Thoracoabdominal Penetrating Trauma Research Articles

Value of Ultrasonography in Detection of Diaphragmatic Injuries Following Thoracoabdominal Penetrating Trauma; a Diagnostic Accuracy Study.

Diagnosis of diaphragmatic rupture following thoracoabdominal penetrating trauma is very challenging in asymptomatic patients with stable vital signs. This study aimed to evaluate the diagnostic accuracy of focused assessment with sonography for trauma (FAST) in this regard. This cross-sectional study was performed on patients referring to emergency department due to left thoracoabdominal stab wound during 2 years. All patients initially underwent ultrasonography and the screening performance characteristics of FAST in detection of diaphragmatic injuries were calculated, considering the findings of diagnostic laparoscopy as the gold standard test. Twenty-four patients with the mean age of 33 ± 10.64 years (16-61 years) were studied (100% male). The mean chest wall laceration size was 2.7 ± 2.7 cm (1-10 cm) and the most frequent location of wounds was posterior chest wall (42%) and in the 6th and 7th intercostal space (50%). Diaphragmatic rupture was seen in 4 (16.7%) patients based on diagnostic laparoscopy. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratio of FAST in detection of diaphragmatic raptures were 50% (95% CI: 9.18 - 90.8), 100% (95% CI: 79.9 - 100.0), 100% (95% CI: 19.8 - 100.0), 9.1% (95% CI: 1.5 - 30.6), Infinity, and 0.1 (95% CI: 0.02 - 0.37), respectively. The overall accuracy of FAST in this regard was 75.0% (95% CI: 42.3 - 100.0). In patients with penetrating trauma to the left thoracoabdominal region, FAST cannot be the definitive alternative to diagnostic laparoscopy to detect diaphragm rupture.

"Pop in a scope": attempt to decrease the rate of unnecessary nontherapeutic laparotomies in hemodynamically stable patients with thoracoabdominal penetrating injuries.

Management of patients with thoracoabdominal penetrating injuries is challenging. Thoracoabdominal penetrating trauma may harbor hollow viscus injuries in both thoracic and abdominal cavities and occult diaphragmatic lesions. While radiological tests show poor diagnostic performance in these situations, evaluation by laparoscopy is highly sensitive and specific. Furthermore, minimally invasive surgery may avoid unnecessary laparotomies, despite concerns regarding complication and missed injury rates. The objective of thepresentstudy is to evaluate the diagnostic and therapeutic performance of laparoscopy in stable patients with thoracoabdominal penetrating injuries. Retrospective analysis of hemodynamically stable patients with thoracoabdominal penetrating wounds was managed by laparoscopy.We collected data regarding the profile of the patients, the presence of diaphragmatic injury, perioperative complications, and the conversion rate. Preoperative imaging tests were compared to laparoscopy in terms of diagnostic accuracy. Thirty-one patients were included, and 26 (84%) were victims of a stab wound. Mean age was 32years. Ninety-three percent were male. Diaphragmatic lesions were present in 18 patients (58%), and 13 (42%) had associated injuries. There were nomissed injuries and noconversions. Radiography and computerized tomography yielded an accuracy of 52% and 75%, respectively. Laparoscopy is a safe diagnostic and therapeutic procedure in stable patients with thoracoabdominal penetrating wound, with low complication rate,andmayavoidunnecessary laparotomies.The poor diagnostic performance of preoperative imaging exams supports routine laparoscopic evaluation of the diaphragm to exclude injuries in these patients.

The hepatothorax: An unusual complication of right sided diaphragmatic injuries

Right diaphragmatic post-traumatic rupture with liver herniation is an extremely rare condition. The diagnosis is mainly radiological and the rupture may go unnoticed in the acute setting. Depending on the size of the right diaphragmatic defect, the initial herniation can be partial and the total hepatothorax is established progressively. The diagnosis may be delayed and made with the onset of the first symptoms. Hepatothorax leads usually to severe right lung atelectasis with respiratory and cardiac impairment. Definitive treatment consists in surgical repair of the diaphragm. We present hereby the case of an hepatothorax diagnosed 4 years after a penetrating thoracoabdominal trauma. Key words: Trauma, diaphragmatic rupture, hepatothorax.

