The simultaneous repair of an Irreducible Diaphragmatic Hernia while carrying out a Cesarean Section

INTRODUCTIONDiaphragmatic hernia complicating pregnancy rarely occurs while it is frequently misdiagnosed.PRESENTATION OF CASEA pregnant woman who had suffered from recurrent right upper-quadrant abdominal pain for 4 months was hospitalized near full term because the unrelieved abdominal pain was so severe that she couldn’t lie down. Following the emergency caesarean, we found a part of the transverse colon and a part of omentum were trapped in the thorax through a 3 cm by 3 cm laceration in the patient's diaphragm. We removed all trapped intestine which was about 40 cm long and repaired diaphragmatic hernia at the same time.DISCUSSIONRadiography is useful to diagonisis diaphragmatic hernia, but it had little use for pregnant women. An irreducible diaphragmatic hernia represent a surgical emergency irrespective of fetal maturity. In our case, she had her hernia repaired just during caesarean section by laparotomy.CONCLUSIONCareful examination and a timely operation are needed to treat diaphragmatic hernia complicating pregnancy.     

Validación de la ecografía Point-of-Care para el diagnóstico de hernia diafragmática: a propósito de un caso

Point-of-care ultrasound (POCUS) is a sensitive, specific tool for early diagnosis of diaphragm pathology in critically ill patients. We report the case of a patient with a history of iatrogenic diaphragmatic hernia who was admitted to the Resuscitation Unit after an emergency exploratory laparotomy. As the diagnosis of diaphragmatic hernia had already been confirmed, we determined the POCUS features that establish the diagnosis of diaphragmatic hernia: (1) normal bilateral diaphragmatic shortening fraction; (2) decreased diaphragmatic excursion, and (3) cephalic position of the diaphragmatic dome (4) greater in supine than in sitting position. We also outline a systematic ultrasound examination of the diaphragm and a POCUS-based differential classification of diaphragmatic dysfunction based on the functional integrity of the peripheral muscle and central diaphragmatic tendon in critically ill patients.     

Laparoscopic repair of congenital diaphragmatic hernia complicated with sliding hiatal hernia with reflux in adult

INTRODUCTIONCongenital diaphragmatic hernia (CDH) in adults is a relatively rare condition being asymptomatic in the majority of cases. Symptomatic CDH should prompt surgical management because they may lead to intestinal obstruction or severe pulmonary disease. This is the first reported case of a symptomatic CDH complicated with sliding hiatal hernia (SHH).PRESENTATION OF CASEA 65 years old women with reflux and dysphagia was complaining of postprandial paroxysmal dyspnea and epigastric pain radiating to her back. Upper endoscopy diagnosed sliding and para-esophageal diaphragmatic hernia with severe esophagitis. Computed tomography-scan revealed a large Bochdalek hernia at the left diaphragm.DISCUSSIONDiagnostic laparoscopy was decided, which confirmed the SHH, but also revealed a CDH defect at the tendonous part of the left diaphragm. The left bundle of the right crus was intact, separating the two hernia components (sliding and congenital). Extensive adhesiolysis was performed, dissecting and separating the stomach away from the diaphragm. Posterior cruroplasty at the esophageal hiatus was performed for the SHH with Nissen fundoplication as antireflux procedure. Primary continuous suture repair was performed for the CDH, reinforced with prosthetic mesh on top. Operative time was 150 min with no morbidity. The patient was discharged home uneventfully the third postoperative day. On 12-months follow-up, she reported no symptoms and improvement in quality of life.CONCLUSIONLaparoscopy is a unique method for a precise diagnosis of symptomatic congenital diaphragmatic hernia in adults being also a safe and viable technique for a successful repair at the same time. Experience of advanced laparoscopic surgery is required.     

Diaphragmatic hernia with ischemic bowel obstruction in pregnancy: Report of a case

Diaphragmatic hernia complicating pregnancy is rare and is associated with high morbidity and mortality, particularly if surgical intervention is delayed. We report a case of diaphragmatic hernia in a pregnant 25-year-old woman. The patient was referred to our hospital in respiratory distress in the 28th week of her pregnancy. Chest radiograph and computed tomography showed air-filled bowel loops in the left side of the chest, with a marked mediastinal shift. Immediately after an emergency caesarean section, the herniated abdominal viscera were reduced through the opening in the diaphragm. We resected the ischemic segment of ileum and repaired the diaphragmatic defect with interrupted sutures and a Gore-Tex sheet. She had an uneventful postoperative course and her baby boy also recovered well. We report this case to alert surgeons to the possibility of this rare surgical emergency during pregnancy.     

