Surgery News - September 2007 - (Page 6) 6 TRAUMA SURGERY NEWS • S E P T E M B E R 2 0 0 7 Incidence of Diaphragmatic Injury Decreases BY MITCHEL L. ZOLER Else vier Global Medical Ne ws WA S H I N G T O N — The incidence of traumatic diaphragmatic injury appears to have dropped during the past 20 years, and increasingly the cause of the injury is penetrating trauma, based on a review of 105 cases at one center. The review also showed that surgeons’ interpretations of chest x-rays can be unreliable in diagnosing traumatic diaphragmatic injury (TDI), highlighting the im- portance of performing exploratory laparoscopy or laparotomy to make a definitive diagnosis in trauma patients, Dr. Wael Hanna said at the annual meeting of the American Association for Thoracic Surgery. Physicians and surgeons need to maintain a high index of suspicion for TDI when examining patients with a penetrating or blunt thoraco-abdominal injury, and they should consider performing laparoscopy to make a definitive assessment, said Dr. Hanna, a surgeon at Mon- treal General Hospital and McGill University. The series reviewed by Dr. Hanna and his associates included 105 patients with confirmed TDI seen at Montreal General during 1993-2006. This is the largest reported series of patients with TDI in more than 20 years, he said. The average annual incidence of TDI was 0.43% of all trauma patients seen at the hospital, a substantial drop from the nearly 3% rate reported more than 20 years ago. The total included 66 patients (63%) with penetrating wounds and 39 patients (37%) with blunt injuries, also a sharp change from prior reports when penetrating trauma accounted for about 25% of TDIs, Dr. Hanna said. Among all patients with blunt trauma, the risk of having TDI was about twofold higher than for patients with a penetrating wound. And patients with blunt injury had hernias that averaged about twice the size of those in patients with TDI secondary to penetrating trauma. Motor-vehicle crashes accounted for most of the blunt trauma, and stab wounds were the most common cause of penetrating trauma seen at Montreal General. Diagnosis of TDI was made by chest xray in 23% of the cases, by CT in 11%, and by exploratory surgery in 57%. The diagnosis of the remaining 9% was missed during the initial, acute phase examination; these cases were not picked up until the patient returned. The 23% diagnostic rate by chest x-ray was achieved by the trauma team leaders involved in these cases, usually surgeons. THE AVERAGE ANNUAL INCIDENCE OF TDI WAS 0.43% OF ALL TRAUMA PATIENTS, DOWN FROM THE NEARLY 3% RATE REPORTED PREVIOUSLY. Radiologists who later reviewed the xrays identified an additional 22 cases (21%) with anatomic findings of TDI, indicating that surgeons need to improve their skill reading chest x-rays for diaphragmatic wounds, Dr. Hanna said. All patients with TDI had associated injuries. Patients with blunt trauma often also had injuries to the head and pelvis. Patients with penetrating trauma most commonly had injuries to the heart and great vessels. Nineteen of the patients (18%) died. The mortality rate was identical in the penetrating and blunt trauma groups. In a multivariate analysis, two clinical features were significantly associated with an increased risk of death. Patients with traumatic brain injury were six times more likely to die than those without brain injury, but only among patients who had blunt trauma. And patients with an injury severity score of more than 15, an indicator of severe injury, were nearly four times more likely to die, compared with patients with a score of 15 or less. This relationship was seen in all patients with TDI regardless of whether they had blunt or penetrating injuries. When asked to account for the difference in blunt vs. penetrating wounds in his study vs. previous reports, Dr. Hanna suggested that there probably was a decrease in blunt automobile and workplace-related injuries from the past, but that a more likely explanation was that these types of blunt injuries tended to be more severe. As a result, many of those patients did not live to make it to the operating room and therefore were not factored into the analysis, he explained. ■ http://www.surgitel.com http://www.surgitel.com
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.