严重复杂的胰腺创伤临床处理探讨

Objective To summarize the experience in diagnosis and management for severe and complicated pancreatic trauma. Methods The clinical data of 21 patients with severe pancreatic trauma treated in our hospital were retrospectively analyzed. Of the 21 with a mean age of 26 (9-53), 14were male and 7 female. The causes of trauma were blunt injuries in 13 and patent injuries in 8 of them. The injury grade distribution for these patients was grade Ⅲ in 8 cases, grade Ⅳ in 8, and grade V in 3. The main diagnostic modalities included amylase measurement, ultrasonography, CT,endoscopic retrograde cholangiopancreatography (ERCP), and magnetic resonance cholangiopancreatography (MRCP) etc. All patients received surgical procedures. Roux-en-Y distal pancreatojejunostomy was performed in 10 patients, pancreatoduodenectomy in 3, modified duodenal diverticulization in 2, distal pancreatectomy in 3, tube installing in major duct and external drainage, and suture of pancreatic section in 2, and suture of two broken side respectively (delayed distal pancreatojejunostomy in the second time) in 1. Results Pancreatic injury was confirmed in 11 cases preoperatively and intraoperatively in the others. The early emergency operation was performed in 18 patients within 12hours, and delayed operation was done in 3 cases. Twenty patients were cured and 1 died after a procedure of pancreatoduodenectomy. The postoperative pancreatic fistula happened in 3 cases and recovered well with conservative line of management. Conclusion The diagnosis of severe and complicated pancreatic trauma is difficultly yet, so the earlier exploratory laparotomy should be suggested. The individual surgical modality based on the grade should be adopted in the operation and the concept of "Damage Control Surgery" should be carried out in the procedure. Extended operation should be avoided.     

Clinical management of abdominal trauma

Objective： To improve the prognosis of patients with abdominal trauma.
Methods： Between January 1993 and December 2005, 415 patients were enrolled in this research. The patients consisted of 347 males and 68 females with mean age of 36 years （ranging from 3-82 years）. All abdominal traumas consisted of closed traumas （360 cases, 86.7%） and open traumas （55 cases, 13.3%）.Results： A total of 407 cases （98.1%） were fully recov- ered from trauma and the other 8 cases （1.9%） died of mul- tiple injuries. The mean injury severity score （ISS） of all patients was 22 while the mean ISS of the patients who died in hospital was 42. Postoperative complications were seen in 9 patients such as infection of incisional wounds （6 cases）, pancreatic fistula （2 cases） and intestinal fistula （1 case）. All these postoperative complications were cured by the conservative treatment. Conclusion： Careful case history inquisition and physical examination are the basic methods to diagnose abdominal trauma. Focused abdominal ultrasonography is always the initial imaging examination because it is non-invasive and can be performed repeatedly with high accuracy. The doctors should consider the severity of local injuries and the general status of patients during the assessment of abdominal trauma. The principle of treatment is to save lives at first, then to cure the injuries. Unnecessary laparotomy should be avoided to reduce additional surgical trauma.     

Surgical management of transected injury to the pancreatic neck

Objective: To present a batch of data of transected pancreatic neck injuries and to sum up the experience insurgical interventions for the in juries. Methods. We analysed 13 patients with a transected injury to the pancreatic neck from Jan. 1995 to Dec. 2000.External drainage was performed in all patients.Pancreatoduodenectomy was conducted in 2 patients with a transected injury to the pancreatic neck associated with duodenal ruptures, and TPN was administered immediately after operation. Proximal closure of the transected margin and distal pancreaticojejunostomy was performed in 4 patients. Proximal closure of the transected margin and distal pancreaticojejunostomy plus splenectomy was performed in 7 patients associated with contusion of pancreatic body or tail plus spleen rupture. Results : 12 patients healed and one patient died of anesthetic accident during the course of restoration of the dislocation of his right hip joint. Complicatious occurred in 7 patients. Conclusions: The operation should be performed according to the degree of the injuries and associated duodenal injuries. Routine drainage and nutrient support should be recommended.     

