[Ortho] неоперативное лечение повреждений селезенки

[Коробушкин Г.]

Коллеги! мне как не общему хирургу сложно говорить о лечении травмы 
органов брюшной полости.
Но работая плечом к плечу с общими хирургами, иногда возникает вопрос 
надо ли делать спленэктомию, когда кровотечения нет.	
Получили тезис на эту тему:

Исследователи выявили, что попытки неоперативного лечения повреждения 
селезенки не увеличивает количество сложний и смертность.
Усилия по сохранению селезенки безопасны.

Successful nonoperative management of splenic injuries in the 
polytraumatized patient
M.P.J. Teuben, T.J. Blokhuis, R. Spijkerman, L.P.H. LeenenUniversity 
Medical Center Utrecht, The Netherlands


INTRODUCTION
Selective nonoperative management (NOM) has become the treatment of 
choice for patients with blunt splenic injury. Historically, 
nonoperative management is contraindicated in polytraumatized patients. 
However, in our institution all hemodynamically stable polytrauma 
patients without concomitant hollow organ injuries are selected for NOM. 
The current study was undertaken to evaluate the outcomes of selective 
nonoperative management for blunt splenic injuy in polytrauma patients.
METHODS
All adult polytrauma patients (ISS>16) admitted over a 12-year period 
with blunt splenic injury were selected from our prospectively 
registered trauma database. Patients were categorized by the type of 
treatment they received. So group one consisted of patients initially 
selected for NOM and group two included all patients which underwent 
direct surgical intervention. We compared complications, hospital length 
of stay (LOS), ICU-stay, failure of NOM and mortality.RESULTSA total of 
93 eligible polytrauma patients sustaining blunt splenic injury were 
admitted, with a median age of 35 (range,16 to 75) an ISS of 29 (IQR, 
25-38). Fifty-three hemodynamically unstable patients underwent direct 
emergency laparotomy, and 40 patients with comparable splenic injury 
were initially selected for nonoperative management.As anticipated, 
patients treated by direct operative intervention had a significantly 
worse hemodynamic status, higher ISS as well as higher grades of splenic 
injuries as compared to those patients treated by NOM. The median 
hospital-LOS did not significantly differ between groups and was 16 
(IQR, 9-26) in the NOM group and 18 (IQR, 5-41) in the OM group. 
Furthermore, there were no significant differences encountered in the 
number of complications and duration of ICU-stay between groups. Failure 
of NOM occurred in 10 patients and resulted in 6 total splenectomies and 
4 spleen preserving procedures. Patients initially treated by surgical 
intervention were significantly less frequently treated by a spleen 
preserving procedure (3 out of 53 procedures, p