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RESUMEN La hernia diafragmática traumática se define como el paso del contenido abdominal a la cavidad torácica a través de un defecto en el diafragma producido por un trauma. Su diagnóstico es difícil, a menudo puede pasar inadvertido, debido a la gravedad de las lesiones que le acompañan. Las claves para el diagnóstico son un alto grado de sospecha y el conocimiento de los distintos signos en la tomografía computarizada. Una vez diagnosticada la ruptura diafragmática, se repara quirúrgicamente para evitar complicaciones. Se presenta el caso de un paciente masculino, de 88 años de edad con antecedentes de haber sufrido trauma toracoabdominal cerrado hacía 35 años, que acudió con un cuadro clínico de oclusión intestinal. Se publica este caso porque, además de ser una entidad poco frecuente, resulta importante el conocimiento de esta enfermedad, para valorarla dentro de las posibilidades diagnósticas en aquellos pacientes que aquejen síntomas relacionados con sus complicaciones.
ABSTRACT Traumatic diaphragmatic hernia is defined as the passage of abdominal contents into the thoracic cavity through a defect in the diaphragm caused by trauma. The diagnosis of traumatic diaphragmatic hernia is difficult, it can often go unnoticed, due to the seriousness of the accompanying injuries. The keys to diagnosis are a high degree of suspicion and knowledge of the various signs on computed tomography. Once the diaphragmatic rupture is diagnosed, it is surgically repaired in order to avoid complications. The case of an 88-year-old male patient with a history of having suffered closed thoracoabdominal trauma 35 years earlier, who presented with a clinical picture of intestinal obstruction is presented. This case is published because, in addition to being a rare entity, knowledge of this disease is important, in order to assess it within the diagnostic possibilities, in those patients who suffer from symptoms related to its complications
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ABSTRACT Introduction: diaphragmatic injury is a challenge for surgeons. It is an injury that can be isolated. It is frequent in penetrating thoracoabdominal trauma. It represents a diagnostic challenge and the ideal approach is not yet well established. The occurrence of spontaneous healing of these injuries is still much discussed and even more, if it does, what is the healing mechanism? Objective: to macroscopically and histologically evaluate the natural evolution of perforation and cutting wounds equivalent to 30% of the left diaphragm. Method: 50 specimens of rats underwent a surgical procedure and, after 30 days, were euthanized and those that presented scar tissue in the diaphragm, the samples were submitted to histopathological study, using the hematoxylin and eosin stains, Massons trichrome and Picrosirius to assess the presence of collagen or muscle fibers (hyperplasia) in the scar. Results: it was found that healing occurred in diaphragmatic injuries in 90% of rats. We also observed the presence of fibrosis in all analyzed samples. Conclusion: Spontaneous healing occurred in most diaphragmatic injuries and the inflammatory reaction represented by the presence of fibrosis and collagen deposition was observed in all our samples. Muscle fiber hyperplasia did not occur.
RESUMO Introdução: o ferimento diafragmático é um desafio para os cirurgiões. É uma lesão que pode ser isolada. É frequente nos traumas penetrantes toracoabdominais. Representa um desafio diagnóstico e a conduta ideal ainda não está bem estabelecida. A ocorrência da cicatrização espontânea dessas lesões é ainda muito discutida e mais ainda, se ocorre, qual o mecanismo de cicatrização? Objetivo: avaliar macroscopicamente e histologicamente a evolução natural das feridas perfuro cortantes equivalentes a 30% do diafragma esquerdo. Método: 50 espécimes de ratos, foram submetidos a procedimento cirúrgico e, após 30 dias, foram submetidos à eutanásia e aqueles que apresentaram tecido cicatricial no diafragma, as amostras foram submetidas a estudo histopatológico, usando as colorações de hematoxilina e eosina, tricrômico de Masson e Picrossirius para avaliar a presença de colágeno ou de fibras musculares (hiperplasia) na cicatriz. Resultados: verificou-se que ocorreu nas lesões diafragmáticas, a cicatrização em 90% dos ratos. Observamos também, a presença de fibrose em todas as amostras analisadas. Conclusão: ocorreu cicatrização espontânea na maioria das lesões diafragmáticas e a reação inflamatória representada pela presença de fibrose e deposição de colágeno foi observada em todas as nossas amostras. Não ocorreu hiperplasia de fibras musculares.
