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Deng X, Deng Z, Huang E. Surgical management of traumatic diaphragmatic hernia: a single institutional experience of more than two decades. BMC Surg 2021; 21:142. [PMID: 33740945 PMCID: PMC7980578 DOI: 10.1186/s12893-021-01141-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/09/2021] [Indexed: 12/03/2022] Open
Abstract
Background We present here our experience with surgical management of traumatic diaphragmatic hernia, trying to find out the era impact of different periods on the outcome and risk factors of mortality. Methods A series of 63 patients with traumatic diaphragmatic hernia were referred to us and operated on during March, 1990-August, 2017. The patient records were reviewed and statistically analyzed to demonstrate injury characteristics and to find out optimal treatment strategy, risk factors of death as well as the difference between two periods (1990–2005, 2005–2017) divided by introduction of computed tomography at our institution. Results The overall mean age was 31.2 ± 16.3 years old with a female to male ratio of 11/52. The mechanism was penetrating trauma in 19 cases (30.2%), and blunt trauma in 44 cases (69.9%). Two thirds of the patients in the second group (2005–2017) yet none in the first group (1990–2005) underwent computed tomography. Ten patients (15.9%), of which 8 in the first and the other 2 in the second group (p = .042), had late diagnoses. The most commonly used incision was a thoracotomy (n = 43, 89.6%). There was no statistical difference in etiology or mortality between the two periods. Univariate analysis showed survivors were younger, and had lesser injury severity scores (ISS) and lower American Association for the Surgery of Trauma (AAST) grade than non-survivors. By multivariate logistic regression analysis, increased age (odds ratio, 1.275; p = .013) and greater ISS (OR, 1.174; p = .028) were risk factors of death in all patients. Conclusions High-definition computed tomography has significantly improved the preoperative diagnosis rate. The transthoracic approach could be used in selected cases with traumatic diaphragmatic hernia with good outcomes. Patients with greater ISS and advanced ages are at a higher risk of death.
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Affiliation(s)
- Xicheng Deng
- Department of Cardiothoracic Surgery, Hunan Children's Hospital, No. 86 Ziyuan Road, Changsha, 410007, Hunan, China.
| | - Zuosheng Deng
- Department of Cardiothoracic Surgery, First People's Hospital of Chenzhou, Chenzhou, 423000, Hunan, China.
| | - Erjia Huang
- Department of Cardiothoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
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2
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The rupture of the diaphragm: Case report. JOURNAL OF SURGERY AND MEDICINE 2018. [DOI: 10.28982/josam.419440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Koo CW, Johnson TF, Gierada DS, White DB, Blackmon S, Matsumoto JM, Choe J, Allen MS, Levin DL, Kuzo RS. The breadth of the diaphragm: updates in embryogenesis and role of imaging. Br J Radiol 2018; 91:20170600. [PMID: 29485899 DOI: 10.1259/bjr.20170600] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Chi Wan Koo
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | | | - David S Gierada
- 2 Department of Radiology, Washington University School of Medicine, Mallinckrodt Institute of Radiology , St. Louis, MO , USA
| | - Darin B White
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Shanda Blackmon
- 3 Department of Thoracic Surgery, Mayo Clinic , Rochester, MN , USA
| | | | - Jooae Choe
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA.,4 Department of Radiology, Asan Medical Center , Seoul , South Korea
| | - Mark S Allen
- 3 Department of Thoracic Surgery, Mayo Clinic , Rochester, MN , USA
| | - David L Levin
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
| | - Ronald S Kuzo
- 1 Department of Radiology, Mayo Clinic , Rochester, MN , USA
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4
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Petrone P, Asensio JA, Marini CP. Diaphragmatic injuries and post-traumatic diaphragmatic hernias. Curr Probl Surg 2016; 54:11-32. [PMID: 28212818 DOI: 10.1067/j.cpsurg.2016.11.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 11/02/2016] [Indexed: 11/22/2022]
Affiliation(s)
- Patrizio Petrone
- New York Medical College, Winthrop University Hospital, Mineola, NY.
