尿道下裂修复中非手术技术因素对疗效的影响

目的:探讨尿道下裂手术修复中的非手术技术因素对手术效果的影响。方法:将1999年1月~2006年1月收治的285例尿道下裂患者,以2003年1月为界限分为两组,比较两组的手术效果,分析非手术技术与疗效的关系。结果:2003前组治疗尿道下裂165例,平均住院时间18d;出现尿瘘17例,并发尿道外口狭窄6例、吻合口狭窄3例、尿道长段狭窄1例,尿囊形成5例。总手术成功率为81%。2003后组共治疗尿道下裂120例,平均住院时间12d;术后近期出现尿瘘5例,其中3例在术后3个月内自行愈合;并发尿道外口狭窄并尿囊形成1例,尿道外口狭窄2例、吻合口狭窄1例。总手术成功率为95%。结论:术中优化非手术技术因素(如:废除膀胱造瘘,容易更换敷料,不用拆线等)能减轻患者痛苦,提高手术成功率。     

创伤性脾破裂非手术治疗45例临床分析

目的探讨采用非手术方法治疗急性创伤性脾破裂的可行性及疗效。方法对2011年5月至2014年8月间本院采用非手术治疗的45例创伤性脾破裂患者临床资料作回顾性分析。结果 45例患者中非手术治愈43例,成功率95.6%。2例Ⅱ级脾损伤患者因血流动力学不稳定、腹腔积液量增多而中转手术,分别行脾切除术和脾部分切除术,45例均痊愈出院。结论对于大多数I级和Ⅱ级创伤性脾破裂者,做好严密血流动力学、影像学监测,进行非手术治疗是安全有效的。     

A multi faceted quality improvement programme results in improved outcomes for the selective non-operative management of penetrating abdominal trauma in a developing world trauma centre

Introduction

The selective non-operative management (SNOM) of penetrating abdominal trauma (PAT) is well established in our environment. As a quality-improvement initiative, we aimed to re-evaluate patient outcomes with PAT. This follows the application of new imaging and diagnostic modalities using protocolised management algorithms.

Methodology

A prospectively maintained digital registry was retrospectively interrogated and all patients with PAT treated by our service from January 2012 to March 2013 were included in this study.

Results

A total of 325 patients sustained PAT during the fourteen-month study period. This included 238 SWs, 80 GSWs and 7 impalement injuries. 11 patients had eviscerated bowel, and 12 had eviscerated omentum. A total of 123 patients (38%) were selected for a trial of SNOM. This included 103 SWs, 15 GSWs and 5 impalement injuries. Emergency laparotomy was performed on 182 patients (115 SWs, 65 GSWs and 2 impalement injuries) and 21 patients with left sided thoraco-abdominal SWs underwent definitive diagnostic laparoscopy (DL). SNOM was successful in 122 cases (99%) and unsuccessful in one case (1%). In the laparotomy group 161 (88%) patients underwent a therapeutic procedure, in 12 cases (7%) the laparotomy was non-therapeutic and in 9 cases (5%) the laparotomy was negative. In the laparoscopy group (24), two patients required conversion for colonic injuries and one for equipment failure. Seven (33.3%) laparoscopies were therapeutic with the identification and intra-corporeal repair of seven left hemi-diaphragm injuries.

Conclusion

We have improved our results with the SNOM of PAT and have also managed to safely and successfully extend the role of SNOM to abdominal GSWs. We have selectively adopted newer modalities such as laparoscopy to assess stable patients with left thoraco-abdominal SWs and abdominal CT scan for the SNOM of abdominal GSWs.     

The contemporary management of penetrating splenic injury

Introduction

Selective non-operative management (NOM) is standard of care for clinically stable patients with blunt splenic trauma and expectant management approaches are increasingly utilised in penetrating abdominal trauma, including in the setting of solid organ injury. Despite this evolution of clinical practice, little is known about the safety and efficacy of NOM in penetrating splenic injury.

Methods

Trauma registry and medical record review identified all consecutive patients presenting to LAC+USC Medical Center with penetrating splenic injury between January 2001 and December 2011. Associated injuries, incidence and nature of operative intervention, local and systemic complications and mortality were determined.

Results

During the study period, 225 patients experienced penetrating splenic trauma. The majority (187/225, 83%) underwent emergent laparotomy. Thirty-eight clinically stable patients underwent a deliberate trial of NOM and 24/38 (63%) were ultimately managed without laparotomy. Amongst patients failing NOM, 3/14 (21%) underwent splenectomy while an additional 6/14 (42%) had splenorrhaphy. Hollow viscus injury (HVI) occurred in 21% of all patients failing NOM. Forty percent of all NOM patients had diaphragmatic injury (DI). All patients undergoing delayed laparotomy for HVI or a splenic procedure presented symptomatically within 24 h of the initial injury. No deaths occurred in patients undergoing NOM.

