Factors Affecting Outcomes in Penetrating Diaphragmatic Trauma

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International Journal of Surgery 11 (2013) 492e495

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International Journal of Surgery

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Original research Factors affecting outcomes in penetrating diaphragmatic trauma

Chien-Hung Liao a,c, Chih-Po Hsu b,c, I-Ming Kuo a, Chun-Hsiang Ooyang a, Shang-Yu Wang a, Jen-Fu Huang a, Chih-Yuan Fu a, Shang-Ju Yang a, Shih-Ching Kang a,*

a Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, No. 5 Fu-Hsing Street, Kwei-Shan Shiang, Taoyuan, Taiwan b Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, No. 5 Fu-Hsing Street, Kwei-Shan Shiang, Taoyuan, Taiwan

article info abstract

Article history: Backgrouds: Diagnosing penetrating diaphragmatic rupture (PDR) is a challenging aspect of managing Received 2 November 2012 thoracoabdominal injuries due to the lack of a typical clinical presentation. The mortality from PDR is Received in revised form variable and center-speciﬁc. In this study, we identiﬁed the incidence and clinical presentation of PDR at 19 March 2013 our institution and analyzed the factors that affected the length of hospital stay and mortality. Accepted 29 March 2013 Methods: We collected all patients who were diagnosed with PDR from January 2001 through December Available online 11 April 2013 2010 at a Level I trauma center. We recorded demographic characteristics, clinical parameters, diagnostic images, trauma mechanism, location and severity of injuries, injury severity score (ISS), time to diag- Keywords: Penetrating diaphragmatic rupture nosis, intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), and mortality. We Diaphragm injury analyzed the risk for mortality and prolonged hospitalization. Diagnostic timing Results: Forty-one patients with a median age of 37 years were included. Thirty-six patients (87.8%) had Diaphragm an early diagnosis, and 5 patients (12.2%) had a delayed diagnosis requiring longer than 24 h. The median Prognosis ICU LOS and HLOS were 2 and 11 days, respectively. High-grade PDR and lung injury increased the ICU LOS and HLOS. The total mortality rate was 7.3%. Multivariate analysis showed that hypothermia and hypotension were independent risk factors for mortality. Conclusion: Overlooking diaphragmatic rupture in patients with thoracoabdominal penetrating injury is not infrequent. A high index of suspicion is important for making the diagnosis. A high-grade PDR and associated lung injury prolonged the length of hospital stay. Profound hemorrhagic shock and associated physical decompensation have an impact on mortality. Ó 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction recent years, the practice of non-operative management has been extended to patients with penetrating injuries.9 Some studies Diagnosing penetrating diaphragmatic rupture is a challenge in advocate using expectant management unless the patient has the management of thoracoabdominal injuries. Acute diaphrag- continuing blood loss or increasing abdominal tenderness.9,10 matic injury occurs in 9%e47% of patients with penetrating in- However, diaphragmatic injury is not usually associated with sig- juries.1,2 However, even today, it is not unusual to overlook the nificant symptoms, which increases the delayed diagnostic rate in diagnosis of penetrating diaphragmatic rupture (PDR); a missed hemodynamically stable patients with no other visceral injury.11 diagnosis is estimated to occur in 12%e66% of patients.3,4 Murray The lack of a typical clinical presentation for PDR makes it diffi- et al. noted that occult diaphragmatic injury was discovered in 42% cult for clinical physicians to manage these patients well. of patients with lower chest penetrating trauma after initially Although the diagnosis of PDR is difficult, reduced mortality and normal physical examinations and radiographic studies.5 Intra- morbidity from PDR has been reported in recent decades.7,12 Posi- operative identification is the gold standard for confirmation of the tive pressure ventilation support and correct repair of the defect diagnosis of PDR for all patients with penetrating injuries to the has decreased respiratory distress and prevented viscera strangu- “dangerous” thoracoabdominal area.6,7 However, a high negative lation, which has improved survival.13,14 Until now, there is limited rate with laparotomy has been reported by several centers.4,8 In literature reporting the risk factors affecting the hospital stay and mortality of this injury. The aim of this study was to identify the incidence and clinical * Corresponding author. Tel.: þ886 3281200x3651; fax: þ886 3 3285818. E-mail address: [email protected] (S.-C. Kang). presentation of PDR among patients with thoracoabdominal c C.-H., Liao and C.-P., Hsu contribute equally to this work. penetrating injury at a Level I trauma center. We also attempted to

