儿童高级别闭合性肾损伤肾动脉栓塞与手术探查的疗效比较

doi:10.3877/cma.j.issn.1674-3253.2023.05.007

目的

探讨高级别闭合性肾损伤患儿肾动脉栓塞相对于手术探查在肾功能保护方面的优势及两者的疗效对比。

方法

回顾性分析2012年1月1日至2021年12月31日桂林地区两大三甲医院（广西壮族自治区南溪山医院、解放军第924医院）高级别闭合性肾损伤患儿的临床资料，并从中筛选出经保守治疗无效或血流动力学不稳定而接受了进一步干预的病例。经筛选，共44例满足条件，其中接受高选择性肾动脉栓塞的患儿共21例，为介入组（A组）；急诊手术探查（依据术中情况行肾修补术、肾部分切除术或切除患肾）共23例，为探查组（B组）。比较A、B两组住院费用、住院天数、止血成功率等术后临床数据。出院后1年复查肾动态显像，比较两组患肾肾小球滤过率。

结果

住院天数、止血成功率两组间差异无统计学意义（P>0.05）。与B组相比，A组疼痛更轻（P<0.05）、住院费用更低（P<0.05）、输血量更少（P<0.05），患肾肾小球滤过率值更高（P<0.05）。

结论

在儿童高级别闭合性肾损伤的治疗中，对于单纯保守治疗无效需要进一步止血干预的病例，高选择性肾动脉栓塞与手术探查相比，止血效率相当，而高选择性肾动脉栓塞疼痛轻、输血量少、住院费用低，且有利于远期肾功能保护，应作为优先选择。

关键词: 儿童, 肾损伤, 肾动脉栓塞, 手术探查

Objective

To compare the renal function protection and curative effect between surgical exploration and renal artery embolization in pediatric with high-grade closed renal trauma.

Methods

The data of patients hospitalized for Grade Ⅲ-Ⅴ blunt renal trauma in Nanxishan Hospital of Guangxi and the 924th Hospital of PLA in Guilin from January 1, 2012 to December 31, 2021 was retrospectively analyzed. Patients who failed to respond to conservative treatment or were hemodynamic unstable and received further intervention were selected. A total of 44 cases were enrolled. 21 patients were given highly selective renal artery embolization (RAE), named Group A. The other 23 cases received emergency surgical exploration, renal repair, partial nephrectomy or removal of the affected kidney, named Group B. The hospitalization expenses, days of hospitalization, glomerular filtration rate and other perioperative data were compared between A and B groups.

Results

There were no significant differences in the length of stay, and successful rate of hemostasis between the two groups (P>0.05). Compared with group B, group A had less pain (P<0.05), lower hospitalization costs (P<0.05), less blood transfusion (P<0.05), and higher glomerular filtration rate of affected kidney (P<0.05).

Conclusions

In the treatment of children with high-grade closed renal injury, compared with surgical exploration, highly selective renal artery embolization has the same hemostatic efficiency, less pain, less blood transfusion, lower hospitalization costs, and is beneficial to the protection of long-term renal function, so it should be priority to surgical exploration.

Key words: Children, Renal trauma, Renal artery embolization, Surgical exploration

表1 介入栓塞（A组）与探查组（B组）儿童高级别闭合性肾损伤患者一般资料比较

组别	例数	性别(例)		年龄[岁，(±s)]	受伤原因(例)			Wong-Baker疼痛评分[M(Q)]	肉眼血尿(例)	血红蛋白<10 g/dL(例)	收缩压<90 mmHg(例)	心率>120次/min(例)	血肿大小[cm，(±s)]	入院肌酐[μmol/L，(±s)]
组别	例数	男	女	年龄[岁，(±s)]	交通事故	高处坠落	撞击	Wong-Baker疼痛评分[M(Q)]	肉眼血尿(例)	血红蛋白<10 g/dL(例)	收缩压<90 mmHg(例)	心率>120次/min(例)	血肿大小[cm，(±s)]	入院肌酐[μmol/L，(±s)]
A组	21	13	8	8±4	13	3	5	7(6，8)	19	8	4	17	5.1±1.0	76±17
B组	23	16	7	9±3	16	3	4	7(6，8)	20	8	5	22	4.9±0.9	70±21
统计值		χ²=0.287		t=0.076	χ²=0.331			Z=0.012	χ²=0.135	χ²=0.052	χ²=0.049	χ²=1.122	t=0.605	t=1.113
P值		0.592		0.500	0.847			0.991	0.713	0.820	0.825	0.290	0.548	0.272

