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目的总结创伤性膈肌破裂(traumatic diaphragmatic rupture,TDR)的诊治经验,提高早期诊断和救治能力。方法回顾性分析2001年4月—2013年11月淮北市人民医院收治的21例TDR的患者临床资料,男性18例,女性3例,左侧17例,右侧4例,开放性损伤13例,闭合性损伤8例,12例锐器伤,5例车祸伤,2例医源性损伤,2例高处坠落伤,10例合并休克,合并血气胸20例,心包破裂5例,心室破裂2例,上腔静脉损伤1例,肺裂伤8例,胃破裂4例,肝破裂4例,脾破裂2例,结肠破裂2例,重度颅脑损伤3例,脊柱骨折4例,截瘫2例,形成膈疝12例。其中16例行胸部CT检查,均手术治疗,单纯经胸手术7例,单纯经腹切口6例,腹部切口附加胸部切口3例,胸腹联合切口2例,胸腔镜手术3例。膈肌裂口均采取粗丝线直接缝合。对其致伤原因、诊断方法、急诊处理及手术方式进行分析。结果 TDR多合并胸腹脏器损伤,临床表现复杂,螺旋CT检查具有较高的诊断价值,术前明确诊断13例(确诊率61.90%),术中探查确诊8例,其中电视胸腔镜探查手术均成功,手术治疗治愈18例,死亡3例。结论提高认识、急诊螺旋CT检查是早期诊断的主要手段,积极抗休克和及早手术治疗是救治成功的关键,电视胸腔镜手术是诊断和治疗TDR最具潜力的方法。
Objective To summarize the experience of diagnosis and treatment of traumatic diaphragmatic rupture (TDR) and to improve the ability of early diagnosis and treatment. Methods The clinical data of 21 TDR patients treated in Huaibei People’s Hospital from April 2001 to November 2013 were retrospectively analyzed. There were 18 males and 3 females, 17 left and 4 right, and 13 patients with open injury , 8 cases of closed injury, 12 cases of sharp injury, 5 cases of traffic accident, 2 cases of iatrogenic injury, 2 cases of falling injury, 10 cases of combined shock, combined pneumothorax in 20 cases, pericardial rupture in 5 cases, ventricular rupture 2 cases, 1 case of superior vena cava injury, 4 cases of lung laceration, 4 cases of gastric rupture, 4 cases of liver rupture, 2 cases of splenic rupture, 2 cases of colon rupture, 3 cases of severe craniocerebral injury, 4 cases of spinal fracture, 2 cases of paraplegia Cases, the formation of diaphragmatic hernia in 12 cases. Thirteen of them were underwent thoracic computed tomography (CT) examination. Thoracotomy was performed in 7 cases, simple abdominal incision in 6 cases, abdominal incision in 3 cases, thoraco-abdominal incision in 2 cases and thoracoscopic surgery in 3 cases. Diaphragm cracks were taken coarse silk suture. The causes of injury, diagnosis, emergency treatment and surgical methods were analyzed. Results TDR combined with complicated thoracoabdominal organs injury, complicated clinical manifestations, spiral CT examination with high diagnostic value, preoperative diagnosis of 13 cases (61.90% confirmed), 8 cases confirmed by intraoperative exploration, including video-assisted thoracoscopic exploration All were successful, surgical treatment cured 18 cases, 3 died. Conclusions Awareness-raising and emergency spiral CT are the main means of early diagnosis. Active anti-shock and early surgical treatment are the keys to successful treatment. Video-assisted thoracoscopic surgery is the most potential method for diagnosis and treatment of TDR.