Fecopneumothorax secondary to a late traumatic diaphragmatic injury

Traumatic diaphragmatic hernias were first described by Ambroise Paré in 1579, who reported the case of an artillery captain, that presented an intestinal perforation that had caused a diaphragmatic hernia (Bhatti and Dawani, 2015). The timely diagnosis of a traumatic diaphragmatic hernia can be a challenge, which requires extensive knowledge of the kinematics of trauma, as well as clinical and radiological evidence (Petrone et al., 2017). We present the case of a 60-year-old male who presented blunt abdominal trauma due to a traffic accident, causing an undetected diaphragmatic hernia in his initial evaluation; months after de incident goes to the emergency room (ER) with hemodynamic instability and septic shock. A diagnosis of complicated diaphragmatic hernia and fecopneumothorax is made, for which he undergoes surgery.

[Diaphragmatic rupture and right ipsilateral intercostal hernia in chronic cough]. / Rupture diaphragmatique et hernie intercostale droites homolatérales sur toux aiguë.

INTRODUCTION: We are reporting the case of a 64-year-old patient with chronic cough who has been diagnosed with an intercostal hernia with pleural and hepatic content associated with a diaphragmatic hernia of non-traumatic origin. CASE REPORT: The patient was treated for an acutely febrile cough with signs of respiratory distress. Thoracic scan showed an intercostal hernia containing an encysted hematoma and a right anterior diaphragmatic hernia with epiploic content. The COVID PCR was negative. This is one of the rare reported cases of intercostal hernia associated with a homolateral diaphragmatic rupture. Visceral and thoracic surgery enabled treatment of the two hernial orifices by raphy as well as omentectomy of the necrotic omentum ascending to the right pulmonary hilum. CONCLUSION: These two parietal complications of chronic cough should be considered in case of intercostal flap or acute respiratory distress. Surgery must then be carried out as a matter of urgency to reduce the content of the hernias and treat the musculoaponeurotic dehiscent orifices.

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)

Late-onset traumatic diaphragmatic hernia associated with acute pancreatitis: A case report.

RATIONALE: Acute pancreatitis (AP) is one of the most common diseases of gastroenterological emergency with a highly variable clinical course and the incidence being on the rise in recent years. Posttraumatic diaphragmatic hernia is an uncommon disease and may manifest immediately or several years after the incident. Delayed presentation of traumatic diaphragmatic hernia associated with AP is relatively rare. PATIENT CONCERNS: A 26-year-old male with history of left chest knife injury 10 years ago, had AP due to delayed traumatic diaphragmatic hernia 5 days after Dragon Boat Race. DIAGNOSES: Thoracoabdominal computerized tomography detected left diaphragmatic hernia with pancreatic head displacement. Emergency surgery confirmed the diagnosis. INTERVENTIONS: Emergency surgery to reduce and repair the hernia. OUTCOMES: The patient was discharged from the hospital on the sixth postoperative day and no recurrence of pancreatitis during follow-up. LESSONS: For patients without obvious etiology of AP, clinicians should be highly vigilant and inquire the history in detail. For patients with trauma, the relevant examination should be improved, and the pancreatitis caused by traumatic diaphragmatic hernia should be treated with emergency operation immediately.

Chronic hepatothorax due to right diaphragmatic rupture: an anesthetic challenge in a rare case / Hepatotórax crônico devido à ruptura do diafragma direito: um desafio anestésico em um caso raro

Abstract Background: Diaphragmatic rupture is an uncommon condition, with 90% of ruptures occurring on the left side. However, its incidence on the right side is increasing along with the increase in traffic accidents. Liver herniation may become progressive causing severe atelectasis of the right lung, resulting in impaired respiratory status and hemodynamic changes. Case report: We report the case of a 40 years old female, ASA III, scheduled for hepatothorax repair that evolved from right diaphragmatic hernia after a car accident when she was 8 years old. Clinically, she had severe restrictive respiratory syndrome caused by the hepatothorax. The anesthetic evaluation was normal, except for the chest X-ray showing elevation of the dome of the right hemidiaphragm without tracheal deviation. Diagnosis was confirmed by CT scan. After liver replacement in the abdominal cavity, a transient increase in central venous pressure, stroke volume index and flow time corrected (35%), and a decrease in systemic vascular resistance were observed. After complete hemodynamic and hepatosplenic stabilization, as well as ventilation, the patient was transferred intubated, under controlled ventilation and monitored, to the liver transplant unit. Conclusions: Hepatothorax is a rare condition and its repair may represent an anesthetic challenge. After liver replacement in the abdominal cavity during corrective surgery under general anesthesia complications may occur, particularly associated with pulmonary re-expansion. Effective teamwork and careful planning of surgery, between the surgical and anesthetic teams, are the key to success.

