Abstract:

Background: the cause of the development of traumatic hernias of the diaphragm is its damage due to open or closed injury In modern conditions, the diaphragm injury is most common trauma in falling from height and car accidents (multiple trauma), and can be unnoticed in againts the background of other injuries.

The dislocation of abdominal organs into the pleural cavity occurs in various, sometimes long, time periods after trauma. This situation is determined by the gradual increase in the size of the defect due to the difference in pressure in the abdominal and pleural cavities.

Aim: was to study the importance of radiodiagnosis of traumatic hernias of the diaphragm.

Materials and methods: two rare clinical cases of traumatic diaphragmatic hernias are presented. In one observation - a woman of 81 years, in the second - a 66 years old man. Results: a woman with a history of trauma as a result of a car accident 10 years ago, basec on a comprehensive survey, revealed posttraumatic hernia of the right half of the diaphragm with a dislocation into the pleural cavity of the small and large intestine.

In the second case report (male), an old rupture of the left half of the diaphragm of unknowr prescription of injury was revealed with the dislocation of the greater part of the intestine and the left kidney

Conclusion. To diagnose traumatic hernias of the diaphragm, a comprehensive examination of patients is necessary. Plain radiography can detect the dislocation of abdominal organs into the pleural cavity, and examination of the gastrointestinal tract with a water-soluble contrast drug is a violation of the passage.

Multi-slice computed tomography (MSCT) in case of such pathology, has a greater importance, because thin sections give the highest resolving power. The construction of multiplanar reformation allows obtaining more complete information on the dislocation of organs, visualizing the defect of the diaphragm and determining its exact localization.

References

1.      Abdominalnaia travma. Rukovodstvo dlia vrachei [Abdominal trauma. Guide-book for doctors](Pod red. A.S. Ermolova). M.: Vidar-M. 2010; 386-399. [In Russ].

2.      Korabelnikov I.D. Travmaticheskie diafragmalnye gryzhi [Traumatic diaphragmatic hernias] (Pod red. V.A. Chernavskogo). M.: Medgiz. 1951; 5-62 [ In Russ].

3.      Borisov A.E., Kubachev K.G., Kukushkin A.V. i dr. Diafragmalnye gryzhi. Diagnostika i khirurgicheskoe lechenie [Diaphragmatic hernias. Diagnosis and surgical treatment.] Vestnik khirurgii im. 1.1. Grekova. 2012; 171 (6): 38-42 [In Russ].

4.      Plekhanov A.N. Khirurgiia travmaticheskikh diafragmalnykh gryzh [Surgery of traumatic diaphragmatic hernias.] Vestnik khirurgii im 1.1. Grekova. 2012; 171(5): 107-110 [In Russ].

5.      Aliev S.A., Bairamov N.Iu., Aliev E.S. Osobennosti diagnostiki i taktiki khirurgicheskogo lecheniia razryvov diafragmy pri zakrytoi sochetannoi travme grudi i zhivota [Features of diagnosis and tactics of surgical treatment of diaphragm ruptures with closed combined injury of chest and abdomen.]. Vestnik khirurgii im. 1.1. Grekova. 2014; 173 (4): 66-72 [In Russ].

6.      Thiam O., Konate I., Gueye M.L. et al. Traumatic diaphragmatic injuries: epidemiological, diagnostic and therapeutic aspects. Springer Plus. 2016; 5 (1): 1614. doi: 10.1186/s40064-016-3291-1.

7.      Al Skaini M.S., Sardar A., Haroon H. et al. Traumatic diaphragmatic hernia: delayed presentation with tension viscerothorax - lessons to learn. Ann R Coll Surg Engl. 2013; 95 (2): 27-29. doi: 10.1308/ 003588413X 13511609955337.

8.      Fischer N.J., Aiono S. Delayed presentation of a traumatic diaphragmatic hernia presenting as a large bowel obstruction: a case report. ANZ J Surg. 2016; 86 (1-2): 9798. doi: 10.1111/ans.125968.

