右侧开胸手术治疗先天性心脏病

目的探讨右侧开胸体外循环手术治疗先天性心脏病的应用指征及效果。方法回顾性分析678例经右侧开胸体外循环手术治疗的先天性心脏病患者的临床资料。结果室间隔缺损修补术512例,房间隔缺损修补术113例,法洛四联症根治术32例,部分型心内膜垫缺损矫治术11例,三房心矫治术5例,其他畸形手术5例;本组手术无死亡病例,术后发生并发症28例,其中术后出血行开胸止血6例,迟发心包积液经心包引流1例,Ⅲ度房室传导阻滞安装永久起搏器1例,<2mm的残余分流19例,行二次气管插管1例。结论右侧开胸手术治疗先天性心脏病由于切口隐蔽,创伤小,术后恢复快,对患儿心理影响较小,在熟练掌握常规手术技术及特殊手术技巧的基础上,是治疗先天性心脏病的较好选择。     

Diaphragmatic rupture due to blunt trauma: morbidity and mortality in 42 cases

We present an analysis of 42 cases of acute rupture of the diaphragm by blunt trauma. There were 31 men (74%) and 11 women (26%); the mean age was 32.8 years +/- 2.4 SEM. At admission, hypovolemic shock was present in 45% of the cases, pelvic fracture in 36%, and severe respiratory distress in 21%. Diaphragmatic rupture was suggested before operation by unilateral elevation of the diaphragm, supradiaphragmatic densities, and displacement of abdominal organs into the thorax, as shown by chest films and GI series in 18 cases (43%). The left hemidiaphragm was injured in 24 cases (57%), the right in 15 (36%), and both sides in three (7%). Of the 17 patients (40%) found to have an abdominal organ in the thorax, 12 had had a left-sided rupture. Only four patients (10%) had solitary diaphragmatic injuries. Associated injuries (usually two or more) occurred in 38 cases (90%); they were abdominal in 34, musculoskeletal in 26, neurologic in 16, and thoracic in nine. The injuries were repaired through a celiotomy in 33 cases, by thoracotomy in six, and by separate celiotomy and thoracotomy in three. Postoperative complications occurred in 29 cases, the most common being pulmonary (18), systemic sepsis (six), and recurrent bleeding (three). There were 14 deaths, for a mortality of 33%. Seven were operative and due to massive hemorrhage; the late deaths were caused by systemic sepsis in five and neurologic trauma in two. We conclude that (1) diaphragmatic rupture after blunt trauma must be suspected when specific radiologic findings are present; (2) solitary diaphragmatic injuries seldom occur; (3) in most cases, morbidity or mortality is caused by the severity of the associated injuries; and (4) most diaphragmatic injuries can be repaired through a celiotomy, and all of them should be repaired to avoid the sequela of entrapment of abdominal organs in the thorax.     

多发肋骨骨折并发创伤性膈疝患者的微创手术效果研究

目的探究多发肋骨骨折并发创伤性膈疝患者的微创手术效果。方法回顾性分析2010年1月-2016年1月该院收治的48例多发肋骨骨折并发创伤性膈疝患者的临床资料,根据患者的手术方法将患者分为对照组和观察组,各24例。对照组患者采用开胸手术治疗,观察组患者采用胸腔镜手术治疗。对比两组患者的围术期情况、临床疗效、并发症发生情况。结果观察组患者的切口长度、手术时间、术中出血量、术后胸腔引流时间和住院时间均低于对照组患者,差异具有统计学意义(P0.05)。两组患者肋骨骨折经绷带固定法治疗后均痊愈,观察组患者入组后均无中转开腹手术。且观察组和对照组患者创伤性膈疝的临床有效率分别为91.67%和79.16%,观察组和对照组患者的并发症总发生率分别为8.32%和37.48%,差异具有统计学意义(P0.05)。结论采用胸腔镜手术治疗多发肋骨骨折并发创伤性膈疝对患者造成的创伤较小,手术时间短,术中出血量少,术后恢复快,且疗效较佳,并发症发生率低,可以在临床上进一步推广和使用。     

创伤性膈肌破裂的诊治

目的探讨膈肌破裂的特点及诊断、治疗方法。方法总结我院收治的创伤性膈肌破裂患者16例的临床资料。手术治疗15例,非手术治疗1例。手术方法包括经胸膈肌破裂修补术8例,经腹膈肌破裂修补术5例,胸腹联合膈肌破裂修补术2例;脾切除2例,脾修补术1例,胃穿孔修补术2例,空肠破裂修补术4例,小肠切除吻合术2例,结肠破裂造瘘术1倒。结果死亡1例,其余所有病例均痊愈出院。结论创伤性膈肌破裂应争取尽早诊断,一经诊断应手术治疗,应根据患者的病情采取相应的手术切口和术式。     

