Traumatic diaphragmatic rupture with combined thoracoabdominal injuries: Difference between penetrating and blunt injuries

Purpose: Traumatic diaphragmatic rupture (TDR) needs early diagnosis and operation. However, the early diagnosis is usually difficult, especially in the patients without diaphragmatic hernia. The objective of this study was to explore the early diagnosis and treatment of TDR. Methods: Data of 256 patients with TDR treated in our department between 1994 and 2013 were analyzed retrospectively regarding to the diagnostic methods, percentage of preoperative judgment, incidence of diaphragmatic hernia, surgical procedures and outcome, etc. Two groups were set up according to the mechanism of injury (blunt or penetrating). Results: Of 256 patients with a mean age of 32.4 years (9-84), 218 were male. The average ISS was 26.9 (13-66); and shock rate was 62.9%. There were 104 blunt injuries and 152 penetrating injuries. Preoperatively diagnostic rate was 90.4% in blunt injuries and 80.3% in penetrating, respectively, P<0.05. The incidence of diaphragmatic hernia was 94.2% in blunt and 15.1% in penetrating respectively, P<0.005. Thoracotomy was performed in 62 cases, laparotomy in 153, thoracotomy plus laparotomy in 29, and combined thoraco-laparotomy in 12. Overall mortality rate was 12.5% with the average ISS of 41.8; and it was 21.2% in blunt injuries and 6.6% in penetrating, respectively, P<0.005. The main causes of death were hemorrhage and sepsis. Conclusions: Diagnosis of blunt TDR can be easily obtained by radiograph or helical CT scan signs of diaphragmatic hernia. For penetrating TDR without hernia, “offside sign” is helpful as initial assessment. CT scan with coronal/sagittal reconstruction is an accurate technique for diagnosis. All TDR require operation. Penetrating injury has a relatively better prognosis.     

Video thoracoscopy expedites the diagnosis and treatment of penetrating diaphragmatic injuries

BACKGROUND: The diagnostic workup in stable patients with penetrating thoracoabdominal injuries can be extremely difficult. Conventional diagnostic tests such as plain chest radiography, computed tomography scan, digital exploration, and diagnostic peritoneal lavage can be misleading. Classically, most of these patients have undergone exploratory laparotomy to determine whether there is a diaphragmatic injury. METHODS: In this study, 52 patients with penetrating thoracoabdominal trauma, and without any indication for immediate surgery, underwent video-assisted thoracoscopy to determine the presence of diaphragmatic injuries. RESULTS: Of the 52 patients, 48 were men. The left hemithorax was involved in 38 patients (73%). Chest x-ray was normal in 40 patients (77%) who were clinically asymptomatic. Stab wounds were responsible for 80% of the injuries. At the time of the thoracoscopy, 35 patients (67%) were found to have a diaphragmatic injury. All 35 diaphragmatic injuries were successfully repaired thoracoscopically. The procedure was completed in 50 patients (96%). There were no deaths or complications. CONCLUSIONS: The incidence of diaphragmatic injuries is higher than anticipated in asymptomatic patients with penetrating thoracoabdominal wounds. Video thoracoscopy can be used as a safe, expeditious, minimally invasive, and extremely useful technique to facilitate the diagnosis of these injuries in asymptomatic patients. Furthermore, diaphragmatic injuries can be repaired easily through a thoracoscopic approach with no complications.     

Electron beam CT scan is a valuable and safe imaging tool for the pediatric surgical patient

Purpose

Electron beam computed tomography (EBCT) is a relatively new technology that has been used primarily to detect coronary artery calcification in adult patients. EBCT has several potential advantages over traditional CT: (1) fast acquisition times resulting in less need for sedation, (2) decreased radiation exposure, and (3) robust software enabling real-time interactive 3-dimensional visualization of anatomic relationships. In this series of case reports, the authors describe their initial experience with the use of EBCT in pediatric noncardiac imaging.

Methods

Children with a variety of thoracic and abdominal disease processes were evaluated by EBCT.

Results

All patients underwent EBCT scanning without the need for sedation, and 3-dimensional images of the data sets were rendered in minutes after their acquisition. The diagnostic images provided equivalent spatial resolution to the multislice CT scanner but without motion artifacts and lower radiation exposure.

Conclusions

EBCT is a safe, effective, and user- and patient-friendly alternative to traditional CT in the care of pediatric surgical diseases. The diagnostic yield of EBCT will continue to improve with new technologic advances and clinical experience.     

