本文選題：兒童 + 肺隔離癥��； 參考：《重慶醫(yī)科大學(xué)》2014年碩士論文

【摘要】：目的探討并歸納總結(jié)兒童肺隔離癥的臨床特點(diǎn)、診斷、治療及預(yù)后,提出最佳診斷及治療方式。 方法回顧性分析重慶市兒童醫(yī)院1994年4月-2013年4月肺隔離癥的臨床資料，并使用統(tǒng)計(jì)軟件SPSS19.0比較葉內(nèi)型及葉外型的臨床特征有無(wú)差異。 結(jié)果 1我院共收治確診肺隔離癥30例。其中男12例，女18例，性別比例為1:1.5。首診年齡13天1小時(shí)~14歲不等，平均診斷年齡52.4±49.3月。其中~28天：1例（3.3%），~1歲：6例（20%），~3歲：10例（33.3%），~6歲：4例（13.3%），~13歲：8例（26.7%），13歲：1例（3.3%）。 227例（90%）表現(xiàn)出非特異性癥狀：發(fā)熱21例（70%）、咳嗽20例（66.7%）、咳痰/喉間痰響13例（43.3%）發(fā)熱+咳嗽：16例（53.3%），發(fā)熱+咳痰/喉間痰響：12例（40%），發(fā)熱+咳嗽+咳痰/喉間痰響：10例（33.3%）,咳嗽+咳痰/喉間痰響：10例（33.3%）。無(wú)癥狀體檢發(fā)現(xiàn)者3例(10%)。21例（70%）體征有異常，15例（50%）患側(cè)呼吸音減低，6例（20%）可聞及少許粗/中濕羅音，9例（30%）無(wú)陽(yáng)性體征。 3行胸片19例，胸部彩超13例，胸部CT平掃26例/CT增強(qiáng)6例/CT增強(qiáng)+血管三維重建9例，主動(dòng)脈逆行造影3例，纖支鏡1例。術(shù)前確診16例（53.3%），確診手段：CT增強(qiáng)+血管三維重建（9例）、CT增強(qiáng)（4例）、DSA（3例）。術(shù)前漏診3例(10%)，均因合并肺囊腫，于肺葉切除術(shù)中發(fā)現(xiàn)。術(shù)前誤診11例(45.8%)，誤診為肺囊腫8例，腫瘤2例，肺大泡1例。 424例行手術(shù)切除，2例行介入堵閉術(shù),4例行保守治療。葉內(nèi)型17例（男6例，女11例），平均首診年齡（58.9±53.7月），臨床無(wú)癥狀1例（體檢發(fā)現(xiàn)），陽(yáng)性體征12例，發(fā)病部位：左下肺葉（9例）、右下肺葉（8例），合并畸形5例（29.4%），異常血管支數(shù):1支（14例）、2支（1例）、5支（1例）、不詳（1例），異常血管來(lái)源：胸主動(dòng)脈（14例）、腹主動(dòng)脈（1例）、肋間動(dòng)脈（1例）、不詳（1例），靜脈引流情況：左下肺靜脈（7例）、右下肺靜脈（8例）、不詳（2例），術(shù)后住院時(shí)間平均10.4±1.9天，置管時(shí)間平均3.6±1.0天。葉外型7例（男3例，女4例），平均首診年齡（31.4±29.1月），無(wú)癥狀1例（孕24周彩超發(fā)現(xiàn)），陽(yáng)性體征7例，均表現(xiàn)為患側(cè)肺呼吸音降低。發(fā)病部位：左肋膈角（5例）、右肋膈角（2例），合并畸形4例（57.1%），異常血管支數(shù):1支（6例）、不詳（1例），異常血管來(lái)源：胸主動(dòng)脈（5例）、腹主動(dòng)脈（1例）、不詳（1例），靜脈引流情況：左下肺靜脈（2例）、奇靜脈（1例）、不詳（4例），術(shù)后住院時(shí)間平均9.3±1.3天，置管時(shí)間平均3.0±0.9天。 5術(shù)中無(wú)死亡發(fā)生，術(shù)后見(jiàn)1例合并包裹性胸腔積液，手術(shù)患兒均治愈出院。慢性炎癥和肺發(fā)育不良為術(shù)后病檢的主要表現(xiàn)。1例因抗酸染色找到結(jié)核桿菌，，診斷合并肺結(jié)核。手術(shù)及介入患兒術(shù)后成功隨訪18例（其中2例為介入患兒），均無(wú)反復(fù)肺部感染或其它并發(fā)癥發(fā)生。 結(jié)論 1兒童PS多發(fā)生于左肺，多于13歲之前出現(xiàn)臨床癥狀，常表現(xiàn)為反復(fù)呼吸道感染，癥狀不典型，漏診誤診率高，易與肺囊腫、肺炎、肺部腫瘤等相混淆，臨床醫(yī)師尤其是兒科醫(yī)師急需提高對(duì)該病的認(rèn)知度。 2兒童PS葉內(nèi)型與葉外型在性別、首診年齡、癥狀、兩肺的發(fā)生率、合并畸形率、異常血管來(lái)源及支數(shù)、術(shù)后住院時(shí)間及置管時(shí)間上均無(wú)明顯差異，僅通過(guò)臨床分型較困難，但葉外型較葉內(nèi)型更易出現(xiàn)患側(cè)肺部呼吸音減低，葉內(nèi)型較葉外型更易合并多種畸形。肺囊腫和先天性心臟病為PS最常見(jiàn)合并畸形。靜脈多回流入下肺靜脈。ELS多位于肋膈角處，ILS多見(jiàn)于肺下葉，尤其是左肺下葉。 3發(fā)現(xiàn)異常體循環(huán)供血?jiǎng)用}是確診PS關(guān)鍵，胸片及彩超可作為PS患兒的常規(guī)篩查，胸部CT血管三維重建為確診首選，對(duì)確診的PS患兒，做胃腸道鋇餐、心臟彩超等檢查排除合并先天性心臟病、膈疝、支氣管胃瘺及食管氣管瘺等畸形很有必要，超聲檢查在新生兒和產(chǎn)前診斷方面有應(yīng)用價(jià)值。 4PS一旦確診，均應(yīng)手術(shù)治療， ILS主要采用肺葉切除術(shù)，而ELS�？蓛H切除病灶，術(shù)前未分型或動(dòng)靜脈走形顯示不清并非手術(shù)絕對(duì)禁忌癥。手術(shù)安全，術(shù)中死亡及術(shù)后并發(fā)癥少見(jiàn)。術(shù)后病檢可排除是否合并真菌、結(jié)核感染甚至惡性變等。
[Abstract]:Objective to explore and summarize the clinical characteristics, diagnosis, treatment and prognosis of children with pulmonary sequestration, and propose the best diagnosis and treatment.
