Rupture spontanée du diaphragme pendant l’accouchement

Diaphragm Muscle Adaptations in Health and Disease

Breathing is achieved without thought despite being controlled by a complex neural network. The diaphragm is the predominant muscle responsible for force/pressure generation during breathing, but it is also involved in other non-ventilatory expulsive behaviors. This review considers alterations in diaphragm muscle fiber types and the neural control of the diaphragm across our lifespan and in various disease conditions.

Evolution and Functional Differentiation of the Diaphragm Muscle of Mammals

Symmorphosis is a concept of economy of biological design, whereby structural properties are matched to functional demands. According to symmorphosis, biological structures are never over designed to exceed functional demands. Based on this concept, the evolution of the diaphragm muscle (DIAm) in mammals is a tale of two structures, a membrane that separates and partitions the primitive coelomic cavity into separate abdominal and thoracic cavities and a muscle that serves as a pump to generate intra-abdominal (Pab ) and intrathoracic (Pth ) pressures. The DIAm partition evolved in reptiles from folds of the pleural and peritoneal membranes that was driven by the biological advantage of separating organs in the larger coelomic cavity into separate thoracic and abdominal cavities, especially with the evolution of aspiration breathing. The DIAm pump evolved from the advantage afforded by more effective generation of both a negative Pth for ventilation of the lungs and a positive Pab for venous return of blood to the heart and expulsive behaviors such as airway clearance, defecation, micturition, and child birth. © 2019 American Physiological Society. Compr Physiol 9:715-766, 2019.

Spontaneous diaphragmatic rupture related to local invasion by retroperitoneal liposarcoma

We report a case of the female patient who was admitted to the hospital because of syncope experienced while climbing stairs. Diagnostic workup raised the suspicion of a right diaphragmatic rupture that was eventually confirmed by surgery (right-sided thoracotomy). Surgery also revealed tissue protruding through the rupture site from within the retroperitoneum that was proven subsequently to be a dedifferentiated liposarcoma. Second surgery was performed to completely remove the liposarcoma tissue and repair a coincident old right lumbar region hernia. The patient recovered fully. Spontaneous rupture of the diaphragm is rare and this is especially true for the right hemidiaphragm. We report the first case of diaphragmatic rupture caused by local infiltration by a retroperitoneal liposarcoma. This and similar reports emphasise that in cases with high clinical suspicion of diaphragmatic rupture, diagnosis should be pursued even in the absence of a preceding traumatic event.

Diaphragmatic rupture during labour, two years after an intra-oesophageal rupture of a bronchogenic cyst treated by an omental wrapping

We report the case of a 27-year-old pregnant woman, presenting a rare but potentially fatal complication of an omental wrapping, transposed in the thorax by a phrenotomy due to an intra-oesophageal rupture of a bronchogenic cyst. Two years later, on time of delivery of her first pregnancy, she has presented a diaphragmatic rupture with a complete transposition of the volvuled stomach. The diagnosis was done using the Gastrographin transit and the CT-scan, showing the specific 'Collar sign'. An urgent surgical correction was performed including the re-instatement of all abdominal organs in the peritoneum, the omental wrapping section and the diaphragmatic closure. The two-year follow-up was uneventful. We discuss the case, the investigations needed and the possibility to cut the omental wrapping without any complication two years after this oesophageal re-inforcement. In conclusion, we believe that omental transpositions must always be done using the retrosternal route or by transhiatal approach to avoid this serious complication after delivery.