C.-H. Liao et al. / International Journal of Surgery 11 (2013) 492e495 493 determine the risk factors that influence the length of hospital stay Table 1 and the mortality rate after PDR. Characteristics of patients with penetrating diaphragmatic rupture. Characteristics 2. Materials and methods Age (years) median (range) 37 (17e54) Male:female; no.(%) 38 (92.7%):3 (7.3%) We retrospectively reviewed the trauma registry for patients with PDR treated Mechanism; no. (%) at the Chang Gung memorial hospital from January 2001 to December 2010. This Knife/impalement/gunshot 23 (56.0%)/9 (22.0%)/9 (22.0%) hospital is an urban, academic, level I trauma center with approximately 40,000 Location of PDR; no. (%) trauma visits annually. Approximately 4000 of these visits involved torsal traumatic Left/right/bilateral 19 (46.3%)/21 (51.2%)/1 (2.4%) e admissions. All medical records were individually reviewed from both the electronic Length of PDR (cm) median (range) 31 15 medical records and a manual search of paper records. Patient data were registered Grade of PDR; no. (%) into a registry prospectively. We extracted patients who suffered from penetrating II (<2 cm)/III (2e10 cm)/IV (>10 cm) 12 (29.3%)/25 (61.0%)/4 (9.8%) thoracoabdominal trauma into this cohort. The thoracoabdominal region was well Immediately diagnosis — no. (%) 12 (29.3%) defined. The thoracic region was defined by the area bounded superiorly by the Diagnosis by operation — no. (%) nipple line over the anterior and posterior chest and by the costal margin inferiorly. Under suspicion 13 (31.7%) The abdominal region was bounded by the costal margin superiorly. The anterior Incidental finding 11 (26.8%) inferior margin was the umbilical line and the posterior inferior margin was the iliac Delayed diagnosis — no. (%) 5 (12.2%) crests. The medial borders were the spine, sternum, and the vertical line between ICU LOS — days, median (range) 2 (0e47)` the xyphoid and pubic symphysis, which divided the thorax and abdomen into left Hospital LOS — days, median (range) 11 (1e66) and right halves. Patients with torsal penetration out of the thoracoabdominal area Mortality — no. (%) 3 (7.3%) were excluded from this cohort. Additionally, patients with both blunt and penetrating injuries during the same incident were also excluded. ISS: Injury severity score; RTS: Revised traumatic score; ICU LOS: Intensive care unit The thoracoabdominal penetrating injury protocol was followed. We performed length of stay; HLOS: Hospital length of stay. a laparotomy if the patient experienced hypotension, omentum or viscera herniation, bile splash, obvious peritoneal irritation, or diaphragmatic injury confirmed by an imaging study. For patients with an equivocal examination but suspicious clinical by liver (n ¼ 23, 56.1%) and lung (n ¼ 15, 36.6%) laceration. All of the picture, we performed an exploratory laparotomy or laparoscopy to exclude PDR. If a patients had a CXR taken upon arrival to the ED, but a definitive patient had no suspicion for PDR or associated injury, the patient was observed in an fi observation area or was admitted to the ward for close monitoring. diagnosis was con rmed in only 7 patients (17.1%). Seventeen pa- The clinical diagnosis of diaphragm rupture was established with perioperative tients underwent CT, and the diagnosis of PDR was confirmed in 8 findings. The imaging diagnosis was confirmed if a chest X-ray (CXR) or computed patients (52.9%) and suspected in 6 patients (35.2%). The median tomography (CT) showed visceral herniation, penetrating foreign body across the AIS of the chest was 3 (range: 0e4), and that of the abdomen was 3 diaphragm, or diaphragmatic discontinuity. If the collar sign or diaphragmatic e e thickening was present, the diagnosis of PDR was highly suspected.15,16 The diag- (range: 0 4). The median ISS score was 18 (range: 9 41), and the nostic time was defined as the time from admission to the emergency department median RTS was 7.84 (range: 1.465e7.84). (ED) to the time the correct diagnosis was established. PDR was diagnosed in 12 patients immediately from the initial The demographic