Damage control orthopaedics in 53 cases of severe polytrauma who have mainly sustained orthopaedic trauma

Objective： To discuss damage control orthopaedics in 53 cases of severe polytrauma who have mainly sustained orthopaedic trauma. Methods： The data of 53 cases of severe polytrauma who had mainly sustained orthopaedic trauma were retrospectively analyzed. And the methods and timing of damage control orthopaedics were discussed in this study.
Results： We succeeded in rescuing the lives of all the 53 patients, and 38 patients returned to their former work. Conclusions： Injury Severity Score （ISS90） should be 17 in severe polytrauma patients, but in severe polytrauma patients who have mainly sustained orthopaedic trauma, the ISS90 of bone and joint injuries should be 16. We recommend that primary minimallyinvasive external fracture stabilization should be made for extremities and pelvis in these patients to avoid additional surgical trauma and that definitive secondary fracture care should be performed after medical stabilization for these patients in intensive care unit （ICU）.     

Treatment of 209 cases of liver injury

Objective: To summarize the experience of the treatment of traumatic hepatorrhexis. Methods: The clinical data of 209 cases of liver trauma treated in the three affiliated hospitals of the Third Military Medical University from 1989 to 1999 were retrospectively analyzed. Among the 209 patients, 108 (51.7%) had Grade Ⅲ or more severe liver injury. Operative treatment was performed in 186 cases and preservative treatment in 23. Results: In the operated group, 169 patients were cured. The eomplications occurred in 18 patients and 17 of them died. In the non-operated group, the complications occurred in 22 patients and only 1 of them died. Conclusions： Severe injury and delayed treatment are two major factors leading to death from liver injuries.Surgical intervention is still the principal measure to treat traumatic hepatorrhexis. The indications for non-operative treatment should be carefully selected.     

Comparison of severe trauma care effect before and after advanced trauma life support training

Objective： To study the emergency care effect of in-hospital severe trauma patients with the injury severity score （ISS）≥ 16 after medical staff received advanced trauma life support （ATLS） training.Methods： ATLS training was implemented by lectures,scenarios, field practices, and examinations. The clinical effect of in-hospital severe trauma care was compared 2 years before and after ATLS training.Results： During 2 years （from January 1, 2004, to December 31, 2005） before ATLS training, 438 cases of severe trauma were admitted and treated emergently in our department. Among them, ISS score was 28.6±7.8 on average, and 87 cases died with the mortality of 19.9%. The duration in emergency department and from admission to operation were 69.5 min±l 1.5 min and 89.6 min±9.3 min respectively. Two years （from January 1,2007, to December 31, 2008） after ATLS training, 382 cases of severe trauma were admitted and treated. The ISS was 25.3 ±6.1 on average and 62 cases died with the mortality of 15.1%. The duration in emergency department and from admission to operation were 47.8 min±10.7 min and 61.5 min±9.9 min respectively. The ISS score showed no significant difference between the two groups （P＞0.05）, but the mortality, the duration in emergency department and from admission to operation were markedly decreased after ATLS training and showed significant difference between the two groups （P＜0.05）.Conclusion： ATLS course training can improve the emergency care effect of in-hospital severe trauma patients,and should be put into practice as soon as possible in China.     

