Diaphragmatic Rupture Research Articles

Radiological management of traumatic lymphatic injuries in children

Traumatic lymphatic leaks are uncommon in children. Outcomes of conservative treatment are variable with surgery being often necessary. Lymphangiography has been successful in adults. Its utility in children is rarely reported. We report two cases of successful lymphangiographic treatment of traumatic lymphatic leak in children. First patient was a 15-year-old male developed a large right-sided pleural effusion 3 weeks after being physical assaulted. Tube thoracostomy yielded high volume chylous output. After failed conservative, operative and initial radiological interventions, he underwent bilateral femoral lymphangiography demonstrating abnormal ducts with contrast extravasation. This was controlled using coils and cyanoacrylate glue. Second patient was an 8-year-old male who following a road traffic accident underwent surgery for left diaphragmatic rupture. Drain was placed in the retroperitoneum where chylous fluid was observed. Postoperatively, after resuming diet, drains had significant chylous output. Lymphangiogram performed via inguinal nodes demonstrated abnormal right retroperitoneal nodes. The drain was exchanged for a pigtail catheter away from the lymphatics resulting in improved lymphatic flow. Lymphangiography is useful for treatment of traumatic lymphatic leaks in children. It should be considered early when conservative treatments fail. We present current evidence on lymphatic mapping and intervention for lymphatic leaks in children with a proposed algorithm.

Laparoscopic management of advanced epithelial ovarian cancer after neoadjuvant chemotherapy: a phase II prospective multicenter non-randomized trial (the CILOVE study)

ObjectiveThe aim of this study was to explore the feasibility and safety of the laparoscopic approach after neoadjuvant chemotherapy among selected chemosensitive patients with advanced ovarian cancer.MethodsThe CILOVE study was...

Rare association of traumatic diaphragmatic hernia with spinal cord injury: A case report.

Introduction and importanceThe traumatic diaphragmatic hernia could be missed in the background of spinal fractures due to neurological weakness. We report the first case of the management of thoracolumbar fracture-dislocation associated with diaphragmatic injury.Presentation of case53-year-old male transferred from local hospital following fallen from a motorbike on the 4th day after the injury. He was paraplegic from L1 below with sacral root involvement. Further imaging showed fracture-dislocation of the vertebral body at the T12-L1 level and anterior displacement of T11 on T12. The left-sided diaphragmatic hernia was detected by chest x-ray with bowel shadows in the left hemithorax. Emergency laparotomy and diaphragmatic repair followed by a posterior spinal exploration and pedicle screw fixation were done. Early mobilization was done after spinal fixation and the patient is successfully continuing rehabilitation.Clinical discussionThoracolumbar fracture-dislocation associated with the traumatic diaphragmatic hernia is rare. Clinical diagnosis of associated visceral injuries could be delayed due to the neurological deficit of the patient. An initial concern was to repair the life-threatening diaphragmatic hernia. Even current studies showed improved neurological function from early spinal surgery, spinal fixation had to delay as surgery needs a prone position.ConclusionEarly identification and management of traumatic diaphragmatic hernia are life-saving and allows early surgical intervention for the spine. Early reduction and fixation are associated with improved neurological function and will allow early mobilization and reduce hospital and ICU stay.

Tips and Tricks for Diaphragmatic Endometriosis Resection and Management of Iatrogenic Pneumothorax

<h3>Study Objective</h3> To highlight the relevant surgical anatomy and techniques for safe and efficient laparoscopic resection of diaphragmatic endometriosis as well as strategies for management of iatrogenic pneumothorax. <h3>Design</h3> Stepwise demonstration of techniques with narrated video footage. <h3>Setting</h3> Diaphragmatic endometriosis has a reported incidence of 0.1-1.5%. Patients may be asymptomatic or present with right upper quadrant abdominal pain, shoulder pain, or chest pain. Treatment may include laparoscopy alone or a combination of laparoscopy and thoracoscopy. <h3>Patients or Participants</h3> A 32-year-old female presents with symptomatic diaphragmatic endometriosis. <h3>Interventions</h3> The patient elected to undergo laparoscopic resection of diaphragmatic endometriosis. The key principles for safe and effective laparoscopic resection of diaphragmatic endometriosis include: • Grasping and tenting the endometriotic lesion away from the diaphragm • Gentle deflection of the liver to improve visualization during the procedure • Use of the open and spread technique to serially thin and separate the endometriotic lesions from the underlying diaphragm, when possible The key principles for management of iatrogenic pneumothorax, which may occur with even the most meticulous surgical technique, include: • Recognition of diaphragmatic injury by visualizing the loss of diaphragmatic tenting • Communication with the anesthesia team • Use of the laparoscopic suction irrigator to re-establish the negative pressure within the pleural cavity • Prompt chest x-ray in the PACU and, in the asymptomatic patient, administration of supplemental oxygen to improve the resolution rate of the pneumothorax • Consideration of needle aspiration or chest tube placement if the patient is symptomatic. <h3>Measurements and Main Results</h3> The patient recovered well without any postoperative complications. <h3>Conclusion</h3> In conclusion, laparoscopic resection of diaphragmatic endometriosis is reasonable in the appropriately selected patient. Surgical techniques used should ensure complete resection of endometriotic lesions while minimizing the risk of diaphragm injury. Prompt recognition and management of iatrogenic pneumothorax is crucial, and a surgeon should use these key principles when managing this complication.

