Acute and chronic traumatic diaphragmatic hernia: 10 years' experience.

Controversy persists regarding many aspects of traumatic diaphragmatic hernia (TDH). We aimed to understand why some traumatic diaphragmatic injuries present with chronic hernia and to evaluate diagnosis and treatment options. Fifty acute and 19 chronic TDH patients were diagnosed and treated at our institution over a 10-year period. Clinical data from these two groups were analyzed statistically and compared. Chronic TDH patients had a significantly lower Injury Severity Score than acute TDH patients (10.26 ± 2.68 vs. 26.92 ± 4.79, P < 0.001). The most common surgical approach for acute and chronic TDH was thoracotomy and laparotomy, respectively. The length of the diaphragmatic rupture was significantly shorter in chronic TDH patients than acute TDH patients (6.00 ± 1.94 cm vs. 10.71 ± 3.30 cm, P < 0.001). The mean length of hospital stay was significantly longer for acute TDH patients than chronic TDH patients (41.18 ± 31.02 days vs. 16.65 ± 9.61 days, P = 0.002). In conclusion, milder trauma and a smaller diaphragmatic rupture were associated with delayed diagnosis. A thoraco-abdominal computed tomography scan is needed for patients with periphrenic injuries to avoid delayed diagnosis of TDH. Improved awareness and understanding of diaphragmatic injuries will increase the rate of early diagnosis and improve prognosis.

Traumatic diaphragmatic rupture in children.

BACKGROUND: The purpose of this study was to describe our experience with traumatic diaphragmatic rupture (TDR). Very little has been written about this condition in the pediatric age group. METHODS: Between January 2000 and December 2011, data on twenty-two patients with TDR were analyzed, and clinical data were recorded. The patients were divided into subgroups based on injury type and ISS values. RESULTS: Four patients were female, and eighteen were male. Mean age was 9.4 years (range 2-15 years). TDR was left-sided in twenty (91%) patients and right-sided in two (9%). The mean ISS (Injury Severity Score) was 19 (range 11-29). No significant difference in morbidity was noted between firearm and other injuries (p=0.565) or between ISS values below and above 16 (p=0.565). Seven patients (32%) had isolated diaphragmatic injury, while the other fifteen cases had additional associated injuries. Diagnoses were determined via a chest radiograph alone in the majority of cases, while suspected cases were confirmed by multidetector computed tomography if the patients were hemodynamically stable. Herniation was observed in twenty patients. Primary suture of the diaphragm and tube thoracostomy were performed in all patients. Postoperative complications included ileus (two cases), intussusception (one case), empyema (one case), and one patient succumbed during the operation. CONCLUSIONS: TDR, while uncommon, should be considered in cases of thoracoabdominal injury. All patients should undergo meticulous examination preoperatively. When the chest radiograph does not provide a definitive diagnosis, multidetector computed tomography, including multiplanar reconstruction or volume rendering, may be beneficial for confirming suspicion of diaphragmatic rupture.

Delayed presentation of posttraumatic diaphragmatic hernia.

BACKGROUND: Missed diaphragmatic injuries after trauma may present with herniation of intraabdominal organs into the thoracic cavity. We aimed to review our patients who presented with delayed posttraumatic diaphragmatic hernia. METHODS: A retrospective review of the medical records of patients with delayed diagnosis of posttraumatic diaphragmatic hernia between 2001 and 2009 was performed. RESULTS: Ten patients with a mean age of 44.3 years were included. Six patients were female. Blunt injuries (n: 7) were more common. Mean duration between trauma and presentation to the hospital was 5.9 years (4 months - 19 years). Nine patients had left-sided diaphragmatic hernia. All patients had chest X-ray and most were diagnostic (n: 8). Additional diagnostic imaging with computerized tomography (CT) and magnetic resonance (MR) was used in seven patients. For the repair, laparotomy incision was chosen for seven patients and thoracotomy incision for two patients. One patient underwent left thoracoabdominal approach. Mesh repair was used in seven patients. Postoperative mean hospitalization was 10.6 days. Empyema and atelectasis were the morbidities in one patient. No postoperative mortality was detected. CONCLUSION: Delayed presentation of posttraumatic diaphragmatic hernia is a serious challenge for trauma surgeons. Prompt diagnosis and treatment prevent serious morbidity and mortality associated with complications such as gangrene and/or perforation of the herniated organ.

Diaphragmatic hernias after sequential left ventricular assist device explantation and orthotopic heart transplant: early results of laparoscopic repair with polytetrafluoroethylene.