Methods the clinical data of pulmonary sequestration in Chongqing children's Hospital in April 1994 -2013 April were analyzed retrospectively, and the statistical software SPSS19.0 was used to compare the clinical characteristics of the inner leaf type and the leaf type.
Result
1 there were 30 cases of confirmed pulmonary sequestration in our hospital, of which 12 cases were male and 18 women. The sex ratio was 13 days, 1 hours, 1 hours, 13 days and 1 hours. The average diagnostic age was 52.4 + 49.3 months. Among them, ~28 days were 1 (3.3%), 6 (20%), 10 cases (33.3%), ~6 years old, ~13 years old.
227 cases (90%) showed non specific symptoms: fever 21 cases (70%), cough 20 cases (66.7%), expectoration / laryngeal phlegm (43.3%) fever + cough: 16 cases (53.3%), fever + expectoration / laryngeal phlegm: 12 (40%), fever + cough + expectoration / laryngeal phlegm ringing: 10 cases (33.3%), cough + expectoration / laryngeal phlegm ringing: asymptomatic physical examination Discoverers .21 (70%) had abnormal signs, 15 cases (50%) had lower respiratory sounds, 6 cases (20%) could hear a little coarse / medium rales, and 9 cases (30%) had no positive signs.
19 cases of 3 lines of chest, 13 cases of chest color Doppler ultrasound, 26 case of chest CT scan, 6 cases of enhanced /CT and three-dimensional reconstruction of blood vessels, 3 cases of aortic retrograde angiography and 1 cases of fiberoptic bronchoscopy (53.3%), CT enhanced + vascular three-dimensional reconstruction (53.3%), CT enhancement (4), DSA (3 cases), pulmonary cysts and lobectomy 11 cases (45.8%) were misdiagnosed before operation, 8 cases were misdiagnosed as pulmonary cysts, 2 cases were tumors, and 1 cases were pulmonary bullae.
There were 424 cases of surgical excision, 2 cases of interventional occlusion and 4 cases of conservative treatment. 17 cases (6 men, 11 cases), the average age of first diagnosis (58.9 + 53.7 months), clinical asymptomatic 1 cases (physical examination), 12 cases of positive signs, the location of the left lower lobe (9), the right lower lobe (8), complicated 5 cases (29.4%), abnormal vascular support 5 (1 cases), unknown (1 cases), abnormal vascular sources: thoracic aorta (14 cases), abdominal aorta (1 cases), intercostal artery (1 cases), unknown (1 cases), venous drainage: left inferior pulmonary vein (7 cases), right lower pulmonary vein (8 cases), not detailed (2 cases), postoperative hospital time average 10.4 + 1.9 days, the average catheter time 3.6 + 1 days. The mean first diagnosis age (31.4 + 29.1 months), 1 cases of asymptomatic (24 Zhou Caichao pregnancy) and 7 cases of positive signs were manifested as decreased respiratory sound in the lateral lung. The site of the disease: left rib diaphragm (5 cases), right rib diaphragm (2 cases), 4 cases (57.1%) with abnormal vascular malformation, 1 branches (6), abnormal vascular sources: thoracic aorta (5 cases), abdominal aorta (1) Cases (1 cases), venous drainage: left inferior pulmonary vein (2 cases), odd vein (1 cases), unknown (4 cases), the average time of postoperative hospitalization was 9.3 + 1.3 days, the average time of catheterization was 3 + 0.9 days.
