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Hogarty J, Jassal K, Ravintharan N, Adhami M, Yeung M, Clements W, Fitzgerald M, Mathew JK. Twenty-year perspective on blunt traumatic diaphragmatic injury in level 1 trauma centre: Early versus delayed diagnosis injury patterns and outcomes. Emerg Med Australas 2023; 35:842-848. [PMID: 37308166 DOI: 10.1111/1742-6723.14255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/25/2023] [Accepted: 05/14/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Blunt traumatic diaphragmatic injury (TDI) is typically associated with severe trauma and concomitant injuries. It is a diagnostic challenge in the setting of blunt trauma and can be easily overlooked especially in the acute phase often dominated by concurrent injuries. METHODS A retrospective review was conducted of patients with blunt-TDI identified from a level 1 trauma registry. Variables associated with early versus delayed diagnosis as well as non-survivor and survivor groups were collected to examine factors associated with delayed diagnosis. RESULTS A total of 155 patients were included (mean age 46 ± 20, 60.6% male). Diagnosis was made <24 h in 126 (81.3%), and >24 h in 29 (18.7%). Of the delayed diagnosis group, 14 (48%) were diagnosed >7 days. Overall, 27 (21.4%) patients had a diagnostic initial CXR and 64 (50.8%) had a diagnostic initial CT. Fifty-eight (37.4%) patients were diagnosed intraoperatively. Of the delayed diagnosis group, 22 (75.9%) had no initial signs on CXR or CT, 15 (52%) of this group had persistent pleural-effusions/elevated-hemidiaphragm leading to further investigation and diagnosis. No significant difference in survival was observed between early and delayed diagnoses, no clinically significant injury patterns to predict delayed diagnoses were noted. CONCLUSION The diagnosis of TDI is challenging. Without frank signs of herniation of abdominal contents on CXR or CT, the diagnosis is often not made on initial imaging. In patients with the evidence of blunt traumatic injury in the lower-chest/upper-abdomen, a high degree of clinical suspicion should be held and follow-up CXRs/CTs arranged.
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Affiliation(s)
- Joseph Hogarty
- Alfred Health Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
| | - Karishma Jassal
- Alfred Health Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, Alfred Hospital, Melbourne, Victoria, Australia
| | | | | | - Meei Yeung
- Alfred Health Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- National Trauma Research Institute, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- Alfred Health Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, Alfred Hospital, Melbourne, Victoria, Australia
| | - Joseph K Mathew
- Alfred Health Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, Alfred Hospital, Melbourne, Victoria, Australia
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Al Babtain I, AlObaid B, Alsogair R, Aljrayed MA, Almohaisen G, Al-Mutairi A. Incidence of Traumatic Diaphragmatic Injury: Results From a Retrospective Cohort Study in a Level I Trauma Center in Riyadh. Cureus 2023; 15:e47215. [PMID: 38022168 PMCID: PMC10653265 DOI: 10.7759/cureus.47215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Traumatic diaphragmatic injuries (TDIs) are uncommon and the incidence of TDI is difficult to estimate because of the variation in reporting missed or late detected diaphragmatic injuries. Therefore, our study's aim was to investigate the prevalence of traumatic diaphragmatic injury in the thoracoabdominal trauma, discuss the etiological factors, diagnostic investigations, and outcomes in TDIs, and evaluate predictors of mortality in patients who were diagnosed at King Abdulaziz Medical City in Riyadh, Saudi Arabia. Materials and methods This observational retrospective cohort study was conducted at King Abdulaziz Medical City (KAMC), a tertiary hospital in Riyadh, Saudi Arabia. The study included all adult patients aged 18 years or older diagnosed with traumatic diaphragmatic injuries between the years 2016 and 2020. The BESTCare electronic system was used to get the patient's medical records and extract the data. Pearson χ2 test was used for categorical variables, and an independent t-test was used for continuous variables to investigate the association between predictors and outcomes. Results A total of eight patients were involved in this study. The mean age of the patients was 49 years old. Males outnumbered females by 75%. Patients admitted with blunt injuries were greater by 75% compared to penetrating injuries by 25%. The left side of the diaphragm was the most common site of injury. The total number of patients who were admitted to the ICU was five, four of whom had blunt trauma and one had a penetrating injury. Conclusion The demographic data of the patients included in this study corresponded to that in the literature. Although not reaching a statistically significant level, ICU admissions and mortality were mostly associated with blunt injuries. Larger multi-center studies are required to further investigate the incidence of traumatic diaphragmatic injuries (TDI).
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Affiliation(s)
| | - Bashayer AlObaid
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Reema Alsogair
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Maha A Aljrayed
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Ghadi Almohaisen
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Abrar Al-Mutairi
- College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
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Giuffrida M, Perrone G, Abu-Zidan F, Agnoletti V, Ansaloni L, Baiocchi GL, Bendinelli C, Biffl WL, Bonavina L, Bravi F, Carcoforo P, Ceresoli M, Chichom-Mefire A, Coccolini F, Coimbra R, de'Angelis N, de Moya M, De Simone B, Di Saverio S, Fraga GP, Galante J, Ivatury R, Kashuk J, Kelly MD, Kirkpatrick AW, Kluger Y, Koike K, Leppaniemi A, Maier RV, Moore EE, Peitzmann A, Sakakushev B, Sartelli M, Sugrue M, Tian BWCA, Broek RT, Vallicelli C, Wani I, Weber DG, Docimo G, Catena F. Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper. World J Emerg Surg 2023; 18:43. [PMID: 37496073 PMCID: PMC10373334 DOI: 10.1186/s13017-023-00510-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable. METHODS A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations. RESULTS CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients. CONCLUSIONS Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.
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Affiliation(s)
| | - Gennaro Perrone
- Department of Emergency Surgery, Maggiore Hospital, Via A. Gramsci 14, 43126, Parma, Italy.
| | - Fikri Abu-Zidan
- Research Office, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Vanni Agnoletti
- Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Gian Luca Baiocchi
- General Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cino Bendinelli
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Walter L Biffl
- Acute Care Surgery at The Queen's Medical Center, John A. Burns School of Medicine, University of Hawai'I, Honolulu, USA
| | - Luigi Bonavina
- Department of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milano, Milan, Italy
| | - Francesca Bravi
- Healthcare Administration, Santa Maria Delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Paolo Carcoforo
- Department of Morphology, Surgery and Experimental Medicine, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, , Riverside, California, USA
| | - Nicola de'Angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Marc de Moya
- Trauma/Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint-Germain-en-Laye Hospitals, Poissy, France
| | - Salomone Di Saverio
- Department of General Surgery, San Benedetto del Tronto General Hospital, San Benedetto del Tronto, Italy
| | - Gustavo Pereira Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Rao Ivatury
- Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Jeffry Kashuk
- Department of Surgery, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Andrew W Kirkpatrick
- Department of General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Ernest Eugene Moore
- Department of Surgery, Denver Health Medical Center,, University of Colorado, Denver, CO, USA
| | - Andrew Peitzmann
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | | | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Donegal, Ireland
| | - Brian W C A Tian
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Richard Ten Broek
- Surgery Department, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Imtaz Wani
- Department of Minimal Access and General Surgery, Government Gousia Hospital, Srinagar, India
| | - Dieter G Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Giovanni Docimo
- Department of Medical and Advanced Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
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LA-Falce TS, Martini Filho D, Botter M, Saad Junior R. Natural evolution of perforating wounds of 30% extension of the left diaphragm and the anatomopathological characteristics of its healing. Experimental Study. Rev Col Bras Cir 2022; 49:e20223162. [PMID: 35792805 PMCID: PMC10578814 DOI: 10.1590/0100-6991e-20223162-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 04/26/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION diaphragmatic injury is a challenge for surgeons. It is an injury that can be isolated. It is frequent in penetrating thoracoabdominal trauma. It represents a diagnostic challenge and the ideal approach is not yet well established. The occurrence of spontaneous healing of these injuries is still much discussed and even more, if it does, what is the healing mechanism? OBJECTIVE to macroscopically and histologically evaluate the natural evolution of perforation and cutting wounds equivalent to 30% of the left diaphragm. METHOD 50 specimens of rats underwent a surgical procedure and, after 30 days, were euthanized and those that presented scar tissue in the diaphragm, the samples were submitted to histopathological study, using the hematoxylin and eosin stains, Massons trichrome and Picrosirius to assess the presence of collagen or muscle fibers (hyperplasia) in the scar. RESULTS it was found that healing occurred in diaphragmatic injuries in 90% of rats. We also observed the presence of fibrosis in all analyzed samples. CONCLUSION Spontaneous healing occurred in most diaphragmatic injuries and the inflammatory reaction represented by the presence of fibrosis and collagen deposition was observed in all our samples. Muscle fiber hyperplasia did not occur.
