Traumatic Diaphragmatic Rupture Research Articles

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.

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 & 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.

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.

Early diagnosis of traumatic diaphragmatic rupture

Early diagnosis of traumatic diaphragmatic rupture

Post-traumatic diaphragmatic rupture with pericardial denudation: A case report.

IntroductionPost-traumatic diaphragmatic rupture is a lesion of variable severity. It is a rare and difficult to diagnose pathology, it has been found in 0.4% of all traumatized patients and in 1.9% of blunt traumas. It can be associated with abdominal andthoracic lesions, particularly cardiac, which can be life-threatening.Materials and methodsOur work is a retrospective case report with a descriptive aim concerning a patient operated for a post-traumatic diaphragmatic rupture within the department of general surgery of CHU Ibn Rochd Casablanca. This work has been reported in line with the SCARE 2020 criteria (17).Case presentationA 60-year-old patient was admitted to the visceral surgical emergency department following a work accident (crushing between two carts) causing a thoraco-abdominal impact point trauma without initial loss of consciousness, nor externalized digestive hemorrhage or associated signs, but with a general condition alteration. The patient was conscious, dyspneic with a blood pressure of 100/50 mmHg and afebrile. Physical examination showed diffuse abdominal sensibility. The thoraco-abdomino-pelvic CT scan revealed the presence of a left thoracic hernia with gastric, colic and epiploic contents through a lateral defect of the left diaphragmatic dome. The decision was to directly send the patient to the operating room. Exploration found a large left diaphragmatic breach of 20 cm, a denudation of the pericardia, a medium-abundant hemoperitoneum and a hematoma of the right mesocolon. The procedure consisted of right hemicolectomy with ileocolic anastomosis, treatment of a diaphragmatic breach with a 2-silk raphia, thoracic drainage with a Joly drain, pericardial drainage with a Joly drain, pre-anastomotic drainage with 2 delbet slides, drainage of the Douglas and left subthreshold with 2 Salem catheters. The post-operative follow-up was simple.DiscussionDiaphragmatic rupture is a rare and difficult to diagnose condition. Traumatic diaphragmatic rupture (TDR) was found in 0.4% of all traumatized patients and in 1.9% of blunt trauma. Associated lesions of the spleen, liver and/or lungs were found in more than 30% of cases, with an overall mortality rate of 26.8% (1). Pericardial rupture following blunt chest trauma is rare and associated with a high mortality rate ranging from 30% to 64% (9).The physiopathology of this type of injury is not well understood, but the most accepted hypothesis describes an increase in intra-abdominal pressure due to a blunt creating a sufficiently high-pressure gradient between the chest and the abdomen to cause a diaphragmatic rupture. The common clinical symptoms of a diaphragmatic rupture are a marked respiratory distress and diffuse abdominal pain but it can be asymptomatic. Medical imaging exams visualize the ascended organs but it's more difficult to visualize the rupture itself. The chest X-ray is currently the first examination to be requested (4) and also helps in the diagnosis of injuries and diaphragm rupture (13). Surgical treatment includes the reduction of any visceral hernia, repair of the diaphragm and restoration of circulation, breathing and digestive functions. Laparotomy is generally used because of the complete exploration of the abdominal viscera, although it is easier to reduce herniated tissue and repair the diaphragm.ConclusionDiaphragmatic rupture with denudation of the heart is rare with poor prognosis and requires emergency surgery with close postoperative monitoring in the intensive care setting.SummaryPost-traumatic diaphragmatic rupture is a lesion of variable severity. It is a rare and difficult to diagnose pathology, it has been found in 0.4% of all traumatized patients and in 1.9% of blunt traumas. The lesions are more frequent in the left diaphragmatic dome compared to the right one, and exceptionally bilateral. Pericardial rupture following blunt chest trauma is rare and associated to a high mortality rate.It is often unrecognized and goes unnoticed in the acute phase. The most common clinical symptoms of diaphragmatic ruptures are respiratory distress and diffuse abdominal pain, as it can be asymptomatic. Its diagnosis is essentially radiological using CT scan, and requires emergency surgical treatment as soon as the diagnosis is suspected, in order to avoid the dreaded complications.Traumatic diaphragmatic rupture remains a diagnostic and therapeutic challenge.We report the case of a patient who presented a post-traumatic diaphragmatic rupture with pericardial damage operated in the visceral emergency department at the Ibn Rochd Hospital c in Casablanca, Morocco.

