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Gastric perforation during chest tube placement for acute diaphragmatic rupture and review of the literature
Injury Extra (2006) 37, 71—75
www.elsevier.com/locate/inext
CASE REPORT
Gastric perforation during chest tube placement for acute diaphragmatic rupture and review of the literature Mehmet Yilmaz a,*, Burak Isik a, Cengiz Ara a, Sezai Yilmaz a, ¨ zcan Kocak a, Murat Ugras a,c, Vedat Kirimlioglu a Ramazan Kutlu b, O a
Inonu University Medical School, Department of General Surgery, Tip Fakultesi, T Ozal Tip Merkezi Genel Cerrahi AD, 44069 Malatya, Turkey b Inonu University Medical School, Department of Radiology, Malatya, Turkey c Inonu University Medical School, Department of Urology, Malatya, Turkey Accepted 8 August 2005
Introduction
Case report
Acute diaphragmatic rupture occurs in 10% to 15% of patients with penetrating trauma to lower chest.12 In penetrating injuries, the insult is direct and visceral migration within the thorax will occur gradually due to the normal pressure difference between thorax and abdominal cavity. Diaphragmatic injuries are sometimes misdiagnosed, because the generally violent symptoms of associated injuries initially disguise the slight clinical sings of them, and not because surgeons pay less attention to this pathology.13 Intercostal drains may have to be placed as emergency procedure in chest trauma. We report a case of an iatrogenic gastric fistula after intercostal drain (ICD) insertion in a male patient who had haemopneumothorax after penetrating trauma to left lower chest.
A 35-year-old male was admitted to the emergency department with penetrating trauma on the left posterior side of the chest. His complaints were chest pain at left side, abdominal pain at left upper quadrant and dispnea. His pulse rate was 94/min, arterial blood pressure was 135/107 mmHg, and respiratory rate was 36/min. On physical examination, there was a 2 cm wide stab wound at the sixth intercostal space, penetrating to posterior thoracal cavity and decreased respiratory sounds at left side at auscultation. A chest radiograph revealed loss of definition at left diaphragmatic border. Left hemopneumothorax was diagnosed and a chest drain was inserted by the attending physician through midaxillary line of seventh intercostal space. A reddish brown drainage of 600 cc occurred for the first 24 h. After oral food intake, he had nausea and vomitting, fever of 38.5 8C and drainage of food particles from chest tube. We consultated him at 36th hour of admittance. A new roentgenogram revealed that the fundal gas collection was located over the left
* Corresponding author. Tel.: +90 422 3410660; fax: +90 422 3410728. E-mail address: [email protected] (M. Yilmaz).
1572-3461/$ — see front matter # 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2005.08.006
72
Figure 1 Posteroanterior chest roentgenogram revealing fundal gas collection at thoracic cavity and superimposing ICD tube.
hemidiaphragmatic area and chest tube was located there too, superimposing with the gastric fundus (Fig. 1). A computed tomography (CT) with both oral and intravenous contrast was obtained, revealing that the stomach was dislocated to the left thorax and the cotrast medium was disseminated to the left pleural cavity (Figs. 2 and 3). He had a white blood cell count of 15900/ml. Our initial diagnosis was posttraumatic diapragmatic hernia and gastric penetration and fistulization due to the tube. An emergency laparotomy with upper abdominal approach revealed that corpus and fundus of the stomach were displaced to the left thoracic cavity through a 3 cm left diaphragmatic defect, leading to
M. Yilmaz et al.
Figure 3 Pneumothorax at thoracoabdominal computed tomography (thick arrow).
proximal acute intrathoracic gastric herniation and obstruction. No contamination of the abdomen with blood or gastric content was present. The chest tube penetrated both posterior and anterior walls of the fundus, causing a iatrogenic gastric fistula. Chest cavity irrigation and a new ICD tube replacement was followed by primary repair of the gastric lesions and diaphragmatic defect and placement of abdominal drain and nasogastric tube. A pneumony that became evident on the second postoperative day with a fever of 38.7 8C resolved with appropriate antibiotic teraphy. Nasogastric tube was removed on the second and oral intake was encoureged on the third postoperative days, respectively. Chest tube was removed on day 7 and the patient was discharged on day 8. Patient was asymptomatic at 3 months follow-up.
