Management of Traumatic Diaphragmatic Injury: Retrospective study of 19 cases

Yıl 2025, Cilt: 18 Sayı: 2, 28 - 31, 15.07.2025

Hıdır Esme

Öz

Traumatic diaphragmatic injury (TDI) is a relatively rare condition. It has a high tendency to be missed without comprehensive clinical evaluation and imaging examination. The aim of this study is to review our diagnostic and therapeutic outcomes in patients who underwent thoracic surgery for TDI.
This study is a retrospective case series of all consecutive patients who presented to our emergency de-partment and surgical clinic during the last 4 years and developed TIA after chest trauma. Demographic data, type of chest injury (blunt and penetrating), cause of diaphragmatic injury, clinical and radiologic examinations, intraoperative findings and complications were reviewed.
A total of 926 patients with chest trauma were obtained from the records between August 2020 and December 2024. Of these 926 patients, 19 (2.05%) had TDI. Indications for surgery were massive hemothorax requiring thoracoscopy in 8 patients (42.1%), hearing bowel sounds on thorax auscultation during clinical evalu-ation in 7 patients (36.8%), and findings of diaphragmatic injury on chest radiography and contrast-enhanced computed tomography. In two patients (10.5%), the defect in the diaphragm was detected in the coronal section of computed tomography taken as a result of severe flank and shoulder pain, in 1 patient (5.2%), intestinal contents came from the chest tube inserted to drain hemopneumothorax, and in 1 patient (5.2%), although the amount of drainage from the chest tube decreased, its color did not lighten.
TDI is an injury that can be missed by emergency, thoracic and general surgery specialists. Interruption of diaphragmatic continuity in the coronal section of thoracic computed tomography is an important sign. Thoracoscopy or laparoscopy should be considered in suspected diaphragmatic injury.

Anahtar Kelimeler

Diaphragmatic injury , Diagnosis , Treatment

Travmatik Diyafragma Yaralanmasının Yönetimi: Retrospektif 19 olgu çalışması

Öz

Travmatik diyafragma yaralanması (TDY) nispeten nadir bir durumdur. Kapsamlı klinik değerlendirme ve görüntüleme incelemesi yapılmazsa yüksek oranda gözden kaçma eğilimi vardır. Bu çalışmanın amacı TDY nedeniyle torasik yolla cerrahi uyguladığımız hastalarda tanı ve tedavi sonuçlarımızı gözden geçirmektedir.
Bu çalışma, son 4 yıl boyunca acil servis ve cerrahi kliniğimize başvuran ve göğüs travması sonrası TDY gelişen ardışık tüm hastaların retrospektif bir vaka serisidir. Hastaların demografik verileri, göğüs yara-lanmasının tipi (künt ve penetran), diyafragma yaralanmasının nedeni, klinik ve radyolojik incelemeleri, intra-operatif bulgular ve komplikasyonları derlenmiştir.
Ağustos 2020 ile Aralık 2024 tarihleri arasındaki kayıtlardan toplam 926 göğüs travmalı hasta elde edilmiştir. Bu 926 hastanın 19'unde (%2,05) TDY vardı. Cerrahi endikasyonları; 8 hastada (%42,1) torakoskopi gerektiren masif hemotoraks, 7 hastada (%36,8) klinik değerlendirme sırasında toraks oskültasyonunda bağır-sak sesinin duyulması ve akciğer grafisi ve kontrastlı bilgisayarlı tomografi incelemelerinde diyafragma yara-lanması bulguları idi. İki hastada (%10,5) şiddetli yan ve omuz ağrısı sonucu çekilen bilgisayarlı tomografinin koronal kesitte diyafragmadaki defektin saptanması, 1 hastada (%5,2) hemopnömotoraksı drene etmek için takılan göğüs tüpünden bağırsak içeriğinin gelmesi, 1 hastada (%5,2) ise göğüs tüpünden gelen drenajın mikta-rının azalmasına rağmen renginin açılmaması idi.
TDY acil, göğüs ve genel cerrahi uzmanları için atlanabilen bir yaralanmadır. Toraks bilgisayarlı to-mografinin koronal kesitinde dayafragmanın devamlılığının kesintiye uğraması önemli bir işarettir. Diyafragma yaralanması şüphesinde torakoskopi veya laparaskopi mutlaka düşünülmelidir.