Resumo Justificativa: A ruptura diafragmática é uma condição incomum e ocorre em 90% no lado esquerdo. No entanto, a incidência de ruptura à direita tem vindo a aumentar junto com o aumento dos acidentes automobilísticos. A herniação do fígado pode tornar-se progressiva, causar atelectasia grave do pulmão direito, resultar num débil estado respiratório e alterações hemodinâmicas. Relato de caso: Mulher de 40 anos, estado físico ASA 3, marcada para reparação de hepatotórax que evoluiu de hérnia diafragmática direita, adquirida aos 8 anos, após um acidente automobilístico. Clinicamente apresentava síndrome respiratória restritiva grave, causada pelo hepatotórax. A avaliação anestésica era normal, com exceção da radiografia do tórax, que evidenciava elevação da hemicúpula diafragmática direita, sem desvio traqueal. Diagnóstico foi confirmado por tomografia computadorizada. Depois da recolocação do fígado na cavidade abdominal foram observados um aumento transitório da pressão venosa central, do Stroke Volume Index e Flow Time Corrected (35%) e uma diminuição da resistência vascular sistêmica. Uma vez alcançada a estabilização hemodinâmica geral e hepatoesplênica, bem como da ventilação, a paciente foi transferida entubada, sob ventilação controlada e monitorada para a Unidade de Transplantação Hepática. Conclusões: O hepatotórax é uma condição rara e a sua correção pode representar um desafio anestésico. Após a recolocação abdominal do fígado, durante uma cirurgia corretiva, sob anestesia geral, podem ocorrer complicações, principalmente as associadas à reexpansão pulmonar. Um trabalho em equipe eficaz e o planejamento cuidadoso da cirurgia, entre as equipes cirúrgica e anestésica, são a chave para o sucesso.

[Chronic hepatothorax due to right diaphragmatic rupture: an anesthetic challenge in a rare case]. / Hepatotórax crônico devido à ruptura do diafragma direito: um desafio anestésico em um caso raro.

BACKGROUND: Diaphragmatic rupture is an uncommon condition, with 90% of ruptures occurring on the left side. However, its incidence on the right side is increasing along with the increase in traffic accidents. Liver herniation may become progressive causing severe atelectasis of the right lung, resulting in impaired respiratory status and hemodynamic changes. CASE REPORT: We report the case of a 40 years old female, ASA III, scheduled for hepatothorax repair that evolved from right diaphragmatic hernia after a car accident when she was 8 years old. Clinically, she had severe restrictive respiratory syndrome caused by the hepatothorax. The anesthetic evaluation was normal, except for the chest X-ray showing elevation of the dome of the right hemidiaphragm without tracheal deviation. Diagnosis was confirmed by CT scan. After liver replacement in the abdominal cavity, a transient increase in central venous pressure, stroke volume index and flow time corrected (35%), and a decrease in systemic vascular resistance were observed. After complete hemodynamic and hepatosplenic stabilization, as well as ventilation, the patient was transferred intubated, under controlled ventilation and monitored, to the liver transplant unit. CONCLUSIONS: Hepatothorax is a rare condition and its repair may represent an anesthetic challenge. After liver replacement in the abdominal cavity during corrective surgery under general anesthesia complications may occur, particularly associated with pulmonary re-expansion. Effective teamwork and careful planning of surgery, between the surgical and anesthetic teams, are the key to success.