儿童先天性膈疝的超声表现及诊断价值

目的分析儿童先天性膈疝的超声表现及超声对其诊断价值。 方法选择2012年1月至2019年1月,屯昌县人民医院收治的先天性膈疝患儿30例,采用超声和X线片对患儿左、右膈疝和疝内容物进行诊断,并通过手术证实其对儿童先天性膈疝诊断的准确性。 结果手术结果表明,30例先天性膈疝的患儿中,左侧疝26例,右侧疝4例;疝内容物为空腔器官者9例,空腔与实质器官合并者21例。先天性膈疝患儿超声表现为上腹部膈肌回声中断,可见肺下界上移;经胸部背、侧腰部扫视隔离肺可见胸腔内与其他肺组织不相连的囊实混合回声区;经腹部扫视,空腔器官疝入则腹腔显示较空虚,实质性器官疝入,在正常位置不能显示器官结构。先天性膈疝患儿X线片表现为膈上可见半圆形肿块影,心脏及气管向健侧移位,腹部较空虚密实。超声诊断对先天性膈疝患儿膈疝位置和疝内容物的判断准确率（100.00%和90.00%）显著高于X线片（93.33%和56.67%,P<0.05）。 结论超声诊断能通过回声和图像结构对儿童先天性膈疝的位置和疝内容物进行判断,其诊断准确率显著高于X线片,值得在临床推广应用。     

Bochdalek diaphragmatic hernia in the elderly: a case report]

We successfully treated surgically an elderly patient, a 80-year-old woman, with Bochdalek diaphragmatic hernia. She had intermittent episodes of intestinal obstruction. A preoperative chest roentgenograph revealed a loop of gas-filled bowel in the left chest and elevation of the left diaphragm. CT scanning of the thorax revealed the bowels filled with gastrografin in the left thoracic cavity. She was treated surgically, through transabdominal and then transthoracic approaches. The herniated large bowel was reduced from the thoracic cavity and the hernial sac was excised. The posterolateral defect of the diaphragm, 5 x 6 cm in size was closed with interrupted mattress sutures. The patient has been well without any symptoms 6 months after the surgery. Bochdalek diaphragmatic hernia is the most common problem in infants with risky respiratory distress and high mortality, however it is preferable to carry out surgical treatment for adult patients because of good postoperative results. As a surgical route in the management of Bochdalek diaphragmatic hernia in adults, a transthoracic approach is preferable since it provides easy separation and reduction of herniated bowels from the thoracic cavity and easy closure of the diaphragmatic defect, furthermore there are no other serious gastrointestinal complications which are required specific repair.     

Delayed hepatothorax due to right-sided traumatic diaphragmatic rupture

We present a 48-year-old man with delayed hepatothorax due to right-sided traumatic diaphragmatic rupture. An initial chest radiograph showed no specific signs except elevation of the right diaphragmatic border. The diagnosis was confirmed by coronal reformatted helical computed tomography (CT) imaging, which revealed intrathoracic displacement of the liver. A follow-up chest radiograph revealed gradual elevation of the right diaphragmatic border, suggesting worsening of the diaphragmatic rupture and progression of hepatothorax, resulting in severe atelectasis of the right lung. Therefore, surgical repair of the diaphragmatic rupture was performed. Impaction of the liver through the diaphragmatic ruptured region was observed. Chest radiographic examination after the operation revealed a more normal position of the right diaphragmatic border and resolution of the right lung atelectasis. The problems associated with the diagnosis and operative treatment of hepatothorax with right-sided traumatic diaphragmatic ruptures are discussed in the light of this case report.     

La ratio de grosor diafragmático (inspiratorio/espiratorio) como método diagnóstico de parálisis diafragmática asociada al bloqueo interescálenico

Introduction

Diaphragmatic paralysis is a side-effect associated with interscalene block. Thickness index of the diaphragm muscle (inspiratory thickness/expiratory thickness) obtained by ultrasound has recently been introduced in clinical practice for diagnosis of diaphragm muscle atrophy. Our objective was to evaluate this index for the diagnosis of acute phrenic paresis associated with interscalene block.

