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1
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Giuffrida M, Perrone G, Abu-Zidan F, Agnoletti V, Ansaloni L, Baiocchi GL, Bendinelli C, Biffl WL, Bonavina L, Bravi F, Carcoforo P, Ceresoli M, Chichom-Mefire A, Coccolini F, Coimbra R, de'Angelis N, de Moya M, De Simone B, Di Saverio S, Fraga GP, Galante J, Ivatury R, Kashuk J, Kelly MD, Kirkpatrick AW, Kluger Y, Koike K, Leppaniemi A, Maier RV, Moore EE, Peitzmann A, Sakakushev B, Sartelli M, Sugrue M, Tian BWCA, Broek RT, Vallicelli C, Wani I, Weber DG, Docimo G, Catena F. Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper. World J Emerg Surg 2023; 18:43. [PMID: 37496073 PMCID: PMC10373334 DOI: 10.1186/s13017-023-00510-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable. METHODS A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations. RESULTS CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients. CONCLUSIONS Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.
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Affiliation(s)
| | - Gennaro Perrone
- Department of Emergency Surgery, Maggiore Hospital, Via A. Gramsci 14, 43126, Parma, Italy.
| | - Fikri Abu-Zidan
- Research Office, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Vanni Agnoletti
- Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Gian Luca Baiocchi
- General Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cino Bendinelli
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Walter L Biffl
- Acute Care Surgery at The Queen's Medical Center, John A. Burns School of Medicine, University of Hawai'I, Honolulu, USA
| | - Luigi Bonavina
- Department of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milano, Milan, Italy
| | - Francesca Bravi
- Healthcare Administration, Santa Maria Delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Paolo Carcoforo
- Department of Morphology, Surgery and Experimental Medicine, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, , Riverside, California, USA
| | - Nicola de'Angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Marc de Moya
- Trauma/Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint-Germain-en-Laye Hospitals, Poissy, France
| | - Salomone Di Saverio
- Department of General Surgery, San Benedetto del Tronto General Hospital, San Benedetto del Tronto, Italy
| | - Gustavo Pereira Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Rao Ivatury
- Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Jeffry Kashuk
- Department of Surgery, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Andrew W Kirkpatrick
- Department of General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Ernest Eugene Moore
- Department of Surgery, Denver Health Medical Center,, University of Colorado, Denver, CO, USA
| | - Andrew Peitzmann
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | | | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Donegal, Ireland
| | - Brian W C A Tian
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Richard Ten Broek
- Surgery Department, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Imtaz Wani
- Department of Minimal Access and General Surgery, Government Gousia Hospital, Srinagar, India
| | - Dieter G Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Giovanni Docimo
- Department of Medical and Advanced Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
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Williams BM, Mulima G, Charles A. Chest Trauma Management in Low- and Middle-Income Countries. Thorac Surg Clin 2022; 32:329-336. [PMID: 35961741 DOI: 10.1016/j.thorsurg.2022.04.008] [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: 11/19/2022]
Abstract
Trauma is a leading cause of death and disability worldwide and disproportionately affects those in low- and middle-income countries (LMICs). Globally, two-thirds of injured patients sustain trauma to the thoracic cavity. Further research, capacity building, and increased awareness are needed to limit the high thoracic trauma-associated morbidity and mortality in LMICs.
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Affiliation(s)
| | | | - Anthony Charles
- Department of Surgery, University of North Carolina-Chapel Hill; Kamuzu Central Hospital, Lilongwe, Malawi.
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3
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İlhan M, Alizade E, Durak G, Kaan Gok A, Ertekin C. Can invasive diagnostic methods be reduced by magnetic resonance imaging in the diagnosis of diaphragmatic injuries in left thoracoabdominal penetrating injuries? J Minim Access Surg 2022; 18:431-437. [PMID: 35708387 PMCID: PMC9306128 DOI: 10.4103/jmas.jmas_259_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ehmann S, Aviki EM, Sonoda Y, Boerner T, Sassine D, Jones DR, Park B, Cohen M, Rosenblum NG, Chi DS. Diaphragm hernia after debulking surgery in patients with ovarian cancer. Gynecol Oncol Rep 2021; 36:100759. [PMID: 33869713 PMCID: PMC8042427 DOI: 10.1016/j.gore.2021.100759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 11/26/2022] Open
Abstract
Over 80% of patients with epithelial ovarian cancer present with advanced disease, FIGO stage III or IV at the time of diagnosis. The majority require extensive upper abdominal surgery to obtain complete gross resection. This may include splenectomy, distal pancreatectomy, partial hepatectomy, cholecystectomy, and usually diaphragmatic peritonectomy or resection. Following surgery, diaphragmatic hernia-a very rare but serious complication-may occur. We describe four cases of left-sided diaphragmatic hernia resulting after debulking surgery, which included left diaphragm peritonectomy and splenectomy, in patients with advanced ovarian cancer. In association with the current shift towards more extensive debulking surgery for ovarian cancer, more patients may present with postoperative left-sided diaphragm hernia, making the prevention, diagnosis, and management of this complication important to practicing gynecologic oncologists. Intraoperatively the diaphragm should be checked thoroughly to rule out any defects, which should be closed. A diaphragmatic hernia may be easily misdiagnosed because the patient can present with various symptoms. While rare, these hernias require prompt identification, intervention and surgical correction to avoid serious complications.