| | - Juan A Asensio
- Division of Trauma Surgery, Creighton University Medical Center, Omaha, NE
| | - Corrado P Marini
- New York Medical College, Winthrop University Hospital, Mineola, NY
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5
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Abstract
Although the plain radiograph and computed tomography remain undoubtedly the primary imaging modalities in the investigation of chest pathology, ultrasound can play an important complementary role, both in the diagnostic workup of a patient and in their subsequent management. Its lack of ionizing radiation, bedside availability and dynamic imaging capacity afford ultrasound certain advantages over other techniques; particularly in the critical care setting where conventional radiography is often suboptimal. This article reviews the technique and diagnostic application of ultrasound in the assessment of pathologies of the diaphragm, pleura, lung, mediastinum and chest wall.
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Petrone P, Leppäniemi A, Inaba K, Søreide K, Asensio JA. Diaphragmatic injuries: challenges in the diagnosis and management. TRAUMA-ENGLAND 2016. [DOI: 10.1177/1460408607087716] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Patrizio Petrone
- Division of Trauma & Critical Care, Department of Surgery, University of Southern California Keck School of Medicine, LAC+USC Medical Center, Los Angeles, CA, USA,
| | - Ari Leppäniemi
- Department of Surgery, Meilahti Hospital, University of Helsinki, Helsinki, Finland
| | - Kenji Inaba
- Division of Trauma & Critical Care, Department of Surgery, University of Southern California Keck School of Medicine, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Kjetil Søreide
- Department of Surgery, Stavanger University Hospital and Acute Care Medicine Research Network, University of Stavanger, Stavanger, Norway
| | - Juan A Asensio
- Division of Trauma & Critical Care, Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, FL, USA
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7
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Wilson E, Metcalfe D, Sugand K, Sujenthiran A, Jaiganesh T. Delayed recognition of diaphragmatic injury caused by penetrating thoraco-abdominal trauma. Int J Surg Case Rep 2012; 3:544-7. [PMID: 22918082 DOI: 10.1016/j.ijscr.2012.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Revised: 07/14/2012] [Accepted: 07/29/2012] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Penetrating trauma to the thoraco-abdomen may cause diaphragmatic injury (DI). We present a case which highlights the difficulties of recognizing DI and the limited role of multimodal diagnostic imaging. PRESENTATION OF CASE A 19 year old male presented with stab wounds to his left lateral chest wall. CT was suspicious for diaphragmatic injury but this could not be confirmed despite ultrasound and serial plain radiographs. He was discharged but re-presented with respiratory compromise and diaphragmatic herniation. DISCUSSION We review the clinical features of diaphragmatic injury after penetrating thoraco-abdominal trauma and the various imaging modalities available to clinicians. CONCLUSION A high index of suspicion must be employed for DI in the context of penetrating thoraco-abdominal trauma. Inpatient observation and laparoscopy/thoracoscopy should be considered when radiological findings are ambiguous. Front line physicians should also consider diaphragmatic herniation in stab victims who re-present with respiratory, circulatory, or gastrointestinal symptomology.
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Affiliation(s)
- Emily Wilson
- St George's Hospital, Blackshaw Road, London SW17 0QT, United Kingdom
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8
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Gangahar R, Doshi D. FAST scan in the diagnosis of acute diaphragmatic rupture. Am J Emerg Med 2010; 28:387.e1-3. [PMID: 20223407 DOI: 10.1016/j.ajem.2009.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2009] [Accepted: 07/07/2009] [Indexed: 12/22/2022] Open
Abstract
Focused assessment with sonography in trauma (FAST) scan can be used by emergency physicians in the diagnosis of diaphragmatic rupture in blunt abdominal trauma. We introduce a new feature 'Rip's absent organ sign' on FAST scan in the diagnosis of acute diaphragmatic rupture.
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Hoffmann B, Nguyen H, Hill HF. Diaphragmatic laceration after penetrating trauma: direct visualization and indirect findings on focused assessment with sonography for trauma in the emergency department. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2009; 28:1259-1263. [PMID: 19710226 DOI: 10.7863/jum.2009.28.9.1259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Beatrice Hoffmann
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21224, USA.