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Affiliation(s)
- Thiago Souza LA-Falce
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia - São Paulo - SP - Brasil
| | - Dino Martini Filho
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Ciências Patológicas - São Paulo - SP - Brasil
| | - Marcio Botter
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia - São Paulo - SP - Brasil
| | - Roberto Saad Junior
- - Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia - São Paulo - SP - Brasil
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Cremonini C, Lewis MR, Jakob D, Benjamin ER, Chiarugi M, Demetriades D. Diagnosing penetrating diaphragmatic injuries: CT scan is valuable but not reliable. Injury 2022; 53:116-121. [PMID: 34607700 DOI: 10.1016/j.injury.2021.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/25/2021] [Accepted: 09/10/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The diagnosis of penetrating isolated diaphragmatic injuries can be challenging because they are usually asymptomatic. Diagnosis by chest X-ray (CXR) is unreliable, while CT scan is reported to be more valuable. This study evaluated the diagnostic ability of CXR and CT in patients with proven DI. METHODS Single center retrospective study (2009-2019), including all patients with penetrating diaphragmatic injuries (pDI) documented at laparotomy or laparoscopy with preoperative CXR and/or CT evaluation. Imaging findings included hemo/pneumothorax, hemoperitoneum, pneumoperitoneum, elevated diaphragm, definitive DI, diaphragmatic hernia, and associated abdominal injuries. RESULTS 230 patients were included, 62 (27%) of which had isolated pDI, while 168 (73%) had associated abdominal or chest trauma. Of the 221 patients with proven DI and preoperative CXR, the CXR showed hemo/pneumothorax in 99 (45%), elevated diaphragm in 51 (23%), and diaphragmatic hernia in 4 (1.8%). In 86 (39%) patients, the CXR was normal. In 126 patients with pDI and preoperative CT, imaging showed hemo/pneumothorax in 95 (75%), hemoperitoneum in 66 (52%), pneumoperitoneum in 35 (28%), definitive DI in 56 (44%), suspected DI in 26 (21%), and no abnormality in 3 (2%). Of the 57 patients with isolated pDI the CXR showed a hemo/pneumothorax in 24 (42%), elevated diaphragm in 14 (25%) and was normal in 24 (42%). CONCLUSIONS Radiologic diagnosis of DI is unreliable. CT scan is much more sensitive than CXR. Laparoscopic evaluation should be considered liberally, irrespective of radiological findings.
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Affiliation(s)
- Camilla Cremonini
- Division of Trauma, Emergency Surgery and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA; General, Emergency and Trauma Surgery Department, Pisa University Hospital, via Paradisa 2, 56124, Pisa, Italy.
| | - Meghan R Lewis
- Division of Trauma, Emergency Surgery and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA.
| | - Dominik Jakob
- Division of Trauma, Emergency Surgery and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA.
| | - Elizabeth R Benjamin
- Division of Trauma, Emergency Surgery and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA.
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, via Paradisa 2, 56124, Pisa, Italy.
| | - Demetrios Demetriades
- Division of Trauma, Emergency Surgery and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA.
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LA-FALCE THIAGOSOUZA, MARTINI FILHO DINO, BOTTER MARCIO, SAAD JUNIOR ROBERTO. Evolução natural das feridas perfurocortantes de 30% de extensão do diafragma esquerdo e das características anatomopatológicas de sua cicatrização. Estudo Experimental. Rev Col Bras Cir 2022. [DOI: 10.1590/0100-6991e-20223162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Introdução: o ferimento diafragmático é um desafio para os cirurgiões. É uma lesão que pode ser isolada. É frequente nos traumas penetrantes toracoabdominais. Representa um desafio diagnóstico e a conduta ideal ainda não está bem estabelecida. A ocorrência da cicatrização espontânea dessas lesões é ainda muito discutida e mais ainda, se ocorre, qual o mecanismo de cicatrização? Objetivo: avaliar macroscopicamente e histologicamente a evolução natural das feridas perfuro cortantes equivalentes a 30% do diafragma esquerdo. Método: 50 espécimes de ratos, foram submetidos a procedimento cirúrgico e, após 30 dias, foram submetidos à eutanásia e aqueles que apresentaram tecido cicatricial no diafragma, as amostras foram submetidas a estudo histopatológico, usando as colorações de hematoxilina e eosina, tricrômico de Masson e Picrossirius para avaliar a presença de colágeno ou de fibras musculares (hiperplasia) na cicatriz. Resultados: verificou-se que ocorreu nas lesões diafragmáticas, a cicatrização em 90% dos ratos. Observamos também, a presença de fibrose em todas as amostras analisadas. Conclusão: ocorreu cicatrização espontânea na maioria das lesões diafragmáticas e a reação inflamatória representada pela presença de fibrose e deposição de colágeno foi observada em todas as nossas amostras. Não ocorreu hiperplasia de fibras musculares.
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Affiliation(s)
| | | | - MARCIO BOTTER
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Brazil
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Morito A, Nakagawa S, Imai K, Uemura N, Okabe H, Hayashi H, Yamashita YI, Chikamoto A, Baba H. Successful surgical rescue of delayed onset diaphragmatic hernia following radiofrequency ablation using a thoracoscopic approach for hepatocellular carcinoma: a case report. Surg Case Rep 2021; 7:130. [PMID: 34037868 PMCID: PMC8155168 DOI: 10.1186/s40792-021-01213-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/18/2021] [Indexed: 12/30/2022] Open
Abstract
Background Radiofrequency ablation (RFA) is widely used as a minimally invasive treatment for hepatocellular carcinoma (HCC). RFA has a low risk of complications, especially compared with liver resection. Nevertheless, various complications have been reported after RFA for HCC; however, diaphragmatic hernia (DH) is extremely rare. Case presentation A 78-year-old man underwent thoracoscopic RFA for HCC located at the medial segment adjacent to the diaphragm approximately 7 years before being transported to the emergency department due complaints of nausea and abdominal pain. Computed tomography revealed a prolapsed small intestine through a defect in the right diaphragm, and emergency surgery was performed. The cause of diaphragmatic hernia was the scar of RFA. We confirmed that the small intestine had prolapsed into the right diaphragm, and we resected the necrotic small intestine and repaired the right diaphragm. Herein, we report a case of ileal strangulation due to diaphragmatic hernia after thoracoscopic RFA. Conclusions Care should be taken when performing thoracoscopic RFA, especially for tumors located on the liver surface adjacent to the diaphragm. Patients should be carefully followed up for possible DH, even after a long postoperative interval.
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Affiliation(s)
- Atsushi Morito
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Shigeki Nakagawa
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Katsunori Imai
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Norio Uemura
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Hirohisa Okabe
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Hiromitsu Hayashi
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Yo-Ichi Yamashita
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Akira Chikamoto
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-0811, Japan. .,Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.
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Koenig ZA, Schick S, Quigley R, Turner J. Penetrating Thoracoabdominal Trauma With a Cryptic Diaphragmatic Injury in a 23-Year-Old Male. Cureus 2021; 13:e13102. [PMID: 33728123 PMCID: PMC7934803 DOI: 10.7759/cureus.13102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Traumatic diaphragmatic injuries are a rare entity and can occur in relation to penetrating thoracic and abdominal trauma. The most common clinical features of diaphragm rupture include chest or abdominal bruising, decreased breath sounds, and signs of bowel obstruction. However, the classic signs and symptoms of diaphragmatic injury are not always present and can be obscured even in the highest resolution imaging. This highlights the importance for maintaining a high index of suspicion to make the diagnosis and properly manage these patients. Here, we present a rare case of a 23-year-old male who experienced a laceration to his left thorax and was later discovered to have concurrent diaphragmatic injury despite an initially noncontributory physical exam and imaging findings. The patient subsequently underwent robotic repair of the injury and reduction of herniated contents.
