Gastric volvulus after ventricular assist device explantation and cardiac transplantation

Diaphragmatic herniation has been recognized as a complication of unrepaired diaphragmatic defects after left ventricular assist device explantation and cardiac transplantation. We believe this to be the 1st report of diaphragmatic herniation that resulted in gastric volvulus in a cardiac transplant recipient. The presentation, diagnosis, and treatment of this potentially fatal condition are discussed herein.Nine months after removal of a Thoratec HeartMate II left ventricular assist device and orthotopic cardiac transplantation, the patient presented with intermittent upper abdominal and lower chest discomfort of 3 weeks' duration. Physical examination was notable for fullness in the upper abdomen. Plain radiographs and computed tomographic scans of the chest and abdomen without contrast were unexceptional. Two weeks later, the patient's pain began to worsen rapidly, and an upper gastrointestinal barium study revealed partial herniation of the stomach into the chest and omento-axial gastric volvulus without luminal obstruction. The patient underwent uncomplicated laparotomy for repair of the diaphragmatic defect and reduction of the herniated stomach.This case highlights the need for increased awareness of diaphragmatic herniation as a complication of unrepaired diaphragmatic defects so that diagnosis is not delayed, and underscores the importance of primary repair of all such defects to prevent future complications.     

Congenital diaphragmatic hernia presenting as massive gastrothorax

Delayed herniation of abdominal contents through a congenital diaphragmatic hernia may occur beyond the neonatal period. The case of a 29-month-old child with a Bochdalek hernia presenting as acute respiratory failure is presented. Chest radiography showed a tension gastrothorax that was misread as a tension pneumothorax. Tube thoracostomy resulted in clinical improvement by perforating and decompressing the stomach. Nasogastric tube placement confirmed herniation of the stomach into the left chest and is the initial treatment of choice when a tension gastrothorax is identified. A congenital diaphragmatic hernia must be recognized promptly so that rapid gastric decompression and surgical repair of the diaphragmatic defect can be performed.     

Endoscopic treatment of acute gastric volvulus causing cardiac tamponade

Acute gastric volvulus occurs when the stomach, or part of the stomach, rotates more than 180 degrees, creating a closed-loop obstruction, which eventually leads to ischemia and strangulation. Acute gastric volvulus may occur in association with a diaphragmatic defect, diaphragmatic elevation of any cause, tumors of the pancreas and stomach, trauma, and congenital abnormalities of mesenteric fixation. We describe an unusual case of an acute gastric volvulus causing cardiac tamponade, which was successfully treated by endoscopic reduction of the gastric volvulus.     

Noninvasive imaging of a retrocardiac spleen. Unusual component of paraesophageal diaphragmatic hernia.

The findings on chest roentgenograms, cardiac ultrasound, computed tomography (CT), and radionuclide liver-spleen scan are described in a 54-year-old man with a paraesophageal diaphragmatic hernia. The CT revealed the spleen as a solid mass with a notched border adjacent to the intrathoracic retrocardiac stomach. The radionuclide scan showed splenic uptake above the diaphragm. The diagnosis in this case, which, to our knowledge, is the first such reported case, was confirmed at surgery.     

Tension pneumothorax secondary to a gastropleural fistula in a traumatic diaphragmatic hernia

We report a case of tension pneumothorax due to a gastropleural fistula resulting from perforation of the stomach in a traumatic diaphragmatic hernia. Awareness of perforation of strangulated stomach or bowel in a diaphragmatic hernia as a cause of pneumothorax, with or without tension physiology, in a patient with a history of trauma is important so that surgical repair can be undertaken without delay.     

Hemoperitoneum secondary to spontaneous rupture of metastatic gastric leiomyosarcoma of the liver: Report of a case.