Confiabilidad interevaluador de la medición de la excursión diafragmática y fracción de engrosamiento diafragmático mediante ultrasonografía en voluntarios sanos

Background and objectiveTo determine the inter-rater reliability in the ultrasonographic (US) measurement of the diaphragmatic excursion (DE) and the diaphragm thickness fraction (DTF) performed by non-medical health professionals in healthy people.Participants and methodsProspective observational study in a third level hospital in Cali, Colombia. Measurements were made to 30 healthy volunteers chosen by convenience sampling, without a history of lung diseases, with ages between 18-60 years. A pilot test was previously carried out with 8 healthy volunteers. US measurements of DE, and DTF were based on previously published protocols. Each assessor independently observed several cycles of normal quiet breathing for 3 minutes to establish a baseline. The Intraclass Correlation Index (ICC) was used to evaluate the inter-rater reliability in the measurements of DE and DTF, with 95% confidence intervals and a P < .05.ResultsSubstantial agreement was identified in the measurement of DE in the splenic and hepatic windows because the ICC was greater than 0.6 (P < .05). The measurement of the DTF in the hepatic window showed slight agreement in both 2D and M modes (P > .05). In the splenic window, the measurement of the DTF in the 2D mode was found to be moderate agreement and for the M mode a slight agreement was found (P > .05)ConclusionsThe diaphragmatic US constitutes a reproducible method with acceptable inter-rater reliability for the measurement of inspiratory/expiratory thickness, and with little reliability for the measurement of DTF.     

Clinical evidence that V456A is a Cystic Fibrosis causing mutation in South Asians

BackgroundCystic Fibrosis (CF) genotypes in South Asians are variable with a decreased incidence of Delta F508 and an increased incidence of novel mutations. The objective of this study is to provide clinical evidence that V456A, a novel mutation in South Asian Cystic Fibrosis patients, can cause significant lung disease.MethodsWe extracted clinical data from a retrospective chart review of 2 CF patients of South Asian descent.ResultsPatient 1, a 10 year and 11 month old Pakistani female at her initial clinic visit, required multiple hospitalizations for bronchiectasis and pulmonary infections. She was pancreatic sufficient but had slow weight gain. Genetic testing revealed that she is homozygous for the CFTR V456A mutation. Patient 2, an Indian female diagnosed with CF on newborn screening, is compound heterozygous for V456A/R709X. She had slow weight gain with BMI ranging from 12.9 to 13.4 kg/m² from 3 to 5 years of age and was 14.2 kg/m² at 6 years of age. At 6 years of age, pulmonary function tests revealed mild lung disease with FVC of 71%, FEV₁ of 75%, FEF_25–75 of 119%, and FEV₁/FVC of 86% predicted. Sputum cultures were intermittently positive for Staphylococcus aureus and Haemophilus influenza.ConclusionsWe provide evidence that V456A can cause significant pulmonary disease in South Asian Cystic Fibrosis patients.     

Dual mesh repair for a large diaphragmatic hernia defect: An unusual case report

IntroductionDiaphragmatic hernia secondary to traumatic rupture is a rare entity which can occur after stab wound injuries or blunt abdominal traumas. We aimed to report successfully management of dual mesh repair for a large diaphragmatic defect.Case reportA 66-year-old male was admitted with a right sided diaphragmatic hernia which occurred ten years ago due to a traffic accident. He had abdominal pain with worsened breath. Chest X-ray showed an elevated right diaphragm. Further, thoraco-abdominal computerized tomography detected herniation a part of the liver, gallbladder, stomach, and omentum to the right hemi-thorax. It was decided to diaphragmatic hernia repair. After an extended right subcostal laparotomy, a giant right sided diaphragmatic defect measuring 25 × 15 cm was found in which the liver, gallbladder, stomach and omentum were herniated. The abdominal organs were reducted to their normal anatomic position and a dual mesh graft was laid to close the diaphragmatic defect. Patients’ postoperative course was uneventful.DiscussionDiaphragmatic hernia secondary to trauma is more common on the left side of the diaphragm (left/right = 3/1). A right sided diaphragmatic hernia including liver, stomach, gallbladder and omentum is extremely rare. The main treatment of diaphragmatic hernias is primary repair after reduction of the herniated organs to their anatomical position. However, in the existence of a large hernia defect where primary repair is not possible, a dual mesh should be considered.ConclusionA dual mesh repair can be used successfully in extensive large diaphragmatic hernia defects when primary closure could not be achieved.     

