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"Spontaneous" and Traumatic Rupture of the Diaphragm: Long-Term Results SZABOLCS M. BEKASSY, M.D., KAMAL S. DAVE, M.D., GEOFFREY H. WOOLER, M.D., MARIAN 1. IONESCU, M.D. TRAUMATIC RUPTURE of the diaphragm is usually caused by stab wounds or crush injuries to the chest and abdomen.

1 "Spontaneous" and Traumatic Rupture of the Diaphragm: Long-Term Results SZABOLCS M. BEKASSY, M.D., KAMAL S. DAVE, M.D., GEOFFREY H. WOOLER, M.D., MARIAN 1. IONESCU, M.D. TRAUMATIC RUPTURE of the diaphragm is usually caused by stab wounds or crush injuries to the chest and abdomen. It is becoming more common due to an increase in road accidents and violent trauma. On the other hand "spontaneous" rupture of the diaphragm is extremely rare. Only two cases, to our knowledge, have been reported so far, and one is from this department.8'23 Long-term results of the surgical repair of ruptured diaghragm have been published by only a few authors.'2,19 The purpose of this paper is to report our experience with 14 patients with traumatic and five with "spontaneous" rupture of the diaphragm, and to discuss the important diagnostic aspects, the surgical management and the long-term results. Clinical Material Nineteen patients with ruptured diaphragms have been seen in this hospital between 1940 and There were 17 males and two females. Their ages ranged from seven to 66 years with an average of 41 years. All had rupture of the left side of the diaphragm. Fourteen patients had a history of trauma (four had bullet wounds and ten crush injuries). Five other patients were considered to have sustained "spontaneous" rupture. In four rupture occurred after sudden severe exertion without direct or indirect trauma to the chest or abdomen (in one while lifting a wardrobe, in another after a severe twisting movement, and in two others during heavy physical work in a mine). In the fifth patient, rupture of the Submitted for publication January 25, Reprint requests: M. I. Ionescu, Department of Cardio-thoracic Surgery, The General Infirmary, Leeds, Great Britain. From the Department of Cardio-thoracic Surgery, The General Infirmary at Leeds and Leeds University, Leeds, Great Britain diaphragm occurred after a severe bout of coughing 6 days after left pneumonectomy. Of the 14 patients with traumatic rupture, the diagnosis was made in three immediately following injury, while in 11 there was a delay of from 1 to 36 years. In half of the patients with traumatic rupture the correct diagnosis was made more than 5 years after injury. Of the five patients with "spontaneous" rupture of the diaphragm, only one was diagnosed within 3 days of the onset of symptoms. In the remainder, although the onset of symptoms was sudden, they subsided and a long symptom-free period followed. The diagnosis in these patients was established between 9 months and 4 years after the onset of symptoms. Clinical Findings In the traumatic group, dyspnea, epigastric and/or subcostal pain and dyspepsia were the most common presenting symptoms, while in the "spontaneous" group nausea, vomiting, epigastric pain and left-sided shoulder pain were more often encountered (Table 1). In the traumatic group, five patients had diminished air entry over the left hemithorax, one had audible intestinal sounds in the chest, and another had surgical emphysema following fractured ribs. Nine patients of the traumatic group had associated injuries which are summarized in Table 2. In the "spontaneous" group physical examination had revealed no abnormal findings attributable to the ruptured diaphragm in three patients. Signs of upper intestinal obstruction were found in one patient and in 320

Vol. 17 7 * No. 3 TABLE 1. Presenting Symptoms in 14 Patients with Traumatic and Five with "Spontaneous" Rutpture of the Diaphragm.