Flow Nonuniformities Behind Accelerating and Decelerating Shock Waves in Shock Tubes

Shock tubes are used to investigate the chemical kinetics and radiative properties of gasses. Analyses of the flow conditions produced in shock tubes typically assume a single, constant shock speed even though the shock speed varies due to driver effects, boundary-layer growth, and diaphragm rupture effects. This paper will investigate the dependence of flow properties upon the entire shock speed history for a 100-mm-diam, 8-m-long shock tube using the FROSST axisymmetric shock tube Navier–Stokes code. A perfect gas is applied to remove the complexity of thermochemistry and allow a focus upon the flow details. Shock speed profiles ranging from accelerating to decelerating are simulated to qualitatively represent different experimental conditions, and the resulting test slugs compared. All shocks reach the test section at the same final shock Mach number of 6.53. Pressure variations caused by the accelerating shock are found to combine with entropy gradients introduced by the changing shock strength, yielding differences in maximum temperature of the test slug by as much as 56%, and differences in maximum pressure as high as 22% despite the shared tube-end Mach number. Local temperature and pressure around gas packets in the test slug are found to relax significantly through time in response to changing postshock conditions. Test slug variations due to boundary-layer effects are found to be present, but overwhelmed by the relaxation processes under many conditions.

497 Delayed Gastropleural Fistula: A Rare Cause of a Persistent Pleural Effusion After Blunt Force Trauma

Abstract Background A gastropleural fistula (GPF) is a rare pathological connection between the stomach and pleural cavity. GPFs have been reported following traumatic diaphragmatic ruptures, perforated hiatal hernias and gastric fundal ulcers, and more recently, after bariatric surgery. Diagnosis and treatment are frequently delayed due to the lack of specific clinical, laboratory and radiological findings. Method We describe a case of a 53-year-old gentleman who presented to our institution with acute respiratory distress and clinical findings of a pleural effusion. Uniquely he was discharged a week prior following an admission for a traumatic fall down a flight of stairs that resulted in a Grade-IV splenic injury, requiring an emergency splenectomy. A CT-proven massive haemothorax resulted in haemodynamic instability requiring resuscitation and chest drain insertion in the intensive care unit. On commencement of enteral diet, purulent exudate with evidence of food particulates was seen in his chest drain. Results Further diagnostic evaluation of drainage contents demonstrated gut flora and a subsequent positive dye test suggested an aero-digestive connection. Repeat CT revealed a fistula between the fundus of the stomach and the left pleural cavity through a ruptured diaphragm. He underwent an open sleeve gastrectomy and primary repair of the diaphragm. Conclusions This is the first case in literature reporting a ‘gastropleural fistula’ presenting in such a fashion. Thorough assessment and decisive action led to a satisfactory outcome. Although rare, a persistent effusion with a history of blunt abdominal and thoracic trauma may herald a GPF, which, if not diagnosed promptly, may result in significant morbidity.

479 Penetrating Chest Trauma Causing A Superior Mesenteric Artery-Inferior Vena Cava Fistula and Pancreatic Injury: A Case Report

Abstract Penetrating traumatic injuries can present a challenging scenario due to the potential for multisystem involvement requiring swift collaboration between surgical specialities. We present the case of a 66-year-old female who was stabbed in the right posterior chest. CT revealed a diaphragmatic injury, liver laceration involving segments 6/7 with active bleeding, and a posterior superior mesenteric artery (SMA) to anterior inferior vena cava (IVC) fistula. Due to the proximity of the SMA injury to a replaced right hepatic artery origin, the fistulous connection with the suprarenal IVC, and suspected pancreatic and duodenal injuries, a hybrid rather than a purely endovascular approach was taken. A large compliant occlusion balloon was placed percutaneously in the hepatic IVC. Subsequent trauma laparotomy and right medial visceral rotation identified SMA and SMV injuries, which were repaired with temporary supracoeliac aortic clamping. Further kocherisation of the duodenum revealed a 10 cm longitudinal IVC laceration causing sudden large volume venous haemorrhage. This was repaired after control was gained with supracoeliac aortic clamping, infrarenal IVC vessel loop and balloon inflation. An abdominal VAC dressing was applied. Before transfer to ICU, however, 1L of blood was noted in the VAC cannister and a relook laparotomy demonstrated more than 1L of intrabdominal fresh blood. Bleeding vessels around the uncinate process were ligated. After 48 hours, a relook laparotomy revealed no significant bleeding, and the abdomen was closed. A post-operative MRCP demonstrated pancreatic divisum and likely laceration of the aberrant ventral duct. A subsequent peripancreatic collection was managed conservatively.

Aspectos clínicos, cirúrgicos e radiográficos em um Gambá-de-orelha-branca (Didelphis albiventris) com hérnia diafragmática traumática.

