Abstract
Introduction:
Diaphragm rupture (DR) is a rare pathological event usually caused by trauma. We aimed to analyse the characteristics of acute diaphragmatic injuries due to trauma and the treatment of such injuries.
Methods:
This study included the data of 15 patients who sustained diaphragmatic injuries due to trauma and underwent surgery at the Diyarbakır Gazi Yaşargil Training and Research Hospital General Surgery Service between January 2016 and December 2019.
Results:
There were 240 patients who presented with abdominal trauma during the study period, and DR was detected in 15 (6.25%) of these patients. The male to female ratio was 14 to 1, and the average age of the patients was 29.66 ± 10.56 (15–46) years. The most common cause of diaphragmatic injury was penetrating abdominal injuries (86.7%). Blunt abdominal trauma accounted for 13.3% of the DR cases. Preoperative shock was present in four (26.7%) patients. Preoperative diagnosis was made in only one (6.7%) of 15 patients with DR. Other patients were diagnosed during operation. Thirteen (86.7%) patients had additional organ injuries, and two patients had isolated diaphragmatic injuries. The most frequently injured organ was the lung (n = 7, 46.6%). Complications developed in six patients (morbidity rate 40%), and pulmonary complications were most frequently encountered (n = 5, 33.3%). The mortality rate was 6.7%.
Conclusion:
As traumatic DRs are uncommon and often associated with additional organ injuries, a careful general assessment of the patient should be made.
Keywords: Abdominal trauma, acute care, major trauma management, pneumothorax, trauma
INTRODUCTION
Diaphragm rupture (DR) is a rare pathological event usually caused by trauma due to traffic accidents or penetrating injuries.[1] Traumatic DR is seen in approximately 1%–7% of patients with major blunt traumas.[2]
Compared to penetrating traumas, blunt traumas typically cause a higher incidence of anatomical injuries and larger diaphragmatic injuries.[3] Early diagnosis and surgical treatments are needed. However, delayed diagnosis is common, especially in patients with penetrating injury; in such cases, herniation of the organs to the chest is almost never seen.[4,5,6] Although computed tomography (CT) shows excellent sensitivity in diagnosing various organ injuries in the chest and abdomen, it is less sensitive for DR.[7] Isolated diaphragmatic injury is rare and is accompanied by other pathologies at a rate of 80%–100%.[8,9] The high morbidity and mortality rates of DR can be explained by the accompanying pathologies.[8]
In this study, we aimed to analyse the characteristics of acute diaphragmatic injuries due to trauma and the treatment of such injuries.
METHODS
This study included the data of 15 patients who sustained diaphragmatic injuries due to trauma and underwent surgery at the Gazi Yaşargil Training and Research Hospital General Surgery Service between January 2016 and December 2019. We collected the data of patients with DR, including age, gender, cause of trauma, presence of additional organ injury, blood transfusion status, size and localisation of rupture, Penetrating Abdominal Trauma Index (PATI) score, presence of herniated organ, and laboratory and radiological findings. The hospital records and surgery reports were analysed retrospectively. Other data such as imaging methods, preoperative time, presence of shock, comorbidity, duration of hospitalisation, surgery performed, morbidity and mortality were also collected. This study was conducted following the principles of the 2008 Helsinki Declaration and was approved by the Research Ethics Committee of Gazi Yaşargil Training and Research Hospital (11.06.2021/E-780).
The numerical data obtained in this study were expressed as arithmetic mean ± standard deviation, and categorical data were expressed as frequency (percentage). Statistical analysis was performed using the IBM SPSS Statistics version 16.0 (IBM Corp, Armonk, NY, USA). Compliance of numerical data to normal distribution was tested using the Shapiro–Wilk test, and homogeneity was tested with the Levene test. Chi-square test, Student’s independent t-test, one-way analysis of variance and post hoc Tukey’s honestly significant difference test were used for statistical analysis. A P value < 0.05 was considered statistically significant.