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Affiliation(s)
- Sarah Ehmann
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emeline M. Aviki
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Thomas Boerner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dib Sassine
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David R. Jones
- Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bernard Park
- Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Murray Cohen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Norman G. Rosenblum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Dennis S. Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
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Mindaye ET, Zegeye A. Massive left hemothorax following left diaphragmatic and splenic rupture with visceral herniation: A case report. Int J Surg Case Rep 2020; 78:4-8. [PMID: 33310468 PMCID: PMC7736767 DOI: 10.1016/j.ijscr.2020.11.144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 11/28/2020] [Accepted: 11/29/2020] [Indexed: 11/29/2022] Open
Abstract
Massive hemothorax due to splenic rupture is exceedingly rare. Delayed or missed diagnosis of massive hemothorax due to splenic rupture is fatal. Isolated diaphragmatic injury is very rare. Diaphragmatic rupture signifies underlying serious injuries. Background Massive left hemothorax following left diaphragmatic and splenic rupture with visceral herniation is quite an uncommon life-threatening condition usually associated with blunt thoracoabdominal trauma. Mortality is generally associated with coexistent vascular and visceral injuries that could be rapidly fatal. Timely, and proper diagnosis is mandatory as survival depends on prompt diagnosis and treatment. Presentation of case We describe a case of massive left hemothorax secondary to blunt thoracoabdominal injury with left diaphragmatic and splenic rupture, gastric, greater omentum and splenic herniation into the left thoracic cavity in a 32 years old male car driver after sustaining a road traffic accident and presented with shortness of breath of 4 h’ duration. He also had zone 3 retroperitoneal hematoma and left acetabular fracture. He was treated surgically and discharged home improved. Discussion Diaphragmatic ruptures following blunt injuries are larger leading to herniation of visceral organs into the thoracic cavity and the most common organ to herniate on the left side is the stomach followed by omentum and small intestine. Splenic rupture is a very rare cause of hemothorax and is often missed in the differential diagnosis. Conclusion Massive hemothorax following splenic and diaphragmatic rupture with visceral herniation following either blunt or penetrating trauma is rare. Delayed or missed diagnosis is associated with higher morbidity and mortality. A high index of suspicion and proper use of diagnostic studies are crucial for early and correct diagnosis.
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Affiliation(s)
- Esubalew Taddese Mindaye
- Department of Surgery, Saint Paul's Hospital Millennium Medical College, Swaziland Street, 1271 Addis Ababa, Ethiopia.
| | - Abraham Zegeye
- Department of Surgery, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
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Abstract
The diaphragm is an inconspicuous fibromuscular septum, and disorders may result in respiratory impairment and morbidity and mortality when untreated. Radiologists need to accurately diagnose diaphragmatic disorders, understand the surgical approaches to diaphragmatic incisions/repairs, and recognize postoperative changes and complications. Diaphragmatic defects violate the boundary between the chest and abdomen, with the risk of herniation and strangulation of abdominal contents. In our surgical practice, patients with diaphragmatic hernias present acutely with incarceration and/or strangulation. Bochdalek hernias are commonly diagnosed in asymptomatic older adults on computed tomography; however, when viscera or a large amount of fat herniates into the chest, surgical intervention is strongly advocated. Morgagni hernias are rare in adults and typically manifest acutely with bowel obstruction. Patients with traumatic diaphragm injury may have an acute, latent, or delayed presentation, and radiologists should be vigilant in inspecting the diaphragm on the initial and all subsequent thoracoabdominal imaging studies. Almost all traumatic diaphragm injury are surgically repaired. Finally, with porous diaphragm syndrome, fluid, air, and tissue from the abdomen may communicate with the pleural space through diaphragmatic fenestrations and result in a catamenial pneumothorax or large pleural effusion. When the underlying disorder cannot be effectively treated, the goal of surgical intervention is to establish the diagnosis, incite pleural adhesions, and close diaphragmatic defects. Diaphragmatic plication may be helpful in patients with eventration or acquired injuries of the phrenic nerve, as it can stabilize the affected diaphragm. Phrenic nerve pacing may improve respiratory function in select patients with high cervical cord injury or central hypoventilation syndrome.
