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Traumatic Diaphragma Rupture: an Experience of 13 Cases

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Traumatic Diaphragma Rupture: an Experience of 13 Cases A. I. Filiz et al / Traumatic lesions of the diaphragm Eastern Journal of Medicine 13 (2008) 25 - 29 Original Article Traumatic diaphragma rupture: an experience of 13 cases Ali Ilker Filiza, Yavuz Kurta, Ilker Sucullua*, Ergun Yucela, M.Levhi Akına aGulhane Military Medical Academy, Haydarpasa Training Hospital, Department of General Surgery, Istanbul, Turkey Abstract. Diaphragmatic injury is a rare condition, but late diagnosis may be associated with increased mortality and morbidity. The aim of this study was to present our experience with the management of this injury. Between 2004 to 2007, 13 patients with traumatic diaphragmatic rupture or diaphragmatic hernia were treated. We described the findings in patients, who had operated urgent or had complaints due to intestinal obstruction months to years after an injury. All patients were male and mean age was 23.1 years. Diaphragmatic rupture was left-sided in all patients. Six of these patients had blunt and the remaining 7 had penetrating trauma. Diagnosis of diaphragmatic rupture was established in less than 24 hours in 4 patients. In the remaining 9 patients, who developed intra- throracic herniation of abdominal organs, diagnostic delay ranged from 12 to 48 months. The most frequent herniated organ was transverse colon. Non-absorbable sutures were used for closure of the defect. Complication rate was 30% and no death was observed. After blunt or penetrating trauma in upper abdomen and distal chest, a high index of suspicion is important to diagnose diaphragmatic rupture. Late presentations are associated with increased morbidity. Key words: Blunt/penetrating trauma, diaphragmatic rupture, diaphragmatic hernia, complication reported that missed diaphragmatic injuries in 1. Introduction conservatively-managed patients range from 12% Traumatic diaphragmatic hernia (TDH) was to 66% (5,6). Undetected injuries may remain first described by Sennertus in 1541 (1). clinically silent for hours to years (7) and are Diaphragmatic hernia is a herniation of often associated with late complications such as abdominal organs to the thoracic cavity through herniation and strangulation of intraabdominal the diaphragmatic defect (2). Traumatic organs. This situation is usually in correlation diaphragma defect usually occurs due to a blunt with increased morbidity and mortality. The aim or penetrating injury. Acute diaphragmatic of this study was to review the experience of our rupture (ADR) arises in 1 - 7% of blunt trauma service with the management of TDH. and in 10 - 15% with penetrating trauma to the 2. Materials and methods lower chest (3). Penetrating trauma, such as gunshot or stab wounds of the upper abdomen The data were collected over the period from and lower thorax, more commonly affects the left 2004 to 2007. Patients with blunt or penetrating hemidiaphragm. In penetrating traumas, the trauma were included in the study. We reviewed possibility of diaphragmatic injury should be kept and analyzed all the records of the patients. The in mind. The diaphragmatic injury can be side of rupture, mechanism of injury, diagnostic diagnosed at laparotomy, but the preoperative methods, mortality and morbidity, herniated diagnosis is difficult in the absence of organs and management of organ injuries were simultaneous organ injury (4). It has been evaluated. Acute diaphragmatic rupture defined as rupture of diaphragm in the acute phase, extends from the time of original trauma to the *Correspondence : Assistant Professor, Ilker SUCULLU, MD apparent recovery from the primary injuries (14 Gulhane Military Medical Academy, Haydarpasa Training days). Traumatic diaphragma hernia is defined as Hospital, Department of General Surgery, Istanbul, Turkey intraabdominal viscera occupy the defect and Phone : + 902165422806, +905057169133 variably herniate into the thoracic cavity and then Fax : + 902164494480 begins with the signs of visceral obstruction or e-mail : [email protected] ischemia as in other hernias. 25 A. I. Filiz et al / Traumatic lesions of the diaphragm Table 1. Characteristics of injury in 13 patients In the TDH group, all patients presented with mechanical obstruction. Preoperative diagnoses Mechanism of ADR group TDH group of intrathoracic herniation were accurately made injury in all of the patients based on physical Penetrating trauma examination, chest x-rays and CT. Chest x-rays Stab wounds 2 5 suggested diaphragmatic hernia in only three Blunt Trauma patients (33%), and intrathoracic bowel gas was Traffic accident 2 3 determined. Computerized tomography scan of Fall from height - 1 the chest and upper abdomen was performed in ADR= Acute diaphragmatic rupture, TDH= Traumatic all hemodynamically stable patients. It was diaphragmatic hernia diagnosed in all of them and indicative of abdominal organ herniation into the chest. 