RESULTS
Of the 240 patients who presented with abdominal traumas during the study period, 15 (6.25%) were diagnosed with DR. The male to female ratio was 14:1. The average age was 29.66 ± 10.56 (15–46) years. The most common cause of diaphragmatic injury was penetrating abdominal injuries (86.7%). The rate of DR due to blunt abdominal trauma was 13.3%. None of the patients had comorbidities [Table 1].
Table 1.
Patient demographic and clinical characteristics (N=15).
| Characteristic | n (%) |
|---|---|
| Agea (yr) | 29.66±10.56 (15–46) |
|
| |
| Gender | |
|
| |
| Male | 14 (93.3) |
|
| |
| Female | 1 (6.7) |
|
| |
| Reason for rupture | |
|
| |
| Traffic accident | 2 (13.3) |
|
| |
| Gun shot wounds | 4 (26.7) |
|
| |
| Stab wounds | 9 (60.0) |
|
| |
| Location | |
|
| |
| Left | 11 (73.3) |
|
| |
| Right | 4 (26.7) |
|
| |
| Size of rupturea (cm) | 3.13±2.19 (1–10) |
|
| |
| Preoperative timea (h) | 3.93±5.00 (1–20) |
|
| |
| Additional organ injury | |
|
| |
| Lung | 7 (46.6) |
|
| |
| Left | 5 (71.4) |
|
| |
| Right | 1 (14.3) |
|
| |
| Bilateral | 1 (14.3) |
|
| |
| Liver | 4 (26.6) |
|
| |
| Spleen | 5 (33.3) |
|
| |
| Costae (rib) | 3 (20) |
|
| |
| Stomach | 2 (13.3) |
|
| |
| Kidney | 3 (20) |
|
| |
| Vertebra | 4 (26.6) |
|
| |
| Colon | 2 (13.3) |
|
| |
| Small intestine | 2 (13.3) |
|
| |
| Vena porta | 1 (6.7) |
|
| |
| Duodenum | 1 (6.7) |
|
| |
| Patellar tendon | 1 (6.7) |
|
| |
| Imaging | |
|
| |
| Chest radiography | 4 (26.7) |
|
| |
| Computed tomography | 13 (86.7) |
|
| |
| Ultrasonography | 7 (46.7) |
|
| |
| PATI scorea | 10.80±14.34 (1–39) |
|
| |
| Length of hospitalisationa (day) | 17.80±38.84 (1–157) |
|
| |
| Blood transfusion | 7 (46.7) |
|
| |
| Units of blood transfusionsa | 2.87±6.10 (0–24) |
|
| |
| Morbidity | 6 (40) |
|
| |
| Mortality | 1 (6.7) |
aData presented as mean±standard deviation (minimum–maximum). PATI: Penetrating abdominal trauma index.
Preoperative shock was present in four (26.7%) patients. Preoperative abdominopelvic CT, ultrasonography (USG) and posteroanterior chest X-ray were performed in 13, seven and four patients, respectively. Two patients did not undergo any imaging before operation, as they were in poor general condition and haemodynamically unstable. In one of them, the small intestine and stomach were herniated to the thorax during the operation. Although there were findings suggestive of abdominal injury in all patients on preoperative CT, only one patient had findings suggestive of diaphragmatic injury. The abdominal organs were observed to be herniated to the thorax in this patient [Figure 1].
Figure 1.
(a) and (b): Posteroanterior chest radiography shows abdominal organs herniated to thorax. (c) Thorax computed tomography shows abdominal organs herniated to thorax.
Pathological findings were observed in one (25%) of the four patients who had preoperative chest X-ray. Herniation of organs with intra-abdominal lumen in the thorax was observed in this patient. Four of the seven patients who underwent USG were reported as normal, whereas three had pathological findings, such as intra-abdominal organ injury and free fluid appearance in the abdomen. Preoperative diagnosis was made in only one (6.7%) of 15 patients with diaphragmatic injury. Other patients were diagnosed during the operation. The average time from injury to operation was 3.93 ± 5.00 (1–20) h.
A total of 13 (86.7%) patients had additional organ injuries, and two patients had isolated diaphragmatic injuries. The most frequently injured organ was the lung (n = 7, 46.6%). Other injured organs are presented in Table 1.