Blunt and penetrating diaphragmatic injuries with or without herniation of organs into the chest

From 1970 to 1984, 189 patients with penetrating injury and 20 with blunt injury were treated at Grady Memorial Hospital. One hundred eight-five patients with penetrating injury (Group 1) and 9 with blunt injury (Group 2) required emergency laparotomy. In the remaining 15 patients (Group 3), the diagnosis of diaphragmatic injury was delayed from 18 hours to 15 years (mean, 8 months) after injury. The vast majority of the Group 1 and all Group 2 patients had injury to other organs, and the diagnosis of the diaphragmatic injury was made in almost all of them during the emergency laparotomy. The diagnosis in Group 3 patients was made by chest roentgenogram alone or with an upper gastrointestinal series or barium enema. All diaphragmatic injuries were repaired primarily except one which was repaired with Prolene mesh. Four of the Group 1 patients died, a mortality of 2.2%, and 2 of the Group 2 patients died, a mortality of 22.2%. All Group 3 patients recovered. This study suggests that diaphragmatic injury should be suspected in all patients with penetrating as well as blunt injury of the chest and abdomen and particularly of the epigastrium and lower chest. The presence of such an injury should be excluded before the termination of the exploratory procedure. Also, diaphragmatic injury should be suspected in patients with roentgenographic abnormalities of the diaphragm or lower lung field following trauma. The presence of diaphragmatic injury in such patients should be excluded with appropriate diagnostic studies to protect the patient from its late complications.     

Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been shown to be an accurate method for identifying diaphragmatic injuries (DIs). The purpose of this investigation was to establish specific indications for the use of VATS after penetrating chest trauma. METHODS: A retrospective review of all patients undergoing VATS after penetrating chest trauma at a level 1 trauma center over an 8-year period was performed. Logistic regression was used in an attempt to identify independent predictors of DI. RESULTS: One hundred seventy-one patients underwent VATS assessment of a hemidiaphragm, and 60 patients (35%) were found to have a DI. Five independent risk factors for DI were identified from analyzing the patient records: abnormal chest radiograph, associated intraabdominal injuries, high-velocity mechanism of injury, entrance wound inferior to the nipple line or scapula, and right-sided entrance wound. CONCLUSIONS: In the largest published series of patients undergoing VATS to exclude a DI, this review identifies five independent predictors of DI after penetrating chest trauma. A diagnostic algorithm incorporating these five factors was designed with the goal of reducing the number of unrecognized DIs after penetrating chest trauma by using VATS for patients at greatest risk for such injuries.     

Cardiac troponin I is reliable with immediate but not medium-term cardiac complications after abdominal aortic repair

BACKGROUND: The diagnosis of cardiac complications is particularly challenging in the postoperative course of non-cardiac surgery. Follow-up of patients suggests that silent or symptomatic postoperative myocardial infarction have similar short-term outcomes. Cardiac troponin I (cTnI) has been reported as being a sensitive and specific marker of these complications. METHODS: We conducted a prospective study to determine the cut-off values of cTnI which may predict cardiac complications, i: in the postoperative period until discharge, and ii: during a 1-year period after aortic surgery. Three hundred and twenty-nine consecutive patients undergoing infrarenal aortic surgery were included over a 2-year period in a single center. cTnI was measured at recovery and on the 1st, 2nd and 3rd postoperative days. The presence or absence of cardiac complications was classified by reviewers who had no knowledge of cTnI. For evaluation of the ideal discrimination value of cTnI between the complicated and uncomplicated patient groups, we calculated receiver-operator characteristics for the mean values of the peak of cTnI. RESULTS: Thirteen patients (4%) developed 19 postoperative cardiac complications. Thirteen patients (4%) died in the postoperative period. Nine patients (3%) developed 10 cardiac complications during the 1-year follow-up in 316 patients. In 280 patients, cTnI was below 0.5 ng/ml, in 22 patients between 0.5 and 1.5 ng/ml and the 27 remaining patients had a cTnI higher than 1.5 ng/ml. The area under the curve for postoperative cardiac complications was 0.84 (SD=0.21). A limit value of 0.54 ng/ml yielded a sensitivity of 75% and a specificity of 89%. The area under the curve for late cardiac complications was 0.45 (SD= 0.13). CONCLUSION: A cTnI level greater than 0.54 ng/ml appears to be correlated with the occurrence of cardiac complications in the period until discharge, but no value of cTnI is predictive of late cardiac complications occurring in the 1st year after aortic surgery.     

The value of CT scan in gunshot injuries of the brain

Summary Fourteen cases of gunshot wounds of the brain, evaluated by CT scanning are presented. The results indicate that CT scanning is superior to other diagnostic tests in missile wounds of the brain. In individual patients it revealed gross injury to the skull, the location of the bullet or its fragments and indriven bone fragments, the track of the bullet, the gross injury suffered by the brain, the extent of oedema, the presence of any intracranial haematoma and late cerebral atrophy.Visualization of the missile track is of particular importance; this cannot be achieved by any other diagnostic method. It is essential for the planning of the surgical approach in these lesions.     