表1 介入栓塞（A组）与探查组（B组）儿童高级别闭合性肾损伤患者一般资料比较

组别	例数	性别(例)		年龄[岁，(±s)]	受伤原因(例)			Wong-Baker疼痛评分[M(Q)]	肉眼血尿(例)	血红蛋白<10 g/dL(例)	收缩压<90 mmHg(例)	心率>120次/min(例)	血肿大小[cm，(±s)]	入院肌酐[μmol/L，(±s)]
组别	例数	男	女	年龄[岁，(±s)]	交通事故	高处坠落	撞击	Wong-Baker疼痛评分[M(Q)]	肉眼血尿(例)	血红蛋白<10 g/dL(例)	收缩压<90 mmHg(例)	心率>120次/min(例)	血肿大小[cm，(±s)]	入院肌酐[μmol/L，(±s)]
A组	21	13	8	8±4	13	3	5	7(6，8)	19	8	4	17	5.1±1.0	76±17
B组	23	16	7	9±3	16	3	4	7(6，8)	20	8	5	22	4.9±0.9	70±21
统计值		χ²=0.287		t=0.076	χ²=0.331			Z=0.012	χ²=0.135	χ²=0.052	χ²=0.049	χ²=1.122	t=0.605	t=1.113
P值		0.592		0.500	0.847			0.991	0.713	0.820	0.825	0.290	0.548	0.272

表2 介入栓塞（A组）与探查组（B组）儿童高级别闭合性肾损伤Ⅳ、Ⅴ级构成比和止血成功率比较(例)

	例数	Ⅳ、Ⅴ级构成比		止血成功率		合计成功率
	例数	Ⅳ	Ⅴ	Ⅳ	Ⅴ	合计成功率
A组	21	17	4	16/17	3/4	19/21
B组	23	18	5	18/18	4/5	22/23
χ²值		0.049		1.475	0.032	0.007
P值		1.000		0.224	0.858	0.935

表2 介入栓塞（A组）与探查组（B组）儿童高级别闭合性肾损伤Ⅳ、Ⅴ级构成比和止血成功率比较(例)

	例数	Ⅳ、Ⅴ级构成比		止血成功率		合计成功率
	例数	Ⅳ	Ⅴ	Ⅳ	Ⅴ	合计成功率
A组	21	17	4	16/17	3/4	19/21
B组	23	18	5	18/18	4/5	22/23
χ²值		0.049		1.475	0.032	0.007
P值		1.000		0.224	0.858	0.935

表3 介入栓塞（A组）与探查组（B组）儿童高级别闭合性肾损伤治疗后数据比较

组别	例数	发热(例)	尿量[ml，(±s)]	Wong-Baker疼痛评分[M(Q)]	血尿天数[d，(±s)]	输血量[ml，M(Q)]	抗生素使用时间[d，(±s)]
A组	21	3	1 523±312	6(4，8)	2.3±1.3	181(0，400)	3.4±1.2
B组	23	2	1 621±353	8(6，10)	1.4±0.8	435(400，600)	3.2±0.6
统计值		χ²=0.120	t=0.976	Z=2.669	t=3.053	Z=-3.800	t=0.738
P值		0.914	0.335	0.008	0.004	<0.001	0.464
组别	卧床时间[d，(±s)]	尿漏或尿性囊肿(例)	住院天数[d，(±s)]	住院花费[元，(±s)]	患肾滤过率(ml/min，(±s)]
A组	3.1±1.1	3	20±8	21 075±5 086	38±6
B组	3.1±1.2	3	18±7	33 629±4 748	27±15
统计值	t=0.024	χ²=0.014	t=0.462	t=6.248	t=2.144
P值	0.981	0.905	0.649	<0.001	0.043

表3 介入栓塞（A组）与探查组（B组）儿童高级别闭合性肾损伤治疗后数据比较

组别	例数	发热(例)	尿量[ml，(±s)]	Wong-Baker疼痛评分[M(Q)]	血尿天数[d，(±s)]	输血量[ml，M(Q)]	抗生素使用时间[d，(±s)]
A组	21	3	1 523±312	6(4，8)	2.3±1.3	181(0，400)	3.4±1.2
B组	23	2	1 621±353	8(6，10)	1.4±0.8	435(400，600)	3.2±0.6
统计值		χ²=0.120	t=0.976	Z=2.669	t=3.053	Z=-3.800	t=0.738
P值		0.914	0.335	0.008	0.004	<0.001	0.464
组别	卧床时间[d，(±s)]	尿漏或尿性囊肿(例)	住院天数[d，(±s)]	住院花费[元，(±s)]	患肾滤过率(ml/min，(±s)]
A组	3.1±1.1	3	20±8	21 075±5 086	38±6
B组	3.1±1.2	3	18±7	33 629±4 748	27±15
统计值	t=0.024	χ²=0.014	t=0.462	t=6.248	t=2.144
P值	0.981	0.905	0.649	<0.001	0.043

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Comparison of surgery and renal artery embolization for high-grade blunt renal trauma in pediatric

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Comparison of surgery and renal artery embolization for high-grade blunt renal trauma in pediatric