Management of Traumatic Diaphragmatic Injuries.

Diaphragm injuries are rarely seen injuries in trauma patients and are difficult to diagnose. With improving technology, computed tomography has become more reliable, but with increasing rates of non-operative management of both penetrating and blunt trauma, the rate of missed diaphragmatic injury has increased. The long-term complications of missed injury include bowel obstruction and perforation, which can carry a mortality rate as high as 85%. When diagnosed, injuries should be repaired to reduce the risk of future complications.

Risk factors for diaphragmatic injury in subxiphoid video-assisted thoracoscopic surgery.

BACKGROUND: Subxiphoid video-assisted thoracoscopic surgery (VATS) is considered a safe and feasible operation for anterior mediastinal mass resection. However, diaphragmatic injury, presented as tearing or puncturing, may occur during subxiphoid VATS despite of low incidence. This study aims to explore risk factors for diaphragmatic injury in subxiphoid VATS, as well as strategies to reduce occurrence of the injury. METHODS: We retrospectively reviewed clinical records of 44 consecutive adult patients who underwent subxiphoid VATS. These patients were divided into two groups: diaphragmatic injury group and non-injury group. Perioperative outcomes and anatomic features derived from 3D CT reconstructions were compared between the two groups. RESULTS: Significant differences were observed in operation time (223.25 ± 92.57 vs. 136.28 ± 53.05, P = 0.006), xiphoid length (6.47 ± 0.85 vs. 4.79 ± 1.04, P = 0.001) and length of the xiphoid below the attachment point on the diaphragm (24.86 ± 12.02 vs. 14.61 ± 9.25, P = 0.029). Odds ratio for the length of the xiphoid below the attachment point on the diaphragm was 1.09 (1.001-1.186), P = 0.048 by binary logistic regression analysis. CONCLUSIONS: We identified the length of the xiphoid below the attachment point on the diaphragm as an independent risk factor for diaphragm injury during subxiphoid VATS. Prior to subxiphoid VATS, a 3D chest CT reconstruction is recommended to assess the patients' anatomic variations within the xiphoid process. For patients with longer xiphoid process, a higher incision at the middle and upper part of the xiphoid process, and partial xiphoid process resection or xiphoidectomy is preferred.

[Traumatic damage to the diaphragm in children]. / Travmaticheskie povrezhdeniya diafragmy u detei.

OBJECTIVE: To analyze treatment outcomes in children with traumatic injuries of the diaphragm. MATERIAL AND METHODS: We followed-up 14 children aged 3-18 years with traumatic injuries of the diaphragm. Diagnostic measures included anamnesis, physical examination, pleural and abdominal puncture, bladder catheterization, ultrasound and X-ray examination including CT. RESULTS: Traumatic brain injury and thoracoabdominal trauma prevailed in children with traumatic injuries of the diaphragm. In 8 children, diaphragm injury was the result of a traffic accident. Of these, 5 ones died at the scene due to traumatic brain injury. In 3 children, diaphragm injury was associated with penetration of an iron pin through the perineum, pelvic cavity, abdominal and chest cavities when falling from a height (n=1) and sledding (n=2). Two children were littered with a pile of bricks and building materials. One girl suffered a diaphragm injury as a result of a stab wound. CONCLUSION: Combined damage to the diaphragm, TBI, chest and abdominal organs are serious injuries. Signs of shock, internal bleeding, respiratory failure and bone fractures come to the fore. Assistance to these children should be carried out in specialized hospitals.

Diagnostic utility of multidetector CT scan in penetrating diaphragmatic injuries: A systematic review and meta-analysis.

