Shah R, Sabanathan S, Mearns A J, Choudhury A K
Department of Thoracic Surgery, Bradford Royal Infirmary, United Kingdom.
Ann Thorac Surg. 1995 Nov;60(5):1444-9. doi: 10.1016/0003-4975(95)00629-Y.
Traumatic diaphragmatic rupture remains a diagnostic challenge, and associated injuries determine the outcome in those diagnosed early, whereas that of latent cases is dependent on the consequence of the diaphragmatic rupture: namely, the diaphragmatic hernia. To analyze the clinical and radiologic features and the therapeutic implications, we reviewed 980 patients reported in the English-language literature. This injury affects predominantly males (male:female = 4:1) in the third decade of life, and is often caused by blunt trauma (75%). There were 1,000 injuries, of which 685 (68.5%) were left-sided, 242 (24.2%) right-sided, 15 (1.5%) bilateral, and 9 (0.9%) pericardial ruptures; 49 cases were unclassified. Chest (43.9%) and splenic (37.6%) trauma were the most common associated injuries. The diagnosis was made preoperatively in 43.5% of cases, whereas in 41.3% it was made at exploration or at autopsy and on the remaining 14.6% of the cases the diagnosis was delayed. The mortality was 17% in those in whom acute diagnosis was made, and the majority of the morbidity in the group that underwent operation was due to pulmonary complications. Uniform diagnosis depends on a high index of suspicion, careful scrutiny of the chest roentgenogram in patients with thoracoabdominal or polytrauma, and meticulous inspection of the diaphragm when operating for concurrent injuries. Repeated evaluation for days after injury is necessary to discern injury in patients not requiring laparotomy. Acute diaphragmatic injuries are best approached through the abdomen, as more than 89% of patients with this injury have an associated intraabdominal injury. Patients with diaphragmatic rupture presenting in the latent phase have adhesion between the herniated abdominal and intrathoracic organs, and thus the rupture is best approached via a thoracotomy.
创伤性膈肌破裂仍然是一个诊断难题，早期诊断出的病例其相关损伤决定预后，而隐匿性病例的预后则取决于膈肌破裂的后果，即膈疝。为分析其临床和放射学特征及治疗意义，我们回顾了英文文献报道的980例患者。这种损伤主要影响30岁左右的男性（男:女 = 4:1），常由钝性创伤引起（75%）。共有1000处损伤，其中685处（68.5%）在左侧，242处（24.2%）在右侧，15处（1.5%）为双侧，9处（0.9%）为心包破裂；49例未分类。胸部创伤（43.9%）和脾脏创伤（37.6%）是最常见的相关损伤。43.5%的病例术前做出诊断，41.3%在探查或尸检时做出诊断，其余14.6%的病例诊断延迟。急性诊断病例的死亡率为17%，手术组的大多数并发症是肺部并发症。统一诊断取决于高度的怀疑指数、对胸腹联合伤或多发伤患者胸部X线片的仔细检查以及在处理合并伤时对膈肌的细致检查。受伤后数天进行反复评估对于不需要剖腹手术的患者辨别损伤很有必要。急性膈肌损伤最好经腹部处理，因为超过89%的此类损伤患者伴有腹内损伤。隐匿期出现膈肌破裂的患者，其疝入胸腔的腹腔脏器与胸腔内器官之间存在粘连，因此最好经胸手术处理破裂。