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Abstract Introduction: Diaphragmatic injuries are a common finding in patients with penetrating thoracoabdominal trauma. Their diagnosis requires exploration through open or laparoscopic surgery. However, multislice computed tomography (MSCT) emerges as a useful noninvasive tool for this purpose. Objective: To determine the diagnostic performance of MSCT for detecting diaphragmatic injuries in hemodynamically stable patients with penetrating thoracoabdominal trauma. Materials and methods: Prospective study conducted on 119 patients treated at the Hospital Universitario del Valle, Cali, Colombia, between March 2012 and June 2015. In order to evaluate the diagnostic performance of MSCT, the results obtained through this test were compared with those reported in the reference test (open surgery). Two readings of the imaging studies were performed by 2 radiologists. Intra- and interobserver agreement on the MSCT readings were analyzed using the Fleiss' Kappa coefficient. Results: MSCT had sensitivity and specificity of 94.4% and 46.8%, respectively. Its positive (PPV) and negative (NPV) predictive values were 44.7% and 94.8%, respectively. The positive likelihood ratio (LR+) was 1.7765, and the negative likelihood ratio (LR-) was 0.1186. Regarding interobserver agreement, Fleiss' Kappa coefficient between the first reading of both radiologists was 0.4425. Conclusions: MSCT specificity for diagnosing diaphragmatic injuries found in this study differs considerably from that reported in the literature. Considering the sensitivity, PPV and LR- values obtained in the present study, MSCT could be an important tool for the management of these patients since conservative treatment may be used in patients whose diaphragmatic injuries are not detected with this type of scan.
Resumen Introducción. Las heridas diafragmáticas son un hallazgo común en pacientes con trauma toracoabdominal penetrante. Su diagnóstico requiere exploración mediante cirugía abierta o laparoscópica. Sin embargo, la tomografía computarizada multidetector (TCMD) surge como una herramienta no invasiva útil para este propósito. Objetivo. Determinar el rendimiento diagnóstico de la TCMD en la identificación de heridas diafragmáticas en pacientes con trauma toracoabdominal penetrante hemodinámicamente estables. Materiales y métodos. Estudio prospectivo realizado en 119 pacientes atendidos en el Hospital Universitario del Valle, Cali, Colombia, entre marzo de 2012 y junio de 2015. Para evaluar el rendimiento diagnóstico de la TCMD, los resultados obtenidos mediante esta prueba fueron comparados con los reportados por el test de referencia (cirugía abierta). Se realizaron 2 lecturas de los estudios de imagen por 2 radiólogos. La concordancia intra e interobservador respecto a la lectura de las TCMD se analizó mediante el coeficiente Kappa de Fleiss. Resultados. La TCDM tuvo una sensibilidad y especificidad de 94.4% y 46.8%, respectivamente. Sus valores predictivos positivo (VPP) y negativo (VPN) fueron 44.7% y 94.8%, respectivamente. La razón de verosimilitud positiva (LR+) fue 1.7765, y la razón de verisimilitud negativa (LR-), 0.1186. Respecto a la concordancia interobservador, el coeficiente Kappa de Fleiss entre la primera lectura de ambos radiólogos fue de 0.4425. Conclusiones. La especificidad de la TCMD para el diagnóstico de heridas diafragmáticas encontrada en el presente estudio difiere considerablemente de lo reportado en la literatura. Teniendo en cuenta la sensibilidad, el VPN y la LR- obtenidos en el presente estudio, la TCMD podría constituir una herramienta importante en el manejo de estos pacientes, ya que en aquellos en los que no se detecte herida diafragmática mediante este tipo de tomografía podría considerarse un manejo conservador.
