{"id":1646,"date":"2013-03-25T11:38:31","date_gmt":"2013-03-25T11:38:31","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1646"},"modified":"2013-06-11T08:04:26","modified_gmt":"2013-06-11T08:04:26","slug":"9-onemocneni-branice-3","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1646","title":{"rendered":"9 Onemocn\u011bn\u00ed br\u00e1nice"},"content":{"rendered":"

9.1 Anatomie a embryologie br\u00e1nice<\/h3>\n
\"Obr.<\/a>

Obr. 1
Br\u00e1nice p\u0159i pohledu z dutiny b\u0159i\u0161n\u00ed. Schematick\u00e9 zobrazen\u00ed anatomick\u00fdch lokalit a defekt\u016f, kde se tvo\u0159\u00ed k\u00fdly:
1. trigonum Bochdaleki vlevo \u010di vpravo
2. fissura Larreyi vlevo
3. fissura Morgagni vpravo
4. dorsolater\u00e1ln\u00ed defekt v centrum tendineum vlevo \u010di vpravo
5. roz\u0161\u00ed\u0159en\u00fd j\u00edcnov\u00fd hi\u00e1tus
6. traumatick\u00e1 ruptura v oblasti centrum tendineum<\/p><\/div>\n

Diafragma \u2013 br\u00e1nice \u2013 vytv\u00e1\u0159\u00ed p\u0159ed\u011bl mezi dutinou hrudn\u00ed a b\u0159i\u0161n\u00ed. Jde o tenkou p\u0159ep\u00e1\u017eku tvo\u0159enou na obvodu svalstvem, kter\u00e9 sm\u011brem do centra p\u0159ech\u00e1z\u00ed v aponeur\u00f3zu. Dorz\u00e1ln\u011b se up\u00edn\u00e1 k p\u00e1te\u0159i ve v\u00fd\u0161i t\u0159et\u00edho lumb\u00e1ln\u00edho obratle, ventr\u00e1ln\u011b k doln\u00ed \u010d\u00e1sti sterna a po obvodu k \u017eebern\u00edm oblouk\u016fm. Kupulovit\u011b se vyklenuje do hrudn\u00edku, tak\u017ee b\u0159i\u0161n\u00ed dutina zasahuje pom\u011brn\u011b vysoko do hrudn\u00edho ko\u0161e. Preformovan\u00fdmi \u0161t\u011brbinami proch\u00e1z\u00ed aorta, doln\u00ed dut\u00e1 \u017e\u00edla a j\u00edcen spolu s bloudiv\u00fdmi nervy (obr. 1).<\/p>\n

Br\u00e1nice vznik\u00e1 z n\u011bkolika komponent: 1) p\u0159edn\u00ed centr\u00e1ln\u00ed vazivov\u00e1 bl\u00e1na ze septum transversum;\u00a02) mal\u00e9 dorsolater\u00e1ln\u00ed \u010d\u00e1sti oboustrann\u011b z pleuroperitone\u00e1ln\u00edch membr\u00e1n; 3) zadn\u00ed snopce z j\u00edcnov\u00e9ho mezenteria se svaly odstupuj\u00edc\u00edmi ze zadn\u00ed bedern\u00ed skupiny; 4) later\u00e1ln\u00ed svalov\u00fd obvod vych\u00e1z\u00ed ze \u017eebern\u00edch svalov\u00fdch skupin. V\u00fdvoj br\u00e1nice za\u010d\u00edn\u00e1 ve 4. t\u00fddnu s formac\u00ed septum transversum, kter\u00e9 odd\u011bluje hrudn\u00ed a b\u0159i\u0161n\u00ed dutinu embryon\u00e1ln\u00edho coelomu, zanech\u00e1vaj\u00edc\u00ed dva pr\u016fchody dorsolater\u00e1ln\u011b. Roz\u0161\u00ed\u0159en\u00edm z later\u00e1ln\u00ed st\u011bny t\u011bla do t\u011bchto pleuroperitone\u00e1ln\u00edch pr\u016fchod\u016f vznikaj\u00ed na jejich kaud\u00e1ln\u00edm konci pleuroperitone\u00e1ln\u00ed \u0159asy, kter\u00e9 rostou medi\u00e1ln\u011b a ventr\u00e1ln\u011b do 7. t\u00fddne, kdy spl\u00fdvaj\u00ed se septum transversum a s mezenteriem j\u00edcnu. N\u00e1sleduje muskularizace br\u00e1nice a po spojen\u00ed bedern\u00ed a \u017eebern\u00ed svalov\u00e9 masy posterolater\u00e1ln\u011b z\u016fst\u00e1v\u00e1 vazivov\u00e9 lumbokost\u00e1ln\u00ed trigonum jako mal\u00fd zbytek pleuroperitone\u00e1ln\u00ed membr\u00e1ny, jeho\u017e odolnost z\u00e1vis\u00ed na pevnosti spojen\u00ed dvou svalov\u00fdch skupin v kone\u010dn\u00e9 f\u00e1zi v\u00fdvoje. Opo\u017ed\u011bn\u00ed nebo selh\u00e1n\u00ed f\u00faze svaloviny vede k lok\u00e1ln\u00edmu oslaben\u00ed predisponuj\u00edc\u00edmu k herniaci.<\/p>\n

9.2 Vrozen\u00e9 defekty br\u00e1nice<\/h3>\n

Nej\u010dast\u011bj\u0161\u00edmi onemocn\u011bn\u00edmi br\u00e1nice jsou vrozen\u00e9 k\u00fdly. Tuto problematiku dnes \u0159e\u0161\u00ed z hlediska diagnostiky a terapie neonatologov\u00e9 spolu s d\u011btsk\u00fdmi chirurgy.<\/p>\n