This is the case of a specimen of Didelphis albiventris with signs of respiratory difficulty after a dog attack. Thoracic radiographic examination revealed pneumothorax, pulmonary contusion, and rib fracture, but no alteration compatible with diaphragmatic hernia was observed. Pneumothorax was reduced and the other alterations were treated. However, clinical manifestations persisted, and thus a contrast-gastrointestinal radiographic study was performed, showing abdominal organs in the thoracic cavity and loss of diaphragmatic line. The surgical approach was instituted, with access to the diaphragm through median laparotomy. Through the diaphragmatic rupture, present in the left antimere, there were herniated liver and gastric portions, intestinal segments, and omentum. After inspection and repositioning of the abdominal organs, the diaphragm raffia was performed with single sutures interrupted with 3-0 Nylon thread. The patient’s complete recovery occurred 14 days after the surgical procedure, with remission of clinical manifestations and normality of thoracic images in radiographic studies.

TRAUMATIC CHEST WALL INJURY WITH DIAPHRAGMATIC RUPTURE AND LUNG HERNIATION

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Traumatic diaphragmatic injuries are a rare injury that can occur after chest wall trauma. Injury to the diaphragm and its surrounding structures can easily be missed as the patients often have polytrauma. We present a case of a penetrating injury with blunt traumatic chest wall injury with diaphragm rupture and herniation of the left lung through the chest wall after a motorcycle collision. CASE PRESENTATION: A 24-year-old male presented to the hospital as a trauma alert after a motorcycle crash. The patient was found to have a large open chest wound with exposed lung and diaphragm. He was taken for CT imaging and found to have a left apical pneumothorax, left lung contusion, left rib fractures 2-10, and a grade 2 spleen laceration. The patient was taken for emergent exploration of his left chest wound. The patient was found to have disruption of his left chest wall and diaphragmatic attachments with rupture of the lateral aspect of his diaphragm at the level of rib 5-6. The wound was explored with evidence of injury to the left inferior lateral lobe of his lung. The lung did not require any resection. The entire left diaphragm was examined with the central tendon of the left diaphragm found to be intact, the diaphragm was repaired along the lateral edge and reattached to the costal cartilage laterally along the chest wall. The left chest was washed out and a chest tube was placed. The patients remaining hospital course was uneventful, and his chest tube was removed with no signs of air leaks. DISCUSSION: There are no specific signs of diaphragmatic injury or rupture on physical exam. Missed diaphragmatic injuries can result in major morbidity or mortality for the patient. All diaphragmatic injuries should be examined along with all surrounding structures at the time of diagnosis. Most diaphragmatic injuries occur on the left side as the right side is protected by the liver. We highly recommend CT imaging to examine the upper abdomen and chest. In the case of our patient which is rare, we were able to visualize his chest wall injury with his diaphragmatic injury on physical exam. When diagnosed early we recommend repair through the abdomen, but if found late repair through the chest is a better approach. In our case we were able to re-approximate the diaphragm to the chest wall. CONCLUSIONS: Traumatic injuries to the diaphragm can be tough to diagnose at times when there is not obvious injury noted to the diaphragm. We recommend full exposure of the diaphragmatic surface and examination of the surrounding organs and structures to rule out further injury that is not obvious on first examination. The diaphragm should be repaired and then reattached to the chest wall along its costal cartilage laterally. Complete repair with reattachment will allow the patient to avoid morbidity and mortality of a chronic diaphragmatic injury that could lead to impaired respiratory or chest wall function. REFERENCE #1: DeBarros, M., Martin, M.J. Penetrating Traumatic Diaphragm Injuries. Curr Trauma Rep 1, 91-101 DISCLOSURES: No relevant relationships by Michael Bishop, source=Web Response No relevant relationships by Alyssa Ritchie, source=Web Response

