Ⅲ级和Ⅳ级肝损伤保守与手术治疗的临床疗效

Clinical efficacies of the conservative and surgical treatment of grade Ⅲ and Ⅳ traumatic hepatic rapture

目的 探讨Ⅲ级和Ⅳ级肝损伤保守治疗与手术治疗的临床疗效.方法 回顾性分析2004年1月至2014年6月南京军区福州总医院收治的77例肝损伤患者的临床资料.美国创伤外科学会-器官损伤分级（AAST-OIS）和影像学Becker分级Ⅲ级患者44例,Ⅳ级患者33例.综合评估患者生命体征、伤情及影像学检查结果,依据适应证选择保守治疗或手术治疗.采用门诊和电话方式进行随访,随访时间截至2014年9月.结果 Ⅲ级肝损伤患者行保守治疗19例,手术治疗25例;Ⅳ级肝损伤患者行保守治疗5例,手术治疗28例.手术治疗患者中,行肝裂伤缝合术31例,行部分肝切除术18例,行损伤控制手术4例.77例患者均成功治愈,无患者死亡.Ⅲ级患者中,保守治疗患者住院时间为（12±9）d,手术治疗患者住院时间为（20±15）d;Ⅳ级患者中,保守治疗患者住院时间为（17±3）d,手术治疗患者住院时间为（34±25）d.77例患者中19例发生并发症,其中肝脓肿10例,胆汁漏5例,均行穿刺引流术后治愈;假性动脉瘤2例,行DSA介入治疗治愈;粘连性肠梗阻1例,迟发性出血1例,行2次手术治愈.71例患者获得随访,随访率为92.2％（71/77）.随访时间为3～15个月,中位随访时间为7个月.随访期间,仅1例患者出院后13个月形成肝脓肿,行穿刺引流术后治愈,其余患者均健康生存,无并发症发生.结论 Ⅲ级肝损伤患者以保守治疗为主,临床疗效好;Ⅳ级肝损伤患者伤情复杂,应严格掌握保守治疗的适应证,以手术治疗为主.肝脓肿、胆汁漏和假性动脉瘤是肝损伤患者术后常见并发症.

Objective To investigate the clinical efficacies of the conservative and surgical treatment of grade m and Ⅳ traumatic hepatic rapture.Methods The clinical data of 77 patients with traumatic hepatic rapture were analyzed.All the patients were admitted to the Fuzhou General Hospital of Nanjing Military Command from January 2004 to June 2014.According to the Organ Injury Scale grading system of the American Association for the Surgery of Trauma （AAST-OIS） and the Becker classification,there were 44 patients and 33 patients had grade Ⅲ and grade Ⅳ traumatic hepatic rapture,respectively.The vital signs,condition of the wound and the resuhs of imaging examination were comprehensively analyzed,and the conservative and surgical treatment methods were selected accordingly.Patients were followed up via outpatient examination or telephone interview till September 2014.Results There were 19 patients received conservative treatment and 25 received surgical treatment among the 44 patients with grade m traumatic hepatic rapture,and 5 received conservative treatment and 28 received surgical treatment among the 33 patients with type Ⅳ traumatic hepatic rapture.Thirty-one patients received suture of the liver,18 received partial hepatectomy and 4 received damage control surgery.All the 77 patients were cured without perioperative death.For patients with grade m traumatic hepatic rapture,the duration of hospital stay were （12 ± 9）days and （20 ± 15）days for patients received conservative and surgical treatment,respectively; and for patients with grade Ⅳ traumatic hepatic rapture,the duration of hospital stay were （17 ± 3） days and （34 ± 25） days for patients received conservative and surgical treatment,respectively.Nineteen patients had complications,including 10 with hepatic abscess,5 with bile leakage （cured by puncture and drainage）,2 with pseudoaneurysm （cured by interventional therapy with digital subtraction angiography）,1 with adhesive intestinal obstruction and delayed hemorrhage （cured by operation for 2 times）.Seventy-one patients were followed up,with the rate of 92.2% （71/77）.The median time of follow-up was 7 months （range,3-15 months）.Only 1 patient was complicated with hepatic abscess at postoperative month 13,and was cured by puncture and drainage,and the other patients were live and well.Conclusions The success rate of operation for patients with grade m traumatic hepatic rapture is relatively high with short hospital stay and quick recovery of patients.The indication of conservative treatment for patients with grade Ⅳ traumatic hepatic rapture should be strictly controlled,and the surgical treatment is the main means of therapy.Hepatic abscess,bile leakage and pseudoaneurysm are the common complications for patients with traumatic hepatic rapture.