Delayed presentation of traumatic diaphragmatic hernia

"Pop in a scope": attempt to decrease the rate of unnecessary nontherapeutic laparotomies in hemodynamically stable patients with thoracoabdominal penetrating injuries

BACKGROUND

Management of patients with thoracoabdominal penetrating injuries is challenging. Thoracoabdominal penetrating trauma may harbor hollow viscus injuries in both thoracic and abdominal cavities and occult diaphragmatic lesions. While radiological tests show poor diagnostic performance in these situations, evaluation by laparoscopy is highly sensitive and specific. Furthermore, minimally invasive surgery may avoid unnecessary laparotomies, despite concerns regarding complication and missed injury rates. The objective of the present study is to evaluate the diagnostic and therapeutic performance of laparoscopy in stable patients with thoracoabdominal penetrating injuries.

METHODS

Retrospective analysis of hemodynamically stable patients with thoracoabdominal penetrating wounds was managed by laparoscopy. We collected data regarding the profile of the patients, the presence of diaphragmatic injury, perioperative complications, and the conversion rate. Preoperative imaging tests were compared to laparoscopy in terms of diagnostic accuracy.

RESULTS

Thirty-one patients were included, and 26 (84%) were victims of a stab wound. Mean age was 32 years. Ninety-three percent were male. Diaphragmatic lesions were present in 18 patients (58%), and 13 (42%) had associated injuries. There were no missed injuries and no conversions. Radiography and computerized tomography yielded an accuracy of 52% and 75%, respectively.

CONCLUSION

Laparoscopy is a safe diagnostic and therapeutic procedure in stable patients with thoracoabdominal penetrating wound, with low complication rate, and may avoid unnecessary laparotomies. The poor diagnostic performance of preoperative imaging exams supports routine laparoscopic evaluation of the diaphragm to exclude injuries in these patients.

Emergency surgery due to diaphragmatic hernia: case series and review

Background

Congenital diaphragmatic hernia (CDH) is a congenital abnormality, rare in adults with a frequency of 0.17–6%. Diaphragmatic rupture is an infrequent consequence of trauma, occurring in about 5% of severe closed thoraco-abdominal injuries. Clinical presentation ranges from asymptomatic cases to serious respiratory or gastrointestinal symptoms. Diagnosis depends on anamnesis, clinical signs and radiological investigations.

Methods

From May 2013 to June 2016, six cases (four females, two males; mean age 58 years) of diaphragmatic hernia were admitted to our Academic Department of General Surgery with respiratory and abdominal symptoms. Chest X-ray, barium studies and CT scan were performed.

Results

Case 1 presented left diaphragmatic hernia containing transverse and descending colon. Case 2 showed left CDH which allowed passage of stomach, spleen and colon. Case 3 and 6 showed stomach in left hemithorax. Case 4 presented left diaphragmatic hernia which allowed passage of the spleen, left lobe of liver and transverse colon. Case 5 had stomach and spleen herniated into the chest. Emergency surgery was always performed. The hernia contents were reduced and defect was closed with primary repair or mesh. In all cases, post-operative courses were uneventful.

Conclusion

Overlapping abdominal and respiratory symptoms lead to diagnosis of diaphragmatic hernia, in patients with or without an history of trauma. Chest X-ray, CT scan and barium studies should be done to evaluate diaphragmatic defect, size, location and contents. Emergency surgical approach is mandatory reducing morbidity and mortality.

Diaphragmatic injuries: challenges in the diagnosis and management

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.

Penetrating diaphragmatic injury: accuracy of 64-section multidetector CT with trajectography

PURPOSE

To (a) determine the diagnostic performance of 64-section multidetector computed tomography (CT) trajectography for penetrating diaphragmatic injury (PDI), (b) determine the diagnostic performance of classic signs of diaphragmatic injury at 64-section multidetector CT, and (c) compare the performance of these signs with that of trajectography.

