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老年患者创伤性连枷胸保守治疗与手术治疗的疗效对比

目的比较老年创伤性连枷胸患者采用手术治疗与保守治疗的疗效。方法回顾性分析自 1998年 1月至 2009年 10月兰州市解放军第一医院 22例老年连枷胸患者经手术治疗 /保守治疗的临床资料，按治疗方法不同将 22例患者分为两组，手术治疗组： 12例，男 9例，女 3例；年龄（ 67.3±10.3）岁；行手术内固定治疗。保守治疗组：10例，男 8例，女 2例；年龄（ 68.7±11.6）岁；为无开胸探查指征患者，行保守治疗。比较两组患者的临床疗效及并发症发生情况。结果围术期死亡 4例，死于脓毒血症 1例，成人呼吸窘迫综合征 2例，急性心肌梗死 1例。手术治疗组患者病死率低于保守治疗组（ 8.3% vs. 30.0%，P＜ 0.05）；手术治疗组患者机械通气时间［（4.7±2.5）d vs.（17.3±7.1）d］、住院时间［（25.6±11.8）d vs.（36.1±16.5）d］和住 ICU时间［（ 8.2±3.5）d vs.（15.9±8.4）d］均短于保守治疗组（ P＜ 0.05）；手术治疗组中呼吸系统并发症、肺外并发症、胸廓畸形等并发症均少于保守治疗组（P＜ 0.05）。随访 18例（保守治疗组 7例、手术治疗组 11例），随访时间 6个月～ 2年，复查胸部 X线片示：骨折全部骨性愈合，但保守治疗组残留胸廓畸形 4例，手术治疗组 2例。结论多发性肋骨骨折，尤其是老年、且伤前具有特定合并疾病的患者预后不良，应积极采取手术内固定治疗。

采用可吸收肋骨钉手术治疗连枷胸九例

巨大右肺囊肿合并肝右叶囊肿的同期手术治疗

目的　探索巨大右肺囊肿合并肝右叶囊肿的同期手术治疗效果。　方法　回顾性分析解放军第一医院1995年6月至2011年5月经右胸行巨大右肺囊肿合并肝右叶囊肿同期手术治疗3例男性患者的临床资料，平均年龄56 （48～62）岁，经胸部X线、CT检查等术前临床诊断为巨大右肺囊肿合并肝右叶囊肿。双腔气管内插管，复合全身麻醉，经右胸后外侧切口第6、第7肋间进胸，先切除右肺囊肿，再经膈肌切口切除肝右叶囊肿。　结果　平均手术时间85 （75～96） min，术后24 h平均胸腔引流量164 （150～180） ml，48 h拔除胸腔引流管。1例放置膈下引流管，术后24 h引流量20 ml，48 h拔除胸腔引流管。切口Ⅰ期甲级愈合。无胸腹腔出血、感染，无支气管胸膜瘘、胆瘘等并发症。术后组织病理学诊断：肺囊肿、肝囊肿。住院时间8 d，随访0.5～16.0年，症状消失，无复发。　结论　经右胸部切口同期手术治疗右肺囊肿合并肝右叶囊肿可减少腹部手术切口、减轻患者痛苦、缩短手术和治疗时间、减少医疗费用，手术疗效确切，远期效果满意。

成人先天性膈肌膨出症七例的临床分析

INTERNAL FIXATION TREATMENT OF MULTIPLE RIB FRACTURES WITH ABSORBABLE RIB-CONNECTINGPINS/

Objective To study the indications, methods, and therapeutic effect of absorbable rib-connecting-pins fixation in the treatment of multi ple rib fractures. Methods Between March 2007 and September 2009, 40 patients with multiple rib fractures received internal fixation with absorbable rib-connecting-pins, including 8 one-side flail chest and 1 twoside flail chest. There were 32 males and 8 females with an average age of 39.8 years (range, 25-72 years). The injury was caused by traffic accident in 32 cases, fall ing from height in 6 cases, and blunt hitting in 2 cases. Preoperatively, imaging data of the chest X-ray or spiral CT three-dimensional (3D) examination showed that all patients had multiple ribs fractures and displacement. The number of fractured ribs was 4-10 (median, 6), and the fracture location ranged from the 2nd to the10th ribs. Of them, 28 cases were accompanied by hemathorax, pneumathorax or hemopneumothorax; 5 cases by thoracic organ injury; and 10 cases byother part trauma. The time from injury to hospital ization was less than 1 day in 26 cases, 1-3 days in 12 cases, and 3-6 days in 2 cases, and the time from hospital ization to operation was 3 hours to 3 days (mean, 1.2 days). Results The median fixation rib number was 5 (range, 3-8). The mean operative time, the time in bed, and hospital ization days were 32 minutes (range, 15-50 minutes), 4.5 days (range, 2-7 days), and 11.2 days (range, 5-18 days), respectively. All incisions healed by first intention. No pulmonary infection, pulmonary atelectasis, intrathoracic infection or other compl ications occurred. All cases were followedup 6-12 months (mean, 8 months). PaO2 [(86.6 ± 2.2) mmHg (1 mm Hg=0.133 kPa)] and SpO2 (97.2% ± 0.6%) at 2 hours after operation were obviously improved when compared with preoperative ones [PaO2 (53.6 ± 4.7) mm Hg and SpO2 (86.2% ± 1.8%)], showing significant differences (t=2.971, P=0.005; t=2.426, P=0.020). The chest X-ray films or spiral CT 3D indicated that fracture of rib healed within 3-6 months (mean, 4.5 months) after operation. Conclusion Severe collapsed chest wall orflail chest caused by fracture of multiple ribs should be treated by absorbable rib-connecting-pins, which is a simple, firm, and effective method.

手术内固定治疗创伤性连枷胸对患者呼吸功能的影响

目的观察连枷胸患者胸壁加压包扎、肋骨牵引和手术内固定的治疗效果。 方法纳入2001年1月至2010年6月解放军第一医院心胸外科收治的56例连枷胸患者，分为3组：牵引治疗组，14例，其中男10例、女4例，年龄（39.7±11.6）岁；包扎治疗组，12例，其中男11例、女1例，年龄（40.2±13.2）岁；手术内固定组，30例，其中男26例、女4例，年龄（42.6±12.5）岁。比较3组的治疗效果。 结果手术内固定组与牵引治疗组和包扎治疗组比较，除需呼吸机支持率与牵引治疗组差异无统计学意义（P>0.05）外，呼吸机通气时间、住ICU时间、胸腔引流管拔除时间均缩短（P<0.05），胸部并发症发生率及死亡率降低（P<0.05），动脉血氧分压（PaO2）、动脉血氧饱和度（SaO2）显著升高（P<0.01），肺挫伤评分下降明显；而牵引治疗组PaO2、SaO2及肺挫伤评分较入院时改善缓慢，胸壁加压包扎治疗组甚至有加重趋势。 结论大面积浮动胸壁的病理改变以胸腔容积减少为基础，胸壁加压包扎无治疗效果，甚至加重低氧；肋骨巾钳悬吊牵引固定对连枷胸缺氧内环境的改善效果不佳；手术切开复位内固定是改善大面积浮动胸壁呼吸功能障碍的有效方法。