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Gillaspie D, Gillaspie EA. Management of Traumatic Diaphragmatic Injuries. Thorac Surg Clin 2024; 34:171-178. [PMID: 38705665 DOI: 10.1016/j.thorsurg.2024.01.008] [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] [Indexed: 05/07/2024]
Abstract
Diaphragm injuries are rarely seen injuries in trauma patients and are difficult to diagnose. With improving technology, computed tomography has become more reliable, but with increasing rates of non-operative management of both penetrating and blunt trauma, the rate of missed diaphragmatic injury has increased. The long-term complications of missed injury include bowel obstruction and perforation, which can carry a mortality rate as high as 85%. When diagnosed, injuries should be repaired to reduce the risk of future complications.
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Affiliation(s)
- Devin Gillaspie
- Division of Acute Care Surgery, Department of Surgery, University of Tennessee Medical Center Knoxville, 1924 Alcoa Highway Box U-11, Knoxville, TN 37920, USA.
| | - Erin A Gillaspie
- Division of thoracic Surgery, Creighton University Medical Center CHI Health, 7500 Mercy Road, Omaha, NE 68124, USA
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Sharma R, Meyer CA, Frazier AA, Martin Rother MD, Kusmirek JE, Kanne JP. Routes of Transdiaphragmatic Migration from the Abdomen to the Chest. Radiographics 2020; 40:1205-1218. [PMID: 32706612 DOI: 10.1148/rg.2020200026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The diaphragm serves as an anatomic border between the abdominal and thoracic cavities. Pathologic conditions traversing the diaphragm are often incompletely described and may be overlooked, resulting in diagnostic delays. Several routes allow abdominal contents or pathologic processes to spread into the thorax, including along normal transphrenic structures, through congenital defects in the diaphragm, through inherent areas of weakness between muscle groups, or by pathways created by tissue destruction, trauma, or iatrogenic injuries. A thorough knowledge of the anatomy of the diaphragm can inform an accurate differential diagnosis. Often, intraperitoneal pathologic conditions crossing the diaphragm may be overlooked if axial imaging is the only approach to this complex region because of the horizontal orientation of much of the diaphragm. Multiplanar capabilities of volumetric CT and MRI provide insight into the pathways where pathologic conditions may traverse this border. Knowledge of these characteristic routes and use of multiplanar imaging are critical for depiction of specific transdiaphragmatic pathologic conditions.©RSNA, 2020.
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Affiliation(s)
- Ruchi Sharma
- From the Department of Radiology, Section of Thoracic Imaging, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 (R.S., C.A.M., M.D.M.R., J.E.K., J.P.K.); and Division of Cardiothoracic Imaging, Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md, and Cardiothoracic Section, American Institute for Radiologic Pathology, Silver Spring, Md (A.A.F.)
| | - Cristopher A Meyer
- From the Department of Radiology, Section of Thoracic Imaging, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 (R.S., C.A.M., M.D.M.R., J.E.K., J.P.K.); and Division of Cardiothoracic Imaging, Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md, and Cardiothoracic Section, American Institute for Radiologic Pathology, Silver Spring, Md (A.A.F.)
| | - Aletta A Frazier
- From the Department of Radiology, Section of Thoracic Imaging, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 (R.S., C.A.M., M.D.M.R., J.E.K., J.P.K.); and Division of Cardiothoracic Imaging, Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md, and Cardiothoracic Section, American Institute for Radiologic Pathology, Silver Spring, Md (A.A.F.)
| | - Maria D Martin Rother
- From the Department of Radiology, Section of Thoracic Imaging, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 (R.S., C.A.M., M.D.M.R., J.E.K., J.P.K.); and Division of Cardiothoracic Imaging, Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md, and Cardiothoracic Section, American Institute for Radiologic Pathology, Silver Spring, Md (A.A.F.)
| | - Joanna E Kusmirek
- From the Department of Radiology, Section of Thoracic Imaging, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 (R.S., C.A.M., M.D.M.R., J.E.K., J.P.K.); and Division of Cardiothoracic Imaging, Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md, and Cardiothoracic Section, American Institute for Radiologic Pathology, Silver Spring, Md (A.A.F.)
| | - Jeffrey P Kanne
- From the Department of Radiology, Section of Thoracic Imaging, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 (R.S., C.A.M., M.D.M.R., J.E.K., J.P.K.); and Division of Cardiothoracic Imaging, Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md, and Cardiothoracic Section, American Institute for Radiologic Pathology, Silver Spring, Md (A.A.F.)