9.      Kubachev K.G., Kukushkin A.V, Zaitsev D.A. Diagnostika i khirurgicheskoe lechenie ushchemlennykh diafragmalnykh gryzh [Diagnosis and surgical treatment of strangulated diaphragmatic hernias.]. Vestnik SPbGU. 2012; Ser. 11. Vyp. 1: 89-97 [In Russ].

10.    Chikinev Iu.V., Drobiazgin E.A. Posttravmaticheskie diafragmalnye gryzhi (diagnostika i lechenie) [Post-traumatic diaphragmatic hernia (diagnosis and treatment).]. Acta Biomedical Scientifica. 2017; 2 (6): 163-166. [In Russ].

11.    Aissa A., Hassine A., Hajji H. et al. Complication rare d'une hernie diaphragmatique gauche post-traumatique. Rev Pneumol Clin. 2013; 69(6): 331-335. doi: 10.1016/j.pneumo.2013.04.006.

12.    Hajong R., Baruah A. Post-traumatic diaphragmatic hernia. Indian J Surg. 2012; 74 (4): 334-335. doi: 10.1007/s12262-012-0418-7.

13.    Ercan M., Aziret M., Karaman K. et al. Dual mesh repair for a large diaphragmatic hernia defect: An unusual case report. Int J Surg Case Rep. 2016; 28: 266-269. doi: 10.1016/j.ijscr. 2016.10.015.

14.    Al-Koudmani I., Darwish B., Al-Kateb K., Taifour Y Chest trauma experience over eleven-year period at al-mouassat university teaching hospital-Damascus: a retrospective review of 888 cases. J Cardiothorac Surg. 2012; 7: 35. doi: 10.1186/1749-8090-7-35.

15.    Akar E., Kaya H. Traumatic rupture of the diaphragm: A 22-patient experience. Biomedical Research. 2017; 28 (20): 8706-8710.

16.    Mikheev A.V., Trushin S.N., Bazzaev T.M. i dr. Ushchemlennaia pravostoronniaia travmaticheskaia diafragmalnaia gryzha [Strangulated right-sided traumatic diaphragmatic hernia.]. Al'manakh instituta khirurgii im. A.V. Vishnevskogo. 2017; 2: 148-149 [In Russ].

17.    Plaksin S.A., Kotelnikova L.P Dvustoronnie posttravmaticheskie diafragmalnye gryzhi [Two-sided post-traumatic diaphragmatic hernia.]. Vestnik khirurgii im. 1.1. Grekova. 2015; 174 (1): 47-51 [In Russ].

18.    Gali B.M., Bakari A.A., Wadinga D.W., Nganjiwa U.S. Missed diagnosis of a delayed diaphragmatic hernia as intestinal obstruction: a case report. Niger J Med. 2014; 23 (1): 83-85.

19.    Demuro J.P A delayed traumatic diaphragmatic hernia presenting with a bowel obstruction 20 years postinjury. J Clin Diagn Res. 2013; 7(4): 736-738. doi: 10.7860/JCDR/2013/4755.2898.

20.    De Nadai T.R., Lopes J.C., Inaco Cirino C.C. et al. Diaphragmatic hernia repair more than four years after severe trauma: Four case reports. Int J Surg Case Rep. 2015; 14: 72-76. doi: 10.1016/j.ijscr.2015.07.014.

21.    Wadhwa R., Ahmad Z., Kumar M. Delayed traumatic diaphragmatic hernia mimicking hydropneumothorax. Indian J Anaesth. 2014; 58 (2): 186-189. doi: 10.4103/ 0019-5049.130825.

22.    Falidas E., Gourgiotis S., Vlachos K., Villias C. Delayed presentation of diaphragmatic rupture with stomach herniation and strangulation. Am J Emerg Med. 2015; 33 (9): 1329. e1-3. doi: 10.1016/j.ajem.2015.02.052.