The average size of the rupture was 3.13 ± 2.19 (1–10) cm. Herniation was observed in two (13.3%) patients during the operation. Small intestine and stomach hernias were present in both patients, and the spleen was also herniated in one of the patients. Primary closure of the diaphragm was performed in one of these patients, whereas primary closure and primary repair to the stomach were performed in the other patient with gastric injury.
Laparotomy was performed in all the patients. One patient underwent laparotomy after diagnostic laparoscopy (DL). Diaphragm injury was primarily repaired with non-absorbable or absorbable sutures. The operations performed in the patients are presented in Table 2. The mean PATI score of our patients was 10.80 ± 14.34 (1–39).
Table 2.
Types of surgery performed (N=15).
| Surgery | n (%) |
|---|---|
| Diaphragm repair + stomach repair | 2 (3.3) |
|
| |
| Diaphragm repair + stomach repair + left CTD | 1 (6.7) |
|
| |
| Diaphragm repair | 3 (20.0) |
|
| |
| Diaphragm repair + left CTD | 1 (6.7) |
|
| |
| Diagnostic laparoscopy + diaphragm repair + left CTD | 1 (6.7) |
|
| |
| Small bowel resection + ileostomy + sigmoid colon resection + anastomosis + liver repair + right CTD | 1 (6.7) |
|
| |
| Liver packing + diaphragm repair | 1 (6.7) |
|
| |
| Liver repair + diaphragm repair | 1 (6.7) |
|
| |
| Right nephrectomy + vena porta repair + diaphragm repair | 1 (6.7) |
|
| |
| Left nephrectomy + left hemicolectomy + colocolic anastomosis + segmental jejunal resection + anastomosis + left CTD | 1 (6.7) |
|
| |
| Splenectomy + diaphragm repair + haemostasis + left CTD | 1 (6.7) |
|
| |
| Splenography + diaphragm repair | 1 (6.7) |
CTD: closed thoracic tube drainage.
Diaphragmatic rupture was left-sided in 11 (73.3%) patients and right-sided in four (26.7%) patients. A total of 43 units of blood were transfused to seven (46.7%) patients. The average blood transfusion was 2.87 ± 6.10 (0–24) units. The mean duration of hospital stay was 17.80 ± 38.84 (1–157) days.
Postoperative complications developed in six patients due to diaphragmatic injury, other injuries or operative factors. The morbidity rate in our cohort was 40%. Pulmonary complications (n=5, 33.3%) were the most frequently observed; other postoperative complications are presented in Table 3. One of the patients underwent re-operation due to the development of postoperative intra-abdominal haemorrhage. An anastomotic leak developed another patient, who subsequently developed acute renal failure. One patient who underwent multiple re-operations due to complications developed pulmonary embolism and ileus; an existing ileostomy was closed and the patient was discharged after 157 days of hospitalisation. Another patient developed hypovolaemic shock as a result of vena porta and kidney injury, and died on postoperative day 1. The mortality rate in our cohort was 6.7% [Table 1]
Table 3.
Postoperative complications (N=15).
| Complication | n (%) |
|---|---|
| Acute renal failure, pulmonary embolism, anastomotic leak after ileostomy closure, ileus, haematoma | 1 (6.7) |
|
| |
| Atelectasis | 2 (13.3) |
|
| |
| Haemorrhage, haemopneumothorax | 1 (6.7) |
|
| |
| Hypovolaemic shock | 1 (6.7) |
|
| |
| Pneumothorax, wound infection, sepsis | 1 (6.7) |
|
| |
| No complication | 9 (60.0) |
DISCUSSION
Diaphragm rupture is rare and difficult to diagnose.[8,9,10] In the case of acute trauma, the rate of missed DR diagnosis is 12%–66%.[1] It is detected in approximately 3% of all abdominal injuries.[8] In the study by Kuo et al.,[11] the rate of DR from blunt and penetrating traumas was reported to be 2.1% and 3.4%, respectively, whereas the rate of DR due to trauma in operated patients was 5%.[11] The rate of DR in our study was 6.25% in patients with abdominal trauma. This high rate in our study might be because we performed the evaluation only in the acute phase and only in patients with abdominal trauma who underwent emergency laparotomy. The dominance of penetrating traumas may also account for the high rate of DR in our study. The rate of additional organ injury in our cohort was 86.7%, which is in line with the literature.[8,9] Isolated diaphragmatic injury is rare, and other pathologies accompany it with a rate of 80%–100%.[8,9] In our study, the rate of isolated diaphragmatic injury was 13.3%. One of these two patients with isolated diaphragmatic injury was involved in a traffic accident, and the patient’s spleen, small intestine and stomach had herniated into the thorax, although no injury to the herniated organs was observed. The other patient had a 2-cm DR caused by a stab wound, and haemopneumothorax developed due to intercostal muscle injury. This patient underwent diaphragm repair and closed thoracic tube drainage (CTD). Both of these patients had left-sided DR.