and diagnostic data abstracted from the medical records imaging study (29.3%). Thirteen patients had an operation because included the following: age, gender, mechanism of injury, site of penetrating of suspicion for PDR and were found to be correctly diagnosed wounds, clinical parameters at presentation, laboratory data, imaging studies, time to diagnosis of PDR, operative findings, length of diaphragmatic rupture, associated (31.7%). There were 11 patients who had a correct diagnosis at the injuries, injury severity score (ISS), revised traumatic score (RTS), Abbreviated Injury time of operation due to other etiologies (26.8%). PDR was diag- scale (AIS) of the chest and abdomen, length of intensive care unit stay (ICU LOS), nosed in 36 patients (87.8%) within 24 h. However, in 5 patients, the length of hospital stay (HLOS), and mortality. All diaphragmatic ruptures were diagnosis took more than 24 h (12.2%). These patients had no graded according to the American Association for the Surgery of Trauma (AAST) organ injury scale.17 For grade II to IV diaphragmatic rupture, we performed single clinical symptoms or imaging abnormalities on admission to the layer repair by interrupted nonabsorbable suture (Polypropylene 2-0). For grade V ED, and their clinical presentations and injury severity were com- rupture or in case of the inability to approximate the cut edges, we used a synthetic parable to the early diagnostic group as Table 2 presented. Thirteen mesh (Marlex, Ethicon) to bridge the defect. Institutional Review Board (IRB) patients had post-operative complications. Two patients need re- approval from the Chang Gung memorial hospital was obtained (approval number: laparotomy and two patients need angiographic embolization. CGMH IRB No.100-2301B). The other nine patients were managed conservatively. 2.1. Statistical analysis 3.1. Hospital and intensive care unit stay A Pearson’s chi-square test and Fisher’s exact test were used, when appropriate, to compare categorical variables. Quantitative variables were compared using Stu- dent’s t-test, the ManneWhitney U test, and one-way ANOVA. Statistical analyses The median length of stay in the ICU (ICU LOS) was 2 days were performed with SPSS v20.0 for Mac (SPSS Inc, Chicago, IL, USA). A value of (range: 0e47 days). The median length of hospital stay (HLOS) was P < 0.05 was considered statistically significant. 11 days (range: 1 day to 66 days). A higher grade of PDR signifi- cantly prolonged the ICU LOS and HLOS. The ICU LOS for grade II, III, 3. Results and IV injuries were 3.0 2.62 days, 4.26 6.59 days, and 13.75 22.23 days, respectively (p ¼ 0.033). The HLOS for grade II, A total of 149 patients with penetrating injuries to the thor- III, and IV injuries were 12.17 7.28 days, 14.87 9.32 days, and acoabdominal area were enrolled, and 41 patients (27.5%) with PDR 31.75 25.70 days, respectively (p ¼ 0.008). Associated lung injury were identified and analyzed. The clinical characteristics of the 41 was another independent factor that prolonged the ICU LOS patients are listed in Table 1. The median age was 37 years (range: 17e54 years). The mechanisms of injury included stabbing by a knife in 23 patients (56%), other impalement or stabbing in 9 pa- Table 2 tients (22%), and gunshot wounds in 9 patients (22%). Comparison between early and delayed diagnostic groups. The most common location of penetrating wounds was the right Characteristics Early diagnosis Delayed diagnosis P-value chest (n ¼ 21, 51.2%), followed by the left chest (n ¼ 14, 34.1%). The ISS 19.39 5.69 17.40 2.61 NS anatomic location of injury to the diaphragm consisted of 21 right- RTS 7.37 1.16 6.79 0.70 NS sided injuries (51.2%), 19 left-sided injuries (46.3%), and one bilat- AIS of chest 3.11 0.88 2.40 1.34 NS eral diaphragmatic injury (2.4%). The median length of diaphrag- AIS of abdomen 2.47 1.13 2.80 0.47 NS e matic injury was 3 cm (range: 1 cm 15 cm). Hemopneumothorax ISS: injury severity score; RTS: revised traumatic score; AIS: Abbreviated Injury (n ¼ 37, 90.2%) was the most common associated injury, followed scale. ORIGINAL RESEARCH

