胃切除术致脾损伤的处理——附15例临床分析

目的 为进一步在胃手术中注意保护健康的脾脏。方法 回顾性分析本院8年来在胃切除术中出现15例医源性脾损伤的临床资料。结果 15例脾损伤中溃疡病胃切除术6例，胃癌根治术8例，贲门癌根治术1例，占同期胃切除术3.3％(15，／457例)。按Pachter脾损伤分级，Ⅰ级2例．Ⅱ级2例．Ⅲ级1例．致伤原因是术人为造成。4例经电凝加医用生物蛋白胶止血，5例行大网膜逢合、明胶海绵压迫止血，3例行逢合修补术．3例全脾切除。全组均痊愈出院，3例脾切除患中2例术后并发感染。结论 胃手术导致脾脏损伤是一种医源性的睥损伤，这种损伤是可以预防或降到最低限度的，及时发现正确处理十分重要。     

胃癌手术中医源性脾损伤的防治

目的：探讨胃癌手术中发生脾损伤的原因和防治方法。方法：回顾性分析胃癌手术中发生脾损伤患者的资料。结果：685例中发生脾损伤27例，损伤率为3.9％。其中I级22例，Ⅱ级3例，Ⅲ级1例，Ⅳ级1例。保脾成功24例，全脾切除3例。结论：良好的麻醉和细致的手术操作可以有效预防医源性脾损伤的发生，根据伤情合理选择术式是治疗的关键。     

术中医源性脾损伤21例分析

医源性脾损伤多发生在腹部手术中，如处理不当，常导致脾切除，甚至危及生命的严重后果。我院1995年10月-2004年9月共发生医源性脾损伤21例，经采用脾缝合修补或部分脾切除术，得以保住脾脏，未发生迟发性出血，亦无死亡病例。现总结分析如下。     

222例脾脏损伤的原因、诊断和治疗

1976～1996年我院共收治脾损伤222例，男177例(79．73％)，女45例外(20.27％)。年龄13～89岁，中位年龄：车祸组31岁，医源性66岁，坠伤组30岁。脾损伤的原因，车祸83例(37．39％)、手术损伤(医源性)45例(20．27％)、坠落伤35例(15．77％)；其他为击伤7例，摔伤6例，自发性脾破裂6例，自行车撞伤5例，跌伤4例，打、踢伤7例，撞在凳上、船弦上5例．还有吊车、铁架、水泥板对胸腹部挤压伤等。手术损伤主要发生在胃癌手术26例、食管癌5例、胃平滑肌瘤、肝癌、溃疡病手术。车祸、坠落伤多数于伤后1～18小时就诊，手术损伤于手术时或术毕时发现。车祸及坠伤时身体受伤部位：左上腹、左季肋，左腰腹、左胸腹、左胸共172例占外伤的97．18％，其他部位如左臂、左下腹、头腹等。     

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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     

腹腔镜胃切除术中医源性脾损伤的原因分析与防治

目的 探讨腹腔镜胃切除术中医源性脾损伤的原因和处理方法.方法 回顾性分析我院2006年12月至2011年6月期间157例行腹腔镜胃切除术中出现8例医源性脾损伤的临床资料.结果 157例行腹腔镜胃切除手术中发生医源性脾损伤8例,脾损伤率为5.1%,脾损伤按Pachter分级,Ⅰ级5例、Ⅱ级2例、Ⅲ级1例,8例患者均保脾成功,痊愈出院.结论 腹腔镜胃切除术中发生医源性脾损伤与手术者及疾病本身因素有关,及时发现及正确处理十分重要.     

胃切除术致脾损伤的处理--附15例临床分析

目的　为进一步在胃手术中注意保护健康的脾脏。方法　回顾性分析本院８ 年来在胃切除术中出现１５ 例医源性脾损伤的临床资料。结果　１５ 例脾损伤中溃疡病胃切除术６ 例，胃癌根治术８ 例，贲门癌根治术１ 例，占同期胃切除术３－３％ （１５／４５７ 例） 。按Ｐａｃｈｔｅｒ 脾损伤分级，Ⅰ级１２ 例，Ⅱ级２ 例，Ⅲ级１ 例。致伤原因是术者人为造成。４ 例经电凝加医用生物蛋白胶止血，５ 例行大网膜逢合、明胶海绵压迫止血，３ 例行逢合修补术，３ 例全脾切除。全组均痊愈出院，３ 例脾切除患者中２ 例术后并发感染。结论　胃手术导致脾脏损伤是一种医源性的脾损伤。这种损伤是可以预防或降到最低限度的，及时发现正确处理十分重要。     