Some studies have suggested that the most common cause of DR was blunt trauma[1,2,10] or penetrating mechanisms.[3,8,12] In our study, the rate of penetrating diaphragmatic injuries was high (86.7%). This could be attributed to the ease of access to piercing and cutting tools in our region.
In some studies, the average age of patients with diaphragmatic injuries was reported to be 30 years,[1,2,6,10] which is consistent with the mean age of 29.6 years in our study, although Lim and Park[2] reported an average age of 51 years in their study. The majority of patients who had diaphragmatic injuries are males.[1,3,9,10,12] Compared to the rates reported in the literature, our study found a higher male predominance (93.3%); we attribute this to the increased exposure of young men to outdoor activities (due to income-generating work) and their tendency to participate in violence in our region.
Diaphragm rupture is mostly seen on the left[1,2,3,6,8,10] because the left region has a weak pleuroperitoneal membrane structure.[1,2] This is consistent with our study where left-sided DR made up 73.3% of the diaphragmatic injuries.
Isolated diaphragmatic injuries are rare. Other pathologies accompany this injury at a rate of 80%–100%.[8] Corbellini et al.[1] reported additional organ injuries at a rate of 71.4%, with bone fractures (70%) being the most common pathology. D’Souza et al.[3] reported intra-abdominal injuries in 99 (77.9%) of 127 penetrating DR cases. In our study, the rate of additional organ injury was 86.7%, and the most frequently injured extra-abdominal and intra-abdominal organs were the lung and spleen, respectively.
The rates of diaphragmatic hernia (DH) in blunt traumas and penetrating traumas have been reported to be 94% and 15.1%, respectively.[6] Overall, the rate of diaphragmatic hernia (DH) in DR was 47.26%, and the stomach and omentum were the most frequently herniated organs.[6] In another study, the herniation rate was reported as 76.3% and the organs with the most frequent hernias were the stomach and intestines.[2] The herniation rate in our study was 13.3%, which we attribute to the high penetrating injury rate.
Methods used in the diagnosis of DR are chest X-ray, upper gastrointestinal contrast study, fluoroscopy, USG, CT, magnetic resonance, laparoscopy and thoracoscopy.[2,10] Before surgery, the diagnosis rate was reported to be 57%–68.4% in studies reporting a higher number of cases with blunt trauma.[1,2,9] In our study, which reported a high number of patients with penetrating trauma,[12] the rate of DR was 22%. Our preoperative diagnosis rate was 6.7%. The specific findings of DR in chest X-ray include herniation of the abdominal organs to the thorax, appearance of the nasogastric tube in the thorax, diaphragm elevation and mediastinal shift.
Computed tomography detects diaphragmatic injuries with a much higher sensitivity and specificity than chest X-ray. Some typical CT findings include direct visualisation of diaphragm damage, absence of the diaphragm segment and intrathoracic herniation of the abdominal viscera.[13] In our study, chest X-ray was performed in four patients and pathological findings were found in one (25%) patient. In this patient, herniation of the abdominal organs was observed in the thorax.
Before surgery, diaphragmatic injury was diagnosed in only one (7.7%) of 13 patients who underwent CT. Our other patient with diaphragmatic herniation underwent operation directly without imaging because his general condition was not stable. Our low preoperative diagnosis rate might have been because most of our cases consisted of penetrating injuries, with small diameters of DRs and a low rate of herniation.