Discussion
Figure 2 Thoracoabdominal computed tomography revealing stomach and fundal gas at thoracic cavity. Note the contrast medium scattered to the cavity (thin arrows).
Traumatic diaphragmatic rupture (TDR) can result from penetrating injuries, falls, blunt trauma and as a complication of pregnancy. Major causes are penetrating injuries such as gunshot and stab wounds. A review on this subject suggested that 75% of the injuries to the diaphragm are caused by blunt trauma and 25% by penetrating trauma.14 Traumatic rupture of diaphragm occurs in up to 5% of patients requiring laparotomy for blunt or penetrating trauma to the chest or abdomen.27 In conservatively managed patients, the rate of initially missed diaphragmatic injuries ranges from 12% to 66% and they may even be overlooked at laparotomy.12,22,20 The true incidence of diaphragmatic injury or rupture,
Gastric perforation during chest tube placement
however, is unknown because some diaphragmatic injuries and ruptures may remain asymptomatic in particular those of the right diaphragm and therefore are never diagnosed.12 In penetrating traumas, there is no predisposing area of injury and the defect of the diaphragm is usually smaller than the defects caused by blunt traumas and therefore potentially more dangerous in terms of later obstruction and strangulation, although many trauma surgeons believe that right-sided diaphragmatic injuries from a penetrating wound will rarely become symptomatic.17 Patients with a ruptured diaphragm can be categorised into one of three groups according to the time of diagnosis after injury:11 1. Patients in whom diagnosis is correctly established immediately, up to 14 days after injury. Our case was diagnosed at this phase. 2. Patients diagnosed in the period after acute injury, but before intestinal obstruction or strangulation. 3. Patients in whom correct diagnosis is established because of intestinal obstruction or strangulation. In this type of injury, intercostal drainage of the pleural cavity is required to drain the air and/or accumulated fluid. Most common indications are haemothorax, haemopneumothorax, hydrothorax and ampyema. Clinical findings and imaging studies help the diagnosis of air and or fluid in the pleural cavity. Intercostal drainage may be necessary as an emergency procedure. In some cases, massively herniated and distended stomach or colon may easily be mistaken as pneumothorax or hydropneumothorax.6 In a review of the literature, we were able to find only three cases of gastric fistula formation following IDC.6,10 A diaphragmatic hernia should be suspected even after a trivial trauma if an erect plain radiograph of the chest shows absence of fundic bubble in its normal position. In such cases, lateral decubitus and true erect frontal chest radiographs can aid in the diagnosis.19 In the presented case, acute hemopneumothorax resulting from stab wound to the lower thorax obscured the existence of posttraumatic diapragmatic hernia, and urgent placement of an ICD tube caused gastric trauma that was displaced through the hernia. Secondary gastric obstruction and fistulization further complicated the case. Early diagnosis and repair of diaphragmatic rupture are desirable because surgical repair is easier before fibrosis develops, and because the morbidity and mortality associated with the latent and
73
obstructive phases of diaphragmatic rupture can be avoided.28,29 The striking problem with traumatic diaphragmatic injuries or ruptures is the difficulty in making the diagnosis in conservatively treated patients with blunt or penetrating traumas of the thoracoabdominal area.30 There is no ‘‘gold standard’’ for early diagnosis of traumatic diaphragmatic rupture, and it still seems to be a diagnostic dilemma.8 Many investigative techniques have been described for the diagnosis of TDR, including chest X-ray, CT, magnetic resonans imaging, upper gastrointesitinal contrast studies, angiography, ultrasonography, thoracoscopy, peritoneal lavage and laparoscopy.7 Sensitivity of the initial chest X-ray interpretation can be increased by heightened awareness of this injury.23 Chest X-rays on admission supported the