Traumatic injuries of the diaphragm: overview of imaging findings and diagnosis

Successful diaphragm repair following radiofrequency ablation for renal cell carcinoma: A case report

INTRODUCTION AND IMPORTANCE

This study aimed to assess the effectiveness of surgical intervention in treating traumatic diaphragmatic rupture accompanied by pleural empyema resulting from radiofrequency ablation for renal cell carcinoma.

CASE PRESENTATION

A 72-year-old female patient underwent radiofrequency ablation at our institution's urology department to address a 4-cm tumor in the left upper kidney detected during routine health screening. Subsequently, the patient experienced persistent fever from the 5th day post- procedure. Chest radiography revealed increased opacity in the left lower lung, prompting further evaluation with contrast-enhanced chest computed tomography. Examination revealed multiple loculated effusions and discernible diaphragmatic defects. Consequently, the patient was referred to the department of thoracic surgery, where an emergency surgery was performed. The surgical procedure was performed under general anesthesia the following day, revealing a 4-centimeter defect in the diaphragm along with damaged surrounding tissue and multiple loculated empyema sacs within the thoracic cavity. The intervention included excision of the empyema sacs, extensive irrigation, and reconstruction of the diaphragm using a 2-mm Gore- Tex membrane. One week postoperatively, the patient was discharged without any complications related to the procedure.

CLINICAL DISCUSSION

Although radiofrequency ablation is considered a relatively safe procedure with low complication rates, vigilant post-procedural monitoring is essential for detecting potentially serious complications.

CONCLUSION

Surgical intervention remains the preferred approach for the repair of traumatic diaphragmatic ruptures and is typically performed via thoracotomy.

Atypical course of incarcerated post-traumatic diaphragmatic hernia

The article focuses on the instrumental imaging methods which greatly enhance the possibilities when arriving at correct and quick diagnosis of acute surgical pathology. Analysis of clinical and anamnestic data of the disease course and the results of instrumental research methods made it possible to arrive at clear clinical diagnosis, determine the indications for surgical treatment in this specific clinical case. The use of modern visualization methods while examining the patients prevents errors in diagnosis and helps to determine the optimal treatment tactics.

Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper

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.

Diaphragmatic Injuries among Severely Injured Patients (ISS ≥ 16)-An Indicator of Injury Pattern and Severity of Abdominal Trauma

Background and Objectives: Abdominal trauma among severely injured patients with an injury severity score (ISS) of 16 and above can lead to potentially life-threatening injuries that might need immediate surgical intervention. Traumatic injuries to the diaphragm (TID) are a challenging condition often accompanied by other injuries in the thoracoabdominal region. Materials and Methods: We retrospectively analyzed the occurrence and clinical course of TID among severely injured patients treated at our center between 2008 and 2019 and compared them to other groups of severely injured patients without TID. Results: Thirty-five patients with TID and a median ISS of 41 were treated in the period mentioned above. They were predominantly middle-aged men and mostly victims of blunt trauma as a consequence of motor vehicle accidents. A total of 70.6% had left-sided TID, and in 69.6%, the size of defect was larger than 10 cm. The diagnosis was made with computed tomography (CT) in 68.6% of the cases, while in 25.8%, it was made intraoperatively or delayed by a false-negative initial CT scan, and in 5.7%, an intraoperative diagnosis was made without preoperative CT imaging. Surgical repair was mostly conducted via laparotomy, performing a direct closure with continuous suture. A comparison to 191 patients that required laparotomy for abdominal injuries other than TID revealed significantly higher rates of concomitant injuries to several abdominal organs among patients suffering from TID. Compared to all other severely injured patients treated in the same period (n = 1377), patients suffering from TID had a significantly higher median ISS and a longer mean duration of hospital stay. Conclusions: Our findings show that TID can be seen as an indicator of particularly severe thoracoabdominal trauma that requires increased attention from the treatment team so as not to miss relevant concomitant injuries that require immediate intervention.

Chest Trauma Management in Low- and Middle-Income Countries

Trauma is a leading cause of death and disability worldwide and disproportionately affects those in low- and middle-income countries (LMICs). Globally, two-thirds of injured patients sustain trauma to the thoracic cavity. Further research, capacity building, and increased awareness are needed to limit the high thoracic trauma-associated morbidity and mortality in LMICs.