Hepatic rupture with resulting hemoperitoneum due to metastatic cancer is uncommon. Reports in the literature have described a wide variety of neoplasms causing this usually fatal phenomenon. We describe a rare case of spontaneous rupture of hepatic metastases from gastric leiomyosarcoma. A 72-year-old male patient with sudden onset severe epigastric pain was rushed into emergency service. After examination, the patient underwent urgent operation withe possible diagnosis of perforated gastric or duodenal ulcer. During exploration, we determined bleeding mass on the diaphragmatic side of the left lobe of the liver and a mass on the posterior wall of the stomach. Hemostasis was provided.     

A case of liver cirrhosis with an unusual portosystemic shunt via the right testicular vein.

We report a case of liver cirrhosis with a rare portosystemic shunt via the right testicular vein. Angiographic examination demonstrated two major hepatofugal collateral pathways. First, the enlarged and tortous left gastric and short gastric veins which drain into the left renal vein after forming varices in the stomach. Second, the superior mesenteric vein forms the large mesenteric varices which drain into the inferior vena cava via the enlarged right testicular vein, which is a very rare shunt.     

Intragastric migration of a plastic prosthesis placed for repair of a diaphragmatic perforation. Case report

CASE: We report the case of a 21-year old female with multiple surgeries. Her problem began after last surgery, which got complicated by a diaphragmatic perforation on the left side so it was necessary to repair the defect with a plastic prosthesis, since that time she complained of abdominal pain. In an abdominal computed axial tomography prosthesis was observed and by endoscopy its presence into stomach was confirmed, because its size and rigidity its endoscopic extraction was impossible, so it was surgically extracted. One and half month after surgery the patient's evolution was satisfactory. DISCUSSION: Migration is one of the most common complications of medical prosthesis placed into abdominal cavity. However precise incidence is unknown, neither intraluminal migration to the gastrointestinal tract. We didn't find previews reports about intragastric migration of a prosthesis that was used to repair a diaphragmatic defect.     

Congenital left intrahepatic bile duct draining into gastric wall mimicking biliary reflux gastritis

Abnormalities and variations of the biliary ducts are not rare.Most aberrant bile ducts eventually drain into the descending part of duodenum through the papilla of vater.However,drainage of the left hepatic bile duct into the stomach is extremely rare.A 29-year old man was admitted to the hospital with the diagnosis of biliary reflux gastritis.Comprehensive imaging modalities were performed including electronic endoscopy,endoscopic ultrasonography,endoscopic retrograde cholangiopancreatography and magnetic resonance cholangio-pancreatography.Finally,congenital ectopic left intrahepatic bile duct draining into the stomach was found,which caused biliary reflux gastritis.The patient did not receive any surgery.Good recovery was achieved by medical treatment.     

Late presentation of Bochdalek hernia: clinical and radiological aspects

Three infants with late presentation of Bochdalek hernia are presented. The presenting symptoms were cough, intermittent vomiting, dyspnea, and cyanosis. Initial diagnoses of isolated paravertebral mass and foreign material aspiration were made in two infants, based on plain chest x-ray findings and history of the patients. Further radiological investigations, such as contrast upper gastrointestinal series or enema, computerized tomography, and magnetic resonance imaging of the chest, suggested the diagnosis of Bochdalek hernia. The hernia was found on the left side in two patients and on the right side in one. At operation, the stomach, small intestine, and spleen were found as herniated organs in one patient, ascending colon in one, and all of the small intestine together with ascending colon in the other. A congenital diaphragmatic defect should be suspected in every child presenting with unusual respiratory or gastrointestinal symptoms and with abnormal chest x-ray findings. The radiological findings vary greatly from one case to another, and even in the same case at different times because of differences in herniated organs and intermittent spontaneous reduction. The possibility of congenital diaphragmatic hernia should be kept in mind to avoid a wrong diagnosis, undue delay in diagnosis, and inappropriate treatment.     