MATERIALS AND METHODS

This HIPAA-compliant retrospective study had institutional review board approval, with a waiver of the informed consent requirement. All patients who had experienced penetrating thoracoabdominal trauma, who had undergone preoperative 64-section multidetector CT of the chest and abdomen, and who had surgical confirmation of findings during a 2.5-year period were included in this study (25 male patients, two female patients; mean age, 32.6 years). After a training session, four trauma radiologists unaware of the surgical outcome independently reviewed all CT studies and scored the probability of PDI on a six-point scale. Collar sign, dependent viscera sign, herniation, contiguous injury on both sides of the diaphragm, discontinuous diaphragm sign, and transdiaphragmatic trajectory were evaluated for sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). Accuracies were determined and receiver operating characteristic curves were analyzed.

RESULTS

Sensitivities for detection of PDI by using 64-section multidetector CT with postprocessing software ranged from 73% to 100%, specificities ranged from 50% to 92%, NPVs ranged from 71% to 100%, PPVs ranged from 68% to 92%, and accuracies ranged from 70% to 89%. Discontinuous diaphragm, herniation, collar, and dependent viscera signs were highly specific (92%-100%) but nonsensitive (0%-60%). Contiguous injury was generally more sensitive (80%-93% vs 73%-100%) but less specific (50%-67% vs 83%-92%) than transdiaphragmatic trajectory when patients with multiple entry wounds were included in the analysis. Transdiaphragmatic trajectory was a much more sensitive sign of PDI than previously reported (73%-100% vs 36%), with NPVs ranging from 71% to 100% and PPVs ranging from 85% to 92%.

CONCLUSION

Sixty-four-section multidetector CT trajectography facilitates the identification of transdiaphragmatic trajectory, which accurately rules in PDI when identified. Contiguous injury remains a highly sensitive sign, even when patients with multiple injuries are considered, and is useful for excluding PDI.

Imaging of diaphragm injuries

Diaphragm injuries are uncommon consequences of blunt and penetrating trauma. Early diagnosis and repair prevent potentially devastating complications that typically result from visceral herniation through the posttraumatic diaphragm defect. Although clinical and radiographic manifestations frequently are nonspecific, the stalwarts of trauma imaging--chest radiography and CT--typically demonstrate these injuries. To render the appropriate diagnosis, the radiologist must be familiar with the varied imaging manifestations of injury, and maintain a high index of suspicion within the appropriate clinical setting.

Impact of deferred treatment of blunt diaphragmatic rupture: a 15-year experience in six trauma centers in Quebec

BACKGROUND

The purpose of this study was to show that blunt diaphragmatic rupture does not require immediate emergency operation in the absence of other indications.

METHODS

We reviewed all patients with blunt diaphragmatic rupture admitted within 24 hours of injury to one of six university trauma centers providing trauma care for the province of Quebec from April 1, 1984, to March 31, 1999. Multivariate analysis of demographic profiles, severity indices, indications for operation, and preoperative delays was performed.

RESULTS

There were 160 patients (91 men and 69 women) with blunt diaphragmatic rupture. Mean age was 40.1 +/- 16.2 years. Mean Injury Severity Score was 26.9 +/- 11.5 and mortality was 14.4%. Patients undergoing emergency surgery for indications other than diaphragmatic rupture had a significantly higher Injury Severity Score than those undergoing surgery for repair of diaphragmatic rupture alone (34.7 +/- 10.7 vs. 22.0 +/- 9.0, p < 0.001). In patients undergoing surgery for diaphragmatic rupture alone, delay before repair of the diaphragmatic hernia did not lead to an increased mortality compared with patients undergoing immediate surgery (3.4% vs. 5.0%, p = NS).

CONCLUSION

Blunt diaphragmatic rupture in the absence of other surgical injuries carries low mortality. Operative repair of diaphragmatic rupture can be deferred without appreciable increased mortality if no other indication mandates immediate surgery.

Video thoracoscopy expedites the diagnosis and treatment of penetrating diaphragmatic injuries

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.