Reassessing the utility of CT angiograms in penetrating injuries to the extremities

Background

Computed tomography angiography has become routine in the management of penetrating trauma to the extremity. Our objective was to evaluate the efficacy of physical examination findings compared with computed tomography angiography for detection of clinically significant vascular injuries associated with penetrating trauma to the extremity.

CT with coronal reconstruction identifies previously missed smaller diaphragmatic injuries after blunt trauma

Diaphragmatic injuries (DIs) are difficult to diagnose and often go unrecognized after blunt trauma. We proposed that CT scan with coronal reconstruction (CTCR) improves the detection of small DIs missed by chest x-ray (CXR) and CT scan with axial views (CTAX). We performed a retrospective review at a Level I trauma center from 2001 to 2006 and identified 35 patients who underwent operative repair of DI after blunt trauma. The size of the DI and the radiographic test (CXR, CTAX, and CTCR) that identified the defect was compared. Results were analyzed using mean, Mann-Whitney U test, and Fisher exact test. Of the 35 DI repairs, nine were performed after CXR alone and 12 after identification by both a CXR and CTAX. There was no significant difference between the mean DI size identified by CXR with and without CTAX (10.6 vs 9.7, P = 0.88). The remaining 14 DIs were undetected by CXR and CTAX. Seven of these (before CTCR) were found during exploratory laparotomy and seven were identified by CTCR (4.6 cm vs 3.5 cm, P = 0.33). The mean DI size identified by CTCR was significantly smaller than that identified by CXR alone (4.6 cm vs 9.7 cm, P < 0.05) and by CXR and CTAX (4.6 cm vs 10.6 cm, P < 0.0005). CTCR improves the ability to detect smaller DI defects (4 to 8 cm) that were previously missed by CXR and CTAX. CTAX adds little to CXR alone for the diagnosis of large defects (greater than 8 cm).     

Computed tomographic scan can be used for surgical decision making in zone II penetrating neck injuries

BACKGROUND: Controversy surrounds the evaluation of zone II penetrating neck injuries. Current literature supports mandatory exploration or selective management. Computed tomographic (CT) scanning provides high-resolution images that are used for trauma in other body regions. The purpose of this study is to prospectively evaluate the utility of CT scanning in the evaluation of zone II penetrating neck injuries. METHODS: From July 1998 to November 1999, 14 stable patients were studied who sustained zone II penetrating neck injuries. All patients had a physical examination, infusion CT scan of the neck, and an operative exploration. Before surgery, the trauma surgeon evaluated the CT scan and interpreted it as demonstrating either "high" or "low" probability for significant injury. Surgical findings were compared with the surgeon's preoperative interpretation of the CT scan. RESULTS: Three of 14 patients had five significant injuries. All these patients had high probability of injury CT scans, with four of the five injuries specifically diagnosed by CT scan. Sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 91%, 75%, and 100% (p < 0.02), respectively. CONCLUSION: This small prospective study demonstrates that zone II penetrating neck injuries can be accurately evaluated by CT scan. In addition, the CT scan can be used for surgical decision making. This will eliminate the need for mandatory exploration and limit the role of angiography, esophagography, and endoscopy in zone II penetrating neck injuries.     

Pax3 gene expression is not altered during diaphragmatic development in nitrofen-induced congenital diaphragmatic hernia

Background/PurposeMalformations of the pleuroperitoneal folds (PPFs) have been identified as the origin of the diaphragmatic defect in congenital diaphragmatic hernia (CDH). Pax3, expressed in muscle precursor cells (MPCs), plays a key role in regulating myogenesis and muscularization in the fetal diaphragm. Pax3 mutant mice display absence of muscular diaphragm. However, the distribution of muscle precursor cells is reported to be normal in the PPF of the nitrofen-CDH model. We designed this study to investigate the hypothesis that Pax3 gene expression is unaltered in the PPF and developing diaphragm in the nitrofen-induced CDH model.MethodsPregnant rats were treated with nitrofen or vehicle on gestational day (D) 9 and sacrificed on D13, D18, and D21. Pleuroperitoneal folds (D13) and developing diaphragms (D18 and D21) were dissected, total RNA was extracted, and real-time quantitative polymerase chain reaction was performed to determine Pax3 messenger RNA levels. Confocal immunofluorescence microscopy was performed to evaluate protein expression/distribution of Pax3.ResultsRelative messenger RNA expression levels of Pax3 in PPFs and developing diaphragms were not significantly different in the nitrofen group compared with controls. Intensity of Pax3 immunofluorescence was also not altered in PPFs and developing diaphragms of the nitrofen group compared with controls.ConclusionPax3 gene expression is not altered in the PPFs and developing diaphragm of nitrofen-CDH model, suggesting that the diaphragmatic defect is not caused by disturbance of myogenesis and muscularization.     