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Affiliation(s)
| | | | - Ryan Quigley
- Medicine, West Virginia University, Morgantown, USA
| | - Jason Turner
- Surgery, West Virginia University, Martinsburg, USA
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9
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Marzban‐Rad S, Sattari P, Taheri HR. Delayed presentation of left traumatic diaphragmatic hernia with displacement of spleen and stomach to left hemi thorax. Clin Case Rep 2020; 8:3260-3263. [PMID: 33363917 PMCID: PMC7752465 DOI: 10.1002/ccr3.3405] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/10/2020] [Accepted: 09/20/2020] [Indexed: 11/12/2022] Open
Abstract
We presented a case of late onset of left traumatic diaphragmatic hernia with displacement of spleen and stomach to the left hemi thorax, a year after the trauma. Gastric and respiratory complications along with herniation should be immediately managed, in order to reduce the risk of cardiac arrest and mortality.
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Affiliation(s)
- Saeid Marzban‐Rad
- Department of Thoracic SurgeryImam‐Reza HospitalAja University of Tehran Medical SciencesTehranIran
| | - Parastesh Sattari
- General PractitionerInstitute of Health Education and ResearchChamran hospitalTehranIran
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Da Costa Medeiros BJ, Oliveira Araujo A, Daumas Pinheiro Guimarães ADPG. Hemopericardio por disparo sin lesión cardíaca, descripción de un mecanismo de trauma. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. Durante muchos siglos, las heridas del corazón se consideraron fatales. Actualmente, el trauma cardíaco sigue siendo una de las lesiones más letales. Los resultados de pacientes con lesión cardíaca penetrante pueden variar de lesiones letales a arritmias que se resuelven espontáneamente. El hemopericardio en el trauma generalmente es debido a la lesión cardíaca penetrante, pero el saco pericárdico puede llenarse de sangre de grandes vasos y de la ruptura de la arteria pericardiofrénica asociada a laceración pericárdica contusa.
Métodos. Para la organización de este estudio, se realizó una búsqueda bibliográfica en la literatura científica. Dos casos fueron observados por el equipo de Cirugía General al describir este raro mecanismo de trauma.
Resultados. Descripción de una causa diferente de hemopericardio, ocasionada por la sangre de la cavidad peritoneal.
Discusión. En los casos presentados, la lesión por arma de fuego rompió la barrera entre las cavidades pericárdica y peritoneal (diafragma), colocando cavidades con diferentes niveles de presión, favoreciendo la entrada de sangre de la cavidad peritoneal al saco pericárdico.
Conclusión. En los casos observados el proyectil pasó muy cerca del corazón, pero sin lesionarlo. La ruptura de la superficie diafragmática del pericardio permitió que la presión de la cavidad peritoneal se igualara con la presión del pericardio.
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Sorour MA, Kassem MI, Ghazal AH, Azzam A, El-Khashab ESI, Shehata GM. Conservative approach in the management of isolated penetrating liver trauma. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2012.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Magdy A. Sorour
- General Surgery Department, Faculty of Medicine , University of Alexandria , Egypt
| | - Mohamed I. Kassem
- General Surgery Department, Faculty of Medicine , University of Alexandria , Egypt
| | - Abdel Hamid Ghazal
- General Surgery Department, Faculty of Medicine , University of Alexandria , Egypt
| | - Aymen Azzam
- General Surgery Department, Faculty of Medicine , University of Alexandria , Egypt
| | | | - Gihan M. Shehata
- Medical Informatics and Medical Statistics Department, Medical Research Institute , Alexandria University , Egypt
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Abstract
Pathologic processes that involve the central nervous system, phrenic nerve, neuromuscular junction, and skeletal muscle can impair diaphragm function. When these processes are of sufficient severity to cause diaphragm dysfunction, respiratory failure may be a consequence. This article reviews basic diaphragm anatomy and physiology and then discusses diagnostic and therapeutic approaches to disorders that result in unilateral or bilateral diaphragm dysfunction. This discussion provides a context in which disorders of the diaphragm and their implications on respiratory function can be better appreciated.
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Affiliation(s)
- F Dennis McCool
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA.
| | - Kamran Manzoor
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA
| | - Taro Minami
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA
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Minami T, Manzoor K, McCool FD. Assessing Diaphragm Function in Chest Wall and Neuromuscular Diseases. Clin Chest Med 2019; 39:335-344. [PMID: 29779593 DOI: 10.1016/j.ccm.2018.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Diaphragm dysfunction is defined as the partial or complete loss of diaphragm muscle contractility. However, because the diaphragm is one of only a few skeletal muscles that is not amenable to direct examination, the tools available for the clinician to assess diaphragm function have been limited. Traditionally, measures of lung volume, inspiratory muscle strength, and radiographic techniques such as fluoroscopy have provided the major method to assess diaphragm function. Measurement of transdiaphragmatic pressure provides the most direct means of evaluating the diaphragm, but this technique is not readily available to clinicians. Diaprhragm ultrasonography is new method that allows for direct examination of the diaphragm.
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Affiliation(s)
- Taro Minami
- The Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA
| | - Kamran Manzoor
- The Warren Alpert Medical School of Brown University, 111 Brewster Street, Pawtucket, RI 02860, USA
| | - F Dennis McCool
- The Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA.
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Hammer MM, Raptis DA, Mellnick VM, Bhalla S, Raptis CA. Traumatic injuries of the diaphragm: overview of imaging findings and diagnosis. Abdom Radiol (NY) 2017; 42:1020-1027. [PMID: 27641159 DOI: 10.1007/s00261-016-0908-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Injuries to the diaphragm muscle occur in penetrating and severe blunt trauma and can lead to delayed hernia formation. Computed tomography is the mainstay in the diagnosis of these injuries, which may be subtle at presentation. Imaging findings differ between blunt and penetrating trauma. Key features in blunt trauma include diaphragm fragment distraction and organ herniation because of increased intra-abdominal pressure. In penetrating trauma, herniation is uncommon, and the trajectory of the object is critical in making the diagnosis of diaphragm injury in these patients. Radiologists must keep a high index of suspicion for injury to the diaphragm in cases of trauma to the chest or abdomen.
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Affiliation(s)
- Mark M Hammer
- Department of Radiology, Brigham & Women's Hospital, 75 Francis St., Boston, MA, 02115, USA.
| | - Demetrios A Raptis
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Vincent M Mellnick
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
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Petrone P, Asensio JA, Marini CP. Diaphragmatic injuries and post-traumatic diaphragmatic hernias. Curr Probl Surg 2016; 54:11-32. [PMID: 28212818 DOI: 10.1067/j.cpsurg.2016.11.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 11/02/2016] [Indexed: 11/22/2022]
Affiliation(s)
- Patrizio Petrone
- New York Medical College, Winthrop University Hospital, Mineola, NY.
| | - Juan A Asensio
- Division of Trauma Surgery, Creighton University Medical Center, Omaha, NE
| | - Corrado P Marini
- New York Medical College, Winthrop University Hospital, Mineola, NY
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16
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Abstract
Thoracic trauma remains an important cause of early and late mortality in the injured patient. This review provides an overview of the emergency room management of thoracic trauma, amplifying the approach and principles of Advanced Trauma Life Support. The presentation, pathophysiology, diagnosis and treatment of the 12 most significant thoracic injuries are described. Focusing on emergency room management, and using the concept of the ‘lethal six’ and ‘hidden six,’ appropriate management strategies are detailed.
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Affiliation(s)
- Nigel RM Tai
- Johannesburg Hospital Trauma Unit, Johannesburg, South Africa
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17
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Petrone P, Leppäniemi A, Inaba K, Søreide K, Asensio JA. Diaphragmatic injuries: challenges in the diagnosis and management. TRAUMA-ENGLAND 2016. [DOI: 10.1177/1460408607087716] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Establishing the clinical diagnosis of diaphragmatic injuries (DI) can be challenging for the trauma surgeon, as it is often clinically occult. Accurate diagnosis is critical however as a missed DI may result in grave sequelae due to herniation and strangulation of displaced intra-abdominal organs. The etiology of DI includes the following mechanisms: blunt, penetrating, and iatrogenic. Vital information about the mechanism of injury should be obtained from the emergency medical personnel. Left-sided hemidiaphragmatic injuries are considerably more common than right-sided injuries. Patients with right-sided hemidiaphragm rupture have higher pre-hospital mortality resulting from the greater impacting force require to produce a right-sided DI, associated with significant vascular injury. The diagnosis of a DI by imaging studies presents a challenge, as evidenced by the large number of investigative procedures employed to establish the diagnosis. Minimally invasive technology in the form of laparoscopy and thoracoscopy is in the trauma surgeon's diagnostic and therapeutic armamentarium. The surgical care of DI can be classified according to the phase of clinical presentation, into injuries requiring management in their acute phase versus those in their chronic phase. The patient's survival depends on the severity of their associated injuries, but if DI is not diagnosed promptly a missed injury can be associated with a high morbidity and mortality.