OLD WOUNDS RUN DEEP: A CASE OF THORACIC SPLENOSIS FOLLOWING REMOTE TRAUMA

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Thoracic splenosis develops as a result of auto-transplantation of splenic tissue into the thoracic cavity following splenic and diaphragmatic injury. Less than 40 cases have been reported in the literature so far and it remains an elusive diagnosis.[1] The majority of cases were asymptomatic and presented as incidental findings on imaging. Few cases reported symptoms like pleuritic chest pain, hemoptysis, and phrenic nerve irritation that prompted a diagnostic workup. [2] We report one such case in which a young female with penetrating abdominal trauma and unexplained shortness of breath was diagnosed with thoracic splenosis. CASE PRESENTATION: Our patient is a 32-year-old female who presented for evaluation of lung nodules found on work-up for recurrent dyspnea. She had previously been treated for suspected bronchitis, however, complained of persistent exertional dyspnea, orthopnea, and fatigue. She denied any chest pain, fever, chills, cough, pedal edema, or weight loss. She had a history of a gunshot to the abdomen that resulted in splenectomy 8 years prior to presentation. Physical exam was unremarkable and bloodwork was normal. Chest x-ray showed pleural irregularities computed tomography revealed nodularity of the left pleural space. PET-CT revealed faint uptake in this area. Transthoracic biopsy of the pleura yielded an acellular specimen. Thoracic splenosis was suspected, and liver and spleen imaging with single-photon emission computed tomography was performed after injecting 5.7 mCi Tc-99m sulfur colloid. The study showed multiple foci of uptake corresponding with underlying soft tissue nodules in the left lower pleura, left lower chest wall, and bilateral mesentery. A diagnosis of thoracic splenosis secondary to penetrating trauma was made. The patient's spirometry was normal and she was managed with supportive care and reassurance. DISCUSSION: The diagnosis of thoracic splenosis can be challenging as there can be a significant lag between thoracoabdominal trauma and chest findings. The Tc-99 m heat-damaged erythrocyte scan has high sensitivity and specificity for splenic tissue, while Tc-99m sulfur colloid and indium-111-labeled platelets are less sensitive alternatives. CT-guided biopsies and needle aspirations typically have a poor yield and increased risk of bleeding. [4,5] As splenic tissue is slow-growing, non-invasive, and mostly asymptomatic, appropriate management is observation and reassurance. Surgical removal carries a significant risk of morbidity and is only attempted in patients with severe, persistent symptoms or increasing size of the mass. [3] CONCLUSIONS: Thoracic splenosis can be diagnosed with a thorough history and appropriate imaging, but patients often undergo invasive procedures such as bronchoscopy or surgery in order to rule out a neoplasm. Pulmonologists should be aware of this rare entity in order to avoid unnecessary procedures REFERENCE #1: Ha YJ, Hong TH, Choi YS. Thoracic Splenosis after Splenic and Diaphragmatic Injury. Korean J Thorac Cardiovasc Surg. 2019;52(1):47-50. doi:10.5090/kjtcs.2019.52.1.47 REFERENCE #2: Le Bars F, Pascot R, Ricordel C, et al. Thoracic splenosis: Case report of a symptomatic case. Chin J Traumatol. 2020;23(3):185-186. doi:10.1016/j.cjtee.2020.05.003 REFERENCE #3: Matthews A, Chesser M, Mand J, Thomas A. A Growth Opportunity: Thoracic Splenosis. Am J Med. 2017;130(4):420-422. doi:10.1016/j.amjmed.2016.11.010 DISCLOSURES: No relevant relationships by Sukhmani Boparai, source=Web Response No relevant relationships by David Chambers, source=Web Response No relevant relationships by Deon Ford, source=Web Response No relevant relationships by Prathik Krishnan, source=Web Response No relevant relationships by Shreedhar Kulkarni, source=Web Response No relevant relationships by Jonathan Packer, source=Web Response

VENTILATOR-INDUCED DIAPHRAGMATIC DYSFUNCTION: MODIFIABLE CAUSES OF INJURY AND CORRELATED OUTCOMES

TOPIC: Critical Care TYPE: Late Breaking PURPOSE: The purposes of this study are to correlate the incidence of ventilator-induced diaphragmatic injury in the MICU to patient outcomes, and to assess for associations between diaphragmatic dysfunction and modifiable variables in mechanical ventilator management or sedation strategy. METHODS: Adult critically-ill patients admitted to Yale New Haven Hospital MICU were enrolled if intubated, mechanically ventilated, and qualified for a breathing trial. Diaphragm thickness, thickening fraction, and excursion were measured by bedside ultrasound, alongside an airway occlusion maneuver and maximum inspiratory pressure. These measurements were correlated with patient outcome variables, including duration of mechanical ventilation, re-intubation within 7 days of extubation, NIV following extubation, tracheostomy, and death during hospitalization, as well as modifiable ventilator settings and level of sedation. RESULTS: In an analysis of our first 13 patients, we found that there was a non-statistical difference in length of hospital stay between those with a reduced diaphragm thickening fraction (TF) ≤ 20% vs those with a normal TF (49.75 vs 32.22 days, p=0.087), although there was no difference in days on mechanical ventilation or length of ICU stay. When dividing patient subsets into categories of reduced or excessive effort (TF ≤ 20% or TF > 30%) vs normal effort (20% < TF ≤ 30%), we found that only those with abnormal effort had re-intubation within 7 days of extubation (3 vs 0) or required tracheostomy (3 vs 0). Those with a diaphragm thickening fraction ≤ 20% had near-statistically significant differences in admission APACHE II score (20.5 in low TF vs 15 in normal TF, p=0.063), as well as lower ventilatory pressure support (inspiratory pressure 17.78 cmH2O in low TF vs 22.39 cmH2O in normal TF, p=0.099). CONCLUSIONS: Although underpowered given a small initial dataset, our study may indicate that a reduced thickening fraction at time of breathing trial may correlate with a prolonged hospital stay, although is not a marker for prolonged mechanical ventilation. Reduced or increased effort may also suggest increased risk of re-intubation or need for tracheostomy. It is also important to note that those who had a higher severity of critical illness at time of intubation, and those who received less inspiratory support while on mechanical ventilation, had a reduced thickening fraction relative to those less ill or receiving greater pressure support. CLINICAL IMPLICATIONS: Only recently has diaphragmatic myotrauma been characterized as a potential mediator for prolonged mechanical ventilation and poor patient outcomes. However, the assessment of its presence by simple, reproducible, and non-invasive means has remained elusive, and its clinical utility dubious at best. This study illustrates the potential use of ultrasound-based diaphragmatic thickening fraction at time of spontaneous breathing trial as a measure of normal, decreased, or increased respiratory muscle effort, and how this may correlate to length of hospital stay, risk of re-intubation, and need for tracheostomy. It also suggests that the level of critical illness may correspond with a higher incidence of diaphragmatic injury, and that increased mechanical support, while maintaining lung protective strategy, may help maintain normal respiratory muscle function. Further studies will be necessary in the future to corroborate these results. DISCLOSURES: No relevant relationships by Jan Fouad, source=Web Response No relevant relationships by Lauren Killingsworth, source=Web Response No relevant relationships by Margaret Pisani, source=Web Response

