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Vol. 12. Issue 3.
Pages 225-239 (May - June 2006)
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Vol. 12. Issue 3.
Pages 225-239 (May - June 2006)
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Traumatic diaphragmatic hernias: Retrospective analysis
Hérnias diafragmáticas traumáticas: Revisão casuística
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474
J.P.A. Sousa1, J.P. Baptista2, L. Martins3, J. Pimentel4,5
1 Assistente Hospitalar Graduado/Graduate Hospital Assistant, Hospitais da Universidade de Coimbra
2 Assistente Hospitalar/Hospital Assistant, Hospitais da Universidade de Coimbra
3 Interno Complementar de Cirurgia Geral/General Surgery Intern, Hospitais da Universidade de Coimbra
4 Director de Serviço/Head of Department, Hospitais da Universidade de Coimbra
5 Serviço de Medicina Intensiva – Hospitais da Universidade de Coimbra
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Abstract
Aims

This study classifies cases of traumatic diaphragmatic hernias (TDH) in patients admitted to the Intensive Care Unit (ICU) of the Coimbra University Hospitals (HUC) from 1990 to 2004.

Methods

Retrospective analysis of 34 cases of TDH, studying anatomical location, place and time of diagnosis, complementary tests aiding diagnosis, herniated organs, associated traumatism, morbidity and mortality.

Results

Twenty-eight male and six female patients with an average age of 40.5 years±20.5, average SAPS score 38.8. Average lenght of stay was 19.1±13.6 days, all suffered from closed traumatism and were put on artificial ventilation. The left-side diaphragm was more frequently affected (94.1%) then the right. Diagnosis in 19 cases was made up in the first six hours following the diagnosis of traumatism, in four cases within 12 hours and in the remaining cases between 48 hours and 16 years after traumatism. In 13 patients the diagnosis was established intra-operatively. The stomach was typically one of the herniated organs. The most frequently associated lesions at the thoracic level were pulmonary contusion, haemothorax and pneumothorax, and at the abdominal level, haemoperitoneum and splenic lesion. The rates for complications and mortality were 55.8% and 11.7% respectively.

Conclusions

TDH mainly occurs on the left side through closed thoraco-abdominal trauma following road traffic accidents. This group of patients, on average younger than others admitted to ICU, presents a longer average hospitalisation period, but has lower rates of mortality and lower SAPS severity scores. The most commonly herniated organ was the stomach and the most frequently encountered lesions were cranial-encephalic, splenic and pleural traumatisms. Pre-operative diagnosis of diaphragmatic injuries is difficult and a high index of clinical suspicion is needed after thoracoabdominal trauma. This diagnosis should always be considered a possibility in cases of closed thoraco-abdominal traumas.

Key-words:
Blunt trauma
trauma
chest trauma
rupture of diaphragm
abdominal trauma
penetrating trauma
visceral herniation
mechanical ventilation
Resumo
Objectivos

Os autores propuseram-se realizar uma revisão e caracterização dos casos de hérnias diafragmáticas (HD) traumáticas internados no Serviço de Medicina Intensiva dos Hospitais da Universidade de Coimbra (SMI-HUC) de 1990 a 2004.

Material e métodos

Análise retrospectiva de 34 casos de HD traumática, tendo em atenção a localização anatómica, o local e o momento do diagnóstico, os exames complementares que permitiram o diagnóstico, os órgãos herniados, os traumatismos associados, a morbilidade e a mortalidade.

Resultados

Vinte e oito doentes eram do sexo masculino e 6 do feminino, com média de idades de 40,2±20,5 anos; o valor médio do SAPS foi de 38,8. A duração média de internamento foi de 19,1±13,6 dias, todos sofreram traumatismo fechado e foram submetidos a ventilação artificial. A hérnia localizava-se à esquerda em 94,1% dos casos. O diagnóstico em 19 dos casos foi efectuado até 6 horas após o traumatismo, em 4 casos até às 12 horas, e os restantes entre 48 horas e 16 anos após o traumatismo. Em 13 doentes o diagnóstico foi intra- operatório. Dos órgãos herniados, o estômago estava presente na maioria da situações. As lesões associadas mais frequentes foram, a nível torácico, a contusão pulmonar, o hemotórax e o pneumotórax, e a nível abdominal o hemoperitoneu e a lesão esplénica. A taxa de complicações e de mortalidade foi 55,8% e de 11,7%, respectivamente.

Conclusões

A HD ocorreu maioritariamente à esquerda por traumatismo toraco-abdominal fechado na sequência de acidente de viação. Este grupo de doentes, em relação aos valores médios do Serviço, era mais jovem, apresentava maior duração média de internamento, apresentando, no entanto, menores taxa de mortalidade e índice de gravidade (SAPS). O órgão herniado mais frequente foi o estômago, e as lesões associadas mais encontradas foram os traumatismos crânio-encefálico, esplénico e pleuro-costal. A dificuldade de diagnóstico pré-operatória continua a requerer elevado grau de suspeição, exigindo-se sempre a colocação desta hipótese de diagnóstico no contexto de traumatismos toraco-abdominais fechados.

Palavras-chave:
Trauma
trauma torácico
trauma abdominal
ruptura diafragmática
traumatismo fechado
traumatismo aberto
hérnia diafragmática
ventilação mecânica
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Copyright © 2006. Sociedade Portuguesa de Pneumologia
Pulmonology
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