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Paes FM, Durso AM, Danton G, Castellon I, Munera F. Imaging evaluation of diaphragmatic injuries: Improving interpretation accuracy. Eur J Radiol 2020; 130:109134. [PMID: 32629213 DOI: 10.1016/j.ejrad.2020.109134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/10/2020] [Accepted: 06/15/2020] [Indexed: 11/18/2022]
Abstract
Diaphragmatic Injuries (DIs) remain a challenging diagnosis with potential catastrophic delayed complications. A high degree of suspicion in every case of severe blunt thoracoabdominal trauma or penetrating thoracoabdominal injury is essential. This review will present the evidence and controversies on this topic providing a practical tutorial for radiologists hoping to improve their interpretive accuracy for both blunt and penetrating DIs. The imaging signs of diaphragmatic injuries will be explained with emphasis on multidetector CT. Diagnostic pitfalls, available protocols and other issues will be presented.
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Affiliation(s)
- Fabio M Paes
- Department of Diagnostic Radiology, University of Miami - Leonard Miller School of Medicine, Jackson Memorial Hospital & Ryder Trauma Center, Miami, FL, USA.
| | - Anthony M Durso
- Department of Diagnostic Radiology, University of Miami - Leonard Miller School of Medicine, Jackson Memorial Hospital & Ryder Trauma Center, Miami, FL, USA.
| | - Gary Danton
- Department of Diagnostic Radiology, University of Miami - Leonard Miller School of Medicine, Jackson Memorial Hospital & Ryder Trauma Center, Miami, FL, USA.
| | - Ivan Castellon
- Department of Diagnostic Radiology, University of Miami - Leonard Miller School of Medicine, Jackson Memorial Hospital & Ryder Trauma Center, Miami, FL, USA.
| | - Felipe Munera
- Department of Diagnostic Radiology, University of Miami - Leonard Miller School of Medicine, Jackson Memorial Hospital & Ryder Trauma Center, Miami, FL, USA.
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Penn C, Khan M. Is laparoscopy still of value in managing the patient with abdominal trauma? TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408618816532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Stabbings are an increasing international problem and the UK is not exempt. Although the incidence and costs of negative laparotomy are well known, and laparoscopy has been available for over 100 years, it is only in the last three decades that has seen its effective utilization in trauma both as a diagnostic and therapeutic modality. Methods A retrospective two-year study of all patients undergoing laparoscopy for suspicion of diaphragmatic injury or breach of the peritoneum who were haemodynamically stable from non-ballistic penetrating torso trauma at St Mary’s Hospital (Imperial Healthcare Trust). Results Three groups of patients were identified: diagnostic laparoscopy without injury (n = 31), laparoscopy with injury ± laparoscopic treatment (n = 41) and diagnostic laparoscopy converted to laparotomy (n = 10). The patients who had laparoscopic intervention had a shorter hospital stay (2 vs. 5 days, p = 0.004), decreased intensive treatment unit admission (p = 0.007) and decreased intensive treatment unit stay (p = 0.007) compared to those who had conversion to laparotomy. Conclusion Trauma laparoscopy is a useful modality in managing selected trauma patient with suspected intra-abdominal injuries and can avoid unnecessary laparotomy. It is associated with a shorter hospital stay.
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Affiliation(s)
- Charles Penn
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mansoor Khan
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
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Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2019; 85:1007-1015. [PMID: 29659472 DOI: 10.1097/ta.0000000000001930] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This is a recommended management algorithm from the Western Trauma Association addressing the management of adult patients with abdominal stab wounds. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithm and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this as a guideline to develop their own local protocols.
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Abstract
The use of computed tomography (CT) for hemodynamically stable victims of penetrating torso trauma continues to increase but remains less singular to the work-up than in blunt trauma. Research in this area has focused on the incremental benefits of CT within the context of evolving diagnostic algorithms and in conjunction with techniques such as laparoscopy, endoscopy, and angiographic intervention. This review centers on the current state of multidetector CT as a triage tool for penetrating torso trauma and the primacy of trajectory evaluation in diagnosis, while emphasizing diagnostic challenges that have lingered despite tremendous technological advances since CT was first used in this setting 3 decades ago. As treatment strategies have also changed considerably over the years in parallel with advances in CT, current management implications of organ-specific injuries depicted at multidetector CT are also discussed.
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Affiliation(s)
- David Dreizin
- From the Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, 22 S Greene St, Baltimore, MD 21201 (D.D.); and Department of Diagnostic Radiology, University of Miami Leonard Miller School of Medicine, Jackson Memorial Hospital & Ryder Trauma Center, Miami Fla (F.M.)
| | - Felipe Munera
- From the Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, 22 S Greene St, Baltimore, MD 21201 (D.D.); and Department of Diagnostic Radiology, University of Miami Leonard Miller School of Medicine, Jackson Memorial Hospital & Ryder Trauma Center, Miami Fla (F.M.)
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