肝损伤的诊断与治疗

目的 总结肝损伤的诊断与治疗经验.方法 回顾性分析2004年1月至2013年12月广东医学院附属南山医院收治的183例肝损伤患者的临床资料.结合B超、CT检查和腹腔穿刺术,明确损伤部位、范围、程度、是否合并其他脏器损伤及其严重程度等,按照美国创伤外科学会-器官损伤分级（AAST-OIS）对患者进行分级.根据体征及各种检查结果综合评估,选择保守治疗或手术治疗.采用门诊及电话方式进行随访,随访时间截至2014年4月.结果 腹上区或肝区疼痛患者176例,不同程度低血压、休克患者98例.142例患者行腹腔穿刺术抽出不凝血,132例患者CT检查结果示肝破裂,88例患者急诊B超检查结果示肝破裂.AAST-OIS Ⅰ级28例,Ⅱ级63例,Ⅲ级45例,Ⅳ级30例,Ⅴ级17例.58例患者保守治疗成功,其中AAST-OIS Ⅰ级21例,Ⅱ级17例,Ⅲ级14例,Ⅳ级5例,Ⅴ级1例.125例患者行手术治疗,其中AAST-OIS Ⅰ级7例,Ⅱ级46例,Ⅲ级31例,Ⅳ级25例,Ⅴ级16例.125例手术治疗患者中,46例仅行腹腔引流术或肝裂伤单纯缝合术;35例行肝裂伤缝合术联合使用大网膜或可吸收止血材料填塞术;13例行不规则性肝切除术;12例行肝动脉结扎或破裂静脉修补术联合清创性肝切除术;9例行规则性肝叶或肝段切除术;8例行肝周纱布填塞术;2例术中因肝静脉、下腔静脉损伤致严重失血性休克死亡.手术治疗患者术中输血量为（400±116） mL.所有患者住院时间为（12±3）d.8例患者术后死亡.保守治疗患者中,1例胆汁漏,1例形成肝内血肿并液化包裹.手术治疗患者中,18例并发胆汁漏,6例术后出血,均经对症处理后治愈.157例患者获得随访,随访率为85.79％（157/183）.随访时间为4～ 30个月,中位随访时间为23个月.随访期间,患者均健康生存,无并发症发生.结论 肝损伤患者临床表现多为腹上区或肝区疼痛,并伴有不同程度休克,结合B超、CT检查及腹腔穿刺术是诊断肝损伤?

Diagnosis and treatment of traumatic hepatorrhexis

Objective To investigate the diagnosis and treatment of traumatic hepatorrhexis.Methods The clinical data of 183 patients with traumatic hepatorrhexis who were admitted to the Nanshan Hospital from January 2004 to December 2013 were retrospectively analyzed.The size,range and degree of the hepatorrhexis and involvement of other organs were investigated by B ultrasound,computed tomography and abdominal puncture.All patients were classified by the Organ Injury Scale grading system of the American Association for the Surgery of Trauma （AAST-OIS）.Conservative treatment or surgical procedure was determined according to the clinical symptoms and results of various examinations.Patients were followed up by outpatient examination and telephone interview till April 2014.Results One hundred and seventy-six patients had epigastria pain or hepatalgia,and 98 patients had hypotension and shock.A total of 142 patients were drawn non-coagulative blood by abdominal puncture.One hundred and thirty-two patients were detected as with hepatorrhexis by CT and 88 patients with hepatorrhexis by urgent ultrasound.Of the 183 patients classified by AAST-OIS,there were 28 patients with grade Ⅰ,63 with grade Ⅱ,45 with grade Ⅲ,30 with grade Ⅳ and 17 with grade Ⅴ.Of the 58 patients received successful conservative treatment,there were 21 patients with grade Ⅰ,17 with grade Ⅱ,14 with grade Ⅲ,5 with grade Ⅳ and 1 with grade Ⅴ.A total of 125 patients were cured by surgery,including 7 patients with grade Ⅰ,46 with grade Ⅱ,31 with grade Ⅲ,25 with grade Ⅳ and 16 with grade Ⅴ.Forty-six patients received peritoneal drainage or simple suture of the liver; 35 with hepatorrhexis received liver suture combined with omentum or absorbent stanching plugging; 13 received irregular hepatectomy; 12 received hepatic artery ligation and ruptured vein suture combined with debridement and hepatectomy,9 received regular hepatic lobectomy or hepatic segmentectomy,8 received gauzes packing and 2 died of serious hemorrhagic shock due t