2 Vol * No. 3 TABLE 1. Presenting Symptoms in 14 Patients with Traumatic and Five with "Spontaneous" Rutpture of the Diaphragm. Traumatic Rupture TRAUMATIC RUPTURE OF THE DIAPHRAGM 321 "Spontaneous" Rupture Epigastric pain 10 3 Dyspnoea 10 1 Left sided subcostal pain 9 Dyspepsia 7 Loss of weight 4 1 Nausea and vomiting 2 4 Respiratory distress 3 1 Left sided shoulder pain 2 3 Acute intestinal obstruction 1 2 Cardio-circulatory shock 2 Dysphagia 2 Melena 1 Gurgling noises in the chest 1 TABLE 3. Radiological Findings in 14 Patients with Traumatic and Five with "Spontaneous" Rupture of the Diaphragm Plain Chest Radiographs-19 Traumatic "Spontaneous" patients Rupture Rupture Displacement of the heart and mediastinum to the right 6 2 Elevated diaphragm on the left side 3 Bowel shadows in the left hemithorax 2 1 Atelectasis of the left lower lobe 3 1 Left pleural effusion 4 1 Right pleural effusion 1 Left pneumothorax 3 Right pneumothorax 3 Opacity suggesting tumour of the left lower lobe 1 Contrast Radiologic Examination-14 patients Stomach in the left hemithorax 9 2 Colon in the left hemithorax 6 another one there had been signs of struction and fluid in the left pleural large bowel obcavity. Radiological Findings Plain X-rays of the chest showed some abnormality in all 19 patients but only in two was a definite diagnosis made by this examination. Suspicion of the lesion was confirmed in 14 cases by contrast radiographic studies (Table 3). In three patients the correct diagnosis was not made until operation (one patient with spontaneous rupture of the diaphragm following pneumonectomy had been first diagnosed as volvulus of the stomach; another was thought to have a volvulus of the stomach also; and in the third patient the lesion was mistaken for a left lower lobe tumor. Operative Findings Eighteen patients have had operative repair of the ruptured diaphragm. One patient, who is now 76 years old, refused operation. She is being followed regularly in the outpatient clinic. A left thoracotomy was used in 16 patients and a left thoracoabdominal approach in two. All 18 patients had rupture of the left diaphragm. In the traumatic group three had lesions in the muscular portion and ten in the tendinous portion, while in the "spontaneous" group all five had tears in the tendinous part of the diaphragm. In one of the traumatic cases the tear extended from the central tendon into the pericardial sac, opening it TABLE 2. Associated Lesions in Nine Patients with Traumatic Rupture of the Diaphragm Fracture of the skull, cerebral commotion 1 Fractured ribs on one or both sides and pneumothorax 3 Multiple fractures of extremities 5 Fractured pelvis 3 widely. The left lobe of the liver had herniated and had adhered to the epicardium. At operation 9 months after injury the diaphragm had been repaired but the pericardial sac had to be left open due to its retraction. The length of the tears varied from 2.5 to 8 cm. Three patients in each group had circular tears with irregular margins, while the remainder had linear tears. Two of the three patients with "spontaneous" rupture and small circular tears in the diaphragm showed symptoms of intestinal obstruction. The organs which herniated into the pleural cavity are shown in Table 4. In one patient the herniated colon, and in another the jejunum, became gangrenous and required resection. A herniated spleen was removed in one patient. The diaphragmatic rupture was closed with multiple interrupted silk sutures in 15 patients, three of whom also had second layers of continuous catgut suture. Catgut sutures alone were used in three patients. Hospital Mortality There were two postoperative deaths. One patient aspirated gastric contents at the end of the operation and died 6 hours later of bronchopneumonia. The second patient died 3 weeks after resection of the gangrenous colon as a result of empyema and septicemia. TABLE 4. Abdominal Viscera Herniated in the Left Hemithorax Across the Ruptured Diaphragm in 18 Patients Operated Upon Stomach Colon Greater Omentum Ileum Spleen Liver Jej unum

322 Followc-up) Seventeen patients who were discharged from the hospital have been followed for 3 to 26 years (average 14 years). One patient had not been operated upon.

