BLUNT AND PENETRATING RUPTURES OF THE DIAPHRAGM

The difficulties in diagnosis of diaphragmatic herniation in the first admission are the common causes of morbidity and mortality. Inadequacy of diagnostic procedures and the severity of additional injured visceras are the main factors of morbidity and mortality. From 1990 to 1996,24 patients with penetrating injury and 15 patients with blunt injury were treated at department of General Surgery, School of Medicine, University of Çukurova. All of the patients with penetrating injury (Group 1) and 12 with blunt injury (Group 2) required emergency laparotomy. In the remaining 3 patients (Group 3), the diagnosis of diaphragmatic injury was delayed from 12hours to 12 years after injury. The vast majority of the Group 1 and Group 2 patients had injury to other organs, the diagnosis of diaphragmatic injury was made in almost all of them during emergency laparotomy. The diagnosis in Group 3 patients was made by chest roentgenogram alone or computed tomography. All diaphragmatic injuries repaired primarily except one which was repaired with prolene mesh. One of the Group 1 patients died, a mortality of %04, and 2 of the Group 2 patients died, a mortality of %16.6. All Group 3 patients recovered. This study suggests that diaghragmatic injury should be suspected in all patients with penetrating as well as blunt injury of the chest and abdomen. The presence of such an injury should be excluded before the termination of the exploratory procedure. The need for diagnosis of diaphragmatic herniation during the initial admission is emphasised. Also, diaphragmatic injury should be suspected in patients with roentgenographic abnormalities of the diaphragm and lower lung field following trauma. The presence of diaphragmatic injury in such patients should be excluded with appropriate diagnostic studies to protect the patient from its late complications.

PENETRAN VE KÜNT DÝYAFRAGMA RÜPTÜRLERÝ

Travmatik diyafragma rüptürlerinin ilk baþvuru anýndaki taný güçlüðü, morbitide ve mortaliteyi arttýran en önemli nedendir. Erken tanýdaki güçlük, taný yöntemlerinin yetersizliði ve ek organ yaralanmalarýna baðlý oluþan klinik tablonun diyafgrama rüptürünü gizlemesine baðlýdýr. Bu çalýþmada, 1990-1996 yýllarý arasýnda Çukurova Üniversitesi Týp Fakültesi Kliniðinde 24 penetren diyafragmatik rüptür (Grup 1), 12 künt travmatik diyafragmatik rüptür taný ve tedavisi 12 saat ile 12 yýl geciken 3 olgu (grup 3) retrospektif olarak deðerlendirilmiþtir. Grup 1 ve Grup 2'deki olgularýn büyük çoðunluðunda ek organ yaralanmasý saptanmýþ ve taný tümünde laparotomi sýrasýnda konulmuþtur. Prolen mesh kullanýlan bir olgu dýþýnda konulmuþtur. Grup 3'teki olgularýn tanýsý akciðer ve bilgisayarlý tomografi ile konulmuþtur. Prolen mesh kullanýlan bir olgu dýþýnda, bütün diyafragmatik rüptürler primer olarak onarýlmýþtýr. Grup 1'de 1 olgu kaybedilmiþ,mortalite % 4; Grup 2'de 2 olgu kaybedilmiþ,mortalite%l6.6 olarak bulunmuþtur. Grup 3'teki olgularda ise mortalite oluþmamýþtýr. Bu çalýþmanýn amacý, göðüs ve karýn travmalý olgularda künt travmada olduðu gibi penetran yaralanmalarda da diafragma rüptürünü düþünmek gerektiðini vurgulamaktadýr. Eksplorasyon tamamlanmadan önce diyafragma rüptürü ekarte edilmelidir. Ayný zamanda, travmayý takiben akciðer grafisinde akciðer bazalinde ve diyafragma sýnýrýnda düzensizlik saptanan olgular, diyafragma rüptürü yönünden araþtýrýlmalýdýr. Diyafragma rüptürlü olgularda uygun tanýsal yaklaþýmlar hastayý geç dönem komplikasyon geliþiminden koruyabilir.