Diaphragmatic Rupture Research Articles

Late-onset traumatic diaphragmatic hernia associated with acute pancreatitis

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.

Extraluminal oesophageal stricture following traumatic diaphragmatic hernia repair in a cat

A one-year six-month-old male neutered domestic shorthaired cat was presented for regurgitation of increasing severity, 10 days following surgical repair of a suspected traumatic diaphragmatic hernia. Diaphragmatic hernia repair had...

Lung- and Diaphragm-Protective Ventilation.

Mechanical ventilation can cause acute diaphragm atrophy and injury, and this is associated with poor clinical outcomes. Although the importance and impact of lung-protective ventilation is widely appreciated and well established, the concept of diaphragm-protective ventilation has recently emerged as a potential complementary therapeutic strategy. This Perspective, developed from discussions at a meeting of international experts convened by PLUG (the Pleural Pressure Working Group) of the European Society of Intensive Care Medicine, outlines a conceptual framework for an integrated lung- and diaphragm-protective approach to mechanical ventilation on the basis of growing evidence about mechanisms of injury. We propose targets for diaphragm protection based on respiratory effort and patient-ventilator synchrony. The potential for conflict between diaphragm protection and lung protection under certain conditions is discussed; we emphasize that when conflicts arise, lung protection must be prioritized over diaphragm protection. Monitoring respiratory effort is essential to concomitantly protect both the diaphragm and the lung during mechanical ventilation. To implement lung- and diaphragm-protective ventilation, new approaches to monitoring, to setting the ventilator, and to titrating sedation will be required. Adjunctive interventions, including extracorporeal life support techniques, phrenic nerve stimulation, and clinical decision-support systems, may also play an important role in selected patients in the future. Evaluating the clinical impact of this new paradigm will be challenging, owing to the complexity of the intervention. The concept of lung- and diaphragm-protective ventilation presents a new opportunity to potentially improve clinical outcomes for critically ill patients.

Bevacizumab associated diaphragm rupture in patients with ovarian cancer

Bevacizumab associated diaphragm rupture in patients with ovarian cancer

Traumatic Diaphragmatic Hernia: Safety and Efficacy of a Minimally Invasive Approach: Case Report

Missed diagnosis of traumatic diaphragmatic hernia is a known complication of blunt trauma as the diagnosis can be difficult to ascertain acutely. Pre-operative diagnosis is challenging, and to date, there is no consensus on the standard management for this condition. Until recently, open primary repair was the standard of care with few centers attempting laparoscopic repair for select patients. The objective of this study was to evaluate the safety, technical feasibility, and clinical outcomes for minimally invasive repair utilizing the DaVinci Robotic platform for traumatic diaphragmatic hernia repair. Robotic repair was performed on a patient who presented with a large diaphragmatic hernia 9 years after blunt trauma. The procedure was recorded, technique detailed, and clinical outcomes assessed. There were no significant adverse events noted. After 1 year, the patient is doing well with no complaints, no evidence of recurrence and no other complications. Robotic repair of traumatic diaphragmatic hernia effectively achieved reduction of herniated contents, primary defect closure, and broad mesh overlap with good results at 1 year. This approach may provide an innovative minimally invasive option for surgeons and patients.

Chest x-ray vs. computed tomography of the chest in pediatric blunt trauma

IntroductionChest x-ray (CXR) has been shown to be an effective detection tool for clinically significant trauma. We evaluated differences in findings between CXR and computed tomography of the chest (CCT), their impact on clinical management and the performance of the CXR. MethodsThis retrospective study examined children (less than 18 years) who received a CXR and CCT between 2009 and 2015. We compared characteristics of children by conducting univariate analysis, reporting the proportion of additional diagnoses captured by CCT, and using it to evaluate the sensitivity and specificity of the CXR. Outcome variables were diagnoses made by CCT as well as the ensuing changes in the clinical management attributable to the diagnoses reported by the CCT and not observed by the CXR. ResultsIn 1235 children, CCT was associated with diagnosing higher proportions of contusion or atelectasis (60% vs 31%; p < .0001), pneumothorax (23% vs 9%; p < .0001), rib fracture (18% vs 7%; p < .0001), other fracture (20% vs 10%; p < .0001), diaphragm rupture (0.2% vs 0.1%; p = .002), and incidental findings (7% vs 2%; p < .0001) as compared to CXR. CCT findings changed the management of 107 children (8.7%) with 32 (2.6%) of the changes being surgical procedures. The overall sensitivity and specificity of the CXR were 57.9% (95% CI: 54.5–61.2) and 90.2% (95% CI: 86.8–93.1), respectively. The positive predictive value and negative predictive value were 93.1% and 48.6%, respectively. ConclusionCXR is a useful initial screening tool to evaluate pediatric trauma patients along with clinical presentation in the Emergency Department in children. Level of evidenceLevel III, diagnostic test.