Traumatic diaphragmatic rupture: associated injuries and outcome

A retrospective case note analysis was performed on all patients treated for traumatic diaphragmatic rupture (TDR) at a major teaching hospital between January 1990 and August 1998. Patients were identified from the prospectively maintained UK Trauma and Research Network Database. Of the 480 cases of torso trauma admitted during the study period, 16 (3.3%) had TDR. Blunt trauma accounted for 13 (81%) of the injuries. A radiological pre-operative diagnosis was made in 10 (62.5%) patients. Seven of these were made on initial chest radiography, two on ultrasound scan and one on computed tomography. All patients underwent a midline laparotomy and TDR was subsequently diagnosed at operation in 6 patients. The left hemidiaphragm was ruptured in 14 (87.5%) patients and there was visceral herniation in 8 (50%). Twelve patients with blunt trauma had associated abdominal and extra-abdominal injuries, but only one of the three patients with penetrating trauma had other injuries. The median Injury Severity Score (range) was 21 (9-50). The median time (range) spent on the intensive care unit was 2 days (0-35 days). Pulmonary complications occurred in 7 (44%) patients. Two (12.5%) patients died from associated head injuries. TDR results from blunt and penetrating torso trauma, is uncommon, rarely occurs in isolation and is associated with a high morbidity and mortality. A high index of suspicion makes early diagnosis more likely as initial physical and radiological signs may be lacking.     

Abdominal vascular injuries: Blunt vs. penetrating

Introduction: Abdominal vascular injuries (AVIs) remain a great challenge since they are associated with significant mortality. Penetrating injury is the most common cause of AVIs; however, some AVI series had more blunt injuries. There is little information regarding differences between penetrating and blunt AVIs. The objective of the present study was to identify the differences between these two mechanisms in civilian AVI patients in terms of patient’s characteristics, injury details, and outcomes.Method: From January 2007 to January 2016, we retrospectively collected the data of AVI patients at King Chulalongkorn Memorial hospital, including demographic data, details of injury, the operative managements, and outcomes in terms of morbidity and mortality. The comparison of the data between blunt and penetrating AVI patients was performed.Results: There were 55 AVI patients (28 blunt and 27 penetrating). Majority (78%) of the patients in both groups were in shock on arrival. Blunt AVI patients had significantly higher injury severity score (mean(SD) ISS, 36(20) vs. 25(9), p?=?0.019) and more internal iliac artery injuries (8 vs. 1, p?=?0.028). On the other hand, penetrating AVI patients had more aortic injuries (5 vs. 0, p?=?0.046), and inferior vena cava injuries (7 vs. 0, p?=?0.009). Damage control surgery (DCS) was performed in 45 patients (82%), 25 in blunt and 20 in penetrating. The overall mortality rate was 40% (50% in blunt vs. 30% in penetrating, p?=?0.205).Conclusions: Blunt AVI patients had higher ISS and more internal iliac artery injuries, while penetrating AVI patients had more aortic injuries and vena cava injuries. Majority of AVI patients in both groups presented with shock and required DCS.     

Pleural biopsy: a reliable method for determining the diagnosis but not subtype in mesothelioma

Background

Survival after tri-modality therapy with extrapleural pneumonectomy (EPP) and postoperative chemoradiotherapy is longer for patients with epithelial MPM versus mixed or sarcomatoid subtypes, leading some to decline aggressive therapy for patients with nonepithelial histology. However, pathologic diagnosis of malignant pleural mesothelioma (MPM) and subclassification into one of the three histologic subtypes (epithelial, mixed, sarcomatoid) can be challenging. Pleural biopsy has been proposed as the diagnostic gold standard. We investigated the accuracy of open pleural biopsy for diagnosis and subtype identification in MPM.

Methods

Patients with suspected MPM routinely undergo open pleural biopsy to establish diagnosis. Those diagnosed definitively by pleural biopsy or cytology are offered pleurectomy or EPP dependent on stage and cardiorespiratory status. We reviewed medical records for all patients undergoing EPP at our institution, comparing tissue and subtype diagnosis at initial diagnostic biopsy versus definitive resection.

Results

Between 1988 and 2000, 305 of 332 consecutive patients undergoing EPP had MPM. One patient diagnosed with MPM at pleural biopsy was misclassified. Subtype analysis at pleural biopsy proved correct in 80% (226/282). Most patients (174/192) with epithelial subtype at final diagnosis were diagnosed correctly at pleural biopsy. However, 44% (45/103) with pathologic diagnosis of nonepithelial subtype at resection were initially misdiagnosed with the epithelial subtype. The sensitivity of pleural biopsy for epithelial MPM was 97% with a specificity of 56%.

Conclusions

Open pleural biopsy is accurate and should be considered the gold standard diagnostic method for MPM. It is less sensitive for determining histologic subclass, particularly with nonepithelial subtypes.