同期双原发食管癌胃癌的外科治疗

目的：探讨同期双原发食管癌胃癌外科治疗的可行性及术式的选择。方法：回顾分析2005年1月—2010年10月15例同期双原发食管癌胃癌接受手术治疗的患者的临床资料。结果：手术经左胸切口6例,左胸、腹联合切口1例,左胸、左颈切口1例,右胸、腹2切口3例,右胸、腹及左颈3切口4例;胃代食管11例,结肠代食管4例。所有患者无围术期病死,平均住院时间：胃代食管组13.4d,结肠代食管组53.0d。围术期并发症发生率为46.7%。结论：同期双原发食管癌胃癌行选择性手术治疗是安全的,在胃无法作为食管替代器官时,可以选择行结肠代替食管。     

Single Lead DDD System: A Comparative Evaluation of Unipolar, Bipolar, and Overlapping Biphasic Stimulation and the Effects of Right Atrial Floating Electrode Location on Atrial Pacing and Sensing Thresholds

Single lead DDD pacing using unipolar or bipolar stimulation is limited by high atrial threshold. Overlapping biphasic (OLBI) waveform stimulation via atrial floating ring electrodes may preferentially enhance atrial pacing and avoid diaphragmatic pacing. Single lead DDD pacing with OLBI atrial pacing was studied in 12 patients (6 men and 6 women; mean age 74 ± 7 years) with complete heart block. At implantation, atrial bipolar rings (area 27 mm², separation 10 mm) were positioned at radiological defined high, mid, and low right atrial (RA) levels, and P wave amplitude and atrial and diaphragmatic pacing thresholds were determined in each position using unipolar, bipolar, and OLBI stimulation in random order. Although statistically insignificant, both the maximum and minimum sensed P wave amplitudes tended to be lower in the low RA position. Independent of the stimulation modes, minimum atrial pacing threshold occurred in the mid-RA. At mid-RA. the atrial pacing threshold was significantly lower with OLBI pacing compared with either unipolar or bipolar mode (3.9 ± 2.2 V vs 6.7 ± 3.5 V and 6.9 ± 3.5 V, P < 0.05). Although the diaphragmatic thresholds were similar, OLBI pacing modes in the mid-RA and final location significantly improved the Safety margin for avoidance of diaphragmatic pacing compared with unipolar mode. There was no correlation between atrial pacing and sensing threshold. At predischarge testing, all but one patient who developed atrial fibrillation had satisfactory atrial capture and a stable atrial pacing threshold (day 0: 2.6 ± 1.1 V vs day 2: 3.2 ± 1.3V, P = NS). However, diaphragmatic pacing occurred in four of 11 (36%) patients, especially in the upright position (sitting and standing). Our preliminary clinical results suggest that OLBI pacing via atrial floating ring electrodes can reduce the atrial pacing threshold. To optimize atrial pacing and sensing, the bipolar electrodes should be located at the mid-RA level first, although the high RA is an alternative. Despite significant improvements in the safety margin for diaphragmatic pacing with OLBI pacing, diaphragmatic stimulation remains a clinical problem.     

Intrathoracic cardiac position in the fetus.

In a 4-year period, 83 fetuses have been noted to have an abnormal fetal heart position within the thorax on fetal echocardiography. In 55 cases where the heart lay in the right chest, this was due to the presence of a left-sided diaphragmatic hernia; in one case, the heart was abnormally far into the left chest because of a left-sided diaphragmatic hernia. Of the remaining 27 cases, the heart lay in the right chest in 16 cases. In seven of those 16, there was a congenital heart malformation; in six, there were lung anomalies; a hiatus hernia was present in one; both congenital heart disease and lung abnormality were present in one and one fetus had isolated dextrocardia. In nine cases, the heart lay in the center of the chest and in three, the heart lay further to the left than normal. Congenital heart disease was found in nine of these 12. Chromosomal anomalies were found in four of the 27 cases with an abnormal heart position but an intact diaphragm. In summary, it is important to be familiar with the normal cardiac orientation within the thorax and to investigate abnormalities of position. A diaphragmatic hernia will be the most common underlying cause but, where the diaphragm is intact, other explanations must be sought in order to counsel correctly or plan appropriate perinatal management. Lung disorders, congenital heart disease and chromosomal anomalies will be the principal differential diagnoses.     

