创伤性膈肌破裂的诊断与治疗

Diagnosis and treatment of traumatic diaphragmatic rupture

目的探讨创伤性膈肌破裂的早期诊断和治疗。方法回顾性分析我科17年间收治的161例创伤性膈肌破裂患者的临床资料，包括诊断方法、术前确诊率、膈疝发生率、手术治疗方式和患者结局等。结果161例中男139例，女22例；年龄9～84岁，平均32．4岁。ISS13～66分，平均27．8；65．2％入院时有休克。钝性伤36例、穿透伤125例。术前膈肌损伤确诊率在钝性和穿透伤分别为88．9％和78．4％。膈疝发生率在钝性和穿透伤分别为94．4％和14．4％（P〈0．01）。手术经胸30例，经腹106例，分别剖胸和剖腹18例、胸腹联合切口7例。病死率10．6％，ISS平均41．6；主要死因为失血性休克和严重感染并发症。钝性和穿透伤病死率分别为22．2％和7．2％（P〈0．01）。结论膈伤诊断依据，钝性伤主要为膈疝的影像学表现，穿透伤伤口远处腹或胸部也有阳性体征或影像学征象。膈疝手术的关键是准确判断疝入胃肠的活力。穿透伤预后相对较好。

Objective To probe timely diagnosis and surgical intervention of traumatic diaphragmatic rupture （TDR）. Methods The clinical data of 161 patients with TDR treated surgically in our depaxtment during the past 17 years were analyzed retrospectively in respects of diagnostic methods, accuracy of preoperative judgment of TDR, incidence of diaphragmatic hernia, surgical procedures and outcome, etc. Results There were 139 males and 22 females at a mean age of 32.4 years （9-84 years） , with average ISS of 27.8 points （ 13-66 points）. Of all patients, 65.2% bad shock at admission. For these 161 patients, 36 suffered from blunt injuries and 125 from penetrating injuries. For diaphragmatic injury, preoperative diagnostic rate was 88.9% for blunt injuries and 78.4% for penetrating injuries （ P 〉 0.01 ）. The incidence of diaphragmatic hernia was 94.4% in blunt injuries and 14.4% in penetrating injuries （P 〈 0. 05 ）. In this series, thoracotomy was performed in 30 patients, laparotomy in 106, thoracotomy plus laparotomy in 18 and combined thoraco-laparotomy in 7, with overall fatality rate of 10.6% and a mean ISS of 41.6 points. The mortality rate was 22.2% in blunt injuries and 7.2% in penetrating injuries （P 〈0.01 ）. The main causes for death were hemorrhagic shock and septic complications. Condusions Blunt diaphragmatic injury can be diagnosed by radiographic signs of diaphragmatic hernia. According to ＂offside sign＂, which implies a thoracic wound with positive physical or radiological signs in the abdomen or in the thorax, penetrating diaphragmatic injury can be recognized. To deal with diaphragmatic hernia, it is important to judge the vitality of viscera. Penetrating injury has a relatively good prognosis.