diagnosis in 70% of cases and the authors concluded that a chest X-ray upon admission is the best diagnostic aid in the evaluation of TDR.21 Although, abnormal radiographs commonly reveal elevation of the hemidiaphragm, blunting of the costophrenic angle, absence of a sharp hemidiaphragm or presence of a hemopneımothorax, only 25— 50% of the initial chest roentgenograms are diagnostic for diaphragmatic rupture or injury.23,29 The likelihood of a false-negative chest roentgenogram appears higher in patients with penetrating injuries, probably because larger defects in seen blunting traumas.12 CT scan is second choice of imaging technique, although the axial-oriented diaphragm is not always well demonstrated by conventional CT. Success rates from 0 to 100% have been reported.26,5,15,1 CT scan may readily demonstrate the herniation of the abdominal viscera in the thorax but may not be able to directly image the diaphragmatic lacerations that lie in different scan planes.26 As compared with the results of initial chest X-ray, CT scanning seems to offer no advantage, statistical analysis did not show a significant difference between the two diagnostic tools.8 In the case presented, insufficient initial evaluation with an X-ray caused the physicians to overlook the diapragmatic hernia and existance of the gut inside thoracic cavity and this led to iatrogenic traumatization of the organ. After 36 h, a second X-ray revealed the fundal gas collection over left hemidiaphragmatic area. Trauma to the herniated stomach was diagnosed by CT with oral contrast which scattered to the thoracic cavity. The situation was verified intraoperatively. Repair of the diaphragmatic ruptures or hernia can be done by classical open method or with minimally invasive methods. Open exploration can be done through the abdominal or the thoracic route. In contrast to acute diaphragmatic injuries or ruptures, in which a transabdominal approach is highly
74
recommended because of the associated injuries, many authors prefer a thoracotomy to reduce the hernia and repair the diaphragm.17,9,2,4,18,3 Laparoscopy and thoracoscopy in the acute setting are discussed controversially. They may offer a good chance for minimal access diagnosis and repair of the injured diaphragm.8 The videothoracoscopic approach can be beneficial to hemodynamically stable patients, but one has to be aware of possible complications due to insufficient diagnosis of abdominal injury. Hence, proper evaluation and indication as well as a more careful postoperative observation are essential.25 Koehler and Smith16 used thoracoscopy to repair penetrating diaphragmatic rupture in two patients. They suggested that combined thoracoscopy and laparoscopy may offer both therapeutic as well as diagnostic benefit in selected stable patients with penetrating injuries to the upper abdomen and lower chest. We preferred abdominal approach as the case was not only a traumatic diapragmatic hernia but was further complicated by gastric trauma, obstruction and fistulization. This approach was thought to be more suitable for hernia reduction, gastric repair and diaphragmatic hernia closure. One of the most serious complications of diaphragmatic rupture is coexisting perforation of a hollow viscus, which contributes to the development of intra-abdominal abscesses and empyema thoracis. Vigorous irrigation of the thoracic cavity and abdomen during operation and adequate drainage are extremely important if there has been a perforation of a hollow viscus.24 In our case, a left sided pneumonia existed despite vigorous irrigation and sufficient drainage.
Conclusion We conclude that in penetrating trauma to the upper abdomen or lower chest, an acute diaphragmatic rupture and visceral herniation should always be kept in mind and investigated before attempting a ICD tube. If an iatrogenic visceral trauma occurs, emergency surgery with an abdominal approach is a suitable way of successful management.
References 1. Arak T, Solheim K, Pillgram-Larsen J. Diaphragmatic injuries. Injury 1997;28:113—7. 2. Brasel KJ, Borgstrom DC, Meyer P, Weigelt JA. Predictors of outcome in blunt diaphragm rupture. J Trauma 1996;41:484.