Clavicle fractures: Associated trauma and morbidity

BackgroundClavicle fractures are frequently associated with trauma to regions beyond the immediate zone of injury. In order to provide surgeons with information on injury prevalence to prevent delays in diagnosis and management, we describe the epidemiology of concomitant injuries in patients with clavicle fractures and identify differences between those with open and closed fractures. Methods:The Nationwide Inpatient Sample (NIS) 2001–2013 database was queried for adult patients discharged with a diagnosis of a clavicle fracture using ICD-9 codes. A “common” injury was defined as prevalence ≥4.0% in our study population. We analyzed data for injury locations associated with open vs. closed clavicle fractures with chi square and independent samples t-tests. ResultsA total of 41,1612 patients were included in our study population. The majority of patients had closed clavicle fractures (98.2%). The most common concomitant fracture was that of the rib, followed by the spine. The most common non-vascular, non-nervous injury was a hemo/pneumothorax followed by a lung, bronchus, or diaphragm injury. Fractures of the humerus, rib, scapula, pelvis, tibia or fibula, and facial bones as well as concussion, pneumo/hemothorax, other pulmonary, and splenic injuries were more common in patients with open clavicle fractures. Patients with open clavicle fractures were, on average, 11.8 years younger than those with closed fractures. ConclusionThere is a significant association between clavicle fractures and concussion, splenic, and thoracic injuries, as well as increased rate of complications with open fractures. Clinicians may use this information to perform risk assessments prevent delays in diagnosis.

Acute Large Bowel Obstruction Following Late Sequelae of Traumatic Diaphragmatic Hernia

A 33 years old patient was admitted in a Military Hospital with the features of acute large gut obstruction. Exploratory laparotomy was done and peroperatively the obstruction was seen in the transverse colon and obstruction seemed to be carcinoma of transverse colon with involvement of left hemidiaphragm which was not negotiable. Transverse loop colostomy with decompression of bowel was done. Subsequently the patient was transferred to tertiary level hospital in Dhaka. In the tertiary hospital, the patient developed left sided massive pleural effusion. With relevant investigation the condition was diagnosed as left sided diaphragmatic hernia. Thoracotomy was done and herniorrhophy was performed after reduction of the content. Post-operative management was stormy and eventful but the condition improved gradually and the patient was discharged in proper time. The patient had history of chest trauma due to RTA he met 4 years back and he received hospital indoor management for 3½ months. The patient was asymptomatic and leading normal active military life before 2nd time admission for acute intestinal obstruction. The patient had past history of trauma to left chest wall 4 years back, presented with acute large gut obstruction and there was diagnostic dilemma. There were management difficulties and post operative events were stormy. The aim of this reporting is to highlight all of these.&#x0D; Journal of Armed Forces Medical College Bangladesh Vol.15 (1) 2019: 119-120

Traumatic diaphragmatic rupture in children

Traumatic diaphragmatic ruptures (TDR) are rare in children and when present are usually associated with polytrauma. Due to the non-specific signs in acute setting and to the occurrence with other main organ injuries, the diagnosis of TDR is often missed. The few reported cases in the literature are showing a high incidence of delayed diagnosis leading to increased morbidity and mortality. We present the case of a boy who was admitted after being run over by a lorry and an early diagnosis of TDR was made. An initial Chest X-ray showed a right elevated hemidiaphragm raising the possibility of TDR. A misleading diagnosis of pleural effusion led to insertion of a chest drain with no significant consequences. A repeated CT confirmed the TDR diagnosis and the patient was taken to theatre the same day for surgical repair. He had an eventful recovery and he was discharged 28 days postoperatively. The diagnosis of TDR remains a challenging clinical and imaging entity. A very high index of suspicion is required in the scenario of a polytrauma patient, especially in victims of blunt abdominal trauma.

Complicated Diaphragmatic Hernia in Emergency Surgery: Systematic Review of the Literature.

