Acute diaphragmatic rupture due to blunt trauma: a retrospective analysis

Twenty-eight cases of diaphragmatic rupture due to blunt trauma are reviewed. The need for accurate and rapid diagnosis and results of treatment are discussed. Chest roentgenogram was found to be the best diagnostic aid. Surgical repair through an abdominal approach is advised in all acute cases. The high mortality rate in this series (28.6%) is related to the multiple injuries rather than to the diaphragmatic lesion itself.     

Update on managing diaphragmatic rupture in blunt trauma: a review of 208 consecutive cases

Background

Blunt diaphragmatic rupture (BDR) is a rare event and represents a diagnostic challenge. The purpose of our study was to review our experience with BDR at the Sunnybrook Health Sciences Centre (Sunnybrook), the largest trauma centre in Canada, and to highlight recent changes in the diagnosis and management of the condition.

Methods

We retrospectively reviewed the cases of patients with BDR who were admitted to Sunnybrook between January 1986 and December 2003 using our trauma registry. We performed Student t and Fisher exact tests to compare our findings on patients with BDR with those on the entire cohort of blunt trauma patients admitted to our centre.

Results

Most patients with BDR were men (64.4%) with a mean age of 42 years. Left-sided tears were most common (65.0%). Patients with BDR had a very high Injury Severity Score (38) and very high mortality (28.8%). Of those who were injured as a result of motor vehicle collisions (MVCs), a significantly greater percentage of patients in the BDR group than in the entire cohort of blunt trauma patients were drivers or front-seat passengers. Patients with BDR were also significantly less likely to be pedestrians, to have experienced a fall or to be involved in a motorcycle collision. Patients with BDR had a higher chest, abdomen, pelvis and extremity Abbreviated Injury Scale score than all blunt trauma patients in general. Most of our patients underwent laparotomy (93.3%). The most common causes of death among patients with BDR were head injury (25.0%), intra-abdominal bleeding (23.3%) and pelvic hemorrhage (18.3%).

Conclusion

Blunt diaphragmatic rupture is rare and difficult to diagnose; however, certain MVC characteristics along with severe associated injuries should raise the index of suspicion. These associated injuries include injuries to the head, chest (including the aorta), abdomen and pelvis. Computed tomographic angiography is essential to rule out associated aortic injury and to increase the diagnostic accuracy of BDR.     

The use of laparotomy in the treatment of recent diaphragmatic rupture due to blunt trauma

The choice of approach is still one of the most controversial points in the surgical treatment of recent rupture of the diaphragm. Most authors agree, however, about the use of thoracotomy in the late cases with strangulation. From 1970 to 1982 inclusive, 40 patients were operated on within a week of closed rupture of the diaphragm. The following data appear from these operations: 1. In 29 patients (73 per cent) one or more subdiaphragmatic organs needed repair. Only 4 patients (10 per cent) required operation for a thoracic lesion. 2. The hernia was easily repaired in the 34 cases treated by laparotomy only. For this reason when confronted by a recent diaphragmatic rupture, we almost always use an abdominal incision knowing that it, can easily be extended into the chest if this becomes necessary for the treatment of an injury there. In our experience, this policy needed to be changed in only a very few special cases.     

Non-operative management of blunt splenic trauma: a 10-year experience.

There is growing awareness that the majority of traumatic splenic injuries should be managed non-operatively. This review of all traumatic spleen injuries at a large community teaching hospital over a 10-year period (1978-1988) confirms that principle. The study generated selection criteria and principles of non-operative management. Of a total of 91 patients, 23 were initially treated non-operatively. The average age was 27 years and all but two were adults. Splenic injury was confirmed by computed tomography scan in 20 patients (87 per cent) and by liver/spleen scan in three patients (13 per cent). Of the 23 patients, 21 (91 per cent) were successfully treated non-operatively. Of these, 14 had intraparenchymal or subcapsular haematomas and seven had splenic lacerations with haemoperitoneum. Two patients (9 per cent) initially treated non-operatively required splenectomy. Haemodynamically stable adult patients with blunt splenic injuries can be managed non-operatively if monitored in a setting where immediate operative intervention is available. Operative intervention is indicated not only in haemodynamically unstable patients, but also in patients who require more than four units of blood during a 48-h period.     

