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Diaphragmatic Hernia Presenting as Empyema Thorax  [PDF]
Satyendra Dhar, Sanjay K. Bhasin, J.G. Langer
JK Science : Journal of Medical Education & Research , 2005,
Abstract: Diaphragmatic injuries are relatively rare and result from either blunt or penetrating trauma. Regardlessof mechanism, seemingly innocent penetrating injuries may be long forgotten by the patient and arethe most commonly missed diaphragmatic injury. Diagnosis is often missed and high index of suspicionis vital. The clinical signs associated with a diaphragmatic hernia can range from no outward signs toimmediately life-threatening respiratory compromise. We report an unusual case of diaphragmatichernia presenting as empyema thorax after suffering from penetrating injury.
Utility of Intrapleural Contrast in the Diagnosis of Occult Diaphragmatic Injury in Thoracoabdominal Stab Wounds, Preliminary Results
Sepideh Sefidbakht,Kambiz Asaadi,Roholah Salahi,Shahram Paydar
Iranian Journal of Radiology , 2009,
Abstract: "nIntroduction: Given the small size of the diaphragmatic defect and absence of visceral herniation, diagnosing diaphragmatic injury in the setting of thoracoabdominal stab wounds is challenging. CT scan with or without IV and oral contrast has been investigated with various efficacy previously. To our knowledge utility of intrapleural water soluble contrast has never been investigated before in the detection of diaphragmatic injury. "nMaterial and Method: 27 patients with thoracostomy tubes inserted for routine indications with thoracoabdominal stab wounds were included in the study. 500cc diluted contrast was administered via the patients' thoracostomy tube. CT and fluoroscopy were carried out. Images were evaluated by two radiologists prospectively and differences settled by consensus. All patients underwent thoracoscopic evaluation of the diaphragm. The diagnostic accuracy was calculated. "nResults: CT scan correctly predicted 21 of the 24 patients with an intact diaphragm. 4 patients showed some form of diaphragmatic injury, only one needed repair. CT scan correctly detected the injury needing repair. One case had an abrasion, one case had a 1.5cm flap with an intact peritoneum and one case had a 1.0cm tear in the right diaphragmatic dome. Negative predictive value in detecting defects needing surgical repair was 100%. Two false positive cases were present. No adverse effects were seen. "nConclusion: Intrapleural contrast administration is a safe and reliable way to rule out diaphragmatic injuries.
Outcome of undiagnosed traumatic diaphragmatic injuries: A review of our management
KG Soro, A Coulibaly, P Yapo, GM Koffi, SF Ehua, MJB Kanga
Nigerian Journal of Surgical Research , 2006,
Abstract: The authors relate on the outcomes of traumatic diaphragmatic injuries unknown early. The files of three patients have been reviewed retrospectively. All of them presented early undiagnosed injuries. The first patient had a left diaphragmatic injury consecutive to a stab wound to the left hypochondrium. The diagnosis was made 18 days later. He died 2 days after operation because of septicaemia. The second patient presented a colonic strangulation through a left diaphragmatic rupture consecutive to a stab wound three years before. A resection and anastomosis to the colon was performed. The patient left the hospital with a definitive pachypleuritis. The third patient was admitted for blunt trauma to the chest with dyspnoea. The chest X-ray showed the diaphragmatic rupture. The peri- operative exploration showed an old rupture with fibrosis banks. The lesion had been respected. The outcomes of early missed traumatic diaphragmatic rupture are various. Their treatment is sometime difficult and dangerous.