Chest tube malposition inserted in thorax increases morbidity at thoracoabdominal injury

Thoracoabdominal penetrating trauma management is challenging when diaphragm injuries are involved. Thorax tube is golden standard for penetrating thoracoabdominal injuries. It has some complications. A 27-year-old male had stabbed thoracoabdominal penetrating trauma thorax tube inserted at another hospital. We decided to explore abdomen laparoscopy when he has symptoms at abdomen. We saw thorax tube ruptured diaphragm. We saturated diaphragm intracorporeally with laparoscopic protege. The clinician should not insert tube from penetrating trauma area. Tube must be inserted from its usual anatomical intercostal space.

Stomach Tear through Chest Making an Awkward Connection (Traumatic Gastro-Pleural Fistula)

We report a case of gastro-pleural fistula following a thoraco-abdominal penetrating trauma that was diagnosed early with very simple noninvasive modalities. Such type of penetrating injuries should be monitored closely and investigated adequately to exclude this type of complication. In spite of being a rare complication for penetrating chest trauma, gastro pleural fistula is a severe and sometimes fatal complication that requires early diagnosis and prompt surgical intervention.

Laparoscopy in the diagnosis and repair of diaphragmatic injuries in left-sided penetrating thoracoabdominal trauma: laparoscopy in trauma.

Diaphragmatic injuries from penetrating thoracoabdominal trauma are notoriously difficult to detect with clinical and radiological evaluation. The aim of this study was to establish the incidence of diaphragmatic injury from penetrating thoracoabdominal trauma, clinical and radiological features predictive of a diaphragmatic injury and the feasibility of laparoscopic repair. This is a prospective consecutive case series conducted in a metropolitan hospital complex. Fifty five patients were enrolled into the study and underwent a standardized laparoscopic procedure. Only stable patients were selected and right-sided penetrating thoracoabdominal injuries were excluded. The patients' clinical details, radiological findings, operative procedure, treatment of the diaphragmatic injury and complications were collected and analysed. There were a total of 55 patients, of whom, 22 (40 %) had diaphragmatic injuries. The mean age was 26.3 ± 7.8 years (range 15-44) with a male:female ratio of 10:1. The causes of injury were stab in 54 (98.2 %) patients and firearm in one (1.8 %). Twenty six (47.3 %) patients had positive radiological findings, of which 10 (38.5 %) had a diaphragmatic injury. There were 6 (27.3 %) associated intra-abdominal injuries. Twenty one (95.5 %) of 22 patients with diaphragmatic injuries were successfully repaired laparoscopically. Mean duration of procedure with diaphragmatic repair was 74.9 ± 22.5 min compared to 38.3 ± 16.9 min without diaphragmatic repair. Six patients (10.9 %) had minor intra-operative complications. There were no deaths. Hospital stay was 2.9 ± 3.4 days. Diaphragmatic injury was present in 40 % of patients with left-sided thoracoabdominal injury. Radiological findings were not reliable in predicting diaphragmatic injury. The majority of these injuries can be safely repaired laparoscopically.

Evolving concepts in MDCT diagnosis of penetrating diaphragmatic injury.

This article reviews current and evolving concepts in the diagnosis of penetrating diaphragmatic injury with multidetector CT (MDCT). As criteria for nonoperative management in the setting of penetrating trauma become more inclusive, confident exclusion of penetrating diaphragmatic injury (PDI) has become imperative. Diagnostic performance of MDCT for PDI has improved substantially with the use of thin sections and multiplanar reformats. Evaluation of injury trajectory in nonstandard planes using 3D post-processing software can aid in the diagnosis. Contiguous injury and transdiaphragmatic trajectory are the best predictors of PDI. Careful appraisal of the diaphragm for defects should be undertaken in all patients with thoracoabdominal penetrating trauma.

