背景:脾损伤是道路交通事故中腹部钝性损伤引起的常见实体器官损伤。很多时候,脾损伤会危及生命.早些时候,脾损伤通常通过手术治疗,比如脾切除术。随着对脾脏免疫功能的认识和脾切除手术可能的并发症,例如压倒性的脾切除术后感染(OPSI),最近出现了非手术管理(NOM)的趋势。
目的:研究预测闭合性腹部创伤合并脾损伤患者NOM失败的变量。
方法:这是一项回顾性研究,包括235名患者,他们被送到Safdarjung医院急诊室(新德里,印度)在2019年1月至2021年12月之间发生钝性腹部和脾脏损伤,有或没有相关损伤。数据输入了MicrosoftExcel电子表格(MicrosoftCorp.,雷德蒙德,WA,美国)。分类变量表示为频率和百分比。Pearson的卡方检验用于确定两个变量之间是否存在关系。P值<0.05被认为是统计学上显著的。
结果:在235例腹部闭合性损伤和脾损伤患者中,尽管进行了复苏,但仍有82例血流动力学不稳定,并接受了紧急剖腹手术。剩下的153名患者,在充分复苏后血流动力学稳定或稳定的人,在NOM线上进行管理。AAST1、2、3、4、5级脾损伤患者分别为36、50、40、24、3,分别。153名患者中,130(85%)由NOM成功管理,而8人(5%)因需要手术干预而不得不停止NOM。NOM(fNOM)的失败主要是5级伤害(2/2,100%,p<0.01),其次是4级(4/20,20%)和3级(2/37,5.7%)。fNOM的平均年龄是58.3岁,相比之下,NOM(sNOM)的成功率为42.2年。所有8名患者都有多处伴随损伤,股骨骨折是多达6例患者中最常见的关联(p<0.01),其次是4例患者的肝损伤。有15人死亡,与AAST严重程度无关。所有这些患者都有相关的伴随损伤,颅内出血(n=10,32%,p<0.01)是最常见的关联,其次是股骨骨折(n=6,20%)和肝损伤(n=5,16%)。此外,死亡原因与脾外伤无关(p=0.67),合并肺栓塞(n=6,40%,p<0.01)是最常见的原因,其次是脑干疝(n=5,34%)。
结论:非手术治疗是治疗血流动力学稳定或稳定的脾损伤患者的一种安全有效的方法。与fNOM相关的因素包括老年人年龄,较高的美国创伤手术协会(AAST)脾损伤分级,以及伴随的伤害。在NOM失败的情况下,股骨骨折是最常见的伴随损伤,其次是肝损伤。这些患者的颅内出血与死亡率有共同的关联,无论脾损伤的程度。
BACKGROUND: Splenic injuries are common solid organ injuries resulting from blunt abdominal trauma in road traffic accidents. Very often, splenic injuries can be life-threatening. Earlier, splenic injuries were often dealt with surgical intervention, such as splenectomy. With the recognition of the immunological function of the spleen and possible complications of splenectomy surgery, such as overwhelming post-splenectomy infections (OPSI), there has been a recent trend for non-operative management (NOM).
OBJECTIVE: To study the variables predicting failure of NOM in blunt abdominal trauma patients with splenic injury.
METHODS: This is a retrospective study that includes 235 patients who presented to the Safdarjung Hospital emergency room (New Delhi, India) with blunt trauma abdomen and splenic injuries with or without associated injuries between January 2019 and December 2021. The data was entered in a Microsoft Excel spreadsheet (Microsoft Corp., Redmond, WA, USA). Categorical variables were expressed as frequencies and percentages. Pearson\'s chi-square test of association was used to determine if there is a relationship between two variables. A p-value of <0.05 was considered statistically significant.
RESULTS: Out of 235 patients with blunt abdominal trauma and splenic injuries, 82 were hemodynamically unstable despite resuscitation and were taken up for emergency laparotomy. The remaining 153 patients, who were either hemodynamically stable or stabilized after adequate resuscitation, were managed on the lines of NOM. The number of patients with splenic injury in AAST grades 1, 2, 3, 4, and 5 was 36, 50, 40, 24, and three, respectively. Out of 153 patients, 130 (85%) were successfully managed by NOM, while eight (5%) had to discontinue NOM as they required surgical intervention. The failure of NOM (fNOM) is seen mostly with grade 5 injuries (2/2, 100%, p<0.01), followed by grade 4 (4/20, 20%) and grade 3 (2/37, 5.7%). The mean age in fNOM was 58.3 years, as compared to 42.2 years in the success of NOM (sNOM). All eight patients had multiple concomitant injuries, with femur fracture being the most common association in up to six patients (p<0.01), followed by liver injury in four patients. There were 15 mortalities, irrespective of AAST severity grade. All of these patients had associated concomitant injuries, with intracranial bleeding (n = 10, 32%, p<0.01) being the most common association, followed by femur fracture (n = 6, 20%) and liver injury (n = 5, 16%). Also, the cause of death was unrelated to splenic trauma (p = 0.67), with pulmonary embolism (n = 6, 40%, p<0.01) being the most common cause, followed by brain stem herniation (n = 5, 34%).
CONCLUSIONS: Non-operative management is a safe and efficient method for treating patients with splenic injuries who are hemodynamically stable or stabilized. The factors associated with fNOM include elderly age, a higher American Association for the Surgery of Trauma (AAST) grade of splenic injury, and associated concomitant injuries. Femur fracture was the most common concomitant injury present in cases where NOM failed, followed by liver injury. The presence of intracranial bleeds in these patients was a common association with mortality, irrespective of the grade of splenic injury.