Diaphragmatic rupture: a frequently missed injury in blunt thoracoabdominal trauma patients

In the US and Western Europe, trauma is the fourth most common cause of death and the leading cause of death in the population less than 45 years of age [Mullinix and Foley, J Comput Assist Tomogr 28(Suppl 1):S20–S27, 2004]. Diaphragmatic injuries occur in 0.8 to 8% of patients after blunt trauma (Gray H, The muscles of the thorax. Anatomy of the human body. Lea & Febiger, Philadelphia, 1918) and may be a predictor of severity of injury in the blunt trauma patient [Worthy et al., Radiology 194(3):885–888, 1995]. The clinical diagnosis of diaphragmatic rupture (DR) is difficult and is missed in anywhere from 7 to 66% of patients [Cantwell, Radiology 238(2):752–753, 2006]. The accurate diagnosis and prognosis of this pathology depend on a complete knowledge of the clinical and radiological presentation. Computed tomography is the imaging modality of choice in the assessment of patients with clinical or radiographic findings suggestive of DR.     

Neonatal-onset nemaline myopathy mimicking congenital diaphragmatic hernia

In a newborn with severe respiratory failure and abnormal elevation of the right diaphragm, congenital diaphragmatic hernia with sac was diagnosed during surgery. However, microscopic examination of the sac showed atrophic striated muscle cells, indicating eventration instead of hernia. After several extubation failures, the final diagnosis of nemaline myopathy was made by skeletal muscle biopsy. In diaphragmatic defects with sac, diaphragm microscopic analysis should be recommended in order to discriminate between hernia and eventration. Congenital myopathies may underlie such diaphragmatic defects and should be promptly recognized, given their prognostic implications.     

Left congenital diaphragmatic hernia, absent pericardium, and liver heterotopia: a case report and review

A case of a left congenital diaphragmatic hernia (CDH), absent pericardium, and a hernial sac containing ectopic liver tissue is presented. This triplicate of defects is exceedingly rare with only 2 previous reports in the literature dating back to 1936. This case supports the evidence that CDH is the result of failure of the closure of the pleuroperitoneal canals by the growth of the posthepatic mesenchymal plate. Moreover, the role of the phrenic nerve as a mediator for both CDH and absent pericardium is discussed.     

鞍隔孔区解剖学研究及其临床意义

目的 通过鞍隔孔区结构的解剖学研究,分析经蝶入路脑脊液漏的发生机制,以及空蝶鞍(ES)的形成原因. 方法 对8例胎儿标本进行组织学连续切片后,做HE和Masson染色,并在显微镜下对鞍隔孔附近结构进行观察;另取10例成人尸头标本,模拟经蝶入路手术,并在手术显微镜下观察鞍隔孔区解剖结构. 结果 鞍上蛛网膜在垂体柄上端和其表面的软脑膜紧密结合,并转折进入鞍内;同时在垂体上表面处,鞍隔从四周紧密包绕并和表面的软脑膜紧密结合,而难以从组织学切片上分辨二者的界限:鞍上蛛网膜池由于蛛网膜、软脑膜和鞍隔的束缚而终止于鞍隔孔上部. 结论 鞍隔、软脑膜和鞍上蛛网膜三者之间存在着严密的解剖学关系,其也是防止脑脊液漏和ES发生的关键因素.这三者的先天性缺损、生理性或者病理性破坏,尤其是在经蝶入路中对垂体腺瘤的过分牵拉,导致鞍上蛛网膜和软脑膜分离或者破裂,可能是造成术中脑脊液漏发生的重要原因;另外鞍隔、软脑膜和垂体上表面之间的分离也可能是造成ES的关键因素.     

腹部闭合性损伤致膈疝的诊治分析

目的总结创伤性膈疝早期诊断与治疗的经验,提高临床诊治水平,并提高对膈疝及膈肌破裂致膈疝的认识,为完善诊治方法创造条件。方法回顾性分析1999～2008年我院收治的16例创伤性膈疝病例,并对因腹部闭合性损伤所致的2种不同类型膈疝所特有的临床表现、体征、手术方式及诊治经验进行分析。结果均急诊手术探查,并进行抗休克、抗感染及对症处理,治愈率达100%。结论创伤性膈疝早期行胸部X线、B超和胸部CT检查是确诊的依据;早期诊断和手术,正确处理合并伤,是提高创伤性膈疝治愈率的关键。     

Diaphragmatic repair of two cases of hepatic hydrothorax using video-assisted thoracoscopic surgery

Hepatic hydrothorax is defined as the presence of a significant pleural effusion that develops in a patient with cirrhosis of the liver who does not have underlying cardiac or pulmonary disease. There are few published case reports dealing with hepatic hydrothorax treated surgically because patients with hepatic hydrothorax have end-stage liver disease. Recently, we treated two patients with refractory hepatic hydrothorax by directly suturing the diaphragmatic defects during video-assisted thoracoscopic surgery (VATS). During surgery, the diaphragmatic defects were identified using abdominal insufflation of saline with indocyanine green or carbon dioxide. After suture closure using fibrin glue, both right pleural effusions were improved. The patients’ postoperative courses were uneventful, and they did not require a drainage tube when they were discharged.     

Diaphragmatic pacing for the treatment of congenital central alveolar hypoventilation syndrome

Purpose

The congenital central alveolar hypoventilation syndrome (CCAHS), also known as Ondine curse, is characterized by the absence of adequate autonomic control of respiration.The purpose of our study is to review our 20-year experience with diaphragmatic pacing as a treatment modality for CCAHS.

Methods

After obtaining institutional review board approval, the medical records of all 6 patients who currently are in the diaphragmatic pacing program at the Montreal Children's Hospital, Montreal, QC, Canada were reviewed. In addition to demographic details, associated anomalies were noted. Data regarding age at surgery, technical approach, and short- and long-term complications, including equipment failure and replacement, were noted. We were interested in the long-term outcome for this group of patients, particularly their quality of life.

Results

Our group of patients is composed of 4 females and 2 males. Their age ranges between 4 and 23 years. They were operated on at an average age of 47.8 months. The surgical approach used was mainly bilateral axillary thoracotomy. Internal component failure is the most common complication. All patients are ventilator free during the day. They all are active and productive, either attending school or working full time.

Conclusion

Diaphragmatic pacing is an effective treatment of Ondine disease. As equipment improved, there is much less need for replacement of components. Patients can lead a much more normal existence by being ventilator free at least during the day, enabling them to participate in normal daily activities.     

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.     

‘Pseudopneumothorax’—Hold that chest tube!

We report a case of herniation of abdominal contents into the left hemithorax in a patient with a history of vague left-sided thoracoabdominal trauma 18 days previous to admission and who also had a recent 1-week history of upper respiratory symptoms, including cough, and then presented with dyspnoea and fever for 3 days. There was no preceding cardiorespiratory pathology of note. We also discuss the epidemiology, pathogenesis and management of blunt-traumatic diaphragmatic rupture.     

Diaphragmatic hernia in an 8-year-old with Ehlers-Danlos syndrome

Ehlers-Danlos syndrome (EDS) includes a group of connective-tissue disorders characterized by abnormal collagen metabolism. The diverse spectrum of this disease and its complications present a distinct challenge to the surgeon. Patients with this hereditary disorder may have hyperelastic or fragile skin, poor wound healing, hypermobile joints, clotting abnormalities, spontaneous pneumothoraces, recurrent hernias, bowel perforation, and vascular complications. An 8-year-old female with EDS type VII and a newly diagnosed diaphragmatic hernia is presented. Surgical considerations of this syndrome are reviewed.