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Frühe klinische Versorgungsstrategien für schwerverletzte Patienten mit Abdominaltrauma

Early clinical care strategy for severely injured patients with abdominal trauma

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Zusammenfassung

Hintergrund

Das Vorliegen von Abdominalverletzungen hat einen großen Einfluss auf die Mortalität schwerverletzter Patienten. Bei operationspflichtigen Verletzungen gilt die Laparotomie als Therapie der Wahl im Rahmen der frühen operativen Versorgung. Allerdings gibt es zunehmend Hinweise, dass die Laparoskopie eine Alternative im Rahmen der Polytraumaversorgung darstellen kann.

Ziel der Arbeit

Die vorliegende Arbeit analysiert das Verletzungsmuster, die Häufigkeit durchgeführter Laparoskopien sowie das Outcome schwerverletzter Patienten mit Abdominaltrauma.

Material und Methode

Es wurde eine retrospektive Analyse von 12.447 Patienten auf Basis der TraumaRegister DGU® (TR-DGU) durchgeführt. Einschlusskriterien waren ein Injury Severity Score (ISS) von ≥9 und ein Abbreviated Injury Scale (AIS; [Abdomen]) ≥1. Die Patienten wurden entsprechend der Therapieform in die Gruppen (1) Laparoskopie, (2) Laparotomie und (3) nichtoperatives Management (NOM) unterteilt. Anschließend wurden die Basisdaten der einzelnen Gruppen beschrieben und das Outcome analysiert.

Ergebnisse

Die Mehrheit der Patienten wurde mittels NOM (52,4 %, n = 6069) behandelt, gefolgt von der Laparotomie (50,6 %, n = 6295) und der Laparoskopie (0,7 %, n = 83). Die meisten Laparoskopien wurden bei Patienten mit einem AIS [Abdomen] ≤ 3 (86,7 %) durchgeführt. Der ISS der Laparoskopie-Gruppe war signifikant geringer als in der Laparotomie-Gruppe und der NOM-Gruppe (ISS: 23,4 vs. 34,5 vs. 28,2; p ≤ 0,001). Die standardisierte Mortalitätsrate (SMR) war in der Laparoskopie-Gruppe geringer als in der Laparotomie-Gruppe und der NOM-Gruppe (SMR: 0,688 vs. 0,931 vs. 0,932; p-Wert = 0,2128), ohne das statistische Signifikanzniveau zu erreichen.

Diskussion

Obwohl die Laparoskopie nicht häufig eingesetzt wurde, weisen die Daten auf die Effektivität dieses Verfahrens in der frühen operativen Versorgung schwerverletzter, hämodynamisch stabiler Patienten mit einem (AIS; [Abdomen]) ≤ 3 hin.

Abstract

Background

The presence of abdominal injuries has a major impact on the mortality of severely injured patients. For injuries that require surgery, laparotomy is still the gold standard for early surgical care; however, there is increasing evidence that laparoscopy may be an alternative in the early clinical care of polytrauma patients.

Objective

The present registry-based study analyzed the utilization and the outcome of laparoscopy in severely injured patients with abdominal trauma in Germany.

Material and methods

A retrospective analysis of 12,447 patients retrieved from the TraumaRegister DGU® (TR-DGU) was performed. The primary inclusion criteria were an injury severity score (ISS) ≥ 9 and an abbreviated injury scale (AIS) [abdomen] ≥ 1. The included patients were grouped according to early treatment management: (1) laparoscopy, (2) laparotomy and (3) non-operative management (NOM). Finally, group-specific patient characteristics and outcome were analyzed.

Results

The majority of patients were treated by NOM (52.4%, n = 6069), followed by laparotomy (50,6%, n = 6295) and laparoscopy (0.7%, n = 83). The majority of laparoscopies were performed in patients with an AIS [abdomen] ≤ 3 (86.7%). The ISS of the laparoscopy group was significantly lower compared to that of the laparotomy and NOM groups (ISS 23.4 vs. 34.5 vs. 28.2, respectively, p ≤ 0.001). The standardized mortality rate (SMR), defined as the ratio between observed and expected mortality, was lowest in the patients receiving laparoscopy followed by laparotomy and NOM (SMR 0.688 vs. 0.931 vs. 0.932, respectively, p-value = 0.2128) without achieving statistical significance.

Conclusion

Despite being rarely employed the data indicate the effectiveness of laparoscopy for the early treatment of severely injured, hemodynamically stable patients with an AIS [abdomen] ≤ 3.

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Authors and Affiliations

  1. Zentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Gießen und Marburg, Standort Marburg, Baldingerstraße, 35043, Marburg, Deutschland

    F. Debus, P. Lechler, S. Ruchholtz & M. Frink

  2. Institut für Forschung in der operativen Medizin (IFOM), Universität Witten/Herdecke, Campus Köln-Merheim, Köln, Deutschland

    R. Lefering

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  1. F. Debus
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  2. R. Lefering
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  3. P. Lechler
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  4. S. Ruchholtz
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  5. M. Frink
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TraumaRegister DGU

Corresponding author

Correspondence to M. Frink.

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Interessenkonflikt

F. Debus, R. Lefering, P. Lechler, S. Ruchholtz, M. Frink und TraumaRegisterDGU® geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Debus, F., Lefering, R., Lechler, P. et al. Frühe klinische Versorgungsstrategien für schwerverletzte Patienten mit Abdominaltrauma. Chirurg 90, 752–757 (2019). https://doi.org/10.1007/s00104-019-0817-4

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  • DOI: https://doi.org/10.1007/s00104-019-0817-4

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