NONTRAUMATIC LIVER HERNIATION MIMICKING A LOWER LOBE LUNG MASS

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Spontaneous diaphragmatic herniation is a rare type of acquired diaphragmatic hernia without any history of trauma. (1) We describe a case where a non-traumatic liver herniation through diaphragm was observed mimicking a lower lobe lung mass. CASE PRESENTATION: A 54-year-old female without prior thoraco-abdominal trauma was seen in the clinic because of growth of 2 right lower lobe lung nodules. These nodules were initially noted incidentally on CT scan in August 2009 and measured 1.5 cm x 2.8 cm and 0.9 cm x 1.3. They remained stable on CT scan and PET performed in 2010. Patient was lost follow-up after that until she had a CT scan in March 2019 because of concern of pneumonia and it was noted that the lung nodules have increased in size to 2.8 cm x 4.1 cm and 1.1 cm x 1.4 cm. The patient was otherwise asymptomatic. A PET scan was obtained which showed hypermetabolic nodules with maximum SUV of 3.29 and 1.4 for the larger and smaller nodule respectively. Radiographic appearance as well as the growth pattern was consistent with low-grade malignancy like carcinoid tumor. We performed robotic thoracoscopy with plan for wedge resection and possible completion lobectomy. Gross inspection of the thoracic cavity revealed abnormal mass on the dome of the diaphragm with appearance like liver. It was noted to be lying in the oblique fissure and corelated with the position of larger nodule seen on CT scan. There was a second area of thinned-out area of the diaphragm where a small nodule was noted pushing on the diaphragm with appearance like liver consistent with location of smaller lesion on CT scan. A Tru-Cut needle biopsy showed that it was benign liver tissue. The decision was made not to proceed with any diaphragmatic repair or reinforcement with mesh as this was an asymptomatic herniation through diaphragm and the liver was fibrosed to the diaphragm protecting from any intestinal herniation. DISCUSSION: A review of literature (1956-2009) revealed that there are 28 reported cases spontaneous diaphragmatic rupture (SDH) and of those only 10% had liver herniation. SDH is caused by events that increase intra-abdominal pressure like complicated labor, intense physical exercise, psychiatric illness, and cough secondary to pertussis. Another predisposing factor for SDH is congenital diaphragmatic defect which creates an area of weakness and increases the likelihood of herniation secondary to increased intra-abdominal pressure. SDH has also been described in association with other conditions like Ehler-Danlos Syndrome (EDS) and endometriosis because of weakness of diaphragmatic tissue. CONCLUSIONS: Our case was unique because the patient had asymptomatic SDH presenting as a lung mass without any history of etiologies leading to increased intra-abdominal pressure or weakness of diaphragm. Liver herniation through diaphragm can be managed without surgical repair if liver if fibrosed to diaphragm. REFERENCE #1: Losanoff JE, Edelman DA, Salwen WA, Basson MD. Spontaneous rupture of the diaphragm: case report and comprehensive review of the world literature. The Journal of thoracic and cardiovascular surgery. 2010 Jun 1;139(6):e127-8. REFERENCE #2: Stoica SC, Craig SR, Soon SY, Walker WS. Spontaneous rupture of the right hemidiaphragm after video-assisted lung volume reduction operation. The Annals of thoracic surgery. 2002 Sep 1;74(3):929-31. REFERENCE #3: Hamaoui K, Riaz A, Hay A, Botha A. Massive spontaneous diaphragmatic rupture in Ehlers–Danlos syndrome. The Annals of The Royal College of Surgeons of England. 2012 Mar;94(1):e5-7. DISCLOSURES: no disclosure on file for Annis Ali; No relevant relationships by Muhammad Adeel Samad, source=Web Response No relevant relationships by Diane Shih-Della Penna, source=Web Response no disclosure on file for Scott Tiedebohl

