纵隔脓肿的开胸手术治疗
摘要
目的：纵隔脓肿临床发病率低，但病情危重、进展快，临床上主要以外科手术治疗为主，本文主要探讨开胸手术治疗纵隔脓肿的有效性。
方法：对2006年6月~2012年1月吉林大学第二临床医学院胸外科收治的9例纵隔脓肿的临床资料进行分析，其中男性6例，女性3例，年龄为35~61岁，平均年龄48岁；其中7例为口腔源性及颈部感染，2例为食管异物致食管穿孔感染；临床表现均伴有发热，其中1例伴全身脓毒血症；影像学上均于CT上发现纵隔内局限性阴影伴纵隔增宽。经诊断明确，积极行开胸手术，充分引流，术后给予抗生素经验用药抗感染，再根据细菌培养结果调整用药，营养支持（6例口腔源性及颈部感染患者术后第1天开始恢复肠内营养，1例脓毒血症患者及2例食管异物穿孔患者术后先给予胃肠减压及肠外营养，待胃肠道功能恢复后给予肠外营养），及呼吸循环对症治疗。
结果：经积极外科手术治疗后临床治愈出院8例，住院时间16~26天，平均住院日21天。家属放弃治疗1例，术后生命体征平稳，因经济原因未愈出院，在当地医院继续治疗，一个月后复诊，恢复良好。
结论：经积极的开胸手术治疗纵隔脓肿是安全可行的，术中充分打开脓肿分隔，多放置多侧孔引流管，术后给予有效的抗生素抗感染，充分的营养支持，通过外科手段系统治疗纵隔脓肿，可以有效的延缓病情进展，纠正病理改变，降低病死率。
Objective:Though the occurrence at a low level,the mediastinal abscess is in a seriously bad condition and progress very fast.The treatments give priority to surgery in clinical conditions.Here we mainly discuss the validity of open thoracotomy on mediastinal abscess.
Methods:By analysing the clinical materials collected from the nine patients of mediastinal abscess which the Thoracic Surgical Department in No.2Hospital of Jin Lin University has received since June2006to January2012, there were six male patients and three female patients,the age vary from35to61,the average age goes to48;seven of them were due to the infection from odontogenic and neck, while the other two were due to the infection of perforation caused by foreign body;They all got a fever,and one of them had pyemia;they were all local shadows in mediastinum on CT with a wider mediastinum.They were all operated open thoracotomies actively once they were diagnosed accurately,with incision and drainage possibly.The therapies after the operation involved anti-infection with experienced antibiotics,which were adjusted to the outcome of bacterial culture,nutritional supports(six of them which were due to the infection from odontogenic and neck received parenteral alimentation as soon as possible,while the one with pyemia and the other two which were due to the infection of perforation caused by foreign body received gastrointestinal decompression and enteral nutrition,which were shifted to parenteral alimentation as soon as their gastrointestinal function recovered),and symptomatic treatment on respiratory and circulatory system.
Results:There were eight cases who were cured by active operations, the length of being in hospital was during16~26day. There was one case whose family gave up the post-op treatment, and whose vital signs were stable, the patient was discharged from hospital uncured, for the poor economic condition, he continued his post-op treatment back to the local and come back to our hospital for a check in one month's time, recovering his health well.
Conclusion:The proactive open thoracotomy for mediastinal abscess is safe and feasible.We can open abscess septum throughly, lay the drainage tube with multi-side possibly,give the anti-infection effectively and ample nutritional supports after the operation.It is the systemic therapies effectively that can we retard the progress of disease development, correct the pathology, and reduce the mortality.