Non-traumatic perforation of common hepatic duct: Case report and review of literature HP

IntroductionNon-traumatic biliary perforation other than the gallbladder is extremely rare and most commonly seen in children in association with congenital biliary anomalies. We present a rare case of choledocholithiasis that progressed to spontaneous perforation of the common hepatic duct probably from ischemic necrosis caused by impaction of large biliary stones.CasereportA 62-year-old female presented with diarrhea and jaundice. She was found to have two 2.5 cm stones in the common hepatic duct. Stones could not be extracted by ERCP, and placement of biliary stent was done to restore patency. The patient was lost to follow up and returned after three months with a new onset of similar symptoms. At that time ERCP and a stent change were done without resolution of the symptoms. Patient then underwent an open exploration and was found to have a free perforation in the lateral aspect of the common hepatic duct just at the bifurcation of the right and left hepatic radicals. Through this perforation stones were both extracted and cholangiogram showed free flow with the distal biliary stent. The stent was nowhere near the site of perforation which appeared to be caused by pressure necrosis from the impacted stones.ConclusionImpacted stones in the biliary tree need to be extracted to avoid pressure necrosis and spontaneous perforation. ERCP and stent placement should be used only as temporizing measures to manage the acute obstructive phase. Definitive surgical intervention must follow initial biliary decompression to extract the impacted biliary stones and avoid complications.     

婴幼儿先天性膈疝的诊断和外科治疗

目的 探讨婴幼儿先天性膈疝的诊断方法和外科治疗效果。方法 回顾性分析近10年来收冶的18例婴幼儿先天性膈疝病例,通过X线吞钡动态透视确诊。食管狭窄采用纵切横缝治疗,并将膈肌切口折叠交叉缝合于食管前后,做成人工膈肌角。另采用Belsey方法行His角成形,防止术后食物反流。结果 本组无死亡病例,均痊愈出院。术后随访1－5年无其他并发症。结论 动态下行X线钡餐透,视对诊断婴幼儿先天性隔疝有决定性帮助。手术是治疗食管狭窄及膈疝所引起呕吐的唯一方法。His角成形对防止术后远期食物反流有良好的作用。     

Acute appendicitis presenting as chest pain

IntroductionAbdominal pain is the primary presenting complaint of patients with acute appendicitis. Acute appendicitis presenting as chest pain is extremely rare and according to our search such presentation due to herniation of appendix into thorax through congenital diaphragmatic defect has not yet been reported.Presentation of caseWe present a case of a 12 year old male child who presented with acute chest pain. ECG was suggestive of ischemic changes. Echocardiogram and cardiac enzymes were within normal limits. Chest X-ray and gastrograffin contrast study confirmed the diagnosis of congenital diaphragmatic hernia. On exploration inflamed appendix was found herniated through the diaphragm along with caecum, ascending colon and transverse colon. Histology confirmed the diagnosis of acute appendicitis.DiscussionAcute appendicitis may sometimes have very varied and rare presentation. In late presenting CDH, the most important factor responsible for acute or chronic presentation seems to be the type of herniated viscera.ConclusionThis report presents a rare case of late-presenting CDH with herniated appendix along with caecum, ascending colon and transverse colon. Unusual presentation of chest pain was due to an attack of acute appendicitis. Late-presenting CDH is a very intriguing defect with a wide spectrum of clinical manifestations. It should be suspected in cases of unexplained acute or chronic respiratory or gastrointestinal symptoms, and abnormal chest radiographic findings. The prognosis is favorable with correct diagnosis and prompt surgical repair.     

Right-sided Bochdalek hernia obstructing in an adult: case report and review of the literature

Bochdalek hernias on the right side of the diaphragm are very rarely diagnosed in adults. We review a case of a 35-year-old female who presented acutely with intestinal obstruction. Plain and cross-sectional imaging identified a large right-sided Bochdalek hernia, containing colon, causing a mechanical obstruction and, surprisingly, concurrent appendicitis. The patient underwent an emergency laparotomy. At surgery the colon was reduced and was viable. The diaphragmatic defect was repaired using non-absorbable sutures and an appendicectomy was then performed for purulent appendicitis. She made an uneventful recovery and remains well at 9-month follow-up. We discuss what we believe to be the first reported case of an obstructed right-sided Bochdalek’s hernia associated with appendicitis in an adult and review the published literature on this rare condition.     

Chronic vomiting and recurrent pneumonia in an adolescent female

A 17-year-old girl presented with episodic vomiting associated with chest pain, a 20-pound weight loss over the past year, and multiple hospitalizations for pneumonia. She was bradycardic, cachectic (< 3rd percentile), pale, and had anterior cervical lymphadenopathy. CT angiography suggested an obstructive vascular ring (formed by a right aortic arch with an aberrant left subclavian artery), diverticulum of Kommerell, and a tracheoesophageal fistula (TEF). She underwent left thoracotomy with ligation and division of the ligamentum arteriosum to relieve the vascular ring. Flexible bronchoscopy at the time demonstrated a large H-type TEF. Eight weeks later, she had the TEF closed via a right cervical incision and recovered uneventfully. Our case is unique, with symptomatic presentation of a congenital TEF and vascular ring in a teenager. Such major congenital anomalies are rarely discovered outside of childhood, and TEFs virtually always (> 90%) present as neonatal emergencies secondary to esophageal obstruction. They have a high incidence of associated abnormalities, cardiovascular being the most common. Unexplained recurrent respiratory symptoms in an otherwise normal child with dysphagia should prompt the clinician to evaluate patients for foreign bodies, reflux and other more common problems. Unusual etiologies, however, do occur – as in this case – and warrant more complex workup.     