V\u00fdvoj br\u00e1nice spad\u00e1 do konce 1. m\u011bs\u00edce nitrod\u011blo\u017en\u00edho \u017eivota, kdy se p\u016fvodn\u011b spole\u010dn\u00e1 coelomov\u00e1 dutina za\u010d\u00edn\u00e1 p\u0159epa\u017eovat p\u0159\u00ed\u010dnou li\u0161tou z tzv. septum transversum, kter\u00e9 je mezodermov\u00e9ho p\u016fvodu, na dutinu b\u0159i\u0161n\u00ed a hrudn\u00ed. Sou\u010dasn\u011b s n\u00edm pror\u016fstaj\u00ed sm\u011brem k periferii peritoneum a pleura, vznik\u00e1 tzv. pleuroperitone\u00e1ln\u00ed membr\u00e1na. Zastav\u00ed-li se proces p\u0159epa\u017eov\u00e1n\u00ed, vznik\u00e1 bu\u010f defekt (neprav\u00e1 k\u00fdla), nebo se zastav\u00ed pouze pror\u016fst\u00e1n\u00ed mezodermu a defekt je p\u0159ekryt pleuroperitone\u00e1ln\u00ed membr\u00e1nou. Tlakem b\u0159i\u0161n\u00edch org\u00e1n\u016f do tohoto oslaben\u00e9ho m\u00edsta vznik\u00e1 k\u00fdln\u00ed vak (prav\u00e1 k\u00fdla). Br\u00e1ni\u010dn\u00ed k\u00fdla je nej\u010dast\u011bji ulo\u017eena v posterolater\u00e1ln\u00ed \u010d\u00e1sti br\u00e1nice. Tuto k\u00fdlu popsal \u010desk\u00fd patolog V. A. Bochdalek v r. 1848 a jako prvn\u00ed nazna\u010dil mo\u017enosti jej\u00edho chirurgick\u00e9ho l\u00e9\u010den\u00ed. Tento typ k\u00fdly b\u00fdv\u00e1 ozna\u010dov\u00e1n jako k\u00fdla Bochdalekova. Vz\u00e1cn\u011bji m\u016f\u017ee b\u00fdt defekt v centrum tendineum nebo v anterolater\u00e1ln\u00ed \u010d\u00e1sti br\u00e1nice. K\u00fdla ve \u0161t\u011brbin\u011b Morganiho vpravo (Morgagniho hernie) je \u010dast\u011bj\u0161\u00ed, v lev\u00e9 \u0161t\u011brbin\u011b je ozna\u010dov\u00e1na jako Lareyova k\u00fdla. Tyto k\u00fdly mohou m\u00edt k\u00fdln\u00ed vak. Maj\u00ed shodnou symptomatologii s Bochdalekovou k\u00fdlou. V novorozeneck\u00e9m v\u011bku se mohou rovn\u011b\u017e vyskytnout k\u00fdly v hi\u00e1tu ezofage\u00e1ln\u00edm. Paraezofage\u00e1ln\u00ed typ, kter\u00fd m\u016f\u017ee b\u00fdt vystup\u0148ov\u00e1n a\u017e do podoby upside-down-stomach je spojen s obstruk\u010dn\u00edmi p\u0159\u00edznaky (obr. 2), skluzn\u00fd typ se v\u011bt\u0161inou projevuje jako gastroezofage\u00e1ln\u00ed reflux. Vz\u00e1cn\u011b m\u016f\u017ee chyb\u011bt polovina nebo dokonce cel\u00e1 br\u00e1nice (ageneze).<\/p>\n

Diagn\u00f3za vrozen\u00e9 br\u00e1ni\u010dn\u00ed k\u00fdly m\u016f\u017ee b\u00fdt pom\u011brn\u011b p\u0159esn\u011b stanovena intrauterinn\u011b. V\u010dasn\u00e1 diagn\u00f3za umo\u017e\u0148uje poskytnout rodi\u010d\u016fm informace od genetika, neonatologa a d\u011btsk\u00e9ho chirurga. Perinat\u00e1ln\u00ed management pak m\u016f\u017ee napl\u00e1novat optim\u00e1ln\u00ed p\u00e9\u010di. Kombinace \u010dasn\u00e9 prenat\u00e1ln\u00ed diagnostiky a vhodn\u00e9 postnat\u00e1ln\u00ed terapie zlep\u0161uje v\u00fdsledky novorozenc\u016f s vrozenou br\u00e1ni\u010dn\u00ed herni\u00ed.<\/p>\n

Incidence br\u00e1ni\u010dn\u00ed k\u00fdly se ud\u00e1v\u00e1 1 na 3000 \u017eiv\u011b narozen\u00fdch, t\u00e9m\u011b\u0159 2\u00d7 \u010dast\u011bji b\u00fdv\u00e1 u chlapc\u016f. V 85\u201390 % jde o levostrannou k\u00fdlu Bochdalekovu. Lev\u00fd hemitorax m\u016f\u017ee obsahovat herniovan\u00e9 tenk\u00e9 st\u0159evo, kolon, slezinu, \u017ealudek, \u010d\u00e1st lev\u00e9ho jatern\u00edho laloku, ale i pankreas a nadledvinku. Pravostrann\u00e9 br\u00e1ni\u010dn\u00ed hernie obsahuj\u00ed prav\u00fd lalok jatern\u00ed. A\u017e 25 % \u017eiv\u011b na-rozen\u00fdch s touto vadou m\u00e1 p\u0159idru\u017een\u00e9 anom\u00e1lie, tak\u0159ka pravideln\u011b maj\u00ed nedokon\u010denou rotaci st\u0159eva, kdy c\u00e9kum je ulo\u017eeno v hernii. U mrtvorozen\u00fdch d\u011bt\u00ed se p\u0159idru\u017een\u00e9 v\u00fdvojov\u00e9 a v\u011bt\u0161inou fat\u00e1ln\u00ed vady vyskytuj\u00ed a\u017e v 95 % \u2013 vrozen\u00e9 srde\u010dn\u00ed vady, extralob\u00e1rn\u00ed plicn\u00ed sekvestrace, st\u0159evn\u00ed atr\u00e9zie, hydronefr\u00f3za, ageneze ledviny \u010di neurologick\u00e9 probl\u00e9my, jako je spina bifida, anencefalie, hydrocefalus, chromozom\u00e1ln\u00ed aberace.<\/p>\n