Penetrating diaphragmatic injuries pose diagnostic and management challenges. Computed tomography (CT) scans are valuable for stable patients, but concern exists for missed injuries and complications in nonoperatively managed cases. The objective of this study was to explore the diagnostic utility of multidetector CT scan (MDCT) in identifying diaphragmatic injuries resulting from penetrating trauma. A systematic review and meta-analysis were conducted, following established guidelines, by searching PubMed, Scopus, Web of Science, and Embase databases up to July 6, 2023. Eligible studies reporting MDCT's diagnostic accuracy in detecting penetrating diaphragmatic injuries were included. Relevant data elements were extracted and analyzed using STATA software. The study included 9 articles comprising 294 patients with confirmed penetrating diaphragmatic injuries through surgical procedures. MDCT's diagnostic performance revealed a pooled sensitivity of 74% (95% CI: 56%-87%) and a pooled specificity of 92% (95% CI: 79%-97%) (Fig. two), with significant heterogeneity in both sensitivity and specificity across the studies. The Fagan plot demonstrated that higher pre-test probabilities correlated with higher positive post-test probabilities for penetrating diaphragmatic injury diagnosis using MDCT, but even with negative results, there remained a small chance of having the injury, especially in cases with higher pre-test probabilities. This study highlights MDCT's effectiveness in detecting diaphragmatic injury from penetrating trauma, with moderate to high diagnostic accuracy. However, larger sample sizes, multicenter collaborations, and prospective designs are needed to address observed heterogeneity, enhancing understanding and consistency in MDCT's diagnostic capabilities in this context.

Phrenic Nerve Stimulation for Acute Respiratory Failure.

Diaphragm inactivity during invasive mechanical ventilation leads to diaphragm atrophy and weakness, hemodynamic instability, and ventilatory heterogeneity. Absent respiratory drive and effort can, therefore, worsen injury to both lung and diaphragm and is a major cause of failure to wean. Phrenic nerve stimulation (PNS) can maintain controlled levels of diaphragm activity independent of intrinsic drive and as such may offer a promising approach to achieving lung and diaphragm protective ventilatory targets. Whereas PNS has an established role in the management of chronic respiratory failure, there is emerging interest in how its multisystem putative benefits may be temporarily harnessed in the management of invasively ventilated patients with acute respiratory failure.

Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper.

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.

Twenty-year perspective on blunt traumatic diaphragmatic injury in level 1 trauma centre: Early versus delayed diagnosis injury patterns and outcomes.

OBJECTIVE: Blunt traumatic diaphragmatic injury (TDI) is typically associated with severe trauma and concomitant injuries. It is a diagnostic challenge in the setting of blunt trauma and can be easily overlooked especially in the acute phase often dominated by concurrent injuries. METHODS: A retrospective review was conducted of patients with blunt-TDI identified from a level 1 trauma registry. Variables associated with early versus delayed diagnosis as well as non-survivor and survivor groups were collected to examine factors associated with delayed diagnosis. RESULTS: A total of 155 patients were included (mean age 46 ± 20, 60.6% male). Diagnosis was made <24 h in 126 (81.3%), and >24 h in 29 (18.7%). Of the delayed diagnosis group, 14 (48%) were diagnosed >7 days. Overall, 27 (21.4%) patients had a diagnostic initial CXR and 64 (50.8%) had a diagnostic initial CT. Fifty-eight (37.4%) patients were diagnosed intraoperatively. Of the delayed diagnosis group, 22 (75.9%) had no initial signs on CXR or CT, 15 (52%) of this group had persistent pleural-effusions/elevated-hemidiaphragm leading to further investigation and diagnosis. No significant difference in survival was observed between early and delayed diagnoses, no clinically significant injury patterns to predict delayed diagnoses were noted. CONCLUSION: The diagnosis of TDI is challenging. Without frank signs of herniation of abdominal contents on CXR or CT, the diagnosis is often not made on initial imaging. In patients with the evidence of blunt traumatic injury in the lower-chest/upper-abdomen, a high degree of clinical suspicion should be held and follow-up CXRs/CTs arranged.

Imaging characteristics and treatment strategies of traumatic diaphragmatic hernia with aortic dissection: a report of 3 cases.