Hernia diafragmática secundaria a trauma: presentación tardía / Complicated diaphragmatic hernia: late outcome of trauma

Resumen Introducción: La hernia diafragmática complicada de presentación tardía constituye una urgencia quirúrgica. Los objetivos del presente estudio son la descripción de las características del diagnóstico de las hernias diafragmáticas de presentación tardía, tratamiento, resultados y la identificación del punto de corte entre el inicio de los síntomas y el desarrollo de necrosis. Pacientes y Métodos: Estudio retrospectivo de una serie de casos constituida por todos los pacientes operados por hernia diafragmática complicada de presentación tardía entre los años 2006 y 2016. Se midieron variables categóricas y continuas que se presentan con estadística descriptiva. Se utilizaron curvas Receiver Operating Characteristics (ROC) a las 6 y 12 h desde el inicio de los síntomas, para determinar el punto de corte del tiempo de presentación clínica en pacientes sometidos a resección de algún órgano. Una vez establecido el punto de corte se calcularon la sensibilidad; especificidad; las razones de verosimilitud positiva y negativa; los valores predictivos positivo y negativo; y la prevalencia. Resultados: La presentación clínica, estudio, diagnóstico y tratamiento fue similar a lo descrito en la literatura quirúrgica. Se estableció el punto de corte a las 12 h con sensibilidad de 80% y especificidad de 83%. Conclusiones: El diagnóstico y tratamiento de estos pacientes debería ser llevado a cabo antes de las 6 h desde el inicio de los síntomas. Aun cuando el universo descrito es reducido, se sugiere que después de las 12 h desde el momento de la estrangulación, los órganos comprometidos se encontrarán necróticos requiriendo resección quirúrgica.

Introduction: Late presentation of traumatic diaphragmatic hernia constitutes a true surgical emergency. The purposes of this study were to describe the diagnostic characteristics, treatment and outcomes of late presentation diaphragmatic hernias and to identify a cutoff point from the onset of symptoms to necrosis development. Patients and Methods: A retrospective series of cases constituted by all patients subjected to emergency diaphragmatic hernia repair form 2006 to 2016 was studied. Categorical and continuous variables were measured and analyzed with descriptive statistics. Receiver Operating Characteristics (ROC) curves at 6 and 12 hours from the onset of symptoms were used to determine the cutoff point for organ resection. Once stablished the cutoff point, sensitivity, specificity, positive and negative predictive values and prevalence were calculated. Results: Clinical presentation, diagnostic study and surgical treatment were similar to what has been already described. The cutoff point was defined at 12 hours from the onset of symptoms with 80% sensitivity and 83% sensibility. Conclusions: The diagnosis and treatment of these cases should be carried on before the first 6 hours after the onset of symptoms. Even though the universe of this study was small, we may suggest that after 12 hours form the onset of symptoms, the implicated organs would be found necrotic requiring surgical resection.

Missed diaphragmatic injury after blunt trauma presenting with colonic strangulation: a rare scenario.

Diaphragmatic rupture occurs in 4%-5% cases of thoracoabdominal injuries. It may present acutely, in a delayed fashion or as a complicated hernia. We are describing the case of a young male presenting in respiratory distress with history of chest trauma 1.5 years back. On investigation, he was found to have left side diaphragmatic hernia containing gangrenous colon with lung collapse. The patient underwent successful operative intervention and discharged after 25 days of hospital stay. Record review suggested that the above mentioned diaphragm injury was missed in his evaluation 1.5 years back. Diaphragmatic injury must always be suspected in thoracoabdominal injuries, as missed injury may cause devastating complications like the one narrated above in due course.

Emergency surgery due to diaphragmatic hernia: case series and review.

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a congenital abnormality, rare in adults with a frequency of 0.17-6%. Diaphragmatic rupture is an infrequent consequence of trauma, occurring in about 5% of severe closed thoraco-abdominal injuries. Clinical presentation ranges from asymptomatic cases to serious respiratory or gastrointestinal symptoms. Diagnosis depends on anamnesis, clinical signs and radiological investigations. METHODS: From May 2013 to June 2016, six cases (four females, two males; mean age 58 years) of diaphragmatic hernia were admitted to our Academic Department of General Surgery with respiratory and abdominal symptoms. Chest X-ray, barium studies and CT scan were performed. RESULTS: Case 1 presented left diaphragmatic hernia containing transverse and descending colon. Case 2 showed left CDH which allowed passage of stomach, spleen and colon. Case 3 and 6 showed stomach in left hemithorax. Case 4 presented left diaphragmatic hernia which allowed passage of the spleen, left lobe of liver and transverse colon. Case 5 had stomach and spleen herniated into the chest. Emergency surgery was always performed. The hernia contents were reduced and defect was closed with primary repair or mesh. In all cases, post-operative courses were uneventful. CONCLUSION: Overlapping abdominal and respiratory symptoms lead to diagnosis of diaphragmatic hernia, in patients with or without an history of trauma. Chest X-ray, CT scan and barium studies should be done to evaluate diaphragmatic defect, size, location and contents. Emergency surgical approach is mandatory reducing morbidity and mortality.

