Abstract
Diagnostic laparoscopy or thoracoscopy can improve diagnosis of occult injuries to the diaphragm and reduce the risk of serious late morbidity
Stabbing injuries are now common, and the number of haemodynamically stable patients with penetrating injuries of the chest and upper abdomen who are treated conservatively has increased. The case we present supports a more aggressive approach to penetrating thoracic injuries that occur between the horizontal planes bounded by nipple line and umbilicus (junctional zone).
No universally accepted strategy for managing this condition exists. Some doctors use advanced cross sectional imaging1 complemented by clinical acumen; others adopt a more invasive approach—laparoscopy or thoracoscopy.2
We present a case where a missed injury to the diaphragm caused by penetrating thoracic trauma resulted in serious morbidity. We conclude that conservative management of such injuries results in a considerable risk of occult hernia of the diaphragm with potentially life threatening sequelae.
Case
A 15 year old healthy boy was assaulted with a knife and sustained a penetrating injury to his left posterior chest wall at the level of the ninth rib. He was haemodynamically stable, but plain x ray showed a left sided haemopneumothorax, which we managed successfully with a chest drain. He remained stable and a contrast enhanced computed tomography scan showed no visceral injury. He was monitored closely and was sent home after seven days. He was asymptomatic at three months' follow-up. Clinical examination and a chest x ray were normal at that point and the patient was discharged.
One year later, he presented to the accident and emergency department with sudden severe epigastric pain, complete dysphagia, and blood stained vomiting. He was constitutionally unwell with tenderness in the left upper abdomen and decreased air entry at the left lung base.
A chest x ray showed collapse of the left lower lobe and blunting of the left costophrenic angle. An urgent double contrast computed tomography scan showed a defect in the diaphragm through which most of the stomach had herniated into the left hemithorax (figure).
Computed tomography scan. Stomach herniated into the chest
An emergency laparotomy showed that all but the pylorus of the stomach had herniated through a 4 cm central defect and was incarcerated in the left chest with evidence of irreversible ischaemia. We performed a total gastrectomy with roux-en-Y reconstruction, and the patient made an uneventful recovery. Histology of the specimen confirmed an ischaemic stomach due to strangulation.
Discussion
Injuries to the diaphragm caused by penetrating trauma to the junctional zone are often missed.3 The management of such injuries in haemodynamically stable patients is contentious. The merits of conservative management versus early surgical exploration have been debated extensively with no universal consensus.
Intrathoracic pressure is negative during inspiration, and over time even a small defect in the diaphragm can result in abdominal viscera being drawn into the chest. Clinical sequelae are rare on the right side because of protection from the liver. The diaphragm is exposed on the left side, however, and it is more vulnerable to these pressure effects.4 The central diaphragm is tendinous and poorly vascularised; this can compound the problem by compromising healing.
A three phase model of the natural course of injuries to the diaphragm has been described.5 The acute phase extends from the time of original trauma to recovery from apparent acute injuries and is followed by a latent phase where abdominal viscera gradually herniate into the thorax. Finally, the obstructive phase begins when the herniated viscera become ischaemic and the patient experiences acute symptoms. Patients whose injury is missed in the acute phase usually re-present in the obstructive phase with serious effects. Adopting a conservative approach during the acute phase can be dangerous in this group of patients. The natural course of the condition is insidious and often obscure, and many patients default on follow-up.
Radiological investigations such as focused ultrasound and double or triple contrast helical computed tomography scans have a sensitivity of up to 95% to detect injury to the diaphragm.6 The problem is the 5% of patients who are asymptomatic but have an occult injury.
Laparoscopy is a valuable tool to investigate suspected injuries to the diaphragm, with a sensitivity of 87.5% and a negative predictive value of 96.8%.7 8 Video assisted thoracoscopy (VATS) provides an accurate assessment of intrathoracic injuries. It can be used for the definitive and effective management of diaphragmatic injuries caused by blunt or penetrating thoracic trauma.9 This technique requires expert single lung anaesthesia but permits fastidious examination of the diaphragm.
In conclusion, we report an adolescent boy who sustained a perforating injury of the diaphragm that was not detected on initial presentation, who subsequently needed a total gastrectomy because of this missed injury. This case supports a more proactive management strategy for penetrating injuries to the junctional zone. The addition of diagnostic laparoscopy or thoracoscopy to currently available imaging techniques can greatly improve diagnosis of occult injuries to the diaphragm and reduce the risk of serious late morbidity. Patients with a penetrating trauma to the junctional zone should be followed up for longer, and detailed clinical examination should be supported by good quality chest radiology.
JA is the primary author. JA, GCB, RK, and WDBC all helped manage the patient and write the paper. JAK was the principal surgeon. JAK and WDBC were the consultants responsible for the patient and are guarantors.
Competing interest: None declared.
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