肝切除治疗肝胆管结石(附644例报告)

分析肝切除治疗肝胆管结石的疗效。方法报告１９７５年至１９９９年１１月６４４例肝内胆管结石病人采用肝切除治疗的术式,并发症及随访情况,结果本组治疗方式中合并的肝切除率为５２％;６４４例中６２．９％经历过１－５次手术,其中２０．５％,合并不同类型的胆肠吻合。肝切除术式：左外叶切除３７８例（５８．７％）;左半肝切除１３２例（２０．５％）;右半肝切除３１例（４．８％）;多段切除６６例（１０．３％）;肝方叶     

肝切除治疗肝内胆管结石

探讨肝切除术治疗肝胆管结石的效果。方法分析１９８９年７月－１９９９年７月采用肝切除术治疗１８４例肝内胆管结石患者的结石部位和分布情况、手术方式、手术后并发症、病理结果等情况。结果肝内胆管结石以左肝为主（１６５例）,肝切除也以左肝叶段切除为多（１５３例）;３２例出现手术后并发症（１７．３９％）无手术死亡。随访３月－１０月年,效果优良者占９６．２０％,包括４例早期胆管癌。结论肝切除术手是治疗内胆管结珠     

肝外伤非手术治疗62例体会

我院自１９９５年１月至１９９９年１月四年间共收治肝外伤１５４例,其中采用非手术治疗６２例,占肝外伤总数的３７．６％。现就该６２例肝外伤非手术治疗体会报告如下。１　临床资料１．１　一般资料　本组男４６例,女１６例。年龄６～７０岁,平均年龄２６岁。病人均以外伤后不同程度腹痛而就诊。来诊时间为伤后１０分钟至３天,平均４．５小时。就诊时伴休克７例。１．２　损伤原因及合并伤情况　本组车祸伤４１例（占６６．７％）,坠落伤１５例（占２４％）,殴打伤６例（占９．３％）。其中伴发肋骨骨折８例,血气胸４例,肾挫伤３…     

肝切除治疗肝胆管结石482例报告

报告我科１９７５年～１９９４年９月１０００例肝胆管结石手术病例中采用肝叶、段切除４８２例的治疗经验与体会。该４８２例中６３％曾经历过１～５次手术，其中２１．６％为不同类型的胆肠吻合。肝切除术式；左外叶切除３２１例（６６．６％）；左半肝切除８０，例（１６．６％）；右半肝切除１９例（３．９％），左前或右后叶切除３９例（８．１％）；肝方叶切除作为附加手术２０例（４．１％）。手术并发症４９例（１０．２％），包括胆瘘、断面及膈下感染，胆道出血等。死亡９例（１．９％），４１０例（８５．１％）病例获平均１３．５年随访，优良率８８％。作者基于病因学及病理基础讨论了治疗要点，强调：①必须根据临床病理类型及病因学决定术式；②肝叶、段切除是治疗原则中的核心。     

损伤控制性手术治疗严重肝外伤23例

探讨损伤控制性手术（DCS）治疗严重肝外伤临床效果。回顾性分析23例按DCS原则进行治疗的严重肝外伤患者的临床资料,其中治愈19例（82．6％）,死亡4例（病死率17．4％）,术后出现并发症5例（发生率21．7％）。DCS治疗严重肝外伤可有效降低病死率和并发症发生率,对符合指征的患者应积极实施,分次手术治疗。     

肝外伤诊断和治疗的改进

为探讨钝性肝外伤时改进诊断和治疗对降低并发症和死亡率的影响，分析了１９５１～１９９６年间长海医院１８０例肝外伤的资料。全组有钝性伤１５２例和开放伤２８例。结果显示：腹腔穿刺诊断钝性肝外伤的阳性率为９２．９％（１０５／１１３），急症室超声检查的阳性率为９６．２％（２５／２６）。治疗方法包括３例非手术治疗和１７７例手术治疗。总并发症发生率、治愈率和总死亡率分别为３２．８％（５９／１８０），８５．６％（１５４／１８０）和１４．４％（２６／１８０）。比较前期（１９５１～１９８８年）与近期（１９８９～１９９６年）的资料，通过近年在诊断和治疗上的改进，并发症发生率有显著差异（Ｐ＜０．０５），死亡率有非常显著差异（Ｐ＜０．０１）。讨论了急症室超声检查对钝性肝外伤早期诊断的价值、非手术治疗的利弊、手术方式的选择和并发症的预防     