方法：对2006年6月~2012年1月吉林大学第二临床医学院胸外科收治的9例纵隔脓肿的临床资料进行分析，其中男性6例，女性3例，年龄为35~61岁，平均年龄48岁；其中7例为口腔源性及颈部感染，2例为食管异物致食管穿孔感染；临床表现均伴有发热，其中1例伴全身脓毒血症；影像学上均于CT上发现纵隔内局限性阴影伴纵隔增宽。经诊断明确，积极行开胸手术，充分引流，术后给予抗生素经验用药抗感染，再根据细菌培养结果调整用药，营养支持（6例口腔源性及颈部感染患者术后第1天开始恢复肠内营养，1例脓毒血症患者及2例食管异物穿孔患者术后先给予胃肠减压及肠外营养，待胃肠道功能恢复后给予肠外营养），及呼吸循环对症治疗。
结果：经积极外科手术治疗后临床治愈出院8例，住院时间16~26天，平均住院日21天。家属放弃治疗1例，术后生命体征平稳，因经济原因未愈出院，在当地医院继续治疗，一个月后复诊，恢复良好。
结论：经积极的开胸手术治疗纵隔脓肿是安全可行的，术中充分打开脓肿分隔，多放置多侧孔引流管，术后给予有效的抗生素抗感染，充分的营养支持，通过外科手段系统治疗纵隔脓肿，可以有效的延缓病情进展，纠正病理改变，降低病死率。
Objective:Though the occurrence at a low level,the mediastinal abscess is in a seriously bad condition and progress very fast.The treatments give priority to surgery in clinical conditions.Here we mainly discuss the validity of open thoracotomy on mediastinal abscess.
Methods:By analysing the clinical materials collected from the nine patients of mediastinal abscess which the Thoracic Surgical Department in No.2Hospital of Jin Lin University has received since June2006to January2012, there were six male patients and three female patients,the age vary from35to61,the average age goes to48;seven of them were due to the infection from odontogenic and neck, while the other two were due to the infection of perforation caused by foreign body;They all got a fever,and one of them had pyemia;they were all local shadows in mediastinum on CT with a wider mediastinum.They were all operated open thoracotomies actively once they were diagnosed accurately,with incision and drainage possibly.The therapies after the operation involved anti-infection with experienced antibiotics,which were adjusted to the outcome of bacterial culture,nutritional supports(six of them which were due to the infection from odontogenic and neck received parenteral alimentation as soon as possible,while the one with pyemia and the other two which were due to the infection of perforation caused by foreign body received gastrointestinal decompression and enteral nutrition,which were shifted to parenteral alimentation as soon as their gastrointestinal function recovered),and symptomatic treatment on respiratory and circulatory system.
Results:There were eight cases who were cured by active operations, the length of being in hospital was during16~26day. There was one case whose family gave up the post-op treatment, and whose vital signs were stable, the patient was discharged from hospital uncured, for the poor economic condition, he continued his post-op treatment back to the local and come back to our hospital for a check in one month's time, recovering his health well.
Conclusion:The proactive open thoracotomy for mediastinal abscess is safe and feasible.We can open abscess septum throughly, lay the drainage tube with multi-side possibly,give the anti-infection effectively and ample nutritional supports after the operation.It is the systemic therapies effectively that can we retard the progress of disease development, correct the pathology, and reduce the mortality.
引文
[1]Makeieff M,Gresillon N,Berthet JP,et al.Management of descending necrotizing mediastinitis.Laryngoscope2004,114(4):772-775.
[2]Kilic D,Findikcioglu A,Ates U,at al.Management of descending mediastinal infections with an unusual cause:a report of3cases.Ann Thorac Cardiovasc Surg,2020,16(3):198-202.
[3]El Oakley RM, Wright JE. Postoperative mediastinitis:classification and management. Ann Thorac Surg,1996,61(3):1030-1036.
[4]黄孝迈,秦文瀚,孙玉鄂,等.现代外科[M],第2版.北京：人民军医出版社,1997：605-607.
[5]Sichel J Y, Attal P, Hocwald E, et al. Redefining parapharyngeal space infections [J]. Ann Otol Rhinol Laryngeal,2006,115(2):117-123.
[6]Pinto A, Scaglione M, Scuderi M G, et al. Infections of the neck leading to descending necrotizing mediastinitis:Role of multidetectorrow computed tomography [J]. Eur JRadio,2008,65(3):389-394.
