肝脏损伤诊治进展

随着影像学诊断和治疗技术的进展,肝脏损伤的非手术治疗越来越多地被接受.但对于有致命性大出血的严重肝脏损伤,尤其伴有肝后静脉损伤时,多予手术治疗,且死亡率和并发症发生率高.按照肝脏损伤的级别合理采用综合手术治疗方法,将明显改善治疗效果,第一肝门阻断(Pringle法)下肝切除是一重要治疗手段.肝后静脉损伤的主要对策是全肝血流阻断或转流下肝切除或肝切开显露和修补肝后静脉;难以耐受此术式时,肝周填塞是明智的选择.     

肝脏损伤救治中几个重要问题

近20年来,肝脏损伤的处理有很大发展和改变,主要是CT扫描的进步带来早期精确的诊断,以及血流动力学稳定的患者更多地采用非手术治疗。选择性肝动脉造影栓塞是主要的非手术治疗手段。与此同时,对需要立即手术的患者的认识和判断变得格外重要。事实上,大多数Ⅳ~Ⅴ级肝脏损伤仍需手术治疗,而且伴有肝后静脉损伤的患者在处理上仍面临巨大挑战,且维持较高的死亡率。因此,处理这类损伤的手术技术必须寻求发展和突破。     

按照损伤控制原则下改进ALPPS一期手术及效果评估

目的 联合肝脏离断和门静脉结扎二步肝切除术（associating liver partition and portal vein ligation for staged hepatectomy,ALPPS）可以提高肝脏恶性肿瘤根治性切除率,但并发症的发生率和围手术期的病死率较高。本研究通过损伤控制原则下的ALPPS一期手术改进,系统评价该术式的安全性及有效性。方法 通过病例的精准纳入、精确的剩余肝脏体积评估和一期手术规划以及微创技术的应用,对ALPPS一期手术进行损伤控制,统计分析手术指标、功能性剩余肝脏体积增生、术后并发症的发生率及总体生存率。结果 空军特色医学中心联合北京天坛医院共计60例患者接受了损伤控制性一期改良式ALPPS手术,一期术后无严重并发症发生,手术时间（146.3±22.7）min,出血量（148.5±27.8）ml,剩余肝脏体积平均增加（179.3±72.4）cm3,与功能性剩余肝脏体积的增加差异无统计学意义。二期手术时间（287.5±48.2）min,出血量（615.7±62.4）ml,严重并发症发生率为16.7%,患者术后中位生存时间为22.4个月。结论 通...     

185例肝脏损伤综合手术治疗体会

目的探讨肝脏损伤的治疗方法,改善肝脏损伤手术的疗效。方法对2006年1月~2015年12月重庆市急救医疗中心创伤科收治的185例肝脏损伤手术患者的处理原则、手术方式及治疗结果进行总结,其中男性149例,女性36例;年龄15~79岁,平均37岁。按美国创伤外科学会(AAST)制订的肝损伤分级标准:Ⅰ级19例,Ⅱ级31例,Ⅲ级59例,Ⅳ级48例,Ⅴ级28例(其中合并肝后静脉损伤17例)。肝损伤AIS评分平均为(3.19±1.19)分。多发伤患者ISS评分平均为(18.76±6.64)分。以肝修补、大网膜填塞修补、Pringle法阻断肝蒂后肝内止血或清创切除、肝周填塞或加选择性肝动脉结扎作为处理肝脏损伤的主要手段。结果本组存活163例,死亡22例,死亡率11.89%。其中17例合并肝后静脉损伤者存活9例。死亡患者中除死于严重合并伤外,大失血或合并凝血障碍为主要死因。结论依据肝脏损伤的分级选择手术方案,肝后静脉损伤进行确切的肝后填塞和适当的辅助措施可提高救治成功率。     

阑尾周围脓肿手术治疗和保守治疗的临床疗效比较

目的:评估阑尾脓肿手术治疗和保守治疗的临床疗效.方法:分析我院2003-01～2009-06我院97例阑尾脓肿患者,评价治愈率、平均住院日、并发症的发生率.结果:手术治疗较非手术治疗治愈率较高,缩短了住院日,但并发症的发生率稍高.结论:应根据患者具体情况选择合适的治疗方式,倾向于选择手术治疗为宜.     