M. Yilmaz et al.
3. Croce MA, Fabian TC, Menke PG, et al. Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients: results of a prospective trial. Ann Surg 1995;221:744. 4. Dajee A, Schepps D, Hurley EJ. Diaphragmatic injuries. Surg Gynecol Obstet 1981;153:31. 5. Demos TC, Solomon C, Posniak HV, et al. Computed tomography in traumatic defects of the diaphragm. Clin Imaging 1989;13:62. 6. Flancbaum L, Dauber M, Demas C, et al. Early diagnosis and treatment of diaphragmatic injury. Am Surg 1988;54: 195. 7. Gelman R, Mirvis SE, Gens D. Diaphragmatic rupture due to blunt trauma: sensitivity of plain chest radiographs. AJR Am J Roentgenol 1991;156:51. 8. Groskin SA, editor. Injuries from Blunt and Penetrating Chest Trauma in Radiological, Clinical and Biomedical Aspects of Chest Trauma. New York: Springer-Verlag; 1995. p. 51—71. 9. Guth AA, Pachter HL, Kim U. Pitfalls in the diagnosis of blunt diaphragmatic injury. Am J Surg 1995;170:5—9. 10. Hegarty MM, Bryer JV, Angorn IB, et al. Delayed presentation of traumatic diaphragmatic hernia. Ann Surg 1978;188:229— 33. 11. Heiberg E, Wolverson MK, Hurd RN, et al. CT recognition of traumatic rupture of the diaphragm. AJR Am J Roentgenol 1980;135:369. 12. Klein J, Bohanes T, Neoral C, et al. Videothoracoscopic diagnosis and treatment of diaphragmatic rupture combined with splenic injury. Eur J Surg 2002;28:200—3. 13. Koehler RH, Smith RS. Thoracoscopic repair of missed diaphragmatic injury in penetrating trauma: case report. J Trauma 1994;36:424—7. 14. Lee WC, Chen RJ, Fang JF, et al. Rupture of the diaphragm after blunt trauma. Eur J Surg 1994;160:479—83. 15. Mansour KA. Trauma to the diaphragm. Chest Surg Clin N Am 1997;7(2):373—83. 16. McConnel DB, Trunkey DD. Nonoperative management of abdominal trauma. Surg Clin North Am 1990;70:677. 17. Meyers BF, McCabe CJ. Traumatic diaphragmatic hernia. Ann Surg 1993;218:783. 18. Mirvis SE, Whitely NO, Vainright JR, et al. Blunt hepatic trauma in adults: CT based classification and correlation with prognosis and treatment. Radiology 1989;171:27. 19. Morgan AS, Flancbaum L, Esposito T, Cox EF. Blunt injury to the diaphragm: an analysis of 44 cases. J Trauma 1986;26:565. 20. Murray JG, Caoili E, Gruden JF, et al. Acute rupture of the diaphragm due to blunt trauma: diagnostic sensitivity and specificity of CT. AJR Am J Roentgenol 1996;166: 1035— 9. 21. Nau T, Seitz H, Mousavi M, et al. The diagnostic dilemma of traumatic rupture of the diaphragm. Surg Endosc 2001;15:992—6. 22. Reber PU, Schmied B, Seiler CA, et al. Missed diaphragmatic injuries and their longterm sequelae. J Trauma 1998;44:183— 8. 23. Rege SA, Narlawar RS, Deshpande AA, et al. Iatrogenic gastric fistula due to inappropriate placement of intercostal drainage tube in a case of traumatic diaphragmatic hernia. J Postgrad Med 2001;47:108—10. 24. Rubikas R. Diaphragmatic injuries. Eur J Cardiothorac Surg 2001;20:53—7. 25. Sapiro MJ, Heiberg E, Durham RM, et al. The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture. Clin Radiol 1996;51:27—30.
Gastric perforation during chest tube placement
26. Sarna S, Kivioja A. Blunt rupture of the diaphragm. A retrospective analysis of 41 patients. Ann Chir Gynaecol 1995;84:261—5. 27. Shah R, Sabanathan S, Mearns AJ, et al. Traumatic rupture of diaphragm. Ann Thorac Surg 1995;60:1444—9. 28. Symbas PN, Vlasis SE, Hatcher C. Blunt and penetrating diaphragmatic injuries with or without herniation of organs into the chest. Ann Thorac Surg 1986;42:158.
