Video-assisted minithoracotomy for blunt diaphragmatic rupture presenting as a delayed hemothorax

Delayed massive hemothorax after blunt thoracic trauma requiring thoracotomy by VATS: a case report

Delayed hemothorax after thoracic trauma is a rare type of thoracic injury that may require angioembolization and surgical treatment. We report a case of a 59-year-old man with a delayed massive hemothorax from a fall-induced blunt thoracic trauma, causing multiple right lower rib fractures. The patient fell from a chair while standing on and working from it. He was diagnosed with right 7th–11th rib fractures, scanty hemothorax and liver contusion. The patient was hospitalized and received conservative treatment, and a delayed massive hemothorax was present on the fourth day after the injury. Chest tube drainage and video-assisted thoracoscopic surgery were performed, and the patient was discharged 16 days after the surgery without bleeding or other complications. Delayed hemothorax should be considered when thoracic trauma patients complain of chest discomfort, dyspnea, cold sweating or fatigue. Early recognition, appropriate diagnosis and rapid intervention can improve prognosis and lead to successful patient treatment.

Late traumatic diaphragmatic rupture complicated by haemothorax and strangulation of the stomach: A case report

Traumatic diaphragmatic rupture (TDR) is an uncommon but life-threatening condition often caused by blunt or penetrating trauma. Symptoms may appear late resulting in delayed or missed diagnosis. We report here a case of a 28-year-old man who presented with left subcostal pain and vomiting after recently binge drinking alcohol. He had experienced bilateral rib fractures two years previously. Computed tomography (CT) showed massive left pleural effusion and pleural fluid drained by thoracentesis had a bloody appearance. The patient developed septic shock but emergency surgery showed no active bleeding. Enhanced-CT showed herniated stomach with ischemic necrosis in the left thoracic cavity. Total gastrectomy and diaphragmatic repair were successful and the patient had an uneventful recovery. A high index of suspicion is necessary when evaluating haemothorax, especially in patients with recent or previous thoraco-abdominal injury.

To be a surgeon may be life saving

In the first 24 h after multiple rib fractures, a life-threatening massive hemothorax is very rare but can cause death at home in cases who have been discharged. A 50-year-old male general surgeon, was admitted to the emergency unit after a motorcycle accident. Multiple rib fractures were diagnosed but no hemopneumothorax or hemodynamic instability were observed. After 24 h of observation, he was discharged. On the fifth day at home he was woken by symptoms of acute massive hemothorax. With the assistance of his wife he commenced intravenous fluid resuscitation to treat his own hemodynamic instability and transferred himself to his own hospital via ambulance where he subsequently underwent thoracotomy for arrest of haemorrhage. Late development of a massive hemopneumothorax after multiple rib fractures is rare, but may be a life-threatening risk. Such patients should be more closely followed up and informed about symptoms and treatment.

Massive hemothorax due to two bleeding sources with minor injury mechanism: a case report

Background

Massive hemothorax resulting from a minor injury mechanism is considered to be rare particularly when the diaphragm is injured. We report a case of massive hemothorax with bleeding from the intercostal artery and diaphragmatic damage caused by minor blunt trauma.

Case presentation

An 83-year-old Japanese man was transported to our hospital 3 hours after falling out of bed. Computed tomography revealed hemothorax and multiple rib fractures. He underwent fluid resuscitation and a tube thoracostomy, but he became hemodynamically unstable. Contrast-enhanced computed tomography revealed worsening hemothorax with contrast extravasation 4 hours after arrival at the hospital. Emergency angiography indicated hemorrhage in the area supplied by the tenth intercostal artery. Transcatheter arterial embolization stabilized his vital signs for a short period. However, further hemodynamic stabilization required a thoracotomy, which revealed diaphragmatic trauma, which was removed and sutured before fixing his fractured ribs. His postoperative course was uneventful, and he was transferred to another hospital for rehabilitation without complications on hospital day 29.

Conclusions

Minor mechanisms of blunt trauma can cause rib fractures and massive hemothorax. Traumatic diaphragm injury should be considered a differential diagnosis if hemodynamic instability persists after transcatheter arterial embolization in patients with lower level rib fractures.

Delayed massive hemothorax requiring surgery after blunt thoracic trauma over a 5-year period: complicating rib fracture with sharp edge associated with diaphragm injury

Delayed massive hemothorax requiring surgery is relatively uncommon and can potentially be life-threatening. Here, we aimed to describe the nature and cause of delayed massive hemothorax requiring immediate surgery. Over 5 years, 1,278 consecutive patients were admitted after blunt trauma. Delayed hemothorax is defined as presenting with a follow-up chest radiograph and computed tomography showing blunting or effusion. A massive hemothorax is defined as blood drainage >1,500 mL after closed thoracostomy and continuous bleeding at 200 mL/hr for at least four hours. Five patients were identified all requiring emergency surgery. Delayed massive hemothorax presented 63.6±21.3 hours after blunt chest trauma. All patients had superficial diaphragmatic lacerations caused by the sharp edge of a broken rib. The mean preoperative chest tube drainage was 3,126±463 mL. We emphasize the high-risk of massive hemothorax in patients who have a broken rib with sharp edges.

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.

A case of delayed hemothorax with an inferior phrenic artery injury detected and treated endovascularly

We report the rare case of delayed hemothorax (DHX) with an inferior phrenic artery (IPA) injury due to blunt thoracic trauma. Our case suggests that DHX almost always occurs early after injury, and endovascular treatment is an effective procedure for traumatic hemothorax including DHX.