Stylianos S, King T C
Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York.
Am Surg. 1992 Jun;58(6):364-8.
No dependable test exists for diagnosis of diaphragmatic injury in asymptomatic patients with thoraco-abdominal stab wounds. Forty-one consecutive patients with anterior stab wounds of the lower left chest were treated in a 30-month period. In the 21 patients seen during the first 15 months, operations were reserved for those with peritoneal signs or continuing blood loss. Ten of these 21 patients (48%) required celiotomy; 2 patients (10%) had isolated diaphragm injuries and there was one negative celiotomy. Of the eleven patients who were not explored, 2 (18%) returned within 18 months after injury with an incarcerated diaphragmatic hernia. During the subsequent 15 months, the next 20 patients were managed by routine celiotomy in a prospective study. The admission systolic blood pressure and incidence of pneumothorax, celiotomy, diaphragm injury, isolated diaphragm injury, and unnecessary celiotomy in these two groups were compared. Ten patients in the prospective group (50%) were found to have isolated diaphragm injuries (P less than 0.005) and 7 (35%) had negative celiotomies (P less than 0.02). The true incidence of occult diaphragm injuries may be underestimated. In the prospectively studied group, the policy of routine celiotomy for anterior stab wounds of the lower left chest resulted in recognition and repair of a fivefold greater number of isolated diaphragm injuries. In the absence of a reliable, noninvasive test to diagnose penetration of the diaphragm, celiotomy should be considered in light of the risks of late strangulation.
对于无症状的胸腹刺伤患者，目前尚无可靠的膈肌损伤诊断检测方法。在30个月的时间里，连续治疗了41例左下胸部前刺伤患者。在前15个月中诊治的21例患者中，手术仅用于有腹膜刺激征或持续失血的患者。这21例患者中有10例（48%）需要进行剖腹手术；2例（10%）有单纯膈肌损伤，有1例剖腹手术结果为阴性。在未接受探查的11例患者中，2例（18%）在受伤后18个月内因膈疝嵌顿而复诊。在随后的15个月里，对接下来的20例患者进行了前瞻性研究，采用常规剖腹手术治疗。比较了这两组患者的入院收缩压、气胸发生率、剖腹手术率、膈肌损伤率、单纯膈肌损伤率以及不必要的剖腹手术率。前瞻性研究组中有10例患者（50%）被发现有单纯膈肌损伤（P<0.005），7例（35%）剖腹手术结果为阴性（P<0.02）。隐匿性膈肌损伤的实际发生率可能被低估。在前瞻性研究组中，对于左下胸部前刺伤采用常规剖腹手术的策略，使得诊断并修复的单纯膈肌损伤数量增加了五倍。在缺乏可靠的非侵入性膈肌穿透诊断检测方法的情况下，鉴于后期绞窄的风险，应考虑进行剖腹手术。