23.    Gao J.M., Du D.Y, Li H. et al. Traumatic diaphragmatic rupture with combined thoracoabdominal injuries: Difference between penetrating and blunt injuries. Chin J Traumatol. 2015; 18 (1): 21-26.

24.    Liao C.H., Chu C.H., Wu YT. et al. The feasibility and efficacy of laparoscopic repair for chronic traumatic diaphragmatic herniation: introduction of a novel technique with literaturereview. Hernia. 2016; 20 (2): 303-309. doi: 10.1007/s10029-015-1405-2.

Abstract:

In patients with severe multiple trauma, posttraumatic period is often complicated by the development of polyorgan insufficiency, development of which is connected with morpho-functional changes of the liver parenchyma.

Aim: was to identify dynamics of ultrasound signs of morphological and functional changes of liver in patients with multiple trauma.

Materials and methods: performed analysis of ultrasound data obtained in dynamics, in 28 patients with severe multiple trauma. From the analysis, we excluded patients with blunt abdominal trauma with injury of liver. In first 2 days, 21 patients underwent surgical operations in treatment of craniocerebral trauma and trauma of musculoskeletal system. All patients underwent ultrasound examination of the abdominal cavity and retroperitoneal space to exclude possibility of appearance of free liquid; also estimated condition of liver, spleen, functional and morphological condition of the gastrointestinal tract. In first days after trauma, ultrasound examination was performed 2-3 times. Color duplex scanning of vessels of liver and spleen was performed once a day or every other day for 2-3 weeks of a traumatic period. Evaluated arterial and venous blood flow of liver by measuring the linear blood flow velocity (LBFV) and resistance index (RI), portal blood flow by measurement of linear and volumetric flow rate.

Results: in all patients on admission to hospital, liver and spleen sizes had normal size. On the 3rd day after the injury, was revealed an increase in the cranio-caudal liver size by 2-4 cm and increased length of spleen by 5-8 cm, which lasts for 10-20 days. During dynamical ultrasound, 8 patients with 10-20 days against a background of increasing level of bilirubin and transaminases, in addition to increasing size of liver and spleen, we marked infiltration of tissues along hepatic veins with their narrowing and along branches of the portal vein with thickness from 0,25 to 0,7 cm. We marked LBFV decreasement by portal vein to 10-13 cm/sec and a volume flow to 250-400 ml / min, increased RI by hepatic artery In 3 patients in the liver parenchyma, we revealed avascular tissue regions with decreased echogenicity, indicating the formation of ischemic regions.

Conclusion: during dynamical ultrasound in patients with severe multiple trauma, on day 3 after injury, were diagnosed morphological changes in liver parenchyma with violation of its hemodynamics. Further progression of the process observed for 10-20 days from the date of trauma: the growth of intrahepatic portal hypertension, increased peripheral resistance in arteries of liver parenchyma, the appearance of ischemic areas of liver parenchyma. The totality of above ultrasonic signs of hemodynamic disorders of liver, characterize organic hepatocellular insufficiency, which is a poor prognostic sign in the development of polyorgan insufficiency.

References

1.     Marushhak E.A. Povrezhdenija pecheni i selezenki u bol'nyh s zakrytoj abdominal'noj travmoj [Injury of liver and spleen in patients with blunt abdominal traums]. Avtoreferat Diss. kand. med. nauk. M. 2009; 31 [In Russ].

2.     Abdominal'naja travma: rukovodstvo dlja vrachej (Pod red. A.S. Ermolov M.Sh. Hubutija, M.M. Abakumov) [Abdominal trauma: manual for physicians]M.: Vidar, 2010; 504 [In Russ].

3.     Travmaticheskaja bolezn' i ee oslozhnenija ( Pod red. S.A. Seleznev, S. F. Bagnenko, Ju.B. Shapot, A.A. Kurygin)[Traumatic disease and its complications] SPb.: Politehnika, 2004; 414 [In Russ].

