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Die Behandlungspraxis bei Patienten mit isolierter stumpfer Milzverletzung

Eine Befragung der Schweizer Traumatologen

Treatment practice in patients with isolated blunt splenic injuries

A survey of Swiss traumatologists

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Zusammenfassung

Hintergrund

Das nicht-operative Management (NOM) des stumpfen Milztraumas hat sich in den vergangenen Jahren als Therapiekonzept etabliert. Es bestehen jedoch zahlreiche Kontroversen bezüglich der Überwachung und Nachsorge dieser Patienten. Ziel dieser Studie war es, mittels einer Umfrage bei Mitgliedern der Schweizerischen Gesellschaft für Allgemeine und Unfallchirurgie (SGAUC) die aktuelle Praxis bezüglich NOM beim isolierten Milztrauma zu erfassen und mögliche Diskrepanzen zur aktuellen Literatur zu eruieren.

Studiendesign und Untersuchungsmethode

Sämtliche praktizierende Mitglieder der SGAUC wurden mittels schriftlichem Umfragebogen adressiert. Dieser enthielt Fragen zu Person und Klinik des Chirurgen, Fragen zu Diagnostik und Management während der Hospitalisation sowie zu radiologischen Verlaufskontrollen und zur stufenweisen Wiederaufnahme von Alltagsaktivitäten.

Ergebnisse

An der Umfrage nahmen 52 von 165 (31,5%) praktizierenden Mitgliedern der SGAUC teil. Diese deckten 62,8% aller Schweizer Traumazentren ab. Vierzehn Befragte (26,9%) verfügen an ihrer Klinik über ein Protokoll zur Behandlung des Milztraumas. Als initiale Bildgebung beim hämodynamisch stabilen Patienten mit stumpfem Abdomaninaltrauma gaben 82,7% der Befragten die Sonographie an. Bei sonographischem Verdacht auf Milztrauma verzichteten allerdings 19,2% der Befragten auf eine weitergehende Diagnostik. Die Hälfte der Chirurgen gab außerdem an, bei sichtbarem Kontrastmittelextravasat aus der Milz keine weiteren therapeutischen Maßnahmen einzuleiten. 86,5% der Befragten würden Patienten mit niedriggradigem Milztrauma für durchschnittlich 1,6 (0–4 Tage) in einem kontinuierlich-monitorisierten Bett überwachen. Keine Unterschiede wurden hinsichtlich der Aktivitätsrestriktion zwischen mittel- und hochgradigen Milztraumata gemacht.

Schlussfolgerung

Aufgrund eines Mangels an evidenzbasierten Richtlinien zum NOM des Milztraumas gibt es eine beträchtliche Variabilität in der klinischen Praxis selbst unter erfahrenen Chirurgen. Die größten Diskrepanzen zu den Empfehlungen in der aktuellen Literatur waren zum einen der Verzicht auf eine Computertomographie bei Verdacht auf Milztrauma, zum anderen das konservative Vorgehen trotz nachgewiesenem Kontrastmittelaustritt.

Abstract

Background

The non-operative management (NOM) of blunt splenic injuries has gained widespread acceptance. However, there are still many controversies regarding follow-up of these patients. The purpose of this study was to survey active members of the Swiss Society of General and Trauma Surgery (SGAUC) to determine their practices regarding the NOM of isolated splenic injuries.

Materials and methods

A survey of active SGAUC members with a written questionnaire was carried out. The questionnaire was designed to elicit information about personal and facility demographics, diagnostic practices, in-hospital management, preferred follow-up imaging and return to activity.

Results

Out of 165 SGAUC members 52 (31.5%) completed the survey and 62.8% of all main trauma facilities in Switzerland were covered by the sample. Of the respondents 14 (26.9%) have a protocol in place for treating patients with splenic injuries. For initial imaging in hemodynamically stable patients 82.7% of respondents preferred ultrasonography (US). In cases of suspected splenic injury 19.2% of respondents would abstain from further imaging. In cases of contrast extravasation from the spleen half of the respondents would take no specific action. For low-grade injuries 86.5% chose to admit patients for an average of 1.6 days (range 0-4 days) with a continuously monitored bed. No differences in post-discharge activity restrictions between moderate and high-grade splenic injuries were found.

Conclusion

The present survey showed considerable practice variation in several important aspects of the NOM of splenic injuries. Not performing further CT scans in patients with suspected splenic injuries and not intervening in cases of a contrast extravasation were the most important discrepancies to the current literature. Standardization of the NOM of splenic injuries may be of great benefit for both surgeons and patients.

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Authors and Affiliations

  1. Department of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, 1200 North State Street, Los Angeles, USA, California

    B. Schnüriger MD & B.M. Eberle

  2. Klinik für Viszerale Chirurgie und Medizin, Inselspital, Universitätsspital Bern, Bern, Schweiz

    B. Schnüriger MD, F. Martens, P. Renzulli, C.A. Seiler & D. Candinas

Authors
  1. B. Schnüriger MD
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  2. F. Martens
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  3. B.M. Eberle
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  4. P. Renzulli
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  5. C.A. Seiler
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  6. D. Candinas
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Correspondence to B. Schnüriger MD.

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Diese Daten wurden im Rahmen eines Referates am Schweizerischen Chirurgiekongress 2009 in Lausanne präsentiert.

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Schnüriger, B., Martens, F., Eberle, B. et al. Die Behandlungspraxis bei Patienten mit isolierter stumpfer Milzverletzung. Unfallchirurg 116, 47–52 (2013). https://doi.org/10.1007/s00113-011-2044-4

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