Anahtar Kelimeler

Diyafragma yaralanması , Tanı , Tedavi

Kaynakça

• 1. Furák J, Athanassiadi K. Diaphragm and trans-diaphragmatic injuries. J Thorac Dis. 2019;11:S152-7.
• 2. Fair KA, Gordon NT, Barbosa RR, Rowell SE, Watters JM, Schreiber MA. Traumatic diaphragma-tic injury in the American College of Surgeons Na-tional Trauma Data Bank: a new examination of a rare diagnosis. Am J Surg. 2015;209:864-8; discus-sion 868-9.
• 3. Waldschmidt ML, Laws HL: Injuries of the di-aphragm. J Trauma. 1980;20:587-92.
• 4. Demetriades D, Kakoyiannis S, Parekh D, Hat-zitheofilou C. Penetrating injuries of the diaphragm. Br J Surg. 1988;75:824-6.
• 5. Schurr LA, Thiedemann C, Alt V, et al. Diaph-ragmatic injuries among severely injured patients (ISS ≥ 16)-an indicator of injury pattern and seve-rity of abdominal trauma. Medicina (Kaunas). 2022;58:10.
• 6. Weber C, Willms A, Bieler D, et al. Traumatic diaphragmatic rupture: epidemiology, associated injuries, and outcome-an analysis based on the TraumaRegister DGU®. Langenbecks Arch Surg. 2022;407:3681-90.
• 7. Kaya S, Altın Ö, Altuntaş YE, Özdemir A, Cesur EE, Bildik N, Küçük HF. Factors affecting mortality in patients with traumatic diaphragmatic injury: an analysis of 92 cases. Ulus Travma Acil Cerrahi Derg. 2020;26:80-5.
• 8. Guth AA, Pachter HL, Kim U. Pitfalls in the diag-nosis of blunt diaphragmatic injury. Am J Surg. 1995;170:5-9.
• 9. Grillo IA, Jastaniah SA, Bayoumi AH, et al. Tra-umatic diaphragmatic hernia: an Asir region (Saudi Arabia) experience. Indian J Chest Dis Allied Sci. 2000;42:9-14.
• 10. Ashy A, Abousteit HH, Salem YA, Badr E, Hassan MI. Laparoscopic versus open repair of posttraumatic diaphragmatic hernia (Saudi expe-rience). Saudi Surgical Journal. 2019;7:128-32.
• 11. Shah R, Sabanathan S, Mearns AJ, Choudhury AK: Traumatic rupture of diaphragm. Ann Thorac Surg. 1995;60:1444-9.
• 12. Matsevych OY. Blunt diaphragmatic rupture: four year's experience. Hernia. 2008;12:73-8.
• 13. Thiam O, Konate I, Gueye ML, Toure AO, Seck M, Cisse M, et al. Traumatic diaphragmatic in-juries: Epidemiological, diagnostic and therapeutic aspects. Springerplus 2016;5:1614.
• 14. Adegboye VO, Ladipo JK, Adebo OA, Brimmo AI. Diaphragmatic injuries. Afr J Med Med Sci 2002;31:149-53.
• 15. Okonta KE, Amadi CE, Okoh PD, Ekwunife CN. Thoracotomy for chest trauma: Indication, operative finding, and outcome. Saudi Surg J 2020;8:180-4.
• 16. Tavakoli H, Rezaei J, Miratashi Yazdi SA, Ab-basi M. Traumatic right hemi-diaphragmatic injury: Delayed diagnosis. Surg Case Rep 2019;6:92.
• 17. Sekusky AL, Lopez RA. Diaphragm trauma. In: StatPearls. Treasure Island (FL): StatPearls Publis-hing; 2021.
• 18. Turhan K, Makay O, Cakan A, Samancilar O, Firat O, Icoz G, et al. Traumatic diaphragmatic rupture: Look to see. Eur J Cardiothorac Surg 2008;33:1082-5.
• 19. Iochum S, Ludig T, Walter F, Sebbag H, Grosdidier G, Blum AG. Imaging of diaphragmatic injury: A diagnostic challenge? Radiographics 2002;22:S103-16; discussion S116-8.
• 20. Beshay M, Krüger M, Singh K, Borgstedt R, Benhidjeb T, Bölke E, et al. Grave thoraco-intestinal complication secondary to an undetected traumatic rupture of the diaphragm: A case report. Eur J Med Res 2021;26:19.
• 21. Gmachowska A, Pacho R, Anysz-Grodzicka A, Bakoń L, Gorycka M, Jakuczun W, et al. The role of computed tomography in the diagnostics of diaphragmatic injury after blunt thoraco-abdominal trauma. Pol J Radiol 2016;81: 522-8.
• 22. Chen HW, Wong YC, Wang LJ, Fu CJ, Fang JF, Lin BC. Computed tomography in left-sided and right-sided blunt diaphragmatic rupture: Experience with 43 patients. Clin Radiol 2010;65:206-12.
• 23. Mehrotra AK, Feroz A, Dawar S, Kumar P, Singh A, Khublani TK. Diaphragmatic rupture pre-cipitated by intercostal chest tube drainage in a patient of blunt thoraco-abdominal trauma. Lung India 2016;33:85-7.
• 24. Silva GP, Cataneo DC, Cataneo AJM. Thora-cotomy compared to laparotomy in the traumatic diaphragmatic hernia. Systematic review and pro-portional. Act Cir Bras 2018;33:49-66.
• 25. Powell L, Chai J, Shaikh A, Shaikh A. Experien-ce with acute diaphragmatic trauma and multiple rib fractures using routine thoracoscopy. J Thorac Dis 2019;11:1024-8.
• 26. Okonta KE. The expected indications for video-assisted thoracoscopy surgery in Sub-Saharan Afri-ca. Sub-Saharan J Endosc Proced 2022;1:2.