A review on delayed presentation of diaphragmatic rupture
Farhan Rashid, Mallicka M Chakrabarty, Rajeev Singh, Syed Y Iftikhar
World Journal of Emergency Surgery , 2009, DOI: 10.1186/1749-7922-4-32
Abstract: A Pubmed search was conducted using the terms "delayed presentation of post traumatic diaphragmatic rupture" and "delayed diaphragmatic rupture". Although quite a few articles were cited, the details of presentation, investigations and treatment discussed in each of these were not identical, accounting for the variation in the data presented below.Late presentation of diaphragmatic rupture is often a result of herniation of abdominal contents into the thorax[1]. Sudden increase in the intra abdominal pressure may cause a diaphragmatic tear and visceral herniation[2]. The incidence of diaphragmatic ruptures after thoraco-abdominal traumas is 0.8–5% [3] and up to 30% diaphragmatic hernias present late[4]. Diaphragmatic, lumbar and extra-thoracic hernias are well described complications of blunt trauma [5]. Incorrect interpretation of the x ray or only intermittent hernial symptoms are frequent reasons for incorrect diagnosis[6].Diaphragmatic rupture with abdominal organ herniation was first described by Sennertus in 1541[7,8]. Diaphragmatic injury is a recognised consequence of high velocity blunt and penetrating trauma to the abdomen and chest rather than from a trivial fall[8]. These patients usually have multi system injuries because of the large force required to rupture the diaphragm[9].Blunt trauma to the abdomen increases the transdiaphragmatic pressure gradient between the abdominal compartment and the thorax[10]. This causes shearing of a stretched membrane and avulsion of the diaphragm from its points of attachments due to sudden increase in intra abdominal pressure, transmitted through the viscera[11]. Delay in presentation of a diaphragmatic hernia could be explained by various different hypotheses. Delayed rupture of a devitalised diaphragmatic muscle may occur several days after the initial injury [8]. This is best exemplified in the case report of bilateral diaphragmatic rupture [12], where the left diaphragmatic rupture was identified 24 hours after th
Stab Injury of the Thoracic Aorta: Computed Tomography Findings  [PDF]
Seyma Yildiz,Huseyin Toprak,Asli Serter,Ercan Kocako?
Case Reports in Radiology , 2013, DOI: 10.1155/2013/397514
Abstract: Stab injury of the thoracic aorta is a rare condition with high mortality rate. Patients must be evaluated carefully, and the diagnosis usually should be confirmed by radiological modalities. In this case, we report a 37-year-old man presented with a penetrating stab injury to the upper back and the thoracic aorta, and the diagnostic role of computed tomography is discussed. 1. Introduction Thoracic traumas take the third place after head and extremity traumas in patients with trauma who presented to emergency department. Thoracic traumas cause the 20–25% of deaths due to trauma in the first four decades of life [1]. Thoracic traumas are caused by blunt and penetrating injuries. Stab injuries of the thoracic aorta are rare. Because the thorax contains the heart, lungs, and great vessels, any thoracic injury of this space is associated with a high mortality rate. In thoracic traumas, accurate diagnosis and appropriate surgical approach form the basis of reducing the morbidity and mortality in such injuries. In this case we report a patient who was admitted to our emergency department due to stab injuries in the upper back region, and diagnostic tools of computed tomography (CT) are discussed. 2. Case Report A 37-year-old unresponsive man with penetrating injuries was admitted to our emergency department. On his physical examination, pulse and blood pressure could not be retrieved. Glasgow coma scale was determined as 3. There were 3?cm long bleeding laceration at the infrascapular region and midline 4?cm long bleeding laceration at the lumbar region. He was accepted as a respiratory and cardiac arrest; he was resuscitated and he responded to resuscitation. During evaluation of thorax, minimal pneumothorax was revealed, a chest tube was inserted, and 4 units of erythrocyte suspension were given to the patient. In order to evaluate the intrathoracic lesions, a contrast-enhanced CT was performed. Thorax CT examination revealed bilateral high density fluid collections at pleural space which were considered as hemothorax, left-sided pneumothorax, and an intraparenchymal hematoma in left lower laterobasal segment of the lung (Figure 1). Soft-tissue density hematoma that was surrounding trachea posteriorly and aorta circumferentially was seen in posterior mediastinum (Figure 2). From this area, adjacent to descending thoracic aorta, active contrast material leak was seen, and therefore this was considered as aortic rupture and contrast material extravasation due to acute aortic rupture (Figure 3). The patient underwent an operation by thoracic and
