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Interact CardioVasc Thorac Surg 2009;9:45-49. doi:10.1510/icvts.2008.198333 © 2009 European Association of Cardio-Thoracic Surgery
Blunt traumatic diaphragmatic rupture: a retrospective observational study of 46 patients
a Department of Cardiothoracic Surgery, Mansoura University Hospitals, Faculty of Medicine, Mansoura University, Gomhoria St., Mansoura, P.O. Box 35516, Egypt Received 13 November 2008; received in revised form 17 March 2009; accepted 22 March 2009
*Corresponding author. Department of Cardiac Surgery, Prince Sultan Cardiac Center, P.O. Box 99911, Riyadh 11625, KSA, Bleep no: 4320. Tel.: +96612068132; mobile: +966558267049.
A retrospective study aimed to analyze our experience in 46 patients with blunt traumatic diaphragmatic rupture (BTDR) admitted to our tertiary hospital from 1995 to 2007. Charts, chest roentgenograms (CXR), and computed tomography (CT) scans were carefully reviewed. The mean age was 36.5±10.1 years, 36 (78.3%) were males. The etiology was a traffic accident in 36 (78.3%) patients. BTDR was left-sided in 34 (73.9%) and right-sided in 12 (26.1%) patients. CXR was diagnostic in 26 (56.5%) and CT in 12 (26.1%) patients. Associated injuries included lung 12 (26.1%), liver 10 (21.7%), spleen 24 (52.2%) and bowel 2 (4.2%) patients. BTDR was approached through thoracotomy 26 (56.5%), laparotomy 16 (34.8%), and combined approach 4 (8.7%) patients. The repair was primarily with interrupted non-absorbable sutures in 42 (91.3%) and by prosthetic mesh in four patients. Complications developed in 20 patients. Mortality was observed in 2 (4.3%) patients. We concluded that BTDR is a common lesion in young adult males on the left side caused by a traffic accident. A high index of suspicion combined with repeated and selective radiologic evaluation is necessary for early diagnosis. Associated injuries represent the main prognostic factor affecting morbidity and mortality. Thoracotomy and primary repair is adequate surgical treatment.
Key Words: Blunt trauma; Diaphragmatic rupture; Associated injuries; Acute presentation; Thoracotomy; Laparotomy
Blunt traumatic diaphragmatic rupture (BTDR) is not an uncommon injury most noteworthy as a marker of severe trauma [1]. It occurs in 0.8–5% of hospitalized automobile accident victims and in approximately 5% of blunt trauma patients that undergo laparotomy [1, 2]. It is a frequently missed diagnosis, and there is commonly a delay between trauma and diagnosis and this is implicated in increased mortality and morbidity [3]. It is usually described as being left, right, bilateral or intrapericardial [4]. Uniform diagnosis depends on a high index of suspicion, careful examination of the chest roentgenogram (CXR) and meticulous inspection of the diaphragm when operating for concurrent injuries. Repeated evaluation hours and days after injury may be necessary to discern injury in those patients not requiring laparotomy [2]. As soon as the patient has been evaluated and stabilized, the associated injuries require prompt operative attention. In the uncommon case of massive herniation into either pleural space or luxation of the heart, the BTDR requires urgent attention [2, 5]. We aimed to analyze the cases of BTDR in our tertiary referral emergency hospital, its time of diagnosis, diagnostic tools, surgical approach and repair technique, and the outcome.
A retrospective observational study of 46 patients with BTDR admitted to our hospital from 1995 to 2007. All cases with penetrating diaphragmatic injuries, life threatening brain injuries and lesions not caused by trauma were excluded. Charts were reviewed for: sex, age, symptoms, types of injury, diagnostic method, time to diagnosis, side and site of the rupture, associated injuries, surgical approach and procedure, visceral herniation, duration of hospitalization, postoperative morbidity and mortality. Mortality was calculated using only deaths related to BTDR or the consequences of the trauma. Other causes of death were excluded. All the radiologic exams including CXR and computed tomography (CT) scans were carefully reviewed in order to identify signs suspicious for BTDR that were overlooked at the initial radiologic interpretation.
A total of 46 patients with BTDR were analyzed. The mean age was 36.5±10.1 years. Male to female ratio was 36:10 patients. The most common type of trauma was a road traffic accident in 36 (78.3%) patients and the left side of the diaphragm affected in 34 (73.9%) patients while right diaphragmatic copula ruptured in 12 (26.1%) patients as shown in Table 1.