4.    Gajduk S.V. Kliniko-patofiziologicheskoe obosnovanie rannej diagnostiki sindroma poliorgannoj nedostatochnosti i visceral'nyh oslozhnenij u postradavshih s politravmoj [Clinical-pathophysiological rationale of early diagnostics of polyorgan insufficiency and visceral complications in patients with polytrauma]. Avtoreferat Diss. kand. med. nauk. SPb., 2009; 47 [In Russ].

5.     Gajduk S.V., Sosjukin A.E., Bojarincev V.V. Travmaticheskaja bolezn' i sindrom poliorgannoj disfunkcii - aktual'nye problemy mediciny kriticheskih sostojanij [Traumatic disease and syndrome of polyorgan dysfunction - actual problems of medicine of critical conditions]. Vestnik Rossijskoj Voenno-medicinskoj akademii. 2008; 1(21): 66-70 [In Russ].

6.    Zolotokrylina E. S. Voprosy patogeneza i lechenija poliorgannoj nedostatochnosti u bol'nyh s tjazheloj sochetannoj travmoj, massivnoj krovopoterej v rannem post- reanimacionnom periode [Questions of pathogenesis and treatment of polyorgan insufficiency in patients with severe multiple trauma, massive bloodloss in early postreanimation period]. Anesteziologija i reanimatologija. 1996; 1: 9-13 [In Russ].

7.    Cibuljak G.N. Obshhaja hirurgija povrezhdenij: rukovodstvo [General surgery of trauma: manual]. SPb.: Gippokrat. 2005; 646 [In Russ].

8.     Chastnaja hirurgija mehanicheskih povrezhdenij (Pod redakciej G.N.Cibuljak) [Particularistic surgery of mechanical injury.].SPB.: Gippokrat. 2011; 570 [In Russ].

9.    Saenko V.F. Desjaterik V.I., Perceva T.A., Shapovaljuk V.V. Sepsis i poliorgannaja nedostatochnost [Sepsis and polyorgan insufficiency]'. Krivoj Rog: Mineral. 2005; 441[In Russ].

10.   Tokmakova T.O.,Kameneva E.A., Grigor'ev E.V. Narushenie mikrocirkuljacii kak prichina poliorgannoj nedostatochnosti u postradavshih s tjazheloj cherepno-mozgovoj travmoj[Microcirculatory disorders as a reason of polyorgan insufficiency in patients with severe craniocerebral trauma]. Politravma. 2011; 4: 47-50 [In Russ].

11.   Gel'fand E. B., Gologorskij V.A., Gel'fand B.R. Abdominal'nyj sepsis: integral'naja ocenka tjazhesti sostojanija bol'nyh i poliorgannoj disfunkci [Abdominal sepsis: estimation of severity of condition of patients and polyorgan disfunction]. Anesteziologija i reanimatologija. 2000;3:29-34 [In Russ].

12.   Chappell D., Jacob M., Hofmann-Kiefer K. et al. A rational approach to perioperative fluid management. Anesthesiology. 2008; 109(4): 723-740.

13.   Brealey D., SingerM. Multiorgan dysfunction in the critically ill: epidemiology, pathophysiology and management. J. Royal Coll. Physic. Lond. 2000; 34(5): 424-427.

14.   Baker S.P, O'Neill B., Haddon W. Jr., Long W.B. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974; 14(3): 187-196.

15.   Trusov O.A. Patologicheskaja anatomija i patogenez poliorgannoj nedostatochnosti pri ostroj arterial'noj neprohodimosti konechnostej i peritonita (na materiale rannih autopsij)[Pathological anatomy and pathogenesis of polyorgan insufficiency in case of acute arterial failure of limb and peritonitis (based on early autopsy)]. Avtoreferat Diss. dokt. med. nauk. M., 2002; 41[In Russ].