C型套管针辅助胸腔内置入细胃管治疗气胸34例临床报道

目的观察应用C型套管针辅助胸腔内置入细胃管治疗气胸的疗效和安全性。方法34例患者应用C型套管针辅助胸腔内置入细胃管治疗气胸。结果2周后,6例张力性气胸有效1例,16例闭合性气胸有效15例。本研究有效率74％（25／34）,改用其它气胸治疗方法6例,皮下气肿、引流管阻塞各2例。结论应用C型套管针辅助胸腔内置入细胃管治疗闭合性和部分交通性气胸是一种简单、安全、价廉和有效的新方法,不适合张力性气胸和部分交通性气胸患者。     

Diaphragmatic lymph vessel drainage of the peritoneal cavity.

We have studied the drainage of peritoneal fluid through the diaphragmatic lymph vessels in sheep. To measure the lymphatic flow rate, we cannulated the lymphatic vessels and timed the flow from the cannula. After we infused Escherichia coli endotoxin into awake sheep, the diaphragmatic lymph flow rate increased substantially. However, we found no increase in lymph flow in anesthetized acutely operated sheep. This indicates that studies in anesthetized animals may yield underestimates of diaphragmatic lymph flow. In sheep, many of the diaphragmatic lymph vessels drain to the caudal mediastinal lymph node. We cannulated an efferent vessel from that node in 5 sheep. Several days later we infused 100 ml/kg of Ringer's solution into the abdominal space of each awake sheep. In response, the lymph flow rate increased from 0.15 +/- 0.16 ml/min (mean +/- SD) to 0.50 +/- 0.17 ml/min. Our results are important because they demonstrate that diaphragmatic lymph flow increases substantially after fluid infusions into the abdominal space.     

Intercostal drain migration post esophagectomy

SUMMARY A 38‐year‐old man underwent an Ivor–Lewis esophagectomy for a squamous carcinoma at the lower third of his esophagus. On the fifth postoperative day one liter of turbid fluid appeared from the intercostal drain and there was a right‐sided pleural effusion on the chest radiograph. A contrast swallow demonstrated a leak at the distal part of the gastric staple line. This leak was managed conservatively and subsequent contrast swallows failed to show any leakage despite the persistent drainage from the drain. At gastroscopy, the intercostal drain was seen to have eroded through the stomach wall. The drain was repositioned and the patient was discharged from hospital 5 days later. We believe this to be the first report of an intercostal drain migration into the stomach after an elective esophagectomy.     

Intestinal obstruction caused by a strangulated Morgagni hernia in an adult patient

A Morgagni hernia is a congenital herniation of abdominal contents into the thoracic cavity through a retrosternal diaphragmatic defect. The reported incidence of congenital diaphragmatic hernias is estimated to be 1 in between 2000 to 5000 births. Morgagni hernias comprise 2% of diaphragmatic hernias. Most Morgagni hernias are found and repaired in children, but 5% are found in adults. They are usually asymptomatic and often found incidentally on chest radiography. Symptoms of these hernias are attributable to the herniated viscera. Morgagni hernias containing bowel may require repair on presentation because of the risk of incarceration. We present a case of an incarcerated and strangulated Morgagni hernia in a 71-year-old woman admitted to our clinic for abdominal pain and symptoms of intestinal obstruction. The diagnosis was made preoperatively by chest radiography, sonography, and computed tomography. Emergent laparotomy was performed, with the herniated transverse colon and omentum reduced into the abdomen. The diaphragmatic defect was repaired, followed by resection of the strangulated omentum. In conclusion, a Morgagni hernia may cause intestinal obstruction. Routine radiographic studies are usually sufficient to arrive at the diagnosis, but a CT scan and sonography may be necessary. Laparotomy is appropriate for the management of symptomatic adult patients with Morgagni hernias, particularly those with findings of intestinal strangulation, with laparoscopic treatment an alternative approach in selected cases.     