BACKGROUND: Traumatic aortic dissection with traumatic diaphragmatic hernia is a rare traumatic disease. The purpose of this article is to investigate the imaging characteristics and treatment strategies for traumatic diaphragmatic hernia with aortic dissection. CASE PRESENTATION: The imaging and clinical data of 3 patients with traumatic diaphragmatic hernia combined with aortic dissection were analyzed retrospectively. Of the three cases, two were males, and one was female; their mean age was 52.7 years (range, 47-62 years). Plain chest CT scans revealed diaphragmatic hernia in 2 patients, but no traumatic aortic dissection was found. Diaphragmatic hernia repair was performed in all patients. Aortic dilatation was found during intraoperative exploration, and aortic dissection was confirmed by postoperative enhanced CT. One patient underwent stent implantation and recovered smoothly (Case 1). The other patient refused stent implantation and died of thoracic hemorrhage (Case 2). The third patient underwent preoperative enhanced CT to identify traumatic diaphragmatic hernia with aortic dissection (Case 3). Aortic covered stent implantation was performed immediately, and diaphragmatic hernia repair was performed at a selected time. The patient's postoperative recovery was good. CONCLUSION: A preoperative plain chest CT scan indicated diaphragmatic hernia in major blunt thoracic trauma patients with a history of trauma and blurred periaortic spaces accompanied by hematocele and other imaging manifestations. Chest-enhanced CT should be performed to improve the diagnostic accuracy of aortic dissection.

A tale of two unconventional adult diaphragmatic hernias.

Diaphragmatic hernias can be congenital or acquired and are a protrusion of intra-abdominal contents through an abnormal opening in the diaphragm. Acquired defects are rare and occur secondary to direct penetrating injury or blunt abdominal trauma. This case review demonstrates two unconventional cases of large diaphragmatic hernias with viscero-abdominal disproportion in adults. Case 1 is a 27-year-old man with no prior medical or surgical history. He presented following a 24-h history of increasing shortness of breath and left-sided pleuritic chest pain, and no history of trauma. Chest X-ray demonstrated loops of bowel within the left hemithorax with displacement of the mediastinum to the right. Computed tomography (CT) scan confirmed a large diaphragmatic defect causing herniation of most of his abdominal contents into the left hemithorax. He underwent emergency surgery, which confirmed the viscero-abdominal disproportion. He required an extended right hemicolectomy to reduce the volume of the abdominal comtents and laparostomy to reduce the risk of abdominal compartment syndrome and recurrence of the hernia. Case 2 is a 76-year-old man with significant medical comorbidities who presented with acute onset of abdominal pain. He had a history of traumatic right-sided chest injury as a child resulting in right-sided diaphragmatic paralysis. Chest X-ray demonstrated a large right-sided diaphragmatic hernia with abdominal viscera in the right thoracic cavity. CT scan of the chest, abdomen and pelvis demonstrated both small and large bowel loops within the right hemithorax, compression of the right lung and displacement of the mediastinum to the left. The CT scan also demonstarted viscero-abdominal disproportion. Operative management was considered initially but following improvement with basic medical management and no further deterioration, a non-operative approach was adopted. Both cases illustrate atypical presentations of adults with diaphragmatic hernias. In an ideal scenario, these are repaired surgically. When the presumed diagnosis shows characteristics of a viscero-abdominal disproportion and surgery is pursued, the surgeon must consider that primary abdominal closure may not be possible and multiple operations may be necessary to correct the defect and achieve closure. Sacrifice of abdominal viscera may also be necessary to reduce the volume of abdominal contents.

[Traumatic Diaphragmatic Injury].

Traumatic diaphragmatic injury( TDI) is rare in traumas, however TDI is associated with high mortality. We follow the notation method by The Japanese Association for The Surgery of Trauma. There are blunt trauma and penetrating trauma of TDI;blunt trauma causes mainly traffic accidents, and penetrating trauma is induced stub or gunshot. Penetrating trauma is more frequent than blunt trauma in Western countries, however there are mainly blunt traumas in Japan. The timing of diagnosis are three points;acute phase, subacute phase and delayed phase. In acute phase we often experienced unstable vital sign, so the patients of TDI need treatment immediately, however in delayed phase the patients of TDI are stable in vital signs. In order to diagnose for TDI, we use chest X-ray and computed tomography (CT), which is useful to diagnose by multi-planar reconstruction of multi-detector row CT. The ways to approach to TDI are from thoracotomy, laparotomy or both. When we repair the diaphragmatic injury, usually interrupted or horizontal mattress suture was applied with non-absorbable string. The mortality is about 8.8 to 19.8% by TDI, so we need to carefully diagnose TDI as soon as possible whether complication and abdominal viscera injury exist or not.

Delayed diagnosis of diaphragmatic rupture after blunt chest trauma - 2 case reports.

