|
文献考察１）：腹部実質臓器鋭的外傷の保存的治療
Ann Surg. 2006 Oct;244(4):620-8.
Selective nonoperative management of penetrating abdominal solid organ injuries.
Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P, Salim A.
OBJECTIVE: To assess the feasibility and safety of selective nonoperative management in penetrating abdominal solid organ injuries. BACKGROUND: Nonoperative management of blunt abdominal solid organ injuries has become the standard of care. However, routine surgical exploration remains the standard practice for all penetrating solid organ injuries. The present study examines the role of nonoperative management in selected patients with penetrating injuries to abdominal solid organs. PATIENTS AND METHODS: Prospective, protocol-driven study, which included all penetrating abdominal solid organ (liver, spleen, kidney) injuries admitted to a level I trauma center, over a 20-month period. Patients with hemodynamic instability, peritonitis, or an unevaluable abdomen underwent an immediate laparotomy. Patients who were hemodynamically stable and had no signs of peritonitis were selected for further CT scan evaluation. In the absence of CT scan findings suggestive of hollow viscus injury, the patients were observed with serial clinical examinations, hemoglobin levels, and white cell counts. Patients with left thoracoabdominal injuries underwent elective laparoscopy to rule out diaphragmatic injury. Outcome parameters included survival, complications, need for delayed laparotomy in observed patients, and length of hospital stay. RESULTS: During the study period, there were 152 patients with 185 penetrating solid organ injuries. Gunshot wounds accounted for 70.4% and stab wounds for 29.6% of injuries. Ninety-one patients (59.9%) met the criteria for immediate operation. The remaining 61 (40.1%) patients were selected for CT scan evaluation. Forty-three patients (28.3% of all patients) with 47 solid organ injuries who had no CT scan findings suspicious of hollow viscus injury were selected for clinical observation and additional laparoscopy in 2. Four patients with a "blush" on CT scan underwent angiographic embolization of the liver. Overall, 41 patients (27.0%), including 18 cases with grade III to V injuries, were successfully managed without a laparotomy and without any abdominal complication. Overall, 28.4% of all liver, 14.9% of kidney, and 3.5% of splenic injuries were successfully managed nonoperatively. Patients with isolated solid organ injuries treated nonoperatively had a significantly shorter hospital stay than patients treated operatively, even though the former group had more severe injuries. In 3 patients with failed nonoperative management and delayed laparotomy, there were no complications. CONCLUSIONS: In the appropriate environment, selective nonoperative management of penetrating abdominal solid organ injuries has a high success rate and a low complication rate.PMID: 16998371（full text）
要旨：鋭的腹部外傷（銃創：70.4％，刺創：29.6%）の中で実質性臓器（肝，脾臓と腎臓）外傷の多数例で保存的治療が可能である．腹膜炎，循環動態不安定，泥酔，頭部外傷や薬物で腹部所見の評価が出来ない例は即手術（59.9%）．経過観察例中，CTでextravasationを認めた4例はTAEを行った．3例が経過観察中に手術を要したが，特に合併症は生じなかった．保存的治療の成功例は全鋭的外傷例の27％．
文献考察２）：腹部刺創例にCT検査は有用で，特にCT所見陰性例で手術になった症例はなく，negative predictive valueは100％であった．
Arch Surg. 2006 Aug;141(8):745-50; discussion 750-2.
Use of computed tomography in anterior abdominal stab wounds: results of a prospective study.
Salim A, Sangthong B, Martin M, Brown C, Plurad D, Inaba K, Rhee P, Demetriades D.
HYPOTHESIS: Computed tomography (CT) can be used to evaluate patients with anterior abdominal stab wounds (AASWs). DESIGN: Prospective observational study. SETTING: Academic level I trauma center. PATIENTS AND METHODS: All of the patients sustaining AASWs, excluding those with hemodynamic instability, peritonitis, or omental evisceration, were admitted for serial abdominal examinations with or without CT depending on attending preference. Patients with associated left thoracoabdominal stab wounds underwent diagnostic laparoscopy. MAIN OUTCOME MEASURES: Change in patient management as a direct result of the CT scan findings, as well as sensitivity, specificity, positive predictive value, and negative predictive value of CT scanning calculated against clinical outcome (the need for laparotomy, uneventful discharge without laparotomy, or return to the hospital for adverse events). RESULTS: One hundred fifty-six consecutive patients with AASWs were included over 24 months. Computed tomography was performed for 67 patients (CT group) whereas 89 patients were admitted for serial examination only (no-CT group). Nineteen of the 67 patients in the CT group had positive CT results, leading to laparotomy in 10 patients. Of the 48 patients with negative CT results, 3 underwent diagnostic laparoscopy for an associated thoracoabdominal stab wound and 2 eventually underwent laparotomy for clinical deterioration with negative results. Excluding patients with associated thoracoabdominal stab wounds, the negative predictive value of CT was 100%. CONCLUSIONS: In patients with AASWs, CT can be used to identify visceral injuries. It is a promising tool that may identify patients who can be discharged after a shorter period of observation. Further evaluation of its use in patients with AASWs is warranted.PMID: 16924081（full text）
|