Diagnosis of BTDR was made within 12 h of admission in 26 (56.5%) cases and before 24 h of admission in 12 (26.1%) patients while eight (17.4%) patients required a longer time to prove their diaphragmatic lesion. Diagnosis was started by clinical suspicion. CXR was done for all patients and diagnosis was based mainly on CXR finding which included; elevation of diaphragmatic copula, presence of gastric air bubble or nasogastric tube in the chest, hepatothorax, or mediastinal shift. It was diagnostic in 26 (56.5%) patients. CT chest was required to confirm the diagnosis in 12 (26.1%) patients while intraoperative diagnosis was made in 8 (17.4%) patients (Figs. 1 and 2).
Associated injuries were present in all patients and distributed as shown in Table 1. The approach for repair in the acute presentation was dictated by the need to explore for life-threatening conditions. BTDR involved different parts of diaphragm and the intrathoracic herniation of abdominal viscera was detected in 36 (78.3%) patients as in Table 2.
BTDR was repaired primarily with interrupted non-absorbable direct sutures in 42 (91.3%) patients while four patients required prosthetic mesh for repair. Management of associated injuries was done in 30 (65.1%) patients. In lung injuries, lobectomy was done in 2 (4.3%) patients and lung suture was done in 10 (21.7%) patients. In abdominal injuries, splenectomy was done in 14 (30.4%) patients, liver suture in 2 (4.3%) patients, and intestinal suture repair in 2 (4.3%) patients. Postoperative complication developed in 20 (43.5%) patients. The pulmonary complications were more prevalent. Mortality was observed in 2 (4.3%) patients. It was related mainly to preoperative hemorrhagic shock, multiple organ injuries, and the development of adult respiratory distress syndrome (ARDS). The hospital stay ranged from 8 to 35 days with mean of 14.1±5.8 days (Table 2). There was no reported recurrence or complications related BTDR repair during the study period.
The diaphragm is the most important respiratory muscle. Damage to the diaphragm, as a partition-wall located between abdominal and chest cavities, is of greater importance than its respiratory dysfunction. This is one of the substantial clinical features of diaphragmatic injuries, especially in cases of BTDR [6]. Traumatic diaphragmatic rupture is an uncommon entity, with an incidence of 0.8–7% in blunt trauma [1]. This relative rarity, although not measured in our study, is reflected in the presence of only 46 patients over a period of 12 years in a tertiary referral emergency hospital with a large number of thoracoabdominal traumas. Many authors reported that BTDR is more common in young men [1, 3, 4, 7–10]. Our study confirms this observation as it was more common in young adult males in the 4th decade of life. Road traffic accident was the most common reason of BTDR followed by falling from a height; this matches with many studies [2, 4, 6, 9–11]. Left-sided BTDR occurred in 34 (73.9%) patients and was more common than right-sided rupture [1, 3, 4, 7–10]. The pre-dominance of left-sided BTDR has been explained by increased strength of the right hemi-diaphragm, hepatic protection of the right side, under-diagnosis of right-sided ruptures, and weakness of the left hemi-diaphragm at points of embryonic fusion [2]. Early diagnosis of BTDR continues to be a challenge both for radiologists and surgeons, and most authors agree on the need to maintain a high level of suspicion in order to diagnose this lesion [2–4, 8, 12]. The clinical diagnosis is unreliable as none of the clinical signs is specific for diaphragmatic rupture [5]. CXR, peritoneal lavage, diagnostic pneumoperitoneum, fluoroscopy, gastrointestinal contrast studies, ultrasound, CT-scan, magnetic resonance imaging, and liver and spleen scintigraphy are the methods generally used for the diagnosis of BTDR. However, none of them in isolation has a high-sensitivity or specificity, and there is currently no gold-standard diagnostic test [2–4, 8, 10]. Plain CXR has been reported to be useful for the diagnosis of diaphragmatic injury, with sensitivities ranging from 30% to 62% in the absence of a hernia, and up to 94% in the presence of a hernia [10]. In our study, it was done for all cases but only early diagnosis was achieved in 56.5% of cases. Diagnostic accuracy of CXR increased by six-hourly follow-up and with insertion of a nasogastric tube with or without oral contrast. CT is highly specific and detects approximately 2/3 of acute diaphragmatic ruptures after blunt trauma. The specificity and sensitivity increases when the helical CT is used [12, 13]. It was required in 12 patients; all of them were diagnosed