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Affiliation(s)
- Patrizio Petrone
- Division of Trauma & Critical Care, Department of Surgery, University of Southern California Keck School of Medicine, LAC+USC Medical Center, Los Angeles, CA, USA,
| | - Ari Leppäniemi
- Department of Surgery, Meilahti Hospital, University of Helsinki, Helsinki, Finland
| | - Kenji Inaba
- Division of Trauma & Critical Care, Department of Surgery, University of Southern California Keck School of Medicine, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Kjetil Søreide
- Department of Surgery, Stavanger University Hospital and Acute Care Medicine Research Network, University of Stavanger, Stavanger, Norway
| | - Juan A Asensio
- Division of Trauma & Critical Care, Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, FL, USA
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18
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Hammer MM, Flagg E, Mellnick VM, Cummings KW, Bhalla S, Raptis CA. Computed tomography of blunt and penetrating diaphragmatic injury: sensitivity and inter-observer agreement of CT Signs. Emerg Radiol 2013; 21:143-9. [DOI: 10.1007/s10140-013-1166-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 10/04/2013] [Indexed: 12/18/2022]
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Factors affecting outcomes in penetrating diaphragmatic trauma. Int J Surg 2013; 11:492-5. [DOI: 10.1016/j.ijsu.2013.03.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 03/19/2013] [Accepted: 03/29/2013] [Indexed: 11/21/2022]
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Ganie FA, Lone H, Lone GN, Wani ML, Ganie SA, Wani NUD, Gani M. Delayed presentation of traumatic diaphragmatic hernia: a diagnosis of suspicion with increased morbidity and mortality. Trauma Mon 2013; 18:12-6. [PMID: 24350143 PMCID: PMC3860644 DOI: 10.5812/traumamon.7125] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Revised: 01/12/2013] [Accepted: 01/28/2013] [Indexed: 02/06/2023] Open
Abstract
Background Diaphragmatic rupture due to blunt or penetrating injury may be a missed diagnosis in an acute setting and can present with a delayed complication with significantly increased morbidity and mortality. Objectives The objective of this study is to better understand why diaphragmatic tears with delayed presentation and diagnosis are so often missed and why traumatic diaphragmatic tears are difficult to diagnose in emergency settings and how they present with grievous complications. Patients and Methods Eleven patients with diaphragmatic hernias with delayed presentation and delayed diagnosis were operated within the last five years. All patients presented with different complications like gut gangrene or respiratory distress. Results Out of eleven patients who were operated on for diaphragmatic hernia, three patients (27%) died. Three patients required colonic resection, one patient needed gastrectomy and one patient underwent esophagogastrectomy. Conclusions A small diaphragmatic tear due to blunt trauma to the abdomen is difficult to diagnosis in acute settings due to ragged margins and possibly no herniated contents and usually present with a delayed complication. Therefore a careful examination of the entire traumatized area is the best approach in treating delayed presentation of traumatic diaphragmatic hernia prior to development of grievous complications.
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Affiliation(s)
- Farooq Ahmad Ganie
- Department of Cardiovascular and Thoracic Surgery, SKIMS Soura, Srinagar, India
- Corresponding author: Farooq Ahmad Ganie, Department of Cardiovascular and Thoracic Surgery, SKIMS Soura, Srinagar, India. Tel.: +94-69064259, Fax: +94-69064259, E-mail:
| | - Hafeezulla Lone
- Department of Cardiovascular and Thoracic Surgery, SKIMS Soura, Srinagar, India
| | - Ghulam Nabi Lone
- Department of Cardiovascular and Thoracic Surgery, SKIMS Soura, Srinagar, India
| | - Mohd Lateef Wani
- Department of Cardiovascular and Thoracic Surgery, SKIMS Soura, Srinagar, India
| | | | - Nasir-u-din Wani
- Department of Cardiovascular and Thoracic Surgery, SKIMS Soura, Srinagar, India
| | - Masaratul Gani
- Department of J and K Health Services, University of Kashmir, Kashmir, India
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Saad Júnior R, Gonçalves R. [Must all diaphragmatic penetrating wounds be sutured?]. Rev Col Bras Cir 2012; 39:222-5. [PMID: 22836572 DOI: 10.1590/s0100-69912012000300011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 03/18/2011] [Indexed: 11/22/2022] Open
Abstract
Wounds to the abdominal-thoracic region are associated with diaphragm wounds in up to 48% of cases. Lesions secondary to diaphragm trauma are present in the majority of cases, facilitating the diagnosis of diaphragm lesion and subsequent surgical management. However, diaphragm lesions are isolated in 8 to 10% of cases and because they present few or no symptoms may be overlooked. In such situations, can the diaphragm be treated conservatively without suturing? Based on experiments in animals and a review of the literature, we concluded there is currently insufficient evidence to affirm that diaphragm injuries require no suturing.
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Affiliation(s)
- Roberto Saad Júnior
- Departamento de Cirurgia, Faculdade de Ciências Médicas da Santa Casa de São Paulo, SP, Brasil.
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23
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Abstract
Chronic traumatic diaphragmatic hernia is an uncommon but persistent diagnosis associated with significant morbidity and mortality. Chronic TDH describes a spectrum of disease in antecedent mechanism of injury, timing of presentation, size of diaphragmatic defect, and amount and type of tissue displaced into the chest. Multiplanar CT with coronal, sagittal, and axial reconstruction is most effective in making this diagnosis. Once diagnosed, repair should be undertaken. Although transabdominal approaches may be successful, the authors prefer an open transthoracic approach, recognizing that either approach may need to incorporate access into the other body cavity to complete the repair. Basic hernia principles apply including the construction of a tension-free repair, which may necessitate the use of prosthetics. As surgeons become increasingly comfortable with minimally invasive techniques, more chronic TDH are likely to be approached in this fashion. Finally, as much of the morbidity and mortality is associated with the catastrophic consequences of chronic TDH, vigilance needs to be applied in an attempt to diagnose and then repair TDH while in the latent stage prior to the development of the catastrophic complications that herald the obstructive stage.
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24
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Morjaria R, Al-Gailani H, Afzal S, Sabir S, Salman S. Twenty-seven year old man presenting with a strangulated diaphragmatic hernia eight years after the initial injury. BMJ Case Rep 2010; 2010:bcr09.2009.2288. [PMID: 22389657 DOI: 10.1136/bcr.09.2009.2288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 27-year-old man presented with a 5 day history of abdominal pain and distension, with associated constipation and vomiting. He had presented 8 years earlier following a traumatic injury to the left side of the chest, and no diaphragmatic injury was reported at that time. On this admission, a computed tomography scan showed herniation of the splenic flexure of the colon into the left hemithorax. Subsequently, he had an emergency laparotomy for resection, with formation of a loop ileostomy. The various imaging techniques all have advantages and disadvantages when diagnosing a traumatic diaphragmatic hernia. It is the clinician's role to maintain a high index of suspicion when a patient initially presents with trauma where a traumatic diaphragmatic hernia may be a possibility.