3 322 Followc-up) Seventeen patients who were discharged from the hospital have been followed for 3 to 26 years (average 14 years). One patient had not been operated upon. There have been three late deaths, at 9, 12 and 15 years postoperatively. The cause of these late deaths was myocardial infarction in one patient, carcinoma of the lung in the second and old age in the third. In the patient who died from coronary thrombosis the diaphragm was found to be normal at post-mortem examination. Fourteen patients are alive to date. One who wvas symptom-free 3 years followving repair, cannot be traced. Of the remaining 13 patients BEKASSY, DAVE, WOOLER AND IONESCU 12 are asvmptomatic and one has abdominal pain with no obvious cause. The patient wnho has not been operated upon is alive and well 11 years after injury. Expeerimental Rupture of the Diaplhragm In order to elucidate the cause of the left sided prevalence of diaphragmatic rupture the following experiment was carried out. Diaphragms were taken from the autopsy room, within the first 24 hours of death. The age at time of death of the ten patients varied from 18 to 68 years. Both the right and left leaves of each diaphragm were mounted in turn into a pressure chamber connected to a manometer and a pump. The pressure inside the chamber was progressively increased until rupture of the diaphragm occurred. The results of this artificial rupture of the diaphragm are showvn in Table 5. Discussion The historical aspects of traumatic rupture of the diaphragm have been well documented.,1"620 Most of the war time injuries causing traumatic rupture of the diaphragm are associated with penetrating bullet TABLE 5. Comparison of Pressuires (kp/cm'il) Required to Ruipture the Diaphragm Age at Time of Death Sex Left Leaf Right Leaf Years I 1.26 I 1.12 F 1.19 \ 1.33 W\I W\I AI F A1I \I 0.46 Mean: Standard deviatioin: t: P > 0.3 injuries. However, in one of our patients the rupture of the diaphragm was caused by a crushing injury from a tank. The majority of civilian injuries are abdominal and/or thoracic crushing injurics usually resulting from road traffic accidents. In one of the patients the rupture was caused by a fall from a height. In our series no relationship wnzas found between the site of rupture and the embryologically weak part of the diaphragm in either the trautiatic or the "spontaneous" groups. Blunt and indirect trauma producing a sudden increase in abdominal pressure relative to the intrathoracic pressure results in a gradient across the diaphragm sufficient to rupture it. This theory is supported by the fact that the rupture is more common on the left side than on the right, presumably because the right hemidiaphragm is protected by the liver. In other published works a leftsided rupture is reported to be about eight times as common as a rightsided rupture.6(9, ,13,17. 1 ),.!2a,26,2 Aiiii. Surg. * MIarch 1973 It seems logical to consider the protective role of the liver which may create an even distribution of the pressure forces over the entire hemidiaphragm.24'6 However, our experiments indicate that the left hemidiaphragm is less resistant to pressure than the right. In eight of ten cases the pressure required to rupture the left diaphragm wvas less as compared with the right. However, the difference was not statistically significant. All the "spontaneous" ruptures occurred on the left side. This finding again supports the contention that the left leaf of the diaphragm is weaker than the right. "Spontaneous" rupture of the diaphragm may result from increased transdiaphragmatic pressures. Unequal mechanical stretching of the diaphragm should also be considered as a contributory factor. The diagnosis of traumatic rupture of the diaphragm is difficult because the clinical picture immediately after trauma is masked by other associated injuries.'9"4 In our series these have been fractures of the skull, ribs, extremities or pelvis, some of them resulting in shock and unconsciousness. After an initial period, the clinical features involving the respiratory, circulatory, or alimentary systems may become apparent.1"'26'7"13,'8'22 Some patients later had symptoms resembling chronic pulmonary disease, coronary artery disease, or chronic gastrointestinal lesions. A relatively high proportion of patients had symptoms of acute gastrointestinal obstruction. The time lapse between trauma and the onset of symptoms is probably related to the size of the tear.4 The defect in the diaphragm possibly enlarges with the passage of time as a result of changing pressures in the abdominal and thoracic cavities. This results in progressive herniation of abdominal viscera into the chest.24

Vol. 177 * No. 3 TRAUMATIC RUPTURE OF THE DIAPHRAGM 323 It seems to be more difficult to establish the correct diagnosis in the cases of "spontaneous" rupture as compared with the traumatic ones.

