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題名 | Nonoperative Treatment for Blunt Splenic Injuries in Adults Clinical Parameters Predicting Successful Results=成人脾臟鈍性外傷的非手術性治療--預估治療成功的臨床因素 |
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作者 | 張財旺; 詹世煌; 洪崇傑; 林柄文; 李伯璋; 黃士銘; 李政昌; 楊友任; | 書刊名 | 中華民國外科醫學會雜誌 |
卷期 | 26:3 民82.05-06 |
頁次 | 頁1744-1751 |
分類號 | 416.14 |
關鍵詞 | 鈍性外傷; 非手術性治療; 脾臟; Adult blunt splenic injuries; Nonoperative treatment; |
語文 | 英文(English) |
中文摘要 | 成人脾臟鈍性外傷行非手術性療法的成功與否有賴於正確的病患選擇,為了進一步了解與治療成功相關的因素及建立病患選擇的方式,我們將成大醫學中心的成人脾臟鈍性外傷患者的數據(1988年6月至1991年12月)做回溯性的分析。這期間一共有49例成人脾臟鈍性外傷,其中25例經非手術治療,結果有18例成功,成功率為72%。統計發現,早期輸血量(24小時內)少於4個單位, Revised Trauma Score大於7.54,及正常的昏迷指數,與治療的成功與否相關。用Logistic Regression Method,我們肯定評估脾臟外傷嚴重度的CT grade (參照American Association for the Surgery of Trauma建議的評估方式)可以用於預測非手術性治療的成功率(Wald Chi Square試驗的p值=0.0272)。用這個方法所得到的公式是:預期成功率=1/(1+e-0580+1.53G),其中,G代表CT grade。由這個公式,可以得到不同CT grade的預估成功率;它們分別是:grade 1 : 98.6% : grade 2 : 94% : grade 3 : 77% : grade 4 : 42% : grade 5 : 13%。這個結果有助於我們事先預估那些病人可成功地施以非手術性療法。在這些病例當中並未見非手術性治療引起之死亡。行非手術性治療的患者,其住院期間與行手術治療的病患相比較,並無顯著延長。根據以上分析我們結論:經適當病患選擇,非手術性療法可安全地使用於治療成人脾臟鈍性外傷。同時,我們建議:在沒有合併其他須要手術治療的腹內傷害,特別是Revised Trauma Score在7.54以上,及Glasgow Coma Score在正常範圍內時,grade 1、grade 2及grade 3的成人脾臟鈍性外傷應先嘗試非手術性療法。然而,當早期輸血的需要量量超過四個單位時,因非手術性治療的成功機會較低,則應考慮改成手術治療。對於grade 4的脾臟外傷,由於預估成功率只有42%,行非手術性療法時,應高度小心。至於grade 5的脾臟外傷,則應於早期行手術治療。 |
英文摘要 | A successful nonoperative management of adult blunt splenic injury requires proper clinical criteria to select treatment candidates. To define such criteria, data for all adult blunt splenic injuries from June of 1988 to December of 1991, at this Hospital, were reviewed. Diagnosis was by either computerized tomography(CT) or laparotomy. Twenty five of 49 adult patients (51%) with splenic traumas were initially treated nonoperatively, with successful outcome in 18 patients (success rate=72%). The parameters which correlated with that success included an initial blood transfusion amount less than four units, a revised trauma score (RTS) more than 7.54, and a normal Glasgow coma score(GCS). CT grading of splenic injury severity, based on the Splenic Injury Scale, was able to predict the success rate for each grade of injury (p value of Wald Chi Square test=0.0272). Using Logistic Regression Method, and equation, i.e., success rate=1/(1 +e -0580+1.53G), where G=CT grading of splenic injury severity, was devised. The predictive success rates calculated from the derived equation were 98.6%, 94%, 77%, 42%, and 13% for Grade 1, 2, 3, 4, and 5 injuries, respectively. No mortality resulted from those who required delayed operation. The hospital stay of the nonoperative group was no different from that of those undergoing early surgery. Nonoperative treatment can be safely used to manage adult splenic injuries in carefully selected patients. Without associated injuries requiring surgical intervention, it is recommended that Grades 1, 2 and 3 adult blunt splenic traumas be treated nonoperatively, particularly when the RTS is above 7.54, and GCS is in normal range. However, when the initial transfusion requirement exceeds four units of blood, nonoperative treatment is likely to fail, and surgery be considered. Since the predictive success rate is only 42%, nonoperative treatment for a Grade 4 adult splenic injury demands great caution. Adult patients with Grade 5 splenic injuries should undergo early operation. |
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