Federal Scientific Clinical Center of Miners’ Health Protection, 

Leninsk-Kuznetsky, Russia

 

Diagnostics and treatment of diaphragm injuries present an unsolved issue in emergency surgery. This pathology is a relatively rare and poorly studied, but is one of the most severe injuries in patients with closed thoracic and abdominal injuries [1, 2, 3]. This injury type is characterized with specific clinical severity, difficulty of timely diagnostics, complexity of treatment and high mortality (19.4-28 %) [4, 5, 6].

The difficulties of timely diagnostics are conditioned by multiple symptoms of clinical course, severity of patients’ state, absence of specific symptoms of diaphragmatic injuries, concomitant injuries to the chest and abdomen [7, 8].

 

Objective ? to assess incidence, injury location, diagnostics and treatment of diaphragmatic injuries in patients with polytrauma.

 

MATERIALS AND METHODS

The research data was obtained from the computerized database for polytrauma after approval from the ethical committee of Clinical Center of Miners’ Health Protection.

During 1999-2013 2,056 patients with polytrauma were treated in Clinical Center of Miners’ Health Protection. Thoracic and abdominal injuries were diagnosed in 567 (27.6 %) patients. A diaphragmatic injury was diagnosed in 76 patients: 3.7 % of all patients with polytrauma. This rate was 13.4 % in the group of the patients with thoracic and abdominal injuries. There were 55 (72.4 %) men and 21 (17.6 %) women. The mean age was 37.1 ± 3.90 (table 1). 

Table 1
The characteristics of patients with diaphragm injury in polytrauma (n = 76)

 Traumatic shock of degrees II-III was diagnosed in all patients at admission (APACHE-III > 80), with approximate blood loss of 1,200-2,500 ml (20-50 % of total blood volume). Individual estimation of blood loss was carried out in relation to the sum of external and internal blood loss with consideration of approximate blood loss after fractures.   

 The inclusion criteria for the study program were age of 16-65, a diaphragmatic injury, ISS > 30, blood loss > 20 % of total blood volume. The patients with severe isolated, potential life-threatening injuries were excluded.

In most cases a diaphragmatic injury combined with injuries to abdomen (65.8 %), the head (61.8 %), extremities (57.9 %) and the chest (56.7 %) (table 1).

43 patients (56.5 %) were admitted to the hospital immediately after an injury (within 4 hours). Transportation was carried out from an accident site with ambulance cars. 23 patients (43.5 %) were transported with a reanimobile by the day-and-night duty teams from other regional hospitals. Transportation was performed within 1-5 days after an injury.

All patients received emergent procedures according to vital signs during the first 24 hours after admission.

A diaphragmatic injury was diagnosed on the basis of clinical and instrumental examination.

The scheme of treatment for patients with a diaphragmatic injury and polytrauma included diagnostic and surgical measures for early diagnostics of injuries, optimal terms, sequence of surgical interventions and intensive care.

The standard surgical tactics included operations (laparoscopy, laparotomy, thoracoscopy, thoracotomy), stabilization of bone fractures in case of locomotor injuries, application of burr holes and trepanations in case of traumatic brain injuries.

Surgical measures supplemented full intensive care with respiratory support with PEEP mode. Artificial lung ventilation was performed for all patients.

The analysis included demographics (age, gender, injury mechanism) and clinical values (ISS, ALV, ICU stay, duration of hospital treatment, complications, mortality).

The statistical analysis was performed with IBM SPSS Statistics 20. Quantitative variables are presented as M ± m (mean arithmetic ± error in mean). Qualitative signs are presented as absolute and relative (%) values.

 

RESULTS AND DISCUSSION

Non-invasive (radiology, chest CT) and invasive (laparoscopy, laparotomy, thoracoscopy, thoracotomy) diagnostic techniques were used for diagnostics of diaphragmatic injuries in patients with polytrauma (table 2). 