Thoracoscopy for the diagnosis of hidden diaphragmatic injuries: penetrating thoraco-abdominal trauma
Bagheri R,Tavassoli A,Sadrizadh A,Rajabi Mashhadi M
Tehran University Medical Journal , 2008,
Abstract: "nBackground: Penetrating thoracoabdominal stab wounds may cause diaphragmatic and abdominal organ laceration. However, 15-20% of these cases who are stable and managed by conservative treatment might have hidden diaphragmatic injuries, which could ultimately lead to chronic diaphragmatic hernia. Therefore, a safe and exact diagnostic method for the detection of occult diaphragmatic injuries is very valuable. In this study we have assessed the diagnostic value of thoracoscopy in occult diaphragmatic injuries resulting from penetrating thoracoabdominal stab wounds. "nMethods: From March 2005 to October 2007, 30 hemodynamically stable patients with penetrating thoracoabdominal injuries, not requiring emergent exploration, were enrolled in this study. All subjects underwent thoracoscopy to evaluate probable diaphragmatic injury. Diaphragmatic injuries were repaired via thoracoscopy or laparatomy. All patients were evaluated for chronic diaphragmatic hernia by CT-scan six months later. "nResults: The mean patient age was 26.2 years, with a male/female ratio of 5:1. Using thoracoscopic exploration, we observed five (16.7%) hidden diaphragmatic injuries, three (9.9%) of which were repaired using the thoracoscopic approach and two (6.6%) by laparatomy. Lung parenchymal laceration was seen in two patients (6.6%), for whom the repair was performed using thoracoscopy. Intra-abdominal injury was seen in one patient (3.3%), which was repaired by laparatomy. After thoracoscopy, there were no complications or evidence of chronic diaphragmatic hernia in the chest and abdominal CT-scans performed six months later. Therefore, the diagnostic accuracy of thoracoscopy in occult diaphragmatic injuries in our study was 100%. "nConclusion: With its high degree of diagnostic accuracy, low degree of invasiveness, as well as its utility in treatment, we recommend thoracoscopy for all clinically stable patients with penetrating thoracoabdominal stab wounds.
Chondrosarcoma of the Thorax  [PDF]
Philip A. Rascoe,Scott I. Reznik,W. Roy Smythe
Sarcoma , 2011, DOI: 10.1155/2011/342879
Abstract: Although a rare entity, chondrosarcoma is the most common malignant tumor of the chest wall. Most patients present with an enlarging, painful anterior chest wall mass arising from the costochondrosternal junction. CT scan with intravenous contrast is the gold standard radiographic study for diagnosis and operative planning. Contrary to previous dictum, resection may be performed in an appropriate surgical candidate based on imaging characteristics or image-guided percutaneous biopsy results; incisional biopsy is rarely required. The keys to successful treatment are early recognition and radical excision with adequate margins, as chondrosarcoma is relatively resistant to radiotherapy and conventional cytotoxic chemotherapy. Overall survival is excellent in most surgical series from experienced centers. Complete excision with widely negative microscopic margins at the initial operation is of the utmost importance, as local recurrence portends systemic metastasis and eventual tumor-related mortality. This paper summarizes data from relevant surgical series and thereupon draws conclusions regarding preoperative, intraoperative, and postoperative management of thoracic chondrosarcoma. 1. Introduction The thoracic vertebrae, sternum, ribs, and costal cartilages provide the rigid structure of the thorax. The soft-tissue constituents include skin, connective tissue, extrathoracic and intercostal musculature, and pleural mesothelium. In addition to providing protection for the underlying thoracic viscera, these structures function harmoniously to support the physiology of respiration. Tumors of the chest wall encompass a wide variety of benign and malignant conditions. The most common entities are blood-borne rib metastases and direct chest wall invasion from contiguous lung and breast carcinoma. Primary chest wall tumors may arise from any of its soft-tissue, bony, or cartilaginous constituents. These tumors are quite rare, with approximately 500 new cases per year in the United States. As such, most reports in the surgical literature consist of single-institutional studies with relatively few patients. Soft-tissue tumors account for roughly two-thirds of cases, while bony and cartilaginous masses account for approximately one-third. In general, 50–80% of these tumors are malignant, with increasing rates of malignancy found as the proportion of soft-tissue tumors increases within the series [1]. Chondrosarcoma is the most common malignant primary tumor of both the bony thorax and, in fact, the entire chest wall [2]. It accounts for nearly one-third of all