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(absence vs presence: 2.24 2.49 vs 9.50 13.18 days, p ¼ 0.011) clinical presentation, imaging studies, and injury severity were and the HLOS (absence vs presence: 12.24 7.49 vs 22.07 16.33 comparable to the early diagnostic group. There was no reliable days, p ¼ 0.014). Most of the patients (n ¼ 35, 85.3%) were followed diagnostic factor for early diagnosis. In the delayed group, three up in the outpatient department for 6 months, and there was no patients underwent follow-up CT, and the other two had serial recurrence of diaphragmatic herniation in this series. CXRs to make the correct diagnosis when their clinical symptoms progressed. Because these patients were closely monitored in the 3.2. Factors that affected mortality observation area or the ward, aggressive management was taken when they developed new signs and symptoms. Therefore, patients The mortality rate was 7.3%. Risk factors for mortality due to PDR did not have visceral strangulation, which is thought to result in are shown in Table 3. A body temperature <35 C, SBP < 90 mm Hg, high mortality and morbidity. Hb < 10 gm/dL, ISS > 20, packed red blood cell (pRBC) transfusion After reviewing the literature, we found that a delayed diagnosis requirement >5 units, and a base deficit >6 all increased the risk of of PDR was associated with morbidity and mortality rates as high as death. Multivariate analysis showed that an SBP < 90 mmHg 36%.20,21 However, a delay in the diagnosis did not increase the (p ¼ 0.004) and BT < 35 C(p < 0.001) were significant risk factors mortality or morbidity in this series, which was supported by some for mortality. authors who advocated that delaying the diagnosis and interven- tion for diaphragmatic rupture did not increase mortality.22,23 We 4. Discussion believe that serial radiologic imaging and close monitoring were helpful to detect delayed onset PDR and initiate prompt interven- Acute penetrating diaphragmatic rupture is a rare entity in tion in the delayed group. As a result, these patients had results trauma care, and its incidence varies throughout the world. The equivalent to those for the patients in the early group.12,24 frequency of PDR is a reflection of the individual geographic and The average ICU LOS and HLOS were prolonged in the presence socioeconomic region served by each hospital. In this series, the of a high-grade diaphragmatic injury and if lung injury occurred. incidence of PDR in thoracoabdominal penetrating injury was The diaphragm is the main muscle of respiration and is the natural 27.7%. barrier between the thorax and abdomen. Defects of the diaphragm The early diagnosis of PDR is still a challenge in trauma care. influence respiration and induce visceral herniation. High-grade Even in experienced trauma centers worldwide, an early diagnosis diaphragmatic injury interferes with respiratory function, even is made in only 34%e88% of patients.18 Physical examination is not after the initial injury is repaired.25 Profound diaphragm injury reliable for making the diagnosis if the patient has no symptoms. decreases functional volume capacity and tidal volume, and in- Penetrating injury may affect a small area of the diaphragm and duces a greater degree of atelectasis. For all of these reasons, high- result in the absence of significant findings on physical examination grade diaphragmatic injury prolongs the patient’s ICU LOS and or radiographic studies. An initial CXR offers a limited advantage for HLOS. Lung parenchymal injury, which may induce hemorrhage, making the diagnosis. Only 7 patients (17%) benefited from a CXR. worsen atelectasis, and interrupt gas exchange, also lengthens the Multi-slice CT is more effective for the diagnosis of PDR. Stein et al. ICU LOS and HLOS. Although there are many papers that focus on reported that an abdominal CT detected penetrating diaphragmatic the mortality following PDR, there were no previous studies that rupture in 82.1% of patients.19 In this study, the CT absolute diag- discussed the ICULOS and HLOS. We identified that diaphragm nostic rate was 52.9%, and the suspicious diagnostic rate was 35.2%. injury severity and associated lung injury were independent