Treatment of limb arterial in juries caused by traffic accidents

Objective:To analyze the features,diagonosis and treatment of limb arterial injuries caused by traffic accidents.Methods:A total of 43 patients with limb arterial injury admitted in our department over the past 30years(about50%of them happened during the last10 years)were analyzed retrospectively in this article.The popliteal,femoral and brachial arteries were mainly involved,accounting for 432%,20.5%and20.5%respectively of all the involvements.There were 35cases of open injury and9of close injury,The involved vessels were transected in 43.2%of the cases and contused in 40.9%,All the patients had various complications,such as fractures,dislocations and severe soft tissue injuries.The injured vessels were repaired by means of end-to-end anastomosis in 10cases,autogenous vein graft in 23cases and intraluminal hydraulic dilatation in 4cases.Results:Successful limb salvage was achieved in 34cases initially,whereas10amputations were carried out due to injuries to popliteal arteries in7,femoral arteries in2and humeral artery in 1and severe soft tissue damages in9 cases.Twenty-nine patients were followed up for 1-156months,with the averageof48.8months.There was good circulation in 22 cases and certain ischemia in 5cases.Two amputations were carried out in the late stage because of popliteal artery thrombosis after repair in 2cases.There was no death in this series.Conclusions:The limb arterial injuries caused by traffic accidents are severe and complicated.It is proposed that particulatr attentions should be paid to the features in diagnosis and treatment for this type of injury and special efforts should be made for both life saving and limb salvage.     

Clinical diagnosis and treatment of abdominal visceral injury complicated by craniocerebral injury

Objective : To improve the cure rate of patients with abdominal visceral injury complicated by craniocerebral injury. Methods: Clinical data of 176 cases of abdominal visceral injury complicated by craniocerebral injury were retrospectively analyzed. Results: In this series, 44 cases died and the mortality was 25.0%. The main cause of death is abdominal visceral injury combined with shock and severe craniocerebral injury. Conclusions: It is essential to improve the cure rate by accurate diagnosis at early stage. Abdominal paracentesis and CT should be performed promptly and dynamically. Priority should be given to the treatment of life-threatening injuries.     

The risk factors of nosocomial infection in severe craniocerebral trauma

Objective:To explore the risk factors of nosocomial infection in severe craniocerebral trauma and the way of prevention.Methods:The clinical data of 387 patients with severe craniocerebral trauma were reviewed.Results:The total nosocomial infection rate of this study was 22.99% .Pulmonary nosocomial infection presented most frequently.The G-bacilli were the most common infectious bacteria.The mortality rate of the infection group was 38.20%.Conclusions:Complications of nosocomial infection affect the prognosis of craniocerebral trauma patients.Nosocomial infection is related to the age of the patients, craniocerebral trauma severity, unreasonable utilization of antibiotics and invasive operations, such as tracheal cannula, mechanical ventilation,urethral catheterization and deep venous catheterization.Patients with severe craniocerebral trauma should be carefully treated and nursed to avoid nosocomial infection.In order to reduce the rate of nosocmial infection,intensive measurement should be adopted.     

Hospital management of abdominal trauma in Tehran, Iran: a review of 228 patients

Objective: Today, trauma is a major public health problem in some countries. Abdominal trauma is the source of significant mortality and morbidity with both blunt and penetrating injuries. We performed an epidemiological study of abdominal trauma (AT) in Tehran, Iran. We used all our sources to describe the epidemiology and outcome of patients with AT.Methods: This study was done in Tehran. The study population included trauma patients admitted to the emergency department of six general hospitals in Tehran during one year. The data were collected through a questionnaire that was completed by a trained physician at the trauma center. The statistical analysis was performed using the SPSS software (version 11.5 for Windows). The statistical analysis was conducted using the chi-square and P＜0.05 was accepted as being statistically significant.Results: Two hundred and twenty-eight (2.8%) out of 8 000 patients were referred to the above mentioned centers with abdominal trauma. One hundred and twenty-five (54.9%)of the patients were in their 2nd and 3rd decades of life and 189 (83%) of our patients were male. Road traffic accidents (RTA) were the leading cause of AT with 119 (52.2%) patients. Spleen was the commonly injured organ with 51 cases. Following the analysis of injury severity, 159 (69.7%) patients had mild injuries (ISS＜16) and 69 (30.3%) patients had severe injuries (ISS= 16). The overall mortality rate was 46 (20.2%).Conclusions: Blunt abdominal trauma is more common than penetrating abdominal trauma. Road traffic accidents and stab wound are the most common causes of blunt and penetrating trauma, respectively. Spleen is the most commonly injured organ in these patients. The mortality rate is higher in blunt trauma than penetrating one.