OBJECTIVE: Patients who undergo an orthotopic heart transplant after explantation of an intraperitoneal left ventricular assist device are at an increased risk of developing diaphragmatic hernias. The aim of this study was to determine the incidence of these hernias and to evaluate the morbidity and short-term efficacy of laparoscopic repair. METHODS: Using our prospectively maintained database, we performed a single-institution, retrospective review of all patients who underwent laparoscopic repair of a diaphragmatic hernia resulting from defects created by left ventricular assist device explantation. RESULTS: From January 1, 1995 to March 1, 2007, 5 men at our institution (median age, 56 years) out of 97 patients at risk developed a diaphragmatic hernia after left ventricular assist device explantation (5.2% incidence). The median time to presentation was 25.4 months (range, 9-62 months). The median size of the hernia defect was 8 cm (range, 6-15 cm). We performed all repairs completely laparoscopically. None of the defects were repaired primarily because doing so would have resulted in significant tension. Instead, we secured a polytetrafluoroethylene patch over the defect with pledget-reinforced, braided, nonabsorbable, handsewn mattress sutures, followed by reinforcement with laparoscopic tacking screws. We noted no perioperative complications. The median length of stay was 2 days (range, 1-4 days). At a median follow-up period of 12.2 months (range, 1-31 months), no recurrences had occurred. CONCLUSION: Laparoscopic repair of diaphragmatic hernias with polytetrafluoroethylene can be performed with minimal morbidity and excellent short-term results.

Thoracoscopy in the diagnosis and treatment of thoracoabdominal stab injuries.

BACKGROUND: Occult diaphragmatic injuries are associated with significant mortality, if the diagnosis is delayed. We report our experience in diagnostic and therapeutic thoracoscopy in a selected group of patients with stab wounds of thoracoabdominal region. METHODS: The patients who underwent thoracoscopic management of thoracoabdominal stab injuries between June 2001-December 2005 were included into the study. The data were retrospectively analyzed. RESULTS: Ninety-three patients with abdominal and thoracoabdominal stab wounds underwent videoendoscopic management. Among them, eleven selected patients with thoracoabdominal stab injuries were managed by thoracoscopy. The procedures were performed under general (n=10) or local anesthesia (n=1). Diaphragmatic injuries were repaired by intracorporeal sutures in three cases and bleeding was controlled in another two cases by electrocautery coagulation. The procedures were simply diagnostic in six patients. The mean operating time and hospital stay were 35 minutes and 3.5 days respectively. There was neither intraoperative or early postoperative complication, nor mortality. CONCLUSION: Thoracoscopy is a safe and efficient tool in the diagnosis and treatment of diaphragmatic stab injuries.

Hernia diafragmática traumática / Diaphragmatic traumatic hernia

Introducción: las hernias diafragmáticas traumáticas comúnmente ocurren posteriores a trauma penetrante cerrado. Debido a las lesiones coexistentes y a la naturaleza silenciosa de las lesiones diafragmáticas, el diagnóstico fácilmente se omite. El objetivo de este estudio fue describir las características clínicas de pacientes consecutivos con hernias diafragmáticas traumáticas tratadas quirúrgicamente en nuestra institución. Material y métodos: cohorte prospectiva de pacientes tratados durante un periodo de seis años. Evaluamos edad, sexo, tipo de mecanismo del trauma, tipo de hernia, método diagnóstico, órganos herniados, lesiones asociadas, tiempo de evolución, morbilidad y mortalidad. Los resultados se describen como frecuencias y medidas de tendencia central y de dispersión. Se empleó χ2 y prueba exacta de Fisher para explorar asociación y riesgo. Resultados: se incluyeron 23 pacientes, 19 fueron hombres (82.6 %) y cuatro mujeres (17.4 %). En nueve pacientes (39.1 %) fueron diagnosticadas hernias diafragmáticas agudas y en 14, hernias crónicas (60.9 %). En 18 (78.3 %) el diagnóstico se hizo mediante radiografía de tórax y la mayoría correspondió a hernias crónicas. La historia médica de trauma toracoabdominal cerrado estuvo presente en 95.7 %, en la mayoría relacionado con accidentes vehiculares. Las principales lesiones asociadas fueron trauma encefálico, fracturas costales y contusión pulmonar. La morbilidad se observó en seis pacientes, todos con hernias crónicas. No hubo mortalidad. Conclusiones: la hernia diafragmática traumática es una entidad clínica poco frecuente y constituye un verdadero desafío debido a las dificultades para el rápido y correcto diagnóstico. En etapa crónica hay mayor riesgo para complicaciones tardías como estrangulamiento y necrosis de vísceras.