AB136. SOH21AS046. Delayed gastropleural fistula: a rare cause of a persistent pleural effusion after blunt force trauma

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.

Laparoscopic repair for delayed right-sided traumatic diaphragmatic rupture (with video)

Laparoscopic repair for delayed right-sided traumatic diaphragmatic rupture (with video)

Traumatic diaphragmatic rupture with liver laceration in a 2-year-old child after blunt abdominal trauma: A case report

Diaphragmatic rupture after blunt abdominal trauma is a rare entity in pediatric age group. We report a 2-year-old child who presented to us with respiratory distress after he fell from bike. Initial evaluation had a suspicion of pneumothorax, but computed tomography scan confirmed that he had a diaphragmatic tear along with herniation of abdominal contents in left hemithorax. The child was managed successfully with open surgical approach. Since there are no specific signs and symptoms to diagnose this condition, high index of suspicion should be kept in all cases of abdomino-thoracic injuries.

Transdiaphragmatic Chest Wall Herniation

The combination of traumatic simultaneous diaphragmatic rupture and chest wall herniation remains rare, with 42 cases of traumatic transdiaphragmatic intercostal hernia (TDIH) reported in the literature since 1946. An accurate count of cases is difficult to obtain, as TDIH nomenclature has been variable.1-5 Risk factors for traumatic TDIH are not well established. As these injuries are uncommon, best management techniques have yet to be established. Reported repair techniques include primary closure, closure with mesh, and implantation of prosthetic or autologous material. We present our single-center series of 7 patients, the largest reported to our knowledge, and discuss the challenges of repairing these difficult injuries. After obtaining institutional review board approval, data were abstracted from the electronic medical record on all adults who underwent evaluation and treatment for traumatic TDIH between July 2014 and January 2019. Of the 7 cases of traumatic TDIH, 6 patients developed TDIH secondary to cough; the seventh patient presented with chronic chest wall pain after an episode of heavy lifting. All patients were obese or overweight. Pain and a "popping sensation" were the most common presenting symptoms. All patients underwent operative intervention with primary repair of the diaphragm and suture approximation of the ribs. 3 patients had onlay mesh repair of the chest wall and/or abdominal wall. 1 patient had plating of his rib fracture. 3 patients had a recurrence of the intercostal portion of the hernia No patients have undergone reoperation thus far. While previously thought to more commonly occur on the left side due to the protective effects of the diaphragm,2 the majority in this series had right-sided injuries. Herniation through the ninth-10th interspace remains the most common location.4 Computed tomography imaging should be used for diagnosis and operative planning. It is best to manage these hernias acutely to re-establish normal anatomy. Mesh may be required in delayed reconstructions of if the chest wall cannot be re-approximated. Rib plating should be considered in cases of instability or flail. High rates of complications are not unexpected given the complicated and rare nature of the injury. Given the high rate of intercostal hernia recurrence, it is likely that mesh repair or should be more often used in the treatment of this injury.

