儿外伤性脾破裂16例体会

目的 为了避免免疫功能下降和继发感染的发生．在小儿外伤性脾破裂时采用选择性保脾术治疗。方法 采用选择性保脾术治疗16例小儿外伤性睥破裂，Ⅰ度伤8例．Ⅱ度伤5例，Ⅲ度伤3例，其中1例合并有左膈肌破裂。结果 本组16例保脾术均获成功．术后恢复顺利，痊愈出院，随访结果，疗效满意。结论 在外伤性脾破裂行保脾术中必须遵循“抢救生命第一，保留脾脏第二”的原则。手术成功的关键在于适当掌握手术适应证和术式的选择。     

脾损伤采用保脾技术的基础和临床应用研究

目的 通过系列的动物实验和临床研究，达到在脾损伤时采用多种方法保留脾功能。方法 在动物实验成功的基础上，应用保脾术于临床，近20年我们收治脾损伤263例，其中全脾切除83例(31．56％)；采用多种保脾技术180例(68．44%)。后者行切脾后自体脾移植90例，脾修补和部分切除45例．脾动脉单纯结扎或保留副脾10例，非手术疗法保脾35例；脾修补的方法是用4号丝线作褥式或间断缝合；脾移植是取脾的25%切成1cm×1cm×0.5cm块状．植入网膜袋中。结果 保脾组死亡6例，占手术保脾组的4．14%，死因与保脾技术无关。存活的保脾病例随访最长15年．B超和核素锝扫描显示术后3个月脾修补裂伤愈合，脾移植的脾块显像良好；脾移植与全脾切除比较，血清Tuftsin显著上升，痘痕红细胞计数明显下降。结论 临床上采用的多种保脾技术．包括自体脾移植均能恢复脾的生理功能。     

外伤性脾破裂的保脾治疗

目的：比较选择性睥动脉栓塞术与非手术治疗外伤性脾破裂的临床应用。方法：回顾性分析1992～2006年我院进行的23例选择性脾动脉栓塞和32例非手术治疗睥破裂的患者。结果：选择性脾动脉栓塞组无输血，非手术组1例输血。选择性脾动脉栓塞组2例并发左侧胸腔积液，1例并发左下肺感染；非手术组1例出现并发脾周脓肿（P=0．298）。非手术组保脾成功率为81．3％（26／32）。选择性脾动脉栓塞组成功率为100％（23／23，P=0．035）。两组患者均无死亡病例。选择性脾动脉栓塞组平均住院（7．9±2．1）d，非手术组平均住院（11．9±4．6）d，P=0．045。结论：脾Ⅰ、Ⅱ级损伤适宜保脾治疗，选择性脾动脉栓塞术比非手术治疗更为安全有效。     

脾动脉结扎加不规则脾部分切除治疗外伤性脾破裂的临床研究

目的：为Ⅲ、Ⅳ级外伤性脾破裂达到原位保脾成功，方法：对1986年7月－2000年7月间的Ⅲ、Ⅳ级外伤性脾破裂149例，分别采用脾动脉结扎加不规则脾切除术治疗87例为治疗组；脾切、自脾移植术62例为对照组，从其术后监测周围血象，免疫球蛋白，补体，B超，彩超，CT查残留脾脏，术后并发症等指标，加以研究分析，结果显示治疗组治愈率100％，无并发症，术后3个月脾功能均恢复正常，脾脏原位出现代偿性增生。而对照组治愈率96．7％，死亡2例（死于脑挫伤），有并发症2例（肠梗阻1例，假性囊肿1例），术后1年脾功能恢复正常，血流变提示血粘稠度仍高于正常。结论：原位保脾术脾功能恢复快，术后并发症少，在条件允许的情况下，对Ⅲ、Ⅳ级外伤性脾破裂，应首选脾动脉结扎加不规则脾部分切除术。     