Misdiagnosis of diaphragmatic rupture in a trauma setting

Distinguishing diaphragmatic eventration from rupture in the trauma setting can be a considerable challenge. We present a case involving a man suffering from chest pain and with a raised left hemidiaphragm on the chest radiograph after a motor vehicle injury. A review of the literature discusses the use of imaging modalities and subsequent surgical diagnostic procedures in the face of uncertainty.     

Endovascular treatment of aortic rupture by blunt chest trauma

BACKGROUND: The usual treatment of blunt aortic injury (BAI) is prompt surgery. Frequently severe injuries to the brain or lungs exclude further surgical treatment. The purpose of this study is to assess the feasibility of placing endovascular stent-grafts. METHODS: From 1992 through 1999, in our primary and referral trauma center, 26 acute BAI, 21 males and 5 females, mean age 40.2+/-16.3 yrs were diagnosed. The last 4 patients underwent prospectively endovascular repair with Talent endograft. Endoprosthesis parameters were measured on three-dimensional spiral CT reconstruction. While waiting for devices, blood pressure was aggressively lowered and aortic lesions were monitored by transesophageal echography. RESULTS: Stent-graft deployment was successful in all 4 patients. There were no complications of endoleak, stent migration, paraplegia or death. Angiographic exclusion was complete in all 4 patients. CT scans at a mean follow-up of 11+/-5 months showed complete healing of the aortic wall in all patients. CONCLUSIONS: For stable acute BAI, endovascular stent-graft repair is feasible and safe, and is an effective therapeutic alternative to open surgery. Because of the normal proximal and distal wall in aortic injuries, endoluminal treatment might be the therapy of choice in the near future.     

Surgical treatment of hepatic haemangiomas: a 15-year experience

BACKGROUND: Hepatic haemangiomas are congenital vascular malformations. They are the most common benign tumours of the liver and are often asymptomatic. Spontaneous or traumatic rupture, intratumoral bleeding, consumption coagulopathy and rapid growth are the mandatory surgical indications. We present our experience over the last 15 years with the surgical management of 15 liver haemangiomas to clarify the safety and effectiveness of this treatment. METHODS: There were 15 patients with hepatic haemangiomas who were surgically treated from 1990 to 2004. Indications for the operation were spontaneous or traumatic rupture, consumption coagulopathy, rapid growth, abdominal pain and uncertain diagnosis. Four of these lesions were located on the left lobe, nine on the right lobe; one lesion was located on the left and the right lobes and one on segments VII and VIII. Methods for diagnosis included ultrasonography, computed tomography scan, magnetic resonance imaging and selective hepatic arteriography or combinations of more than one technique. RESULTS: The procedures included five right-extended lobectomies, five right lobectomies, one left-extended lobectomy, two left lobectomies and two segmental resections. There was no death. The postoperative morbidity was minimal and was mainly correlated to two subdiaphragmatic collections, one intra-abdominal collection and one wound infection. The postoperative hospital stay was 12.7 days (range, 10-19 days). During the follow-up period, there was no recurrence. CONCLUSION: The resection of the hepatic haemangioma is safe. The indications for resection, however, should be carefully analysed before embarking on such a major operation.     

Evolution, not revolution: splenic salvage for blunt trauma in a statewide voluntary trauma system--a 10-year experience

BACKGROUND: State-legislated trauma systems have been enacted in an attempt to improve trauma care. Blunt splenic injury incidence without a legislated trauma system was examined for changes in care with a hypothesis that a voluntary system may perform equally with a legislated system. METHODS: Data from a statewide discharge database for the years 1993 to 2002 were examined. RESULTS: There were 276,425 trauma admissions overall, with blunt splenic injury occurring in 1.76%. Average Injury Severity Score (ISS) increased in trauma centers and decreased in the community. Trauma centers (TC) had more multisystem injuries. Splenic injury diagnosis increased 44% in TC between the early and late periods but only 7% in community facilities. Splenectomies increased 16% in TC but declined 16% in community hospital. Splenic salvage rate improved at both types of facilities. CONCLUSIONS: Splenic salvage rates improved over time in hospitals with no formal trauma system. Community hospitals cared for more than 50% of splenic injuries but transferred complex multisystem injuries, including splenic injuries, suggesting evolving care. Non-invasive imaging has increased the recognition of splenic injuries in both community hospitals and TC. Splenectomies are performed less, but have increased in TC with increasing ISS scores.     