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Mancini A, Duramé A, Barbois S, Abba J, Ageron FX, Arvieux C. Relevance of early CT scan diagnosis of blunt diaphragmatic injury: A retrospective analysis from the Northern French Alps Emergency Network. J Visc Surg 2018; 156:3-9. [PMID: 30472050 DOI: 10.1016/j.jviscsurg.2018.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Diaphragmatic rupture following blunt trauma occurs rarely. Classically described after high-velocity accidents, ruptures are often associated with multiple organ injuries. The diagnosis is sometimes difficult. The goal of this study was to analyze and to discuss the modalities of early radiologic diagnosis and management of these injuries. PATIENTS AND METHODS This multicenter retrospective study included patients seen between 2009 and 2017 within the Northern Alpine Emergency Network [REseau Nord Alpin des Urgences (RENAU)]. Clinical, radiologic and surgical data from all patients sustaining blunt diaphragmatic rupture were studied. RESULTS Thirty-one patients (18 men and 13 women), median age 44, were included. The principle mechanism of injury was road or traffic accidents for 22 patients. Diaphragmatic rupture occurred on the left side in 23 patients. Diagnosis was delayed in two patients, at 11 days and three months after the initial accident. Chest X-rays were diagnostic in 18 of 29 patients. CT scan was the reference investigation since it was performed in all patients and confirmed the diagnosis in 26 instances. Repair was surgical via a midline laparotomy in 27 patients, via laparoscopy in three, and via thoracoscopy in one. Three patients died. CONCLUSION At urgent surgical exploration in the unstable blunt trauma patient, the surgeon should keep in mind the relatively poor diagnostic performance of chest X-rays. Accurate diagnosis relies on routine inspection of the diaphragmatic cupolas. In the stable trauma victim, contrast-enhanced abdomino-thoracic CT with reconstruction can lead to early diagnosis, which allows for repair under optimal conditions, whether by laparotomy, laparoscopy or thoracoscopy, according to local conditions and expertise.
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Affiliation(s)
- A Mancini
- Service de chirurgie digestive et de l'urgence, CHU Grenoble-Alpes, CS 102017, 38043 Grenoble cedex, France
| | - A Duramé
- Service de chirurgie digestive et de l'urgence, CHU Grenoble-Alpes, CS 102017, 38043 Grenoble cedex, France
| | - S Barbois
- Service de chirurgie digestive et de l'urgence, CHU Grenoble-Alpes, CS 102017, 38043 Grenoble cedex, France
| | - J Abba
- Service de chirurgie digestive et de l'urgence, CHU Grenoble-Alpes, CS 102017, 38043 Grenoble cedex, France
| | - F-X Ageron
- Urgences SAMU-SMUR, centre hospitalier Annecy-Genevois, 74370 Metz-Tessy, France
| | - C Arvieux
- Service de chirurgie digestive et de l'urgence, CHU Grenoble-Alpes, CS 102017, 38043 Grenoble cedex, France.
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8
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Verma N, White CS, Mohammed TL. Blunt Cardiothoracic Trauma: Common Injuries and Diagnosis. Semin Roentgenol 2018; 53:171-177. [PMID: 29861008 DOI: 10.1053/j.ro.2018.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Nupur Verma
- Department of Radiology, University of Florida, Gainesville, FL.
| | - Charles S White
- Department of Radiology, University of Maryland, Baltimore, MD
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9
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Haranal MY, Buggi S, Sanjeevaiah S, Venkatappa V. Traumatic diaphragmatic hernia—17 years experience. Indian J Thorac Cardiovasc Surg 2018. [DOI: 10.1007/s12055-017-0534-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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10
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Hammer MM, Raptis DA, Mellnick VM, Bhalla S, Raptis CA. Traumatic injuries of the diaphragm: overview of imaging findings and diagnosis. Abdom Radiol (NY) 2017; 42:1020-1027. [PMID: 27641159 DOI: 10.1007/s00261-016-0908-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Injuries to the diaphragm muscle occur in penetrating and severe blunt trauma and can lead to delayed hernia formation. Computed tomography is the mainstay in the diagnosis of these injuries, which may be subtle at presentation. Imaging findings differ between blunt and penetrating trauma. Key features in blunt trauma include diaphragm fragment distraction and organ herniation because of increased intra-abdominal pressure. In penetrating trauma, herniation is uncommon, and the trajectory of the object is critical in making the diagnosis of diaphragm injury in these patients. Radiologists must keep a high index of suspicion for injury to the diaphragm in cases of trauma to the chest or abdomen.