胃肠道肿瘤手术中医源性脾损伤的原因及预防(附26例报告)

胃肠道肿瘤手术尤其是经腹近侧胃切除、全胃切除术和横结肠切除术中易发生脾损伤。2000年1月至2005年12月我院行胃肠道肿瘤切除术2200例，术中发生脾损伤26例，损伤率为1．18％。现分析报道如下。     

消化道手术中医源性脾损伤的预防和处理

医源性脾损伤(iatrogenicsplenicinjury)通常是指处理脾脏邻近器官的手术时,由于手术操作、医疗器械使用不当或局部解剖变异所造成的脾脏损伤。在临床上因各种原因导致的医源性脾损伤并不罕见,而且一旦发生损伤将会引发手术时间延长、术中失血量增加、病人住院时间延长等一系列问题;有的尚须行无辜性脾切除,导致脾切除术后发生并发症的风险增加,不仅给病人带来痛苦,甚至危及其生命。因此,医源性脾损伤已成为外科领域值得关注的问题。1应尽力避免医源性脾损伤消化道手术中医源性脾损伤的发病情况国内外报道不尽相同。Cassar等[1]报告,近40%…     

脾损伤

脾损伤可由穿透性、钝性或医源性损伤引起。穿透性损伤约占7％,钝性外伤远为常见,多发生于交通事故,左季肋部挫伤、坠落的对冲性损伤。医源性损伤多发生于上腹部手术时,如胃大部分切除时,术者操作粗疏,器械直接损伤或牵拉不当。近十年来由于对脾脏免疫功能和凶险性感染(OPSI)的认识,对脾损伤的处理已趋于尽可能保脾,至90年更发展到选择性有效保脾新阶段,对脾损伤诊断治疗有了更高的要求,需从多种方法中作出选择。     

Incidental splenic injury during abdominal vascular surgery: a case-controlled analysis

BACKGROUND: The small but finite risk of postsplenectomy sepsis is generally regarded as a firm indication for splenic preservation after iatrogenic injury, especially in the young. But splenectomy may be preferable in patients who sustain splenic injuries during vascular operations because of the potential for continued bleeding associated with anticoagulation. The purpose of this study was to determine the perioperative morbidity of incidental splenectomy among patients undergoing abdominal vascular operations. STUDY DESIGN: We studied 17 patients who underwent incidental splenectomy at the time of abdominal vascular operations. Complete data collected on each subject included preoperative and postoperative blood counts, operative indications and details, transfusion requirements, length of hospital stay, and outcomes. Using age- and gender-matched case controls undergoing identical vascular operations from the same period, we evaluated the complication rate and outcomes of patients who underwent splenectomy for iatrogenic injuries of the spleen, versus those who did not sustain splenic injuries. RESULTS: The estimated prevalence of iatrogenic splenic injury during the study period was 0.5%. Mean operative time, estimated blood loss, and duration of mechanical ventilation tended to be greater in the splenectomy patients, but the differences did not achieve statistical significance. Splenorrhaphy was attempted in seven patients, but continued bleeding mandated spleen removal in all cases. Splenectomy patients had a higher transfusion requirement (p = 0.03) and a longer mean length of stay (p = 0.03) than controls. Compared with controls, there was a higher prevalence of infectious complications in the splenectomy patients (p = 0.015), but there was no difference in the prevalence of thromboembolic complications between groups. Two of the splenectomy patients died in the postoperative period from multisystem organ failure, and one died of a missed splenic injury. CONCLUSIONS: These data suggest that incidental splenectomy during abdominal vascular operations is associated with increased postoperative infectious complications and prolonged hospitalization.     

