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.     

Surgical management of diaphragmatic injuries

Background Traumatic diaphragmatic lesions have variable presentations and need a high index of suspicion to be diagnosed in the acute phase. Delayed diagnosis is frequently associated with considerable comorbidity. Material and Methods The present retrospective study aims to evaluate the radiological findings and discuss the surgical approach for the repair of the injured diaphragm. This study includes fifteen cases with diaphragmatic injuries, which were surgically managed between 1994 and 2005. Injuries resulted from violent blunt trauma in twelve patients and three patients had penetrating injuries. Patients presented with hypotension, respiratory insufficiency, acute abdomen and hemothorax. Preoperative diagnosis was established in 12/15 (80%) patients depending on the clinical and the chest skiagram findings. Intra-operative diagnosis was made in the rest. Injuries were more common on the left side (11/15, 73.33%). All these patients underwent repair of the defect by direct closure in double layer using monofilament polypropylene suture. In addition, laparotomy was performed in four patients who had liver and spleen injury. Concomitant procedures included lobectomy, segmentectomy, repair of lung laceration, spleenectomy, spleenorraphy, repair of gastric perforation, intestinal perforation and mesenteric tear. Results One patient died (1/15, 6.66%) of associated injuries. Two patients with major liver injuries had prolonged drainage and repeated subdiaphragmatic collections. Conclusions Associated lesions particularly influence the outcome after traumatic lesions of the diaphragm. Surgical exploration is mandatory whenever diaphragmatic injuries are suspected. Right-sided injuries are best exposed and managed through the right thoracotomy. Direct suture is effective in preventing future specific complications.     

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目的评价经腹、膈肌裂孔途径行根治性切除累及食管下段近侧部进展期胃癌的可行性和有效性。方法1999～2001年针对20例经腹、膈肌裂孔途径切除全胃和食管下段的病人，收集手术时间、术中失血量、ICU治疗时间、切除标本病理资料。结果与20例经胸腹途径切除全胃和食管下段病人相比。结果经腹、膈肌裂孔手术时间较短，术中失血量减少，ICU治疗时间短。结论经腹、膈肌裂孔途径手术切除近侧部进展期胃癌是替代胸腹途径手术的合理手术方法，避免剖胸手术对病人的创伤。     

Aging of phrenic nerve conduction in the elderly.

OBJECTIVE: We elucidated the possible relationship between age and conduction parameters of phrenic nerve in subjects above the sixth decade, comparing with the data from middle-age controls. METHODS: Diaphragmatic action potentials (DAPs) were recorded on bilateral hemithoraces of 41 volunteers aged 60-101 years (old group) and 25 volunteers aged 35-55 years (middle-age group). Statistical analyses were performed to assess the effects of aging on latency, latency corrected by size (Lat/Dist), amplitude, and the right-left difference of these DAP parameters. RESULTS: In all 61 subjects, age showed a significant quadratic correlation with latency and with Lat/Dist, and a linear correlation with amplitude. The right-left differences ranged from 0.0 to 14.5% for latency and from 6.5 to 112.4% for amplitude in the elderly. CONCLUSIONS: The normal ranges of DAP parameters should be determined according to age. The left-right difference may be a useful reference in diagnosing unilateral phrenic nerve lesion. SIGNIFICANCE: The precise normal ranges of phrenic nerve conduction parameters presented will encourage investigations of neuropathies in subjects aged above 60.     

Laparoscopic distal gastrectomy in a patient with gastric cancer complicated by eventration of the diaphragm: A case report

Diaphragmatic eventration refers to an abnormal elevation of the diaphragm. Here, we report the case of a patient with gastric cancer who underwent successful laparoscopic distal gastrectomy despite the presence of diaphragmatic eventration. The patient was a 72-year-old man diagnosed with early gastric cancer in the antrum, as detected by upper gastrointestinal endoscopy. Preoperative imaging revealed an elevation of the left side of the diaphragm, which was diagnosed as diaphragmatic eventration. Laparoscopic surgery is beneficial for obtaining an optimal field of view. However, there are critical points that must be considered when laparoscopic distal gastrectomy is performed in patients with gastric cancer complicated by diaphragmatic eventration. There were difficulties that affected manipulation because the elevated diaphragm drew the intraperitoneal organs into the thoracic cavity, causing displacement of the normal anatomical position. We found it beneficial to secure the lesser curvature of the stomach given the possible effects of gastric deformation.     

创伤性膈肌破裂术前诊断及手术入路探讨

目的 探讨创伤性膈肌破裂术前诊断及手术入路,以期提高患者的术后生活质量.方法 回顾性分析1990年1月至2009年3月收治的63例创伤性膈肌破裂患者的临床资料.所有患者均经手术证实为膈肌破裂,均有不同程度的血胸和/或血气胸.急性腹膜炎49例,失血性休克41例.术前诊断明确37例,术中探查发现22例,4例经保守治疗无效后行手术治疗.单纯经胸入路24例,单纯经腹入路14例,胸腹联合入路8例,经胸经腹分别入路17例.结果 57例痊愈,死亡6例,其中2例死于失血性休克,1例死于心包填塞,1例死于术后呼吸衰竭,2例于术后1周死于肾衰竭.结论 术前诊断的准确及时和正确的手术入路选择是争取抢救时间、抢救成功与否、避免并发症的关键.     

Induced negative pressure proposed as a new method for diagnosing hepatic hydrothorax involving minor leaks

Hepatic hydrothorax is known as pleural effusion of hepatic origin, and is difficult to diagnose. We herein report the novel strategy combining radioisotope scintigraphy with chest drainage to definitively diagnose hepatic hydrothorax of an 85‐year‐old patient which would have been missed with conventional diagnostic methods.     

Delayed recognition of diaphragmatic injury caused by penetrating thoraco-abdominal trauma

INTRODUCTIONPenetrating trauma to the thoraco-abdomen may cause diaphragmatic injury (DI). We present a case which highlights the difficulties of recognizing DI and the limited role of multimodal diagnostic imaging.PRESENTATION OF CASEA 19 year old male presented with stab wounds to his left lateral chest wall. CT was suspicious for diaphragmatic injury but this could not be confirmed despite ultrasound and serial plain radiographs. He was discharged but re-presented with respiratory compromise and diaphragmatic herniation.DISCUSSIONWe review the clinical features of diaphragmatic injury after penetrating thoraco-abdominal trauma and the various imaging modalities available to clinicians.CONCLUSIONA high index of suspicion must be employed for DI in the context of penetrating thoraco-abdominal trauma. Inpatient observation and laparoscopy/thoracoscopy should be considered when radiological findings are ambiguous. Front line physicians should also consider diaphragmatic herniation in stab victims who re-present with respiratory, circulatory, or gastrointestinal symptomology.     

Sutureless “button and hole” splenopexy

A new technique for fixation of a mobile spleen is described. It offers the advantages of a minimally risky procedure that very effectively keeps a mobile spleen in its bed without foreign materials and is feasible even when the gastrosplenic ligament is absent and the splenic vessels are uncovered. Our “button and hole” sutureless splenopexy was performed in six patients from 1979 to 1995. Three had a gastric volvulus (GV) and an extremely mobile spleen; one of these also had a diaphragmatic eventration. Another three had torsion of the spleen; in one it occurred 9 months after repair of a diaphragmatic hernia. We achieved good results with splenopexy as the sole operation in two cases where a wandering spleen produced a GV. Accepted: 11 February 1997