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Affiliation(s)
- Mark M Hammer
- Department of Radiology, Brigham & Women's Hospital, 75 Francis St., Boston, MA, 02115, USA.
| | - Demetrios A Raptis
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Vincent M Mellnick
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
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11
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Bonatti M, Lombardo F, Vezzali N, Zamboni GA, Bonatti G. Blunt diaphragmatic lesions: Imaging findings and pitfalls. World J Radiol 2016; 8:819-828. [PMID: 27843541 PMCID: PMC5084060 DOI: 10.4329/wjr.v8.i10.819] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/31/2016] [Accepted: 08/29/2016] [Indexed: 02/06/2023] Open
Abstract
Blunt diaphragmatic lesions (BDL) are uncommon in trauma patients, but they should be promptly recognized as a delayed diagnosis increases morbidity and mortality. It is well known that BDL are often overlooked at initial imaging, mainly because of distracting injuries to other organs. Sonography may directly depict BDL only in a minor number of cases. Chest X-ray has low sensitivity in detecting BDL and lesions can be reliably suspected only in case of intra-thoracic herniation of abdominal viscera. Thanks to its wide availability, time-effectiveness and spatial resolution, multi-detector computed tomography (CT) is the imaging modality of choice for diagnosing BDL; several direct and indirect CT signs are associated with BDL. Given its high tissue contrast resolution, magnetic resonance imaging can accurately depict BDL, but its use in an emergency setting is limited because of longer acquisition times and need for patient’s collaboration.
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12
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Ghionzoli M, Bongini M, Piccolo RL, Martin A, Persano G, Deaconu DE, Messineo A. Role of thoracoscopy in traumatic diaphragmatic hernia. Pediatr Int 2016; 58:601-3. [PMID: 27072876 DOI: 10.1111/ped.12887] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/17/2015] [Accepted: 11/04/2015] [Indexed: 11/30/2022]
Abstract
Thoraco-abdominal trauma can in rare cases involve diaphragmatic rupture and subsequent herniation of intra-abdominal contents. We report a case of this complication in a 5-year-old boy who was injured in a car crash, and who manifested respiratory distress and hemodynamic instability after 48 h of being monitored in the pediatric intensive care unit. Multiple radiologic investigations were inconclusive and the definite diagnosis was established only on thoracoscopic exploration.
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Affiliation(s)
- Marco Ghionzoli
- Department of Emergency, Critical Area and Pediatric Surgery, University of Florence and Children's University Hospital "A. Meyer", Florence, Italy
| | - Martina Bongini
- Department of Emergency, Critical Area and Pediatric Surgery, University of Florence and Children's University Hospital "A. Meyer", Florence, Italy
| | - Roberto Lo Piccolo
- Department of Emergency, Critical Area and Pediatric Surgery, University of Florence and Children's University Hospital "A. Meyer", Florence, Italy
| | - Alessandra Martin
- Department of Emergency, Critical Area and Pediatric Surgery, University of Florence and Children's University Hospital "A. Meyer", Florence, Italy
| | - Giorgio Persano
- Department of Emergency, Critical Area and Pediatric Surgery, University of Florence and Children's University Hospital "A. Meyer", Florence, Italy
| | - Diana E Deaconu
- Department of Emergency, Critical Area and Pediatric Surgery, University of Florence and Children's University Hospital "A. Meyer", Florence, Italy
| | - Antonio Messineo
- Department of Emergency, Critical Area and Pediatric Surgery, University of Florence and Children's University Hospital "A. Meyer", Florence, Italy
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13
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Lee MA, Choi KK, Lee GJ, Yu BC, Ma DS, Jeon YB, Lee JN, Chung M. Right Diaphragmatic Injury Accompanied by Herniation of the Liver: A Case Report. JOURNAL OF TRAUMA AND INJURY 2016. [DOI: 10.20408/jti.2016.29.2.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Min A Lee
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Kang Kook Choi
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Gil Jae Lee
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Byung Chul Yu
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Dae Sung Ma
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Yang Bin Jeon
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Jung Nam Lee
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Min Chung
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
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Siow SL, Wong CM, Hardin M, Sohail M. Successful laparoscopic management of combined traumatic diaphragmatic rupture and abdominal wall hernia: a case report. J Med Case Rep 2016; 10:11. [PMID: 26781191 PMCID: PMC4717597 DOI: 10.1186/s13256-015-0780-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 12/02/2015] [Indexed: 12/04/2022] Open
Abstract
Background Traumatic diaphragmatic rupture and traumatic abdominal wall hernia are two well-described but rare clinical entities associated with blunt thoracoabdominal injuries. To the best of our knowledge, the combination of these two clinical entities as a result of a motor vehicle accident has not been previously reported. Case presentation A 32-year-old Indian man was brought to our emergency department after being involved in a road traffic accident. He described a temporary loss of consciousness and had multiple tender bruises at his right upper anterior abdominal wall and left lumbar region. An initial examination revealed blood pressure of 99/63 mmHg, heart rate of 107 beats/minute, and oxygen saturation of 93 % on room air. His clinical parameters stabilized after initial resuscitation. A computed tomographic scan revealed a rupture of the left diaphragm as well as extensive disruptions of the left upper anterior abdominal wall. We performed exploratory laparoscopic surgery with the intention of primary repair. The diaphragmatic and abdominal wall defect was primarily closed, followed by reinforcement with PROLENE onlay mesh. The patient’s postoperative recovery was complicated by infected hematomas over both flanks that were managed with ultrasound-guided percutaneous drainage. He was discharged well despite a prolonged hospital stay. Conclusions We present a complex form of injuries managed successfully via a laparoscopic approach. Meticulous attention to potential complications in both the acute and convalescent phases is important for achieving a successful outcome following surgery.
