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Evaluation and management of traumatic diaphragmatic injuries

A Practice Management Guideline from the Eastern Association for the Surgery of Trauma

McDonald, Amy A. MD; Robinson, Bryce R.H. MD; Alarcon, Louis MD; Bosarge, Patrick L. MD; Dorion, Heath MD; Haut, Elliott R. MD, PhD; Juern, Jeremy MD; Madbak, Firas MD; Reddy, Srinivas MD; Weiss, Patricia MLIS; Como, John J. MD

Journal of Trauma and Acute Care Surgery: July 2018 - Volume 85 - Issue 1 - p 198–207
doi: 10.1097/TA.0000000000001924

BACKGROUND Traumatic diaphragm injuries (TDI) pose both diagnostic and therapeutic challenges in both the acute and chronic phases. There are no published practice management guidelines to date for TDI. We aim to formulate a practice management guideline for TDI using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

METHODS The working group formulated five Patient, Intervention, Comparator, Outcome questions regarding the following topics: (1) diagnostic approach (laparoscopy vs. computed tomography); (2) nonoperative management of penetrating right-sided injuries; (3) surgical approach (abdominal or thoracic) for acute TDI, including (4) the use of laparoscopy; and (5) surgical approach (abdominal or thoracic) for delayed TDI. A systematic review was undertaken and last updated December 2016. RevMan 5 (Cochran Collaboration) and GRADEpro (Grade Working Group) software were used. Recommendations were voted on by working group members. Consensus was obtained for each recommendation.

RESULTS A total of 56 articles were used to formulate the recommendations. Most studies were retrospective case series with variable reporting of outcomes measures and outcomes frequently not stratified to intervention or comparator. The overall quality of the evidence was very low for all Patient, Intervention, Comparator, Outcomes. Therefore, only conditional recommendations could be made.

CONCLUSION Recommendations were made in favor of laparoscopy over computed tomography for diagnosis, nonoperative versus operative approach for right-sided penetrating injuries, abdominal versus thoracic approach for acute TDI, and laparoscopy (with the appropriate skill set and resources) versus open approach for isolated TDI. No recommendation could be made for the preferred operative approach for delayed TDI. Very low-quality evidence precluded any strong recommendations. Further study of the diagnostic and therapeutic approaches to TDI is warranted.

LEVEL OF EVIDENCE Guideline; Systematic review, level IV.

From the Case Western Reserve University (A.A.M., J.J.C.), Cleveland, Ohio; University of Washington (B.R.H.R.), Seattle, Washington; University of Pittsburgh (L.A., P.W.), Pittsburgh, Pennsylvania; University of Alabama (P.L.B.), Birmingham, Alabama; Northeastern Ohio Medical University (H.D.), Youngstown, Ohio; Johns Hopkins University (E.R.H.), Baltimore, Maryland; Medical College of Wisconsin (J.J.), Milwaukee, Wisconsin; University of Florida Jacksonville (F.M.), Jacksonville, Florida; and Albert Einstein College of Medicine (S.R.), New York, New York.

Submitted: January 2, 2018, Accepted: January 8, 2018, Published online: April 3, 2018.

All authors are from the Department of Surgery at said institutions except for P.W. who is from Health Sciences Library System (University of Pittsburgh).

Presented at: The Eastern Association for the Surgery of Trauma 30th Annual Scientific Assembly, January 10–14, 2017, Hollywood, Florida.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Address for reprints: Amy A. McDonald, MD, Louis Stokes Cleveland VA Medical Center, 10701 East Blvd, Surgery 112(W), Cleveland, OH 44106; email:

© 2018 Lippincott Williams & Wilkins, Inc.