Complicated diaphragmatic hernia (DH) can be congenital or acquired. Congenital diaphragmatic hernias (CDH) are rare and often can be asymptomatic until adulthood. Traumatic diaphragmatic hernia (TDH) is a complication that occurs in about 1-5% of victims of road accidents and in 10-15% of penetrating traumas of the lower chest. CDH and TDH are potentially life-threatening conditions, and the management in emergency setting still debated. This study aims to evaluate the surgical treatment options in emergency setting. A bibliographic research reporting the item "emergency surgery" linked with "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia" was performed. Several parameters were recorded including sex, age, etiology, diagnosis, treatment, site and herniated organs. The research included 146 articles, and 1542 patients were analyzed. Most of the complicated diaphragmatic hernias occurred for a diaphragmatic defect due to trauma, only 7.2% occurred for a congenital diaphragmatic defect. The main diagnostic method used was chest X-ray and CT scan. Laparotomic approach still remains predominant compared to the minimally invasive approach. Surgery is the treatment of choice and is strongly influenced by the preoperative setting, performed mainly with X-ray and CT scan. Minimally invasive approach is safe and feasible but is highly dependent on the surgeon's expertise, especially in emergency setting.

Injuries to the Spleen and Diaphragm

The spleen is one of the most commonly injured abdominal organs in blunt trauma patients. The mechanisms of injury are similar to those seen with liver injuries: motor vehicle collisions, automobile-pedestrian collisions, falls, and any type of penetrating injury. Stab wounds to the abdomen are less likely to cause spleen injury compared with liver injury due to the spleen’s protected location. Stab wounds to the spleen typically result in direct linear tears, whereas gunshot wounds result in significant cavitary injuries. This review covers injuries to the spleen and injuries to the diaphragm. Figures show findings on imaging that may be associated with failure of nonoperative management for splenic injuries, intraparenchymal splenic blush noted on an initial computed tomographic scan, the first step in mobilizing the spleen by making an incision in the peritoneum and the endoabdominal fascia, beginning at the inferior pole and continuing posteriorly and superiorly, splenorrhaphy performed using interrupted mattress sutures through pledgets along the raw edge of the spleen, left diaphragm ruptures evident with the gastric bubble located in the left hemithorax, whereas right-sided ruptures present with the appearance of an elevated hemidiaphragm, and the use of Allis clamps to approximate the diaphragmatic edges, with the defect closed with a running No. 1 polypropylene suture. The table lists American Association for the Surgery of Trauma organ injury scales for diaphragm and spleen. This review contains 6 figures, 1 table, and 55 references Keywords: spleen, injury grading, angioembolization, splenorrhaphy, splenic salvage

Total thoracic herniation of the liver: a case of delayed right-sided diaphragmatic hernia after blunt trauma

BackgroundTraumatic diaphragmatic injuries (TDIs) are relatively uncommon and require surgical repair to prevent or address herniation. Three quarters of TDIs are due to blunt thoraco-abdominal trauma. In blunt TDIs, variable clinical presentations and frequent concurrent life-threatening injuries may hinder early recognition and treatment, leading to diagnostic delays, which may result in technically more challenging repairs. Right-sided blunt TDIs are much less common than left-sided ones, are difficult to visualize on imaging studies, are more frequently associated with other potentially lethal injuries, and tend to present more subtly, so that diagnostic delays are more likely.Case presentationWe report the diagnosis and elective repair of a large right-sided traumatic diaphragmatic hernia resulting from a distant blunt abdominal injury, describing the techniques used to address the challenges presented by the chronic intrathoracic displacement of the entire liver with the gallbladder, as well as the right side of the colon and part of the duodenum.ConclusionsEarly diagnosis of right-sided TDIs can be especially elusive. The management of delayed diaphragmatic hernias can be challenging, but with meticulous planning and a flexible surgical approach, a repair can be achieved resulting in good recovery and low risk of recurrence.

First case of cough-induced combined intercostal artery rupture with partial diaphragm tear

We describe a case of vigorous cough-induced left intercostal artery rupture with partial diaphragmatic tear in a 60-year-old obese male with chronic obstructive pulmonary disease. He presented with left hemothorax, a rapidly spreading chest and abdominal wall hematoma, and progression of anemia. Computed tomography (CT) scan revealed a bleeding focus from the left 8th intercostal artery. CT-guided surface marking of the bleeding point was done over the chest wall. The patient underwent open thoracotomy with drainage of clotted hemothorax and ligation of bleeding intercostal artery. Incidentally, a partial diaphragm tear was detected during the surgery which was repaired. The combined presentation of cough-induced intercostal artery rupture with partial diaphragm tear is not reported earlier. Awareness of these co-existing pathologies can facilitate timely diagnosis and appropriate life-saving management.