严重肝脏损伤的损害控制性手术治疗

目的探讨损害控制性手术(DCO)治疗严重肝脏损伤的经验。方法回顾分析2008年5月~2015年5月期间治疗的83例严重肝脏损伤患者的临床资料。其中男性47例,女性36例;年龄20~74岁,平均32岁。按照美国创伤外科协会(AAST)肝损伤分级标准,其中Ⅲ级31例,Ⅳ级30例,Ⅴ级22例,无Ⅵ级病例。结果 83例严重肝脏损伤患者中58例按DCO原则治疗,经复苏病情稳定后再接受相应术式的再次确定性手术,治愈56例(96.6%),再次手术后出现肝脓肿3例(5.1%)、膈下脓肿1例(1.7%)、胆漏2例(3.4%),经非手术治疗痊愈;死亡2例(3.4%),均死于肺部感染。25例患者按常规方式进行治疗,治愈20例(80.0%),术后再次手术3例(12.0%),肝脓肿3例(12.0%)、膈下脓肿2例(8.0%)、胆漏3例(12.0%),经非手术治疗痊愈;死亡5例,4例死于肺部感染,1例死于严重出血。结论严重肝脏损伤治疗选择损害控制性手术,能达到提高存活率和减少并发症的目的。     

静脉全身麻醉在经皮肝穿刺胆道引流术中的应用

目的 通过局部麻醉与静脉全麻比较,探讨静脉全麻在经皮经肝胆道引流(PTBD)手术中的安全性与有效性.方法 收集2012年10月至2015年8月125例行PTBD治疗患者的临床资料.其中48例患者采用局部麻醉,77例采用静脉全麻.观察患者术中及术后疼痛情况、心率及血压,随访观察手术操作时间,患者术后疼痛持续时间及穿刺相关并发症发生率.结果 静脉全麻组术中仅5例(6.5％)出现轻度疼痛,术后8例(10.4％)轻度疼痛,明显低于局部麻醉组(P＜0.01),疼痛评分亦低于局部麻醉组(P＜0.05).局部麻醉组术中患者心率、血压较术前、术后明显升高且波动较大,静脉全麻组术中患者心率、血压较术前、术后降低,但波动较小.局部麻醉组手术操作时间长于静脉全麻组(P＜0.05).静脉全麻组术后疼痛持续时间明显短于局部麻醉组(P＜0.05).手术相关并发症方面,局麻组3例患者发生肝动脉损伤,2例出现胆心反射综合征,2例出现胸膜损伤,静脉全麻组仅2例出现肝动脉损伤,无患者出现其他手术相关并发症.2组患者均无手术相关性死亡.结论 PTBD术中应用静脉全麻可有效降低手术风险,缩短手术时间并减轻手术痛苦,增加舒适性,值得临床应用推广.     

严重肝脏损伤的损害控制外科治疗策略及术中止血技巧

目的 探讨严重肝脏损伤治疗的损害控制外科策略和术中的止血技巧.方法 回顾性分析46例严重肝脏损伤病人的损害控制外科治疗的情况,统计其治疗效果.结果 46例均经损害控制性手术治疗.外科重症监护病房(SICU)复苏后,所有病人均接受适宜方式的再次确定性手术.治愈40例(87 0%),再次手术术后出现并发症3例(6.5%,肝...     

下颈椎损伤分类系统和手术治疗策略

下颈椎损伤发生率较高,在脊柱损伤中的发生率仅次于胸腰椎骨折。下颈椎解剖结构复杂,致伤机制多样,且由于损伤平面较高,致残率高,常给家庭及社会带来巨大的影响和经济负担。目前对下颈椎损伤的诊疗策略存在争议,如最新AO Spine分类系统是否更有利于治疗方案制定,急诊手术是否更有利于术后脊髓神经功能康复,前后联合入路适合哪些患者等。本文就下颈椎损伤分类系统、是否需手术治疗、手术时机及手术方式展开讨论。     