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Affiliation(s)
- Reena Morjaria
- Rochdale Infirmary (Pennine Acute Hospitals Trust), Whitehall Street, Rochdale OL12 0NB, UK
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De Rezende Neto JB, Guimarães TN, Madureira JL, Drumond DAF, Leal JC, Rocha A, Oliveira RG, Rizoli SB. Non-operative management of right side thoracoabdominal penetrating injuries--the value of testing chest tube effluent for bile. Injury 2009; 40:506-10. [PMID: 19342047 DOI: 10.1016/j.injury.2008.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Accepted: 11/11/2008] [Indexed: 02/02/2023]
Abstract
INTRODUCTION While mandatory surgery for all thoracoabdominal penetrating injuries is advocated by some, the high rate of unnecessary operations challenges this approach. However, the consequences of intrathoracic bile remains poorly investigated. We sought to evaluate the outcome of patients who underwent non-operative management of right side thoracoabdominal (RST) penetrating trauma, and the levels of bilirubin obtained from those patients' chest tube effluent. PATIENTS AND METHODS We managed non-operatively all stable patients with a single RST penetrating injury. Chest tube effluent samples were obtained six times within (4-8 h; 12-16 h; 20-24 h; 28-32 h; 36-40 h; 48 h and 72 h) of admission for bilirubin measurement and blood for complete blood count, bilirubin, alanine (ALT) and aspartate aminotransferases (AST) assays. For comparison we studied patients with single left thoracic penetrating injury. RESULTS Forty-two patients with RST injuries were included. All had liver and lung injuries confirmed by CT scans. Only one patient failed non-operative management. Chest tube bilirubin peaked at 48 h post-trauma (mean 3.3+/-4.1 mg/dL) and was always higher than both serum bilirubin (p<0.05) and chest tube effluent from control group (27 patients with left side thoracic trauma). Serum ALT and AST were higher in RST injury patients (p<0.05). One RST injury patient died of line sepsis. CONCLUSION Non-operative management of RST penetrating trauma appears to be safe. Bile originating from the liver injury reaches the right thoracic cavity but does not reflect the severity of that injury. The highest concentration was found in the patient failing non-operative management. The presence of intrathoracic bile in selected patients who sustain RST penetrating trauma, with liver injury, does not preclude non-operative management. Our study suggests that monitoring chest tube effluent bilirubin may provide helpful information when managing a patient non-operatively.
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Affiliation(s)
- João Baptista De Rezende Neto
- Department of Surgery Universidade Federal de Minas Gerais and Hospital Universitario Risoleta Tolentino Neves, Brazil
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Parreira JG, Rasslan S, Utiyama EM. Controversies in the management of asymptomatic patients sustaining penetrating thoracoabdominal wounds. Clinics (Sao Paulo) 2008; 63:695-700. [PMID: 18925332 PMCID: PMC2664730 DOI: 10.1590/s1807-59322008000500020] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Accepted: 06/12/2008] [Indexed: 11/21/2022] Open
Abstract
The most challenging diagnostic issue in the management of thoracoabdominal wounds concerns the assessment of asymptomatic patients. In almost one-third of such cases, diaphragmatic injuries are present even in the absence of any clear clinical signs. The sensitivity of noninvasive diagnostic tests is very low in this situation, and acceptable methods for diagnosis are limited to videolaparoscopy or videothoracoscopy. However, these procedures are performed under general anesthesia and present real, and potentially unnecessary, risks for the patient. On the other hand, diaphragmatic hernias, which can result from unsutured diaphragmatic lesions, are associated with considerable morbidity and mortality. In this paper, the management of asymptomatic patients sustaining wounds to the lower chest is discussed, with a focus on the diagnosis of diaphragmatic injuries and the necessity of suturing them.
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MESH Headings
- Diagnosis, Differential
- Hernia, Diaphragmatic, Traumatic/diagnosis
- Hernia, Diaphragmatic, Traumatic/etiology
- Hernia, Diaphragmatic, Traumatic/surgery
- Humans
- Sensitivity and Specificity
- Thoracic Injuries/diagnosis
- Thoracic Injuries/etiology
- Thoracic Injuries/surgery
- Thoracoscopy/methods
- Treatment Outcome
- Wounds, Penetrating/complications
- Wounds, Penetrating/diagnosis
- Wounds, Penetrating/surgery
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Affiliation(s)
- Jose Gustavo Parreira
- Division of Clinical Surgery III, Department of Surgery, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
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The Current Status of Traumatic Diaphragmatic Injury: Lessons Learned From 105 Patients Over 13 Years. Ann Thorac Surg 2008; 85:1044-8. [DOI: 10.1016/j.athoracsur.2007.10.084] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Revised: 10/24/2007] [Accepted: 10/24/2007] [Indexed: 11/18/2022]
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Laparoscopy Offers Diagnosis and Treatment in Abdominal Stab Injuries. Surg Laparosc Endosc Percutan Tech 2007; 17:396-401. [DOI: 10.1097/sle.0b013e3181378e79] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW To review the literature on the use of video-assisted thoracoscopic surgery for the diagnosis and treatment of intrathoracic injuries. RECENT FINDINGS Video-assisted thoracoscopic surgery is a relatively recent innovation. It was originally promoted for the treatment of retained hemothorax and the diagnosis of diaphragm injury. It is highly effective for the management of those problems. Recent studies have focused on video-assisted thoracoscopic surgery for treatment of chest wall bleeding, diagnosis of transmediastinal injuries, pericardial window and persistent pneumothorax. In properly selected patients, video-assisted thoracoscopic surgery is extremely efficacious in managing these problems. SUMMARY The role of video-assisted thoracoscopic surgery in the management of acute chest injury is expanding. It is an invaluable tool for the trauma surgeon.
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Affiliation(s)
- Steven R Casós
- Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky 40292, USA
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Alimoglu O, Eryilmaz R, Sahin M, Ozsoy MS. Delayed traumatic diaphragmatic hernias presenting with strangulation. Hernia 2005; 8:393-6. [PMID: 15098101 DOI: 10.1007/s10029-004-0225-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Traumatic diaphragmatic injuries commonly occur following blunt and penetrating trauma, and that may be missed during a first evaluation, resulting in chronic diaphragmatic hernia and/or strangulation. In this study, we present three cases of delayed traumatic diaphragmatic hernias presenting with strangulation. The type of trauma was blunt in two and penetrating in one patient. In all three cases, the diagnoses of diaphragmatic injuries were missed in acute and chronic settings. While two patients had transverse colonic strangulation, the other one had strangulated stomach and spleen. Transverse colon resection was performed in one patient. Two patients had postoperative complications, and no postoperative mortality was detected. Patients complaining of upper abdominal pain and dyspnea with past history of thoracoabdominal trauma should be evaluated for a missed diaphragmatic injury. A high index of suspicion, physical examination of the chest, and x-ray film are helpful for diagnosis of delayed traumatic diaphragmatic hernias presenting with strangulation.
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Affiliation(s)
- O Alimoglu
- First Department of Surgery, Vakif Gureba Training Hospital, Istanbul, Turkey.
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Zellweger R, Navsaria PH, Hess F, Omoshoro-Jones J, Kahn D, Nicol A. Transdiaphragmatic pleural lavage in penetrating thoracoabdominal trauma. Br J Surg 2004; 91:1619-23. [PMID: 15505872 DOI: 10.1002/bjs.4598] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The purpose of this study was to determine the incidence of thoracic sepsis following a systematic thoracic cavity washout through the injured diaphragm in patients with penetrating thoracoabdominal trauma. METHODS Prospectively collected data on all patients presenting with penetrating thoracoabdominal trauma between July 1999 and July 2002 were analysed. Patients with peritoneal biliary-gastroenteric (BGE) contamination and a diaphragmatic laceration were managed by laparotomy and transdiaphragmatic thoracic lavage. RESULTS A total of 217 patients had penetrating thoracoabdominal injuries, of whom 110 had BGE contamination of the peritoneal cavity with spillage into the pleural cavity. The mean Injury Severity Score was 38.1. Gunshot and stab wounds occurred in 79 (71.8 per cent) and 31 (28.2 per cent) respectively. Contamination was from the stomach (55.4 per cent), large bowel (37.3 per cent), small bowel (29.1 per cent), gallbladder and bile ducts (9.1 per cent) and pancreas (6.4 per cent). Thoracic complications occurred in six patients (5.5 per cent): empyema in two, Escherichia coli-related pneumonia in three and pleuritis in one. There were no deaths. CONCLUSION A thoracic washout through the injured diaphragm in patients with penetrating thoracoabdominal trauma and BGE contamination was associated with a low rate of intrathoracic septic complications.