3. Results 4. Management The study identified 13 male patients ranging in In the ADR group, one patient presented with age from 20 to 37 years (mean 23.1 years). The massive haemorrhage via the chest tube and was most common cause of diaphragmatic injury was suspected of having an intrathoracic injury. We penetrating trauma (7 patients, 53%). All preferred an emergency left thoracotomy as an penetrating injuries were due to stab wounds. initial approach and determined that no Blunt injuries had a prevalance of 47% (6 intrathoracic injury was present. The reason for patients). While 83% of blunt traumas were from the massive haemorrhage was herniation of the traffic accidents, the remaining 17% (one patient) spleen into the thoracic cavity and iatrojenic occurred in falling from a height. We divided the splenic laceration due to chest tube insertion. A patients into two groups. While the ADR group splenectomy was performed through the included 4 patients, the TDH group had 9 thoracotomy incision. The other patient, who patients. Table-1 shows the characteristics of presented with drainage of colonic contents via injuries in both of the groups. the chest tube, underwent laparotomy. It was seen Patients diagnosed with ADR were admitted to that the transverse colon was also injured because our hospital within 24 hours after the trauma. of the chest tube which had been accidentally Nine patients with a history of trauma more than placed into the herniated colon. These two one year presented with intestinal obstruction as a patients were referred from other hospital with late complication of traumatic rupture of the chest tubes inserted. The other two patients had diaphragm. undergone laparoscopy and the defects were The patients, who were managed due to repaired laparoscopically with interrupted mechanical obstruction in our center, were nonabsorbable sutures. Chest tubes were initially followed-up in another health center routinely placed in all patients. after the injury and diagnostic delay ranged from All patients in the TDH group were treated 12 to 48 months. All the patients had rupture on surgically. Reduction of the herniated organs and the left hemidiaphragm. The patients in the ADR repair of the diaphragm were done through group had associated injuries which include laparotomy in all patients (Fig. 1). hemothorax in one, pneumothorax in one, Interrupted non-absorbable sutures were used clavicle fracture in one and extremity fracture in for closure of the diaphragmatic defect through a one patient. thoracotomy in one patient and through a Preoperative chest x-rays were obtained for all laparotomy in the others in the ADR group. No patients in the ADR group, and one of those was mesh was required to repair the defect. considered as hemothorax and the other as Intrathoracic herniation was seen in two pneumothorax. Chest tubes were inserted in these patients in the ADR group (50%), which included patients. Chest x-rays and thoracoabdominal spleen (n=1) and transverse colon (n=1). The computerized tomography (CT) were performed herniated organs in the TDH group respectively on the other two patients, who were were, transverse colon (n=3), small bowel (n=3), hemodynamically stable, during the initial stomach (n=1), omentum-small bowel (n=1) (Fig. evaluation, but the radiological findings were not 2) and stomach-colon (n=1). In one patient diagnostic in these patients. Laparoscopic transverse colon resection was necessary because evaluations were made with the suspicion of of the herniated and strangulated colon part. diaphragmatic rupture (DR), and diaphragmatic injuries were detected by laparoscopy. 26 A. I. Filiz et al / Traumatic lesions of the diaphragm Original Article a b Fig. 1. a) Herniated organs through the defect. Omentum (thin arrow), small bowel (thick arrow) b) Diaphragmatic defect (arrow) 6. Discussion 5. Outcome Traumatic diaphragmatic hernia can be divided Four patients developed postoperative into three phases: the acute phase where a complications releated to surgery (30%). These patient’s diagnosis is established immediately up included thoracic empyema in one patient, to 14 days after injury; the second phase where mechanical bowel obstruction in one, pneumonia patients are diagnosed in the period after acute in two. They were all treated succesfully either injury, but before intestinal obstruction or surgically or conservatively. No patients died in strangulation; and the third phase because the our study groups. The mean hospital stay was 14 patients were in that phases. days (range 2 – 36 days). Follow-up ranged from Diaphragmatic rupture (DR) is an uncommon, 2 to 36 months. Four patients (30%) were lost to but severe problem
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