腹部钝性创伤中肠道及肠系膜损伤的CT表现

肠道及肠系膜损伤在腹部钝性伤中的发生率较高且易出现诊断延迟或漏诊。多层X线计算机断层成像具有较高的空间、时间和对比度分辨率,提高了肠道及肠系膜损伤诊断率。可显示腹腔内脏器损伤的直接和间接影像,指导非手术治疗或手术治疗的选择和效果评估。本文就肠道及肠系膜损伤在CT中特异性和非特异性征象作一论述。     

MDCT diagnosis of post-traumatic hepatic arterio-portal fistulas

The purpose of this study is to evaluate the performance of multidetector computed tomography (MDCT) in diagnosing arterioportal fistulas (APF) in high-grade liver injury. A retrospective analysis of catheter-based hepatic angiograms performed for major penetrating and blunt liver injuries identified 11 patients with APFs. Using the trauma registry, two additional demographically matched groups with and without liver injury were formed. A randomized qualitative consensus review of 33 MDCTs was performed by three trauma radiologists for the following MDCT findings of APF: transient hepatic parenchymal attenuation differences (THPAD), early increased attenuation of a peripheral or central portal vein compared with the main portal vein, and the "double-barrel" or "rail tract" signs. THPAD was the most sensitive finding and also had a high specificity for diagnosing APF. Both the early increased attenuation of a peripheral or central portal vein compared with the main portal vein and the double-barrel or rail tract signs had a100% specificity and a sensitivity of 64% and 36%, respectively. Measurement of differences in attenuation values between the APF and the contralateral central portal vein was most sensitive and specific in diagnosing APF. Traumatic APF of the liver can be optimally diagnosed with arterial phase imaging of solid organ using MDCT.     

肝损伤累及肝静脉主干或下腔静脉的救治体会

目的探讨肝损伤累及肝静脉主干或肝后段下腔静脉的救治。方法回顾分析我院2010年4月～2011年11月收治的10例手术治疗外伤性肝破裂(Ⅴ级)临床资料,其中,男性8例,女性2例;年龄19～46岁,平均32岁。致伤原因:道路交通伤6例,重物砸伤1例,马踏伤1例,刀刺伤2例。均属Ⅴ级的严重肝破裂。血管损伤:下腔静脉破裂9例,肝右静脉主干破裂4例,肝左静脉破裂1例,门静脉主干破裂1例;10例均合并有右侧或(和)双侧肋骨骨折;9例有肺挫伤;入院时均呈休克表现。10例均在积极抗休克的同时急诊行手术治疗。结果治愈8例,死亡2例。全肝血流阻断下行下腔静脉破裂+肝破裂修补术2例,肝上下腔静脉局部血流阻断(用血管阻断钳)下腔静脉修补术1例,肝右静脉破裂修补术3例,肝后下腔静脉破裂修补术5例,不规则右肝切除术6例(其中Ⅵ、Ⅶ、Ⅷ段肝切除1例)。结论在严重的外伤性肝破裂(Ⅴ级)救治过程中,需要多科积极配合,缩短术前准备时间,充分游离肝脏,合理阻断肝脏血流,正确的处理肝断面和大血管的损伤,可提高严重肝破裂的救治成功率。     

肝脏损伤并发腹腔感染的防治

目的探讨肝脏损伤并发腹腔感染的防治方法。方法回顾性分析2006年1月~2015年12月314例肝脏损伤患者的临床资料,男性221例,女性93例;年龄15~76岁,平均38岁。其中129例行非手术治疗,185例行手术治疗。结果 54例出现腹腔感染,均发生在手术组,感染率为29.2%。185例手术治疗患者中单纯性肝损伤73例[美国创伤外科学会(AAST)分级Ⅰ~Ⅱ级5例,发生腹腔感染0例;Ⅲ~Ⅴ级以上68例,发生腹腔感染14例],合并腹部其他脏器损伤或腹部外脏器损伤112例(AASTⅠ~Ⅱ级肝损伤45例,发生腹腔感染7例;Ⅲ~Ⅴ级肝损伤67例,发生腹腔感染33例)。54例腹腔感染中,49例治愈,治愈率为90.7%。结论严重肝脏损伤或合并腹部其他脏器损伤较易并发腹腔感染,根据肝脏损伤级别采取合理术式、保证充分引流、重视综合预防治疗措施可有效减少感染发生率和死亡率。     