75
29. van Vugt AB, Schoots FJ. Acute diaphragmatic rupture due to blunt trauma: a retrospective analysis. J Trauma 1989;29:683—6. 30. Wyffels PL, Kenny JN. Primary repair of bilateral diaphragmatic rupture with crural involvement. Am J Surg 1984;147:414.
www.elsevier.com/locate/inext
CASE REPORT
Gastric perforation during chest tube placement for acute diaphragmatic rupture and review of the literature Mehmet Yilmaz a,*, Burak Isik a, Cengiz Ara a, Sezai Yilmaz a, ¨ zcan Kocak a, Murat Ugras a,c, Vedat Kirimlioglu a Ramazan Kutlu b, O a
Inonu University Medical School, Department of General Surgery, Tip Fakultesi, T Ozal Tip Merkezi Genel Cerrahi AD, 44069 Malatya, Turkey b Inonu University Medical School, Department of Radiology, Malatya, Turkey c Inonu University Medical School, Department of Urology, Malatya, Turkey Accepted 8 August 2005
Introduction
Case report
Acute diaphragmatic rupture occurs in 10% to 15% of patients with penetrating trauma to lower chest.12 In penetrating injuries, the insult is direct and visceral migration within the thorax will occur gradually due to the normal pressure difference between thorax and abdominal cavity. Diaphragmatic injuries are sometimes misdiagnosed, because the generally violent symptoms of associated injuries initially disguise the slight clinical sings of them, and not because surgeons pay less attention to this pathology.13 Intercostal drains may have to be placed as emergency procedure in chest trauma. We report a case of an iatrogenic gastric fistula after intercostal drain (ICD) insertion in a male patient who had haemopneumothorax after penetrating trauma to left lower chest.
A 35-year-old male was admitted to the emergency department with penetrating trauma on the left posterior side of the chest. His complaints were chest pain at left side, abdominal pain at left upper quadrant and dispnea. His pulse rate was 94/min, arterial blood pressure was 135/107 mmHg, and respiratory rate was 36/min. On physical examination, there was a 2 cm wide stab wound at the sixth intercostal space, penetrating to posterior thoracal cavity and decreased respiratory sounds at left side at auscultation. A chest radiograph revealed loss of definition at left diaphragmatic border. Left hemopneumothorax was diagnosed and a chest drain was inserted by the attending physician through midaxillary line of seventh intercostal space. A reddish brown drainage of 600 cc occurred for the first 24 h. After oral food intake, he had nausea and vomitting, fever of 38.5 8C and drainage of food particles from chest tube. We consultated him at 36th hour of admittance. A new roentgenogram revealed that the fundal gas collection was located over the left
* Corresponding author. Tel.: +90 422 3410660; fax: +90 422 3410728. E-mail address: [email protected] (M. Yilmaz).
1572-3461/$ — see front matter # 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2005.08.006
72
Figure 1 Posteroanterior chest roentgenogram revealing fundal gas collection at thoracic cavity and superimposing ICD tube.
hemidiaphragmatic area and chest tube was located there too, superimposing with the gastric fundus (Fig. 1). A computed tomography (CT) with both oral and intravenous contrast was obtained, revealing that the stomach was dislocated to the left thorax and the cotrast medium was disseminated to the left pleural cavity (Figs. 2 and 3). He had a white blood cell count of 15900/ml. Our initial diagnosis was posttraumatic diapragmatic hernia and gastric penetration and fistulization due to the tube. An emergency laparotomy with upper abdominal approach revealed that corpus and fundus of the stomach were displaced to the left thoracic cavity through a 3 cm left diaphragmatic defect, leading to
M. Yilmaz et al.
Figure 3 Pneumothorax at thoracoabdominal computed tomography (thick arrow).
proximal acute intrathoracic gastric herniation and obstruction. No contamination of the abdomen with blood or gastric content was present. The chest tube penetrated both posterior and anterior walls of the fundus, causing a iatrogenic gastric fistula. Chest cavity irrigation and a new ICD tube replacement was followed by primary repair of the gastric lesions and diaphragmatic defect and placement of abdominal drain and nasogastric tube. A pneumony that became evident on the second postoperative day with a fever of 38.7 8C resolved with appropriate antibiotic teraphy. Nasogastric tube was removed on the second and oral intake was encoureged on the third postoperative days, respectively. Chest tube was removed on day 7 and the patient was discharged on day 8. Patient was asymptomatic at 3 months follow-up.