Vrozen\u00e1 br\u00e1ni\u010dn\u00ed k\u00fdla se po narozen\u00ed projev\u00ed jako n\u00e1hl\u00e1 p\u0159\u00edhoda hrudn\u00ed, \u017eivot ohro\u017euj\u00edc\u00ed stav s \u010dasto velmi dramatick\u00fdm pr\u016fb\u011bhem. V symptomatologii dominuj\u00ed t\u011b\u017ek\u00e9 d\u00fdchac\u00ed pot\u00ed\u017ee, cyan\u00f3za, srde\u010dn\u00ed ozvy sly\u0161iteln\u00e9 vpravo, nesly\u0161n\u00e9 d\u00fdchac\u00ed \u0161elesty nad klenut\u011bj\u0161\u00edm lev\u00fdm hemitoraxem, kde naopak b\u00fdvaj\u00ed sly\u0161iteln\u00e9 st\u0159evn\u00ed zvuky, a vpadl\u00e9 b\u0159\u00ed\u0161ko. P\u0159\u00edznaky mohou b\u00fdt r\u016fzn\u011b vyzna\u010deny podle toho, kter\u00e9 \u00fatroby jsou obsahem k\u00fdln\u00edho vaku a jak dalece jsou \u017ealudek a st\u0159eva distendov\u00e1ny spolykan\u00fdm vzduchem. Posti\u017een\u00fd hemitorax je v inspira\u010dn\u00edm postaven\u00ed a ned\u00fdch\u00e1. U d\u00edt\u011bte doch\u00e1z\u00ed k respira\u010dn\u00ed insuficienci, rozvoji nejd\u0159\u00edve respira\u010dn\u00ed a postupn\u011b ke sm\u00ed\u0161en\u00e9 respira\u010dn\u011b-metabolick\u00e9 acid\u00f3ze. V d\u016fsledku \u00fatlaku plic se zv\u011bt\u0161uje pravolev\u00fd zkrat dosud otev\u0159enou tepennou du\u010dej\u00ed a smrt nast\u00e1v\u00e1 srde\u010dn\u00edm selh\u00e1n\u00edm.<\/p>\n

Diagn\u00f3zu stanov\u00edme na z\u00e1klad\u011b nativn\u00edho sn\u00edmku hrudn\u00edku a b\u0159icha. U nej\u010dast\u011bj\u0161\u00ed Bochdalekovy hernie nach\u00e1z\u00edme deviaci mediastina a srdce doprava, prav\u00e1 pl\u00edce je utla\u010dena, lev\u00e1 zpravidla hypoplastick\u00e1. Lev\u00fd hemitorax je prostoupen vzduchov\u00fdmi bublinami v dislokovan\u00e9m st\u0159evu a \u017ealudku, oblast b\u0159icha je pr\u00e1zdn\u00e1 (obr. 3).<\/p>\n\n\n\n
\n

\"Obr.<\/a>

Obr. 2
Rentgenov\u00fd obraz up-side-down stomach u 8denn\u00edho chlapce s ne\u00faplnou obstrukc\u00ed v oblasti pyloru<\/p><\/div><\/td>\n

\n

\"Obr.<\/a>

Obr. 3
Levostrann\u00e1 vrozen\u00e1<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Bochdalekova br\u00e1ni\u010dn\u00ed hernie<\/h6>\n

V\u010dasn\u00e9 rozpozn\u00e1n\u00ed br\u00e1ni\u010dn\u00ed k\u00fdly u asfyktick\u00e9ho d\u00edt\u011bte po narozen\u00ed je pro jeho dal\u0161\u00ed osud velmi d\u016fle\u017eit\u00e9. U t\u011bchto d\u011bt\u00ed je kontraindikov\u00e1na resuscitace maskou, jeliko\u017e \u00fanik plyn\u016f do za\u017e\u00edvac\u00edho traktu zhor\u0161uje ji\u017e tak dramatick\u00fd stav d\u00edt\u011bte. D\u00edt\u011b je nutn\u00e9 zaintubovat a \u0161etrn\u011b ventilovat p\u0159es endotrache\u00e1ln\u00ed kanylu, aby nedo\u0161lo k barotraumatu. K dekompresi \u017ealudku a st\u0159ev je nutn\u00e9 zav\u00e9st nasogastrickou sondu. D\u00edt\u011b polohujeme na bok na posti\u017eenou stranu.<\/p>\n