MDCT OF ABDOMINAL WALL LUMBAR HERNIAS

Purpose:To review the anatomical landmarks of the abdominal wall lumbar region and its normal appearance on multidetector computed tomography (MDCT) and to briefly describe the MDCT features of lumbar hernias.Diagnosis of traumatic diaphragmatic hernia due to blunt abdominal trauma requires a high index of suspicion. This study was conducted to assess the accuracy of multidetector computed tomogram (MDCT) in the diagnosis of traumatic diaphragmatic hernia.Diaphragmatic injuries remain a diagnostic challenge for both radiologists and surgeons. The detection of traumatic diaphragmatic rupture in the acute setting is problematic because specific clinical signs are usually not evident. Furthermore, the high frequency of associated injuries (52–100%) may distract from diaphragmatic injury. In conservatively managed patients, the rate of initially missed diaphragmatic injuries ranges from 12 to 66%, and they may even be overlooked at laparotomy. Diagnosis of a diaphragmatic injury requires a high index of suspicion, as delayed diagnosis increases the chance of visceral herniation and strangulation, which has mortality as high as 60%. Thus, the ability to detect diaphragmatic injuries with noninvasive techniques is increasingly important. Initial reports found CT to have sensitivity equal to that of chest radiography (i.e., 0–50%). Because of a dramatic reduction in motion and beam-hardening artifacts and significant improvement of spatial resolution, especially along the z-axis, helical CT and multisection CT allow better demonstration of most subtle signs of diaphragmatic herniation. In addition, these are also useful tools in the evaluation of patients with multiple traumatic injuries. Traumatic diaphragmatic hernias (TDHs) are sometimes difficult to identify at an early stage and can consequently result in diagnostic delays with life-threatening outcomes. It is the aim of this case study to highlight the difficulties encountered with the earlier detection of traumatic diaphragmatic hernias. Methods: We performed a retrospective search of the imaging report database from November 2007 to October 2011. We retrieved the clinical data and MDCT studies of patients suffering from abdominal wall lumbar hernias. We reviewed the imaging features of abdominal lumbar hernias and compared those with the normal appearance of the lumbar region in asymptomatic individuals.We assessed variables such as age, gender, mechanism of trauma, methods of diagnosis, herniated organs and associated lesions, time of evolution, morbidity, and mortality. Anteroposterior supine chest radiograph, which was performed in all patients, was also analyzed. Computed tomogram (CT) was performed on four-slice MDCT after an IV bolus of iodinated contrast agents. A slice thickness of 4 mm at a pitch of 1.5 was useful to evaluate thorax and abdomen with reconstruction at 1 mm reconstruction increment. An oral contrast agent was given whenever required. Multiplanar reconstruction was done in sagittal and coronal planes. Images were read in lung parenchyma, soft tissues, and bone windows. Findings were analyzed in a prospective manner to evaluate their use as a diagnostic modality as well as to determine their contribution to patient management. Results:We classified lumbar wall hernias as diffuse, superior (or Grynfelt–Lesshaft) and inferior (or Petit) lumbar hernias. We briefly describe the imaging features of each subtype and review the anatomy and MDCT appearance of normal lumbar region.Currently available MDCT provides an excellent opportunity for reviewing the normal anatomy of the wall lumbar region and may be considered a useful modality for evaluating lumbar hernias.Regarding Diaphragmatic hernia following blunt trauma:MDCT is a highly accurate modality for diagnosing traumatic diaphragmatic hernia. In addition, it is fast and compatible with various life-support systems hence, it can be used in acute trauma setting for making a diagnosis and helping in the management.Delayed traumatic diaphragmatic hernias are not common, but can lead to serious consequences once occurred. Early detection of diaphragmatic injuries is crucial to prevent the occurrence of dTDHs. Surgeons should maintain a high suspicion for injuries of the diaphragm in patients who had suffered abdominal or lower chest traumas, especially during the initial surgical explorations. The need for radiographical follow-ups is emphasized to detect diaphragmatic injuries at an earlier stage.

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.