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Affiliation(s)
- R Zellweger
- Department of General Surgery, Trauma Unit, Groote Schuur Hospital and the University of Cape Town, Cape Town, South Africa
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Fontelles MJ, Mantovani M, Ajub JR, Pinto FS. Incidência de empiema pleural nos ferimentos tóraco-abdominais. Rev Col Bras Cir 2004. [DOI: 10.1590/s0100-69912004000500007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJETIVO: Os ferimentos penetrantes com comprometimento simultâneo das cavidades torácica e abdominal (FTA), além da dificuldade diagnóstica, merecem especial atenção em relação à conduta adotada para o tratamento do espaço pleural. O objetivo do presente estudo foi identificar os principais fatores relacionados à incidência de empiema pleural em pacientes com ferimentos penetrantes localizados na transição toracoabdominal. MÉTODO: Utilizando-se o modelo estatístico de regressão logística múltipla, os autores analisaram 110 pacientes com ferida toracoabdominal penetrante, submetidos à drenagem pleural fechada e laparotomia. A complicação empiema pleural foi estudada quanto à incidência e fatores envolvidos. Considerou-se o nível alfa igual a 0,05. RESULTADOS: Do total, 91 (82,7%) pacientes eram do sexo masculino e 19 (17,3%) do feminino. A faixa etária situou-se entre 13 e 63 anos. Os FTA foram causados por projétil de arma de fogo em 60 casos (54,5%) e por arma branca em 50 casos (45,5%). O empiema pleural incidiu em quatro (3,6%) dos pacientes estudados. Na análise estatística a incidência de empiema pleural esteve relacionada com: lesão de víscera oca (OR=3,1386, p=0.4005); lesão do lado esquerdo do diafragma (OR= 12,98, p=0,1178) e choque hemorrágico à admissão (OR=23,9639, p=0,0250). CONCLUSÕES: A chance da ocorrência de empiema pleural foi cerca de três vezes maior em pacientes com lesão de víscera oca e, de 13 vezes se a esta lesão estava associada à lesão do lado esquerdo do diafragma; aumentando para 24 vezes se estes pacientes apresentavam, concomitantemente, estado de choque hemorrágico à admissão.
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Mcquay N, Britt L. Laparoscopy in the Evaluation of Penetrating Thoracoabdominal Trauma. Am Surg 2003. [DOI: 10.1177/000313480306900911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The evaluation of penetrating thoracoabdominal trauma for the presence of a diaphragmatic injury presents a diagnostic challenge to the trauma surgeon. The use of diagnostic laparoscopy (DL) in this setting was reviewed at a level-one trauma institution. Eighty patients (71 males, 9 females) with penetrating injuries to the thoracoabdominal region underwent DL to rule out injury to the diaphragm. Fifty-eight patients (72.5%) had a negative study and were spared a celiotomy. In the remaining 22 patients (27.5%), injury to the diaphragm was identified. This subset of patients underwent a mandatory celiotomy to rule out an associated intra-abdominal injury. Seventeen out of 22 (77.2%) patients had a positive exploration requiring surgical intervention, representing an associated intra-abdominal injury rate of 21.2 per cent. Intra-abdominal injuries requiring repair included small bowel, colon, spleen, liver, and stomach, in descending order. There were no missed injuries or deaths. One patient with a left diaphragmatic injury secondary to a stab wound developed a subdiaphragmatic abscess. Respiratory insufficiency secondary to atelectasis was the most common complication. Diagnostic laparoscopy is an essential and safe modality for the evaluation of diaphragmatic injuries in penetrating thoracoabdominal trauma.
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Affiliation(s)
- Nathaniel Mcquay
- From the Department of Surgery, University of Maryland, Baltimore, Maryland
| | - L.D. Britt
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia
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Demetriades D, Velmahos G. Technology-driven triage of abdominal trauma: the emerging era of nonoperative management. Annu Rev Med 2003; 54:1-15. [PMID: 12471178 DOI: 10.1146/annurev.med.54.101601.152512] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Selective nonoperative management of blunt or penetrating abdominal trauma is safe, has eliminated the complications associated with nontherapeutic laparotomies, and is cost-effective. Appropriately selected investigations, such as focused abdominal sonography for trauma, diagnostic peritoneal lavage, spiral computed tomography (CT) scan, diagnostic laparoscopy, or thoracoscopy and angiography, play a critical role in the triage of patients. Future technological advances, such as improvement of the ultrasonic hardware and software that provide automated interpretation and the availability of portable CT scan machines in the emergency room, may improve the speed and accuracy of the initial evaluation. Improvement of the optical system of minilaparoscopes may allow reliable bedside laparoscopy for suspected diaphragmatic injuries.
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Affiliation(s)
- D Demetriades
- Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.
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36
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Thoman DS, Hui T, Phillips EH. Laparoscopic diaphragmatic hernia repair. Surg Endosc 2002; 16:1345-9. [PMID: 11984662 DOI: 10.1007/s00464-001-8162-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2001] [Accepted: 01/07/2002] [Indexed: 10/26/2022]
Abstract
BACKGROUND Adult-congenital diaphragmatic hernias and chronic traumatic diaphragmatic hernias are uncommon entities that are often technically challenging to repair. There is growing experience with a minimal access approach to these defects. METHODS We reviewed the English-language literature using a MEDLINE search for "diaphragmatic hernia" and "laparoscopy." RESULTS We found 19 case reports of laparoscopic adult-congenital diaphragmatic hernia repair. Reported complications included two enterotomies, one of which required conversion to laparotomy. We also found 11 case reports of laparoscopic chronic traumatic diaphragmatic hernia repair, with no reported complications or recurrences. Average operative time was 98 min, and average length of stay was 4.5 days. All reports claimed that there was less postoperative pain and an earlier return to full activity with the laparoscopic approach. Herein we discuss anatomy, pathophysiology, diagnosis, method of repair, and recurrence. CONCLUSION Adult-congenital diaphragmatic hernia and chronic traumatic diaphragmatic hernia are amenable to laparoscopic repair. Although experience is still limited, laparoscopic repair appears safe and is associated with a shorter hospital stay.
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Affiliation(s)
- D S Thoman
- Division of Minimally Invasive Surgery, Cedars-Sinai Medical Centre, 8700 Beverly Blvd., Los Angeles, CA 90048, USA
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37
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Freeman RK, Al-Dossari G, Hutcheson KA, Huber L, Jessen ME, Meyer DM, Wait MA, DiMaio JM. Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma. Ann Thorac Surg 2001; 72:342-7. [PMID: 11515863 DOI: 10.1016/s0003-4975(01)02803-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Video-assisted thoracoscopic surgery (VATS) has been shown to be an accurate method for identifying diaphragmatic injuries (DIs). The purpose of this investigation was to establish specific indications for the use of VATS after penetrating chest trauma. METHODS A retrospective review of all patients undergoing VATS after penetrating chest trauma at a level 1 trauma center over an 8-year period was performed. Logistic regression was used in an attempt to identify independent predictors of DI. RESULTS One hundred seventy-one patients underwent VATS assessment of a hemidiaphragm, and 60 patients (35%) were found to have a DI. Five independent risk factors for DI were identified from analyzing the patient records: abnormal chest radiograph, associated intraabdominal injuries, high-velocity mechanism of injury, entrance wound inferior to the nipple line or scapula, and right-sided entrance wound. CONCLUSIONS In the largest published series of patients undergoing VATS to exclude a DI, this review identifies five independent predictors of DI after penetrating chest trauma. A diagnostic algorithm incorporating these five factors was designed with the goal of reducing the number of unrecognized DIs after penetrating chest trauma by using VATS for patients at greatest risk for such injuries.
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Affiliation(s)
- R K Freeman
- Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas 75390, USA
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38
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Kozar RA, Kaplan LJ, Cipolla J, Meija J, Haber MM. Laparoscopic repair of traumatic diaphragmatic injuries. J Surg Res 2001; 97:164-71. [PMID: 11341794 DOI: 10.1006/jsre.2001.6131] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Laparoscopy has been proposed as a diagnostic and potentially therapeutic modality for penetrating diaphragmatic lacerations. The purpose of this study was to assess the technical feasibility and strength of various laparoscopic repairs of diaphragmatic injuries. METHODS Swine underwent either open suture repair or laparoscopic repair by staple, suture, or patch technique of a 2-cm laceration to both the right and the left muscular or tendinous diaphragmatic leaflets. Six weeks after operation, diaphragms were harvested for either histologic analysis or bursting strength measurements. RESULTS All methods of repair proved technically feasible. There was no significant difference in bursting strength measurements between treatment groups. Bursting was due to tissue failure either at or adjacent to the repair site. Histologic analysis confirmed healing of all specimens with the laparoscopic patch technique inciting less inflammation and greater fibroblastic proliferation than the other techniques. CONCLUSIONS Laparoscopic repair of diaphragmatic lacerations can be accomplished using any of the currently available techniques. Laparoscopic stapling, suturing, or patch techniques all result in complete healing with a strong and durable repair. When selecting a particular technique, familiarity of the surgeon should be used as a guideline.
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Affiliation(s)
- R A Kozar
- Department of Surgery, Houston School of Medicine, University of Texas, 77030, USA.