Electromyographic tools to assess hemidiaphragm paralysis

Non‐invasive measurements of the phrenic nerve conduction time (CT) and diaphragmatic electromyographic response to voluntary inspiratory efforts may help to document an abnormal diaphragmatic function in the presence of hemidiaphragm elevation on chest radiographs. Twenty‐one patients were addressed for the diagnosis of abnormal placement and motion of the right (13) or left (8) cupola on chest radiographs. CT was measured by recording the diaphragmatic M‐wave evoked by electrical transcutaneous phrenic nerve stimulation. The integrated diaphragmatic surface electromyogram (Edi) was recorded during sniff and Müller manoeuvres. Four patients were followed up during the next 8–16 months. Among the twenty‐one patients, five (24%) had a lengthened or absent CT. A right‐to‐left peak Edi asymmetry was measured in fourteen (67%), including those having abnormal CT. Agreement between side‐related radiographic abnormalities and Edi asymmetry was high in the cases of an elevation of the right cupola (12/13, 92%) but poor when the left cupola was suspected (1/8, 13%). Long‐term follow‐up of Edi asymmetry showed a partial or total recovery. Thus, the combination of measurements of phrenic nerve CT and Edi recordings during voluntary inspiratory efforts confirmed 67% of the radiographic suspicion of diaphragmatic dysfunction.     

Blunt traumatic rupture of the diaphragm: sonographic diagnosis.

Ultrasonographic features of seven patients with diaphragmatic rupture due to blunt trauma were analyzed. The ruptures occurred at the left hemidiaphragm in four patients and at the right in three. Direct ultrasonographic findings were as follows: disrupted diaphragm in four patients; nonvisualized diaphragm in three patients; floating diaphragm in two patients; and herniation of the liver or bowel loops through the diaphragmatic defect in three patients. Indirect sonographic findings included pleural effusion or subphrenic fluid collection in five patients and splenic laceration in one. Although the number of patients was limited, ultrasonography was very useful for the diagnosis of diaphragmatic rupture.     

全身麻醉胸部术后早期半卧位的探讨

目的探讨全身麻醉胸部术后早期半卧位对患者生理机能康复及舒适度的影响。方法选择2006年1月-2007年2月全身麻醉＋硬膜外麻醉胸部手术患者100例，随机分为实验组50例和对照组50例。实验组术后2h给予半卧位，对照组按照常规术后平卧6h。于术后2h和4h分别测定两组患者的心率、血压、血氧饱和度（SpO2），评定胸腔引流和肺不张的发生情况，比较两组患者的舒适度。结果两组患者术后SpO2、胸腔引流量、肺不张发生率和舒适度差异有统计学意义（P〈0．05）。结论早期半卧位全身麻醉胸部手术后患者在呼吸、循环功能的恢复，提高患者术后生活质量。     

产前超声诊断先天性膈膨升及漏误诊分析

目的:探讨超声诊断胎儿先天性膈膨升的声像图特征并对漏诊、误诊进行分析.方法:分析2014年1月—2018年12月产前超声诊断先天性膈膨升的10例胎儿病例资料及随访结果,总结其胸腔横切面、冠状面、矢状面的产前超声图像特征,观察双侧膈肌的矛盾运动,并与产前MRI、产后胸片、解剖结果对比分析.结果:10例胎儿膈膨升中右侧6例...     

Point-of-care sonographic detection of left endobronchial main stem intubation and obstruction versus endotracheal intubation.

OBJECTIVE: Determining the correct position of endotracheal tubes in critically ill patients may be complicated by external factors such as noise, body habitus, and the need for ongoing resuscitation. Multiple detection techniques have been developed to determine the correct endotracheal tube position, recently including the use of sonography to evaluate lung expansion and diaphragmatic excursion. These techniques have also been applied to diagnosis of right endobronchial main stem intubation, which may be confused with a unilateral pneumothorax in some cases. METHODS: We describe the sonographic findings in a case series of endobronchial main stem intubations and obstruction, highlighting the utility of this sonographic application. Previous literature and future applications are discussed. RESULTS: Sonographic detection of the sliding lung sign, the lung pulse, and diaphragmatic excursion can accurately detect main stem bronchial intubation as well as bronchial obstruction. CONCLUSIONS: Clinical use of lung sonography may decrease the need for chest radiography and may allow more rapid diagnosis of main stem intubation and bronchial obstruction.     