Iatrogenic splenic injury

In a previous report from this institution, 21% of splenectomies performed between 1957 and 1967 were for iatrogenic injury to the spleen. In the present study, encompassing the years 1971 to 1987, the frequency of iatrogenic splenic injury was reduced to 9% (134 of 1,557 splenectomies). However, there has been no evidence of a progressive decrease in accidental splenic injury from 1971 to 1987. Although the number of injuries related to operations on the stomach or repair of hiatus hernia have declined somewhat in the past decade, the incidence of splenic injuries secondary to colectomy and nephrectomy has not changed appreciably, and injuries linked to complex operations on the aorta and its branches (19 cases) have increased. No evidence could be found that morbidity was increased if the splenic injury is promptly recognized and managed by splenectomy. However, 13 of these 134 patients required reoperation for control of continued bleeding from unrecognized iatrogenic splenic trauma. Constant awareness of the continued prevalence of this operative complication and the mechanisms by which it is produced should enable surgeons to lessen its frequency and potential sequelae.     

脾创伤保脾手术术式的选择（附158例分析体会）

目的　探讨脾创伤保脾术的术式选择。方法　对脾创伤采用术中保脾的 15 8例手术方式进行分析 ,其中氩气刀止血 5例 ,ZT生物胶止血 3例 ,单纯脾修补术 2 6例 ,脾部分切除术 77例 ,修补加脾部分切除术 12例 ,脾切除自体脾组织片网膜囊内移植术 35例。结果　全组病例治愈出院。脾切除自体脾组织片网膜囊内移植术组 35例中 ,2例出现粘连性肠梗阻 ,11例出现各类术后感染 ,而其它术中保脾组 12 3例中 ,10例出现术后感染 ,两组总感染数比较 ,P <0 .0 1。结论　脾创伤术中保脾术的术式选择 ,应根据病人个体情况及脾破裂的类型而定 ,必要时采用联合多种术式保脾。对伴有空腔脏器破裂者也可选择性保脾。但应慎重选择脾切除自体脾组织片网膜囊内移植术。     

Is splenectomy after trauma an endangered species?

Nonoperative management of splenic trauma is now the most common treatment modality for splenic injuries and splenectomy has almost disappeared in some trauma centers. Splenectomy for cancer staging is infrequently performed suggesting that the indications for splenectomy continue to evolve. We evaluated a state database to assess a communitywide experience with splenic surgery. International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were used to determine the indication for splenic surgery. Indications for splenic surgery were listed as trauma (injury codes), medical (hematological diseases, neoplasms, or procedures in which the spleen might be removed contiguously like distal pancreatectomy), or incidental (noncontiguous procedures). Splenectomies for medical indications (n = 607, 43%) were more common than splenectomies for trauma (n = 518, 37%) or incidental splenectomies (n = 276, 20%). Splenectomy for medical reasons was associated with hematologic disease in 56 per cent, neoplastic disease in 34 per cent, and other diagnoses in 10 per cent of cases. Incidental splenectomies were most commonly associated with operations on the esophagus/stomach (32%) and colon (30%). Mortality rate and length of stay were greatest for incidental (14.4 +/- 0.9 days, 10.9% mortality) compared with trauma (11.0 +/- 0.5 days, 7.7% mortality) or medical (9.7 +/- 0.4 days, 4.8% mortality) splenectomies (all P < 0.05 versus incidental). Our results suggest that in the era of nonoperative management of splenic injuries, medical indications now represent the most common reason for splenectomy. As laparoscopic techniques for elective splenectomy become more common, the changing indication for splenectomy has important ramifications for surgical education and training.     

Experience with selective operative and nonoperative treatment of splenic injuries in 193 patients.

During the past decade splenic salvage procedures rather than splenectomy have been considered the preferred treatment for traumatic splenic injuries. Splenic preservation has been most often accomplished by splenorrhaphy and more recently by a controversial nonoperative approach. This report delineates indications, contraindications, and results with splenectomy, splenorrhaphy, and nonoperative treatment based on an 11-year experience (1978 to 1989) in which 193 consecutive adult patients with splenic injuries were treated. One hundred sixty-seven patients (86.5%) underwent urgent operation. Of these, 111 (66%) were treated by splenorrhaphy or partial splenectomy and 56 (34%) were treated by splenectomy. During the last 4 years, 26 additional patients (13.5%) were managed without operation. Patients considered for nonoperative treatment were alert, hemodynamically stable with computed tomographic evidence of isolated grades I to III splenic injuries. Overall 24% of the injuries resulted from penetrating trauma, whereas 76% of the patients sustained blunt injuries. Complications were rare, with two patients in the splenorrhaphy group experiencing re-bleeding (1.8%) and one patient (4%) failing nonoperative treatment. The mortality rate for the entire group was 4%. This report documents that splenorrhaphy can safely be performed in 65% to 75% of splenic injuries. Splenectomy is indicated for more extensive injuries or when patients are hemodynamically unstable in the presence of life-threatening injuries. Nonoperative therapy can be accomplished safely in a small select group (15% to 20%), with a success rate of nearly 90% if strict criteria for selection are met.     