Conclusions

Although the vast majority of penetrating splenic trauma requires urgent operative management, a group of patients does present without haemodynamic instability, peritonitis or radiologic evidence of hollow viscus injury. Management of these patients is complicated as over half may remain clinically stable and can avoid laparotomy, making them potential candidates for a trial of NOM. HVI is responsible for NOM failure in up to a fifth of these cases and typically presents within 24 h of injury. Delayed laparotomy, within this limited time period, did not appear to increase mortality nor preclude successful splenic salvage. In clinically stable patients, diagnostic laparoscopy remains essential to evaluate and repair occult DI. As NOM for penetrating abdominal trauma becomes more common, multi-centre data is needed to more accurately define the principles of patient selection and the limitations and consequences of this approach in the setting of splenic injury.     

38例闭合性肝外伤的非手术治疗

目的　探讨闭合性肝外伤非手术治疗的指征、方法及并发症的处理。方法　总结 3 8例非手术治疗闭合性肝外伤的临床资料 ,分析生命体征、肝损伤分级、输血量情况。结果　全组肝损伤分级为Ⅰ～Ⅲ级 ,3 1例非手术治疗痊愈 ,治愈率为 82 %。其中Ⅰ～Ⅱ级非手术治愈率为 93 %。 3 1例非手术痊愈患者生命体征稳定 ,输血量少于 80 0ml,与中转手术者有显著差别 (P <0 .0 1)。结论　非手术治疗闭合性肝外伤是可行的 ;生命体征、肝损伤分级、输血量可作为选择指征参考 ;在非手术治疗中 ,应密切监测 ,注意并发症 ,及时手术治疗     

LIVER TRAUMA

A series of 97 patients has been studied who were treated for liver injury at Westmead Hospital between Jaunaury 1979 and January 1985. Patients were noted to be younger than those reported in previous series from Sydney, and to have suffered more frequent, significant, head injuries. Paramedical roadside intervention probably allowed more patients to reach hospital alive than was the case before the advent of the Intensive Care Ambulance system. Improved organ imaging has allowed more confident non-operative management of 13% of patients. Hepatic resection has been used infrequently (10%). Packing has been used in six patients as part of the definitive treatmen of severe injuries and coagulopathy, and to allow the transfer of a further seven patients from peripheral hospitals. Ten of these 13 patients survived. Head injury continues to be a major cause of death in these patients. Death from the liver injury itself is usually associated with high grade damage to the liver and the associated hepatic veins and vena cava. It is speculated that improvement in the management of these lethal injuries will come about only from the early identification of patients likely to have suffered such trauma, and the pre-operative control of bleeding. Balloon catheter placement under radiological control, to tamponade the inferior vena cava and abdominal aorta, is suggested as one means by which this goal might be achieved.     

THE SAFETY AND DURATION OF NON-OPERATIVE TREATMENT FOR ADHESIVE SMALL BOWEL OBSTRUCTION

Small bowel obstruction (SBO) due to adhesions is often initially treated non-operatively but the safety and duration of non-operative treatment is controversial. The aims of this study were to assess the safety of non-operative treatment and determine the optimal duration of non-operative treatment in adhesive SBO. A retrospective analysis of patients admitted with a diagnosis of adhesive SBO following an initial period of non-operative treatment was performed. Patients whose condition resolved with non-operative treatment were compared with patients who required surgical intervention after an initial period of non-operative treatment. There were 123 admissions having an initial period of non-operative treatment. The SBO resolved in 85, the remaining 38 required surgical intervention. Complete resolution occurred within 48 h in 75 (88%) cases, the remaining 10 had resolved by 72 h. Thirty-one of 38 patients required surgical intervention for SBO more than 48 h duration after admission. The difference between cases resolving within 48 h and those requiring surgery after 48 h was significant (x²= 113, P < 0.001). Three (2.4%) patients, initially treated non-operatively, had small bowel strangulation. All three were operated on within 24 h of admission when changes in clinical findings suggested small bowel strangulation may be present. There were no deaths in the group having an initial period of non-operative treatment. In the absence of any signs of strangulation, patients with an adhesive SBO can be managed safely with non-operative treatment. Most cases of adhesive SBO that will resolve, do so within 48 h of admission. In the absence of any clinical or radiological evidence of resolution within 48 h, non-operative treatment should be abandoned in favour of surgical intervention.     

Traumatic pancreatitis: long-term review of initial non-operative management in children

OBJECTIVE: To assess the safety and long-term efficacy of an initial non-operative approach to the management of pancreatic trauma in children. METHODOLOGY: Retrospective case-note review of children admitted to our institution with the diagnosis of pancreatic trauma over a 10-year period from 1985 to 1994 inclusive. RESULTS: Fourteen children were identified with a diagnosis of traumatic pancreatitis. Eleven of the injuries were secondary to motor vehicle accidents or trauma from a bicycle handlebar. In seven patients there were associated intra-abdominal injuries and in eight patients the traumatic pancreatitis was complicated by development of a pseudocyst. Three pseudocysts settled without intervention, two resolved with percutaneous external drainage and the remaining three required open surgery. The mean in-patient stay was 21.2 days. The average length of follow-up was 7.7 years with no observed long-term complications. CONCLUSIONS: Non-operative management of traumatic pancreatitis in the absence of complete duct transection is safe in children and does not appear to be associated with adverse sequelae.