[7]上官诚芳,吴继昌,王士礼,等.严重颈深部感染引发下行性坏死性纵隔炎1例[J].临床耳鼻喉头颈外科杂志,2009,23：665-666.
[8]Feigin RD,et al.Textbook of Pediatic infection Disease[M],2ed. London WB Satinders,1987;493.
[9]陶正德.耳鼻咽喉科理论和实践[M].北京：人民卫生出版社,1991：516-527.
[10]刘联合.颈深部脓肿37例[J].山东大学耳鼻喉眼学报,2008,22(2)：180-181.
[11]Khan OA,Barlow CW,Weeden DF,et al.Recurrent spontaneous esophageal rupture [J]. Eur J Cardiothorac Surg,2005,28(1):204-209.
[12]郑修振,杨尊良,向昭华,等.自发性食管破裂二例报告[J].医学影像学杂志,1995,5(2)：64.
[13]Ryckman FC, Rosenkrantz JG. Thoracic surgical problems in infancy and childhood. Surg Clin North Am.1985Dec;65(6):1423-54.
[14]王永功,侯明,刘青青,等.牙源性坏死性纵隔炎[J].华西口腔医学杂志,2001,19(5)：336-337.
[15]纪振东,范志民.纵隔脓肿的诊断和治疗[J].中华外科杂志,1990；28(10)：610.
[16]杨亲明,卢永德,黄献贵.颈深部感染并发化脓性纵隔炎[J].中华耳鼻咽喉科杂志,1993；28(4)：276.
[17]Isaacs LM, Kotton B, Peralta MM Jr,et al. Fatal Mediastinal abscess from upper respirator infection[J]. Ear Nose Throat J,1993,72(9):620.
[18]史向阳,井松,赵文刚,等.下行性坏死性纵隔炎的诊治及护理[J].中国实用护理杂志：下旬版,2005,21(6)：38.
[19]杜晓燕,陈威华,陈建福,等.颈性下行性纵隔脓肿15例分析[J].中华耳鼻咽喉科杂志,2000,35.141-143.
[20]Estrera AS, Landay MJ, Grisham JM, et al. Descending necrotizing mediastinitis[J]. Surg Gvnecol Obstet,1983,157:545-552.
[21]王斌全,夏立军,杨辉.上纵隔脓肿颈侧径路持续负压引流时脓腔冲洗术[J].山西医学大学学报,1997,28：231-232.
[22]韩学得,潘蕴倩,陈茂华,等.现代外科感染[M],第1版.北京：科学技术文献出版社,1995,268-278.
[23]蔡春春,邓小明,范丽,等.颈深部脓肿并发纵隔脓肿5例[J].临床耳鼻咽喉头颈外科杂志,2007,21：716-717.
[24]Kumar P, Sarkar PK. Personal management of57consecutive patients with esophageal perforation [J]. Am J Surg,2004,187:58-63.
[25]陈银梅,杨敏.异物性食管穿孔伤的护理9例[J].中国实用护理杂志,2004,34：634.
[26]Papalia ERO,Oliaro A.Descending necrotizing mediastinitis:surgical management[J]. Eur J Cardiothorac Surg,2001,20(4):739-742.
[27]Kerschner JE, Beste DJ, Conley SF, et al. Mediastinitis associated with foreign body erosion of the esophagus in children[J].Int J Pediatr Otorhinolaryngol,2001,59(2):89-97.
[28]Al-Qudah A, Daradkeh S, Abu-khalaf M. Esophageal foreign bodies[J]. Eur J Cardiothorac Surg,1998,13(5):494-498.
[29]Alqudah A, Daradkeh S, Abukhalaf M, et al. Esophageal foreign bodies[J]. Eur J Cardiothorac Surg,1998,13:494-498.
[30]Chang YC, Chen CW. Thoracoscopic drainage of ascending mediastinitis arising from pancreatic pseudocyst[J]. Interact Cardiovasc Thorac Surg,2009,9(1):144-145.
[31]黄忠达,鲁世千.纵隔炎.见：鲁世千,徐中凡,主编.普胸外科学.武汉：湖北科学技术出版社,2002,370-373.
