Acute and chronic traumatic diaphragmatic hernia: 10 years’ experience

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Abstract

Controversy persists regarding many aspects of traumatic diaphragmatic hernia (TDH). We aimed to understand why some traumatic diaphragmatic injuries present with chronic hernia and to evaluate diagnosis and treatment options. Fifty acute and 19 chronic TDH patients were diagnosed and treated at our institution over a 10-year period. Clinical data from these two groups were analyzed statistically and compared. Chronic TDH patients had a significantly lower Injury Severity Score than acute TDH patients (10.26 ± 2.68 vs. 26.92 ± 4.79, P < 0.001). The most common surgical approach for acute and chronic TDH was thoracotomy and laparotomy, respectively. The length of the diaphragmatic rupture was significantly shorter in chronic TDH patients than acute TDH patients (6.00 ± 1.94 cm vs. 10.71 ± 3.30 cm, P < 0.001). The mean length of hospital stay was significantly longer for acute TDH patients than chronic TDH patients (41.18 ± 31.02 days vs. 16.65 ± 9.61 days, P = 0.002). In conclusion, milder trauma and a smaller diaphragmatic rupture were associated with delayed diagnosis. A thoraco-abdominal computed tomography scan is needed for patients with periphrenic injuries to avoid delayed diagnosis of TDH. Improved awareness and understanding of diaphragmatic injuries will increase the rate of early diagnosis and improve prognosis.

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Emergency surgery due to diaphragmatic hernia: case series and review

Mario Testini, Antonia Girardi, Roberta Maria Isernia … (2017)

Background Congenital diaphragmatic hernia (CDH) is a congenital abnormality, rare in adults with a frequency of 0.17–6%. Diaphragmatic rupture is an infrequent consequence of trauma, occurring in about 5% of severe closed thoraco-abdominal injuries. Clinical presentation ranges from asymptomatic cases to serious respiratory or gastrointestinal symptoms. Diagnosis depends on anamnesis, clinical signs and radiological investigations. Methods From May 2013 to June 2016, six cases (four females, two males; mean age 58 years) of diaphragmatic hernia were admitted to our Academic Department of General Surgery with respiratory and abdominal symptoms. Chest X-ray, barium studies and CT scan were performed. Results Case 1 presented left diaphragmatic hernia containing transverse and descending colon. Case 2 showed left CDH which allowed passage of stomach, spleen and colon. Case 3 and 6 showed stomach in left hemithorax. Case 4 presented left diaphragmatic hernia which allowed passage of the spleen, left lobe of liver and transverse colon. Case 5 had stomach and spleen herniated into the chest. Emergency surgery was always performed. The hernia contents were reduced and defect was closed with primary repair or mesh. In all cases, post-operative courses were uneventful. Conclusion Overlapping abdominal and respiratory symptoms lead to diagnosis of diaphragmatic hernia, in patients with or without an history of trauma. Chest X-ray, CT scan and barium studies should be done to evaluate diaphragmatic defect, size, location and contents. Emergency surgical approach is mandatory reducing morbidity and mortality.

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Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis.

Kelly Fair, Nicole T Gordon, Ronald R Barbosa … (2015)

Traumatic diaphragmatic injury (TDI) is a rarely diagnosed injury in trauma. Previous studies have been limited in their evaluation of TDI because of small population size and center bias. Although injuries may be suspected based on penetrating mechanism, blunt injuries may be particularly difficult to detect. The American College of Surgeons National Trauma Data Bank is the largest trauma database in the United States. We hypothesized that we could identify specific injury patterns associated with blunt and penetrating TDIs.

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The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years.

E. Ferri, Tarek Razek, Paola Fata … (2008)

Our understanding of traumatic diaphragmatic injury (TDI) is based primarily on outdated retrospective series. We sought to reexamine present day patterns of diagnosis, associated injuries, predictors of mortality, and long-term outcomes of this condition. A prospectively entered trauma database from the Montréal General Hospital was reviewed for patients admitted with a TDI from 1993 to 2006. Hospital charts were reviewed, and patient characteristics, mechanism of injury, associated injuries, operative management, and postoperative outcomes were recorded. Logistic regression was used to identify predictors for mortality. Identified were 105 patients with TDI consisting of blunt in 37% and penetrating in 63%. Only 23% of TDI were diagnosed on initial chest roentgenogram. External wounds in penetrating TDI cases were found in the abdomen alone in 19%, in the chest alone in 46%, and in both in 35%, which was associated with intraabdominal organ injury in 83%, 55%, and 87%, respectively. Less than half of patients had a diaphragmatic hernia. Lung, chest wall, and thoracic organ injuries were more common in blunt trauma, but there was no significant difference between abdominal injuries in both mechanisms. Overall mortality from TDI was 18%, and there was no difference between blunt and penetrating injury. In blunt trauma, brain injury and an Injury Severity Score (ISS) exceeding 15 were independently associated with increased death. In penetrating trauma, only an ISS exceeding 15 predicted death. Traumatic diaphragmatic injury remains a challenge to diagnose and treat, primarily due to the presence of associated injuries. The high incidence of intraabdominal organ injury, irrespective of the site of penetrating wound, dictates a transabdominal approach for exploration and repair. Severity of associated injuries (ISS) predicts death.

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Contributors

Pengcheng Gu: Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: ValidationRole: Writing – original draft

Yang Lu: Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: ValidationRole: Writing – original draft

Xigong Li:

ORCID: http://orcid.org/0000-0003-1096-2839

Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing

Xiangjin Lin: Role: ConceptualizationRole: Data curationRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: Writing – original draft

Linda L. Maerz: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 12 December 2019

Publication date Collection: 2019

Volume: 14

Issue: 12

Electronic Location Identifier: e0226364

Affiliations

[1 ] Trauma centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China

[2 ] Department of Orthopedics, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China

Yale University, UNITED STATES

Author notes

Competing Interests: The authors have declared that no competing interests exist.

* E-mail: 3100104986@ 123456zju.edu.cn

Author information

Xigong Li http://orcid.org/0000-0003-1096-2839

Article

Publisher ID: PONE-D-19-14160

DOI: 10.1371/journal.pone.0226364

PMC ID: 6907826

PubMed ID: 31830097

SO-VID: 56d2a3f3-5095-4041-b8ac-ddcf31cc5f48

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This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 19 May 2019

Date accepted : 24 November 2019

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Figures: 2, Tables: 2, Pages: 9

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The authors received no specific funding for this work.

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Data Availability All relevant data are within the manuscript and its Supporting Information files.

Acute and chronic traumatic diaphragmatic hernia: 10 years’ experience

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Most cited references 32

Emergency surgery due to diaphragmatic hernia: case series and review

Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis.

The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years.

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