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Thermal ablation, including radiofrequency ablation and microwave ablation, is a frequently used method for local treatment of primary liver cancer with a marked clinical effect, and it has been widely used in clinical practice in recent years. Diaphragmatic hernia is a rare complication of thermal ablation, but its incidence rate tends to gradually increase in recent years. This article reviews the cases of diaphragmatic hernia after thermal ablation for primary liver cancer in China and globally and elaborates on possible risk factors, diagnosis and treatment, and prevention strategies, so as to improve the understanding of diaphragmatic hernia after thermal ablation for primary liver cancer among clinicians and achieve the goal of preoperative prevention, rapid diagnosis and intervention, and reduced mortality rate.
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La hernia diafragmática traumática representa un reto al momento del diagnóstico. Una detección oportuna permite establecer un correcto tratamiento quirúrgico. Se presenta el caso de un paciente masculino de 37 años de edad con antecedente de trauma torácico por arma blanca 4 años antes; quien acude por cuadro de dolor abdominal intenso localizado en epigastrio que se irradia a hipocondrio izquierdo de aparición súbita 72 horas antes de su ingreso. Al examen físico murmullo vesicular disminuido en campo pulmonar izquierdo, y abdomen doloroso a la palpación a nivel de epigastrio e hipocondrio izquierdo. En exámenes de laboratorio no se evidencian alteraciones, mientras que la tomografía reporta hernia diafragmática izquierda; la misma que fue resuelta quirúrgicamente mediante técnica laparoscópica.
Traumatic diaphragmatic hernia represents a challenge at diagnosis. A timely detection allows to establish a correct surgical treatment. It is presented the case of a 37-year-old male patient with a history of stabbing chest trauma 4 years earlier; who comes for symptoms of intense abdominal pain located in the epigastrium that radiates to the left hypochondrium of sudden onset 72 hours before admission. On physical xamination, vesicular murmur decreased in the left lung field, and a painful abdomen on palpation at the level of the epigastrium and left hypochondrium were showed. Laboratory tests did not show any alterations, but tomography reports a left diaphragmatic hernia; this one was solved surgically by laparoscopic technique.
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Humans , Male , Adult , Laparoscopy , Hernia, Diaphragmatic , Hernia, Diaphragmatic, Traumatic , Therapeutics , Diagnosis , AbdomenABSTRACT
Abstract Purpose: To evaluate the most used approach to treat traumatic diaphragmatic ruptures, and in which one the requirement to assess the second cavity is more frequent. Methods: Systematic review, observational studies. Outcomes: moment of approach, most commonly via addressed and the requirement to open the other cavity. Bases searched: Lilacs, Pubmed, Embase, Clinicaltrials.gov and Web of Science. Statistical analysis: StatsDirect 3.0.121 software. Results: Sixty eight studies (2023 participants) were included. Approach in acute phase was performed four times more than in chronic phase. Approach: abdominal 65% (IC 95% 63-67%), thoracic 23% (IC 95% 21-24%), abdominal in the acute phase 75% (IC 95% 71-78%), and chronic 24% (IC 95% 19-29%), thoracic in the acute phase 12% (IC 95% 10-14%) and chronic 69% (IC 95% 63-74%). Thorax opening in the abdominal approach: 10% (95% CI 8-14%). Abdomen opening in the thoracic approach: 15% (95% CI 7-24%). Conclusions: The most common approach was the abdominal. The approach in the acute phase was more common. In the acute phase the abdominal approach is more frequent than the thoracic approach. In the chronic phase the thoracic approach is more frequent than the abdominal one. The requirement to open the second cavity was similar in both approaches.