4 Vol. 177 * No. 3 TRAUMATIC RUPTURE OF THE DIAPHRAGM 323 It seems to be more difficult to establish the correct diagnosis in the cases of "spontaneous" rupture as compared with the traumatic ones. The symptoms in patients with "spontaneous" rupture are frequently vague, intermittent, and spread over a long period of time with intervals of excellent health. The patient has to be interrogated carefully as to the association of sudden severe exertion with the onset of symptoms. Symptoms of acute upper intestinal obstruction were seen more often in patients with "spontaneous" rupture as compared with traumatic diaphragmatic rupture. This is probably related to the small size of the tear in these cases. Two out of the three patients who had a small tear were in the "spontaneous" group. Plain chest radiographs were abnormal in all the patients and confirmed the diagnosis in three. In 14 patients the diagnosis was suspected on plain radiographs and confirmed by contrast radiography. Barium swallow X-ray was found to be the most useful diagnostic procedure in both groups. In one patient, however, barium swallow was suggestive of a volvulus of the stomach and the diagnosis of ruptured diaphragm was made at operation. The diagnostic value of radiologic examination is of equal importance in both traumatic and spontaneous rupture of the diaphragm. The differential diagnosis of ruptured diaphragm may be difficult. The diagnosis of pneumothorax is often made first, as it is a common finding after chest injuries.22'25'28 Breathlessness, absence of breath sounds, decreased air entry on the affected side, and in some cases an elevation of the diaphragm may occur in both pneumothorax and rupture of the diaphragm.23 The paralyzed diaphragm of traumatic origin caused by damage to the phrenic nerve is rare but should be excluded. Diagnostic chest aspiration carries the risk of injury to the herniated viscera. Stacker and Korner25 reported two patients in whom gastric contents were aspirated through the thoracic wall. Salomon, Feller and Levy23 reported one case in which the spleen was injured during chest aspiration. In doubtful cases exploration should be performed preferably through thoracotomy. In one of our patients the lesion was missed at laparotomy and the patient returned 3 months later with an incarcerated stomach. Operative repair of the ruptured diaphragm should be carried out in all patients because of the ever present danger of incarceration and its complications. '7"10,21'22'27 However, one patient in this series refused operation and at the present time is 76 years old and asymptomatic. The lower thoracic incision gives an excellent view of the diaphragm and can easily be extended into the abdomen if necessary. Stomach, colon and omentum herniated most commonly. In four patients the liver was also found to have herniated into the chest. In one the left lobe of the liver was found in the pericardial cavity. Associated pericardial rupture is rare. 3,11,17,18,22 In our series it was encountered only once. The patient complained of abdominal pain and shortness of breath on exertion. The use of non-absorbable material is the safest means of repairing the diaphragm. There were two hospital deaths (10.5%). One was due to aspiration of gastric contents into the trachea and bronchial tree; the other death occurred in a severely ill patient with a gangrenous colon in the chest requiring resection. The three late deaths were not related to the diaphragmatic rupture per se. Recurrence after repair is rare.'12'14"5 In our series there has been no recurrence on long-term follow-up study. Except for one patient who had persistent abdominal pain, all the others are asymptomatic three to 26 years after repair of the diapbragmatic rupture. Summary Fourteen patients with traumatic and five with "spontaneous" rupture of the diaphragm are reported. Eighteen had been operated upon. There were two hospital deaths and three late deaths; the latter were not related to the diaphragmatic rupture. The clinical and radiologic features are described. The diagnostic aspects, surgical management, probable mechanism of rupture and some experimental evidence regarding its location are discussed. The long-term results three to 26 years postoperatively are presented. "Spontaneous" rupture of the diaphragm should be suspected in patients with sudden onset of respiratory, circulatory or abdominal symptoms following severe instantaneous effort. Traumatic rupture should be suspected in patients with similar symptoms following injury to the chest or abdomen. The diagnosis depends on adequate radiological examination with accurate selection of the procedure and correct interpretation of the X-ray findings. Acknowledgments We wish to thank Mr. L. A. Catchpole, Mr. R. W. Catchpole and Mr. V. Taide for technical assistance and Mrs. J. Ladley for secretarial help. References 1. Arbulu, A., Read, R. C. and Berkas, E. M.: Delayed Symptomatology in Traumatic Diaphragmatic Hernia with a Note on Eventration. Dis. Chest, 47:527, Balas, A., Drexler, M. and Ratkai, I.: Ober Zwerchfellruptur und Nachfolgende Incarceration. Chirurg, 38:416, Beddingfield, G. W.: Cardiac Tamponade Due to Traumatic Hernia of the Diaphragm and Pericardium. Ann. Thorac. Surg., 6:178, Blades, B.: Ruptured Diaphragm. Am. J. Surg., 105:501, 1963.