Pro vrozenou br\u00e1ni\u010dn\u00ed k\u00fdlu je typick\u00e1 perzistuj\u00edc\u00ed plicn\u00ed hypertenze, kterou zhor\u0161uje p\u0159\u00edtomnost hypoxie, acid\u00f3zy a hyperkapnie. V\u011bt\u0161inou nesta\u010d\u00ed pouh\u00e1 konven\u010dn\u00ed plicn\u00ed ventilace (PPV), je nutn\u00e1 vysokofrekven\u010dn\u00ed oscila\u010dn\u00ed ventilace (HFOV) \u010dasto s inhalac\u00ed kysli\u010dn\u00edku dusnat\u00e9ho (iNO). Opera\u010dn\u00ed z\u00e1krok je t\u0159eba odlo\u017eit a prov\u00e9st a\u017e po stabilizaci d\u00edt\u011bte. Novorozenci se v\u011bt\u0161inou letecky transportuj\u00ed do specializovan\u00e9ho centra, kde krom\u011b dostupnosti zku\u0161en\u00fdch d\u011btsk\u00fdch chirurg\u016f funguje dob\u0159e vybaven\u00e1 jednotka resuscita\u010dn\u00ed a intenzivn\u00ed p\u00e9\u010de pro novorozence se zku\u0161enost\u00ed s l\u00e9\u010dbou t\u011bchto d\u011bt\u00ed. Poopera\u010dn\u00ed p\u00e9\u010de spo\u010d\u00edv\u00e1 p\u0159edev\u0161\u00edm v zaji\u0161t\u011bn\u00ed adekv\u00e1tn\u00ed ventila\u010dn\u00ed podpory, v nejt\u011b\u017e\u0161\u00edch p\u0159\u00edpadech a\u017e v mimot\u011bln\u00ed membr\u00e1nov\u00e9 oxygenaci (ECMO).<\/p>\n

Celkov\u00e1 mortalita u vrozen\u00e9 br\u00e1ni\u010dn\u00ed k\u00fdly je asi 40%, p\u0159i\u010dem\u017e plat\u00ed, \u017ee u novorozenc\u016f s norm\u00e1ln\u00edmi prenat\u00e1ln\u00edmi n\u00e1lezy a prvn\u00edmi p\u0159\u00edznaky a\u017e v prvn\u00edch 24 hodin\u00e1ch po narozen\u00ed se p\u0159e\u017eit\u00ed bl\u00ed\u017e\u00ed 100%. \u0160patnou progn\u00f3zu maj\u00ed posti\u017een\u00e9 d\u011bti, m\u011bla-li matka v t\u011bhotenstv\u00ed polyhydramnion, d\u011bti narozen\u00e9 p\u0159ed\u010dasn\u011b,novorozenci s velmi n\u00edzk\u00fdm sk\u00f3re podle Apgarov\u00e9, P\u0159idru\u017een\u00fdmi srde\u010dn\u00edmi \u010di jin\u00fdmi vrozen\u00fdmi vadami,\u0161patn\u00fdmi krevn\u00edmi plyny a velk\u00fdm br\u00e1ni\u010dn\u00edm defektem.L\u00e9\u010den\u00ed je operativn\u00ed a prov\u00e1d\u00ed je ve specializovan\u00fdch centrech d\u011bt\u0161t\u00ed chirurgov\u00e9 v \u00fazk\u00e9 spolupr\u00e1ci s neonatology. Kolem opera\u010dn\u00ed intenzivn\u00ed p\u00e9\u010de je z\u00e1kladn\u00edm p\u0159edpokladem \u00fasp\u011bchu operace. Po \u0159adu let byla za standard pova\u017eov\u00e1na urgentn\u00ed operace. Nyn\u00ed se ukazuje, \u017ee lep\u0161\u00ed v\u00fdsledky p\u0159in\u00e1\u0161\u00ed, jak ji\u017e uvedeno, odlo\u017een\u00e1 operace po stabilizaci d\u00edt\u011bte. Jako opera\u010dn\u00ed p\u0159\u00edstup se nej\u010dast\u011bji vol\u00ed subkost\u00e1ln\u00ed \u0159ez, p\u0159i lokalizaci vpravo p\u0159ich\u00e1z\u00ed v \u00favahu i torak\u00e1ln\u00ed cesta. U men\u0161\u00edch defekt\u016f se prov\u00e1d\u00ed prim\u00e1rn\u00ed sutura, v\u011bt\u0161\u00ed defekty se pak uzav\u00edraj\u00ed pomoc\u00ed implantace s\u00ed\u0165ky. Pokud by repozice org\u00e1n\u016f do dutiny b\u0159i\u0161n\u00ed vedla k ne\u00fam\u011brn\u00e9mu zv\u00fd\u0161en\u00ed intraabdomin\u00e1ln\u00edho tlaku, je t\u0159eba prov\u00e9st jen provizorn\u00ed uz\u00e1v\u011br dutiny b\u0159i\u0161n\u00ed pouhou suturou k\u016f\u017ee nebo p\u0159echodn\u00fdm uz\u00e1v\u011brem b\u0159i\u0161n\u00ed dutiny v\u0161it\u00edm s\u00ed\u0165ky.<\/p>\n

9.3 Br\u00e1ni\u010dn\u00ed k\u00fdly v dosp\u011blosti<\/h3>\n

Nej\u010dast\u011bj\u0161\u00edmi br\u00e1ni\u010dn\u00edmi k\u00fdlami v dosp\u011blosti jsou hi\u00e1tov\u00e9 hernie<\/b>.<\/p>\n