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Martinez M, Briz JE, Carillo EH. Video thoracoscopy expedites the diagnosis and treatment of penetrating diaphragmatic injuries. Surg Endosc 2001; 15:28-32; discussion 33. [PMID: 11178756 DOI: 10.1007/s004640002090] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The diagnostic workup in stable patients with penetrating thoracoabdominal injuries can be extremely difficult. Conventional diagnostic tests such as plain chest radiography, computed tomography scan, digital exploration, and diagnostic peritoneal lavage can be misleading. Classically, most of these patients have undergone exploratory laparotomy to determine whether there is a diaphragmatic injury. METHODS In this study, 52 patients with penetrating thoracoabdominal trauma, and without any indication for immediate surgery, underwent video-assisted thoracoscopy to determine the presence of diaphragmatic injuries. RESULTS Of the 52 patients, 48 were men. The left hemithorax was involved in 38 patients (73%). Chest x-ray was normal in 40 patients (77%) who were clinically asymptomatic. Stab wounds were responsible for 80% of the injuries. At the time of the thoracoscopy, 35 patients (67%) were found to have a diaphragmatic injury. All 35 diaphragmatic injuries were successfully repaired thoracoscopically. The procedure was completed in 50 patients (96%). There were no deaths or complications. CONCLUSIONS The incidence of diaphragmatic injuries is higher than anticipated in asymptomatic patients with penetrating thoracoabdominal wounds. Video thoracoscopy can be used as a safe, expeditious, minimally invasive, and extremely useful technique to facilitate the diagnosis of these injuries in asymptomatic patients. Furthermore, diaphragmatic injuries can be repaired easily through a thoracoscopic approach with no complications.
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Affiliation(s)
- M Martinez
- Department of Surgery, Hospital General de Accidentes, Guatemala, Guatemala
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40
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Mantovani M, Fontelles MJP, Ajub JCVDFR, Pinto FDS. Incidência de fístulas digestivas nos ferimentos toracoabdominais. Rev Col Bras Cir 2000. [DOI: 10.1590/s0100-69912000000300004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Os ferimentos penetrantes localizados na transição toracoabdominal (FTA), além da dificuldade diagnóstica, merecem especial atenção em relação à conduta adotada para o controle das complicações abdominais. Os autores analisaram 110 pacientes atendidos na Disciplina de Cirurgia do Trauma do Departamento de Cirurgia da UNICAMP, de 1988 a 1998, apresentando ferida penetrante toracoabdominal e submetidos à laparotomia exploradora com drenagem pleural fechada. As fístulas digestivas foram estudadas quanto à incidência, ao tratamento e à evolução pós-operatória. Do total de pacientes, 91 (82,7%) eram do sexo masculino e 19 (17,3%) do sexo feminino. A faixa etária situou-se entre 13 e 63 anos. Os FTA foram causados por projétil de arma de fogo (PAF) em 60 (54,5%) casos e por arma branca (FAB) em 50 (45,5%). As fístulas digestivas ocorreram em seis (5,4%) dos pacientes estudados, sendo quatro (3,6%) casos de fístula pancreática, um (0,9%) de fístula gástrica e um (0,9%) de fístula biliar, todos tratados de maneira conservadora, apresentando evolução favorável com resolução espontânea.
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41
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Abstract
The management of penetrating chest injuries has evolved significantly over the past few years, with an increasing emphasis on less invasive diagnostic and therapeutic modalities. Only 15% of patients need a therapeutic operative procedure. The challenge is to detect and treat these injuries rapidly while maximizing the use of noninvasive examinations and decreasing costs. The areas potentially at risk for injury include the heart, major vessels, thoracoabdomen, neck, spine, and aerodigestive tract. A review of injuries to these areas, including the use of new diagnostic modalities such as echocardiography and computed tomography (CT) scans, are discussed.
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Affiliation(s)
- S D LeBlang
- Department of Radiology, University of Miami/Jackson Memorial Hospital, Florida 33136, USA.
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42
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Velho ÁV, Siebert Júnior M, Gabiatti G, Ostermann RAB, Poli D. Videolaparoscopia no trauma abdominal. Rev Col Bras Cir 2000. [DOI: 10.1590/s0100-69912000000200010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A videolaparoscopia (VL) vem contribuindo de forma crescente, para diagnóstico e terapêutica de várias afecções cirúrgicas abdominais, introduzindo profundas mudanças na cirurgia contemporânea. Esse avanço incorporou-se também às urgências traumáticas, fazendo parte da avaliação diagnóstica e, às vezes, da terapêutica do trauma abdominal. Os autores apresentam uma revisão concisa da literatura sobre a VL no trauma, atualizando o tema e discutindo os aspectos mais relevantes das indicações, limitações e complicações do método.
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Murray JA, Demetriades D, Asensio JA, Cornwell EE, Velmahos GC, Belzberg H, Berne TV. Occult injuries to the diaphragm: prospective evaluation of laparoscopy in penetrating injuries to the left lower chest. J Am Coll Surg 1998; 187:626-30. [PMID: 9849737 DOI: 10.1016/s1072-7515(98)00246-4] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND To evaluate the incidence of occult diaphragmatic injuries and investigate the role of laparoscopy in patients with penetrating trauma to the left lower chest who lack indications for exploratory celiotomy other than the potential for a diaphragm injury. STUDY DESIGN Patients with penetrating injuries to the left lower chest who were hemodynamically stable and without indications for a celiotomy were prospectively evaluated with diagnostic laparoscopy to determine the presence of an injury to the left hemidiaphragm. Diagnostic laparoscopy was performed in the operating room under general anesthesia. RESULTS One-hundred-ten patients (94 stab wounds, 16 gunshot wounds) were evaluated with laparoscopy. Twenty-six (24%) diaphragmatic injuries were identified (26% for stab wounds and 13% for gunshot wounds). Comparison of patients with diaphragmatic injuries with those without diaphragmatic injuries demonstrated a slightly greater incidence of hemo/pneumothoraces (35% versus 24%, NS). The incidence of diaphragmatic injuries in patients with a normal chest x-ray was 21% versus 31% for patients with a hemo/pneumothorax. An elevated left hemidiaphragm was associated with a diaphragmatic injuries in only 1 of 7 patients (14%). The incidence of diaphragmatic injuries was similar for anterior, lateral, and posterior injuries (22%, 27%, and 22% respectively). CONCLUSIONS The incidence of occult diaphragmatic injuries in penetrating trauma to the left lower chest is high, 24%. These injuries are associated with a lack of clinical and radiographic findings, and would have been missed had laparoscopy not been performed. Patients with penetrating trauma to the left lower chest who do not have any other indication for a celiotomy should undergo videoscopic evaluation of the left hemidiaphragm to exclude an occult injury.
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Affiliation(s)
- J A Murray
- Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, Los Angeles 90033, USA
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44
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Giannini JA, Rasslan S, Silva LED, Coimbra R, Saad Júnior R. Ferimentos penetrantes tóraco-abdominais e de tórax e abdome: análise comparativa da morbidade e mortalidade pós-operatórias. Rev Col Bras Cir 1998. [DOI: 10.1590/s0100-69911998000500002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Analisamos 145 doentes portadores de ferimentos penetrantes tóraco-abdominais e de tórax e abdome, operados no Serviço de Emergência da Santa Casa de São Paulo de julho de 1987 a fevereiro de 1996, sendo 72 (49,7%) produzidos por arma branca e 73 (50,3%) por projétil de arma de fogo. Foram estudados fatores relacionados à ocorrência de complicações pós-operatórias (pleuropulmonares, abdominais e sistêmicas), ao prolongamento do tempo de permanência hospitalar e à mortalidade ocorrida durante a internação. Caracterizamos os doentes quanto a sua gravidade, através da aplicação de índices objetivos de trauma, tanto fisiológico (RTS) quanto anatômicos (ISS, PATI, PTTI e PTI). Tanto nos ferimentos tóraco- abdominais quanto de tórax e abdome, o tratamento de escolha foi a drenagem pleural associada à laparotomia exploradora. Os ferimentos tóraco-abdominais apresentaram maior incidência de complicações em geral, em relação aos de tórax e abdome, quando a variável controle foi o ferimento produzido por arma branca. A análise por tipo de complicação mostrou que essa diferença foi dada pelo empiema pleural. Não encontramos diferença significante entre esses ferimentos com relação às demais complicações pleuropulmonares infecciosas, abdominais e sistêmicas. Os fatores que se correlacionaram com a evolução para empiema foram: o tipo de órgão lesado (estômago, esôfago e reto), a presença de fístula digestiva, o ferimento produzido por arma branca e a presença de lesão diafragmática. O prolongamento do tempo de permanência hospitalar foi determinado pela ocorrência de complicações e não pela lesão diafragmática. Houve doze (8,3%) mortes no estudo, sendo que a mortalidade correlacionou-se com maior média de lesões orgânicas por doente, com as lesões de rim, grandes vasos e esôfago, com a ocorrência de complicações especialmente de natureza infecciosa e com o ferimento produzido por projétil de arma de fogo. A análise dos nossos resultados permitiu concluir que os ferimentos penetrantes tóraco-abdominais apresentam maior número de lesões orgânicas por doente quando comparados aos ferimentos de tórax e abdome (sem lesão diafragmática), mas esses ferimentos não diferem quanto à mortalidade pós-operatória. Com relação à morbidade, a lesão diafragmática não foi fator determinante do prolongamento do tempo de permanência hospitalar e, na comparação dos ferimentos tóraco-abdominais e de tórax e abdome, a lesão diafragmática produzida por arma branca foi fator determinante do aparecimento de empiema pleural.