Traumatic Diaphragmatic Rupture, Incidence, Presentation, and Outcome

Objective: The aim of this prospective study is to highlight the incidence of a traumatic diaphragmatic rupture occurring in thoraco-abdominal penetrating or blunt trauma, and discuss their presentation and outcome Methods: We performed a prospective study, between 1st January 2017 to 30th June 2020 at the Department of General Surgery of the Al-Thawra Modern General Hospital, and 48-Modrn hospital -Sana'a city -Yemen. We included all the patients who were diagnosed and admitted with traumatic diaphragmatic rupture during the study period. Data included demographics, mechanism of injury, associated injuries, time of presentation post- trauma, length of hospital stay and ICU, ventilator days, management, postoperative complication, and outcomes. The variables were analyzed and compared for patients. Result: A total of 38 patients had traumatic diaphragmatic injury of (1843) thoracoabdominal trauma (2.1%)(855 blunt trauma &amp; 988 penetrating trauma), 31 patients (81.6%) have sustained penetrating trauma, while only 7 patients (18.4%) have blunt trauma. There were 33 male patients (86.8%) and 5 female patients (13.2%) with a mean age of 25 years (range 3–52 years), the location of rupture was 30 patients (78.9%) on the left-sided, and 8 patients (21.1%) on right-sided, 4 patients presented early with a diaphragmatic hernia, and 5 patient presented late with diaphragmatic hernia. Associated injuries were presented in 36 patients (94.7%). The diagnosis was preoperatively established in (36.8%), and intraoperative (63.2%). The diaphragmatic rupture was repaired with interrupted nonabsorbable sutures. Postoperative complications were observed in 23 patients (60.5%). Mortality was observed in 4 patients (10.5%). The outcome affected by associated injuries hemo/pneumothorax, rib fractures/lung contusion, hollow viscous injury, post-operative complication, time of presentation post- trauma, and hemodynamically state before admission. Conclusion: Traumatic diaphragmatic rupture, usually masked by multiple associated injuries which aggravate the condition of patients and are responsible for morbidity and mortality. The left-sided is involved more than the right-sided.

Диафрагмальная дисфункция среди детей на искусственной вентиляции легких: проспективное обсервационное когортное исследование

Актуальность. Искусственная вентиляция легких (ИВЛ) может приводить к повреждению диафрагмы, которое называют вентилятор-индуцированной диафрагмальной дисфункцией и связывают с неблагоприятными результатами лечения, длительным отлучением от респираторной терапии и длительным пребыванием в отделении интенсивной терапии. Целью нашего исследования было установить распространенность диафрагмальной дисфункции среди детей в зависимости от стратегии ИВЛ. Рабочей была гипотеза, что возникновение диафрагмальной дисфункции не зависит от стратегии проведения ИВЛ. Материалы и методы. Нами проведено проспективное когортное одноцентровое исследование в отделении анестезиологии с койками интенсивной терапии КНП «Львовская областная детская клиническая больница «ОХМАТДЕТ». В исследование включали пациентов с острой дыхательной недостаточностью, требующих ИВЛ более 3 суток. Критериями исключения из исследования были: отказ законных представителей пациента от участия в исследовании на любом из его этапов, агональное состояние пациента при поступлении на лечение. В исследование были включены 89 пациентов в возрасте от 1 мес. до 18 лет. Все пациенты были разделены случайным образом на 2 группы (с помощью сервиса random.org). В I группу вошли пациенты, у которых применяли легочно-протективную стратегию ИВЛ, во II группу — пациенты, у которых применяли легочно-протективную и диафрагм-протективную стратегии ИВЛ. В анализ данных включены 82 пациента. Для оценки показателей, зависящих от возраста, пациенты были разделены на возрастные подгруппы: 1-я подгруппа — дети в возрасте 1 мес. — 1 год; 2-я подгруппа — дети 1–3 лет; 3-я подгруппа — дети 3–6 лет; 4-я подгруппа — дети 6–13 лет; 5-я подгруппа — дети 13–18 лет. Этапы исследования: 1-е сутки (d1), 3-и сутки (d3), 5-е сутки (d5), 7-е сутки (d7), 9-е сутки (d9), 14-е сутки (d14), 28-е сутки (d28). В обеих группах пациентов изучали: изменения амплитуды движений диафрагмы в ходе исследования; контрактильные свойства диафрагмы с помощью определения фракции ее истончения и динамику в ходе исследования; рассматривали снижение данного показателя менее 15 % как маркер диафрагмальной слабости; повышение его более 35 % как маркер высокой работы дыхания и потенциально повреждающий фактор для диафрагмы; время вдоха по ультразвуковым данным; мониторировали показатели кислотно-щелочного равновесия крови и параметры искусственной вентиляции легких. Результаты. Нами выявлены специфические возрастные особенности: среди пациентов 1-й возрастной подгруппы в І группе мы регистрировали слабость правого купола диафрагмы с компенсаторным чрезмерным сокращением левого купола в начале отлучения и на этапе d9, тогда как во II группе эпизод чрезмерной работы диафрагмы был зарегистрирован только на этапе d5. Среди пациентов 2-й возрастной подгруппы I группы изменения были диаметрально противоположными по сравнению с 1-й возрастной подгруппой — преобладала чрезмерная работа правого купола с низкими показателями сокращения левого купола на всех этапах исследования, тогда как во II группе был зарегистрирован эпизод диафрагмальной слабости на этапе d3. В 3-й возрастной подгруппе достоверно позже восстанавливалась надлежащая диафрагмальная активность в І группе пациентов по сравнению со II группой. В 4-й возрастной подгруппе среди пациентов I группы отмечен эпизод высокой работы диафрагмы на этапе d5, тогда как во II группе все показатели были в пределах, рекомендованных диафрагм-протективной стратегией. В 5-й возрастной подгруппе в І группе достоверно чаще регистрировали чрезмерную работу как правого, так и левого куполов диафрагмы, во II группе были эпизоды как диафрагмальной слабости, так и чрезмерной ее работы. Использование в комплексе интенсивной терапии диафрагм-протективной стратегии при проведении отлучения от ИВЛ позволило снизить продолжительность ИВЛ: у пациентов 1-й возрастной подгруппы — в 1,5 раза (p = 0,08); у пациентов 2-й возрастной подгруппы — в 2,4 раза (p = 0,18); в 4-й возрастной подгруппе — в 1,75 раза (p = 0,1); в 5-й возрастной подгруппе — в 4,25 раза (p = 0,009). У пациентов 3-й возрастной подгруппы продолжительность ИВЛ возросла в 1,1 раза (p = 0,68). Выводы. Распространенность и разнообразие проявлений диафрагмальной дисфункции зависят от стратегии проведения механической вентиляции легких. Комплексный подход на этапе отлучения от респираторной терапии, включающей проведение диафрагм-протективной стратегии ИВЛ, позволяет уменьшить инцидентность возникновения дисфункции диафрагмы и снизить продолжительность отлучения от ИВЛ.