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10
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Wening JV, Tesch C, Huhnholz J, Friemert B. [The value of sonography in traumatology and orthopedics : Part 2: emergency diagnostics in blunt abdominal and thoracic trauma]. Unfallchirurg 2008; 111:958-64, 966-7. [PMID: 19039569 DOI: 10.1007/s00113-008-1440-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Ultrasound examinations in trauma patients should be done in the emergency department using curved-array (3.5-7.5 MHz) probes. Blunt trauma of the abdomen and thorax must be regarded as a single organ injury. Sonography is the imaging technique of first choice and has completely replaced peritoneal lavage. Paramount advantages are its ability to provide rapid information and reproducible results at short intervals and in a noninvasive manner. The sensitivity and specificity of sonography in detecting intraabdominal fluid are 97-100% and 80-90%, respectively. To achieve such good results, though, adequate education in ultrasound and state-of-the-art devices is crucial. Clinical experiences prove that standardized sonography must be part of polytrauma management and should be integrated in advanced trauma life support courses. Technical improvements with better image quality and miniaturization of hardware will contribute to increase the use of this technique. However, ultrasound does not replace computed tomography for follow-up in answering more sophisticated questions in multiple injured patients.
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Affiliation(s)
- J V Wening
- Hand-und Wiederherstellungschirurgie, Asklepiosklinik Altona, 22763, Hamburg, Deutschland.
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11
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Megremis SD, Segkos NI, Gavridakis GP, Mattheakis MG, Kehayas EG, Triantafyllou LB, Sfakianaki EE, Chalkiadakis GE. Sonographic appearance of a late-diagnosed left bochdalek hernia in a middle-aged woman: case report and review of the literature. JOURNAL OF CLINICAL ULTRASOUND : JCU 2005; 33:412-7. [PMID: 16240423 DOI: 10.1002/jcu.20158] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
A 53-year-old woman complaining of left upper lateral quadrant pain was first referred for an abdominal ultrasound. The spleen was disfigured, the suprasplenic echogenic line of the hemidiaphragm was fragmented, and part of bowel was inserted into the thorax. A diaphragmatic hernia was suggested and was further confirmed in a posterolateral position.
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12
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Blaivas M, Brannam L, Hawkins M, Lyon M, Sriram K. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med 2005; 22:601-4. [PMID: 15666270 DOI: 10.1016/j.ajem.2004.08.015] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abdominal injury from significant blunt trauma can include injury to bowel, kidneys, liver, and spleen. In approximately 5% of all injuries one of the diaphragms is ruptured. Diaphragmatic rupture may not be easily detected and this can lead to significant morbidity and even mortality. Rupture may be suggested on chest X-ray film especially with abnormal nasogastric tube location but the accuracy of this method is modest only. Abdominal computed tomography is not accurate and magnetic resonance imaging, although very sensitive and specific, is not feasible in most trauma situations. Surgeons have often resorted to exploratory laparotomy or laparoscopy to make the diagnosis. Although not typically part of the basic Focused Abdominal Sonography for Trauma (FAST) examination, ultrasonographic diagnosis of diaphragmatic rupture is possible with little added time to the examination. We present 3 cases of diaphragmatic rupture discovered shortly after the patients' arrival, on initial trauma evaluation with the FAST. A discussion of previous literature and ultrasound technique for diagnosis follows the cases.
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Affiliation(s)
- Michael Blaivas
- Department of Emergency Medicine, Medical College of Georgia, 1120 15th Street, Atlanta, GA 30912-4007, USA.
