梅毒性主动脉瘤的外科诊治策略

Surgical treatment on syphilitic aortic aneurysm

目的:分析梅毒性主动脉瘤患者的外科诊治经验,探讨梅毒性主动脉瘤的疾病特点及治疗方法。方法:选取2010年10月至2018年8月在海军军医大学长海医院诊断为梅毒性主动脉瘤的20例患者,包括12例非急诊手术患者和8例急诊手术患者。所有患者梅毒血清学检验结果均呈阳性,同时全主动脉CT增强造影提示主动脉明显扩张。对于非急诊患者,术前给予驱梅治疗及激素治疗以降低患者梅毒血清学指标水平,同时预防吉海反应的发生;对于急诊入院的患者,及时进行手术干预,预防主动脉瘤破裂导致死亡。结果:在接受治疗的20例患者中(无论是在急诊手术还是非急诊手术),呼吸机辅助时间、ICU停留时间、住院时间,术后24h和48h白细胞计数、中性粒细胞比例,术后感染等结果均优于常规动脉瘤手术患者。病理染色提示,血管壁炎性细胞浸润,且炎性细胞主要位于滋养血管周围。术后随访结果提示,两组患者术后均取得了良好的远期效果。结论:对于主动脉瘤患者,应充分考虑梅毒性主动脉瘤的可能。对于非急诊患者,常规药物治疗配合手术是治疗的首选手段;对于主动脉内径大于6cm,或发生急性主动脉夹层的急诊患者,直接手术更为安全、可行、有效。

Objective: To discuss the characteristics and treatment of syphilitic aortic aneurysm by analyzing the situation of syphilitic aortic aneurysm in the cardiovascular surgery. Methods: Twenty patients who were diagnosed as syphilitic aortic aneurysm from October 2010 to August 2018 in Changhai Hospital, including 12 non-emergency patients and 8 emergency patients. All the patients showed positive results in serological test for syphilis and obvious aortectasia according to the computed tomographic angiography. For non-emergency patients, antibiotic therapy combined with hormonotherapy were given pre-operatively to reduce the serum syphilis level and prevent the incidence of Jarisch-Herxheimer reaction. For the emergency patients, surgeries were given in time to prevent death from aortoclasia. Results: Of the 20 patients receiving treatment (emergency or non-emergency surgery), ventilator assist time, ICU stay time, hospital stay, 24 h and 48 h postoperative white blood cell count and neutrophil ratio, and postoperative infection were better than those of patients underwent conventional aneurysm surgery. The pathological staining of vascular wall showed that infiltration inflammatory cells infiltrated and mainly located around the nourishing blood vessels. Postoperative follow-up results showed that patients in both groups achieved good long-term results after surgery. Conclusions: For patients with aortic aneurysm, the possibility of syphilitic aortic aneurysm should be fully considered. For the non-emergency patients, regular pharmaceutical and surgery therapy should be the first choice. For those whose aortic diameter bigger than 6 cm or suffer aortic dissection, emergency operation without antibiotic and hormone therapy could be more safe, feasible, and effective.