严重肝外伤的诊断与治疗

目的 总结严重肝外伤临床诊断与治疗的经验。方法 对９４例严重肝外伤病人的临床诊断与治疗进行回顾性分析。结果 本组９４例均为外伤所致,入院时伴出血性休克８２例（８７．２％）,明显腹膜炎７１例（７５．５％）,伴有合并伤者７２例（７６．６％）,肝外伤分级（按Ｍｏｏｒｅ氏分级法）,Ⅲ级５２例,Ⅳ级３２例,Ⅴ级１０例。９４例均行手术治疗,治愈７８例（８３．０％）,死亡１６例（１７．０％）,死亡原因：严重失血     

重症急性胰腺炎119例治疗分析

目的　探索一种减少重症急性胰腺炎（ｓｅｖｅｒｅ ａｃｕｔｅ ｐａｎｃｒｅａｔｉｔｉｓ,ＳＡＰ） 并发症,降低其病死率的新途径。 方法　将我院普外科１９８０ 年１ 月至１９９８ 年１０ 月治疗的ＳＡＰ１１９ 例按不同的治疗阶段分为三组。Ａ组：１９８０ 年１ 月至１９９３ 年１０ 月的手术治疗为主的手术组;Ｂ 组：１９９３ 年１０ 月至１９９５ 年１０ 月以周围静脉给药为主的非手术组;Ｃ组：１９９５ 年１０ 月至１９９８ 年１０ 月采用以区域性动脉灌注（ｌｏｃａｌａｒｔｅｒｉａｌｉｎｆｕｓｓｉｏｎ,ＬＡＩ） 给药为主的介入治疗组。结果　Ａ组６８ 例,死亡１４ 例,病死率２０％ （１４／６８）,Ｂ组２０ 例,死亡２ 例,病死率１０％ （２／２０）,Ｃ组３１ 例,无死亡。 结论　ＳＡＰ以区域性动脉灌注给药为主的治疗方法优于周围静脉给药组和手术组     

人工心脏瓣膜替换术后抗凝治疗并发症

自１９８０年至１９９２年１０月我们行人工心脏瓣膜替换术３７０例，康复出院３２９例，经３月至１２５月随访，有２例失访，共发生与抗凝治疗有关并发症１７例（５．２％或１．４８％病人－年），死亡１２例（３．６％或１．０３％病人－年），其中血栓栓塞６例（１．８２％），死亡３例（０．９１％）；抗凝出血１１例（３．３４％），死亡９例（２．７３％）。抗凝治疗并发症中出血明显多于血栓栓塞，并发症发生时间主要在术后３个月内（含术后９４天），占８９％。     

经皮肝穿刺引流治疗肝脓肿89例体会

经皮肝穿刺引流治疗肝脓肿８９例体会浙江宁海人民医院外科（邮编：３１５６００）徐一魏，杨绍荣目前肝脓肿在农村仍然是发病率较高的疾病之一。我科从１９８５年１０月至１９９０年１０月共收治３２４例，占同期外科住院人数的２．１％。肝脓肿传统的手术治疗并发症和死...     

Does splenic embolization and grade of splenic injury impact nonoperative management in patients sustaining blunt splenic trauma?