Neuregulin-1β Protects the Rat Diaphragm during Sepsis against Oxidative Stress and Inflammation by Activating the PI3K/Akt Pathway.

Sepsis-induced diaphragm dysfunction (SIDD) which is mainly characterized by decrease in diaphragmatic contractility has been identified to cause great harms to patients. Therefore, there is an important and pressing need to find effective treatments for improving SIDD. In addition, acetylcholinesterase (AChE) activity is a vital property of the diaphragm, so we evaluated both diaphragmatic contractility and AChE activity. Though neuregulin-1β (NRG-1β) is known to exert organ-protective effects in some inflammatory diseases, little is known about the potential of NRG-1β therapy in the diaphragm during sepsis. Our study was aimed at exploring the effects of NRG-1β application on diaphragmatic contractility and AChE activity during sepsis. Proinflammatory cytokines, muscle injury biomarkers in serum, contractile force, AChE activity, proinflammatory cytokines, oxidative parameters, histological condition, terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) staining, and expression of phosphoinositide 3-kinase (PI3K)/protein kinase B (PKB/Akt) signaling proteins in the diaphragm were measured and compared between nonseptic and septic groups with or without NRG-1β treatment. In vitro, the effects of NRG-1β on reactive oxygen species (ROS) production in the lipopolysaccharide- (LPS-) stimulated L6 rat muscle skeletal cells with or without the Akt inhibitor MK-2206 were detected. NRG-1β inhibited proinflammatory cytokine release and muscle injury biomarkers soaring in serum and improved the sepsis-induced diaphragm dysfunction and AChE activity decrease significantly during sepsis. Meanwhile, the inflammatory response, oxidative stress, pathological impairment, and cell apoptosis in the diaphragm were mitigated by NRG-1β. And NRG-1β activated the PI3K/Akt signaling in the diaphragm of septic rats. Elevated ROS production in the LPS-stimulated L6 rat skeletal muscle cells was reduced after treatment with NRG-1β, while MK-2206 blocked these effects of NRG-1β. In conclusion, our findings underlined that NRG-1β could reduce circulating levels of proinflammatory cytokines in rats with sepsis, adjust diaphragmatic proinflammatory cytokine level, mitigate diaphragmatic oxidative injury, and lessen diaphragm cell apoptosis, thereby improving diaphragmatic function, and play a role in diaphragmatic protection by activating PI3K/Akt signaling.

A case of empyema due to injury of diaphragm and transverse colon caused by rib fracture

A case of empyema due to injury of diaphragm and transverse colon caused by rib fracture

Absent Lung Slide but No Pneumothorax: A Case of Spontaneous Diaphragmatic Hernia Presenting with Dyspnea

Spontaneous diaphragmatic rupture is one of the rarest thoracoabdominal emergencies. The diagnosis may be delayed if a patient presents with respiratory symptoms without any history of trauma. In this report, we present a case who was admitted to the emergency department with shortness of breath, nausea, vomiting lasting for 3 h, and was diagnosed initially with pneumothorax based on chest X-ray and ultrasonography thorax findings. An intercostal drain was placed in the emergency ward. This was later diagnosed to have spontaneous diaphragmatic rupture. The patient was operated upon, and the defect was repaired. Diaphragmatic rupture should be considered along with other possible diagnoses, especially in the presence of suspicious appearances on the chest radiography in a patient with respiratory and/or gastrointestinal symptoms. The utility of bedside ultrasound in the diagnosis of spontaneous diaphragmatic hernia is yet unproven. The only treatment is surgical along with supportive care.