胃癌根治术保留胰脾功能清除脾门和脾动脉干淋巴结的临床意义

目的 探讨胃癌根治术保留胰脾功能清除脾门和脾动脉干淋巴结（即No10、No11)的合理性和可行性。方法 分析439例手术切除的胃贲门、体部和全胃癌侵入胰脾情况;对54例胃癌患者在术中从贲门和体部浆膜下注入亚甲兰观察胃的淋巴流向;63例胃癌采用保留胰脾功能性清除No10、No11淋巴结方法,与同期保胰法和胰脾切除法比较,分析No10、No11淋巴结转移率,观察术后并发症发生率和生存率。结果 439例胃贲门、体部和全胃癌侵入胰脾机会不多,分别为5．7％（25／439）和2．3％（10／439）;54例胃的美兰淋巴引流不进入脾脏和胰腺内。保留胰腺法、保胰法和胰脾切除法3组No10、11淋巴结转移率分别为17．5％（11／63）,19．1％（12／63）;20．8％（45／216）,25％（54／216）;20％（6／30）,23％（7／30）,差异无显著意义。63例保留胰脾法术后并发症发生率和病死率均较保留胰法和胰脾联合切除法低,而生存期较高,5、10年生存率分别为57．5％、52％,57．4％、47．4％和37．3％、30％。Ⅱ、Ⅲa期患者保留胰脾手术的5、10年生存率明显改善。结论 保胰脾法是一个安全、切实可行的保留脏器功能的胃癌手术,术后并发症低、生存率高。尤对Ⅱ、Ⅲa期患者应行保留胰脾手术。     

小儿脾外伤保脾诊治分析

腹外伤中．脾脏是最容易受损伤的器官。儿童（尤其是小于5岁）失脾将会引起免疫缺陷乃至发生暴发凶险性感染（OPSI），故小儿脾外伤中应尽量避免行单纯脾切除手术。本文总结本院自1996年1月至2005年6月救治的32例保脾治疗的脾外伤病例．同期收治脾外伤共38例．占84-2％，均获成功。现结合小儿脾外伤特点对保脾诊治分析如下。     

保留性脾手术在脾损伤中的应用体会

在脾损伤的手术治疗中,为更好地保护脾脏功能,降低OPSI的发生率,提高自身血液调节,抗肿瘤的免疫等能力,自1988.1～1997.2行保留性脾手术135例。保脾的原则是,结合伤情,保证生命安全是前提;术中的生命体征稳定是手术施实的保证;技术操作是保脾手术成败的关键;脾破裂的程度及有无合并伤是决定术式的依据。做到保命第一,保脾第二,最大限度地保护脾功能,提高生存质量。     

医源性脾损伤的处理

目的探讨医源性脾损伤保留脾脏的处理方式．方法回顾性分析11例医源性脾损伤患者的临床资料。结果对该11例医源性脾损伤的患者进行处理时．采用压迫和／或电凝止血者3例，直接缝合止血者3例，自体腹膜加垫缝合修补术5例。11例医源性脾损伤的患者均成功保住脾脏．无1例因术后出血或脾周脓肿行再次手术。无手术或术后近期死亡病例。结论压迫、电凝、缝合以及自体腹膜加垫缝合等方式在医源性脾损伤的处理中是安全、可行的，可以避免不必要的脾切除。     

外伤性脾破裂49例保脾治疗体会

目的　总结脾破裂保脾治疗经验。方法　有选择的对 49例脾破裂行保脾治疗。其中非手术治疗 2 2例 ,手术治疗 2 7例。单纯缝合 11例 ;缝合 +脾动脉结扎 2例 ;填塞 +缝合 4例 ;全脾切除 +自体脾片移植 10例。结果　全部治愈。手术组无再手术病例。结论　正确掌握非手术治疗指征和合理选择术式是保脾治疗的关键     

Management of intraoperative splenic injury during laparoscopic urological surgery

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? The exact incidence of splenic injury during laparoscopic urologic procedures is not known; however, it is an uncommon occurrence. Also, the optimal treatment algorithm is not well delineated and the efficacy of successfully treating minor injuries to the spleen without resorting to splenectomy is not well described in the urologic literature. This study outlines the rate of splenic injury during a variety of laparoscopic urologic procedures and we outline a treatment algorithm that has been successfully employed in the management of these patients, which in all cases, did not lead to splenectomy. An important point is also that multiple adjunctive hemostatic measures should be used when a splenic injury is recognized and that a thorough search should ensue when suspicion of an occult splenic injury exists, as an unrecognized splenic injury may lead to severe post operative haemorrhagic complications.

