Non-operative management of blunt liver trauma: feasible and safe also in centres with a low trauma incidence

Background and Aims

Non-operative management (NOM) of blunt liver trauma is currently, if possible, the preferred treatment of choice. The present study evaluates the experience of blunt liver injury in adults in a Swedish university hospital.

Material and Methods

Forty-six patients with blunt liver trauma were treated from January 1994 through to December 2004. Patient charts were reviewed retrospectively to examine injury severity score (ISS), liver injury grade, diagnostics, treatment and outcome.

Results

Thirty-five patients (76%) were initially treated non-operatively and 11 (24%) patients had immediate surgery. In four (11%) patients, NOM failed and the patients required surgery 8–72 h after admission. Patients failing non-operative care had a significantly lower systolic blood pressure on admission as compared with patients with successful NOM (P = 0.001). Patients immediately operated upon had higher ISS (P < 0.001) and were haemodynamically unstable to a greater extent (P < 0.001) as compared with patients initially considered for NOM. Operated patients had increased transfusion requirements (P < 0.001), longer total hospital stay (P = 0.011) and stay in the intensive care unit (ICU) unit (P < 0.001) as compared with NOM. One immediately operated and one failed NOM died (total mortality 4%). Seventeen patients in the NOM group were successfully treated without surgery despite the presence of at least one described risk factor.

Conclusions

Most patients with blunt liver trauma can be treated without surgery, and non-operative management may be performed even in the presence of established risk factors.     

Antibiotics-first strategy for uncomplicated acute appendicitis in adults is associated with increased rates of peritonitis at surgery. A systematic review with meta-analysis of randomized controlled trials comparing appendectomy and non-operative management with antibiotics

Background

Acute appendicitis is the most common surgical diagnosis in young patients, with lifetime prevalence of about 7%. Debate remains on whether uncomplicated AA should be operated or not. Aim of this meta-analysis of randomized controlled trials was to assess current evidence on antibiotic treatment for uncomplicated AA compared to standard surgical treatment.

Predicting complete response: is there a role for non-operative management of rectal cancer?

Pre-operative chemoradiotherapy followed by a total mesorectal excision (TME) is the standard of care for patients with locally advanced (stage II or III) rectal cancer. Approximately 20% of patients may achieve a pathologic complete response after chemoradiation therapy (CRT), which has been shown to be associated with better oncologic outcomes. Whether surgery can be avoided in this population is an area of active investigation. Recent studies demonstrated feasibility and safety of non-operative management in patients with clinical complete response (cCR) after chemoradiotherapy. In this article, we set out to review the current data on non-operative management and to identify areas requiring further investigation, including improvement in imaging for reassessment after CRT and identifying the optimal time frame for restaging. As the field moves forward with non-operative management in select patients with rectal cancer, there continues to be a need to better understand the prognostic factors and biomarkers that may more accurately characterize patients who are qualified for this “wait-and-see” approach and thereby avoid overtreatment, potentially leading to improvements in long-term quality of life.     

直肠癌经新辅助治疗后达到临床完全缓解的评估策略及观察和等待策略

术前新辅助放化疗联合全直肠系膜切除术已成为局部晚期直肠癌患者治疗的金标准。临床上部分患者经放化疗治疗后达到病理完全缓解,并与不全缓解患者相比局部复发率显著降低,生存期延长。为了避免手术相关并发症、改善患者生活质量（造瘘和保肛问题）,一些机构尝试对放化疗后临床完全缓解患者采用非手术方案—“观察和等待策略”。然而,临床完全缓解并不总是预示病理完全缓解,需要综合评估策略更准确地预测哪些患者已经达到病理完全缓解来安全行“观察和等待策略”。本文就目前关于非手术方案的数据作一综述并讨论与此方案相关的持续争议。     

Ankle Fractures: Supination-Eversion Fractures Stage II Primary and Late Results of Operative and Non-Operative Treatment

Sixty-nine patients with stage II supination-eversion fractures of the ankle, 34 treated by operation and 35 treated conservatively, were seen at follow-up after 3–10 years. There was no statistically significant difference between the results of the two methods. However, larger series and perhaps a longer observation time are probably needed to decide whether the displacement of the lateral malleolus as a result of non-operative treatment affords the same possibility of unhindered ankle function as union of the lateral malleolus in the anatomical position obtained by operation.     

