13例闭合性创伤性膈肌破裂临床分析

Clinical analysis of 13 patients with blunt diaphragmatic rupture

目的研究老年人闭合性创伤性膈肌破裂的临床特点。方法回顾性分析本科1996—2005年收治的闭合性创伤性膈肌破裂13例老年患者（年龄≥65岁）和46例中青年患者（年龄〈65岁）的临床病例资料，就年龄、性别、伴随疾病、创伤程度评分（ISS评分）、膈肌破裂长度、手术前延误（入院24h内未手术）发生率、手术后并发症及病死率等指标比较和分析两者结果的异同。结果与中青年组相比较，老年组基础疾病发生率高，初诊时胸部x片未发现异常的病例数吏多，手术前延误发生率显著增加，膈肌破裂长度偏短[（5．6±2．3）cm vs （10．0±6．0）cm，P〈0．05]，手术后机械通气时程更长[（17．7±21．2）d vs （3．2±5．0）d，P〈0．01]，手术后并发肺炎发生率更高，死亡率远高于前组。两组创伤程度评分差异无统计学意义。结论老年组由于膈肌破裂长度偏短以及机械通气、初诊时胸部x片未发现异常的病例数显著增多，从而导致手术前延误发生率显著增加；进而需要更长时间的手术后机械通气，更易并发手术后肺炎，加之基础疾病发生率高，因而病死率显著增高。

Objective To study the difference between elderly and young patients in terms of blunt diaphragmatic rupture. Method Records from 59 patients with blunt diaphragmatic rupture at our hospital from July 1996 to January 2005 were retrospectively reviewed. Age, gender, co-morbid disease, injury severity score, size of diaphragmatic rupture, delay before operation, and postoperative complications and mortality were determined in elderly （〉1 65 years old） and young （ 〈 65 years old） patients. Results Thirteen elderly and 46 young patients were collected and reviewed. Elderly patients had higher rate of basic disease, initial normal chest roentgenogram and significant delays before operation. Furthermore, elderly patients had shorter diaphragmatic ruptures and longer periods of postoperative ventilatory support [ （17.7 ± 21.2） days vs （3.2 ± 5.0） days, P 〈 0.01 ]. Also, elderly patients had significantly higher rate of postoperative complications of pneumonia and nigher mortality than young patients did. There were no statistically significant differences between elderly and young patients in injury severity score. Conclusions Compared to young patients, elderly patients with blunt diaphragmatic rupture had significantly higher rate of initial normal chest roentgenogram, partly because of shorter length of diaphragmatic rupture and partly because of ventilatory support. Elderly patients had higher rate of delays before surgery. Furthermore, elderly patients needed longer postoperative ventilator, and had higher rates of comorbid disease, postoperative pneumonia, and mortality.