Supine fall in lung volumes in the assessment of diaphragmatic weakness in neuromuscular disorders

OBJECTIVE: To determine whether diaphragmatic function can be determined by noninvasive respiratory indices in neuromuscular disease. DESIGN: Vital capacity (VC) and mouth pressure generated during a maximal static inspiratory effort (Pi max) were measured with patients in both sitting and supine positions. SETTING: Rehabilitation hospital. PATIENTS: Twenty-four patients with generalized neuromuscular disease. MAIN OUTCOME MEASURES: Changes in indices from sitting to supine position were compared with invasive diaphragmatic function indices consisting of transdiaphragmatic pressures during maximal sniff (Pdi sniff) and the ratio of gastric pressure (Pga) increases over transdiaphragmatic pressure (DeltaPga/DeltaPdi) during quiet breathing. RESULTS: The fall in VC in the supine position was greater in the 15 patients who had spontaneous paradoxical diaphragmatic motion (DeltaPga/DeltaPdi < 0) than in the 9 patients who did not. Specificity and sensitivity of a greater than 25% supine fall in VC for the diagnosis of diaphragmatic weakness (DeltaPga/DeltaPdi < 0 and/or Pdi sniff < 30cmH2O) were 90% and 79%, respectively. Stepwise multiple regression analysis of Pdi sniff showed that both the supine fall in VC and Pi max were associated with diaphragmatic weakness (R(2) =.66; p <.0001). These factors contributed 52% and 14% of the Pdi sniff variance, respectively. CONCLUSIONS: Simple VC measurement in the sitting and supine positions may be helpful in detecting severe or predominant diaphragmatic weakness.     

X线下膈影异常108例分析

目的:通过膈影异常形态,位置,运动的改变来分析胸部及膈肌病变,从而进一步评价X线检查对膈影异常的诊断价值。材料与方法:搜集经临床确诊的108例膈影异常者,均行胸部正侧位摄片,并选择性结合透视,消化道造影。结果:一侧膈影位置升高,膈影尚清晰者,常见于肺部病变及膈肌本身病变,前者,主要是胸腔压力减低所致,故可有纵隔移位,移向患侧,对侧代偿性肺气肿征象;后者多无纵隔移位;一侧隔肌位置升高,膈影部分或完全不能见到者,多见于膈疝。膈肌位置正常,膈影部分或完全消失者,多见于胸腔、肺底积液。膈影位置大致正常或有升高,形态黏连不规整者,多见于胸膜病变。结论:X线下可观察到由胸部病变和肺肌本身病变引起的膈影异常,进而提供临床有价值的诊断。     

右室流入道起搏治疗缓慢性心律失常44例临床研究

目的采用右室流入道和传统的右室心尖部起搏两种不同的方法治疗缓慢性心律失常,观察起搏参数、并发症、心电图QRS时限和心功能的变化。方法随机将86例患者分为右室流入道起搏组44例,右室心尖部起搏组42例,分别观察两组起搏器植入时、起搏3和6个月时的起搏参数、并发症、心电图QRS时限和心功能的变化。结果两组不同时期起搏参数、并发症比较,差异无统计学意义;而右室流入道起搏组心电图QRS时限明显短于右室心尖部,心功能改善也显著优于右室心尖部,差异有统计学意义,且心功能改善随起搏时间延长呈逐步好转趋势,而心电图QRS时限不同时期时限较固定。结论采用右室流入道起搏治疗,其心功能改善明显优于传统的右室心尖部起搏,值得在临床上推广。     

创伤性膈肌损伤50例诊治分析

目的探讨创伤性膈肌损伤的早期诊断与治疗方法。方法对2002年2月至2009年3月收治的50例创伤性膈肌损伤患者的临床资料进行回顾性分析。结果 50例患者均为闭合性损伤,其中交通事故伤23例,高处坠落伤19例,挤压伤8例;术前经X线检查明确诊断23例,经CT检查明确诊断20例,7例经剖胸或剖腹探查时确诊;伤后24 h内手术34例,24 h～48 h手术6例;术前给予抗休克治疗并同时紧急行手术治疗,经胸手术38例,胸腹联合切口手术10例,经腹手术2例。术后发生全身炎症反应综合征(SIRS)导致器官功能障碍综合征(MODS)死亡3例,其余47例手术治疗出院,随访疗效满意。结论早期采用胸部X射线、CT检查结合临床表现综合诊断创伤性膈肌损伤是可行的,及时和正确地给予手术治疗是救治的关键。     