INTRODUCTION: Diaphragmatic rupture is a rare but life-threatening condition that occurs in 0.85% of surgically managed thoracoabdominal injuries. In most cases, the condition is accompanied by associated traumas responsible for poor prognosis. Signs of diaphragmatic rupture are often masked by more serious manifestations of the associated trauma. The rupture is usually revealed by an X-ray of the chest or CT scan. However, a minor defect may be missed, especially if the patient is not indicated for urgent surgery. METHODS: The authors present 2 case reports of patients treated for chronic diaphragmatic rupture at the Department of Surgery of the Faculty of Medicine, Charles University and University Hospital in Pilsen between 01 January 2009 and 31 December 2021. The aim was to analyze the clinical data and to compare this data with literature. RESULTS: Both patients with the chronic diaphragmatic rupture were men in their productive age. The mechanism of their primary trauma was a traffic accident. In the first case, the rupture was diagnosed 6 years after the trauma. The second case was diagnosed 14 years after the primary trauma. The diaphragmatic rupture was present on the left side in the first case and on the right in the other. Both patients underwent suture of the diaphragmatic defect via thoracotomy. CONCLUSION: Unrecognized diaphragmatic rupture is a severe condition that can result in a life-threatening complication, namely incarceration of abdominal organs dislocated to the chest. It is necessary to keep this diagnosis in mind in patients with gastrointestinal or respiratory problems after a previous high-energy, blunt-force abdominal and thoracic injury, even many years after the trauma.

Development of Diaphragmatic Hernia in Patients with Penetrating Left Thoracoabdominal Stab Wounds.

BACKGROUND: This study aimed to investigate the consequences of repairing versus not repairing diaphragmatic injury caused by penetrating left thoracoabdominal stab wounds. METHODS: Diagnostic laparoscopy was performed to evaluate the left diaphragm in patients with penetrating left thoracoabdominal stab wounds who did not have an indication for emergency laparotomy. Patients who did not consent to laparoscopy were discharged without undergoing surgery. Post-discharge radiological images of patients who underwent diaphragmatic repair and radiological images of patients who could not undergo laparoscopy, both during hospitalization and after discharge, were evaluated and compared. RESULTS: Diagnostic laparoscopy was performed on 109 patients. Diaphragmatic injuries were detected and repaired in 32 (29.36%) of these patients. Seventeen patients were lost to follow-up. After a mean follow-up of 57.67 months, none of the remaining 15 patients developed a diaphragmatic hernia. On the other hand, 43 patients refused to undergo diagnostic laparoscopy. Twenty of them were lost from follow-up. The diaphragmatic injury was detected in seven of the remaining 23 patients (30.44%) during initial computed tomography (CT) examinations. In this group, the mean follow-up time was 42.57 months, and delayed diaphragmatic hernia developed in one patient (14.30%). Patients who underwent diaphragmatic repair were compared to patients who did not undergo diagnostic laparoscopy but had diaphragmatic injuries detected on their CT. No statistical differences were detected. CONCLUSIONS: Diaphragmatic injuries caused by penetrating stab wounds can sometimes heal spontaneously. However, diagnostic laparoscopy is still relevant for revealing and repairing possible diaphragmatic injuries.

Reduction in Ventilation-Induced Diaphragmatic Mitochondrial Injury through Hypoxia-Inducible Factor 1α in a Murine Endotoxemia Model.

Mechanical ventilation (MV) is essential for patients with sepsis-related respiratory failure but can cause ventilator-induced diaphragm dysfunction (VIDD), which involves diaphragmatic myofiber atrophy and contractile inactivity. Mitochondrial DNA, oxidative stress, mitochondrial dynamics, and biogenesis are associated with VIDD. Hypoxia-inducible factor 1α (HIF-1α) is crucial in the modulation of diaphragm immune responses. The mechanism through which HIF-1α and mitochondria affect sepsis-related diaphragm injury is unknown. We hypothesized that MV with or without endotoxin administration would aggravate diaphragmatic and mitochondrial injuries through HIF-1α. C57BL/6 mice, either wild-type or HIF-1α-deficient, were exposed to MV with or without endotoxemia for 8 h. MV with endotoxemia augmented VIDD and mitochondrial damage, which presented as increased oxidative loads, dynamin-related protein 1 level, mitochondrial DNA level, and the expressions of HIF-1α and light chain 3-II. Furthermore, disarrayed myofibrils; disorganized mitochondria; increased autophagosome numbers; and substantially decreased diaphragm contractility, electron transport chain activities, mitofusin 2, mitochondrial transcription factor A, peroxisome proliferator activated receptor-γ coactivator-1α, and prolyl hydroxylase domain 2 were observed (p < 0.05). Endotoxin-stimulated VIDD and mitochondrial injuries were alleviated in HIF-1α-deficient mice (p < 0.05). Our data revealed that endotoxin aggravated MV-induced diaphragmatic dysfunction and mitochondrial damages, partially through the HIF-1α signaling pathway.