Discussion
Figure 2 Thoracoabdominal computed tomography revealing stomach and fundal gas at thoracic cavity. Note the contrast medium scattered to the cavity (thin arrows).
Traumatic diaphragmatic rupture (TDR) can result from penetrating injuries, falls, blunt trauma and as a complication of pregnancy. Major causes are penetrating injuries such as gunshot and stab wounds. A review on this subject suggested that 75% of the injuries to the diaphragm are caused by blunt trauma and 25% by penetrating trauma.14 Traumatic rupture of diaphragm occurs in up to 5% of patients requiring laparotomy for blunt or penetrating trauma to the chest or abdomen.27 In conservatively managed patients, the rate of initially missed diaphragmatic injuries ranges from 12% to 66% and they may even be overlooked at laparotomy.12,22,20 The true incidence of diaphragmatic injury or rupture,
Gastric perforation during chest tube placement
however, is unknown because some diaphragmatic injuries and ruptures may remain asymptomatic in particular those of the right diaphragm and therefore are never diagnosed.12 In penetrating traumas, there is no predisposing area of injury and the defect of the diaphragm is usually smaller than the defects caused by blunt traumas and therefore potentially more dangerous in terms of later obstruction and strangulation, although many trauma surgeons believe that right-sided diaphragmatic injuries from a penetrating wound will rarely become symptomatic.17 Patients with a ruptured diaphragm can be categorised into one of three groups according to the time of diagnosis after injury:11 1. Patients in whom diagnosis is correctly established immediately, up to 14 days after injury. Our case was diagnosed at this phase. 2. Patients diagnosed in the period after acute injury, but before intestinal obstruction or strangulation. 3. Patients in whom correct diagnosis is established because of intestinal obstruction or strangulation. In this type of injury, intercostal drainage of the pleural cavity is required to drain the air and/or accumulated fluid. Most common indications are haemothorax, haemopneumothorax, hydrothorax and ampyema. Clinical findings and imaging studies help the diagnosis of air and or fluid in the pleural cavity. Intercostal drainage may be necessary as an emergency procedure. In some cases, massively herniated and distended stomach or colon may easily be mistaken as pneumothorax or hydropneumothorax.6 In a review of the literature, we were able to find only three cases of gastric fistula formation following IDC.6,10 A diaphragmatic hernia should be suspected even after a trivial trauma if an erect plain radiograph of the chest shows absence of fundic bubble in its normal position. In such cases, lateral decubitus and true erect frontal chest radiographs can aid in the diagnosis.19 In the presented case, acute hemopneumothorax resulting from stab wound to the lower thorax obscured the existence of posttraumatic diapragmatic hernia, and urgent placement of an ICD tube caused gastric trauma that was displaced through the hernia. Secondary gastric obstruction and fistulization further complicated the case. Early diagnosis and repair of diaphragmatic rupture are desirable because surgical repair is easier before fibrosis develops, and because the morbidity and mortality associated with the latent and
73
obstructive phases of diaphragmatic rupture can be avoided.28,29 The striking problem with traumatic diaphragmatic injuries or ruptures is the difficulty in making the diagnosis in conservatively treated patients with blunt or penetrating traumas of the thoracoabdominal area.30 There is no ‘‘gold standard’’ for early diagnosis of traumatic diaphragmatic rupture, and it still seems to be a diagnostic dilemma.8 Many investigative techniques have been described for the diagnosis of TDR, including chest X-ray, CT, magnetic resonans imaging, upper gastrointesitinal contrast studies, angiography, ultrasonography, thoracoscopy, peritoneal lavage and laparoscopy.7 Sensitivity of the initial chest X-ray interpretation can be increased by heightened awareness of this injury.23 Chest X-rays on admission supported the