BACKGROUND: Traumatic diaphragmatic hernias commonly occur after blunt and penetrating trauma. Due to coexisting injuries and the silent nature of the diaphragmatic injuries, the diagnosis is easily missed. We undertook this study to describe the clinical characteristics of consecutive patients with traumatic diaphragmatic hernias treated surgically at our institution. METHODS: We conducted a prospective cohort of patients treated during a 6-year period. We assessed variables such as age, gender, type of mechanism of trauma, type of hernia, methods of diagnosis, herniated organs and associated lesions, time of evolution, morbidity and mortality. Results are described as frequencies, dispersion and central tendency measures. Chi(2) and Fisher's exact tests were used to explore association and risks. RESULTS: Twenty three patients were included, 19 men (82.6%) and 4 women (17.4%). Acute DTH were diagnosed in nine patients (39.1%) and 14 cases presented as chronic DTH (60.9%). In 18 cases (78.3%) the diagnosis was made by chest x-ray and most corresponded to chronic hernias. Medical history of blunt thoracoabominal trauma was present in 95.7% of the cases, most related to car accidents. The principal associated lesions were head injuries, rib fractures and lung contusion. morbidity was observed in six patients, all with chronic hernias. there was no mortality. CONCLUSIONS: DTH is a rare clinical entity and constitutes a true challenge due to difficulties for a rapid and correct diagnosis. In the chronic stage there is an increased risk for late complications such as visceral strangulation and necrosis.

[Diaphragmatic traumatic hernia]. / Hernia diafragmática traumática.

BACKGROUND: Traumatic diaphragmatic hernias commonly occur after blunt and penetrating trauma. Due to coexisting injuries and the silent nature of the diaphragmatic injuries, the diagnosis is easily missed. We undertook this study to describe the clinical characteristics of consecutive patients with traumatic diaphragmatic hernias treated surgically at our institution. METHODS: We conducted a prospective cohort of patients treated during a 6-year period. We assessed variables such as age, gender, type of mechanism of trauma, type of hernia, methods of diagnosis, herniated organs and associated lesions, time of evolution, morbidity and mortality. Results are described as frequencies, dispersion and central tendency measures. Chi(2) and Fisher's exact tests were used to explore association and risks. RESULTS: Twenty three patients were included, 19 men (82.6%) and 4 women (17.4%). Acute DTH were diagnosed in nine patients (39.1%) and 14 cases presented as chronic DTH (60.9%). In 18 cases (78.3%) the diagnosis was made by chest x-ray and most corresponded to chronic hernias. Medical history of blunt thoracoabominal trauma was present in 95.7% of the cases, most related to car accidents. The principal associated lesions were head injuries, rib fractures and lung contusion. morbidity was observed in six patients, all with chronic hernias. there was no mortality. CONCLUSIONS: DTH is a rare clinical entity and constitutes a true challenge due to difficulties for a rapid and correct diagnosis. In the chronic stage there is an increased risk for late complications such as visceral strangulation and necrosis.

Blunt diaphragmatic rupture in elderly patients.

BACKGROUND/AIMS: Severe blunt torso trauma can cause diaphragmatic rupture. Such trauma remains a diagnostic challenge to the trauma surgeon, particularly when the initial chest roentgenogram is unrevealing. Owing to age, preexisting diseases, and poor physiological reserves, elderly patients suffer higher mortality rates after trauma than young patients. The difference between elderly and young patients in terms of blunt diaphragmatic rupture is particularly interesting. METHODOLOGY: Records from 78 patients presenting with blunt diaphragmatic rupture at our hospital from July 1992 to January 2001 were retrospectively reviewed. Age, gender, co-morbid disease, trauma mechanism, associated organ injury, injury severity score, hemodynamic status on arrival at our Emergency Room, injury side and size of diaphragmatic rupture, delay before operation, and postoperative complications and mortality were determined for elderly (> or = 65 years) and young (<65 years) patients. RESULTS: 10 elderly and 68 young patients were collected and reviewed. Elderly patients had higher rate of preexisting disease (60% vs. 16.2%), associated injury of long bone fracture (60% vs. 23%), and initial normal chest roentgenogram (50% vs. 12%) and they had significant delays before operation. Only 20% of elderly patients were operated on within 24 hours of trauma, compared to 87% of young patients, and 50% elderly patients were actually operated on over a week after the trauma. Furthermore, no statistically significant differences existed between elderly and young patients in ISS (19.9 +/- 6.3 & 22.8 +/- 10.4), or the injury side of diaphragmatic rupture, although elderly patients did display shorter diaphragmatic ruptures (5.6 +/- 3.3 & 10.0 +/- 6.0cm, p<0.05), and longer periods on postoperative ventilatory support (17.7 +/- 21.2 & 3.2 +/- 5.0 days, p<0.05). Finally, elderly patients also had significantly higher rates of postoperative complications of pneumonia (30% & 5.9%), and mortality (50% & 2.9%) than young patients did. CONCLUSIONS: Compared to young patients, elderly patients with blunt diaphragmatic rupture had significantly higher rates of initial normal CXR, partly due to shorter length of diaphragmatic rupture, and partly due to ventilatory support, and consequent higher rate of delays before surgery. Furthermore, they also needed longer postoperative ventilator help, and prevailed higher rates of co-morbid disease, postoperative pneumonia, and mortality. Careful initial investigation and prudent radiological follow-up is recommended for elderly patients with severe blunt torso trauma.