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13
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Gamblin TC, Wall CE, Morgan JH, Erickson DJ, Dalton ML, Ashley DW. The Natural History of Untreated Penetrating Diaphragm Injury: An Animal Model. ACTA ACUST UNITED AC 2004; 57:989-92. [PMID: 15580021 DOI: 10.1097/01.ta.0000112911.03802.c4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical repair of diaphragm injuries is rather straightforward, but diagnosis can be difficult. The natural history of diaphragm injury is quite controversial. Undoubtedly, many diaphragmatic injuries are missed at the initial evaluation. Some theories state that diaphragm injuries do not heal, and that all eventually lead to herniation. Current theories regarding uniform herniation of all diaphragm injuries are not supported by animal models. The authors developed a penetrating diaphragm injury model to study the natural history of this injury. METHODS This study used 48 male Sprague-Dawley rats weighing 300-425 g. During the study, 24 of the rats received a 16-gauge needle puncture of the left diaphragm mimicking a small penetrating wound, whereas 24 of the rats received an injury produced with a 2.7-mm aortic punch, which created a defect comparable to a much larger penetrating wound. Half of the animals in each group were euthanized at 1 month, and the other half at 10 months. This allowed short- and long-term follow-up of the injuries. Gross inspection of the left diaphragm was performed after the animals were sacrificed via a thoracoabdominal incision. All diaphragms then were removed for examination. RESULTS All the rats experienced perioperative recovery. None of the 24 rats with a 16-gauge needle injury had an injury at 1 month (n = 12) or 10 months (n = 12). No patent injury was noted in the aortic punch injury group (n = 12) sacrificed at 1 month. At 10 months, 1 of 12 animals had a small hepatic herniation through the aortic punch injury. All the injuries displayed adhesions to the underlying left hepatic lobe. CONCLUSIONS The authors developed a penetrating diaphragm injury model to understand better the natural history of this injury. Spontaneous healing occurred in 98% of the animals. In this animal model, because the left lobe of the liver is present beneath the left diaphragm, healing without herniation usually occurs. A role may exist for nonoperative treatment of human right diaphragm injuries in clinical practice. This animal model may prove useful in further defining future management for these injuries.
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Affiliation(s)
- T Clark Gamblin
- Department of Surgery, Mercer University School of Medicine, Macon, Georgia, USA
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Genotelle N, Lherm T, Gontier O, Le Gall C, Caen D. Hémothorax droit intarissable révélateur d'une plaie hépatique avec rupture diaphragmatique. ACTA ACUST UNITED AC 2004; 23:831-4. [PMID: 15345257 DOI: 10.1016/j.annfar.2004.05.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2004] [Accepted: 05/25/2004] [Indexed: 11/22/2022]
Abstract
We report a case of a woman with a blunt thoracic trauma and haemorrhagic shock after a road traffic accident. The clinical and complementary examinations revealed an isolated right haemothorax, which was compressive and uncontrollable. The source of bleeding was discovered with delay and during a surgical exploration: it was a liver injury with diaphragmatic rupture but without hepatic herniation and peritoneal effusion. The diagnostic features of blunt diaphragmatic rupture are discussed.
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Affiliation(s)
- N Genotelle
- Service de réanimation polyvalente, hôpital Gilles-de-Corbeil, centre hospitalier Sud-Francilien, 59, boulevard Henri-Dunant, 91106 Corbeil-Essonnes cedex, France
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15
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Abstract
Ruptured diaphragm following blunt trauma occurs with an incidence of 3 to 8% with right-sided rupture recognised with increasing frequency. This study aimed to investigate the influence of occupant position in right-hand drive (RHD) vehicles on the side of diaphragmatic injury. A retrospective analysis of the Scottish Trauma Audit Group database was performed to gather data on blunt diaphragmatic lacerations. Police records were also searched to ascertain the point of impact in the accidents studied. In total, 35 patients were studied, 25 drivers and 10 front-seat passengers. The incidence of right-sided rupture was 40% in drivers and 20% in FSPs. The incidence of associated pulmonary contusion, rib fracture and liver injury was also higher in drivers. Given the small sample size, these differences were not statistically significant, but they show an interesting trend. The right side of a driver's body is more exposed to injury in RHD vehicles, a fact that explains the significant association between driver's side impact and right-sided rupture. As right-sided injury is more difficult to detect, it is important that a high index of suspicion is maintained, especially when managing drivers from RHD vehicles.