Table 2
Diagnostics of diaphragm injuries and identified concomitant injuries in patients with polytrauma (n = 76)

In 8 (10.5 %) patients a diaphragmatic injury was confirmed with X-ray examination. Among them, only 2 patients had injury prescription less than 4 hours. In remaining 6 patients the injury prescription was 3-14 days. Computer tomography is more informative for diagnostics of diaphragmatic injuries, but its application is limited because of severity of patient’s state in acute period of polytrauma. In our study thoracic and abdominal computer tomography for diagnosing diaphragmatic injuries was performed after eliminating the signs of traumatic shock. According to CT study the diaphragmatic injuries were found in 16 (21.1 %) of the patients on days 2-5 after an injury. According to the literature data [9], the high diagnostic accuracy (up to 100 %) is related only to surgical, invasive diagnostic methods. Laparoscopy and thoracoscopy found diaphragmatic injuries in 44 (57.9 %) of the patients. All patients were transported to the hospital during 4 hours after trauma. Laparoscopy did not diagnose a diaphragmatic injury in 3 patients. Laparotomy found an injury to the left cupula of the diaphragm in 2 patients. Thoracotomy verified an injury to the right cupula of the diaphragm in 1 patient. Relaparotomy identified diaphragmatic injuries in 5 patients of the second group on days 3-5 after an injury. Therefore, invasive techniques (laparotomy and laparoscopy) are most informative for patients with polytrauma. The injuries to pulmonary tissue, the ribs, the liver and the spleen were most common injuries during diagnostic examinations and surgical interventions. The average amount of abdominal and thoracic injuries was 2.62 ± 0.03 per patient.

Surgical interventions for diaphragmatic injuries and polytrauma were performed for 36 patients with a diaphragm rupture (table 3).

Table 3
The types of surgical interventions in patients with ruptured diaphragm in polytrauma (n = 36)

In 2 patients after their transition to independent breathing on days 5-7 the injuries to the left cupula of the diaphragm were found at the site of hematoma (two-stage ruptures). These patients received emergent surgery. The choice of surgical approach was individual and it depended on the characteristics of thoracic and abdominal injuries. Laparotomy approach was used for 29 (90.5 %) patients, thoracotomy approach ? for 7 (19.5 %). Consequent realization of laparotomy and thoracotomy was used for 2 patients with injuries to the right cupula of the diaphragm; laparotomy approach was not appropriate for sealing the injuries. For the identified diaphragm defects we used interrupted sutures with non-absorbable suture material and creation of duplication ? 15 (41.7 %) of the patients (Fig. 1, 2, 3). In case of small defects of the diaphragm (< 5 cm) and impossibility of duplication creation we used continuous sutures with non-absorbable suture material ? 19 (52.7 %) patients (Fig. 4, 5). Mesh grafts were used for two cases: an injury to the right cupula of the diaphragm and high risk of inconsistent diaphragmatic suture (table 3). The surgical approach was carried out by means of anteriolateral thoracotomy to the right.

Figure 1

The X-ray picture of an injury to the right diaphragm cupula with impaction of the right lobe of the liver

 

Figure 2                                                                                     Figure 3

The surgical view of the disruption of the right diaphragm     Suturing the right diaphragm cupula by means of duplication

 cupula                              

                                              

 Figure 4                                                                                   Figure 5

The rupture of the left diaphragm cupula                                Suturing the left diaphragm cupula with continuous suture

                                    

There were no intrasurgical complications. The postsurgical period included mostly inflammatory complications ? posttraumatic pneumonia and pulmonary infiltrations, exudative pleuritis. 39.4 % of the patients had systemic complications ? acute respiratory distress syndrome and multiple organ insufficiency. The total mortality was 21 % (16 patients). During 24 hours after an injury the mortality was conditioned by extraabdominal injuries. The causes of late lethal outcomes (> 5 days) were systemic complications (table 4). Bleeding was the most common cause of early death (66 %). The main causes of late death were head injury (39.1 %) and multiple organ insufficiency (47.1 %).

Table 4
The characteristics of clinical values in patients with diaphragm injuries with polytrauma (n = 76)

 

CONCLUSION

Therefore, diaphragmatic injuries were diagnosed in 3.7 % of all patients with polytrauma. In the group of patients with thoracic and abdominal injuries this rate was 13.4 %. Road traffic accidents were the causes of injuries in 71 %. Invasive methods are most informative for diagnostics of diaphragmatic injuries in patients with polytrauma. Laparoscopy and thoracoscopy found diaphragmatic injuries in 57.9 % of the patients. In 80.5 % of the cases suturing for a diaphragm injury was realized with laparotomy approach. The total mortality was 21 % and was conditioned by decompensated blood loss in early posttraumatic period and systemic complications in late period.