MANAGEMENT OF ACUTE TRAUMATIC DIAPHRAGMATIC RUPTURE
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The aim of this work is to describe the diagnostic and therapeutic work-up for the management of 13 blunt trauma cases with acute traumatic diaphragmatic rupture (TDR) in a single institution. This study was conducted at King Saud Hospital (350 beds), Al-Qassim Region, Saudia Arabia All patients were resuscitated and underwent emergency chest xray examination, abdominal ultrasonography (US) and thoraco-abdominal CT. After hernodynamic stabilization, patients underwent exploratory laparotomy through a midline incision to deal with injuries including repair of the diaphragmatic rupture. The study included 13 patients; 11 males & 2 females with a mean age of 38.6+7.6 years. Admission chest x-ray defined 5 cases with TDR; 4 left and one right rupture with a sensitivity rate of 38.5%. Preoperative CT scan was conclusive in 10 cases (including the five cases suggested by chest X-ray) with a sensitivity rate of 76.9%. There was a significant increase (X2=3.26, p<0.05) of diagnostic sensitivity with CT in comparison to chest x-ray. Concomitant injuries included liver laceration (n=2), splenic rupture (n=3), bowel injury (n=2), pelvic fractures (n = 4), rupture bladder (n=2), intracerebral hemorrhage (n=2); and traumatic left below knee amputation in one case, either as a solitary injury or in combination. In all cases the diaphragmatic defect was identified, herniated organs were gently reduced and the diaphragmatic defect was repaired using monofilantent non-absorbable sutures and chest cavity was drained. Abdominal exploration showed isolated diaphragmatic tear without herniating viscera in 3 (23.1%) cases, herniated stomach in 6 (46.2%) cases, herniated omentwn in 3 (23.1%) cases, herniated dome of the right lobe of the liver in one (7.7%) case, herniated spleen in 3 (23.1%) cases and herniated colon in one (7.7%) case, either alone or in combirtadon. Nine cases hail linear diaphragmatic defect 2 cases had a V-shaped defect, one case had irregular laceration of the diaphragmatic copula and one case had a Y-shaped defect Two patients died throughout the postoperative follow-up period with a mortality rate of 15.4%. It could be concluded that TDR should be suspected in all thoraco-abdorninal trauma and to be looked for during surgical exploration irrespective of the results ' of preoperative investigations. Chest radiographs and helical CT are the best screening tests for diagnosis of TDR.