Traumatic Diaphragmatic Hernia: Management and Review

Traumatic diaphragmatic injury (TDI) is a fairly uncommon with incidence of 0.8 and 1.6 %, commonest fallowing blunt trauma abdomen. Right-side have higher mortality rate compared to left side and penetrating injuries. It present as occult to obvious. Laparoscopy offers diagnostic and therapeutic tool of care. Lack of awareness of the condition may delay in diagnosis, results life threatening complications. Missed hernia is a known complication of blunt trauma as acute diagnosis can be difficult to ascertain. An early diagnosis and treatment lead to better outcome. In present study CECT revealed acute diaphragmatic hernia, bilateral pleural effusion and hair line fracture of right tibia on skiagram limb. Because of uncertainty in diagnosis of acute diaphragmatic hernia or rupture surgeons faces challenges for the management, high suspicion index required to diagnose the cases. An early diagnosis and treatment lead to better outcome

Diagnosing penetrating diaphragmatic injuries: CT scan is valuable but not reliable

BackgroundThe diagnosis of penetrating isolated diaphragmatic injuries can be challenging because they are usually asymptomatic. Diagnosis by chest X-ray (CXR) is unreliable, while CT scan is reported to be more valuable. This study evaluated the diagnostic ability of CXR and CT in patients with proven DI. MethodsSingle center retrospective study (2009–2019), including all patients with penetrating diaphragmatic injuries (pDI) documented at laparotomy or laparoscopy with preoperative CXR and/or CT evaluation. Imaging findings included hemo/pneumothorax, hemoperitoneum, pneumoperitoneum, elevated diaphragm, definitive DI, diaphragmatic hernia, and associated abdominal injuries. Results230 patients were included, 62 (27%) of which had isolated pDI, while 168 (73%) had associated abdominal or chest trauma. Of the 221 patients with proven DI and preoperative CXR, the CXR showed hemo/pneumothorax in 99 (45%), elevated diaphragm in 51 (23%), and diaphragmatic hernia in 4 (1.8%). In 86 (39%) patients, the CXR was normal. In 126 patients with pDI and preoperative CT, imaging showed hemo/pneumothorax in 95 (75%), hemoperitoneum in 66 (52%), pneumoperitoneum in 35 (28%), definitive DI in 56 (44%), suspected DI in 26 (21%), and no abnormality in 3 (2%). Of the 57 patients with isolated pDI the CXR showed a hemo/pneumothorax in 24 (42%), elevated diaphragm in 14 (25%) and was normal in 24 (42%). ConclusionsRadiologic diagnosis of DI is unreliable. CT scan is much more sensitive than CXR. Laparoscopic evaluation should be considered liberally, irrespective of radiological findings.

Factors Associated with Successful Video-Assisted Thoracoscopic Surgery and Thoracotomy in the Management of Traumatic Hemothorax