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Affiliation(s)
- S Thakore
- Specialist Registrar, Accident and Emergency, Ninewells Hospital, Dundee, UK
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16
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Duverger V, Saliou C, Lê P, Chatel D, Johanet H, Acar C, Gigou F, Laurian C. [Blunt force rupture of the thoracic aorta and diaphragm: an unusual association]. ANNALES DE CHIRURGIE 2001; 126:339-45. [PMID: 11413815 DOI: 10.1016/s0003-3944(01)00522-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of this study was to report two cases of rupture of the right hemidiaphragm with intra-thoracic liver hernia, associated with a traumatic aortic disruption. These two lesions followed traffic accidents, and were both treated separately. Both patients had a long-term favourable progression. Association of these two lesions is particularly rare: fewer than 50 cases have been previously described in an extensive review of the literature. CT-scan seems to be particularly efficient in diagnosis, even if less efficient than other more specific explorations. The order of surgical management is guided by the physical examination, and especially by abdominal emergency.
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Affiliation(s)
- V Duverger
- Service de chirurgie vasculaire, hôpital d'instruction des armées Begin, 69, avenue de Paris, 94160 Saint-Mandé, France
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Little DM, Streeter E, Gleeson FV, Dyar O, Preston JM, Cranston DW. Diaphragmatic hernia associated with adult polycystic kidney disease. J Urol 1999; 162:2082-3. [PMID: 10569575 DOI: 10.1016/s0022-5347(05)68106-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- D M Little
- Department of Transplantation and Urology, Oxford Transplant Centre, Churchill Hospital, Oxford, United Kingdom
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Abstract
OBJECTIVE To highlight areas where surgeon-performed ultrasound (US) is an effective diagnostic and therapeutic tool. SUMMARY BACKGROUND DATA The success of US in trauma and technologic advances have enhanced the interest and ability of surgeons to perform their own US examinations. METHODS General surgeons perform US examinations of the thyroid gland, breast, gastrointestinal tract, peritoneal cavity (laparoscopy), and vascular system. Essentials of these examinations are discussed and a plan for educating surgical residents in US is outlined. RESULTS Focused assessment for the sonographic examination of the trauma patient, or FAST, is replacing central venous pressure measurements to detect hemopericardium and diagnostic peritoneal lavage to detect hemoperitoneum. Bedside US can be used to detect a pleural effusion so well in critically ill patients that lateral decubitus x-rays are rarely needed. US-directed biopsy of breast lesions is a common office procedure. Laparoscopic US allows tumor staging without formal celiotomy, and many hepatic and pancreatic surgical procedures include US as an adjunct. Endoscopic and endorectal US have added a new dimension to the assessment of many gastrointestinal lesions. Color flow duplex imaging and endoluminal US have significantly expanded the diagnostic and therapeutic aspects of vascular imaging. The training program developed at Emory University and Grady Memorial Hospital is offered as a model for educating surgical residents in US techniques. CONCLUSIONS US is a valuable addition to the general surgeon's diagnostic armamentarium and is rapidly becoming an integral part of the surgeon's clinical practice.
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Affiliation(s)
- G S Rozycki
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30303, USA
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19
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Abstract
Measurement of respiratory muscle strength is useful in order to detect respiratory muscle weakness and to quantify its severity. In patients with severe respiratory muscle weakness, vital capacity is reduced but is a non-specific and relatively insensitive measure. Conventionally, inspiratory and expiratory muscle strength has been assessed by maximal inspiratory and expiratory mouth pressures sustained for 1 s (PImax and PEmax) during maximal static manoeuvre against a closed shutter. However, PImax and PEmax are volitional tests, and are poorly reproducible with an average coefficient of variation of 25%. The sniff manoeuvre is natural and probably easier to perform. Sniff pressure, and sniff transdiaphragmatic pressure are more reproducible and useful measure of diaphragmatic strength. Nevertheless, the sniff manoeuvre is also volition-dependent, and submaximal efforts are most likely to occur in patients who are ill or breathless. Non-volitional tests include measurements of twitch oesophageal, gastric and transdiaphragmatic pressure during bilateral electrical and magnetic phrenic nerve stimulation. Electrical phrenic nerve stimulation is technically difficult and is also uncomfortable and painful. Magnetic phrenic nerve stimulation is less painful and transdiaphragmatic pressure is reproducible in normal subjects. It is a relatively easy test that has the potential to become a widely adopted method for the assessment of diaphragm strength. The development of a technique to measure diaphragmatic sound (phonomyogram) during magnetic phrenic nerve stimulation opens the way for noninvasive assessment of diaphragmatic function.