Injuries of the gastrointestinal tract from blunt trauma in children: a 12-year experience at a designated pediatric trauma center

INTRODUCTION: Nonoperative management of solid organ injury from blunt trauma in children has focused concern on potential delays in diagnosis of hollow viscus injury with resultant increases in morbidity, mortality, and cost. This study of a large pediatric trauma database will review the issues of difficulty and/or delay in diagnosis as it relates specifically to definitive treatment and outcome. METHODS: We surveyed 11,592 consecutive admissions to a designated pediatric trauma center from 1985 to 1997 to identify children with documented injury of the gastrointestinal (GI) tract from blunt trauma. The records were extensively analyzed specifically in regard to mechanism of injury, type and site of injury, time to diagnosis, operative treatment, complications, and final outcome. RESULTS: The 79 children identified, 4 months to 17 years old, included 27 females and 52 males. Mechanism of injury included 15 restrained and 7 unrestrained passengers, 15 pedestrians, 15 child abuse victims, 10 bike handlebar intrusions, 8 discrete blows to the abdomen, 4 bike versus auto, 3 falls, and 2 crush injuries. There were 51 perforations, 6 avulsions, and 22 lesser injuries including contusions. Injury of the small bowel was most common, 44 cases, followed by the duodenum, 18 cases, colon, 17 cases, and stomach, 6 cases. In 45 children, diagnosis was made quickly by a combination of obvious clinical findings, plain x-ray and/or initial computed tomographic findings mandating urgent operative intervention. Diagnosis was delayed beyond 4 hours in 34 children, beyond 24 hours in 17 children and was made by persistent clinical suspicion, aided by delayed computed tomographic findings of bowel wall edema or unexplained fluid. The six deaths were caused by severe head injury. Complications included two delayed abscesses and two cases of intestinal obstruction. All 73 survivors left the hospital with normal bowel function. CONCLUSIONS: Injury to the GI tract from blunt trauma in children is uncommon (<1%). The majority of GI tract injuries (60%) are caused by a discrete point of energy transfer such as a seatbelt (19%), a handle bar (13%), or a blow from abuse (19%), or other blows and is unique to this population. Although diagnosis may be difficult and often delayed, this did not result in excessive morbidity or mortality. Safe and effective treatment of GI tract injuries is compatible with nonoperative management of most other injuries associated with blunt abdominal trauma in children, while reducing the risk of nontherapeutic laparotomy.     

Gastroschisis: a 15-year experience

Between January 1, 1971 and December 31, 1985, 59 cases of gastroschisis were treated at H?pital Sainte-Justine in Montreal. In the period before 1978, 6 of 19 patients (31.6%) were closed primarily at the time of surgery and 13 of 19 patients (68.4%) had silon pouch closure. After 1978, 33 of 40 patients (82.5%) had primary closure and 7 of 40 (17.5%) had a silon pouch. Our overall mortality rate was 13.6%. The complication rate for the primary closure group was 25.6% with a 12.8% (5/39) mortality rate, interestingly, in the higher birth weight group. Those closed with a silon pouch had a 75% complication rate, mostly infectious, with 15% mortality. Neither low birth weight nor gestational age influenced mortality. A significant difference in the length of hospital stay was observed. This was 33.6 days for the primary closures and 56 days for the silon pouch closures. Our series demonstrates a definite favorable trend in the results of treatment of this malformation. The most important factor affecting these results is a change in surgical approach. Primary abdominal wall closure, being usually possible, should always be attempted. We also note an association between high birth weight and death due to bowel dysmotility.     

Laparoscopic repair of missed blunt diaphragmatic rupture using a prosthesis

A 54-year-old man underwent a therapeutic laparoscopy for giant diaphragmatic rupture complicating a blunt trunk trauma that had occurred 13 months earlier. Laparoscopy revealed a left hemidiaphragm 12-cm defect with an intrathoracic herniation of the omentum, the entire gastric fundus, the splenic flexure of the colon, and the two upper thirds of the spleen. The defect was not suitable for primary suture due to the diaphragmatic edges retraction. We repaired the hernia using a large polypropylene mesh covering the defect with 2-cm overlap. There was no intraoperative surgical or anesthetic complication. Postoperative course was uneventful and 3-month follow-up confirmed the healing of the diaphragmatic hernia. This case is discussed regarding the safety of the procedure, the best minimally invasive approach, and technical aspects of the repair. Received: 6 June 1997/Accepted: 11 August 1997     

Intraperitoneal air in the diagnosis of blunt diaphragmatic rupture

We present here a case of blunt traumatic right hemidiaphragmatic rupture with hepatic hernia that was diagnosed preoperatively on the basis of clinical, chest radiogram, and computed tomography scan suspicions. We proposed that the presence of free intraperitoneal air without guarding or peritoneal signs should be considered to be a clinical indication of hemidiaphragmatic rupture with pneumothorax.     