Nonoperative management (NOM) for blunt splenic trauma (BST) is an established practice. The impact of splenic embolization (SE) in the algorithm for NOM has not been well studied. This study evaluates the role of SE and spleen injury grade on failure of NOM. Retrospective cohort of trauma registry over a 7-year period (2000-2006) for patients who suffered BST was studied. Data including demographics, splenic injury grade, and SE were recorded. Characteristics were compared between the successful and failed NOM groups. Kaplan-Meier, life table, and Cox-proportional hazard regression analyses were performed. Of the 499 patients who suffered BST, 407 (81.6%) patients had successful NOM and 92 (18.4%) patients failed NOM (including splenectomies performed within 1 hour of admission). Failed NOM group had a higher splenic injury grade compared with the successful NOM group (P < 0.0001). Seventy-five per cent underwent a splenectomy within 7.7 hours of admission. Nearly all grade I and II splenic injuries that failed NOM occurred by 24 hours. Grade 3 and 4 injuries that failed NOM occurred by 150 hours. SE was protective against splenectomy (Hazard Ratio (HR) 0.18, 95% confidence interval: 0.06-0.55, P = 0.004), whereas splenic injury grades III or higher was associated with increased risk of splenectomy (grade III: HR 5.26, P = 0.003; grade IV: HR 6.84, P = 0.002; grade V: HR 9.81, P = 0.002) compared with those with splenic injury grade I. Splenic embolization is a protective measure to reduce the failure of NOM. Spleen injury grade III and higher was significantly associated with NOM failure and would require a 5-day inpatient observation.     

Predictive factors of operative or nonoperative management of blunt hepatic trauma

AIM: Nonoperative management (NOM) has revolutionized the care of blunt hepatic trauma patients. The aim of the present study was to identify and evaluate the predictors of NOM of these patients. METHODS: The Trauma Registry data of 55 consecutive adult patients admitted with blunt hepatic trauma over a 4-year period was reviewed. Patients were divided into immediately operated (OP-group) and selected for NOM (NOM-group). Factors analyzed were: demographics, injury mechanism, initial vital signs, liver injury grade, concomitant injuries, and total injury severity scoring systems. RESULTS: Concomitant abdominal trauma, high Injury Severity Score (ISS), low International Classification of Diseases 9(th) revision Injury Severity Score (ICISS), and low probability of survival (Ps) were predictors for operative management. Compared to NOM-patients (66%, N=36), OP-patients (34%, N=19) suffered more frequently concomitant abdominal injuries (84.2% vs 47.2%, P=0.004) and were more severely totally injured as expressed by higher ISS (25 vs 20, P=0.01), lower ICISS (0.51 vs 0.74, P=0.003), and lower Ps (0.81 vs 0.98, P=0.005). NOM resulted in lower intensive care unit admission and mortality rates (47.2% vs 78.9%, P=0.002 and 2.7% vs 15.8%, P=0.03, respectively). NOM-success rate was 92%. CONCLUSION: NOM of blunt hepatic trauma is safe and efficient. Concomitant abdominal trauma, ISS, ICISS, and Ps are predictors for operative or nonoperative management.     

Management of Blunt Hepatic and Splenic Trauma in a Greek Level I Trauma Centre

Background and purposes: Non-operative management (NOM) has revolutionized the care of blunt hepatic and splenic trauma patients. The objective of this study is to evaluate treatment of such patients in a Greek level I trauma centre, to identify factors that are important for selecting them for NOM and to investigate for predictors of NOM failure.

Material and methods: We reviewed the Trauma Registry data of 96 consecutive adult patients admitted with blunt liver and/or splenic injuries over a 4-year period.

Results: Immediately operated patients (32.3%) had lower diastolic arterial pressure (p = 0.02), lower International Classification of Diseases-9^th revision Injury Severity Score (ICISS) (p = 0.01), and a higher grade of splenic injury (p = 0.002) than NOM patients. NOM success rate was 80%. No predictors of NOM failure were found; however, isolated splenic trauma patients failed NOM more frequently than hepatic patients (p = 0.02).

Conclusions: NOM of adult blunt hepatic and splenic trauma patients is safe and efficient. Haemodynamic stability, ICISS and the grade of splenic injury are important for selecting these patients for NOM while splenic trauma patients need more intense observation.     