Traumatick\u00e9 ruptury<\/h6>\n

P\u0159\u00ed\u010diny a v\u00fdskyt: <\/b>nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou jsou zav\u0159en\u00e1 poran\u011bn\u00ed <\/b><\/i>zp\u016fsoben\u00e1 stla\u010den\u00edm hrudn\u00edku a doln\u00ed \u010d\u00e1sti b\u0159icha, nap\u0159. n\u00e1razem na volant p\u0159i autonehod\u011b. Podle toho, jde-li o kompresi p\u0159edozadn\u00ed nebo bo\u010dn\u00ed, vznikaj\u00ed trhliny \u010dast\u011bji se sagit\u00e1ln\u00edm nebo front\u00e1ln\u00edm pr\u016fb\u011bhem. V\u00edce je posti\u017eena lev\u00e1 br\u00e1nice, <\/b><\/i>co\u017e se vysv\u011btluje ochrann\u00fdm vlivem jatern\u00edho masivu nad pravou br\u00e1nic\u00ed. \u010casto jsou ruptury br\u00e1nice sou\u010d\u00e1st\u00ed polytraumat. M\u00e9n\u011b \u010dast\u00fdm mechanismem jsou u n\u00e1s poran\u011bn\u00ed otev\u0159en\u00e1. Tato penetruj\u00edc\u00ed poran\u011bn\u00ed jsou nej\u010dast\u011bji zp\u016fsobena bodn\u00fdmi \u010di st\u0159eln\u00fdmi zran\u011bn\u00edmi v doln\u00ed \u010d\u00e1sti hrudn\u00edku pod \u00farovni prsn\u00edch bradavek, \u010dasto jde pak o poran\u011bn\u00ed dvoudutinov\u00e9.<\/p>\n

Diagn\u00f3za <\/b>traumatick\u00fdch ruptur br\u00e1nice v akutn\u00edm stadiu je obt\u00ed\u017en\u00e1. Vypl\u00fdv\u00e1 to z \u010dast\u00e9 koincidence s jin\u00fdmi poran\u011bn\u00edmi a z mal\u00e9 specifity p\u0159\u00edznak\u016f. \u010casto je diagn\u00f3za stanovena a\u017e peropera\u010dn\u011b. Vedle herni\u00ed s akutn\u00edmi projevy v bezprost\u0159edn\u00ed n\u00e1vaznosti na \u00faraz z\u016fst\u00e1v\u00e1 a\u017e 50 % <\/i>br\u00e1ni\u010dn\u00edch ruptur nerozpoznan\u00fdch. <\/i>Mohou se p\u0159ihl\u00e1sit n\u011bkdy a\u017e za n\u011bkolik let neur\u010dit\u00fdm\u00ed obt\u00ed\u017eemi, nebo jako n\u00e1hl\u00e1 p\u0159\u00edhoda b\u0159i\u0161n\u00ed p\u0159i inkarceraci. Symptomatologie bezprost\u0159edn\u011b po \u00farazu je d\u00e1na lokalizac\u00ed \u00farazu a charakteru pr\u016fvodn\u00edch poran\u011bn\u00ed. Pro br\u00e1ni\u010dn\u00ed rupturu sv\u011bd\u010d\u00ed du\u0161nost, ka\u0161el, dysfagie, tlak na hrudn\u00edku, p\u0159el\u00e9v\u00e1n\u00ed \u017ealude\u010dn\u00edho obsahu v hrudn\u00edku a pocit \u00falevy v horizont\u00e1ln\u00ed poloze. Objektivn\u011b lze prok\u00e1zat ztemn\u011bn\u00ed poklepu na hrudn\u00edku, oslaben\u00e9 d\u00fdch\u00e1n\u00ed a sly\u0161itelnou peristaltiku a \u0161pl\u00edchoty v hrudn\u00edku. Rutinn\u00ed rentgenologick\u00e9 vy\u0161et\u0159en\u00ed je st\u00e1le nejvhodn\u011bj\u0161\u00edm objektivn\u00edm vy\u0161et\u0159en\u00edm. Rentgenologicky je patrn\u00fd zv\u00fd\u0161en\u00fd stav a nepohyblivost br\u00e1nice, zast\u0159en\u00ed hemitoraxu a p\u0159\u00edtomnost hydroaerick\u00fdch \u00fatvar\u016f. Tam, kde stav nevy\u017eaduje urgentn\u00ed operaci, je mo\u017eno diagn\u00f3zu zp\u0159esnit kontrastn\u00edm vy\u0161et\u0159en\u00edm tr\u00e1vic\u00edho \u00fastroj\u00ed \u010di CT vy\u0161et\u0159en\u00edm (obr. 4a,b,c,d). U nejasn\u00e9ho n\u00e1lezu m\u00e1 pro stanoven\u00ed rozsahu dutinov\u00fdch poran\u011bn\u00ed v\u00fdznam torakoskopie \u010di laparoskopie. V\u00fdhodou je, \u017ee se ob\u011b metody mohou st\u00e1t po stanoven\u00ed diagn\u00f3zy okam\u017eit\u011b i terapeutickou metodou.<\/p>\n

Terapie<\/strong>: Indikac\u00ed k operaci je v akutn\u00edm stadiu celkov\u00fd stav nemocn\u00e9ho s p\u0159\u00edznaky n\u00e1hl\u00e9 \u00farazov\u00e9 p\u0159\u00edhody b\u0159i\u0161n\u00ed \u010di hrudn\u00ed. V del\u0161\u00edm odstupu od operace upozorn\u00ed na mo\u017enost ruptury p\u0159\u00edznaky z \u00fatlaku org\u00e1n\u016f dislokovan\u00fdch do hrudn\u00edku, nebo jde jen\u00a0o n\u00e1hodn\u00fd n\u00e1lez p\u0159i rentgenu plic. P\u0159\u00edstup z laparotomie umo\u017e\u0148uje sou\u010dasn\u00e9 vy\u0161et\u0159en\u00ed ostatn\u00edch nitrob\u0159i\u0161n\u00edch org\u00e1n\u016f a vylou\u010den\u00ed \u010di o\u0161et\u0159en\u00ed jejich poran\u011bn\u00ed. Jak z horn\u00ed st\u0159edn\u00ed laparotomie, tak ze subkost\u00e1ln\u00edho \u0159ezu je i dostate\u010dn\u00fd p\u0159\u00edstup k proveden\u00ed sutury br\u00e1nice. M\u00e9n\u011b \u010dasto je k uzav\u0159en\u00ed br\u00e1ni\u010dn\u00edho defektu nutno u\u017e\u00edt s\u00ed\u0165ky. Sou\u010d\u00e1st\u00ed operace mus\u00ed b\u00fdt i revize a dren\u00e1\u017e hrudn\u00ed dutiny. Stoj\u00ed-li v pop\u0159ed\u00ed nitrohrudn\u00ed p\u0159\u00edznaky nebo u pravostrann\u00fdch ruptur, je mo\u017eno volit p\u0159\u00edstup z torakotomie. Alternativou laparotomie a torakotomie je dnes dle stavu nemocn\u00e9ho a rozsahu poran\u011bn\u00ed, jak ji\u017e bylo uvedeno, torakoskopie \u010di laparoskopie.<\/p>\n\n\n\n\n
\n