[32]李襄五.中华结核和呼吸系统疾病杂志,1982,5(1)：5.
[33]张志泰,陈玉平,胡燕生,等.胸膜外闭式引流治愈纵隔脓肿1例[J].中华耳鼻咽喉科杂志,1995,30(4)：86.
[34]程波,汪天虎,张立平,等.食管穿孔的诊断与外科治疗[J].重庆医科大学学报,2006,31(3)：443-445.
[35]高松,廖增华.扁桃体周脓肿并纵隔脓肿及脓胸1例[J].中国耳鼻咽喉头颈外科,2006,13：148.
[36]何泽锋,王建军,汪文东,等.食管穿孔营养支持方式的探讨[J].临床外科杂志,2006,14(4)：221-223.
[37]明自强,俞林明,吕银祥,等.重度颅脑损伤早期营养支持的临床研究[J].实用医学杂志,2007,23(10)：1487-1489.
[38]张慧,罗远芳,陈玉萍.颌骨骨折内固定术后营养支持治疗42例[J].实用医学杂志,2006,22(21)：2265-2266.
[39]李种,戚合德.食管癌切除术后功能性胃排空障碍的营养支持[J].实用医学杂志,2006,22(3)：321.
[40]Emil S G.Neonatal esophageal perforation[J]. Ediatr Surg,2004,9(8):1296-1298.
[41]房宁,汪欣,祝威,等.咽喉脓肿累及上纵隔1例[J].中国耳鼻咽喉头颈外科,2009,16：663.
[2]Kilic D,Findikcioglu A,Ates U,at al.Management of descending mediastinal infections with an unusual cause:a report of3cases.Ann Thorac Cardiovasc Surg,2020,16(3):198-202.
[3]El Oakley RM, Wright JE. Postoperative mediastinitis:classification and management. Ann Thorac Surg,1996,61(3):1030-1036.
[4]黄孝迈,秦文瀚,孙玉鄂,等.现代外科[M],第2版.北京：人民军医出版社,1997：605-607.
[5]Sichel J Y, Attal P, Hocwald E, et al. Redefining parapharyngeal space infections [J]. Ann Otol Rhinol Laryngeal,2006,115(2):117-123.
[6]Pinto A, Scaglione M, Scuderi M G, et al. Infections of the neck leading to descending necrotizing mediastinitis:Role of multidetectorrow computed tomography [J]. Eur JRadio,2008,65(3):389-394.
[7]上官诚芳,吴继昌,王士礼,等.严重颈深部感染引发下行性坏死性纵隔炎1例[J].临床耳鼻喉头颈外科杂志,2009,23：665-666.
[8]Feigin RD,et al.Textbook of Pediatic infection Disease[M],2ed. London WB Satinders,1987;493.
[9]陶正德.耳鼻咽喉科理论和实践[M].北京：人民卫生出版社,1991：516-527.
[10]刘联合.颈深部脓肿37例[J].山东大学耳鼻喉眼学报,2008,22(2)：180-181.
[11]Khan OA,Barlow CW,Weeden DF,et al.Recurrent spontaneous esophageal rupture [J]. Eur J Cardiothorac Surg,2005,28(1):204-209.
[12]郑修振,杨尊良,向昭华,等.自发性食管破裂二例报告[J].医学影像学杂志,1995,5(2)：64.
[13]Ryckman FC, Rosenkrantz JG. Thoracic surgical problems in infancy and childhood. Surg Clin North Am.1985Dec;65(6):1423-54.
[14]王永功,侯明,刘青青,等.牙源性坏死性纵隔炎[J].华西口腔医学杂志,2001,19(5)：336-337.
[15]纪振东,范志民.纵隔脓肿的诊断和治疗[J].中华外科杂志,1990；28(10)：610.
[16]杨亲明,卢永德,黄献贵.颈深部感染并发化脓性纵隔炎[J].中华耳鼻咽喉科杂志,1993；28(4)：276.
