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.

Lesiones diafragmáticas, cardiovasculares y traqueobronquiales en los traumatismos torácicos cerrados / Diaphragmatic, cardiovascular and tracheobronquial lesions in blunt chest trauma

Objetivo. Llamar la atención de clínicos y cirujanos sobre la posibilidad y frecuencia de lesiones diafragmáticas, de los órganos cardiovasculares y de las grandes vías respiratorias, en el marco clínico de los traumatismos torácicos cerrados, así como resaltar los aspectos pronósticos y terapéuticos de estas lesiones. Pacientes y método. Esta reflexión se basa en el estudio de un grupo de 17 historias clínicas extraídas de nuestra experiencia reciente y que incluye lesiones de los órganos que comentamos. Conclusiones. A pesar del progreso en los métodos exploratorios, un importante número de casos aún hoy día no son diagnosticados con tiempo para instaurar precozmente el oportuno tratamiento, lo que justifica a nuestro entender esta revisión (AU)

[Diaphragmatic injuries--classification, diagnosis and therapy]. / Zwerchfellverletzungen--Klassifikation, Diagnostik und Therapie.

Diagnosis of diaphragmatic rupture is often missed after blunt thoracic and abdominal injuries. Rupture of the diaphragm is caused either by direct or indirect violence. The clinical manifestations are unpredictable and of infinite variety, and, especially in massively traumatized patients, masked by other injuries. Between 1987 and 1995, 17 patients were treated for traumatic injury of the diaphragm. Four of 17 patients sustained isolated diaphragmatic rupture; in 13 the rupture was combined with other injuries. Preoperatively the following diagnostic procedures were performed: ultrasonography in 12 patients, chest X-ray in 6, computed tomography of the abdomen in 2, water soluble enema into the stomach in 1, and computed tomography of the thorax in 1 patient. Therapy of diaphragmatic injury was performed in 15 patients within 2 days, in one within 1 year and in one 23 years after the accident. Two patients died due to accompanying injuries.

[Iatrogenic perforation of the intrathoracic colon after a late traumatic diaphragmatic hernia]. / Perforación iatrogénica de colon intratorácico tras hernia diafragmática traumática tardia.

A case of delayed presentation of traumatic diaphragmatic hernia and colonic injury leading to a review of the literature. Relative diagnostic difficulty in this type of lesions and its acute presentation make managements by mistake, as this one. In a patient with very important acute respiratory embarrassment and chest pain, an Argyle tube was placed because pneumothorax was suspected; the patient improved, but a fluid bowel content was obtained through the drainage tube; TAC and barium enema film showed the colon into the thorax. The patient underwent thoracotomy and laparotomy. In her history, she suffered from a stab wound on the left abdominal flank four years ago; it did not require surgical treatment but it caused the start of the colon movement into the thorax. The ways of presentation and its development are reviewed with the aim of remembering that it must be borne in mind if a patient present a penetrating trauma in the lower chest or upper abdomen, especially if surgical operation was not required, as it happened in this case. A careful history, examination, and review of follow up chest X-ray appears to be the easiest mechanism to avoid delays in diagnosis and reduce the morbi-mortality of this important disease.

[Missed traumatic diaphragmatic rupture--a legal insurance problem]. / Die übersehene traumatische Zwerchfellruptur--Ein versicherungsrechtliches Problem.

Even nowadays traumatic ruptures of the diaphragm cause diagnostic difficulties. Especially diaphragmatic ruptures of the so-called "late-type" are accompanied by uncharacteristic abdominal or cardio-respiratory complaints. These complaints depend on the type and the volume of the prolapsed organs. By hearing the classic previous history and symptoms the expert has to consider the diagnosis. Beside the previous history, the clinical evidents, the thoracic as well as the abdominal survey radiography, further informations can be given by Gastrointestinal passage with Gastrographin, by Colon contrast fluid enema and by abdominal CT. If there are no general contraindications, diaphragmatic ruptures have to be treated by surgery. There after patients are usually without complaints. Insurance-law-problems are unnecessarily created by "not identifying" fresh diaphragmatic ruptures and by "not considering" the possibility of "late-type" ruptures.

Blunt and penetrating diaphragmatic injuries with or without herniation of organs into the chest.

From 1970 to 1984, 189 patients with penetrating injury and 20 with blunt injury were treated at Grady Memorial Hospital. One hundred eight-five patients with penetrating injury (Group 1) and 9 with blunt injury (Group 2) required emergency laparotomy. In the remaining 15 patients (Group 3), the diagnosis of diaphragmatic injury was delayed from 18 hours to 15 years (mean, 8 months) after injury. The vast majority of the Group 1 and all Group 2 patients had injury to other organs, and the diagnosis of the diaphragmatic injury was made in almost all of them during the emergency laparotomy. The diagnosis in Group 3 patients was made by chest roentgenogram alone or with an upper gastrointestinal series or barium enema. All diaphragmatic injuries were repaired primarily except one which was repaired with Prolene mesh. Four of the Group 1 patients died, a mortality of 2.2%, and 2 of the Group 2 patients died, a mortality of 22.2%. All Group 3 patients recovered. This study suggests that diaphragmatic injury should be suspected in all patients with penetrating as well as blunt injury of the chest and abdomen and particularly of the epigastrium and lower chest. The presence of such an injury should be excluded before the termination of the exploratory procedure. Also, diaphragmatic injury should be suspected in patients with roentgenographic abnormalities of the diaphragm or lower lung field following trauma. The presence of diaphragmatic injury in such patients should be excluded with appropriate diagnostic studies to protect the patient from its late complications.

[Diagnosis and treatment of blunt injury to the diaphragm (author's transl)]. / Diagnose und Therapie der stumpfen Zwerchfellverletzungen.

Blunt injuries to the diaphragm are rare. They usually occur in combination with injuries to other structures (craniocerebral trauma, fracture of the pelvis, rupture of the spleen or liver). Regarding the diagnosis, knowledge of the mechanism of the accident may point to the possibility of a ruptured diaphragm, and so may auscultation and percussion of the chest. Examination of the gastrointestinal tract and contrast enema may show up displacement of abdominal viscera into the left pleural cavity. In cases of rupture of the right diaphragm coeliacography and scintillation scanning are indicated. As regards treatment: every rupture of the diaphragm needs surgical repair. If prolapse of viscera has been established, prompt intervention is necessary because of the risk of acute incarceration. Asymptomatic prolapse causing only minor complaints should also be rectified to obviate complications. The best approach for both early and late repair of the diaphragm is via the thorax.