Laparoscopic-assisted Minithoracotomy for Repair of Diaphragmatic Penetrating Trauma

Stable patients with thoracoabdominal penetrating or blunt trauma resulting in diaphragmatic injuries represent a challenging dilemma. Laparoscopy has emerged as the most reliable and efficient diagnostic and treatment modality for such patients. The aim of this study was to analyze our novel surgical technique for the management of penetrating diaphragmatic injuries in stable patients. In this retrospective study, we analyzed data that had been prospectively collected on a new surgical repair technique established at our institution. We reviewed the records of 7 hemodynamically stable trauma patients with thoracoabdominal penetrating trauma resulting in diaphragmatic injuries. The 7 patients (5 with stab wounds, 2 with gunshot wounds) underwent laparoscopic exploration and laparoscopic-assisted minithoracotomy for the repair of diaphragmatic injuries. The mean length of stay was 4.4 days (range, 1 to 8 d). There were no tension pneumothoraces, missed injuries, or other procedure-related complications. If complete laparoscopic repair is not possible, laparoscopic-assisted repair of diaphragmatic injuries using minithoracotomy is a viable option. In our 7 patients, the results were good, with no morbidity.

Incarcerated Gastro-thorax: a rare and delayed presentation of diaphragmatic injury due to multiple stab wounds.

Diaphragmatic injuries due to thoraco-abdominal penetrating trauma may often go unnoticed at the initial admission, especially in patients who are asymptomatic, with stable hemodynamic and respiratory parameters. Such occult diaphragmatic perforations can result in latent morbidity and mortality due to delayed trans-diaphragmatic herniation of the abdominal viscera leading to incarceration, strangulation and perforation. Here we report a case of an initially asymptomatic patient who had sustained multiple truncal stab injuries and presented two months later with a trans-thoracic incarceration of the stomach which was accurately diagnosed and successfully repaired at the time of surgery. This case report highlights the importance of exploring thoraco-abdominal penetrating injuries even in the absence initial clinical and radiological signs, so as to promptly identify occult and isolated diaphragmatic perforations and prevent delayed catastrophes. The clinical features, radiological findings, diagnostic difficulties and surgical options are discussed along with review of relevant literature.

Diagnostic laparoscopy for the evaluation of occult diaphragmatic injury following penetrating thoracoabdominal trauma

Occult diaphragmatic injury following penetrating thoracoabdominal trauma can be difficult to diagnose. Radiographic findings are often non-specific or absent. Undetected injuries may remain clinically silent, only to present later with life-threatening complications associated with diaphragmatic herniation. Diagnostic laparoscopy allows for the evaluation of trauma patients lacking clinical indications for a formal laparotomy. The purpose of this study was to evaluate the incidence of occult diaphragmatic injury and investigate the role of laparoscopy in patients with penetrating thoracoabdominal trauma who lack indications for exploratory laparotomy except the potential for a diaphragmatic injury. Haemodynamically stable patients with penetrating thoracoabdominal trauma without indications for laparotomy (haemodynamic instability, evisceration, or peritonitis on exam) and evaluated with diagnostic laparoscopy to determine the presence of a diaphragmatic injury were retrospectively reviewed. Thoracoabdominal wounds were defined as wounds bounded by the nipple line over the anterior and posterior chest superiorly and the costal margin inferiorly. One hundred and eight patients were evaluated for penetrating thoracoabdominal injuries (80 stabs and 28 gunshots) over the study period. 22 (20%) diaphragmatic injuries were identified. These were associated with injuries to the spleen (5), stomach (3) and liver (2). There was a greater incidence of haemopneumothorax (HPTX) in patients with diaphragmatic injury (32%) compared to those without injury (20%). 29% of patients with a HPTX had a diaphragmatic injury. However, 18% of patients with a normal chest radiograph were also found to have a diaphragmatic injury. The incidence of diaphragmatic injury associated with penetrating thoracoabdominal trauma is high. Clinical and radiographic findings can be unreliable for detecting occult diaphragmatic injury. Diagnostic laparoscopy provides a vital tool for detecting occult diaphragmatic injury among patients who have no other indications for formal laparotomy.