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Abstract
Penetrating injuries to the thoracoabdominal region represent a complex and diverse population of injuries. The clinician managing such cases must be able to consider all potential injuries, rapidly recognize life-threatening sequelae, and precisely diagnose and quickly manage these patients. The diverse nature of some of the potential presentations of patients with penetrating thoracoabdominal trauma is discussed. The most recent advances and controversies involving the evaluation and management of patients with penetrating thoracoabdominal trauma are also discussed.
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Affiliation(s)
- J A Murray
- Department of Surgery, University of Southern California School of Medicine, Los Angeles, USA
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46
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Lerner CA, Dang H, Kutilek RA. Strangulated traumatic diaphragmatic hernia simulating a subphrenic abscess. J Emerg Med 1997; 15:849-53. [PMID: 9404803 DOI: 10.1016/s0736-4679(97)00192-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Traumatic diaphragmatic hernias can be difficult to diagnose because of their varied clinical and radiologic signs and because patients may not present with symptoms for months to years following the injury. We report a case of a delayed presentation of a traumatic diaphragmatic rupture through which a portion of the stomach herniated and simulated a large subphrenic abscess.
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Affiliation(s)
- C A Lerner
- Department of Radiology, St. Joseph Hospital, Creighton University Medical Center, Omaha, Nebraska 68131, USA
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47
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Murray JA, Demetriades D, Cornwell EE, Asensio JA, Velmahos G, Belzberg H, Berne TV. Penetrating left thoracoabdominal trauma: the incidence and clinical presentation of diaphragm injuries. THE JOURNAL OF TRAUMA 1997; 43:624-6. [PMID: 9356058 DOI: 10.1097/00005373-199710000-00010] [Citation(s) in RCA: 100] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The objective of this study was to (1) determine the incidence of diaphragmatic injuries in penetrating left thoracoabdominal trauma and (2) evaluate the role of laparoscopy in detecting clinically occult diaphragmatic injuries. PATIENTS AND METHODS One hundred nineteen consecutive patients with penetrating injuries to the left thoracoabdominal region presenting to Los Angeles County-University of Southern California Medical Center were prospectively evaluated during an 8-month period. Either celiotomy (with hemodynamic instability or peritonitis) or laparoscopy was performed. Results of the clinical examination and roentgenographic findings were recorded preoperatively. RESULTS One hundred seven patients were fully evaluated. Fifty patients required emergent celiotomy. Fifty-seven patients underwent laparoscopy. The overall incidence of diaphragmatic injuries was 42% (59% for gunshot wounds, 32% for stab wounds). Among the 45 patients with diaphragmatic injuries, 31% had no abdominal tenderness, 40% had a normal chest roentgenogram, and 49% had an associated hemopneumothorax. Fifteen of the patients undergoing laparoscopy (26%) had occult diaphragm injuries. CONCLUSION (1) The incidence of diaphragmatic injuries in association with penetrating left thoracoabdominal trauma is high. (2) The clinical and roentgenographic findings are unreliable at detecting occult diaphragmatic injuries. (3) Laparoscopy is a vital tool for detecting occult diaphragmatic injuries among patients who have no other indications for formal celiotomy.
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Affiliation(s)
- J A Murray
- Department of Surgery, Los Angeles County-University of Southern California Medical Center, USA
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48
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Murray J, Demetriades D, Ashton K. Acute tension diaphragmatic herniation: case report. THE JOURNAL OF TRAUMA 1997; 43:698-700. [PMID: 9356072 DOI: 10.1097/00005373-199710000-00024] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- J Murray
- University of Southern California, Los Angeles County-USC Medical Center, Department of Surgery, 90033, USA.
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49
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Degiannis E, Levy RD, Sofianos C, Potokar T, Florizoone MG, Saadia R. Diaphragmatic herniation after penetrating trauma. Br J Surg 1996; 83:88-91. [PMID: 8653376 DOI: 10.1002/bjs.1800830128] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A study was made of 45 patients with diaphragmatic herniation after penetrating trauma. In 29 the diagnosis was established during the first admission (early presentation) and in 16 during a subsequent admission (delayed presentation). The mortality rate in the early presentation group was 3 per cent compared with 25 per cent in the delayed presentation group. The presence of gangrenous or perforated abdominal viscus in the chest cavity was the single most common and severe aggravating factor. The need for diagnosis of diaphragmatic herniation during the initial admission is emphasized. As isolated diaphragmatic injuries provide few helpful clinical features to aid diagnosis, appropriate investigations and good follow-up are of paramount importance in preventing late herniation of intra-abdominal viscera through a penetrating diaphragmatic injury.
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MESH Headings
- Adult
- Female
- Hernia, Diaphragmatic, Traumatic/etiology
- Hernia, Diaphragmatic, Traumatic/mortality
- Hernia, Diaphragmatic, Traumatic/surgery
- Humans
- Male
- Middle Aged
- Postoperative Complications
- Retrospective Studies
- Wounds, Gunshot/complications
- Wounds, Gunshot/surgery
- Wounds, Stab/complications
- Wounds, Stab/surgery
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Affiliation(s)
- E Degiannis
- Department of Surgery, Baragwanath Hospital, University of the Witwatersrand Medical School, Johannesburg, South Africa
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50
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Ortega AE, Tang E, Froes ET, Asensio JA, Katkhouda N, Demetriades D. Laparoscopic evaluation of penetrating thoracoabdominal traumatic injuries. Surg Endosc 1996; 10:19-22. [PMID: 8711598 DOI: 10.1007/s004649910003] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND General surgeons' recent familiarity with advanced laparoscopic techniques have rendered laparoscopy feasible safely in the trauma setting. Traditionally high rates of nontherapeutic laparotomies also contribute to this increased interest. This study was undertaken to determine the predictive value and accuracy of diagnostic laparoscopy (DL) in evaluation of penetrating thoracoabdominal trauma. METHODS Entry criteria included thoracoabdominal gunshot (GSW) or stab wounds (SW) in otherwise hemodynamically stable patients. A high index of suspicion for either hemoperitoneum, peritonitis, or diaphragmatic injury was required for inclusion. All patients underwent DL in the operating room followed by standard laparotomy. The findings of the two evaluations were compared. RESULTS Twenty-four patients were included in the study. Twenty males and 4 females with an average age of 34 years made up the group. Violation of the peritoneal cavity was present in 21 cases and absent in 3. No intraabdominal injuries were found during laparotomy in the latter three cases without peritoneal violation. The specificity and positive predictive value were 100% for lesions of the diaphragm, liver, spleen, pancreas, kidney, and hollow viscus. The sensitivity was highest for liver and spleen injuries (88%), followed by diaphragmatic injuries (83%), pancreas and kidney injuries (50%), and lowest for injuries of hollow viscus (25%). The negative predictive value was 95, 99, 91, and 57%, respectively, for these organs. CONCLUSIONS DL could have avoided unnecessary laparotomy in 38% of cases in this study. There were no complications related to laparoscopy. The greatest value of DL in penetrating thoracoabdominal injuries is in the evaluation of peritoneal violation, diaphragmatic, and upper abdominal solid-organ injuries. It is not ideal for predicting hollow viscus injuries.
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Affiliation(s)
- A E Ortega
- Department of Surgery, University of Southern California, School of Medicine, Los Angeles 90033, USA
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