Tension gastrothorax complicating acute traumatic diaphragmatic rupture

Herniation of abdominal viscera into the thorax following traumatic diaphragmatic hernia can simulate acute tension pneumothorax. A case is presented of a blunt trauma victim with apparent acute diaphragmatic rupture, tension hemothorax, or tension hemopneumothorax. Nasogastric tube insertion demonstrated tension gastrothorax, but was followed by acute clinical decompensation. Percutaneous needle thoracostomy decompressed the stomach without causing spillage of gastric contents. Autopsy experimentation was performed to demonstrate that needle decompression of the distended stomach is well tolerated. Tension gastrothorax is a rare, life-threatening complication of traumatic diaphragmatic hernia. Although nasogastric tube placement should be attempted first, it may exacerbate the condition. Percutaneous needle decompression of the stomach through the chest wall can stabilize the situation and is safer and more rapid than chest tube placement, which might be either ineffective or dangerous. Paralyzing the patient with acute diaphragmatic rupture before tracheal and gastric intubation might prevent progression to tension gastrothorax.

Delayed traumatic intrapericardial diaphragmatic hernia associated with cardiac tamponade

We describe a case of delayed presentation of traumatic intrapericardial diaphragmatic hernia associated with cardiac tamponade. A 71-year-old woman presented to our emergency department complaining of epigastric and midabdominal pain one month after hospitalization for multiple injuries suffered in an automobile accident. Chest radiograph showed a diaphragmatic hernia. In the ED, the patient became hypotensive and tachycardic with elevated central venous pressure. At surgery, she was found to have omentum and transverse colon herniated into the pericardial sac causing cardiac tamponade. The defect was repaired, and her postoperative course was uncomplicated. Cardiac tamponade should be included in the differential diagnosis of hypotension in patients with radiographic evidence of diaphragmatic hernia.

Massive bilateral diaphragmatic rupture after an apparently minor automobile accident

A case of massive bilateral diaphragmatic rupture following a low impact motor vehicle accident is described. The patient experienced herniation of intraabdominal contents into the thoracic cavity, but suffered no additional injuries. Few cases of bilateral diaphragmatic rupture have been reported and no cases of acute bilateral rupture have been described as an isolated injury. Diaphragmatic rupture in general may be a difficult injury to recognize. Based on our review of recent cases of diaphragmatic rupture (1979-1990), most patients presenting acutely have additional trauma (89.9%) but only vague symptoms related to their diaphragmatic insult. A chest roentgenogram may be a useful diagnostic tool, although many patients with diaphragmatic rupture have only nonspecific findings. A nasogastric tube placed prior to chest roentgenogram may enable the physician to recognize the injury more readily. A high index of suspicion is required to recognize diaphragmatic rupture and should be maintained for all victims of motor vehicle accidents with abnormal but nondiagnostic chest roentgenograms.

Traumatic diaphragmatic rupture

Twenty-three cases of traumatic diaphragmatic rupture due to blunt and penetrating trauma are reviewed. The need for early diagnosis is stressed. Chest radiography was the most sensitive diagnostic method (66% for blunt trauma), although other techniques are discussed. The high incidence of associated intra-abdominal injury (83%) mandates primary abdominal approach to repair. An overall mortality of 31% reflects the severity of the trauma.

Delayed traumatic diaphragmatic hernia simulating acute tension pneumothorax

The diagnosis of acute diaphragmatic injury is difficult to establish in the immediate posttraumatic period. Patients with delayed diaphragmatic herniation frequently present months to years after the initial injury with manifestations of visceral incarceration, obstruction, ischemia from strangulation, or perforation. Patients with diaphragmatic herniation presenting with clinical tension pneumothorax are rare. We describe the case of a 23-year-old female who 16 weeks following a stab wound to the low chest presented with this clinical picture caused by herniation of abdominal viscera into the chest. A review of this entity and methods of discovery of delayed traumatic diaphragmatic herniation are described.

Bilateral rupture of diaphragm with delayed strangulation

A 64-year-old woman presented in shock. The computed tomography (CT) scan confirmed rupture of the left diaphragm with strangulation. Three days after surgery, the patient developed herniation of abdominal contents on the right side with cardiorespiratory collapse. Marlex mesh was used to repair on the right side. Postoperatively, she needed partial gastrectomy for massive duodenal ulcer bleeding. A dual chamber pacemaker was used to correct the complete heart block.