324 BEKASSY, DAVE, WOOLER AND IONESCU Ann. Surg. MMarch 1973 5. Bowditch, H.: Diaphragmatic Hernia. Buffalo Med. J., 9: 1, 1853. 6. Carter, B. N., Giuseffi, J. and Felson, B.

5 324 BEKASSY, DAVE, WOOLER AND IONESCU Ann. Surg. MMarch Bowditch, H.: Diaphragmatic Hernia. Buffalo Med. J., 9: 1, Carter, B. N., Giuseffi, J. and Felson, B.: Traumatic Diaphragmatic Hernia. Am. J. Roentgenol., Radium Ther. Nucl. Med.,65:56, Carter, R. and Brewer, L. A.: Strangulating Diaphragmatic Hernia. Ann. Thorac. Surg., 12:281, Dave, K. S., Bekassy, S. M., Wooler, G. H. and Ionescu, M. I.: "Spontaneous" Rupture of the Diaghragm During Delivery. Accepted for publication, Grage, T. B., MacLean, L. D. and Campbell, G. S.: Traumatic Rupture of the Diaphragm. Surgery, 46:669, Hardy, K. J., Hughes, E. S. R. and Cuthbertson, A. M.: Largebowel Obstruction and Rupture of the Diaphragm. Med. J. Aust., 1:684, Heberer, G., Senno, A. and Laur, A.: Traumatische Intraperikardiale Zwerchfellrisse mit Baucheingeweideprolaps. Chirurg., 38:410, Hedblom, C. A.: Diaphragmatic Hernia. J. A. M. A., 85:947, Hollander, A. G. and Dugan, D. J.: Herniation of the Liver. J. Thorac. Surg., 29:357, Hood, R. M.: Traumatic Diaphragmatic Hernia. Ann. Thorac. Surg., 12:311, Lewis, E. A. and Lagundoye, S. B.: Traumatic Diaphragmatic Hernia. West Afr. Med. J., 19:145, Lindskog, G. E.: Some Historical Aspects of Thoracic Trauma. J. Thorac. Cardiovasc. Surg., 42:1, Lucido, J. L. and Wall, C. A.: Rupture of the Diaphragm Due to Blunt Trauma. Arch. Surg., 86:989, Moore, T. C.: Traumatic Pericardial Diaphragnmatic Hernia. Arch. Surg., 79:827, Noon, G. P., Beall, A. C. Jr. and De Bakey, M. E.: Surgical Management of Traumatic Rupture of the Diaphlragm. J. Trauma, 6:344, Riolfi, cited by Hedblom, C. A.: Diaphragmatic Hernia. JAMA, 85:947, Rosolleck, H.: Traumatische Zwerchfellruptur. Med. Welt, 2:141, Samaan, H. A.: Undiagnosed Traumatic Diaphragmatic Hernia. Br. J. Surg., 58:257, Salomon, J., Feller, N. and Levy, MI. J.: A Case of Spontaneous Rupture of the Diaphragmii. J. Thorac. Cardiovasc. Surg., 58:221, Schneider, C. F.: Traumatic Diaphragmatic Hernia. Am. J. Surg., 91:290, Stacker, A. D. and K6rner, K.: Diagnose, Differentialdiagnose und Therapie der Stumpfen Traumatischen Zwerchfellruptur. Hefte Unffallheilkd. 94:230, Sutherland, H. D.: Indirect Traumatic Rupture of the Diaphragm. Postgrad. Med. J. 34:210, Sutton, J. P., Carlisle, R. B. and Stephenson, S. E. Jr.: Traumatic Diaphragmatic Hernia. Ann. Thorac. Surg., 3:136, Wren, H. B., Texada, P. J. and Krementz, E. T.: Traumatic Rupture of the Diaphragm. J. Trauma, 2:117, 1962.

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