Resultados en el tratamiento de traumatismos esplénicos utilizando un protocolo multidisciplinar en 110 pacientes consecutivos en un hospital de nivel II

IntroductionNon-operative treatment (NOM) of splenic trauma is the management of choice in hemodynamically stable patients. The aim of the present study was to assess the failure rate of NOM after implementation of a multidisciplinary protocol for splenic injuries compared to literature results.MethodsA retrospective study was performed over a 16-year period. Patient data and management of splenic trauma was recorded according to our hospital protocol: demographic data, blood pressure, respiratory rate, Glasgow Coma Scale(GCS), Revised Trauma Score(RTS), Injury Severity Score(ISS), injury grade according to the American Association for the Surgery of Trauma(AAST), failure of NOM, morbidity and mortality.ResultsOne hundred ten patients were included: 90(81.8%) men, 20(18.2%) women; mean age 37 years; 106(96.5%) cases were blunt and four(3.5%) penetrating by knife. The diagnosis was established by US/CT. AAST classification: 14(13%) grade I; 24(22%) grade II; 34(31%) grade III; 37(34%) grade IV. Emergency laparotomy was performed in 54 patients: 37 due to grade IV injuries, 17 due to hemodynamic instability. NOM was utilized in 56 patients, spleen-preserving surgery in 16, and splenectomy in 38. Ten patients had postoperative complications: seven in the splenectomy group, two in the spleen-preserving surgery group, and one in the NOM group. One patient died. Average hospital stay: 22.8 days- NOM 17.6 days, conservative surgery 29 days, splenectomy 22.4 days.ConclusionsAlthough we continue with a high hospital stay, the literature reports support our results. The implementation of the protocol by consensus contributed to the change towards NOM.     

Nonoperative management of blunt renal trauma: a prospective study

Despite the abundance of literature on nonoperative management (NOM) of blunt trauma to the liver and spleen there is limited information on NOM of blunt renal injuries. In an effort to evaluate the role of NOM 37 consecutive unselected patients with renal injuries (grade 1, four; grade 2, 12; grade 3, 11; grade 4, six; and grade 5, four) were followed prospectively over 30 months (Match 1999 to September 2001). Patients without peritonitis or hemodynamic instability were managed nonoperatively regardless of the appearance of the kidney on CT scan. Six (16%) patients were operated on immediately but only two (5.4%) for the kidney (grades 3 and 5 respectively). Of the remaining 31 patients 26 (84%) were managed successfully without an operation (grade 1 or 2, 12; grades 3-5, 14). Five patients were taken to the operating room after a period of observation (3, 3.5, 9, 36, and 44 hours respectively) but only three for the kidney (grades 4 and 5). The overall failure rate was 16 per cent (5 of 31); the rate of failure specifically related to the renal injury was 9.6 per cent (three of 31). Compared with the patients with successful NOM the five patients with failed NOM were more severely injured (Injury Severity Score > or = 15 in 80% vs 27%, P = 0.04), required in the first 6 hours more fluids (4.17 +/- 1.72 vs 1.87 +/- 1.4 liters, P = 0.003) and blood transfusions (2.40 +/- 2 vs 0.42 +/- 1.17 units, P = 0.005), and more frequently had a positive trauma ultrasound (80% vs 11.5%, P = 0.005). We conclude that NOM is the prevailing method of treatment after blunt renal trauma. It is successful in the majority of patients without peritonitis or hemodynamic instability and should be considered regardless of the severity of renal injury. Predictors of failure may exist on the basis of injury severity, fluid and blood requirements, and abdominal ultrasonographic findings and need validation by a larger sample size.     

Splenic artery angioembolization for high-grade splenic injury: Are we wasting money?

BackgroundNon-operative management (NOM) is accepted treatment of splenic injury, but this may fail leading to splenectomy. Splenic artery embolization (SAE) may improve rate of salvage. The purpose is to determine the cost-utility of the addition of SAE for high-grade splenic injuries.MethodsA cost-utility analysis was developed to compared NOM to SAE in patients with blunt splenic injury. Sensitivity analysis was completed to account for uncertainty. Utility outcome was quality-adjusted life years (QALY).ResultsFor patients with grade III, IV and V injury NOM is the dominant strategy. The probability of NOM being the more cost-effective strategy is 87.5% in patients with grade V splenic injury. SAE is not the favored strategy unless the probability of failure of NOM is greater than 70.0%.ConclusionFor grade III–V injuries, NOM without SAE yields more quality-adjusted life years. NOM without SAE is the most cost-effective strategy for high-grade splenic injuries.     

Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study

HYPOTHESIS: Nonoperative management (NOM) of injuries to the liver, spleen, and kidney is highly successful, as shown in retrospective studies, but needs prospective validation. Patients in whom NOM is likely to fail can be identified by specific criteria. DESIGN: Prospective observational study. SETTING: Academic level I trauma center at a county hospital. PATIENTS: Two hundred six patients with injuries to the liver (n = 99), spleen (n = 103), and/or kidney (n = 40). MAIN OUTCOME MEASURES: Failure of NOM. RESULTS: Fifty-seven patients (28%) underwent immediate operation; among the other 149, NOM failed in 33 (22%). The rate of failure for spleen injury (34%) was higher than for liver (17%) or kidney injury (18%) (P<.01). Failure of NOM was due to delayed bleeding from a solid viscus in 20 of the 33 patients. Intestinal injury was detected in only 1 patient initially selected for NOM. Specifically among patients with liver injury, no failure was due to delayed bleeding from the liver. Patients with failed NOM were more likely to have a positive abdominal ultrasonographic finding (61% vs 22%; P<.01), a grade of splenic injury of at least III on computed tomographic scan (CT) (n = 20 [17%] vs n = 16 [48%]; P<.01), and an amount of free fluid of greater than 300 mL on CT (36% vs 8%; P<.01) and to receive blood transfusions during NOM (58% vs 16%; P<.01). The groups were not different with regard to associated extra-abdominal injuries (including head injuries). Mortality was not different, but morbidity was marginally higher in patients with failed NOM (29% vs 45%; P =.08). We identified the following 4 independent risk factors of failure by means of stepwise logistic regression: nonliver (splenic or renal) injury, positive abdominal ultrasonography findings, amount of free fluid on CT of greater than 300 mL, and need for blood transfusion. According to a statistical model, the presence of all 4 independent risk factors predicted NOM failure in 96% of the patients, and the absence of all predicted success in 98%. CONCLUSIONS: In a prospective study, the rate of NOM failure for solid abdominal organ injuries is higher than the rates reported in retrospective studies. Nonoperative management is less likely to fail in liver injuries than in splenic or kidney injuries. Use of NOM should be exercised with caution if blood transfusion is needed, fluid is identified on the screening ultrasonogram, or a significant quantity of blood is discovered on CT.     

The failure of nonoperative management in pediatric solid organ injury: a multi-institutional experience

BACKGROUND: Nonoperative management (NOM) is the accepted treatment of most pediatric solid organ injuries (SOI) and, is typically successful. We sought to elucidate predictors of, and the time course to, failure in the subset of children suffering SOI who required operative intervention. METHODS: A retrospective analysis was performed from January 1997 through December 2002 of all pediatric patients (age 0-20 years) with a SOI (liver, spleen, kidney, pancreas) from the trauma registries of seven designated, level I pediatric trauma centers. Failure of NOM was defined as the need for intra-abdominal operative intervention. Data reviewed included demographics, injury mechanism, injury severity (ISS, AIS, SOI grade, and GCS), and outcome. For the failures of NOM, time to operation and relevant clinical variables were also abstracted. A summary AIS (sAIS) was calculated for each patient by summing the AIS values for each SOI, to account for multiple SOI in the same patient. Univariate and multivariate analyses were employed, and significance was set at p < 0.05. RESULTS: A total of 1,880 children were identified. Of these, 62 sustained nonsurvivable head injuries that precluded assessment of NOM outcome and were thus excluded. The remaining 1,818 patients comprised the overall study population. There were 1,729 successful NOM patients (controls -- C) and 89 failures (F), for an overall NOM failure rate of 5%. For isolated organ injuries, the failure rates were: kidney 3%, liver 3%, spleen 4%, and pancreas 18%. There were 14 deaths in the failure group from nonsalvageable injuries (mean ISS = 54 +/- 15). The two groups did not differ with respect to mean age or gender. An MVC was the most common injury mechanism in both groups. Only bicycle crashes were associated with a significantly increased risk of failing NOM (RR = 1.76, 95% CI = 1.02-3.04, p < 0.05). Injury severity and organ specific injuries were associated with NOM failure. When controlling for ISS and GCS, multivariate regression analysis confirmed that a sAIS > or = 4, isolated pancreatic injury, and >1 organ injured were significantly associated with NOM failure (p < 0.01). The median time to failure was 3 hours (range, 0.5-144 hours) with 38% having failed by 2 hours, 59% by 4 hours, and 76% by 12 hours. CONCLUSIONS: Failure of NOM is un common (5%) and typically occurs within the first 12 hours after injury. Failure is associated with injury severity and multiplicity, as well as isolated pancreatic injuries.     