\"Obr.<\/a>

Obr. 4a
Vy\u0161et\u0159en\u00ed 58let\u00e9 nemocn\u00e9 s bolestmi na hrudn\u00edku a du\u0161nost\u00ed p\u016fl roku po \u00faraze
Z p\u0159edozadn\u00edho rtg sn\u00edmku hrudn\u00edku lze usuzovat na dislokaci nitrob\u0159i\u0161n\u00edch org\u00e1n\u016f do lev\u00e9 pohrudni\u010dn\u00ed dutiny<\/p><\/div><\/td>\n

\n

\"Obr.<\/a>

Obr. 4b
Vy\u0161et\u0159en\u00ed 58let\u00e9 nemocn\u00e9 s bolestmi na hrudn\u00edku a du\u0161nost\u00ed p\u016fl roku po \u00faraze
Kontrastn\u00ed vy\u0161et\u0159en\u00ed \u017ealudku prokazuje norm\u00e1ln\u00ed ulo\u017een\u00ed kardie a dislokaci \u017ealudku krani\u00e1ln\u011b do hrudn\u00edku. Later\u00e1ln\u011b a dorz\u00e1ln\u011b od n\u011bj je patrn\u00fd nehomogenn\u00ed nativn\u00ed obsah tlust\u00e9ho st\u0159eva<\/p><\/div><\/td>\n<\/tr>\n

\n

\"Obr.<\/a>

Obr. 4c
Vy\u0161et\u0159en\u00ed 58let\u00e9 nemocn\u00e9 s bolestmi na hrudn\u00edku a du\u0161nost\u00ed p\u016fl roku po \u00faraze
Stav v lev\u00e9 bo\u010dn\u00ed projekci. Kardie je v normotopn\u00ed pozici. \u017daludek je vysunut krani\u00e1ln\u011b a sto\u010den tak, \u017ee fundus je ulo\u017een kaud\u00e1ln\u011b, t\u011blo a antrum naopak krani\u00e1ln\u011b a st\u00e1\u010dej\u00ed se dop\u0159edu. N\u00e1lez odpov\u00edd\u00e1 organoaxi\u00e1ln\u00edmu volvulu \u017ealudku bez poruchy evakuace<\/p><\/div><\/td>\n

\n

\"Obr.<\/a>

Obr. 4d
Vy\u0161et\u0159en\u00ed 58let\u00e9 nemocn\u00e9 s bolestmi na hrudn\u00edku a du\u0161nost\u00ed p\u016fl roku po \u00faraze
Poopera\u010dn\u00ed kontrastn\u00ed vy\u0161et\u0159en\u00ed \u017ealudku prokazuje jeho fyziologickou polohu<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Hernia foramen Morgagni<\/h6>\n

Jde o vz\u00e1cnou retrostern\u00e1ln\u00ed hernii, poprv\u00e9 popsanou italsk\u00fdm anatomem Morgagnim v roce 1769. Jde obvykle o pravou k\u00fdlu s peritone\u00e1ln\u00edm vakem, jej\u00edm\u017e obsahem je v\u011bt\u0161inou jen preperitone\u00e1ln\u00ed lipom \u010di mesenterium, vz\u00e1cn\u011b pronikaj\u00ed do hrudn\u00edku jin\u00e9 org\u00e1ny a pak je nebezpe\u010d\u00ed usk\u0159inut\u00ed. K\u00fdla pronik\u00e1 pravou kostostern\u00e1ln\u00ed \u0161t\u011brbinou, \u0161t\u011brbinou vlevo od sterna (Larreyova \u0161t\u011brbina) <\/i>pronik\u00e1 z\u0159\u00eddka, proto\u017ee tomu br\u00e1n\u00ed perikard. V\u011bt\u0161inou jde o n\u00e1hodn\u00fd n\u00e1lez a pacienti nemaj\u00ed obt\u00ed\u017ee. Vz\u00e1cn\u011b p\u0159i herniaci st\u0159eva \u010di \u017ealudku m\u016f\u017ee doj\u00edt k usk\u0159inut\u00ed. Diagn\u00f3za se stanov\u00ed CT \u010di kontrastn\u00edm rtg vy\u0161et\u0159en\u00edm. L\u00e9\u010dba je chirurgick\u00e1,\u00a0spo\u010d\u00edv\u00e1 v resekci vaku a uz\u00e1v\u011bru defektu, je doporu\u010dov\u00e1na aplikace s\u00ed\u0165ky jako prevence recidivy. Pops\u00e1n je jak abdomin\u00e1ln\u00ed, tak transtorak\u00e1ln\u00ed p\u0159\u00edstup a p\u0159ib\u00fdv\u00e1 zpr\u00e1v o \u0159e\u0161en\u00ed z laparoskopie \u010di torakoskopie.<\/p>\n