Heart hypoplasia in an animal model of congenital diaphragmatic hernia  [cached]
Tannuri Uenis
Revista do Hospital das Clínicas , 2001,
Abstract: PURPOSE: In previous papers, we described a new experimental model of congenital diaphragmatic hernia in rabbits, and we also reported noninvasive therapeutic strategies for prevention of the functional and structural immaturity of the lungs associated with this defect. In addition to lung hypoplasia, pulmonary hypertension, biochemical, and structural immaturity of the lungs, the hemodynamics of infants and animals with congenital diaphragmatic hernia are markedly altered. Hence, cardiac hypoplasia has been implicated as a possible cause of death in patients with congenital diaphragmatic hernia, and it is hypothesized to be a probable consequence of fetal mediastinal compression by the herniated viscera. Cardiac hypoplasia has also been reported in lamb and rat models of congenital diaphragmatic hernia. The purpose of the present experiment was to verify the occurrence of heart hypoplasia in our new model of surgically produced congenital diaphragmatic hernia in fetal rabbits. METHODS: Twelve pregnant New Zealand rabbits underwent surgery on gestational day 24 or 25 (normal full gestational time - 31 to 32 days) to create left-sided diaphragmatic hernias in 1 or 2 fetuses per each doe. On gestational day 30, all does again underwent surgery, and the delivered fetuses were weighed and divided into 2 groups: control (non-surgically treated fetuses) (n = 12) and congenital diaphragmatic hernia (n = 9). The hearts were collected, weighed, and submitted for histologic and histomorphometric studies. RESULTS: During necropsy, it was noted that in all congenital diaphragmatic hernia fetuses, the left lobe of the liver herniated throughout the surgically created defect and occupied the left side of the thorax, with the deviation of the heart to the right side, compressing the left lung; consequently, this lung was smaller than the right one. The body weights of the animals were not altered by congenital diaphragmatic hernia, but heart weights were decreased in comparison to control fetuses. The histomorphometric analysis demonstrated that congenital diaphragmatic hernia promoted a significant decrease in the ventricular wall thickness and an increase in the interventricular septum thickness. CONCLUSION: Heart hypoplasia occurs in a rabbit experimental model of congenital diaphragmatic hernia. This model may be utilized for investigations in therapeutic strategies that aim towards the prevention or the treatment of heart hypoplasia caused by congenital diaphragmatic hernia.
Penetrating Stab Wound of the Right Ventricle  [PDF]
Ahmet ?a?mazel,Hasan Erdem,Fuat Büyükbayrak,Onursal Bu?ra
Ko?uyolu Kalp Dergisi , 2010,
Abstract: 18 years old male patient was admitted to our emergency unit with a penetrating stab wound to the right ventricle. A stab wound to the right ventricle was found to be 3 cm in diameter. The bleeding was controlled by insertion of a Foley catheter and inflation of the balloon. The stab wound had transected distal acute marginal side ofthe right coronary artery. A successful repair was performed with the use of a foley catheter and application of the Medtronic Octopus Tissue Stabilization System. The wound was closed with pledgeted mattress sutures. The distal acute marginal side of the right coronary artery was ligated. In this presentation, the surgical intervention method was reported and followed by a discussion of emergency surgical procedures of the heart.
Congenital Bochdalek’s Diaphragmatic Hernia  [PDF]
Baba Usman Ahmadu,Chinda John Yola,Kaleb Abalis Abew
Journal of Nepal Paediatric Society , 2012, DOI: 10.3126/jnps.v32i3.6968
Abstract: Diagnosis of a rare Bochdalek’s congenital diaphragmatic hernia may be challenging. Our patient presented with respiratory and gastrointestinal findings. Chest radiograph revealed the stomach in the left thorax. Diagnosis of recurrent bacterial pneumonia was incorrectly made because of repeated symptoms. Chest radiograph can provide sufficient information for rapid diagnosis. DOI: http://dx.doi.org/10.3126/jnps.v32i3.6968 J. Nepal Paediatr. SocVol.32(3) 2012 254-256
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