Due to the high rate of additional abdominal organ injuries in patients with DR, laparotomy should also be performed in patients who initially underwent thoracotomy.[2,3] This procedure increases the operation time and morbidity.[2] Therefore, laparotomy should be the first choice in DR cases.[2,6] Thoracotomy can also be performed in some patients with only right DR or chronic DH.[6] Thoracoscopy and/or laparoscopy are the methods used for diagnosis and treatment.[1] Koganti et al. demonstrated the usefulness of DL for the initial assessment of intra-abdominal injury in haemodynamically stable trauma patients. They found that it reduced the number of negative and non-therapeutic laparotomy without increasing the risk of missed injury. Of 316 cases, 178 (56%) were DL negative or non-therapeutic. Of 110 patients with blunt traumatic injuries, 64 (58%) had negative or non-therapeutic DL. Of 206 patients admitted after penetrating trauma, 114 (55%) had negative or non-therapeutic DL. They reported a 50% lower length of hospitalisation in patients who underwent DL compared to patients who underwent laparotomy.[14]
Primary closure is the gold standard in small- and medium-width DRs. However, defects >10 cm may require patch closure. Patch closure is not recommended in cases of emergency operations.[1] Due to the high rate of additional intra-abdominal organ injuries and low preoperative diagnosis of DR, laparotomy was performed in all of our patients. One of our patients underwent laparotomy after DL. Primary closure was applied to all our patients during operation, as the defects were <10 cm.
The high morbidity and mortality rates in DR can be explained by the accompanying pathologies.[8] Pulmonary complications are the most common postoperative complications.[1,9,15] They lead to increased morbidity and mortality, rather than DR itself, associated organ injuries, haemorrhagic shock and incomplete or delayed diagnosis.[1] Studies have found a postoperative complication rate of 36.8% to 48% in DR, with pulmonary complications being the most common complication.[2,9] Consistent with the literature, our study had a morbidity rate of 40% with pulmonary complications being the most common.
The PATI is a method developed to measure the risk of complications after penetrating abdominal trauma. The PATI score is calculated by assigning a risk factor (1–5) to each injured organ and then multiplying this by a severity of injury estimate (1–5). The sum of the injured organ scores forms the final PATI. The total PATI scores range from 0 to 200, and scores >25 increase the risk of postoperative complications.[16] The PATI mean score of our patients was 10.80 ± 14.34 (1–39).
The rate of mortality due to DRs has been reported to be in the range of 1%–28%.[1,2,8,10] Some authors have suggested that the mortality associated with blunt DR is due to concomitant injuries rather than DR itself. Furthermore, haemorrhagic shock and trauma mechanisms are associated with mortality.[10,15] In our study, one patient (6.7%) with kidney and vena porta injury died due to haemorrhagic shock. Our mortality rate was consistent with the literature. The average hospital stay of patients operated on for DR is between 16.6 and 27.8 days.[1,9] In our study, the mean duration of hospitalisation was 17.80 ± 38.84 (1–157) days, which was consistent with the literature.
In conclusion, given that traumatic DRs are uncommon and often associated with additional organ injuries, a careful general assessment should be made. Preoperative diagnosis is difficult, especially in penetrating traumas. Therefore, diaphragmatic injuries should be excluded during laparotomy. A missed diagnosis of DR will increase the morbidity and mortality rates. Computed tomography is important in the diagnosis of DR and should be performed in trauma patients whose general condition is stable. Diaphragm rupture must be considered in thoracoabdominal penetrating injuries.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
We would like to thank the staff of Gazi Yaşargil Teaching and Research Hospital General Surgery Clinic.
Funding Statement
Nil.