No death occurred during the 5 operation. 1 cases were combined with encapsulated pleural effusion after operation. All the children were cured and discharged from the operation. Chronic inflammation and pulmonary dysplasia were the main manifestations of postoperative disease detection in.1 cases. The diagnosis of tuberculosis with acid staining was found. 18 cases (2 of them were intervened) after operation and intervention. Pulmonary infection or other complications.
conclusion
1 children with PS were mostly born in the left lung, which had clinical symptoms before 13 years old, often manifested as recurrent respiratory infection, the symptoms were not typical, the misdiagnosis rate was high, and it was easy to be confused with the lung cysts, pneumonia, lung tumor and so on. The clinicians, especially the pediatrician, were in urgent need of improving the recognition of the disease.
2 the PS leaf type and outer leaf type in children had no obvious difference in sex, first diagnosis age, symptom, two lung incidence, combined malformation rate, abnormal blood vessel source and number, no obvious difference in postoperative hospital time and time of intubation. Pulmonary cysts and congenital heart diseases are the most common deformities of PS. More than.ELS in the inferior pulmonary veins are located at the costal angle, and the ILS is more common in the lower lobe of the lung, especially in the left lower lobe.
3 it is found that abnormal circulation of blood supply artery is the key to diagnosis of PS. Chest and color Doppler ultrasound can be used as routine screening for children with PS. The three-dimensional reconstruction of CT vessels in the chest is the first choice. It is necessary to exclude congenital heart disease, diaphragmatic hernia, bronchostomy fistula and esophagotracheal fistula in the diagnosis of PS children, gastrointestinal barium meal, heart color Doppler ultrasound and so on. Sound examination is valuable in the diagnosis of neonatal and prenatal diagnosis.
Once the 4PS is confirmed, all of them should be operated on. ILS mainly adopts lobectomy, and ELS can only be excised only. The preoperative undivided or arteriovenous malformation is not an absolute contraindication. The operation is safe, the intraoperative death and postoperative complications are rare.
【學(xué)位授予單位】：重慶醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：R725.6

【參考文獻(xiàn)】

相關(guān)期刊論文 前1條

1 吳楠;孫宇;鄭慶鋒;呂超;閻石;張力建;楊躍;;葉內(nèi)型肺隔離癥的診斷、治療及分子病理學(xué)特點(diǎn)[J];中華醫(yī)學(xué)雜志;2007年37期

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