[17]Isaacs LM, Kotton B, Peralta MM Jr,et al. Fatal Mediastinal abscess from upper respirator infection[J]. Ear Nose Throat J,1993,72(9):620.
[18]史向阳,井松,赵文刚,等.下行性坏死性纵隔炎的诊治及护理[J].中国实用护理杂志：下旬版,2005,21(6)：38.
[19]杜晓燕,陈威华,陈建福,等.颈性下行性纵隔脓肿15例分析[J].中华耳鼻咽喉科杂志,2000,35.141-143.
[20]Estrera AS, Landay MJ, Grisham JM, et al. Descending necrotizing mediastinitis[J]. Surg Gvnecol Obstet,1983,157:545-552.
[21]王斌全,夏立军,杨辉.上纵隔脓肿颈侧径路持续负压引流时脓腔冲洗术[J].山西医学大学学报,1997,28：231-232.
[22]韩学得,潘蕴倩,陈茂华,等.现代外科感染[M],第1版.北京：科学技术文献出版社,1995,268-278.
[23]蔡春春,邓小明,范丽,等.颈深部脓肿并发纵隔脓肿5例[J].临床耳鼻咽喉头颈外科杂志,2007,21：716-717.
[24]Kumar P, Sarkar PK. Personal management of57consecutive patients with esophageal perforation [J]. Am J Surg,2004,187:58-63.
[25]陈银梅,杨敏.异物性食管穿孔伤的护理9例[J].中国实用护理杂志,2004,34：634.
[26]Papalia ERO,Oliaro A.Descending necrotizing mediastinitis:surgical management[J]. Eur J Cardiothorac Surg,2001,20(4):739-742.
[27]Kerschner JE, Beste DJ, Conley SF, et al. Mediastinitis associated with foreign body erosion of the esophagus in children[J].Int J Pediatr Otorhinolaryngol,2001,59(2):89-97.
[28]Al-Qudah A, Daradkeh S, Abu-khalaf M. Esophageal foreign bodies[J]. Eur J Cardiothorac Surg,1998,13(5):494-498.
[29]Alqudah A, Daradkeh S, Abukhalaf M, et al. Esophageal foreign bodies[J]. Eur J Cardiothorac Surg,1998,13:494-498.
[30]Chang YC, Chen CW. Thoracoscopic drainage of ascending mediastinitis arising from pancreatic pseudocyst[J]. Interact Cardiovasc Thorac Surg,2009,9(1):144-145.
[31]黄忠达,鲁世千.纵隔炎.见：鲁世千,徐中凡,主编.普胸外科学.武汉：湖北科学技术出版社,2002,370-373.
[32]李襄五.中华结核和呼吸系统疾病杂志,1982,5(1)：5.
[33]张志泰,陈玉平,胡燕生,等.胸膜外闭式引流治愈纵隔脓肿1例[J].中华耳鼻咽喉科杂志,1995,30(4)：86.
[34]程波,汪天虎,张立平,等.食管穿孔的诊断与外科治疗[J].重庆医科大学学报,2006,31(3)：443-445.
[35]高松,廖增华.扁桃体周脓肿并纵隔脓肿及脓胸1例[J].中国耳鼻咽喉头颈外科,2006,13：148.
[36]何泽锋,王建军,汪文东,等.食管穿孔营养支持方式的探讨[J].临床外科杂志,2006,14(4)：221-223.
[37]明自强,俞林明,吕银祥,等.重度颅脑损伤早期营养支持的临床研究[J].实用医学杂志,2007,23(10)：1487-1489.
[38]张慧,罗远芳,陈玉萍.颌骨骨折内固定术后营养支持治疗42例[J].实用医学杂志,2006,22(21)：2265-2266.
[39]李种,戚合德.食管癌切除术后功能性胃排空障碍的营养支持[J].实用医学杂志,2006,22(3)：321.
[40]Emil S G.Neonatal esophageal perforation[J]. Ediatr Surg,2004,9(8):1296-1298.
[41]房宁,汪欣,祝威,等.咽喉脓肿累及上纵隔1例[J].中国耳鼻咽喉头颈外科,2009,16：663.