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的有效方法.早期明确AAST-OIS级别,AAST-OIS Ⅰ～Ⅱ级肝损伤患者以保守治疗为主,Ⅲ～Ⅳ级肝损伤患者以手术治疗为主,遵循损伤控制原则,选择合适治疗方法是治愈肝损伤的关键.
目的 總結肝損傷的診斷與治療經驗.方法 迴顧性分析2004年1月至2013年12月廣東醫學院附屬南山醫院收治的183例肝損傷患者的臨床資料.結閤B超、CT檢查和腹腔穿刺術,明確損傷部位、範圍、程度、是否閤併其他髒器損傷及其嚴重程度等,按照美國創傷外科學會-器官損傷分級(AAST-OIS)對患者進行分級.根據體徵及各種檢查結果綜閤評估,選擇保守治療或手術治療.採用門診及電話方式進行隨訪,隨訪時間截至2014年4月.結果 腹上區或肝區疼痛患者176例,不同程度低血壓、休剋患者98例.142例患者行腹腔穿刺術抽齣不凝血,132例患者CT檢查結果示肝破裂,88例患者急診B超檢查結果示肝破裂.AAST-OIS Ⅰ級28例,Ⅱ級63例,Ⅲ級45例,Ⅳ級30例,Ⅴ級17例.58例患者保守治療成功,其中AAST-OIS Ⅰ級21例,Ⅱ級17例,Ⅲ級14例,Ⅳ級5例,Ⅴ級1例.125例患者行手術治療,其中AAST-OIS Ⅰ級7例,Ⅱ級46例,Ⅲ級31例,Ⅳ級25例,Ⅴ級16例.125例手術治療患者中,46例僅行腹腔引流術或肝裂傷單純縫閤術;35例行肝裂傷縫閤術聯閤使用大網膜或可吸收止血材料填塞術;13例行不規則性肝切除術;12例行肝動脈結扎或破裂靜脈脩補術聯閤清創性肝切除術;9例行規則性肝葉或肝段切除術;8例行肝週紗佈填塞術;2例術中因肝靜脈、下腔靜脈損傷緻嚴重失血性休剋死亡.手術治療患者術中輸血量為(400±116) mL.所有患者住院時間為(12±3)d.8例患者術後死亡.保守治療患者中,1例膽汁漏,1例形成肝內血腫併液化包裹.手術治療患者中,18例併髮膽汁漏,6例術後齣血,均經對癥處理後治愈.157例患者穫得隨訪,隨訪率為85.79％(157/183).隨訪時間為4～ 30箇月,中位隨訪時間為23箇月.隨訪期間,患者均健康生存,無併髮癥髮生.結論 肝損傷患者臨床錶現多為腹上區或肝區疼痛,併伴有不同程度休剋,結閤B超、CT檢查及腹腔穿刺術是診斷肝損傷的有效方法.早期明確AAST-OIS級彆,AAST-OIS Ⅰ～Ⅱ級肝損傷患者以保守治療為主,Ⅲ～Ⅳ級肝損傷患者以手術治療為主,遵循損傷控製原則,選擇閤適治療方法是治愈肝損傷的關鍵.
목적 총결간손상적진단여치료경험.방법 회고성분석2004년1월지2013년12월엄동의학원부속남산의원수치적183례간손상환자적림상자료.결합B초、CT검사화복강천자술,명학손상부위、범위、정도、시부합병기타장기손상급기엄중정도등,안조미국창상외과학회-기관손상분급(AAST-OIS)대환자진행분급.근거체정급각충검사결과종합평고,선택보수치료혹수술치료.채용문진급전화방식진행수방,수방시간절지2014년4월.결과 복상구혹간구동통환자176례,불동정도저혈압、휴극환자98례.142례환자행복강천자술추출불응혈,132례환자CT검사결과시간파렬,88례환자급진B초검사결과시간파렬.AAST-OIS Ⅰ급28례,Ⅱ급63례,Ⅲ급45례,Ⅳ급30례,Ⅴ급17례.58례환자보수치료성공,기중AAST-OIS Ⅰ급21례,Ⅱ급17례,Ⅲ급14례,Ⅳ급5례,Ⅴ급1례.125례환자행수술치료,기중AAST-OIS Ⅰ급7례,Ⅱ급46례,Ⅲ급31례,Ⅳ급25례,Ⅴ급16례.125례수술치료환자중,46례부행복강인류술혹간렬상단순봉합술;35례행간렬상봉합술연합사용대망막혹가흡수지혈재료전새술;13례행불규칙성간절제술;12례행간동맥결찰혹파렬정맥수보술연합청창성간절제술;9례행규칙성간협혹간단절제술;8례행간주사포전새술;2례술중인간정맥、하강정맥손상치엄중실혈성휴극사망.수술치료환자술중수혈량위(400±116) mL.소유환자주원시간위(12±3)d.8례환자술후사망.보수치료환자중,1례담즙루,1례형성간내혈종병액화포과.수술치료환자중,18례병발담즙루,6례술후출혈,균경대증처리후치유.157례환자획득수방,수방솔위85.79％(157/183).수방시간위4～ 30개월,중위수방시간위23개월.수방기간,환자균건강생존,무병발증발생.결론 간손상환자림상표현다위복상구혹간구동통,병반유불동정도휴극,결합B초、CT검사급복강천자술시진단간손상적유효방법.조기명학AAST-OIS급별,AAST-OIS Ⅰ～Ⅱ급간손상환자이보수치료위주,Ⅲ～Ⅳ급간손상환자이수술치료위주,준순손상공제원칙,선택합괄치료방법시치유간손상적관건.
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 to hepatic vein and inferior vena injury.The volume of intraoperative blood transfusion was (400 ± 116)mL.The duration of postoperative hospital stay was (12 ± 3)days.Eight patients died at postoperative period.Of the patients who were treated by consenvarive treatment,1 patient with bile leakage and 1 with hepatic haematomas were cured by symptomatic treatment in the conservative treatment group.Of the patients who were treated by conservative treatment,18 patients with bile leakage and 6 patients with postoperative hemorrhage were cured by symptomatic treatment in the surgery proceduregroup.One hundred and fifty-seven patients were followed up for 4 to 30 months with a mean time of 23 months,and the follow-up rate was 85.79％ (157/183).The patients were survived normally without complication.Conclusions The B ultrasound,computed tomography and abdominal puncture are effective methods for the patients with traumatic hepatorrhexis combined with epigastric pain,hepatalgia and shock.These are key factors for the patients with traumatic hepatorrhexis,determining early AAST-OIS grading evaluation,including Ⅰ and Ⅱ grade of AAST-OIS are administered by conservative treatment as the main method,Ⅲ to Ⅳ grade of AAST-OIS are administered by surgical procedure as the main method,keeping to injury control principles and deciding appropriate treatment methods.
