RESUMO

RESUMEN La hernia diafragmática traumática se define como el paso del contenido abdominal a la cavidad torácica a través de un defecto en el diafragma producido por un trauma. Su diagnóstico es difícil, a menudo puede pasar inadvertido, debido a la gravedad de las lesiones que le acompañan. Las claves para el diagnóstico son un alto grado de sospecha y el conocimiento de los distintos signos en la tomografía computarizada. Una vez diagnosticada la ruptura diafragmática, se repara quirúrgicamente para evitar complicaciones. Se presenta el caso de un paciente masculino, de 88 años de edad con antecedentes de haber sufrido trauma toracoabdominal cerrado hacía 35 años, que acudió con un cuadro clínico de oclusión intestinal. Se publica este caso porque, además de ser una entidad poco frecuente, resulta importante el conocimiento de esta enfermedad, para valorarla dentro de las posibilidades diagnósticas en aquellos pacientes que aquejen síntomas relacionados con sus complicaciones.

ABSTRACT Traumatic diaphragmatic hernia is defined as the passage of abdominal contents into the thoracic cavity through a defect in the diaphragm caused by trauma. The diagnosis of traumatic diaphragmatic hernia is difficult, it can often go unnoticed, due to the seriousness of the accompanying injuries. The keys to diagnosis are a high degree of suspicion and knowledge of the various signs on computed tomography. Once the diaphragmatic rupture is diagnosed, it is surgically repaired in order to avoid complications. The case of an 88-year-old male patient with a history of having suffered closed thoracoabdominal trauma 35 years earlier, who presented with a clinical picture of intestinal obstruction is presented. This case is published because, in addition to being a rare entity, knowledge of this disease is important, in order to assess it within the diagnostic possibilities, in those patients who suffer from symptoms related to its complications

RESUMO

ABSTRACT Introduction: diaphragmatic injury is a challenge for surgeons. It is an injury that can be isolated. It is frequent in penetrating thoracoabdominal trauma. It represents a diagnostic challenge and the ideal approach is not yet well established. The occurrence of spontaneous healing of these injuries is still much discussed and even more, if it does, what is the healing mechanism? Objective: to macroscopically and histologically evaluate the natural evolution of perforation and cutting wounds equivalent to 30% of the left diaphragm. Method: 50 specimens of rats underwent a surgical procedure and, after 30 days, were euthanized and those that presented scar tissue in the diaphragm, the samples were submitted to histopathological study, using the hematoxylin and eosin stains, Massons trichrome and Picrosirius to assess the presence of collagen or muscle fibers (hyperplasia) in the scar. Results: it was found that healing occurred in diaphragmatic injuries in 90% of rats. We also observed the presence of fibrosis in all analyzed samples. Conclusion: Spontaneous healing occurred in most diaphragmatic injuries and the inflammatory reaction represented by the presence of fibrosis and collagen deposition was observed in all our samples. Muscle fiber hyperplasia did not occur.

RESUMO Introdução: o ferimento diafragmático é um desafio para os cirurgiões. É uma lesão que pode ser isolada. É frequente nos traumas penetrantes toracoabdominais. Representa um desafio diagnóstico e a conduta ideal ainda não está bem estabelecida. A ocorrência da cicatrização espontânea dessas lesões é ainda muito discutida e mais ainda, se ocorre, qual o mecanismo de cicatrização? Objetivo: avaliar macroscopicamente e histologicamente a evolução natural das feridas perfuro cortantes equivalentes a 30% do diafragma esquerdo. Método: 50 espécimes de ratos, foram submetidos a procedimento cirúrgico e, após 30 dias, foram submetidos à eutanásia e aqueles que apresentaram tecido cicatricial no diafragma, as amostras foram submetidas a estudo histopatológico, usando as colorações de hematoxilina e eosina, tricrômico de Masson e Picrossirius para avaliar a presença de colágeno ou de fibras musculares (hiperplasia) na cicatriz. Resultados: verificou-se que ocorreu nas lesões diafragmáticas, a cicatrização em 90% dos ratos. Observamos também, a presença de fibrose em todas as amostras analisadas. Conclusão: ocorreu cicatrização espontânea na maioria das lesões diafragmáticas e a reação inflamatória representada pela presença de fibrose e deposição de colágeno foi observada em todas as nossas amostras. Não ocorreu hiperplasia de fibras musculares.

RESUMO

Abstract Introduction: Diaphragmatic injuries are a common finding in patients with penetrating thoracoabdominal trauma. Their diagnosis requires exploration through open or laparoscopic surgery. However, multislice computed tomography (MSCT) emerges as a useful noninvasive tool for this purpose. Objective: To determine the diagnostic performance of MSCT for detecting diaphragmatic injuries in hemodynamically stable patients with penetrating thoracoabdominal trauma. Materials and methods: Prospective study conducted on 119 patients treated at the Hospital Universitario del Valle, Cali, Colombia, between March 2012 and June 2015. In order to evaluate the diagnostic performance of MSCT, the results obtained through this test were compared with those reported in the reference test (open surgery). Two readings of the imaging studies were performed by 2 radiologists. Intra- and interobserver agreement on the MSCT readings were analyzed using the Fleiss' Kappa coefficient. Results: MSCT had sensitivity and specificity of 94.4% and 46.8%, respectively. Its positive (PPV) and negative (NPV) predictive values were 44.7% and 94.8%, respectively. The positive likelihood ratio (LR+) was 1.7765, and the negative likelihood ratio (LR-) was 0.1186. Regarding interobserver agreement, Fleiss' Kappa coefficient between the first reading of both radiologists was 0.4425. Conclusions: MSCT specificity for diagnosing diaphragmatic injuries found in this study differs considerably from that reported in the literature. Considering the sensitivity, PPV and LR- values obtained in the present study, MSCT could be an important tool for the management of these patients since conservative treatment may be used in patients whose diaphragmatic injuries are not detected with this type of scan.