Repair of Intrapericardial Diaphragmatic Hernia during Aortic Surgery in a 78-Year-Old Woman.

Intrapericardial diaphragmatic hernias are reported very rarely. Those of congenital origin are most often diagnosed in neonates, and those caused by indirect blunt trauma occur chiefly in adults. The latter type can be asymptomatic; however, the results of a computed tomographic scan can yield a definitive diagnosis. Once discovered, these hernias should be corrected to avoid severe sequelae such as bowel strangulation and necrosis, peritonitis, mediastinitis, and cardiac tamponade. We report the case of a 78-year-old woman who presented for elective ascending aortic aneurysm repair. Computed tomographic angiograms incidentally revealed a large intrapericardial diaphragmatic hernia, which had probably developed years earlier, after a traffic accident. The patient underwent a median sternotomy and repair of the intrapericardial diaphragmatic hernia with use of a bovine pericardial patch, followed by ascending aortic and hemiarch repair, aortic valve repair, and aorto-right coronary artery bypass grafting. We discuss the details of these procedures and alternative treatment options. To our knowledge, this is the first report of concomitant aortic surgery and repair of a trauma-induced intrapericardial diaphragmatic hernia in an adult.

Non-traumatic tension gastrothorax in a young lady.

Tension gastrothorax is a very rare but potentially fatal clinical condition in which the stomach that herniates through a diaphragmatic defect into the thorax is massively distended by trapped air. It leads to severe symptoms due to the compression of the lung and mediastinum. A 27-year-old female, who had no prior trauma history, applied to the emergency service with the complaint of respiratory disorder, and was consulted by the department of thoracic surgery. Thorax CT revealed presence of gastrothorax in the left hemithorax. Thus, the patient went into cardiopulmonary arrest and was resuscitated. Emergency thoracotomy was performed, abdominal organs were reduced and diaphragmatic defect was repaired. She was discharged on the fifth postoperative day without any complications.

Right ventricle collapse secondary to hepatothorax caused by diaphragm rupture due to blunt trauma.

Traumatic diaphragm ruptures occur frequently after motor vehicle accidents through penetrating traumas. In 90% of the patients, traumatic diaphragm rupture commonly coexists with other organ injuries. Posteroanterior chest x-ray, computed tomography, magnetic resonance imaging, upper gastrointestinal system contrast-enhanced examinations, and thoraxoscopy/laparoscopy are several modalities which can be used for diagnosing traumatic diaphragm rupture in clinical practice. A case of right ventricle collapse secondary to hepatothorax caused by diaphragm rupture was presented in this study. Patient was diagnosed by posteroanterior chest x-ray and computed tomography. Emergency surgery was planned due to hemodynamic instability. When mechanical pressure on the right ventricle disappeared, hemodynamic improvement was observed simultaneously.

Hérnia diafragmática à direita por trauma contuso: uma revisão bibliográfica / Right diaphragmatic hernia due to blunt trauma: a literature review

As hérnias diafragmáticas são decorrentes principalmente de traumas contusos e são mais comuns à esquerda. Essa menor frequência à direita é explicada pela contenção e proteção do fígado ao hemidiafragma homolateral. Entretanto, apesar de as lesões à esquerda serem mais frequentes, aquelas situadas à direita associam-se a lesões mais graves e resultam em mais instabilidade hemodinâmica, o que gera elevada mortalidade no momento do trauma. Além disso, a hérnia diafragmática direita, pode permanecer assintomática por longo tempo, favorecendo a aparecimento de complicações como isquemia e ruptura das vísceras herniadas dentro do tórax. Assim é fundamental um diagnóstico precoce, a fim de se realizar o tratamento cirúrgico, uma vez que o diafragma não cicatriza espontaneamente. (AU)

The diaphragmatic hernias are mainly due to blunt trauma and are more common on the left. This lower frequency on the right side is explained by liver protection of the ipsilateral hemidiaphragm. However, despite the injuries are more frequent on the left, those situated on the right are associated with more severe injuries and result in more hemodynamic instability, which leads to high mortality at the time of trauma. Furthermore, the right diaphragmatic hernia can remain asymptomatic for long time, favoring the onset of complications such as ischemia and rupture of the herniated organs inside the chest. Therefore early diagnosis is fundamental in order to perform surgical treatment, since the diaphragm does not heal spontaneously. (AU)

Why a chest physician should be interested in abdominal pain.