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Affiliation(s)
- N Syabbalo
- Faculty of Medicine, Kuwait University, Safat, Kuwait
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20
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Abstract
Many physicians believe that ultrasound has limited usefulness in chest disease. Our clinical experiences and a review of the literature in preparation for this monograph have convinced us that sonography can be a very useful and versatile tool for thoracic diagnosis and intervention. Although there are some limitations caused by interposed ribs and air-containing lung, almost all of the compartments of the chest can be evaluated with ultrasound, which gives unique and clinically useful information. Ultrasound guidance for biopsy and drainage does take some time to learn, but we feel that the effort is very worthwhile. The same advantages ultrasound enjoys for other body regions make it a modality that will see increased use in the chest as well. We hope that this monograph will stimulate our colleagues to explore and expand upon the techniques described.
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Affiliation(s)
- C L Sistrom
- Department of Radiology, University of Virginia, Charlottesville, USA
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21
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Burchell SA, Takiguchi SA, Myers SA, Yu M. Unilateral lung hyperinflation and auto-positive end-expiratory pressure due to a ruptured right hemidiaphragm. Crit Care Med 1996; 24:1418-21. [PMID: 8706501 DOI: 10.1097/00003246-199608000-00024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- S A Burchell
- Department of Surgery, University of Hawaii, Honolulu 96813-7825, USA
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22
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Shapiro MJ, Heiberg E, Durham RM, Luchtefeld W, Mazuski JE. The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture. Clin Radiol 1996; 51:27-30. [PMID: 8549043 DOI: 10.1016/s0009-9260(96)80214-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE There is no gold standard for early and reliable diagnosis of traumatic diaphragmatic rupture (TDR). The purpose of this study is to correlate CT scans, chest radiographs, and intubation on the ability to diagnosis traumatic diaphragmatic rupture. MATERIALS AND METHODS Twenty patients with blunt trauma induced diaphragmatic rupture were identified from a five year review of a Level 1 Trauma Registry. RESULTS Ten of the 20 (50%) patients had TDR on initial chest X-ray, all on the left side. Twelve patients had both chest X-rays and a chest and abdominal CT scan; however, only five (42%) of the CT scans were diagnostic. Of the 12 patients initially intubated, TDR was diagnosed in only four (33%) patients on initial chest X-ray and in one (14%) of seven patients having chest and abdominal CT scans and being intubated. CONCLUSION The early diagnosis of blunt traumatic diaphragmatic rupture, especially in intubated patients, continues to be a diagnostic dilemma. There is a significantly better possibility of identifying left over right-sided TDR (P < or = 0.05). Diagnosing TDR is also facilitated by extubation. If the suspicion exists, a post extubation chest radiograph should be performed to evaluate for TDR.
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Affiliation(s)
- M J Shapiro
- Department of Surgery, St. Louis University Health Sciences Center, MO 63110-0250, USA
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23
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Sleth JC, Chircop R, Jubier P. [Contribution of laparoscopy to the diagnosis of right diaphragmatic rupture]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1994; 13:267. [PMID: 7818215 DOI: 10.1016/s0750-7658(05)80564-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Mealy K, Murphy M, Broe P. Diagnosis of traumatic rupture of the right hemidiaphragm by thoracoscopy. Br J Surg 1993; 80:210-1. [PMID: 8443653 DOI: 10.1002/bjs.1800800225] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- K Mealy
- Department of Surgery, Beaumont Hospital, Dublin, Ireland
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Houston JG, Morris AD, Howie CA, Reid JL, McMillan N. Technical report: quantitative assessment of diaphragmatic movement--a reproducible method using ultrasound. Clin Radiol 1992; 46:405-7. [PMID: 1493655 DOI: 10.1016/s0009-9260(05)80688-9] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- J G Houston
- Department of Radiology, Western Infirmary, Glasgow
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