Presentation and Management of a Traumatic Right Sided Diaphragmatic Hernia: A Case Report.

Traumatic diaphragmatic injury (TDI) is a rare and dangerous sequela of trauma. Right sided TDI is even more uncommon due to the usual protection of the diaphragm by the liver. TDI can present in a delayed fashion, making diagnosis difficult to obtain. In any case TDI needs to be taken very seriously as it can lead to bowel strangulation and require emergency surgery. Multiple approaches have been described in order to definitively repair diaphragmatic defects. This report describes a patient who developed a delayed onset right sided diaphragmatic hernia after experiencing blunt trauma.

Traumatic rupture of diaphragm with splenic herniation. An unusual cause of hemothorax.

The traumatic diaphragmatic hernia is considered a rare clinic condition and represents a diagnostic challenge. Its presentation is mainly a surgical emergency, leading to scarce time for complementary image studies. We present a case of a 21-year-old male who suffered a penetrating wound in the left hemitorax from whom is suspected to have a traumatic visceral herniation into the thoracic cavity by chest X-ray, confirming a splenic herniation with intrathoracic hemorrhage, as well as the proposal of a management algorithm for this defiant cases.

La hernia diafragmática traumática es poco frecuente en la clínica y representa un reto diagnóstico, ya que su aparición es principalmente de emergencia y esto propicia poco tiempo para la realización de estudios de imagen complementarios. Presentamos el caso de un varón de 21 años que sufrió una herida penetrante en el hemitórax izquierdo con sospecha de herniación traumática diafragmática de vísceras abdominales al tórax por radiografía, y en el quirófano se confirmó una herniación esplénica con hemorragia intratorácica. Se propone un algoritmo de manejo en estos casos tan desafiantes.

Hernia diafragmática: Un desafío diagnóstico / Diaphragmatic Hernia: A Diagnostic Challenge

Introducción: La hernia diafragmática traumática es una complicación grave del traumatismo abdominal o torácico. Se considera una entidad poco frecuente. El diagnóstico es difícil y, a menudo, puede pasar inadvertido. Objetivo: El propósito de este caso clínico es demostrar la necesidad de sospechar la presencia de hernia diafragmática en los pacientes con trauma toracoabdomial. Presentación del Caso: Paciente de 75 años que sufre accidente de tránsito, con evaluación inicial sin alteraciones clínico-radiológicas, que posteriormente presentan evolución desfavorable con hallazgo radiográfico de una hernia diafragmática traumática. Conclusiones: La hernia diafragmática cuando se presenta constituye un verdadero reto para el diagnóstico por parte del personal médico; pues esta requiere de un alto índice de sospecha y el uso adecuado de las imágenes diagnósticas. Se considera una entidad importante para la evaluación del paciente traumatizado(AU)

Introduction: Traumatic diaphragmatic hernia is a serious complication of abdominal or thoracic trauma. It is considered a rare pathology. The diagnosis is difficult and can often go unnoticed. Objective: The purpose of this clinical case is to demonstrate the need to suspect the presence of diaphragmatic hernia in patients with thoracoabdomial trauma. Case Presentation: Seventy-five-year-old patient who suffers a traffic accident. At initial evaluation no clinical-radiological alterations were observed, but later the patient presented an unfavorable evolution with radiographic finding of a traumatic diaphragmatic hernia. Conclusions: Diaphragmatic hernia, when present, is a real challenge for the diagnosis by the medical staff since it requires a high index of suspicion and an adequate use of diagnostic images. It is considered an important entity in the evaluation of the trauma patient(AU)