Paediatric traumatic rupture of the diaphragm

Traumatic diaphragmatic rupture is not a common injury in children. It is an important cause of morbidity and mortality, though diagnosis may be missed or delayed with atypical clinical presentation and confounding radiological features. A 4-year-old male presented with periumbilical abdominal pain, bilious vomiting, fever and progressive difficulty in breathing for two days. He had complained of vague left-side chest pain on return from the swimming pool about 6 weeks earlier. An initial chest radiograph showed a non-outlined left hemidiaphragm, a left pneumothorax, rightward mediastinal shift and suspected bowel in the chest. He could not afford a CT scan, hence a repeat chest radiograph was performed, which outlined the stomach with an air-fluid level in the left hemithorax. Keywords: Traumatic Diaphragmatic Rupture, Child, Atypical Chest pain, Blunt injury

Surgical Management of Herniated Intrathoracic Gastric Perforation in Traumatic Diaphragmatic Rupture: An Unusual Two Rare Cases

Gastric perforation into the thoracic cavity through a diaphragmatic rupture is rare but, when it occurs, patients present in severe distress, with mortality approaching 50%. We present our experience of two rare and unusual cases of traumatic diaphragmatic rupture from penetrating chest injury associated with herniated intrathoracic gastric perforation over a five-year period from January 2015 to December 2020 at the cardiovascular and thoracic surgery department of the Komfo Anokye Teaching Hospital in Kumasi, Ghana. Both patients underwent successful surgical repair through standard posterolateral thoracotomy with one having earlier negative exploratory laparotomy. The essence of the paper is to share and discuss the clinical presentation, diagnostic challenges, surgical management and the postoperative care of this very rare complication of traumatic diaphragmatic rupture.

Considerations about Traumatic Diaphragmatic Rupture, Case Series and Review of Literature

Considerations about Traumatic Diaphragmatic Rupture, Case Series and Review of Literature

Traumatic Rupture of Diaphragm and Chest Wall Secondary to COPD Exacerbation

Traumatic Rupture of Diaphragm and Chest Wall Secondary to COPD Exacerbation

Delayed traumatic diaphragmatic rupture: diagnosis and surgical treatment.

To investigate the diagnosis and surgical therapy of delayed diaphragmatic rupture. Forty patients with traumatic diaphragmatic rupture with delayed presentation and diagnosis were collected in Peking Union Medical College Hospital from 2000 to 2018, and a retrospective analysis was performed. In all forty patients, 36 (90%) patients had a traumatic past history, and 32 (80%) patients had clinical manifestations when diagnosed. Left-sided diaphragmatic rupture was found in 32 (80%) patients and right in 8 (20%) patients. One patient received emergency surgery, and 39 received selective surgery. Thirty-eight patients received thoracotomy, and 2 patients received combined thoracic-abdominal surgery. Thirty-six patients received direct diaphragm suture, and 4 patients received mesh repair. One patient had an intestinal obstruction and received enterolysis 19 days after surgery. During follow-up, 1 patient experienced recurrence 2 years later. Careful recording of past history and physical examination are the best approaches in diagnosing delayed presentation of traumatic diaphragmatic rupture. CT scan with reconstruction of the diaphragm is helpful in both diagnosis and differential diagnosis. Surgical therapy after diagnosis is the best treatment.

The Successful Removal of a Foreign Body in the Spleen via Diaphragm Laceration Site by Video-Assisted Thoracoscopic Surgery

A 73-year-old man, who, in an inebriated state, had slipped in a flowerbed and was wounded on the left f lank, was transferred to Trauma Center, Gil Medical Center, Gachon University College of Medicine. Based on the chest and abdominopelvic computed tomography, he was diagnosed with multiple rib fractures and hemopneumo-thorax on the left hemithorax and was found to have a bony fragment in the spleen. He had not presented peritonitis and exsanguinous symptoms during the observation period. Seven days later, computed tomography of the abdomen showed suspected diaphragmatic injury and a retained foreign body in the spleen. On exploration by video assisted thoracoc surgery (VATS), a herniated omentum through the lacerated site of the diaphragm was observed. After omentectomy using Endo Gia, the foreign body in the spleen was observed through the lacerated site of the diaphragm. Traumatic diaphragm rupture with a foreign body, in the spleen, was successfully managed by video assisted thoracic surgery via the lacerated site of the diaphragm.

Two-Stage Detected Traumatic Right Diaphragm Rupture after Blunt High-Velocity Trauma

Two-Stage Detected Traumatic Right Diaphragm Rupture after Blunt High-Velocity Trauma