背景:纵隔气肿是由于多种原因空气进入胸膜内结缔组织间隙之间的纵隔的一种情况。它可以是自发性的或继发于胸部创伤,食管穿孔,医学诱发因素,等。它的常见症状是胸痛,胸闷,和呼吸窘迫。大多数纵隔气肿患者症状轻微,但是严重的纵隔气肿会导致呼吸和循环衰竭,造成严重后果。
方法:一位75岁的老人,独自生活,饮酒后突然出现严重的上腹痛伴胸闷。由于他的住所偏远,没有邻居,病人被他的侄子发现,并在疾病发作后的第二天早上被送往医院。计算机断层扫描(CT)显示腹腔中有游离气体,纵隔气肿,皮下气胸.上消化道造影显示食管粘膜完整,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对患者进行开腹胃穿孔修补术。对患者腹壁的肌肉层进行手术切口,并显示出大量腹膜下气体。腹膜的持续切口显示胃窦存在约0.5厘米的穿孔,我们在病理检查后修复了它。术后,患者接受了高流量吸氧和咳嗽锻炼。术后第一天和第六天进行胸部CT检查,纵隔和皮下气体逐渐减少。
结论:胃穿孔后,腹腔内大量游离气体可通过膈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。纵隔气肿患者,与腹腔镜手术相比,开放手术避免了气腹引起的膈肌抬高,并避免了纵隔压力的增加。此外,胸段硬膜外麻醉联合静脉麻醉也避免了机械通气对纵隔的压力。
BACKGROUND: 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, etc. 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.
METHODS: 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.
CONCLUSIONS: 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.