REFERENCES
- 1.Corbellini C, Costa S, Canini T, Villa R, Avesani EC. Diaphragmatic rupture: A single-institution experience and literature review. Ulus Travma Acil Cerrahi Derg. 2017;23:421–6. doi: 10.5505/tjtes.2017.78027. [DOI] [PubMed] [Google Scholar]
- 2.Lim KH, Park J. Blunt traumatic diaphragmatic rupture single-center experience with 38 patients. Medicine. 2018;97:e12849. doi: 10.1097/MD.0000000000012849. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.D’Souza N, Clarke D, Laing G. Prevalence, management and outcome of traumatic diaphragm injuries managed by the Pietermaritzburg Metropolitan Trauma Service. Ann R Coll Surg Engl. 2017;99:394–401. doi: 10.1308/rcsann.2017.0029. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Gao JM, Gao YH, Zeng JB. Polytrauma with thoracic and/or abdominal injuries: Experience in 1540 cases. Chin J Traumatol. 2006;9:108–14. [PubMed] [Google Scholar]
- 5.Liao CH, Hsu CP, Kuo IM, Ooyang CH, Wang SY, Huang JF, et al. Factors effecting outcomes in penetrating diaphragmatic trauma. Int J Surg. 2013;11:492–5. doi: 10.1016/j.ijsu.2013.03.014. [DOI] [PubMed] [Google Scholar]
- 6.Gao J, Du D, Li H, Liu C, Liang S, Xiao Q, et al. Traumatic diaphragmatic rupture with combined thoracoabdominal injuries: Difference between penetrating and blunt injuries. Chin J Traumatol. 2015;18:21–6. doi: 10.1016/j.cjtee.2014.07.001. [DOI] [PubMed] [Google Scholar]
- 7.Kwon J, Lee JC, Moon J. Diagnostic significance of diaphragmatic height index in traumatic diaphragmatic rupture. Ann Surg Treat Res. 2019;97:36–40. doi: 10.4174/astr.2019.97.1.36. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Yetim TD, Karaarslan K, Koçal S, Kılıç E. Traumatic diaphragm rupture in early period. Mustafa Kemal Univ Med J. 2017;8:41–5. [Google Scholar]
- 9.Tiberio GAM, Portolani N, Coniglio A, Baiocchi GL, Vettoretto N, Giulini SM. Traumatic lesions of the diaphragm. Our experience in 33 cases and review of the literature. Acta Chir Belg. 2005;105:82–8. [PubMed] [Google Scholar]
- 10.Kuo IM, Liao CH, Hsin MC, Kang SC, Wang SY, Ooyang CH. Blunt diaphragmatic rupture-A rare but challenging entity in thoracoabdominal trauma. Am J Emerg Med. 2012;30:919–24. doi: 10.1016/j.ajem.2011.03.014. [DOI] [PubMed] [Google Scholar]
- 11.Morgan BS, Watcyn-Jones T, Garne JP. Traumatic diaphragmatic injury. JR Army Med Corps. 2010;156:139–44. doi: 10.1136/jramc-156-03-02. [DOI] [PubMed] [Google Scholar]
- 12.Tokgöz S, Akkoca M, Uçar Y, Yılmaz KB, Sevim Ö, Görkem Gündoğan G. Factors affecting mortality in traumatic diaphragm ruptures. Ulus Travma Acil Cerrahi Derg. 2019;25:567–74. doi: 10.14744/tjtes.2019.58133. [DOI] [PubMed] [Google Scholar]
- 13.Tan KK, Yan ZY, Vijayan A, Chiu MT. Management of diaphragmatic rupture from blunt trauma. Singapore Med J. 2009;50:1150–3. [PubMed] [Google Scholar]
- 14.Koganti D, Hazen BJ, Dente CJ, Nguyen J, Gelbard RB. The role of diagnostic laparoscopy for trauma at a high-volume level one center. Surg Endosc. 2021;35:2667–70. doi: 10.1007/s00464-020-07687-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Shah R, Sabanathan S, Mearns AJ, Choudhury AK. Traumatic rupture of diaphragm. Ann Thorac Surg. 1995;60:1444–9. doi: 10.1016/0003-4975(95)00629-Y. [DOI] [PubMed] [Google Scholar]
- 16.Moore EE, dunn EL, moore JB, Thompson JS. Penetrating abdominal trauma index. J trauma. 1981;21:439–45. [PubMed] [Google Scholar]