ROLE OF LAPAROSCOPY IN MANAGEMENT OF ABDOMINAL TRAUMA

Background: Abdominal trauma affects 10% to 15% of injured patients. Although significant intra-abdominal injury is relatively infrequent, the consequences of missed or delayed diagnosis can be significant. Therefore, accurate and timely diagnosis of injuries is essential. Objective: To study the feasibility, the advantages, and the disadvantages of laparoscopy in diagnosis and treatment of abdominal trauma. Patients and Methods: This randomized prospective study included 50 patients with abdominal trauma of any type whether blunt or penetrating, road traffic accident (RTA) or falling from height, stab or gunshot. Mean age was of patients was 29.26±8.55 years old and mean BMI was 26.36±3.12. Ninety eight percent of them were males and 2% of them were females. Results: The intraoperative bleeding occurred in one patient (2%). Female patient presented after lower abdominal stab wound (BP 90/50 -HB 8 –HR 120). After resuscitation diagnostic laparoscopy found uncontrolled bleeding from uterine tear. Post-operative complications occurred in 8% post laparotomy and 14% post laparoscopy. Patients underwent laparotomy delayed in return to daily activity (8-9 days) and to work (12-24 days) due to time of operation, length of incision and occurrence of complications and depended on age, BMI, power of healing and intraoperative technique. In our experience, the use of laparoscopy as a diagnostic and therapeutic tool led to avoidance of an open surgery in more than 64% of patients. Negative and non-therapeutic laparoscopies were performed in 7 patients and therapeutic laparoscopy was performed in 25 patients: 8 patients hand assisted splenectomy, 5 patients needed repair of liver tears, 3 patients needed diaphragmatic tear repair, 7 patients needed primary repair for bowel and 2 patients needed stomach repair. However, conversion to laparotomy was needed in 18 cases more than 30%. Multiple organ injuries occurred in 16%, colostomy for descending and sigmoid colonic tears (10%), resection anastomosis for multiple small bowel injuries (2%), repair for uterine injuries (2%). Conclusion: The keys to successfully diagnosing and treating significant intra-abdominal injuries laparoscopically include a systemic exploration to avoid missed injuries using appropriate changes in position of the patient, careful planning of port placement. Minimally invasive surgery has become a useful tool in the management of trauma. Laparoscopy can detect and repair injuries to the hollow viscus and diaphragm and exclude the risks of non-therapeutic laparotomy. Further advantages are reduced morbidity, shortened hospital stay, and lower cost. In the future, there may be exciting advancements for this field of surgery through innovative developments.

ROLE OF LAPAROSCOPY IN MANAGEMENT OF ABDOMINAL TRAUMA

Background: Abdominal trauma affects 10% to 15% of injured patients. Although significant intra-abdominal injury is relatively infrequent, the consequences of missed or delayed diagnosis can be significant. Therefore, accurate and timely diagnosis of injuries is essential. Objective: To study the feasibility, the advantages, and the disadvantages of laparoscopy in diagnosis and treatment of abdominal trauma. Patients and Methods: This randomized prospective study included 50 patients with abdominal trauma of any type whether blunt or penetrating, road traffic accident (RTA) or falling from height, stab or gunshot. Mean age was of patients was 29.26±8.55 years old and mean BMI was 26.36±3.12. Ninety eight percent of them were males and 2% of them were females. Results: The intraoperative bleeding occurred in one patient (2%). Female patient presented after lower abdominal stab wound (BP 90/50 -HB 8 –HR 120). After resuscitation diagnostic laparoscopy found uncontrolled bleeding from uterine tear. Post-operative complications occurred in 8% post laparotomy and 14% post laparoscopy. Patients underwent laparotomy delayed in return to daily activity (8-9 days) and to work (12-24 days) due to time of operation, length of incision and occurrence of complications and depended on age, BMI, power of healing and intraoperative technique. In our experience, the use of laparoscopy as a diagnostic and therapeutic tool led to avoidance of an open surgery in more than 64% of patients. Negative and non-therapeutic laparoscopies were performed in 7 patients and therapeutic laparoscopy was performed in 25 patients: 8 patients hand assisted splenectomy, 5 patients needed repair of liver tears, 3 patients needed diaphragmatic tear repair, 7 patients needed primary repair for bowel and 2 patients needed stomach repair. However, conversion to laparotomy was needed in 18 cases more than 30%. Multiple organ injuries occurred in 16%, colostomy for descending and sigmoid colonic tears (10%), resection anastomosis for multiple small bowel injuries (2%), repair for uterine injuries (2%). Conclusion: The keys to successfully diagnosing and treating significant intra-abdominal injuries laparoscopically include a systemic exploration to avoid missed injuries using appropriate changes in position of the patient, careful planning of port placement. Minimally invasive surgery has become a useful tool in the management of trauma. Laparoscopy can detect and repair injuries to the hollow viscus and diaphragm and exclude the risks of non-therapeutic laparotomy. Further advantages are reduced morbidity, shortened hospital stay, and lower cost. In the future, there may be exciting advancements for this field of surgery through innovative developments.

Clinical-evolutive, diagnostic and treatmental particularities in traumatic diaphragmatic hernia in children. Clinical case presentation and literature review

Clinical-evolutive, diagnostic and treatmental particularities in traumatic diaphragmatic hernia in children. Clinical case presentation and literature review

Successful management of right-sided diaphragmatic injury via video-assisted thoracoscopic surgery

Successful management of right-sided diaphragmatic injury via video-assisted thoracoscopic surgery