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Filosso PL, Guerrera F, Sandri A, Lausi PO, Lyberis P, Bora G, Roffinella M, Ruffini E. Surgical management of chronic diaphragmatic hernias. J Thorac Dis 2019; 11:S177-S185. [PMID: 30906583 DOI: 10.21037/jtd.2019.01.54] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Chronic diaphragmatic hernia (CDH) is an uncommon disease which may be associated with significant morbidity and mortality. Antecedent (even many months or years before CDH development) blunt or penetrating thoracic/thoraco-abdominal trauma is generally recognized. A wide spectrum of different mechanisms of injury, timing in presentation, size of the diaphragmatic defect, types and amount of abdominal viscera herniated into the chest cavity, clinical symptoms are observed in CDHs. Thoracic and abdominal CT scan (with coronal, axial and sagittal reconstructions) is the best diagnostic tool; sometimes thoracic MRI is needed to better define the extent of the diaphragmatic defect and the number of abdominal organs displaced into the chest cavity. Surgery (sometimes urgent) represents the treatment of choice for CDH; diaphragmatic hernia direct repair with a tension-free suture is generally attempted; in case of very large defects or when a tension-free suture is deemed unfeasible, the use of prosthesis is recommended. This review article will discuss about CDH aetiology, clinical presentation diagnosis and surgical treatment.
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Affiliation(s)
- Pier Luigi Filosso
- Unit of Thoracic Surgery, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Francesco Guerrera
- Unit of Thoracic Surgery, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Alberto Sandri
- Unit of Thoracic Surgery, Department of Oncology, San Luigi Gonzaga Hospital, University of Torino, Torino, Italy
| | - Paolo Olivo Lausi
- Unit of Thoracic Surgery, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Paraskevas Lyberis
- Unit of Thoracic Surgery, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Giulia Bora
- Unit of Thoracic Surgery, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Matteo Roffinella
- Unit of Thoracic Surgery, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Enrico Ruffini
- Unit of Thoracic Surgery, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Torino, Torino, Italy
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Abbas A, Thakker M, Booth M, Rechner I. Emergency endoscopic decompression of a delayed posttraumatic tension gastrothorax. Am J Emerg Med 2010; 29:574.e1-3. [PMID: 20708877 DOI: 10.1016/j.ajem.2010.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 05/15/2010] [Indexed: 10/19/2022] Open
Affiliation(s)
- Ausami Abbas
- Department of Radiology, Southampton University Hospitals, NHS Trust, Southampton, UK.
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3
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Abstract
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.
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Affiliation(s)
- Clint W Sliker
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
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5
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Gilbert TB, McGrath BJ. Tension Pneumothorax: Etiology, Diagnosis, Pathophysiology, and Management. J Intensive Care Med 1994. [DOI: 10.1177/088506669400900304] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The normally air-free pleural cavity exists at subatmospheric pressure to promote pleural apposition and proper lung excursion. Owing to its unique bilayer structure, air introduced into this space either from within the thoracic cavity or from an extrathoracic source causes pleural separation and simple pneumothorax (PTX). Most simple pneumothoracies of a small or static volume in healthy patients do not appreciably impair cardiopulmonary function despite variable collapse of the lung. If increasing pressure develops within this pleural air collection, however, a cascade of pathophysiological changes can result from altered anatomical positions of heart, lung, and great vessels. The development of increasing pressure within the pleural space, with resultant ipsilateral lung collapse and hemithoracic expansion into the mediastinum and the contralateral lung, is termed tension pneumothorax (TPTX). The exact incidence of TPTX is unknown, but it is reported in up to 2 to 3% of all pneumothoracies. Certain medical and surgical disease states—many found within the critical care environment—place patients at higher risk for development of TPTX and also limit physiological tolerance to TPTX once it occurs. Although physical examination and chest radiography generally confirm the occurrence of TPTX, physiological monitoring may herald the development of increasing intrapleural pressure. Expeditious recognition and pleural decompression are necessary to prevent the untoward hemodynamic and respiratory consequences of TPTX. Significant morbidity and mortality may arise from TPTX if treatment is unduly delayed, particularly in mechanically ventilated patients.
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Affiliation(s)
- Timothy B. Gilbert
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Maryland Medical System Baltimore, MD
| | - Brian J. McGrath
- Division of Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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8
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Abstract
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.
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Affiliation(s)
- R G Slater
- Department of Emergency Medicine, Natividad Medical Center, Salinas, California
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9
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Girzadas DV, Fligner DJ. Delayed traumatic intrapericardial diaphragmatic hernia associated with cardiac tamponade. Ann Emerg Med 1991; 20:1246-7. [PMID: 1952315 DOI: 10.1016/s0196-0644(05)81482-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- D V Girzadas
- Emergency Medicine Residency Program, Christ Hospital and Medical Center, Oak Lawn, Illinois 60465
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Humphreys TR, Abbuhl S. Massive bilateral diaphragmatic rupture after an apparently minor automobile accident. Am J Emerg Med 1991; 9:246-9. [PMID: 2018596 DOI: 10.1016/0735-6757(91)90088-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- T R Humphreys
- University of Pennsylvania School of Medicine, Philadelphia
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