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Affiliation(s)
- Sze Li Siow
- Department of Surgery, Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia. .,Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, 94300, Kota Samarahan, Sarawak, Malaysia.
| | - Chee Ming Wong
- Department of Surgery, Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia. .,Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, 94300, Kota Samarahan, Sarawak, Malaysia.
| | - Mark Hardin
- Department of Surgery, Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia.
| | - Mushtaq Sohail
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, 94300, Kota Samarahan, Sarawak, Malaysia.
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Imaging of Traumatic Diaphragmatic Rupture: Evaluation of Diagnostic Accuracy at a Level 1 Trauma Centre. Can Assoc Radiol J 2015; 66:310-7. [DOI: 10.1016/j.carj.2015.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 02/04/2015] [Accepted: 02/17/2015] [Indexed: 01/30/2023] Open
Abstract
Purpose Traumatic diaphragmatic rupture (TDR) is an uncommon injury that can be associated with significant morbidity if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (64-MDCT) for the detection of TDR in patients at our level 1 trauma centre. Methods We used our hospital's trauma registry to identify patients with a diagnosis of TDR from January 1, 2008, to December 31, 2012. Only patients with a 64-MDCT scan at presentation who subsequently underwent laparotomy/laparoscopy were included in the study cohort. Using surgical findings as the gold standard, the accuracy of the prospective radiology reports was analyzed. Results Of the 3225 trauma patients who presented to our institution, 38 (1.2%) had a TDR. Fourteen of the 38 were excluded as they did not have MDCT before surgery. The study cohort consisted of 20 males and 4 females with a median age of 34.5 years and a median Injury Severity Score (ISS90) of 26. Fifteen had blunt trauma while 9 had a penetrating injury. The overall sensitivity of the radiology reports was 66.7% (95% confidence interval [CI]: 46.7%-82.0%), specificity was 100% (95% CI: 94.1%-100%), positive predictive value was 100% (95% CI: 80.6%-100%), negative predictive value was 88.4% (95% CI: 78.8%-94.0%), and accuracy was 90.6% (95% CI: 82.5%-95.2%). However, only 3 of 9 patients with penetrating injury had a correct preoperative diagnosis. Two of the 6 missed penetrating trauma cases had only indirect signs of injury. Conclusions The detection of TDR in trauma patients on 64-MDCT can be improved, especially in patients presenting with penetrating injury. A careful search for subtle diaphragmatic defects and indirect evidence of injury is important to avoid missing the diagnosis.
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17
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Mehrzad H, Jones RG, McCafferty IJ, Mangat K. Imaging in abdominal trauma. TRAUMA-ENGLAND 2014. [DOI: 10.1177/1460408614548006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Abdominal trauma is increasing and although penetrating wounds are also on the increase, blunt trauma remains more common. The cornerstone of management is accurate diagnosis and the advent of high-quality rapid CT scanning has revolutionised the treatment of serious abdominal injury. It has allowed the introduction of selective non-operative management which is applicable to many low- and intermediate-grade injuries, whereas application of interventional radiology can avert laparotomy in higher grade injuries. This review examines the pathophysiology of the commonest forms of abdominal injury and uses a series of cases to illustrate the impact of modern radiology in management.
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Affiliation(s)
- Homoyoon Mehrzad
- Department of Interventional Radiology, University Hospital Birmingham, UK
| | - Robert G Jones
- Department of Interventional Radiology, University Hospital Birmingham, UK
| | - Ian J McCafferty
- Department of Interventional Radiology, University Hospital Birmingham, UK
| | - Kamarjit Mangat
- Department of Interventional Radiology, University Hospital Birmingham, UK
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18
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Hammer MM, Flagg E, Mellnick VM, Cummings KW, Bhalla S, Raptis CA. Computed tomography of blunt and penetrating diaphragmatic injury: sensitivity and inter-observer agreement of CT Signs. Emerg Radiol 2013; 21:143-9. [DOI: 10.1007/s10140-013-1166-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 10/04/2013] [Indexed: 12/18/2022]
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Lozano JD, Munera F, Anderson SW, Soto JA, Menias CO, Caban KM. Penetrating wounds to the torso: evaluation with triple-contrast multidetector CT. Radiographics 2013; 33:341-59. [PMID: 23479700 DOI: 10.1148/rg.332125006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Penetrating injuries account for a large percentage of visits to emergency departments and trauma centers worldwide. Emergency laparotomy is the accepted standard of care in patients with a penetrating torso injury who are not hemodynamically stable and have a clinical indication for exploratory laparotomy, such as evisceration or gastrointestinal bleeding. Continuous advances in technology have made computed tomography (CT) an indispensable tool in the evaluation of many patients who are hemodynamically stable, have no clinical indication for exploratory laparotomy, and are candidates for conservative treatment. Multidetector CT may depict the trajectory of a penetrating injury and help determine what type of intervention is necessary on the basis of findings such as active arterial extravasation and major vascular, hollow viscus, or diaphragmatic injuries. Because multidetector CT plays an increasing role in the evaluation of patients with penetrating wounds to the torso, the radiologists who interpret these studies should be familiar with the CT findings that mandate intervention.