Few studies have identified factors associated with successful VATS or thoracotomy as the initial operative strategy among patients with traumatic hemothorax. We performed an exploratory analysis using the 2008 to 2017 TQP database. We identified all patients aged 18 to 89 years with traumatic hemothorax who were treated with tube thoracostomy alone in the first 24-hours of admission, followed by VATS or thoracotomy. Logistic regression was used to identify factors associated with successful VATS (no conversion or reoperation) or thoracotomy (no reoperation) as the initial operative strategy. Among 2052 patients managed with initial VATS after chest tube drainage, 1710 (83%) were successful, while 263 (13%) were converted to thoracotomy and 79 (4%) required reoperation. On multivariable analysis, poor GCS (OR=0.96 [95% CI=0.94-0.99]), major injury (OR=0.69 [95% CI=0.53-0.90]), and diaphragmatic injury (OR=0.42 [95% CI=0.30-0.60]) were associated with lower odds of successful VATS, while rib fractures (OR=1.29 [95% CI=1.01-1.66]) were associated with higher odds of success of the initial operative plan. Among 3486 patients initially managed with thoracotomy after drainage with tube thoracostomy, 3118 (89.4%) were successful, while 11% (n=368) required reoperation. Multivariable analysis revealed that major injury (OR=0.68 [95% CI=0.50-0.92]), blunt mechanism (OR=0.63 [95% CI=0.50-0.78]), and diaphragmatic injury (OR=0.67, 95% CI=0.53-0.84]) were associated with lower odds of successful thoracotomy as the initial operative plan. More severe injuries and diaphragmatic injuries have lower odds of successful of VATS or thoracotomy as the initial operative management strategy among patients with traumatic hemothorax. Rib fractures may be associated with higher odds of success of VATS as the initial management strategy.

Diaphragmatic Rupture With Left Colon and Spleen Herniation and Small Intestine Injury After Blunt Trauma

Traumatic Diaphragmatic Rupture (TDR) is a rare type of trauma. Small intestine injuries are the third most common type of injury resulting from blunt trauma to abdominal organs. The immediate diagnosis of TDR and bowel injuries is a daunting task. We reported a 53-year-old male patient who was transferred to the hospital by EMS because of a car accident. The chest X-ray showed the left diaphragm elevation. Also, a computed tomography scan revealed that the greater omentum, a portion of the colon, spleen, and stomach were transposed in the hemithorax through a diaphragm rupture. The patient underwent laparotomy and the incidental findings in laparotomy showed bowel injuries. This case was a common cause of traumatic left-sided diaphragmatic rupture and intestinal injury. The suspicion of diaphragmatic rupture and intestinal injury in a patient with multiple traumas contributes to early diagnosis. Surgical repair remains the only treatment for diaphragmatic rupture. The severe injury in a part of the intestine may result in the resection of that part.

Traumatic diaphragmatic hernia in children

Traumatic diaphragmatic hernia is a relatively uncommon clinical entity, especially in children. It is often undiagnosed because of its rarity and coexistence with more obvious and serious injuries. Mortality of traumatic diaphragmatic rupture alone is rare, however delayed diagnosis may lead to higher mortality and morbidity rate. Outcome is usually determined by concomitant injuries and complications. Usually a diaphragmatic injury occurs in cases of blunt abdominal trauma (e.g. motor vehicle accidents) or penetrating trauma (e.g. gunshot or stab injury). Iatrogenic causes are rare. It has three stages: 1. initial, 2. latent, and 3. obstructive. Clinical findings vary depending on the stage of traumatic diaphragmatic injury. Subsequent complications, such as herniation or strangulation of viscera may occur months or even years after primary injury. High index of suspicion of this injury should be maintained when dealing with patients having respiratory or abdominal symptoms following trauma of the thoracoabdominal region, and patients after high-velocity blunt abdominal or penetrating trauma. We present two cases of traumatic diaphragmatic rupture and subsequent diaphragmatic hernia in pediatric patients, admitted in our hospital 2 months apart in a row, with different clinical and radiological findings.

Predictors of blunt diaphragm injury in Australia

Introduction Blunt diaphragm injury (BDI) is an uncommon, potentially fatal consequence of blunt torso injury. While associations between BDI and other factors such as mechanism of injury or other injuries have been described elsewhere, little recent research has been done in Australia into BDI. The aims of this study were to determine the incidence rate of BDI in our centre, identify how it was diagnosed, determine rates of missed injury and identify predictive factors for BDI. The hypothesis was that patients with BDI would significantly differ to those without BDI. Methods All major trauma patients with blunt torso injuries at our Level 1 major trauma service from 2010 to 2018 were included. Data for patient demographics, other injuries, diagnosis and treatment of BDI were extracted. Patients with BDI were compared with patients without BDI in order to identify differences that could be used to predict BDI in future patients. Results Of 5190 patients with a blunt torso injury, 51 (0.98%) had a BDI at a mean age of 53 ± 19.6 years, and median Injury Severity Score (ISS) of 27(IQR 21–38.5) compared with 5139 patients with a mean age of 48.2 ± 20.7 years and median ISS of 21.9(IQR 14–26) who did not have a BDI. The diagnosis of BDI was made at CT ( n = 35), surgery ( n = 14) or autopsy ( n = 2). Blunt diaphragm injury was missed on index imaging for 11 of 43 patients (25.6%). On multivariate analysis, each point increase in ISS (OR 1.03, p = 0.02); rib fractures (OR 4.65, p = 0.004); splenic injury (OR 2.60, p = 0.004); and liver injury (OR 2.78, p = 0.003) were independently associated with BDI. Conclusion Injury Severity Score, rib fractures and solid abdominal organ injury increase the likelihood of BDI. In patients with these injuries, BDI should be considered even in the presence of normal CT findings.