Evaluation of a 15-year experience with splenic injuries in a state trauma system

BACKGROUND: The management of splenic injuries has evolved with a greater emphasis on nonoperative management. Although several institutions have demonstrated that nonoperative management of splenic injuries can be performed with an increasing degree of success, the impact of this treatment shift on outcome for all patients with splenic injuries remains unknown. We hypothesized that outcomes for patients with splenic injuries have improved as the paradigm for splenic injury treatment has shifted. METHODS: Consecutive patients from 1987 to 2001 with splenic injuries who were entered into a state trauma registry were reviewed. Demographic variables, injury characteristics, and outcome data were collected. RESULTS: The number of patients who were diagnosed with splenic injuries increased from 1987 through 2001, despite a stable number of institutions submitting data to the registry. The number of minor injuries and severe splenic injuries remained stable, and the number of moderately severe injuries significantly increased over time. Overall mortality rate improved but primarily reflected the decreased mortality rates of moderately severe injuries; the mortality rate for severe splenic injuries was unchanged. CONCLUSION: Trauma centers are seeing increasing numbers of splenic injuries that are less severe in magnitude, although the number of the most severe splenic injuries is stable. The increased proportion of patients with less severe splenic injuries who are being admitted to trauma centers is a significant factor in the increased use and success rate of nonoperative management.     

Rib tumors: a 15-year experience

Objective

A retrospective study of rib tumors was conducted to review their clinical, radiological, and pathological features, the difficulties in differentiating benign from malignant tumors, as well as the early and long-term results of surgical management.

Methods

All patients with rib lesions evaluated by the Thoracic Surgery Department from 1998 to 2012 were studied. The patient’s age, sex, symptoms, radiologic evaluation, surgical procedure, pathologic diagnosis and follow-up were assessed.

Results

Ninety-one patients (81 male, 10 female, age range 16–80) with rib tumors underwent surgery in a period of 15 years (1998–2012). 64 patients (70.33 %) had benign lesions and 27 patients (29.67 %) had malignant tumors. In the group with malignant tumors, the main symptom was pain, and in the group with benign tumors the main symptom was swelling. Ten patients with benign rib tumor and two with malignant tumor were detected during routine chest radiograph. All patients were treated surgically with wide excision of the tumor and the diagnosis was established histologically. In the benign cohort, osteochondromas, fibrous dysplasia, enchondroma, eosinophilic granuloma and posttraumatic fibro-osseous lesion/dysplasia were among the most customary diagnoses. In the malignant cohort, 13 patients (48.15 %) had metastatic lesions, with the remaining 14 patients having primary malignant rib tumor.

Conclusions

Although radiographic imaging has evolved, all rib lesions must be considered as potentially malignant until proven otherwise. Prompt intervention is necessary and surgery must consist of wide resection with tumor-free margins to provide the best chance for cure in both benign and malignant lesions.     

Scalp reconstruction: a 15-year experience

Scalp reconstruction after ablative surgery can be challenging. A useful reconstructive algorithm is lacking. The purpose of this study was to evaluate the authors' experience and to identify an appropriate reconstructive strategy. This was a retrospective review of all patients treated by the authors' service for scalp defects during a 15-year period. Reconstructive methods, independent factors, and outcomes were analyzed. A total of 73 procedures were performed in 64 patients. Techniques for reconstruction included primary closure, grafts, and local and distal flaps. A correlation between reconstructive technique and complications could not be demonstrated. However, an increased incidence of complications was correlated with a history of radiation, chemotherapy, cerebrospinal fluid leaks, and an anterior location of the ablative defect (P < 0.05). Important tenets for successful management of scalp defects are durable coverage, adequate debridement, preservation of blood supply, and proper wound drainage. Local scalp flaps with skin grafts, and free tissue transfer remain the mainstay of reconstruction in most instances.