Splenectomy versus splenic salvage for spleens ruptured by blunt trauma

Of 339 patients treated in three Charlotte hospitals from January 1960 through March 1983 for splenic rupture caused by blunt trauma, 317 (93.5%) underwent splenectomy, and 22 (6.5%) underwent splenic salvage operations. Perioperative mortality for splenectomized patients was 7.9 per cent, and that for those who received splenic salvage operations was 22.7 per cent. Perioperative sepsis occurred in 4.4 per cent of the splenectomized patients and in 9 per cent of those whose spleens were salvaged. Perioperative deaths and sepsis in both groups were related to associated injuries, not to splenic injuries. Follow-ups from 5 months to 22.4 years (mean, 9.5 years) of the 292 splenectomized patients who survived their injuries show that 252 (86.3%) are living, 22 (7.5%) have died of causes unrelated to splenic injuries, 18 (6.1%) could not be found, and none of the patients traced has died of sepsis. One patient (0.34%) experienced an episode of sepsis i.e., a nonfatal septicemia 7 years postsplenectomy, that may be related to splenectomy. These data suggest that the importance of splenic salvage for prevention of postsplenectomy sepsis has been overemphasized and that expeditious splenectomy remains the procedure of choice for patients with ruptured spleens, especially for those with hypovolemic hypotension, anemia from hemorrhage, or multiple injuries. Data to substantiate these views will be presented.     

Traumatic lesions of the spleen. Analysis of 35 cases

A retrospective review of all the traumatic splenic ruptures from 1974 to 1988 was performed. Thirty-five patients were treated with splenectomy: 24 were males and 11 women. Teenagers and young adults were the most affected age groups. The mechanisms of injuries were: road accidents (78.8%), falls (12.1%), aggression, autoaggression and iatrogenic mishap (3%). Eighty per cent of the patients had associated injuries. Authors suggest a decisional algorithm to precise preoperative diagnosis and to treat the patients correctly. Mortality was 11.4% and primarily due to associated injuries.     

Comparison of iatrogenic splenectomy during open and laparoscopic colon resection

Iatrogenic splenic injury requiring splenectomy is a well-recognized and potentially serious complication of colon resection. Iatrogenic splenectomy is associated with significant morbidity and mortality, including bleeding and the postsplenectomy sepsis syndrome. Our study aims to compare the incidence of iatrogenic splenectomy in laparoscopic colon resection with that of open colon resection over an 11-year-period at Mount Sinai. A retrospective chart review of all patients undergoing colon resection at Mount Sinai Medical Center during the last 11 years was performed to identify patient demographics, procedure, indication, and outcome. There was a significant difference (P=0.03) in the incidence of iatrogenic splenectomy during open colectomy (13/5477, 0.24%) versus laparoscopic colectomy (0/1911, 0%). All cases complicated by iatrogenic splenectomy involved splenic flexure mobilization. Laparoscopy has many recognized advantages over open procedures, including shorter recovery and length of stay. This retrospective review of our experience at Mount Sinai presents another potential benefit of the laparoscopic approach to colon resection.     

Conservative treatment of the spleen. Report of 50 cases

From 1983 to 1989, 50 patients have been treated by spleen conservation. Traumatism was iatrogenic in 9 cases, caused by public highway accidents in 31 cases, domestic accident in 9 cases and penetrating trauma in one case. Spleen conservation includes: 26 partial splenectomies, 11 cauterisations, 10 sutures, 5 auto-transplantations, and 3 abstensions after laparotomy and little spleen trauma. Three deaths were observed secondary to cerebral trauma, and two complications have been seen: one during the operative solved by total splenectomy, and one rebleeding after splenorraphy, reoperated and splenectomy was performed with good evolution. The follow-up of partial splenectomy showed that splenic remnant keeps an epuration activity.     

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.