Relaxace<\/h6>\n

Relaxace br\u00e1nice p\u0159edstavuje oslaben\u00ed a vysok\u00fd stav zpravidla lev\u00e9 br\u00e1nice. P\u0159\u00ed\u010dinou je vrozen\u00e1 \u010di z\u00edskan\u00e1 atrofie br\u00e1nice nebo porucha inervace n. phrenicus. Diferenci\u00e1ln\u00ed diagn\u00f3za oproti br\u00e1ni\u010dn\u00ed ruptu\u0159e je t\u011b\u017ek\u00e1 a n\u011bkdy p\u0159inese rozhodnut\u00ed a\u017e operace. \u010casto je tento stav asymptomatick\u00fd. Jinak obt\u00ed\u017ee vznikaj\u00ed obdobn\u011b jako u br\u00e1ni\u010dn\u00ed ruptury z dislokace a \u00fatlak\u016f org\u00e1n\u016f. Mnohdy doch\u00e1z\u00ed k organoaxi\u00e1ln\u00edmu volvulu \u017ealudku. <\/i>Operace je indikov\u00e1na jen p\u0159i obt\u00ed\u017e\u00edch. \u010cast\u011bji z abdomin\u00e1ln\u00edho ne\u017e torak\u00e1ln\u00edho p\u0159\u00edstupu se provede z\u0159asen\u00ed br\u00e1nice. <\/i>Ke zpevn\u011bn\u00ed br\u00e1nice p\u0159ipad\u00e1 v \u00favahu plastika z m. latissimus dorsi nebo zes\u00edlen\u00ed alopatick\u00fdm materi\u00e1lem (s\u00ed\u0165kou). Ide\u00e1ln\u00ed obnoven\u00ed norm\u00e1ln\u00edho stavu se obvykle neda\u0159\u00ed a recidivy jsou \u010dast\u00e9.<\/p>\n

9.4 N\u00e1dory br\u00e1nice<\/h3>\n

N\u00e1dory br\u00e1nice jsou vz\u00e1cn\u00e9. Z prim\u00e1rn\u00edch p\u0159ich\u00e1z\u00ed v \u00favahu lipom, fibrom nebo malign\u00ed sarkom. \u010cast\u011bj\u0161\u00ed jsou n\u00e1dory sekund\u00e1rn\u00ed, zpravidla metast\u00e1zy z malign\u00edch nitrob\u0159i\u0161n\u00edch \u010di nitrohrudn\u00edch n\u00e1dor\u016f. Tumory br\u00e1nice nemaj\u00ed charakteristick\u00e9 obt\u00ed\u017ee a \u010dasto jsou asymptomatick\u00e9. P\u0159edopera\u010dn\u00ed diagn\u00f3za se stanov\u00ed obvykle modern\u00edmi zobrazovac\u00edmi metodami (CT a MRI). Nutnost chirurgick\u00e9 excize z\u00e1vis\u00ed na povaze n\u00e1dor\u016f a obt\u00ed\u017e\u00edch.<\/p>\n