Traumatic diaphragmatic rupture in children.

BACKGROUND: We aimed to emphasize the importance of early diagnosis and treatment of traumatic diaphragmatic (TDR) rupture which is an uncommon but potentially life-threatening problem with a high incidence of associated injuries. METHODS: We presented 8 children with traumatic diaphragmatic ruptures who were admitted to our department within a 13 year period after the incident. Relevant information about clinical and radiological findings herniated organs into the thorax, type of injury and applied surgical intervention and outcome of patients were evaluated so as to draw important clues leading to early diagnosis and treatment of this potentially life threatening condition with associated morbidities. RESULTS: In five patients, TDR occurred after a blunt trauma. Five patients underwent laparotomy while 3 of them were managed with thoracotomy. The surgical interventions were performed successfully and only one patient failed to survive. One patient died of associated severe head injury. CONCLUSIONS: The TDR in children could be promptly identified and easily diagnosed, only if this pathology is highly suspected. Since, TDR must be ruled out in all severe cases of trauma, information related to the experiences of various centers must be considered as important clues which might lead to earlier diagnosis and prompt treatment.

[Diaphragmatic rupture in abdominal trauma]. / Karin Travmasinda Diyfragma Rüptürü.

BACKGROUND: The aim of the study is to evaluate the patients with diaphragmatic rupture due to penetrating or blunt abdominal trauma. METHODS: Thirty-eight patients with diaphragmatic rupture due to penetrating or blunt abdominal trauma were investigated retrospectively. RESULTS: The average age was 41,72 and there were 31 male and seven female patients. The injury forms were penetrating trauma in 22 (58%) and blunt trauma in 16 (42%) cases. Associated abdominal organ injuries were found in 27 (71%) cases. Among 47 diaphragmatic ruptures, 27 (57%) were on the left and 20 (43%) were on the right side. The average diameter of the rupture was 5,45 (1-20) cm. Management of the diaphragmatic rupture and other associated organ injuries were accomplished through laparotomy. Morbidity was developed in 18 cases and mortality in four cases with associated abdominal organ injuries. CONCLUSION: Diaphragmatic rupture results in high morbidity and mortality due to associated organ injuries.

[Traumatic diaphragm injuries: a review of 8 cases]. / Lesión diafragmática traumática. Revisión de 8 casos.

Traumatic rupture of the diaphragm is a rare event that is usually found in polytrauma cases or after violent attacks. Patients are usually males between 20 and 50 years old, and car accidents are the main causes. Diagnosis can be difficult and injuries may go unnoticed, leading to serious delayed complications. We present 8 cases from 1991 through 2000. All patients came to the emergency department of our hospital with a diagnosis of traumatic rupture of the diaphragm. We analyze the reasons for admission, signs and symptoms, diagnostic approach, associated lesions, treatment and course, comparing our experience with reports in the literature.

Diaphragmatic injuries.

