Koizumi K, Shoji T, Tanaka S, Osaka S, Shioda M, Mashiko K
Department of Thoracic Surgery, Nippon Medical School, Tokyo, Japan.
Nihon Kyobu Geka Gakkai Zasshi. 1990 Jan;38(1):165-70.
A 22 year-old man was brought to our hospital about twenty-three minutes following a high-speed motorbicycle accident in which he had blunt chest trauma. He was in severe respiratory distress with marked dyspnea and restless with extensive subcutaneous emphysema involving anterior chest wall, cervical and bilateral inguinal regions. A chest X-ray revealed bilateral pneumothorax involving mediastinal emphysema and also fracture of right submandibular and clavicula. In spite of orotracheal intubation and insertion of bilateral chest tube, continuous air leak and pneumothorax did not improve. Bronchoscopy revealed the disruption of mucosa of the right main bronchus at the bifurcation. Emergency right thoracotomy was performed and there was the complete disruption of the right main bronchus. Anastomosis of the right main bronchus with circumferential resection was undertaken on May 30, 1987 about two hours after trauma. About three months after reconstruction, bronchoscopic examination revealed stomal stenosis with deformation of tracheobronchial cartilage and granulation. The stenosis showed severe irregularity by deformed cartilage and thickened scar, so widening by Nd-YAG laser vaporization was inadequate in effect. Seven months after first reconstruction, we performed re-reconstructive operation, right upper sleeve lobectomy with partial resection of carcina and right wall of trachea for scar with severe deformation of cartilage. Following the operation, the patient suffered from sepsis with pneumonitis accompanied by lung edema. This complication was treated successfully. We considered that acute pneumonitis was caused by reventilation with increase of perfusion after tracheobronchial reconstruction. Consequently, we thought it important to treat such patients with long term IPPB postoperatively with adequate medication for respiratory system.
一名22岁男性在高速摩托车事故中胸部受到钝性创伤，事故发生约23分钟后被送往我院。他处于严重的呼吸窘迫状态，呼吸急促且烦躁不安，前胸壁、颈部及双侧腹股沟区广泛皮下气肿。胸部X线显示双侧气胸伴纵隔气肿，右侧下颌骨及锁骨骨折。尽管进行了经口气管插管及双侧胸腔闭式引流，持续漏气及气胸仍未改善。支气管镜检查显示右主支气管分叉处黏膜破裂。急诊行右开胸手术，发现右主支气管完全断裂。于1987年5月30日，即创伤后约两小时，对右主支气管进行了环形切除吻合术。重建术后约三个月，支气管镜检查显示吻合口狭窄，气管支气管软骨变形并有肉芽组织。狭窄因软骨变形和瘢痕增厚而严重不规则，因此用Nd-YAG激光汽化扩宽效果不佳。首次重建术后七个月，我们进行了再次重建手术，即右上叶袖状肺叶切除术，同时部分切除癌肿及气管右壁瘢痕，该瘢痕软骨严重变形。术后患者发生败血症伴肺炎并伴有肺水肿。该并发症得到成功治疗。我们认为急性肺炎是由气管支气管重建后再通气增加伴灌注增加所致。因此，我们认为术后对这类患者进行长期间歇性正压通气（IPPB）并给予适当的呼吸系统药物治疗很重要。