after 12 h of admission. The delay of diagnosis in our series was related mainly to delay of referral and absence of clinical signs of BTDR that became more obvious with radiologic follow-up. Thoracoscopy represents a useful diagnostic tool for BTDR and has a sensitivity, specificity, and positive predictive value of 100%. It has also been used for repair of diaphragmatic defects [5, 11, 14]. To date, however, thoracoscopic diagnosis and repair of BTDR has not been performed in our hospital. As a result of the difficulty in diagnosing BTDR and the presence of severe associated lesions that are the initial focus of attention; diagnosis of the diaphragm lesion is delayed and there is a high rate of intraoperative diagnoses and even lesions that pass unnoticed despite surgery [11]. Therefore, careful visual and manual inspections of diaphragm are necessary [9]. In our study, intraoperative diagnosis was done in eight patients during thoracotomy for lobectomy (2 patients) and laparotomy for surgical exploration of intra-abdominal bleeding (6 patients). In our experience of associated injuries reported in all patients, the most common were splenic and hepatic injuries in the abdomen, and fractured ribs and lung injuries in the chest. This result was confirmed by many authors [2, 4, 6, 9–11]. Trauma related syndromes were reported in our study and were comparable to other studies [4, 6, 9]. BTDR associated with massive visceral herniation and respiratory compromise is a true surgical emergency. These patients require endotracheal intubation, positive pressure ventilation, and decompression of gastro-intestinal tract. Bag mask support of ventilation should be discouraged as it may result in gastric distention and further respiratory embarrassment [5]. The choice of surgical approach depends greatly on associated injuries and trauma related syndrome. The part of the body, abdomen or chest, in which pathologic processes are the most threatening must be first explored [13]. Laparotomy must be performed in patients with associated abdominal lesions or hemodynamic instability [5]. This approach allows repair of the left side without significant difficulties. On the right side, the liver can hinder repair, and additional thoracotomy may be necessary. In delayed and chronic cases, the approach of choice is thoracotomy [2, 8]. Inspite of acute presentation, thoracotomy was the most common approach in our series followed by laparotomy as the majority of the patients were referred to the cardiothoracic team for trauma associated syndromes that were confined to the chest, with no obvious abdominal injuries. The establishment of the diagnosis and repair were done by the same team. This result confirmed by Rubikas and Hirshberg and their colleagues [6, 15]. In our study, most of the defects were repaired directly using interrupted figure-of-eight non-absorbable sutures [3, 4, 9, 10, 15]. In four patients the diaphragmatic edge was lacerated and the defect was too large to be directly sutured so a prosthetic (prolene) dual mesh was required to repair the diaphragmatic injury. Our technique was confirmed by many authors [3, 7, 9, 10]. During surgery, visceral herniation detected is mostly correlated to previous reports [9, 10]. The postoperative morbidity varies from 11% to 62.9% and the pulmonary problems were the most common complications. Severity and multiplicity of injuries, hemodynamic status at admission, and time of diagnosis were the most frequent attributing factors for morbidity after BTDR [2–4, 6, 8, 9, 11]. In our experience, the postoperative morbidity was 30.4% and the pulmonary complications including atelectesis, ARDS, pleural effusion and empyema were the most encountered complications. The mortality rates published in the literature range from 1% to 42%, and are invariably due to associated lesions, shock, blunt injury, increased grade of injury, and the presence of splenic injury [2–4, 6–9, 11, 14, 15]. In our study, mortality was the fate in 2 (4.3%) patients. None of the deaths were directly related to the diaphragmatic repair. The hospital stay for survivors ranged from 8 to 35 days with a mean of 14.1±5.8 days [9].
BTDR is a common lesion in young adult males on the left side caused by traffic accident. A high index of suspicion combined with repeated and selective radiologic evaluation is necessary for early diagnosis. Associated lesions are present in most cases and represent the main prognostic factor affecting morbidity and mortality. It is considered a relative surgical emergency. Thoracotomy and primary repair is adequate surgical treatment.
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Abstract
1. Introduction