risk Detecting occult diaphragm injury is a difficult task and some au- factors that affected the length of hospital stay and ICU stay. thors advocate an aggressive attitude to exclude possible PDR in The mortality rate in this study was 7.3% (3/41). We analyzed the patients with equivocal presentations.1,2 We applied a relatively diagnostic time to PDR and found no obvious effect on mortality. aggressive protocol. In our study, 6 patients had laparoscopic ex- Furthermore, neither length nor location of the diaphragmatic amination and 11 patients had laparotomy for suspicion of PDR, and injury posed a significant risk to survival. As Table 3 shows, all of 13 patients had a correct diagnosis and repair within 24 h. More these risk factors were related to profound bleeding and severe than one-third of patients with PDR may be diagnosed early under associated injuries. Our findings provide support to previous a high index of suspicion, which is one of the most important in- studies.12,26 On multivariate analysis, a SBP < 90 and BT < 35 C dicators of early diagnosis. For patients with high suspicion of PDR, were independent risk factors for mortality. This implies that dia- aggressive approach might be applied. In order to prevent the phragmatic injury itself does not induce mortality, but severe complications of laparotomy, diagnostic laparoscopy was advised associated injuries and profound hemorrhagic shock are the major to exclude this easily missing injury.1,8 causes of death. Therefore, appropriate resuscitation and correction Although we used a relatively aggressive therapeutic protocol, of physiologic compromise are more meaningful12,23 in the man- there were still five patients with delayed diagnosis (12.2%). Their agement of patients with thoracoabdominal penetration rather than diagnosing or treating PDR itself. In a crowded emergency department, rapid correction of the physiologic compromise and early transfer of patients who meet the risk criteria will increase Table 3 Risk factors that influenced mortality for penetrating diaphragmatic rupture. survival for patients with PDR. Although the results of this study offer valuable insights into Risk factors Univariate analysis Multivariate analysis PDR, the study itself has some limitations. First, this was a retro- p-Value p-Value spective review at a single trauma center, and although most char- Diagnostic time <24 h 1.000 acteristics were recorded prospectively, selection bias cannot be Temperature <35 C <0.001 <0.001 completely excluded. Second, due to geographic distribution, thor- < SBP 90 mm Hg 0.035 0.004 acoabdominal penetrations were not common at our institution, Hemoglobin <10 g/dL 0.018 NS PRBC transfusion >5 units 0.028 NS and the small number of cases in this series may lead to type II ISS > 20 0.025 NS statistical error. Role of thoracoscopy in managing PDR was well Base deficit >6 0.048 NS established.6,27 However, we had no experience of diagnostic thor- SBP: systolic blood pressure; PRBC: packed red blood cells; ISS: injury severity score; acoscopy. We can perform thoracoscopy for PDR after development NS: non-significant. of experience and improvement of instruments in the future. ORIGINAL RESEARCH

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In conclusion, the diagnosis of PDR is still a clinical dilemma 9. Demetriades D, Rabinowitz B. Indications for operation in abdominal stab 205 e in patients with thoracoabdominal penetrating injury. There are wounds. A prospective study of 651 patients. Ann Surg 1987; (2):129 32. [Epub 1987/02/01]. fi no reliable clinical parameters to con rm PDR. A high index of 10. Velmahos GC, Demetriades D, Toutouzas KG, Sarkisyan G, Chan LS, suspicion is important. A high-grade diaphragmatic injury and Ishak R, et al. Selective nonoperative management in 1,856 patients associated lung injury prolong hospital stay. Hypotension and hy- with abdominal gunshot wounds: should routine laparotomy still be the standard of care? Ann Surg 2001;234(3):395e402 [discussion -3. Epub pothermia are the main risk factors for mortality. 2001/08/29]. 11. Wilson E, Metcalfe D, Sugand K, Sujenthiran A, Jaiganesh T. 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