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Affiliation(s)
- J Diego Lozano
- Department of Radiology, University of Miami Leonard Miller School of Medicine, University of Miami Health System, Jackson Memorial Hospital, and Ryder Trauma Center, 1611 NW 12th Ave, West Wing 279, Miami, FL 33136, USA
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20
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Scumpia AJ, Aronovich DA, Roman L, Vasudevan V, Shadis RM, Lynn M. Diaphragmatic rupture secondary to blunt thoracic trauma. West J Emerg Med 2013; 14:435-6. [PMID: 24106535 PMCID: PMC3789901 DOI: 10.5811/westjem.2013.4.15826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Revised: 01/28/2013] [Accepted: 04/22/2013] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Daniel A. Aronovich
- Mount Sinai Medical Center, Department of Emergency Medicine, Miami, Florida
| | - Loredana Roman
- Victor Babes University of Medicine and Pharmacy, Department of Medicine, Timisoara, Romania
| | - Vanitha Vasudevan
- Ryder Trauma Center, Department of Surgery, Jackson Memorial Health System, Miami, Florida
| | - Ryan M. Shadis
- Ryder Trauma Center, Department of Surgery, Jackson Memorial Health System, Miami, Florida
| | - Mauricio Lynn
- Ryder Trauma Center, Department of Surgery, Jackson Memorial Health System, Miami, Florida
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21
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Safdar G, Slater R, Garner JP. Laparoscopically assisted repair of an acute traumatic diaphragmatic hernia. BMJ Case Rep 2013; 2013:bcr2013009415. [PMID: 23813999 PMCID: PMC3702891 DOI: 10.1136/bcr-2013-009415] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 60-year-old man with chronic obstructive pulmonary disease and a heavy smoker and drinker presented to the emergency department with left-sided thoracoabdominal pain after falling down the stairs. Initial clinical findings were left-sided chest tenderness with no clinical evidence of subcutaneous emphysema. Twenty-four hours later the patient's respiratory distress increased-repeat chest X-ray showed a left gastrothorax indicative of a ruptured left hemi diaphragm. Diagnostic laparoscopy in the supine position via an umbilical port confirmed the presence of the stomach, spleen and splenic flexure of the colon in the left chest. Laparoscopic reduction of the stomach and colon was performed, but a small upper midline incision was required to reduce the spleen without injury. The diaphragmatic tear was repaired by direct open suture. The patient required a brief period of postoperative ventilation via a tracheostomy. The patient remained well at a 3-month follow-up visit.
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Affiliation(s)
- G Safdar
- Department of General Surgery, The Rotherham NHS Foundation Trust, Rotherham, UK.
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22
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Weerink LBM, Ten Duis K, Van der Velde D, Rakic S. Delayed presentation of diaphragmatic rupture after blast injury. J ROY ARMY MED CORPS 2013; 159:304-6. [PMID: 23720513 DOI: 10.1136/jramc-2013-000068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A diaphragmatic injury is usually associated with injury to thoracic or abdominal organs due to blunt or penetrating trauma, and is uncommon after blast injury. We describe a patient with respiratory distress due to herniation of the stomach into the chest through a diaphragmatic injury, sustained 1 year previously when he suffered a blast injury while on deployed military operations, but without obvious visceral injury at that time. At emergency laparotomy there was a gastric perforation which was exteriorised as a gastrostomy and the diaphragmatic rupture closed. Postoperative pneumonia and pelvic abscess were both treated successfully and he left the hospital in good condition. Delayed treatment of traumatic diaphragmatic injury leads to an increased risk for herniation and/or strangulation of abdominal organs, which can be life-threatening. Recognising the symptoms indicating diaphragmatic injury is especially important in cases in which the relationship to previous trauma is less clear.
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Affiliation(s)
- Linda B M Weerink
- Department of Surgery, Ziekenhuisgroep Twente Almelo, Almelo, The Netherlands
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Bocchini G, Guida F, Sica G, Codella U, Scaglione M. Diaphragmatic injuries after blunt trauma: are they still a challenge? Reviewing CT findings and integrated imaging. Emerg Radiol 2012; 19:225-35. [PMID: 22362421 DOI: 10.1007/s10140-012-1025-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 01/23/2012] [Indexed: 12/28/2022]
Abstract
Traumatic diaphragmatic rupture is a life-threatening injury that may occur in patients with blunt trauma. At present, supine chest radiographs is the initial, most commonly performed imaging test to evaluate a traumatic injury of the thorax. However, computed tomography (CT) is the imaging tool of choice, as it is the 'gold standard' for the detection of diaphragmatic injury after trauma. In particular, recent literature indicates that multidetector CT with multiplanar reformations has significantly improved in accuracy. Radiologists working in the emergency room should keep in mind the possibility of diaphragmatic injuries and should routinely integrate the axial images CT with multiplanar reformations in order to detect any potential, subtle or doubtful sign of incomplete diaphragmatic injury.