OBJECTIVE

? To evaluate incidence, risk factors for, and management of intraoperative splenic injury in our laparoscopic patient cohort.

PATIENTS AND METHODS

? All patients undergoing laparoscopic urological upper tract procedures at two institutions between January 2001 and April 2006 and January 2000 and December 2008, respectively, were retrospectively examined for complications. ? From these patients, those with intraoperative splenic injuries were selected and examined. ? Possible factors predisposing patients to splenic injury were evaluated and the management plan for each patient was analysed to identify optimal treatment efficacy.

RESULTS

? Of 2620 patients undergoing upper tract urological laparoscopic surgery, 14 patients (0.5%) sustained splenic injury and underwent left‐sided surgery, 13 via a transperitoneal approach. ? In 12 of the 14 patients, the splenic injury was recognized intraoperatively and all were effectively managed laparoscopically with a combination of argon beam coagulation, biological haemostatic agent FloSeal^TM (Baxter, Deerfield, IL, USA), and bio‐absorbable Surgicel® (Johnson and Johnson, Somerville, NJ, USA); none of these patients required splenectomy or developed any postoperative complications. ? In two patients, the splenic injury was not recognized intraoperatively; both patients presented with delayed haemorrhage necessitating open splenectomy in each instance.

CONCLUSIONS

? Splenic injuries are uncommon during laparoscopic urological surgery, but when a significant splenic injury occurs, it can be effectively managed laparoscopically, using conservative measures, without need for splenectomy. ? If the splenic injury is not recognized intraoperatively, delayed haemorrhage is likely to occur necessitating emergent re‐exploration and splenectomy. ? Prompt and accurate intraoperative diagnosis of splenic injury is critical for achieving a good outcome.     

成人外伤性脾破裂非手术治疗55例分析

目的对非手术治疗外伤性脾破裂进行临床分析，为外伤性脾破裂临床治疗方法的选择提供初步证据。方法回顾1992年至2006年我院收治的包括选择性脾动脉栓塞和保守治疗的非手术治疗脾破裂患者55例，对治疗成功率、死亡率和并发症发生率进行分析比较，并评价其卫生经济学效益。结果治疗总成功率87．27％（48／55），元患者死亡。损伤严重程度分组，51例脾Ⅰ、Ⅱ级损伤，总有效率90．19％（46／51），再次栓塞或开腹手术5例。4例脾外伤Ⅲ级患者，2例非手术治疗成功，再次栓塞或开腹手术2例。治疗分组分析，传统保守治疗组保脾成功率为81．3％（26／32），选择性脾动脉栓塞组成功率为100％（23／23）（P=0．035）。选择性脾动脉栓塞组2例并发左侧胸腔积液，1例并发左下肺感染；保守治疗组1例并发脾周脓肿。选择性脾动脉栓塞组平均住院日较保守治疗组[（7．9±4．2．1）d比（11．9±4．4．6）d]明显缩短（P=0．045），但住院花费增加[（4216±668．4）元比（2616±437．8）元]（P〈0．05）。结论脾损伤Ⅰ、Ⅱ级患者适宜保脾治疗，选择性脾动脉栓塞术比传统非手术保守治疗疗效更为可靠，在医疗设备和经济条件允许的情况下建议考虑栓塞治疗。     

