儿童重度闭合性肾挫裂伤的处理

目的 探讨儿童重度闭合性肾挫裂伤的处理.方法 回顾性总结分析2000至2008年临床诊治小儿闭合性肾损伤33例,重点是其中的15例重度肾挫裂伤(3例系肾积水合并肾挫裂伤的特殊病例)的资料.结果 全组无死亡,无早期肾切除病例,18例轻度肾损伤经保守治疗愈合.15例重度闭合性肾挫裂伤患儿中,其中8例采用保守治疗成功,1例肾蒂血管损伤早期急诊行肾静脉修补术,3例行选择性肾动脉栓塞治疗,3例肾积水外伤后肾破裂.3例肾积水肾破裂中,2例行早期肾盂成形肾周引流术,1例因合并肾功能不全,对侧肾萎缩,早期作肾造瘘,延期肾盂成形术,重度肾损伤病例随访5～28个月(平均18个月).4例继发尿性囊肿,1例早期行肾盂输尿管吻合,3例延期做尿性囊肿剥离切除;1例6个月后出现高血压、受损肾萎缩行肾切除.结论 轻度的肾损伤采用保守治疗易于治愈,重度的肾损伤因应病情选用相宜的方法 处理,绝大多数不需早期手术探查,以减少肾切除,选择性肾动脉栓塞微创止血效果好,重度肾挫裂伤需要密切随访,以处理相续可能发生的尿性囊肿和高血压等并发症.

Management of severe blunt renal trauma in children

Objective To study the management of severe blunt renal trauma in children. Methods From 2000 to 2008, clinical outcomes of 33 children with blunt renal trauma were retrospectively analyzed, especially focusing on the 15 severe blunt renal trauma cases (3 cases were hydronephrosis complicating with renal trauma).Results Neither deaths nor early nephrectomy was noted in this study. Eighteen patients with mild renal injury were cured after non operative management. Of the 15 severe cases, 8 were cured after conservative treatment, 3 with active bleeding were treated by selective renal artery embolization, and 1 with renal vascular injury underwent exploratory surgery and surgical repair of renovascular trauma; the other 3 were hydronephrosis complicating with renal trauma, of which 2 underwent pyloplasty and early postoperative drainage, and the last patient with renal failure and contralateral congenital renal atrophy underwent early post-injury nephrostomy and delayed pyloplasty to conserve more renal function. All severe cases have been followed-up for 5-28 months (mean follow-up duration: 18 months). One patient underwent nephrectomy of the atrophic kidney 6 months later for persistent secondary hypertension. Of the 4 cases complicated with urinary cysts, 1 underwent early ureteropelvic anastomosis, the other 3 underwent delayed urinary cysts resection.Conclusions Mild renal injury has a good prognosis after conservative treatment. The management of severe renal trauma should be based on specific clinical conditions of individuals. Early exploratory surgery and nephrectomy are not advocated on most severe renal trauma cases. The selective renal artery hemostatic embolization is a good option to stop active bleeding in blunt renal trauma patients. The severe renal trauma patients need close interval postoperative follow-up to prevent the complications such as urinary cyst and secondary hypertension.