MISTAKES IN DIAGNOSIS AND TREATMENT OF RUPTURE OF DIAPHRAGM IN PATIENTS WITH CLOSED COMBINED TRAUMA OF THORAX AND ABDOMEN

S.A. ALIYEV, B.M. ZEYNALOV, N.A. ZEYNALOV, N.M. KHIDIROVA

Azerbaijan Medical University, Baku, AZERBAIJAN

The problem of topical diagnosis and surgical tactics in rupture of diaphragm in patients with closed combined thoracic and abdominal trauma is relevant because of difficulty in-time recognition of this injury, high rate of diagnostic and tactic mistakes causing mortality as high as 19.4 – 28 %.

Aim of the study: To analyze the causes of diagnostic and tactic mistakes committed in rupture of diaphragm in patients with closed combined trauma of thorax and abdomen.

Material and methods: In the I Department of Surgical Diseases of Azerbaijan Medical University 32 patients have been managed because of severe closed combined trauma of thorax and abdomen complicated with the rupture of diaphragm. 26 of patients were males, 6 – females, age varied from 18 to 63 years. The diagnostic protocol included X-ray, ultrasonography, CT scan and endoscopic investigation. Among 32 patients the injury of 2 anatomic regions (thorax and abdomen) was diagnosed in 16 (50%) patients, 3 anatomic regions (scull, thorax and abdomen) in 12 (37.5%), 4 anatomic regions (thorax, abdomen, pelvis and lower extremities) in 4 (12.5%) patients. The rupture of diaphragm was diagnosed preoperatively in 8 (23.7%) patients. In 11 (34.4%) patients the clinical presentation of closed combined thoracoabdominal injury included the signs of intraabdominal and/or intrapleural bleeding. The deterioration of condition of 10 (31.2%) patients with severe craniocerebral injury and prolonged pulmonary ventilation after the extubation and change to spontaneous respiration with the progress of “dislocation syndrome” allowed to suspect the rupture of diaphragm later proved by instrumental investigations. In 1 patient with undiagnosed isolated left side rupture of diaphragm lead to formation of post-traumatic (false) hernia of diaphragm with following strangulation of the abdominal organs dislocated into the thorax.

Results: Urgent operations were carried out in 14 patients during first 24 hours. In 7 patients the surgery was conducted within 24 – 38 hours. On the 5-th day were operated 6 patients, on the 7-th day 3, and on the 12-th day 2 patients. In 1 patient with injury of 4 anatomic regions who died 2 hours after the admission to hospital the rupture of diaphragm was diagnosed at autopsy. Among the operated patients the left side rupture of diaphragm was diagnosed in 29 patients, and right side rupture of diaphragm in 2 patients. The dislocation into the pleural cavity of stomach was detected in 15 patients, stomach and transverse colon in 5, stomach, transverse colon and greater omentum in 4, stomach and spleen in 2, stomach and greater omentum in 2, liver in 1, liver and stomach in 1 patient. 7 (20.6%) of 32 patients have died. The causes of death were severe shock and multiorgan failure.

Conclusion: The main causes of difficult in-time diagnosis of rupture of diaphragm in patients with closed combined thoracoabdominal injuries have to do with unclear clinical presentation of the rupture, severe polytrauma and less informative methods of X-ray based investigations. High mortality rate related to delayed diagnosis and surgical treatment dictates the necessity of optimization and improvement of methods of examination of patients with severe combined injury of thorax and abdomen.

Date: 2014-12-28; view: 891