Delayed traumatic intrapericardial diaphragmatic hernia associated with cardiac tamponade

We describe a case of delayed presentation of traumatic intrapericardial diaphragmatic hernia associated with cardiac tamponade. A 71-year-old woman presented to our emergency department complaining of epigastric and midabdominal pain one month after hospitalization for multiple injuries suffered in an automobile accident. Chest radiograph showed a diaphragmatic hernia. In the ED, the patient became hypotensive and tachycardic with elevated central venous pressure. At surgery, she was found to have omentum and transverse colon herniated into the pericardial sac causing cardiac tamponade. The defect was repaired, and her postoperative course was uncomplicated. Cardiac tamponade should be included in the differential diagnosis of hypotension in patients with radiographic evidence of diaphragmatic hernia.     

Coronary to pulmonary artery fistula--diagnosis by transesophageal echocardiography

Coronary artery fistulas (CAFs) are rare coronary anomalies which generally require coronary angiography for definitive diagnosis. CAFs most commonly drain into the right atrium or right ventricle, but occasionally can drain into the pulmonary artery. We report the case of an asymptomatic coronary to pulmonary artery fistula, which could only be definitively diagnosed with transesophageal echocardiography.     

Laparoscopic repair of hiatal hernia with mesenterioaxial volvulus of the stomach

Although mesenterioaxial gastric volvulus is an uncommon entity characterized by rotation at the transverse axis of the stomach, laparoscopic repair procedures have still been controversial. We reported a case of mesenterioaxial intrathoracic gastric volvulus, which was successfully treated with laparoscopic repair of the diaphragmatic hiatal defect using a polytetrafluoroethylene mesh associated with Toupet fundoplication. A 70-year-old Japanese woman was admitted to our hospital because of sudden onset of...     

Unilateral diaphragmatic paralysis in a diabetic patient: a case of trepopnea

Dyspnea is a common presenting complaint. Trepopnea, an under-recognized form of dyspnea, is difficult breathing in only one lateral decubitus position. One cause of trepopnea is unilateral diaphragmatic paralysis, which in itself is an uncommon diagnosis. We report a unique case of a 55-year-old diabetic man who presented with trepopnea and was found to have unilateral diaphragmatic paralysis secondary to isolated diabetic phrenic neuropathy. This case highlights the importance of recognizing trepopnea as an early clinical symptom of diaphragmatic paralysis and discusses diabetic phrenic neuropathy which can occur in the absence of peripheral neuropathy.     

经皮肾微造瘘输尿管镜术治疗上尿路结石(附8例报告)

采用经皮肾穿刺置入造瘘管建立微造瘘通道后，同期经皮肾输尿管镜气压弹道碎石治疗上尿路结石患者8例。结果结石一期一次取净4例，3－5日二次取净2例，其余2例二次取石后肾下极肾盏内仍有小块结石残留，经体外震波碎石后结石排空。8例患者平均住院7．5天，术中及术后未出现并发症。认为Trocar造瘘管创伤小，术中出血及并发症少，可进入大部分肾盏及输尿管上段，视野清晰，大块结石碎屑能通过管腔冲出体外，取石效率提高；术毕能置入F14或F12气囊尿管，肾盂引流畅通，气囊稍牵拉有利于术后止血。     

Delayed diagnosis of traumatic diaphragmatic hernia during pregnancy

We present a case of delay in diagnosis of diaphragmatic rupture and herniation in a pregnant 25-year-old woman. The diaphragmatic rupture was secondary to trauma sustained five months prior to presentation. Subsequent to her accident, she was provided medical care on multiple occasions for symptoms of intractable nausea, vomiting, and weight loss that were probably related to an expanding uterus and diaphragmatic herniation of abdominal contents. At the time she presented to us the herniation had progressed and she was experiencing severe respiratory difficulty. A nasogastric tube was placed for diagnosis and decompression. A chest radiograph provided the diagnosis of herniation of gastrointestinal contents through the left hemidiaphragm. A healthy 5-lb boy was delivered vaginally and subsequently a left thoracotomy was performed for decompression and repair of the diaphragm. The patient's hospital course after hernia repair was uneventful.