diagnosis in 70% of cases and the authors concluded that a chest X-ray upon admission is the best diagnostic aid in the evaluation of TDR.21 Although, abnormal radiographs commonly reveal elevation of the hemidiaphragm, blunting of the costophrenic angle, absence of a sharp hemidiaphragm or presence of a hemopneımothorax, only 25— 50% of the initial chest roentgenograms are diagnostic for diaphragmatic rupture or injury.23,29 The likelihood of a false-negative chest roentgenogram appears higher in patients with penetrating injuries, probably because larger defects in seen blunting traumas.12 CT scan is second choice of imaging technique, although the axial-oriented diaphragm is not always well demonstrated by conventional CT. Success rates from 0 to 100% have been reported.26,5,15,1 CT scan may readily demonstrate the herniation of the abdominal viscera in the thorax but may not be able to directly image the diaphragmatic lacerations that lie in different scan planes.26 As compared with the results of initial chest X-ray, CT scanning seems to offer no advantage, statistical analysis did not show a significant difference between the two diagnostic tools.8 In the case presented, insufficient initial evaluation with an X-ray caused the physicians to overlook the diapragmatic hernia and existance of the gut inside thoracic cavity and this led to iatrogenic traumatization of the organ. After 36 h, a second X-ray revealed the fundal gas collection over left hemidiaphragmatic area. Trauma to the herniated stomach was diagnosed by CT with oral contrast which scattered to the thoracic cavity. The situation was verified intraoperatively. Repair of the diaphragmatic ruptures or hernia can be done by classical open method or with minimally invasive methods. Open exploration can be done through the abdominal or the thoracic route. In contrast to acute diaphragmatic injuries or ruptures, in which a transabdominal approach is highly
74
recommended because of the associated injuries, many authors prefer a thoracotomy to reduce the hernia and repair the diaphragm.17,9,2,4,18,3 Laparoscopy and thoracoscopy in the acute setting are discussed controversially. They may offer a good chance for minimal access diagnosis and repair of the injured diaphragm.8 The videothoracoscopic approach can be beneficial to hemodynamically stable patients, but one has to be aware of possible complications due to insufficient diagnosis of abdominal injury. Hence, proper evaluation and indication as well as a more careful postoperative observation are essential.25 Koehler and Smith16 used thoracoscopy to repair penetrating diaphragmatic rupture in two patients. They suggested that combined thoracoscopy and laparoscopy may offer both therapeutic as well as diagnostic benefit in selected stable patients with penetrating injuries to the upper abdomen and lower chest. We preferred abdominal approach as the case was not only a traumatic diapragmatic hernia but was further complicated by gastric trauma, obstruction and fistulization. This approach was thought to be more suitable for hernia reduction, gastric repair and diaphragmatic hernia closure. One of the most serious complications of diaphragmatic rupture is coexisting perforation of a hollow viscus, which contributes to the development of intra-abdominal abscesses and empyema thoracis. Vigorous irrigation of the thoracic cavity and abdomen during operation and adequate drainage are extremely important if there has been a perforation of a hollow viscus.24 In our case, a left sided pneumonia existed despite vigorous irrigation and sufficient drainage.
Conclusion We conclude that in penetrating trauma to the upper abdomen or lower chest, an acute diaphragmatic rupture and visceral herniation should always be kept in mind and investigated before attempting a ICD tube. If an iatrogenic visceral trauma occurs, emergency surgery with an abdominal approach is a suitable way of successful management.
References 1. Arak T, Solheim K, Pillgram-Larsen J. Diaphragmatic injuries. Injury 1997;28:113—7. 2. Brasel KJ, Borgstrom DC, Meyer P, Weigelt JA. Predictors of outcome in blunt diaphragm rupture. J Trauma 1996;41:484.