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Humans , Thoracotomy/methods , Hernia, Diaphragmatic, Traumatic/surgery , Laparotomy/methods , Wounds, Nonpenetrating/surgery , Acute Disease , Chronic Disease , Reproducibility of ResultsABSTRACT
El trauma diafragmático se produce de forma secundaria tras lesiones penetrantes y trauma cerrado del abdomen y tórax. La hernia diafragmática traumática representa una entidad poco frecuente en la clínica. Cuando se presenta constituye un verdadero reto diagnóstico para el internista, cirujano y el radiólogo. Requiere de un alto índice de sospecha y el uso adecuado de las imágenes diagnósticas. El tratamiento siempre es quirúrgico. Por tales razones se presenta el caso de un paciente que fue operado debido a una herida por arma blanca en el tórax y que con posterioridad se le diagnosticó una hernia diafragmática traumática en el lado izquierdo del torax. Volvió a ser operado y la evolución posquirúrgica resultó satisfactoria.
Diaphragmatic trauma is secondary to penetrating injuries and blunt abdominal and thoracic trauma. Traumatic diaphragmatic hernia is an uncommon entity. Its diagnosis poses a real challenge to internists, surgeons and radiologists since it requires a high level of suspicion and appropriate use of diagnostic imaging. Surgical treatment is always needed. For these reasons, we present the case of a patient operated on due to a stab wound to the chest who was subsequently diagnosed with a traumatic diaphragmatic hernia on the left side of the chest. He underwent surgery again and had a successful postoperative recovery.
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Objective: to evaluate natural evolution of right diaphragmatic injury after the surgical removal of a portion from hemi diaphragm. Methods: the animals were submitted to a surgical removal of portion from right hemi diaphragm by median laparotomy. The sample consists of 42 animals being 2 animals from pilot project and 40 operated animals. And the variables of the study were herniation, liver protection, healing, persistent diaphragm injury, evaluation of 16 channels tomography and the variables "heart rate" and "weight". Results: we analyzed 40 mice, we had two post-operative deaths; we had 17 animals in this group suffered from herniation (42.5%) and 23 animals didn't suffer from herniation (57.5%). Analyzing the tomography as image method in the evaluation of diaphragmatic hernia, we had as a method with good sensitivity (78.6%), good specificity (90.9%), and good accuracy (86.1%) when compared to necropsy. Conclusion: there was a predominance of healing of right hemi diaphragm, the size of initial injury didn't have influence on occurrence of the liver protection or hernia in mice.
Objetivo: avaliar a evolução natural do ferimento diafragmático à direita após a retirada cirúrgica de uma porção do hemidiafragma. Métodos: os animais foram submetidos à ressecção de uma porção do hemidiafragma à direita através da laparotomia mediana. Foram operados 40 ratos. As variáveis analisadas foram: herniação, proteção hepática, cicatrização, lesão persistente do diafragma, avaliação da tomografia computadorizada, frequência cardíaca e peso. Resultados: foram analisados 40 ratos. Houve duas mortes no pós-operatório. Dezessete animais tiveram herniação (42,5%) e 23 (57,5%), não. Analisando emprego da tomografia computadorizada na avaliação da hérnia diafragmática, tivemos um método com boa sensibilidade (78,6%), boa especificidade (90,9%) e boa acurácia (86,1%) quando comparados com a necrópsia. Conclusão: houve predomínio de cicatrização do hemidiafragma à direita e o tamanho da lesão inicial não influenciou na ocorrência de proteção hepática ou hérnia em ratos.