Iatrogenic splenic injury

BACKGROUND: Iatrogenic injury to the spleen is a recognised complication of abdominal surgery but the extent of the problem is often under-estimated. This may be due to failure to report splenic injury on the operation note or inaccurate recording of the indication for splenectomy. In this review article we have tried to estimate the incidence of iatrogenic splenic injury during abdominal surgery, the morbidity and mortality associated with splenic injury and the risk factors for injury to the spleen. We have also identified the common types and mechanisms of injury to the spleen and have made suggestions as to how splenic injury can be avoided and, when it occurs, how it should be managed. METHODS: A Medline literature search was performed to identify articles relating to "incidental splenectomy", "iatrogenic splenic injury", "iatrogenic splenectomy" and "splenectomy as a complication of common abdominal procedures". The relevant articles from the reference lists were also obtained. RESULTS: Up to 40% of all splenectomies are performed for iatrogenic injury. The risk of splenic injury is highest during left hemicolectomy (1-8%), open anti-reflux procedures (3-20%), left nephrectomy (4-13%) and during exposure and reconstruction of the proximal abdominal aorta and its branches (21-60%). Splenic injury results in prolonged operating time, increased blood loss and longer hospital stay. It is also associated with a two to ten-fold increase in infection rate and up to a doubling of morbidity rates. Mortality is also reported to be higher in patients undergoing splenectomy for iatrogenic injury. The risk of injury to the spleen is higher in patients who have previously undergone abdominal surgery, in the elderly and in obese patients. A transperitoneal approach significantly increases the risk of splenic injury during left nephrectomy compared with an extraperitoneal approach and the risk is even higher if the indication for surgery is malignancy. Excessive traction, injudicious use of retractors and direct trauma are the commonest mechanisms of injury. CONCLUSIONS: The incidence of iatrogenic splenic injury is underestimated because of poor documentation. Splenic injury during abdominal surgery can be reduced by achieving good exposure and adequate visualisation, avoiding undue traction and by early careful division of splenic ligaments and adhesions. When the spleen is injured splenic preservation is desirable and often feasible, but this should not be at the expense of excessive blood loss     

基层医院外伤性脾破裂诊治特点——附72例分析

目的探讨外伤性脾破裂在基层医院的临床特点,指导临床诊治和提高疗效。方法对1995年至2005年10年间收治的72例外伤性脾破裂病例的临床资料进行回顾性分析。结果本组手术治疗64例,非手术治疗8例,全部治愈出院,术后无并发症。本组资料伤后到手术时间,与文献报道无明显差异;无死亡病例,全部治愈。结论根据脾损伤伤情,分别实施不同的脾手术方式,术中尽量保留脾脏及其功能。在掌握适应征的前提下行保守治疗也是治疗脾外伤的一种方法。     

Trend toward nonoperative management of splenic injuries

Treatment of splenic injuries has evolved over the past decade to reflect more effort to conserve function of the spleen. Records of 169 patients admitted over a 6-year period were identified as documenting the treatment of splenic injuries. We collected data regarding patient age, gender, degree of hemodynamic stability, number of units of blood required, severity of splenic injury, Injury Severity Score, and results of treatment. There were 143 adults (age greater than 16 years) and 26 pediatric patients (age less than 17 years), with mean age in the 2 groups of 31.6 and 11.4 years, respectively. Males comprised 72% of the group, and blunt injury occurred in 154 of the 169 patients. In the adults, splenectomy, splenorrhaphy, laparotomy without operative treatment of the spleen, and nonoperative management were observed 48%, 30%, 14%, and 8% of the time and in the pediatric group 31%, 27%, 19%, and 23% of the time, respectively. By using operative splenic repair techniques and increased use of nonoperative management, the splenic salvage rate has increased in the last 6 years from 41% to 61% without an increase in morbidity and mortality. Incidence of spleen salvage correlated with severity of spleen and overall injury and cardiovascular stability.     

Nonoperative management of blunt splenic injury: a 5-year experience

OBJECTIVES: The purpose of this study was to examine the success rate of nonoperative management of blunt splenic injury in an institution using splenic embolization. METHODS: We conducted a retrospective review of all patients admitted to a Level I trauma center with blunt splenic injury. Data review included patient demographics, computed tomographic (CT) scan results, management technique, and patient outcomes. RESULTS: A total of 648 patients with blunt splenic injury were admitted, 280 of whom underwent immediate surgical management. Three hundred sixty-eight underwent planned nonoperative management, and 70 patients were treated with observation, serial abdominal examination, and follow-up abdominal CT scanning. All were hemodynamically stable, with a 100% salvage rate. One hundred sixty-six patients had a negative angiogram, with a nonoperative salvage rate of 94%, and 132 patients underwent embolization, with a nonoperative salvage rate of 90%. Overall salvage rates decreased with increasing injury grade; however, over 80% of grade 4 and 5 injuries were successfully managed nonoperatively. The salvage rate was similar for main coil embolization versus selective or combined embolization techniques. Admission abdominal CT scan correlated with splenic salvage rates. Significant hemoperitoneum, extravasation, and pseudoaneurysm had acceptable salvage rates, whereas arteriovenous fistula had a high failure rate, even after embolization. CONCLUSION: Splenic embolization is a valuable adjunct to splenic salvage in our experience, allowing for the increased use of nonoperative management and higher salvage rates for American Association for the Surgery of Trauma splenic injury grades when compared with prior studies. Main coil embolization has a similar salvage rate when compared with other angiographic techniques. An arteriovenous fistula as a CT finding was predictive of a 40% nonoperative failure rate.     