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Affiliation(s)
- Giorgio Bocchini
- Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno 81030, Italy
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Das S, Kumar V. Avulsion injuries of the male external genitalia & rupture of the diaphragm following road traffic accident. J Forensic Leg Med 2011; 18:380-2. [DOI: 10.1016/j.jflm.2011.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 05/10/2011] [Accepted: 06/15/2011] [Indexed: 11/15/2022]
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Svensson E, Heimann TM. Unusual case of an upset stomach. Diagnosis: Traumatic diaphragmatic rupture with intrathoracic gastric herniation. Gastroenterology 2011; 141:e8-9. [PMID: 21640109 DOI: 10.1053/j.gastro.2010.04.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 04/08/2010] [Accepted: 04/22/2010] [Indexed: 12/02/2022]
Affiliation(s)
- Erik Svensson
- Department of Surgery, Mount Sinai School of Medicine, New York, New York, USA
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26
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Wani AM, Al Qurashi T, Rehman SA, Al Harbi ZS, Sabbag ARY, Al Ahdal M. Massive haematemesis due to strangulated gangrenous gastric herniation as the delayed presentation of post-traumatic diaphragmatic rupture. BMJ Case Rep 2010; 2010:2010/sep06_1/bcr0420102874. [PMID: 22778192 DOI: 10.1136/bcr.04.2010.2874] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Diaphragmatic injuries are quite uncommon and often result from either blunt or penetrating trauma. Diaphragmatic ruptures are usually associated with abdominal trauma; however, it can occur in isolation. Acute traumatic rupture of the diaphragm may go unnoticed and there is often a delay between the injury and the diagnosis. Patients present with non-specific symptoms and may complain of chest pain, abdominal pain, dyspnoea, tachypnoea and cough, heartburn and symptoms of gastro-oesophageal reflux. Respiratory distress and faeco-pneumothorax have been reported. We present an interesting case of traumatic diaphragmatic hernia presenting 5 years after a road traffic accident as acute abdomen and massive haematemesis due to strangulated gangrenous gastric hernia.
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Affiliation(s)
- Abdul Majid Wani
- Department of Emergency Medicine, Hera General Hospital, Makkah, Saudi Arabia.
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27
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28
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Navallas M, Borruel S, Cano R, Ibáñez L. [Delayed diagnosis of a diaphragmatic hernia in a patient on mechanical ventilation]. RADIOLOGIA 2010; 52:552-5. [PMID: 20541784 DOI: 10.1016/j.rx.2010.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Revised: 03/25/2010] [Accepted: 04/14/2010] [Indexed: 10/19/2022]
Abstract
Traumatic rupture of the diaphragm is uncommon. Its early diagnosis is a challenge in diagnostic imaging. We present the case of a male multiple trauma patient in whom a left diaphragmatic hernia was discovered on weaning from mechanical ventilation 23 days after admission. We discuss the key imaging features of diaphragmatic rupture based on its physiopathology and thoracoabdominal pressure gradients. Very few cases of radiologically documented diaphragmatic hernias masked by mechanical ventilation have been reported.
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Affiliation(s)
- M Navallas
- Servicio de Radiología, Hospital 12 de Octubre, Madrid, España.
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29
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Traumatic diaphragmatic hernia: tertiary centre experience. Hernia 2009; 14:159-64. [PMID: 19908108 DOI: 10.1007/s10029-009-0579-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Accepted: 10/16/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Traumatic diaphragmatic hernia (TDH) resulting from traumatic diaphragmatic rupture (TDR) may not be easily detected and can lead to significant morbidity and mortality. PATIENTS AND METHODS A retrospective case note analysis was performed of all patients treated for TDR at a major teaching hospital between March 2003 and March 2008. The aetiological factors, associated injuries, management and outcome were analysed. RESULTS Twenty-seven patients were studied (24 males, 3 females) and their ages ranged from 16 to 72 years (median 35 years). TDR was left-sided in 85% and right-sided in 15%. Aetiology was blunt trauma in 81% and 19% had penetrating injury. Associated injuries were present in 81%. The most common approach for repair was transabdominal (89%); additional thoracotomy was needed in 11%. Herniation of abdominal contents was present in 85% and herniation of more than one organ was present in 57%. The diaphragmatic rent was repaired primarily in 89% using nonabsorbable sutures. Post-operative pulmonary complications occurred in 52% of patients. Three patients (11%) died. CONCLUSION Left-sided blunt traumatic diaphragmatic rupture was more common than right-sided rupture. The most commonly herniated organs were the stomach and colon. Most ruptures could be repaired by an abdominal approach, which also allowed a complete exploration of the abdominal organs. Careful attention should be given to associated intra-abdominal injuries. Most of the defects were repaired directly using nonabsorbable sutures.