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Animals , Diaphragm/injuries , Hernias, Diaphragmatic, Congenital , Thoracic Injuries , Pilot Projects , Disease Models, Animal , Abdominal Injuries , MiceABSTRACT
OBJETIVO: Descrever as alterações do exame radiográfico de tórax em pacientes com diagnóstico de hérnia diafragmática pós-traumática (HDPT) confirmado no intraoperatório. MÉTODOS: No período entre janeiro de 1990 e agosto de 2008 foram tratados 45 pacientes com HDPT. Foram analisados dados demográficos, mecanismo de trauma, alterações na radiografia convencional de tórax (Rtx), extensão e localização da lesão do diafragma e órgãos herniados. Foram descritos os achados radiográficos mais frequentes identificados por assistentes da cirurgia e da radiologia. RESULTADOS: A Rtx foi realizada em 32 pacientes, com predomínio do sexo masculino (27 casos - 84,4%) e a média das idades foi 34 anos. O mecanismo de trauma mais frequente foi o contuso (25 casos - 78,1%). O exame radiográfico de tórax apresentava alterações sugestivas de HDPT em 26 casos (81,3%). Na laparatomia exploradora constatou-se HDPT à esquerda em 28 casos (87,5%) e à direita em 4 (12,5%). O órgão herniado mais frequente foi o estômago. CONCLUSÃO: O estudo mostrou que o Rtx é muito útil na pesquisa inicial no diagnóstico de HDPT. A dificuldade é que as lesões de diafragma, principalmente após trauma penetrante, podem passar inicialmente despercebidas, sem alterações nesse método de imagem, tornando o diagnóstico difícil.
OBJECTIVE: To describe changes in the radiographic examination of the chest in patients with post-traumatic diaphragmatic hernia (PTDH) confirmed intra-operatively. METHODS: Between January 1990 and August 2008 45 patients with PTDH were treated. We analyzed demographic data, cause of injury, changes in chest radiography (CXR), extent and location of the diaphragmatic lesion and herniated organs. We described the radiographic findings most frequently identified by surgeons and radiologists. RESULTS: CXR was performed on 32 patients, predominantly male (27 cases, 84.4%) and the mean age was 34 years. The most common cause of injury was blunt trauma (25 cases, 78.1%). Radiographic examination of the chest showed changes suggestive of PTDH in 26 cases (81.3%). During exploratory laparotomy, left PTDH was found in 28 cases (87.5%) and right in four (12.5%). The most frequently herniated organ was the stomach. CONCLUSION: The study showed that CXR is very useful in the initial diagnostic approach to PTDH. The difficulty is that diaphragmatic injuries, particularly after penetrating trauma, may initially go unnoticed, and without changes in the CXR images, diagnosis is made difficult.
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Adolescent , Adult , Female , Humans , Middle Aged , Young Adult , Hernia, Diaphragmatic, Traumatic , Radiography, Thoracic/methodsABSTRACT
As hérnias diafragmáticas são decorrentes principalmente de traumas contusos e são mais comuns à esquerda. Essa menor frequência à direita é explicada pela contenção e proteção do fígado ao hemidiafragma homolateral. Entretanto, apesar de as lesões à esquerda serem mais frequentes, aquelas situadas à direita associam-se a lesões mais graves e resultam em mais instabilidade hemodinâmica, o que gera elevada mortalidade no momento do trauma. Além disso, a hérnia diafragmática direita, pode permanecer assintomática por longo tempo, favorecendo a aparecimento de complicações como isquemia e ruptura das vísceras herniadas dentro do tórax. Assim é fundamental um diagnóstico precoce, a fim de se realizar o tratamento cirúrgico, uma vez que o diafragma não cicatriza espontaneamente. (AU)
The diaphragmatic hernias are mainly due to blunt trauma and are more common on the left. This lower frequency on the right side is explained by liver protection of the ipsilateral hemidiaphragm. However, despite the injuries are more frequent on the left, those situated on the right are associated with more severe injuries and result in more hemodynamic instability, which leads to high mortality at the time of trauma. Furthermore, the right diaphragmatic hernia can remain asymptomatic for long time, favoring the onset of complications such as ischemia and rupture of the herniated organs inside the chest. Therefore early diagnosis is fundamental in order to perform surgical treatment, since the diaphragm does not heal spontaneously. (AU)
Subject(s)
Humans , Contusions/complications , Hernia, Diaphragmatic, Traumatic/diagnostic imaging , Hemodynamics/physiology , Hernia, Diaphragmatic, Traumatic/surgery , Hernia, Diaphragmatic, Traumatic/complicationsABSTRACT
Objective To summarize the diagnosis and surgical treatment experiences of traumatic diaphagmatic hernia. Methods Clinical data of 12 patients with traumatic diaphragmatic hernia were analyzed retrospectively. Results The diagnosis was established preoperatively in 10 cases(83. 3% ) ,10 patients were cured and 2 cases died( 16.2% ). Conclusion The possible diaphragmatic injury in the patients with thoracic and abdominal injuries should be alerted. Diagnosis could be made based on CT and radiography. Early diagnosis, timely operation were the key to improve the cure rate and reduce mortality.