How to deliver an effective primary survey report for the trauma CT: A radiological and surgical perspective

Whole body contrast-enhanced multidetector CT (WB-CE MDCT) is integral to the assessment of the severely injured patient with stable haemodynamic parameters or in those who respond to resuscitation with blood products. WB-CE MDCT is able to identify the number and severity of injuries sustained by the patient and enable time critical intervention.

In this narrative review article we discuss how communication within the trauma team, including the radiologists and appropriate clinicians is crucial in optimizing the effectiveness of WB-CE MDCT. We review the time critical imaging findings and their clinical relevance, which should be included in a succinct CT primary survey report.

We also discuss the process through which the effectiveness of the trauma report may be maximised and how non technical factors including teamwork may be optimised to facilitate decision making in this high pressure environment.

Magnetic Resonance Imaging of the Diaphragm: From Normal to Pathologic Findings

The diaphragm is a musculotendinous structure that divides the chest from the abdomen. Its motility, unintentional or voluntary, is crucial for the physiologic respiratory function due to its contribution to lung volume expansion and contraction. Therefore, diaphragmatic dysfunction may cause a respiratory failure without any pathology of the lungs. Different imaging modalities can be employed for diaphragmatic evaluation. Among all, magnetic resonance imaging (MRI) has demonstrated to be the most accurate technique in providing a morphologic and functional assessment of the diaphragm as well as information about the adjacent structures. However, its diagnostic value is still underrated and its performance is often far from the daily clinical practice. Backward, physicians and radiologists should be aware of the undoubted advantages of MRI and confident about the normal or pathologic imaging features, to avoid misdiagnosis.

Isolated Right-Sided Posttraumatic Diaphragmatic Hernia

Diaphragm is a compliant musculoaponeurotic barrier located between thoracic and abdominal cavities. Traumatic diaphragmatic rupture is a rare clinicopathological entity. We report a case of right-sided posttraumatic hernia in a child following blunt trauma to highlight diagnostic difficulties and therapeutic specific aspects. A 10-year-old boy was admitted to the emergency surgical department with thoracic trauma following pedestrian accident. At admission a haemothorax was suspected and treated by pleural drainage. The diagnosis of a right-sided diaphragmatic rupture was made after computed tomographic scan forty-eight hours later. At surgery, a reduction of herniated abdominal content and a suture of diaphragmatic defect were performed. The postoperative recoveries were uneventful and the patient was followed up for 12 months without symptoms. The possibility of a diaphragmatic rupture should be kept in mind and sought after any trauma of the thoracoabdominal junction as the diagnosis can be challenging in emergency department.

The breadth of the diaphragm: updates in embryogenesis and role of imaging

The diaphragm is an unique skeletal muscle separating the thoracic and abdominal cavities with a primary function of enabling respiration. When abnormal, whether by congenital or acquired means, the consequences for patients can be severe. Abnormalities that affect the diaphragm are often first detected on chest radiographs as an alteration in position or shape. Cross-sectional imaging studies, primarily CT and occasionally MRI, can depict structural defects, intrinsic and adjacent pathology in greater detail. Fluoroscopy is the primary radiologic means of evaluating diaphragmatic motion, though MRI and ultrasound also are capable of this function. This review provides an update on diaphragm embryogenesis and discusses current imaging of various abnormalities, including the emerging role of three-dimensional printing in planning surgical repair of diaphragmatic derangements.

Missed diagnosis of a large, right-sided diaphragmatic rupture with herniated liver and concomitant liver laceration after blunt trauma: consequences for delayed surgical repair

Diaphragmatic injuries are relatively rare and as such frequently missed, particularly if they occur as a rare event on the right-sided dome. Even if detected in the early phase, the concomitant injury of other organs may delay the time to repair. The delay in surgical correction may aggravate additional adherences between thoracic and abdominal organs and cause the diaphragmatic muscle to retract, causing a larger tissue defect that may prevent primary suture repair. This should be taken into consideration when choosing access to repair (thoracic, abdominal or both cavities), mode (open or laparoscopic) and type of repair (primary suture or use of mesh material to close the defect). Here we present a case of delayed right-sided, blunt diaphragmatic injury with herniation of liver. Repair was performed in a delayed manner with an initial laparoscopic exploration converted to open abdominal repair with closing of defect with Gore-tex mesh material.