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30
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Somford MP, Nuytinck HKS, Vos DI. A case of delayed diagnosis of a right-sided diaphragm rupture with a review of the literature. Eur J Trauma Emerg Surg 2009; 35:499-502. [PMID: 26815218 DOI: 10.1007/s00068-008-8124-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2008] [Accepted: 10/15/2008] [Indexed: 10/21/2022]
Abstract
Right-sided diaphragm rupture is one of the typical injuries found during a secondary or tertiary survey after a major blunt trauma. This is mainly due to the apparently normal aspect of primary X-rays of the thorax. A right-sided diaphragm rupture can cause severe atelectasis of the right lower lobe of the lung, due to a hepatothorax. We present a case of a delayed diagnosis of right-sided diaphragm rupture, which was discovered by accident because of a new trauma. We review the literature on right-sided diaphragm rupture and its treatment.
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Affiliation(s)
| | | | - Dagmar I Vos
- Amphia Hospital, Surgery, Breda, The Netherlands. .,Amphia Hospital, Surgery, Molengracht 21, 4800 RK, Breda, The Netherlands.
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31
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Rashid F, Chakrabarty MM, Singh R, Iftikhar SY. A review on delayed presentation of diaphragmatic rupture. World J Emerg Surg 2009; 4:32. [PMID: 19698091 PMCID: PMC2739847 DOI: 10.1186/1749-7922-4-32] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Accepted: 08/21/2009] [Indexed: 11/10/2022] Open
Abstract
Diaphragmatic rupture is a life-threatening condition. Diaphragmatic injuries are quite uncommon and often result from either blunt or penetrating trauma. Diaphragmatic ruptures are usually associated with abdominal trauma however, it can occur in isolation. Acute traumatic rupture of the diaphragm may go unnoticed and there is often a delay between the injury and the diagnosis. A comprehensive literature search was performed using the terms "delayed presentation of post traumatic diaphragmatic rupture" and "delayed diaphragmatic rupture". The diagnostic and management challenges encountered are discussed, together with strategies for dealing with them. We have focussed on mechanism of injury, duration, presentation and site of injury, visceral herniation, investigations and different approaches for repair. We intend to stress on the importance of delay in presentation of diaphragmatic rupture and to provide a review on the available investigations and treatment methods. The enclosed case report also emphasizes on the delayed presentation, diagnostic challenges and the advantages of laparoscopic repair of delayed diaphragmatic rupture.
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Affiliation(s)
- Farhan Rashid
- Division of GI Surgery, University of Nottingham, Graduate Entry Medical School, Uttoxeter Road, Derby, DE22 3DT, UK.
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The dangling diaphragm sign: sensitivity and comparison with existing CT signs of blunt traumatic diaphragmatic rupture. Emerg Radiol 2009; 17:37-44. [PMID: 19449046 DOI: 10.1007/s10140-009-0819-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Accepted: 04/28/2009] [Indexed: 01/20/2023]
Abstract
The objectives of our study were to describe a new CT sign of diaphragmatic injury, the "dangling diaphragm" sign, and assess its comparative utility relative to other signs in the diagnosis of diaphragmatic injury resulting from blunt trauma. CT scans of 16 blunt trauma patients (12 men and four women, mean age 36.6 years old) with surgically proven diaphragmatic injury and 32 blunt trauma patients (24 men and eight women; mean age 37.4 years old) without evidence of diaphragmatic injury at surgery were blindly reviewed by three board certified radiologists specializing in body imaging. Studies were evaluated for the presence of established signs of diaphragmatic injury, as well as the dangling diaphragm sign, in which the free edge of the torn hemidiaphragm curls inward from its normal course parallel to the body wall. The sensitivity and specificity of each sign were determined, as were the correlation between the signs and the interobserver agreement in evaluation of these findings. The radiologists' overall impression as to whether rupture was present was also recorded. In select cases, coronal and/or sagittal reformatted images were available, and they were reviewed following evaluation of the original axial images. Any change in interpretation due to these images was noted. The sensitivity of the radiologists' overall impression for detection of diaphragmatic injury was 77%, with 98% specificity. Individual signs of diaphragmatic injury had sensitivities ranging from 44% to 69%, with specificities of 98% to 100%. The dangling diaphragm sign had a sensitivity of 54% and a specificity of 98%, similar to the other signs. Multiple signs were present in most cases of diaphragmatic injury, and coronal and sagittal reformatted images had little impact. Diaphragmatic injury remains a challenging radiographic diagnosis. The dangling diaphragm is a conspicuous sign of diaphragmatic injury, and awareness of it may increase detection of diaphragmatic injury on CT studies.
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