A 37-year-old woman presented at casualty with a 1-day history of progressive spontaneous left iliac fossa pain. She was having her menstruations for 4 days. She had no respiratory symptoms. Her medical history consisted of laparoscopic surgery for endometriosis and ovarian cysts. A very small right basal pneumothorax with visualisation of a hypervascular nodular lesion on the right diaphragm was incidentally noticed on the right diaphragm. We suspected here a catamenial pneumothorax. During video-assisted thoracoscopy the surgeon observed in the centrum tendineum of the diaphragm a small and a large perforation with partial intrathoracic herniation of the liver, but without visible diaphragmatic or pleural endometriosis. The surgeons converted to a small anterior thoracotomy in order to reinforce the large perforation with interrupted non-absorbable sutures and plication of the smaller perforation, and finally performed a mechanical pleural abrasion with a surgical pad.

Large-bowel obstruction as a late sequela of retrosternal diaphragmatic hernia.

A 37-year-old man with a past history of a fall from height 16 years previously was admitted with acute abdomen. Investigations revealed intestinal obstruction caused by a diaphragmatic hernia. He had an incarcerated omentum and Richter's hernia of the transverse colon secondary to left diaphragmatic hernia leading to colonic ileus. Following resection of the strangulated omentum and reduction of the colon intraabdominally, a surgical repair of the hernia was performed using an abdominal and transthoracic approach. The relatively rare late complication of a left-sided enterothorax with ileus makes this a remarkable case and underlines the need for early surgery to avoid late complications.

Traumatic diaphragmatic hernia presenting as a tension fecopneumothorax.

A traumatic diaphragmatic hernia is a well-known complication following blunt abdominal or penetrating thoracic trauma. Although the majority of cases are diagnosed immediately, some patients may present later with a diaphragmatic hernia. It occurs in approximately 3% of abdominal traumas. Diagnosis requires a high index of suspicion since diaphragmatic injury can only reliably be ruled out by direct visualization, i.e., laparoscopy. Hence, delayed presentation with complications secondary to the injury is not uncommon. We discuss a case of a young man who presented in respiratory distress 5 years after a stab wound to the left chest. The patient was hypoxic, with a chest X-ray (CXR) demonstrating a pneumothorax with effusion. A chest tube was placed with a rush of air and feculent drainage. CT scan revealed an incarcerated transverse colon in a diaphragmatic hernia. The laparotomy demonstrated necrotic colon in the chest with gross fecal contamination in the chest. The diaphragmatic defect was closed and a Hartmann's procedure performed. The patient developed empyema in the postoperative period. Our patient is the twelfth reported case of a tension fecopneumothorax resulting from traumatic diaphragmatic herniation. This paper reviews all cases, including the diagnostic workup, operative approach, and expected postoperative course of this unusual condition.

Laparoscopic repair of a posttraumatic left-sided diaphragmatic hernia complicated by strangulation and colon obstruction.

BACKGROUND: Posttraumatic diaphragmatic hernias (PDH) are serious complications of blunt and penetrating abdominal or thoracic trauma. Traditional thoracic or abdominal operations are usually performed in these cases. METHODS: We present 2 cases of posttraumatic left-sided diaphragmatic hernia complicated by strangulation and colon obstruction. Both cases were successfully treated with laparoscopy. RESULTS: We found that laparoscopy is a safe, successful, and gentle procedure not only for diagnosis but also for treatment of complicated PDH. Strangulation and colon obstruction were not contraindications to performing laparoscopic procedures. The postoperative course and long-term follow-up (range, 12 to 30 months) were uneventful and short. We expect the same good long-term results after laparoscopic repair as after open conventional surgery. CONCLUSION: We recommend the use a minimally invasive approach to treat posttraumatic diaphragmatic hernia complicated by strangulation and colon obstruction in hemodynamically stable patients.