Clinical and functional outcomes of Paediatric femoral shaft fractures managed non-operatively at Nkhotakota District Hospital,Malawi

BackgroundFemoral shaft fracture is a common paediatric injury, managed non-operatively with skin traction in Malawian public hospitals. The clinical and functional outcomes of this treatment modality are unknown in Malawi.MethodsWe retrospectively identified all children who were managed at Nkhotakota District Hospital with skin traction after sustaining closed femoral shaft fractures from January 1, 2013 to December 31, 2016. We collected demographic characteristics and treatment history from the patient''s inpatient medical records, then invited each patient to undergo in-person follow-up clinical and functional assessment.ResultsWe identified 149 patients. Gallows traction 26 (17%) and 123 Bucks skin traction (83%). The mean age for Gallows traction was 10 months (95% CI: 8–11), most were males (16, 62%). Fall was the most common cause of injury (19, 73%), and mean hospitalization of 15.8 days (95% CI: 13.8–17.9). Eighteen patients (69%) were followed up at a mean of 4.2 years after discharge, all were full weight bearing, had achieved radiographic fracture union, and had no functional limitations or pain during regular activity. Buck''s skin traction mean age was 5.2 years (95% CI: 4.7–5.8), most were males (82, 67%), and fall (85, 69%). We followed up 83 patients (67%) at a mean of 4.1 years after hospital discharge, all of whom had achieved radiographic fracture union. All but one patient were full weight bearing and had normal gait. At follow-up, 14 patients (17%) reported some level of pain, 5 patients reported that their injury limited their return to household chores, and 2 reported that their injury also limited their return to school.ConclusionDespite the limitations of this study, non-operative management of paediatric femoral shaft fractures at Nkhotakota District Hospital may have good clinical and functional outcomes and minimal complications. A future prospective study may be helpful to confirm these findings.     

腰椎间盘突出症规范化非手术治疗模式下的个性化方案

腰椎间盘突出症是坐骨神经痛的常见病因,病因与临床表现复杂多变,各种非手术治疗疗效满意且被多国推荐使用,其有效性与优势取决于如何被有效运用。在规范化的治疗方案指导下,根据具体患者的疾病特点,制定出既有原则性,又有针对性的个性化治疗方案,具有非常重要的临床意义。     

钝性腹部创伤致内出血的非手术治疗

目的：探讨非手术治疗在钝性腹部损伤并仙出血的地位和作用。方法：回顾性分析1992－1999年我院收治的32例经选择的钝性腹部创伤致内出血病人行非手术治疗的疗效。结果：30例经保守治疗痊愈,2例需中转手术,没有发生严重的迟发性并发症。结论：经选择的钝性腹部创伤致内出血病人行非手术治疗是安全有效的,对血流动力学稳定的患者可作为首选。     

外伤性肝破裂的救治

目的 分析创伤性肝破裂外科多种干预治疗的效果。方法 总结分析1982-2002年我院收治创伤性肝破裂76例的救治方法和病死率。其中Ⅲ级以上的严重肝破裂46例(60．53％)。手术治疗56例，手术方式包括单纯修补、清创性肝切除、规则性肝切除、肝周填塞止血；非手术治疗20例。结果 手术组：治愈44例，术后并发症17例均经保守治疗治愈，死亡12例，其中术中死亡2例；非手术组：治愈12例，好转6例，2例失访。全组治愈64例，死亡12例，病死率15．8％。结论 Ⅰ-Ⅱ级单纯性外伤性肝破裂可保守治疗；手术是治疗创伤性肝破裂的主要措施，正确的手术方式，积极处理合并伤，重视综合治疗可提高救治成功率。     

肝外伤的治疗策略探讨

目的 探讨肝外伤的治疗策略.方法 回顾性分析1997年1月至2008年1月收治的112例肝外伤患者的临床资料.根据美国创伤外科学会(AAST)分级标准,对加例血流动力学稳定的Ⅰ～Ⅱ级肝外伤患者行非手术治疗,48例Ⅱ～Ⅳ级肝外伤患者行肝修补术治疗,13例Ⅳ～Ⅴ级肝外伤患者行肝部分切除术或联合选择性肝动脉结扎术,11例Ⅳ～Ⅴ级肝外伤患者行肝周纱布填塞或再加选择性肝动脉结扎的损伤控制性手术.结果 手术治疗72例患者中治愈60例,死亡12例;非手术治疗40例患者全部治愈.结论 非手术治疗是血流动力学稳定的肝外伤患者治疗的重要手段;外科手术是严重肝外伤患者治疗的主要措施.根据术中情况正确选择术式、损伤控制性手术、积极处理合并伤是提高严重肝外伤患者抢救成功率的关键.