Dislocation of three segments of the liver due to hernia of the right diaphragm

Right diaphragmatic hernia is a rare injury (0.25–1%) following blunt abdominal trauma. The diagnosis may be delayed and achieved years after the trauma during laparotomies for other reasons. A 75-year-old male fell 6 years before, and was symptom-free since then. He was admitted to the hospital for abdominal pain, and chest X-rays revealed intestinal gas in the lower right thoracal region. Abdominal ultrasonography showed agenesis of the gallbladder, and computed tomography demonstrated that the right upper abdominal viscera were located in the vicinity of the heart. The patient underwent a laparotomy for right diaphragmatic hernia, and the right hepatic lobe and the medial segment of the left lobe, the gall bladder, the proximal part of the transverse colon, the omentum and some segments of the intestine were dislocated into the thoracal cavity by a tear in the right diaphragm. The organs were returned to the abdominal cavity uneventfully and the defect in the diaphragm, measuring 10 × 5 cm, was repaired by unabsorbable sutures. The diagnosis, surgical treatment and postoperative course of the right diaphragmatic hernia is discussed with a review of the literature.     

Pancreatic schwannoma: A rare case and a brief literature review

IntroductionPancreatic schwannoma (PS) is an extremly rare benign tumor. Less than 50 cases of pancreatic schwannoma have been described in the English literature over the past thirty years.Presentation of case reportA 63-year-old female underwent left modified radical mastectomy 2 years ago due to breast cancer. During her routine check-up, a 65 × 63 × 55 mm measured calcified, well-demarcated, cystic-mass having septations and calcifications that localized to the pancreatic head was detected by abdominal computerized tomography. She was asymptomatic and her tumor markers were in normal ranges. A standard Whipple procedure was performed, and the histo-pathological diagnosis of the resected specimen was reported as ancient schwannoma with clear surgical margins. Patient’s postoperative course was eventful. She had a biliary leakage after surgery which was managed conservatively. She is under follow-up.DiscussionPancreatic schwannoma also known as neurilemoma or neuroma is a slowly growing, encapsulated, mostly benign tumor with smooth well-delineated margins that originates from myelin producing schwann cells located on the nerve sheath of the peripheral epineurium of either the sympathetic or parasympathetic autonomic fibers. PS’s are extremly rare. The head of pancreas being involved in the vast majority of cases (40%), followed by its body (20%). Management of pancreatic schwannomas remains largely controversial. Both enucleation and radical surgical resections have revealed great therapeutic efficiency. with a well prognosis without recurrences.ConclusionAlthough rare, PS’s should be considered in the differential diagnosis of the other solid or cystic masses of the pancreas.     

Primary retroperitoneal mucinous cystadenoma

Mucinous cystadenomas and carcinomas of the ovary are well-established and common tumors. However, Primary retroperitoneal mucinous cystadenomas (PRMCs) are very rare. We present a 50-year-old woman referred to our institution with history of intermittent abdominal pain and palpable mass in her left flank. On CT-scan an unilocular cystic mass with thin wall measuring 171 × 155 × 108 mm in the retroperitoneum was shown. Patient underwent surgical excision of the tumor. The histopathology examination showed a cystic mass with a fibrous wall and an epithelium composed of a single layer of columnar cells with mucin vacuoles compatible with PRMC.     

Hyperfuctioning insular thyroid carcinoma: A rare case report

IntroductionInsular carcinoma of thyroid (ICT) is a rare pattern of thyroid tumor. Being hyperfunctioning makes the condition rarer. Here we reported a case of ICT associated with hyperthyroidism.Case reportA 65-year-old female presented with neck mass for 4 years. She had symptoms of thyrotoxicosis and received antithyroid treatment. She was referred for surgical management. She had multiple, non tender, mobile masses in the neck. Ultrasound showed midline multiple heterogenous mass lesions with multiple lymph nodes in right side of the neck largest one measuring 2 × 2 cm. The patient was prepared for total thyrodectomy with radical neck dissection. The result of histopathology confirmed unifocal, poorly differentiated ICT. The post operative course was uneventful.ConclusionInsular carcinoma is a rare disease. It may present with long history of signs and symptoms of hyperthyroidism. Total thyroidectomy is the main line of treatment.