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Objective To explore the clinical characteristics and the treatments on traumatic diaphragmatic rupture and diaphragmatic hernia.Method A retrospective study was carried out in 49 cases of traumatic diaphragmatic rupture and diaphragmatic hernia.Results There were 32 cases with left diaphragmatic hernia,13 cases with right diaphragmatic hernia and 4 cases with bilateral diaphragmatic hernia.One case with closed combined thoraco-abdominal wound and shock,died of multiple organ failure after the surgery,3 cases were diagnosed more than 24 h after injury,the others closed injury patients were diagnosed within 24 h and cured.In patients with open diaphragmatic rupture and diaphragmatic hernia,16 cases underwent laparotomy surgery,5 cases of misdiagnosis experienced re-thoracotomy,7 cases thoracotomy,2 cases changed the thoraco-abdominal surgery.Three cases underwent thoraco-abdominal surgery.Twenty-five cases were cured; 1 patient with suppurative costal chondritis,duration up to 13months.Conclusion Traumatic diaphragmatic rupture and diaphragmatic hernia is easily missed and misdiagnosed,the establish of rational examination preoperatively can reduce complications,misdiagnosis and mortality.
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Objective To clarify the features and early diagnosis of the traumatic diaphragmatocele associated with pelvic fracture. Methods The clinical materials of 486 multiple injuried patients with pelvic fractures as main trauma were retrospectively analysed. The pathogenesis, clinical manifestation and reasons for misdiagnosis in 9 cases of traumatic diaphragmatocele were analysed. Results In this series, the incidence of the traumatic diaphragmatocele was 1.9%(9 of 486). Because of under recognition of this associated injury, 7 in 9 cases of traumatic diaphagmatocele were misdiagnosed or undiagnosed. The incidence of misdiagnosis was 77.8% in this series. Conclusion The main reason for the occurrence of diaphragmatocele was the rapid increase of the intra abdominal pressure which resulted in rupture of the weak area of the diaphragm. Type B1 pelvic fracture can cause traumatic diaphragmatocele easily. The symptoms of the diaphragm hernia are easily overlooked when the trauma is serious or the patient is in shock. Because the early symptoms are not often evident and typical, the doctor can not notice it thoroughly. The main reason for misdiagnosis of the diaphragm hernia is the poor clinical presentation and sign of the diaphragmtocele which initially is very similar to that of the thoraco abdominal injury. In the case with chest and abdominal symptoms concomitant with pelvic fracture should be observed carefully and the chest and abdominal radiographs should be taken as soon as possible. Closed attention should be paid to diaphragmatocele when treating a pelvic fracture in consideration of 7 out of 9 patients being misdiagnosed in this series.
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Objective To study the early diagnosis and treatment of traumatic diaphragmatic hernia(TDH). Methods Retrospective analysis of the clinical data of 23 cases of TDH was made. Result 12 cases(51%) were preoperatively diagnosed,10 cases(43.5%) misdiagnosed,1 case was misdiagnosed during exploration laporatomy. 20 cases(86.9%) were cured and 3(13.1%) died. 1 case died of toxic shock because of misdignosis resulted in intestinal strangulation. Conclusions Increasing knowledge, dynamic observation of the disease and X-ray, promptly exploration can reduce the rate of misdiagnosis of TDH. With early diagnosis and treatment, most cases of TDH can be cured. The main cause of the death results from delayed diagnosis and treatment, and not related to TDH itself.