APPLICATION OF NOVEL HEMOSTATIC AGENT DURING LAPAROSCOPIC PARTIAL NEPHRECTOMY

We determined if QuikClot, a novel hemostatic agent made of a granulated mineral substance, could be used to control renal parenchymal bleeding and collecting system leakage during open and laparoscopic partial nephrectomy. After obtaining renal hilar vascular control 2 domestic female pigs underwent bilateral open and 4 underwent unilateral laparoscopic partial nephrectomy. After excision of the lower pole without cautery the hemostatic agent was applied to the cut surface of the kidney and hilar vascular control was released. Additional QuikClot was added until complete hemostasis was achieved. One week postoperatively the animals were sacrificed and the operated kidneys were harvested for ex vivo retrograde pyelograms and histopathological analysis. All partial nephrectomies were performed without complication. Mean operative and warm ischemia times were 62 and 16 minutes, respectively. An average of 23% of renal mass by weight was resected with a mean blood loss of 73 ml per procedure. No cautery, additional hemostatic agents or techniques were used. No animal had clinical or radiographic evidence of urinoma or delayed hemorrhage. Histopathological analysis showed preservation of the renal parenchyma immediately beneath the QuikClot layer. In the porcine model QuikClot allowed the resection of large renal segments, while providing reliable hemostasis and closure of the renal collecting system. No deleterious effect on underlying renal parenchyma or surrounding tissues was observed.

Thoracic splenosis mimicking thoracic schwannoma: case report and review of the literature

Background Thoracic splenosis is a rare entity. It occurs sometime after splenic and diaphragmatic injury, and it is rarely symptomatic. Case Description We report a case of left upper thoracic paraspinal splenosis 25 years after a thoracoabdominal penetrating trauma that required a splenectomy. The pathology was suspected on a routine chest x-ray and it mimicked a schwannoma on magnetic resonance imaging. Less than 40 cases of thoracic splenosis were described in the literature, but few were misinterpreted as schwannoma. Conclusion Alertness to the possibility of thoracic splenosis can lead to confirmation of the diagnosis with technetium Tc 99m–tagged red blood cell radionuclide scanning based on a previous history of traumatic splenectomy.

A prospective evaluation of thoracoscopy for the diagnosis of penetrating thoracoabdominal trauma.

Penetrating thoracoabdominal trauma presents a difficult diagnostic dilemma. Violation of the diaphragm may be very difficult to establish. Conventional diagnostic procedures such as chest radiography, computed tomography, and diagnostic peritoneal lavage have been shown to be unreliable. Mandatory exploratory celiotomy carries a 20%-30% negative rate. Twenty-eight patients with penetrating thoracoabdominal trauma over a 6-month period were prospectively evaluated by thoracoscopy at a major urban trauma center. All patients were hemodynamically stable, had no indications for immediate celiotomy, and demonstrated thoracic injury on chest radiography or physical examination. All thoracoscopy was performed in the operating room under general anesthesia. Patients consisted of 25 males and 3 females with an age range of 15-48 years. Mechanism of injury consisted of 24 stab wounds and 4 gunshot wounds. Twelve of the procedures were for right chest wounds and 16 involved the left hemithorax. Diaphragmatic injury was identified at thoracoscopy in 9 patients (32%), with all confirmed and repaired at celiotomy. Eight of 9 patients (89%) undergoing celiotomy were found to have significant intra-abdominal injuries requiring surgical repair. Thoracoscopy was also useful for evacuation of blood from the pleural space. There were no procedure-related complications. Thoracoscopy is a safe, accurate, reliable diagnostic technique for evaluating thoracoabdominal penetrating trauma. It is less invasive than celiotomy and has the added benefit of diagnosis and therapy of the intrathoracic injuries.

Peritoneal lavage in penetrating thoraco-abdominal trauma.

Forty-five consecutive patients with penetrating thoraco-abdominal trauma underwent surgical exploration to evaluate the ability of peritoneal lavage to detect peritoneal penetration. Eight patients fulfilled standard criteria for operation and did not undergo lavage. The remaining 37 patients underwent diagnostic peritoneal lavage using a closed technique before exploratory laparotomy. Using 10,000 RBC/mm3 as our previously established criterion for peritoneal penetration, there were seven true positive, one false positive, 28 true negative, and one false negative lavage for an overall accuracy of 94.6% with 87.5% sensitivity and 96.6% specificity as determined by subsequent laparotomy. While 33% of this patient cohort were found to have significant injuries (four had isolated diaphragmatic injuries, all detected by peritoneal lavage), 67% were subjected to negative surgical exploration, as accurately predicted by peritoneal lavage. Negative laparotomy carried a 10.7% operative morbidity. Based on these data we advocate diagnostic peritoneal lavage in patients with thoraco-abdominal penetrating trauma who otherwise lack operative indications.