Nonoperative management of splenic injuries: improved results with angioembolization

BACKGROUND: Nonoperative management (NOM) of patients with severe splenic injuries carries a significant risk of failure. We hypothesized that adding angiographic embolization (AE) to the NOM protocol would decrease the laparotomy rate, and increase the success rate of NOM and splenic salvage rate. METHODS: A protocol introducing AE in the treatment of splenic injuries was implemented. AE was performed in OIS splenic injury grades 3 to 5 and in all cases where signs of ongoing bleeding were encountered regardless of injury grade. Patients included in a prospective study during a 24-month period were compared with a historic control group. RESULTS: Group 1 (before AE) consisted of 69 patients with a mean Injury Severity Score (ISS) of 31, and group 2 (after introducing AE) included 64 patients with a mean ISS of 30. In group 1, 30 patients underwent immediate laparotomy (43%), and the NOM success rate was 79%. After introducing AE, 17 patients underwent immediate laparotomy (27%; p = 0.04), with a NOM success rate of 96% (p = 0.02). Overall splenic salvage rate increased from 57% to 75% (p = 0.02). Angiography was performed in 31 patients in group 2. Embolization was performed in 27 of these patients. AE failure rate was 4%. NOM was successful in 14 of 15 patients with OIS injury grades 4 and 5 after the introduction of AE (93%). CONCLUSION: A formal protocol adding mandatory AE to NOM for severe splenic injuries increased the percentage of patients in whom NOM was attempted, the NOM success rate, and the splenic salvage rate.     

Liver injuries--improved results with a formal protocol including angiography

OBJECTIVE: We hypothesised that a formal treatment protocol for liver injuries including angiography would increase the non-operative management (NOM) rate and would be efficient as an adjunct to damage control surgery. METHODS: During the 4-year period from 1 August 2000, a total of 138 adult patients with liver injuries were admitted to the largest trauma centre in Norway and prospectively included in the institutional trauma registry. On 1 August 2002, a protocol mandating angiography in all NOM patients with OIS grades 3-5 liver injuries and after packing of the liver was implemented. All patients admitted during the subsequent 2-year period (group 2) were compared with the previous 2 years as historic controls (group 1). RESULTS: Fifty-five patients were included in group 1 and 59 in group 2. The groups were statistically comparable, both with a mean ISS of 31. Patients selected for NOM increased from 28 (51%) to 45 (76%) (p<0.05), without increasing failure rate, liver-related complications, mortality or transfusion rate. Angiography was performed in 26 patients in group 2 (44%). Only nine patients underwent embolisation (35%), and five of these were in the NOM group. Angiography was negative in the eight NOM stable patients with OIS grade 3 injury. CONCLUSION: The implementation of a formal NOM protocol decreased total laparotomy rate and seemed to improve patient outcome without jeopardising patient safety. Surprisingly few of the patients undergoing angiography required embolisation. Angiography is not indicated in stable OIS grade 3 liver injuries, and the protocol in our institution has been adjusted accordingly. AE seems to be a valuable adjunct to DCS with packing of liver injuries.