Nonoperative management of hepatic trauma

In an attempt to determine whether selective, nonoperative management of hepatic trauma might be efficacious, a retrospective review of liver injuries was undertaken. Of the 48 patients with liver injuries identified, there were 34 men and 14 women with an average age of 28.5 years. Mechanism of injury consisted of blunt trauma in 23 patients, stab wounds in 14 patients, and 11 patients had gunshot wounds. There were 12 grade I injuries, 15 grade II injuries, 17 grade III injuries, 2 grade IV injuries, and 1 grade V injury. Diagnosis of liver trauma was made at the time of exploratory laparotomy in 15 patients and suggested by abdominal computed tomography (CT) scan in 18 patients; the remaining 15 patients had a positive peritoneal lavage which led to exploratory laparotomy. Following blunt trauma, 14 patients, all of whom underwent diagnostic abdominal CT scans which confirmed hepatic injury, had nonoperative treatment. All patients who received nonoperative management maintained stable vital signs and only five required transfusion. None of the patients who were treated nonoperatively developed complications or required delayed laparotomy. There were no deaths in this group. Of the 34 patients undergoing exploratory laparotomy, 19 required either no treatment or minor hepatorrhaphy. However, 17 of 25 patients with penetrating wounds had associated abdominal injuries which required operative treatment. Based on the information obtained in this review, it is recommended that stable patients with isolated hepatic injuries, secondary to blunt trauma confirmed by CT scan, may be managed nonoperatively. Due to the high frequency of associated injuries found in patients with penetrating trauma, nonoperative therapy is not advised.     

Liver trauma--operative management

Civilian liver trauma is generally sustained by blunt injury, with management strategies increasingly focusing on selective non-operative strategies and endovascular intervention. Military liver trauma is more often ballistic in nature and almost always requiring operative intervention. This article reviews established and evolving surgical techniques in the operative management of liver trauma.     

闭合性肝外伤的治疗决策

目的探讨闭合性肝外伤治疗方案的进展。方法回顾性分析15年来解放军总医院急诊收治的闭合性肝外伤患者的临床资料，结合近年国内外相关文献，从流行病学角度阐述国内外在闭合性肝外伤治疗方案选择上的异同及变化。结果国内闭合性肝外伤非手术治疗比例（10％～30％）与国外（50％～80％）相比仍偏低，相关CT检查应用还不充分，治疗方案选择观念较陈旧。结论非手术治疗是闭合性肝外伤治疗的重要手段，血流动力学稳定的患者均可列为候选对象；应适当扩大CT检查指征；临床上观念更新很有必要。     

CT criteria for management of blunt liver trauma: correlation with angiographic and surgical findings

PURPOSE: To determine the contrast material-enhanced computed tomographic (CT) criteria for selection of hemodynamically stable patients with blunt hepatic injury for angiographic evaluation. MATERIALS AND METHODS: Seventy-two patients with blunt liver injury underwent CT and hepatic angiography. Hepatic injuries were graded with CT-based classification. Scans were assessed for evidence of contrast extravasation and laceration or contusion extending into the hepatic vein(s), inferior vena cava, porta hepatis, or gallbladder fossa. Medical, angiographic, and surgical records were reviewed to determine angiographic findings, surgical indications and findings, and outcomes. RESULTS: Compared with hepatic angiography, CT was 65% (11 of 17 patients) sensitive and 85% (41 of 48 patients) specific for detection of arterial vascular injury. When CT severity grades 2 and 3 were analyzed, the sensitivity and specificity of CT were 100% (three of three patients) and 94% (34 of 36 patients), respectively (P <.001). Injury involving at least one major hepatic vein was found in 15 (88%) of 17 patients who required liver-related surgery and in 23 (42%) of 55 of the other patients (P <.01). CONCLUSION: CT-based criteria, including hepatic injury grade, signs of arterial vascular injury, and presence or absence of major hepatic venous involvement assists in selecting patients for hepatic angiography and those at increased risk of ongoing or delayed hepatic bleeding or other posttraumatic complications.