Factors affecting mortality in traumatic diaphragm ruptures

BACKGROUND: Traumatic diaphragm ruptures (TDR) are rarely seen. Although TDR does not cause morbidity in the acute period, undiagnosed TDR may cause clinical states, such as herniation, strangulation, pneumonia, pleural effusion, empyema, and cardiac tamponade, which have high morbidity and mortality rates in the late period. This study aims to evaluate the epidemiology, clinical characteristics, diagnosis and treatment methods of TDR encountered in thoracoabdominal trauma and to identify the factors affecting mortality.

METHODS: A retrospective examination was carried out on the patients who were operated in our clinic because of traumatic diaphragm injury between January 2012 and December 2017. Each patient operated because traumatic diaphragm injury was evaluated in respect of age, gender, manner of injury, preoperative examination findings, laboratory test results, imaging methods, time of diagnosis, operation findings, concomitant injuries to other organs, operations performed, length of stay in hospital, the development of postoperative morbidity and mortality, and the calculated Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS).

RESULTS: Between January 2012 and December 2017, a total of 1066 patients were operated in our clinic because of thoracoabdominal trauma, and of 1066 patients, 45 of the patients were determined with TDR. Of the 45 patients, surgery was applied because of penetrating trauma in 32 cases (7 firearms injuries, 25 penetrating cutting injuries), blunt trauma in nine cases, and in four cases, diaphragm rupture was seen to have developed associated with iatrogenic injury during an operation. The most common injuries concomitant to traumatic diaphragm rupture were hemopneumothorax (70%), liver (43%), spleen (32%), colon (20%), stomach (17%) injuries and rib fractures (15%), respectively. Mortality developed in seven (17%) patients; five patients were lost because of hemorrhagic shock intraoperatively or in the early postoperative hours, and two because of multiorgan failure during follow-up in the intensive care unit.

CONCLUSION: In high energy blunt and penetrating thoracoabdominal traumas, diaphragm injuries should be suspected. Factors affecting mortality were found to be the AISS, ISS, number of concomitant organ injuries and the combination with pneumohemothorax.

Travmatik diyafragma yaralanmalarýnda mortaliteye etkili faktör

AMAÇ: Travmatik diyafragma rüptürleri (TDR) nadir görülür. Genellikle akut dönemde morbiditeye neden olmazlar, ancak klinik taný konulamayan tüm TDR’ler geç dönemde herniasyon, strangülasyon, pnömoni, plevral effüzyon, ampiyem, kalp tamponadý ve solunum bozukluklarý gibi morbidite ve mortalitesi yüksek klinik durumlara neden olabilir. Bu çalýþmada travmatik diyafragma rüptürünün epidemiyolojisi, klinik özellikleri, taný, tedavi yöntemleri ve mortalite üzerine etkili faktörleri deðerlendirildi.
GEREÇ VE YÖNTEM: Ocak 2012-Aralýk 2017 tarihleri arasýnda kliniðimizde travmatik diyafragma yaralanmasý nedeni ile ameliyat edilen hastalarýn kayýtlarý geriye dönük olarak incelendi. Travmatik diyafragma rüptürü nedeni ile ameliyat edilen hastalarýn; yaþ, cins, yaralanma þekli, operasyon öncesi muayene bulgularý, laboratuvar tetkikleri, görüntüleme yöntemleri, taný konulma zamanlarý, ameliyat bulgularý, eþlik eden diðer organ yaranlamalarý, yapýlan ameliyatlar, hastane kalýþ süreleri, ameliyat sonrasý dönemde geliþen mortalite ve morbiditeler Abbreviated Injury Scale (AIS) ve Injury Severty Score’larý (ISS) incelendi.
BULGULAR: Ocak 2012–Aralýk 2017 tarihleri arasýnda kliniðimizde torakoabdominal travma nedeniyle 1066 hasta ameliyat edildi ve bu hastalardan 45’ine diyafragma rüptürü tanýsý konuldu. 45 hastanýn 32’sinde penetran travma (7 ateþli silah 25 delici kesici alet yaralanmasý), 9’unda künt travma ve 4 hastada ise kariniçi kitle nedeniyle ameliyat edildiði sýrada oluþan iyatrojenik yaralanma nedenli diyafragma rüptürü geliþtiði görüldü. Travmatik diyafragma rüptürüne en sýk eþlik eden yaralanmalar sýrasýyla hemopnömotoraks (%70), karaciðer (%43), dalak (%32), kolon (%20), mide (%17), ve kot fraktürü (%15) yaralanmalarýydý. Mortalite toplamda yedi (%17) hastada görüldü; beþ hasta hemorajik þok nedeniyle intraoperatif veya ameliyat sonrasý erken saatlerde kaybedilirken, iki hasta yoðun bakým takiplerinde çoklu organ yetersizliði nedeniyle kaybedildi.
TARTIÞMA: Yüksek enerjili künt ve penetran torako-abdominal travmalarda diyafragma rüptüründen þüphelenmek gerekir. Mortalite üzerine etkili faktörler AIS, ISS, eþlik eden organ yaralanmasý sayýsý ve pnömo-hemotoraks birlikteliði olarak bulundu.