新生儿期膈疝的超声表现及诊断价值

目的探讨新生儿期膈疝的超声声像图特点。 方法选择2000年1月至2017年12月首都医科大学附属北京儿童医院超声及手术病理检查确诊为新生儿期膈疝的患儿19例,平均出生（12.8±11.7）d,其中3例产前已诊断膈疝,11例表现为呼吸困难,3例表现为呕吐,2例表现为心动过速。总结19例新生儿超声声像图特点。 结果19例新生儿膈疝术前超声显示自左侧胸腔内疝入小肠4例,胃底2例,脾脏3例,1例疝入物为左侧肾上腺及左肾上极;右侧胸腔内疝入肠管3例,4例疝入物为部分肝脏右叶及胆囊,2例疝入物为右肾上腺及右肾。食道裂孔疝疝入物均为胃。后外侧疝表现为膈肌不连续,位于腹腔内或腹膜后的脏器通过不连续的膈肌进入胸腔水平。食道裂孔疝表现为胃体通过食管裂孔疝入胸腔。术前超声诊断后外侧疝16例,食道裂孔疝2例,1例膈疝与膈膨升不能鉴别。与术前相关影像及手术检查结果对照,术前超声诊断符合率为94.74%（18/19）。 结论新生儿期患儿胸壁软组织薄,超声检查可清晰实时多角度显示膈肌情况,诊断符合率不低于CT或磁共振成像,且无放射性损伤,是新生儿期膈疝患儿首选的影像学检查方法。     

粗大膈肌束的超声表现

目的探讨隔肌束的发生率及其超声表现。方法连续观察217例门诊及住院患者．超声仔细扫查肝脏膈顶区域．发现并记录膈肌束的位置、数目．超声表现，同时与脾脏膈顶区作比较。结果217例患者．共出现膈肌束38例．其巾多发5例，男女间未见差异，但随年龄增加有增多趋势．70岁以上患者发生率明显增高。膈肌束可表现为肝内结节样强回声结构．动态观察可行鉴别．脾脏未观察到相似现象．结论粗大膈肌束并不少见．正确认阻膈肌不的超声表现可拭少肝内病变的误诊。     

创伤性膈疝15例

目的总结膈肌破裂和创伤性膈疝的临床表现及诊断治疗方法。方法对15例创伤性膈疝（左侧13例,右侧2例）患者的发病原因、合并伤、临床表现、诊断及治疗情况进行回顾性分析。结果本组15例均有2处以上合并损伤,其中多发肋骨骨折及血气胸9例,肺裂伤2例,胃破裂1例,骨盆骨折3例。第12胸椎椎体骨折伴截瘫1例,肝破裂2例,脾破裂1例,颅脑外伤2例,失血性休克5例。本组病例伤后确诊时间为24 h以内7例,24~72 h 7例,7 d 1例。12例术前已明确诊断,其中1例曾被误诊为张力性气胸,直到胸腔引流管引出食物残渣才得以诊断。3例在手术探查中发现。本组15例均经手术治疗后痊愈。结论单纯创伤性膈疝较少见,多有较严重的合并伤,表现缺乏特异性,易被伴发的胸腹部脏器损伤所掩盖,从而造成误诊或漏诊。详细了解受伤原因、部位及作用力方向,是早期诊断的关键。通过全面细致的体格检查、X线检查结合胸部CT、胃肠钡餐透视、B超等,可明确诊断。早期治疗应以抢救生命为重要原则,按照先重后轻的原则首先处理致命伤。膈疝一经确诊,无论裂口大小,均应及时手术。     

The impact of different positions and thoracial restrains on respiratory induced cardiac motion.

One of the limiting factors for high resolution magnetic resonance coronary angiography (MRCA) is the motion of the heart during breathing. Current approaches use mainly motion correction in one dimension. We aimed to determine the relation between diaphragmatic motion and cardiac motion as well as the potential influence from external restraints reducing thoracical anterior posterior (AP) motion. Four real time navigators were used to collect motion parameters, diaphragmatic cranio-caudal, cardiac cranio-caudal, diaphragmatic anterior-posterior, and thoracical anterior-posterior. Measurements were performed in prone and supine position and supine position with a thorax restraint. In supine, the highest correlation was found between cranio-caudal diaphragmatic and cardiac motion (r2 = 0.71, slope = 0.26; p < 0.05). Prone positioning or external restraints led to significant changes of motion patterns, with a lower correlation between diaphragmatic and cardiac position. External manipulation of breathing by prone positioning or thoracical restraints leads to a less accurate prediction of cardiac position from assessment of diaphragmatic positions compared to standard supine positioning.