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Evolution in the management of traumatic diaphragmatic injuries: A multicenter review

Ties, Jill S. MD; Peschman, Jacob R. MD; Moreno, Andres MD; Mathiason, Michelle A. MS; Kallies, Kara J. MS; Martin, Ronald F. MD; Brasel, Karen J. MD; Cogbill, Thomas H. MD

Journal of Trauma and Acute Care Surgery:
doi: 10.1097/TA.0000000000000140
Original Articles
Abstract

BACKGROUND: Traumatic diaphragmatic injury (TDI) is uncommon and has historically been identified by chest x-ray and repaired by laparotomy with nonabsorbable suture. Blunt TDI was more frequently (90%) detected on the left. With advances in imaging and operative techniques, our objective was to evaluate evolution in incidence, location, and management of TDI.

METHODS: The medical records of patients admitted to three Wisconsin regional trauma centers with TDI from 1996 to 2011 were reviewed. Patients were stratified into blunt and penetrating injury and early (1996–2003) and recent (2004–2011) periods. p < 0.05 was significant.

RESULTS: A total of 454 patients was included, 87% were men. Median Injury Severity Score (ISS) was 22 and 19 in the early and recent periods, respectively. Diagnostic modality for TDI did not change over time when comparing chest x-ray, computed tomography, or intraoperative diagnosis for blunt (p = 0.214) or penetrating (p = 0.119) TDI. More right-sided penetrating TDI were identified in the recent versus early group (49% vs. 27%). Perihiatal injury was rare (2%). Minimally invasive repairs increased in the recent versus early group of penetrating TDI (5.8% vs. 0.9%, p = 0.040). Complex repairs (mesh, transposition) were required in only three patients. In-hospital mortality was 15% and 4% for blunt and penetrating TDIs, respectively (p < 0.001).

CONCLUSION: A large increase in the frequency of both blunt and penetrating TDIs in our region was documented. While no difference was observed regarding diagnosis of blunt TDI during the two study periods, our data show a change from historical reports; more injuries were detected by computed tomography. An increase in right-sided penetrating TDI was also observed. A small but previously unreported incidence of perihiatal/pericardial injury occurred with both blunt and penetrating TDIs. While the majority of injuries were repaired with laparotomy, minimally invasive repairs were used more frequently in the recent period.

LEVEL OF EVIDENCE: Epidemiologic study, level III. Therapeutic study, level IV.

Author Information

From the Department of Medical Education (J.S.T.), Gundersen Medical Foundation; Department of Research (M.A.M., K.J.K.), Gundersen Medical Foundation; and Department of General and Vascular Surgery (T.H.C.), Gundersen Health System, La Crosse; Departments of Medical Education (J.R.P.) and Surgery (K.J.B.), Medical College of Wisconsin, Milwaukee; Departments of Medical Education (A.M.) and Surgery (R.F.M.), Marshfield Clinic, Marshfield, Wisconsin.

Submitted: August 12, 2013, Revised: November 18, 2013, Accepted: November 21, 2013.

Address for reprints: Thomas H. Cogbill, MD, Department of General and Vascular Surgery, Gundersen Health System, 1900 South Ave, C05-001, La Crosse, WI 54601; email: thcogbil@gundersenhealth.org.

© 2014 Lippincott Williams & Wilkins, Inc.