Patient: Zhao XX, female, 51 years old, hospitalization number: 121201028. Admission date: 2012-12-01.
Complaint: epigastric pain for more than half a month, nausea and vomiting, with shortness of breath for one week. He had dyspnea and shortness of breath, no chills and fever, no abdominal distension and diarrhea, no shortness of breath, no jaundice.
Signs: He was seen in a famous tertiary hospital in Shanghai. The abdominal pain was not significantly relieved after treatment with gastrointestinal decompression, oxygen and symptomatic support. At the same time, he was hospitalized in a famous tertiary hospital in Nanjing for 7 days without any significant improvement, and needed mask oxygen, so he was pushed to our hospital on an oxygen-absorbing flat cart in an outside hospital. Preoperative CT showed: esophageal hiatal hernia; postoperative esophageal cancer with massive fluid accumulation in both chest cavities; limited lobar atelectasis in both lungs; diaphragmatic hernia with partial intestinal canal and intestinal obstruction. Postoperative esophageal cancer, thoracic stomach at mediastinum, esophageal hiatal hernia, herniation of small intestinal tube, dilated small intestinal tube, large amount of intestinal tube in the right thoracic cavity and small amount in the left, dilated intestinal tube in the abdomen.
After oxygen inhalation, continuous gastrointestinal decompression and oral administration of a small amount of enteral nutrition solution, the patient showed symptoms of abdominal pain, abdominal distension and vomiting.
The patient had a large amount of pleural effusion on both sides, and the patient had significant shortness of breath after a small amount of activity. 2012-12-03 pulmonary function showed: severe mixed ventilatory dysfunction.
After intravenous nutrition and correction of hypoproteinemia, the anesthesiology department consulted the patient and concluded that the patient had severe cardiopulmonary insufficiency, the right side of the lung was severely atelectatic and could not tolerate general anesthesia, and recommended thoracic surgery to perform thoracentesis, which was performed on 2012-12-05, and 550 ml of pleural fluid was extracted. On December 12, 2012, the patient underwent surgery under general anesthesia with intubation in the awake state, and intraoperatively, he saw that the middle part of the transverse colon was herniated into the thoracic cavity, and the small intestine and its mesentery were herniated into the thoracic cavity from about 40 cm from the flexor ligament to about 20 cm from the ileocecal area. The transverse colon, small intestine and mesenteric adhesions in the thoracic cavity were obvious and difficult to be retracted, so it was decided to retract the herniated contents through the chest. After opening the thoracic cavity, about 500 ml of thoracic washed water-like pleural fluid was seen, and the herniated small intestine and part of the small intestine were ruptured, and the small intestine and colon were retracted by thoracoabdominal union. The diaphragm was sutured, the esophageal hiatal fissure was reduced to about 3*2 cm, the biologic hernia patch was laid flat around the cardia, the patch was fixed to the diaphragm intermittently, and the esophageal hiatal hernia was repaired. After surgery, the patient was admitted to the ICU with a tube and given mechanical ventilation PC mode: FIO2 40%, PEEP 5cmH2O, F 15 times/min, PS 12cmH2O, pulse oxygen could be maintained at 100%, sputum in the airway was promptly aspirated, and treatment was given to piperacillin tazobactam for anti-infection, sputumification, growth inhibitor to inhibit intestinal secretion, protection of gastrointestinal mucosa, supplemental albumin and nutritional support.
The patient was discharged from the ventilator on 2012-12-15 with a clear consciousness, a clear spirit, a slight cough, no sputum, and pulse oxygen fluctuating at 96-99%. Today he is ventilated and his stool is not resolved. Body temperature was 37.6 this morning, which improved after physical cooling was given. The urine volume is about 3530ml, the chest drain is in place, the water column is seen to fluctuate, the drainage is about 150ml, the gastrointestinal decompression is in place, the drainage is about 100ml of yellow-green gastric juice, the pelvic drainage is about 200ml, the abdominal drainage is about 110ml. The chest and abdominal drainage tubes were gradually removed.
On 2012-12-20, the patient developed shortness of breath and fever with a maximum temperature of 38.8°, and the closed chest drain was removed. Ultrasound at the bedside: bilateral pleural effusion (the left side was more), thoracic puncture was performed at 4:00 pm on the same day, and 800 ml of pleural fluid was withdrawn in the form of flesh-washing water. On 12-26 at 4:00 p.m., another thoracentesis was performed and 920 ml of pleural fluid was withdrawn. The chest X-ray was basically normal on review. The patient recovered well after the operation. The patient had no discomfort in the postoperative diet, no abdominal pain, nausea, vomiting and other gastrointestinal symptoms, no shortness of breath and other respiratory symptoms, and no recurrence was seen in the subsequent six-month review.