Dai Zhi-Cheng, Gui Xun-Wu, Yang Feng-He, Zhang Hao-Yuan, Zhang Wen-Feng
Department of General Surgery, Mengcheng County First People's Hospital, Mengcheng 233500, Anhui Province, China.
Department of Medical Imaging, Mengcheng County First People's Hospital, Mengcheng 233500, Anhui Province, China.
World J Clin Cases. 2024 Feb 6;12(4):859-864. doi: 10.12998/wjcc.v12.i4.859.
Mediastinal emphysema is a condition in which air enters the mediastinum between the connective tissue spaces within the pleura for a variety of reasons. It can be spontaneous or secondary to chest trauma, esophageal perforation, medically induced factors, Its common symptoms are chest pain, tightness in the chest, and respiratory distress. Most mediastinal emphysema patients have mild symptoms, but severe mediastinal emphysema can cause respiratory and circulatory failure, resulting in serious consequences.
A 75-year-old man, living alone, presented with sudden onset of severe epigastric pain with chest tightness after drinking alcohol. Due to the remoteness of his residence and lack of neighbors, the patient was found by his nephew and brought to the hospital the next morning after the disease onset. Computed tomography (CT) showed free gas in the abdominal cavity, mediastinal emphysema, and subcutaneous pneumothorax. Upper gastrointestinal angiography showed that the esophageal mucosa was intact and the gastric antrum was perforated. Therefore, we chose to perform open gastric perforation repair on the patient under thoracic epidural anesthesia combined with intravenous anesthesia. An operative incision of the muscle layer of the patient's abdominal wall was made, and a large amount of subperitoneal gas was revealed. And a continued incision of the peritoneum revealed the presence of a perforation of approximately 0.5 cm in the gastric antrum, which we repaired after pathological examination. Postoperatively, the patient received high-flow oxygen and cough exercises. Chest CT was performed on the first and sixth postoperative days, and the mediastinal and subcutaneous gas was gradually reduced.
After gastric perforation, a large amount of free gas in the abdominal cavity can reach the mediastinum through the loose connective tissue at the esophageal hiatus of the diaphragm, and upper gastrointestinal angiography can clarify the site of perforation. In patients with mediastinal emphysema, open surgery avoids the elevation of the diaphragm caused by pneumoperitoneum compared to laparoscopic surgery and avoids increasing the mediastinal pressure. In addition, thoracic epidural anesthesia combined with intravenous anesthesia also avoids pressure on the mediastinum from mechanical ventilation.
纵隔气肿是一种因多种原因导致空气进入胸膜内结缔组织间隙之间的纵隔的病症。它可以是自发性的，也可以继发于胸部创伤、食管穿孔、医源性因素。其常见症状为胸痛、胸闷和呼吸窘迫。大多数纵隔气肿患者症状较轻，但严重的纵隔气肿可导致呼吸和循环衰竭，造成严重后果。
一名75岁独居男性，饮酒后突发严重上腹部疼痛伴胸闷。由于其住所偏远且无邻居，患者被侄子发现，发病次日早晨被送至医院。计算机断层扫描（CT）显示腹腔内游离气体、纵隔气肿和皮下气肿。上消化道造影显示食管黏膜完整，胃窦穿孔。因此，我们选择在胸段硬膜外麻醉联合静脉麻醉下为患者行开放性胃穿孔修补术。在患者腹壁肌肉层做一个手术切口，发现大量腹膜下气。继续切开腹膜发现胃窦有一个约0.5厘米的穿孔，经病理检查后进行修补。术后，患者接受高流量吸氧和咳嗽训练。术后第1天和第6天进行胸部CT检查，纵隔和皮下气体逐渐减少。
胃穿孔后，腹腔内大量游离气体可通过膈肌食管裂孔处的疏松结缔组织到达纵隔，上消化道造影可明确穿孔部位。对于纵隔气肿患者，与腹腔镜手术相比，开放手术可避免气腹引起的膈肌抬高，避免增加纵隔压力。此外，胸段硬膜外麻醉联合静脉麻醉还可避免机械通气对纵隔的压力。