9.5 Literatura<\/h3>\n
    \n
  1. Belaabidia B, Sellami S, Benelkhayat R, et al. Leiomyosarcoma of the diaphragm: a case report and review of the literature. Cancer Radiother. 2006;10(3):137\u2013141.<\/li>\n
  2. Berardi RS. An update on the surgical aspects ofMorgagni\u2019s hernia. Surgical Rounds. 1997;370\u2013376.<\/li>\n
  3. Bochdalek VA. Einige Betrachtungen uber die en-tstehung des angoborenen Zwerchfellbruches: alsBietrag zur patologischen Anatomie de Hernien.Vierteljahrsschr. Prakt Heilk. 1984;169:130<\/li>\n
  4. Bollman R, et al. Associated malformations andchromosomal defects in congenital diaphragmatichernia. Fetal Diagn Ther. 1995;10:52.<\/li>\n
  5. Butler MW, Stolar CJH, Altman RP. Contemporary Management of Congenital Diaphragmatic Hernia. World J Surg. 1993;17:350\u2013355.<\/li>\n
  6. Cada M, Gersle JT, Traubici J, et al. Approach to diagnosis and treatment of pediatric primary tumors of the diaphragm. Pediatr Surg. 2006;41:1722\u20131726.<\/li>\n
  7. Cohen MS, et al. Influence of congenital heartdisease od survival in children with congenitaldiaphragmatic hernia. J Pediatr Surg. 2002;141:25.<\/li>\n
  8. Duda M, Dlouh\u00fd M, Ro\u010dek V, Zl\u00e1mal Z. Trau-matick\u00e9 br\u00e1ni\u010dn\u00ed ruptury. Rozhl. Chir. 1980;59(4):273\u2013282.<\/li>\n
  9. Duda M, Dlouh\u00fd M, Ro\u010dek V, Zl\u00e1mal Z. Trauma-tische Zwerchlellrupturen. Zbl Chirurgie. 1981;106(5):285\u2013292.<\/li>\n
  10. Gelman R, Mirvis SE, et al. Diaphragmatic rup-ture due to blunt trauma: sensitivity of plainchest radiographs. AJR Am J Roentgenol. 1991;156(1):51\u201357.<\/li>\n
  11. Gibson C, Fonkalsrud EW. Iatrogenic pneumo-torax and mortality in congenital diaphragmatichernia. J Pediatr Surg. 1983;18:355.<\/li>\n
  12. Gross RE. Congenital hernia of the diaphragm. In:The Surgery of Infancy and Childhood. Philadel-phia: Saunders; 1953. p. 428\u2013444.<\/li>\n
  13. Hanna WC, et al. The current status of traumat-ic diaphragmatic injury: lessons learned from105 patients over 13 years. Ann Thorac Surg.2008;85(3):1044\u20131048.<\/li>\n
  14. Heiberg E, et al. CT recognition of traumaticrupture of the diaphragm. AJR Am J Roentgenol.1980;135:369.<\/li>\n
  15. Holub E, Farga\u0161 E, Schwarzer M. AngeborenenHernien in Bochdalekschen Dreick und poste-rolateralen Zwerchfellhernien. Zbl Chir. 1961;86:1433\u20131447.<\/li>\n
  16. Hussong RL, Landreneau RJ, Cole FH. Diagno-sis and repair of a Morgagni hernia with video-assisted thoracic surgery. Ann Thorac Surg. 1997;63:1474.<\/li>\n
  17. Kluth D, et al. Embryology of congenital diaphrag-matic hernia. Semin Pediatr Surg. 1996;5:224).<\/li>\n
  18. Koehler RH, Smith RS. Thoracic repair of misseddiaphragmatic injury in penetrating trauma: casereport. J Trauma. 1994;36:424.<\/li>\n
  19. Kuster G, Kline LE, Garzo G. Diaphragmatichernia through the foramen of Morgagni: lapa-roscopic repair. J Laparosc Surg. 1992;2:93.<\/li>\n
  20. Lindsey I, Woods DS, Nottle PD. Laparoscopicmanagement of blunt diaphragmatic injury . AustN Z J Surg. 1997;67:619.<\/li>\n
  21. Martin I, et al. Laparoscopy in the management of diaphragmatic rupture due to blunt trauma. Aust N Z J Surg. 1998;68:584.<\/li>\n
  22. Medeiros CW, Kondo W, Baptista I jr, et al. Primary rhabdomyosarcoma of the diaphragm: case report and literature review. Rev Hosp Clin Cace Med S Paulo. 2002;57(2):67\u201372.<\/li>\n
  23. Metkus AP, et al. Sonographic predictors of survival in fetal diaphragmatic hernia. J Pediatr. Surg.1996;31:148.<\/li>\n
  24. Mineo TC, et al. Changing indications for thora-cotomy in blunt chest trauma after the advent ofvideothoracoscopy. J Trauma. 1999;47:1088.<\/li>\n
  25. Morgagni GB. The Seats et Causes of Disease Inv-astigated by Anatomy. London: Millar and Cadell;1769. p. 205.<\/li>\n
  26. Nakayama DK, Motoyama EK, Tagge EM. Effectof preoperative stabilization on respiratory sys-tem compliance and outcome in newborn infantswith congenital diaphragmatic hernia. J Pediatr.1991;118:793.<\/li>\n
  27. Ochsner MG, et al. Prospective evalution of thora-coscopy for diagnosing diaphragmatic injury inthoracoabdominal trauma: a preliminary report.J Trauma. 1993;34:74.<\/li>\n
  28. Olafsson G, Rausing A, Holen O. Primary tumorsof the diaphragm. Chest. 1971;59:568\u2013570.<\/li>\n
  29. Orita M, et al. Laparoscopic repair of a a diphragmatic hernia through the foramen of Morgagni. Surg Endosc. 1977;11:668.<\/li>\n
  30. Potaris K, Mihos P, et al. Role of video-assisted thoracic surgery in the evoluation and management of thoracic injuries. Interact Cardiovasc Thorac Surg. 2005;4(4):292\u2013294.<\/li>\n
  31. Simpson J, et al. Traumatic diaphragmatic rupture: associated injuries and outcome. Ann R Coll Surg Engl. 2000;82:97.<\/li>\n
  32. Stevens TP, et al. Survival et early and late term infants with congenital diaphragmatic hernia treated with extracorporeal membrane oxygenation. Pediatrics. 2002;110:590.<\/li>\n
  33. Thoman DS, Hui T, Phillips EH. Laparoscopic diaphragmatic hernia repair. Surg Endosc. 2002;16:1345.<\/li>\n
  34. Vanamo K, et al. Long-term pulmonary sequelaein survivors of congenital diaphragmatic defects.J Pediatr Surg. 1996;31:1096.<\/li>\n
  35. Witters I, et al. Associated malformations andchromosomal anomalies in 42 cases of prenatally diagnosed diaphragmatic hernia. Am J MedGenet. 2001;103:278.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    9.1 Anatomie a embryologie br\u00e1nice Diafragma \u2013 br\u00e1nice \u2013 vytv\u00e1\u0159\u00ed p\u0159ed\u011bl mezi dutinou hrudn\u00ed a b\u0159i\u0161n\u00ed. Jde o tenkou p\u0159ep\u00e1\u017eku tvo\u0159enou na obvodu svalstvem, kter\u00e9 sm\u011brem do centra p\u0159ech\u00e1z\u00ed v aponeur\u00f3zu. Dorz\u00e1ln\u011b se up\u00edn\u00e1 k p\u00e1te\u0159i ve v\u00fd\u0161i t\u0159et\u00edho lumb\u00e1ln\u00edho obratle, ventr\u00e1ln\u011b k doln\u00ed \u010d\u00e1sti sterna a po obvodu k \u017eebern\u00edm oblouk\u016fm. Kupulovit\u011b se vyklenuje […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1347,"menu_order":45,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-1646","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1646","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1646"}],"version-history":[{"count":9,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1646\/revisions"}],"predecessor-version":[{"id":1716,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1646\/revisions\/1716"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1347"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1646"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}