Traumatic diaphragmatic hernias: Retrospective analysis
JPA Sousa 1
JP Baptista 2
L Martins 3
J Pimentel 4
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Resumo
Objectivos: Os autores propuseram-se realizar uma revisão e caracterização dos casos de hérnias diafragmáticas (HD) traumáticas internados no Serviço de Medicina Intensiva dos Hospitais da Universidade de Coimbra (SMI-HUC) de 1990 a 2004.
Material e métodos: Análise retrospectiva de 34 casos de HD traumática, tendo em atenção a localização anatómica, o local e o momento do diagnóstico, os exames complementares que permitiram o diagnóstico, os órgãos herniados, os traumatismos associados, a morbilidade e a mortalidade.
Resultados: Vinte e oito doentes eram do sexo masculino e 6 do feminino, com média de idades de 40,2 ± 20,5 anos; o valor médio do SAPS foi de 38,8. A duração média de internamento foi de 19,1 ± 13,6 dias, todos sofreram traumatismo fechado e foram submetidos a ventilação artificial. A hérnia localizava-se à esquerda em 94,1% dos casos. O diagnóstico em 19 dos casos foi efectuado até 6 horas após o traumatismo, em 4 casos até às 12 horas, e os restantes entre 48 horas e 16 anos após o traumatismo. Em 13 doentes o diagnóstico foi intra-operatório. Dos órgãos herniados, o estômago estava presente na maioria da situações. As lesões associadas mais frequentes foram, a nível torácico, a contusão pulmonar, o hemotórax e o pneumotórax, e a nível abdominal o hemoperitoneu e a lesão esplénica. A taxa de complicações e de mortalidade foi 55,8 % e de 11,7 %, respectivamente.
Conclusões: A HD ocorreu maioritariamente à esquerda por traumatismo toraco-abdominal fechado na sequência de acidente de viação. Este grupo de doentes, em relação aos valores médios do Serviço, era mais jovem, apresentava maior duração média de internamento, apresentando, no entanto, menores taxa de mortalidade e índice de gravidade (SAPS). O órgão herniado mais frequente foi o estômago, e as lesões associadas mais encontradas foram os traumatismos crânio-encefálico, esplénico e pleuro-costal. A dificuldade de diagnóstico pré-operatória continua a requerer elevado grau de suspeição, exigindo-se sempre a colocação desta hipótese de diagnóstico no contexto de traumatismos toraco-abdominais fechados.
Palavras-chave: Trauma, trauma torácico, trauma abdominal, ruptura diafragmática, traumatismo fechado, traumatismo aberto, hérnia diafragmática, ventilação mecânica.
Abstract
Aims: This study classifies cases of traumatic diaphragmatic hernias (TDH) in patients admitted to the Intensive Care Unit (ICU) of the Coimbra University Hospitals (HUC) from 1990 to 2004.
]]> Methods: Retrospective analysis of 34 cases of TDH, studying anatomical location, place and time of diagnosis, complementary tests aiding diagnosis, herniated organs, associated traumatism, morbidity and mortality.Results: Twenty-eight male and six female patients with an average age of 40.5 years ± 20.5, average SAPS score 38.8. Average lenght of stay was 19.1± 13.6 days, all suffered from closed traumatism and were put on artificial ventilation. The left-side diaphragm was more frequently affected (94.1%) then the right. Diagnosis in 19 cases was made up in the first six hours following the diagnosis of traumatism, in four cases within 12 hours and in the remaining cases between 48 hours and 16 years after traumatism. In 13 patients the diagnosis was established intra-operatively. The stomach was typically one of the herniated organs. The most frequently associated lesions at the thoracic level were pulmonary contusion, haemothorax and pneumothorax, and at the abdominal level, haemoperitoneum and splenic lesion. The rates for complications and mortality were 55.8% and 11.7% respectively.
Conclusions: TDH mainly occurs on the left side through closed thoraco-abdominal trauma following road traffic accidents. This group of patients, on average younger than others admitted to ICU, presents a longer average hospitalisation period, but has lower rates of mortality and lower SAPS severity scores. The most commonly herniated organ was the stomach and the most frequently encountered lesions were cranial-encephalic, splenic and pleural traumatisms. Pre-operative diagnosis of diaphragmatic injuries is difficult and a high index of clinical suspicion is needed after thoraco-abdominal trauma. This diagnosis should always be considered a possibility in cases of closed thoraco-abdominal traumas.
Key-words: Blunt trauma, trauma, chest trauma, rupture of diaphragm, abdominal trauma, penetrating trauma, visceral herniation, mechanical ventilation.
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]]> Bibliografia/Bibliography
1. Beeson A, Popovici Z: Diaphragmatic injuries. Invited Comment in Thoracic Surgery: Surgical Management of Chest Injuries. In: Webb WR, Beeson A. eds. St. Louis: Mosby - Year Book 1991:317-322. [ Links ]
2. Robert F. Wilson: Diaphragmatic Injuries in Handbook of Trauma; eds McGraw-Hill, 2nd edition, 1999
3. Juan A. Ascensio, Patrizio P, Demetrios D: Injury to the Diaphragm, in Trauma (Eds. McGraw-Hill, fifth edition 2004
4. Rodriguez-Morales G, Rodriguez A, Shatney. Acute rupture of the diaphragm in blunt trauma: analysis of 60 patients. J Trauma 1986; 26(5):438-44.