Predictability of splenic salvage by computed tomography

The recognition of overwhelming post-splenectomy infection (OPSI) has led to greater efforts to conserve splenic tissue in patients sustaining blunt torso trauma. Nonoperative management of splenic trauma has emerged as a means to enhance splenic salvage yet criteria to assure the safety of such an approach remain ill defined and controversial. Since severity of injury directly influences outcome, a need exists for identification of splenic injuries that require early operation and repair or removal. Using our recently reported classification of splenic trauma, 46 patients with blunt splenic trauma were evaluated preoperatively with computed tomography (CT). Injuries were graded I through IV and were described as capsular or subcapsular disruptions without parenchymal injury (four); capsular and parenchymal injuries not involving the major vessels or hilum (24); injuries involving major vessels and/or the hilum (17); and fragmentation/devascularizing injuries (one). Additional modifiers were added for associated intra-abdominal and/or extra-abdominal injuries. Sixteen patients had their splenic injuries managed nonoperatively and the remainder underwent operation for the splenic injury or associated injuries. The CT classification was confirmed in all patients and we believe early operation optimized splenic salvage. We conclude that: 1) CT is an accurate technique to determine the extent of splenic injury; 2) CT classification of splenic trauma has a high correlation with anatomic findings and need for operation; 3) early operation in patients with severe class II and all class III injuries affords optimal conditions for splenic salvage; and 4) early definitive management of splenic trauma significantly reduces late splenectomy and shortens hospitalization.     

ҽԴ��Ƣ���˵ķ���

目的 分析医源性脾损伤的原因，提出防范措施。方法 回顾性分析５１例与手术有关的脾损伤和文献报告的病例。结果 脾损伤与胃癌根治术，胃十二指肠手术（８０．８４％），食管癌手术（１１．７６％），肝肿瘤手术报告的病例。结果 脾损伤与胃癌根治术，胃十二指肠心肺复苏时也可能引起脾脏损伤。遗传性传染单核细胞增多症等血液病在发病过程中可发生自发性脾破裂。结论 改进手术操作，积极治疗某些疾病，有望降低医源性脾损伤的     

Solitary splenic abscess: a new complication of splenic salvage treated by percutaneous drainage

A patient sustained a gunshot injury to the spleen. The spleen was left intact in an attempt to maintain normal immune function in the patient. The patient developed a splenic abscess as a result of the injury, a complication of splenic salvage that we have not found reported before. The abscess was treated successfully via CT-guided percutaneous drainage.     

Spleen-saving procedures in paediatric splenic trauma

The aim of this study is to assess the advantages of 'spleen-saving procedures' in paediatric splenic trauma. Since January 1979, 87 children with splenic trauma were treated. Six were treated without operation. Eighty-one patients were treated surgically. Sixteen cases with type I splenic injury were subject to simple splenorrhaphy, and twenty-three cases with type II splenic injury underwent splenorrhaphy plus omentoplasty. Twenty-four cases had type III splenic injury; of these, 20 were treated by ligation of the splenic artery (the main splenic artery in 14 cases and the upper segmental artery in six cases) with splenorrhaphy and omentoplasty, and the remaining four cases were treated by partial splenectomy and omentoplasty. In 16 of the 18 patients with type IV splenic injury, splenectomy was inevitable and heterotopic splenic autotransplantation was added. In the remaining two cases, it was possible partially to preserve the spleen. No complication was observed due to any of these spleen-saving procedures. Moreover, splenic implants increased complement C3 levels and improved filtration function. Despite other injuries, the mortality rate of this group was 5.7 per cent. The splenic salvage rate was 82 per cent.