OBJECTIVES: (1) To determine the actual incidence rate of blunt and penetrating diaphragmatic injuries (DI); (2) to evaluate the effectiveness of urgent surgical intervention for treatment of DI; and (3) to reveal main causes of postoperative complications. METHODS: We reviewed: (1) forensic medical examination charts of 3353 subjects, who died due to polytrauma (including injuries to the chest and/or abdomen) at accident sites; and (2) medical case reports of 4857 patients, treated for thoracoabdominal trauma (TAT) from 1962 to 1998. A detailed analysis was completed with 12 years (1987--1998) of clinical experience, involving 65 (43 penetrating, and 22 blunt) cases of DI. RESULTS: According to forensic medical data, blunt and penetrating DI occurred in 3.7% and 2.6% of individual cases, respectively. Among patients suffering from TAT, it was revealed that blunt DI had occurred in 1.1%, and penetrating in 3.9% of the cases. This data indicates if all the victims, who had sustained TAT, had survived, the incidence rate of DI would have been 2.6% (blunt -- 2.1%, and penetrating -- 3.4%). All the patients, provided surgical operations due to DI, survived. Morbidity in patients, suffering from blunt and penetrating DI, was 50%, and 35%, respectively. In the group of patients, suffering from penetrating DI, shock, intrapleural and/or intraabdominal haemorrhage, and liver injuries constituted a significant (P<0.05) influence, relevant to development of postoperative complications. The risk of complications was significantly (P<0.05) greater in cases of gunshot injuries. Fractures of chest bones, injuries of abdominal organs, and intraabdominal haemorrhage constituted a significant influence (P<0.05), relevant to development of complications after blunt DI. CONCLUSIONS: (1) The danger to the health or even life of patients is not directly caused by DI, but by consequential complications and associated injuries; (2) the effectiveness of treatment is determined by purposeful surgical diagnostics with particular regard to DI and urgent surgical intervention.

Traumatic diaphragmatic hernia: an Asir region (Saudi Arabia) experience.

Ten patients (nine males, one female), seen at the Asir Central Hospital of South-Western Saudi Arabia with proven traumatic diaphragmatic hernia between 1987 and 1997, were reviewed retrospectively. The mean age was 29.6 years, range 5 to 50 years. Chest pain and vomiting were the commonest symptoms. Blunt trauma (road traffic accident--5, fall from height--1, (accounted for 60% of the cases) while gunshot wound and stab wounds were the causes in two patients each. The chest radiograph suggested the diagnosis in all the cases. Barium meal (in two patients) and barium enema (in two patients) complemented the diagnosis. Computed tomography (CT) scan was done in only one patient. Thoracotomy (in 2 patients), laparotomy (in 5 patients) and thoraco-laparotomy (in 3 patients) were the surgical approaches to management. Common herniated organs were liver, stomach, spleen and large bowel. The injuries were on the left side in seven patients and on the right side in three cases. Immediate surgical repair was done in four patients while it was done two days to four years later in others. Complications were minimal and there was only one death.

Trauma to the diaphragm.

Traumatic diaphragmatic hernia is being seen with increasing frequency. Early recognition is of upmost importance because catastrophic complications may occur at any time following the diaphragmatic disruption. A high index of suspicion, history of previous thoracoabdominal trauma, physical examination of the chest, and roentgenographic evidence should aid in early and definitive diagnosis. All patients with serious body injury should have upper and lower gastrointestinal series performed before hospital discharge. Right-sided herniation occurs with more frequency than previously reported. In managing these injuries, the transabdominal route should be used in acute ruptures; chronic herniation should be approached through the chest, with the addition of a separate laparotomy when indicated.

[Rupture of the diaphragm in closed traumas: apropos of 28 cases]. / Rupture du diaphragme lors des traumatismes fermés: à propos de 28 observations.

Twenty-eight cases of ruptured diaphragm due to blunt trauma are reported, including three with rupture on the right. Most of the patients were young men and rupture was an isolated lesion in only 6 patients, all others having multiple trauma. One patient died during surgery (3.6%) and complications, mostly respiratory, occurred in 17 patients (60.7%). Mid-term functional digestive and respiratory sequellae were evaluated. The gravity of ruptured diaphragm is basically related to the severity of the trauma and associated lesions. The diagnosis remains unrecognized in an important number of cases emphasizing the importance of repeated chest X-rays.

[The surgical treatment of traumatic diaphragmatic hernias]. / Khirurgicheskoe lechenie travmaticheskikh diafragmal'nykh gryzh.

The article discusses experience in treating traumatic diaphragmatic hernias in 68 patients, 63 of them underwent operation. Closed injuries to the diaphragm suffered in falling from a height and in car accidents and knife thoracoabdominal injuries were the main causes of this type of hernia. The principal role in their diagnosis belongs to X-ray examination with obligatory contrast study of the organs of the gastrointestinal tract. Among 41 patients who were operated on for non-strangulated hernia of this localization one died. In a group of 21 patients with a strangulated diaphragmatic hernia 11 died after surgery. Necrosis of the gastric and colonic wall, incompetence of the anastomosis sutures, peritonitis, and pleuritis were causes of death.