5. Simpson J, Lobo DN, Shah AB, Rowlands BJ. Traumatic diaphragmatic rupture: associated injuries and outcome. Ann R Coll Surg Engl 2000; 82(2):97-100.
6. Wiencek RG Jr, Wilson RF, Steiger Z: Acute injuries of the diaphragm. An analysis of 165 cases. J Thorac Cardiovasc Surg 1986; 92(6):989-93.
7. Symbas PN, Vlasis SE, Hatcher C Jr. Blunt and penetrating diaphragmatic injuries with or without herniation of organs into the chest. Ann Thorac Surg 1986;42(2):158-62.
8. Kearney PA, Rouhana SW, Burney RE. Blunt rupture of the diaphragm: mechanism, diagnosis, and treatment. Ann Emerg Med 1989;18(12):1326-30.
9. Hegarty MM, Bryer JV, Angorn IB, Baker LW: Delayed presentation of traumatic diaphragmatic hernia. Ann Surg 1978;188 (2): 229-33.
]]> 10. Saber WL, Moore EE, Hopeman AR, Aragon WE: Delayed presentation of traumatic diaphragmatic hernia. J Emerg Med 1986; 4(1):1-7.11. McHugh K, Ogilvie BC, Brunton FJ: Delayed presentation of traumatic diaphragmatic hernia. Clin Radiol 1991; 43(4): 246-50
12. Cristofaro MG, Lazzaro F, Cafaro D, Natale R, Mauro P, Savino N, Musella S: Post-traumatic diaphragmatic hernia with late diagnosis. Report of a clinical case. Ann Ital Chir 2000; 71(5): 595-8.
13. Cupitt JM, Smith MB: Missed diaphragm rupture following blunt trauma. Anaesth Intensive Care 2001; 29(3): 292-6.
14. Mercadante E, De Giacomo T, Rendina EA, Venuta F, Moretti M, Aratari MT, Furio Coloni G: Diagnostic delay in post-traumatic diaphragmatic ruptures. Minerva Chir 2001; 56(3): 299-302.
15. Seleem MI, Al-Hashemy AM: Delayed presentation of traumatic rupture of the diaphragm. Saudi Med J. 2001; 22(8): 714-7.
16. Shreck GL, Toalson TW: Delayed presentation of traumatic rupture of the diaphragm. J Okla State Med Assoc 2003; 96(4): 181-3.
17. Lin YK, Huang BS, Shih CS, Hsu WH, Huaug MH, Lee CH:Traumatic diaphragmatic hernia with delayed presentation. Zhonghua Yi Xue Za Zhi (Taipei) 1999; 62(4): 223-9.
18. Prieto I, Robledo JP, Trelles V, Ibanez R, Prieto A, Celada A. Gastric incarceration and perforation following posttraumatic diaphragmatic hernia. Acta Chir Belg 2001;101(2): 81-3.
19. Lee WC, Chen RJ, Fang JF, Wang CC, Chen HY, Chen SC, Hwang TL, Jeng LB, Jan YY, Wang CS: Rupture of the diaphragm after blunt trauma. Eur J Surg. 1994; 160(9): 479-83.
]]> 20. Versaci A, Caminiti R, Centorrino T, Rossitto M, Pante S, Mastrojeni C, Monaco F, Ciccolo A: Diaphragm rupture caused by closed trauma. A more and more frequent condition; G Chir 2000; 21(8-9): 343-7.21. Shanmuganathan K, Killeen K, Mirvis SE, White CS: Imaging of diaphragmatic injuries. J Thorac Imaging 2000;15(2): 104-11.
22. Scaglione M, Pinto F, Grassi R, Romano S, Giovine S, Sacco M, Forner AL, Romano L: Diagnostic sensitivity of computerized tomography in closed trauma of the diaphragm. Retrospective study of 35 consecutive cases. Radiol Med (Torino) 2000; 99:46-50.
23. Nau T, Seitz H, Mousavi M, Vecsei V: The diagnostic dilemma of traumatic rupture of the diaphragm; Surg Endosc 2001;15(9): 992-6.
24. Iochum S, Ludig T, Walter F, Sebbag H, Grosdidier G, Blum AG: Imaging of diaphragmatic injury: a diagnostic challenge? Radiographics 2002; 22: S103-16.
25. Carter BM, Giuseffi J, Felson F: Traumatic diaphragmatic hernia. AJR Am J Roentgenol 1951; 65: 56.
26. Stagnitti F, Priore F, Corona F, Tiberi R, De Pascalis M, Schillaci F, Costantini A, Natalini E: Traumatic lesions of the diaphragm. G Chir 2004; 25(8-9): 276-82.
27. Mihos P, Potaris K, Gakidis J, Paraskevopoulos J, Varvatsoulis P, Gougoutas B, Papadakis G, Lapidakis E: Traumatic rupture of the diaphragm: experience with 65 patients. Injury 2003; 34(3):169-72.
]]> 1 Assistente Hospitalar Graduado/Graduate Hospital Assistant
2 Assistente Hospitalar/Hospital Assistant
3 Interno Complementar de Cirurgia Geral/General Surgery Intern
4Director de Serviço/Head of Department
Serviço de Medicina Intensiva – Hospitais da Universidade de Coimbra. (Director: Prof. Dr. Jorge Pimentel)
Recebido para publicação/received for publication: 06.02.01
Aceite para publicação/accepted for publication: 06.03.31
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