M. Yilmaz et al.
3. Croce MA, Fabian TC, Menke PG, et al. Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients: results of a prospective trial. Ann Surg 1995;221:744. 4. Dajee A, Schepps D, Hurley EJ. Diaphragmatic injuries. Surg Gynecol Obstet 1981;153:31. 5. Demos TC, Solomon C, Posniak HV, et al. Computed tomography in traumatic defects of the diaphragm. Clin Imaging 1989;13:62. 6. Flancbaum L, Dauber M, Demas C, et al. Early diagnosis and treatment of diaphragmatic injury. Am Surg 1988;54: 195. 7. Gelman R, Mirvis SE, Gens D. Diaphragmatic rupture due to blunt trauma: sensitivity of plain chest radiographs. AJR Am J Roentgenol 1991;156:51. 8. Groskin SA, editor. Injuries from Blunt and Penetrating Chest Trauma in Radiological, Clinical and Biomedical Aspects of Chest Trauma. New York: Springer-Verlag; 1995. p. 51—71. 9. Guth AA, Pachter HL, Kim U. Pitfalls in the diagnosis of blunt diaphragmatic injury. Am J Surg 1995;170:5—9. 10. Hegarty MM, Bryer JV, Angorn IB, et al. Delayed presentation of traumatic diaphragmatic hernia. Ann Surg 1978;188:229— 33. 11. Heiberg E, Wolverson MK, Hurd RN, et al. CT recognition of traumatic rupture of the diaphragm. AJR Am J Roentgenol 1980;135:369. 12. Klein J, Bohanes T, Neoral C, et al. Videothoracoscopic diagnosis and treatment of diaphragmatic rupture combined with splenic injury. Eur J Surg 2002;28:200—3. 13. Koehler RH, Smith RS. Thoracoscopic repair of missed diaphragmatic injury in penetrating trauma: case report. J Trauma 1994;36:424—7. 14. Lee WC, Chen RJ, Fang JF, et al. Rupture of the diaphragm after blunt trauma. Eur J Surg 1994;160:479—83. 15. Mansour KA. Trauma to the diaphragm. Chest Surg Clin N Am 1997;7(2):373—83. 16. McConnel DB, Trunkey DD. Nonoperative management of abdominal trauma. Surg Clin North Am 1990;70:677. 17. Meyers BF, McCabe CJ. Traumatic diaphragmatic hernia. Ann Surg 1993;218:783. 18. Mirvis SE, Whitely NO, Vainright JR, et al. Blunt hepatic trauma in adults: CT based classification and correlation with prognosis and treatment. Radiology 1989;171:27. 19. Morgan AS, Flancbaum L, Esposito T, Cox EF. Blunt injury to the diaphragm: an analysis of 44 cases. J Trauma 1986;26:565. 20. Murray JG, Caoili E, Gruden JF, et al. Acute rupture of the diaphragm due to blunt trauma: diagnostic sensitivity and specificity of CT. AJR Am J Roentgenol 1996;166: 1035— 9. 21. Nau T, Seitz H, Mousavi M, et al. The diagnostic dilemma of traumatic rupture of the diaphragm. Surg Endosc 2001;15:992—6. 22. Reber PU, Schmied B, Seiler CA, et al. Missed diaphragmatic injuries and their longterm sequelae. J Trauma 1998;44:183— 8. 23. Rege SA, Narlawar RS, Deshpande AA, et al. Iatrogenic gastric fistula due to inappropriate placement of intercostal drainage tube in a case of traumatic diaphragmatic hernia. J Postgrad Med 2001;47:108—10. 24. Rubikas R. Diaphragmatic injuries. Eur J Cardiothorac Surg 2001;20:53—7. 25. Sapiro MJ, Heiberg E, Durham RM, et al. The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture. Clin Radiol 1996;51:27—30.
Gastric perforation during chest tube placement
26. Sarna S, Kivioja A. Blunt rupture of the diaphragm. A retrospective analysis of 41 patients. Ann Chir Gynaecol 1995;84:261—5. 27. Shah R, Sabanathan S, Mearns AJ, et al. Traumatic rupture of diaphragm. Ann Thorac Surg 1995;60:1444—9. 28. Symbas PN, Vlasis SE, Hatcher C. Blunt and penetrating diaphragmatic injuries with or without herniation of organs into the chest. Ann Thorac Surg 1986;42:158.
75
29. van Vugt AB, Schoots FJ. Acute diaphragmatic rupture due to blunt trauma: a retrospective analysis. J Trauma 1989;29:683—6. 30. Wyffels PL, Kenny JN. Primary repair of bilateral diaphragmatic rupture with crural involvement. Am J Surg 1984;147:414.