Resumen Introducción. Las heridas diafragmáticas son un hallazgo común en pacientes con trauma toracoabdominal penetrante. Su diagnóstico requiere exploración mediante cirugía abierta o laparoscópica. Sin embargo, la tomografía computarizada multidetector (TCMD) surge como una herramienta no invasiva útil para este propósito. Objetivo. Determinar el rendimiento diagnóstico de la TCMD en la identificación de heridas diafragmáticas en pacientes con trauma toracoabdominal penetrante hemodinámicamente estables. Materiales y métodos. Estudio prospectivo realizado en 119 pacientes atendidos en el Hospital Universitario del Valle, Cali, Colombia, entre marzo de 2012 y junio de 2015. Para evaluar el rendimiento diagnóstico de la TCMD, los resultados obtenidos mediante esta prueba fueron comparados con los reportados por el test de referencia (cirugía abierta). Se realizaron 2 lecturas de los estudios de imagen por 2 radiólogos. La concordancia intra e interobservador respecto a la lectura de las TCMD se analizó mediante el coeficiente Kappa de Fleiss. Resultados. La TCDM tuvo una sensibilidad y especificidad de 94.4% y 46.8%, respectivamente. Sus valores predictivos positivo (VPP) y negativo (VPN) fueron 44.7% y 94.8%, respectivamente. La razón de verosimilitud positiva (LR+) fue 1.7765, y la razón de verisimilitud negativa (LR-), 0.1186. Respecto a la concordancia interobservador, el coeficiente Kappa de Fleiss entre la primera lectura de ambos radiólogos fue de 0.4425. Conclusiones. La especificidad de la TCMD para el diagnóstico de heridas diafragmáticas encontrada en el presente estudio difiere considerablemente de lo reportado en la literatura. Teniendo en cuenta la sensibilidad, el VPN y la LR- obtenidos en el presente estudio, la TCMD podría constituir una herramienta importante en el manejo de estos pacientes, ya que en aquellos en los que no se detecte herida diafragmática mediante este tipo de tomografía podría considerarse un manejo conservador.

RESUMO

La hernia diafragmática traumática representa un reto al momento del diagnóstico. Una detección oportuna permite establecer un correcto tratamiento quirúrgico. Se presenta el caso de un paciente masculino de 37 años de edad con antecedente de trauma torácico por arma blanca 4 años antes; quien acude por cuadro de dolor abdominal intenso localizado en epigastrio que se irradia a hipocondrio izquierdo de aparición súbita 72 horas antes de su ingreso. Al examen físico murmullo vesicular disminuido en campo pulmonar izquierdo, y abdomen doloroso a la palpación a nivel de epigastrio e hipocondrio izquierdo. En exámenes de laboratorio no se evidencian alteraciones, mientras que la tomografía reporta hernia diafragmática izquierda; la misma que fue resuelta quirúrgicamente mediante técnica laparoscópica.

Traumatic diaphragmatic hernia represents a challenge at diagnosis. A timely detection allows to establish a correct surgical treatment. It is presented the case of a 37-year-old male patient with a history of stabbing chest trauma 4 years earlier; who comes for symptoms of intense abdominal pain located in the epigastrium that radiates to the left hypochondrium of sudden onset 72 hours before admission. On physical xamination, vesicular murmur decreased in the left lung field, and a painful abdomen on palpation at the level of the epigastrium and left hypochondrium were showed. Laboratory tests did not show any alterations, but tomography reports a left diaphragmatic hernia; this one was solved surgically by laparoscopic technique.

Assuntos

RESUMO

Abstract Purpose: To evaluate the most used approach to treat traumatic diaphragmatic ruptures, and in which one the requirement to assess the second cavity is more frequent. Methods: Systematic review, observational studies. Outcomes: moment of approach, most commonly via addressed and the requirement to open the other cavity. Bases searched: Lilacs, Pubmed, Embase, Clinicaltrials.gov and Web of Science. Statistical analysis: StatsDirect 3.0.121 software. Results: Sixty eight studies (2023 participants) were included. Approach in acute phase was performed four times more than in chronic phase. Approach: abdominal 65% (IC 95% 63-67%), thoracic 23% (IC 95% 21-24%), abdominal in the acute phase 75% (IC 95% 71-78%), and chronic 24% (IC 95% 19-29%), thoracic in the acute phase 12% (IC 95% 10-14%) and chronic 69% (IC 95% 63-74%). Thorax opening in the abdominal approach: 10% (95% CI 8-14%). Abdomen opening in the thoracic approach: 15% (95% CI 7-24%). Conclusions: The most common approach was the abdominal. The approach in the acute phase was more common. In the acute phase the abdominal approach is more frequent than the thoracic approach. In the chronic phase the thoracic approach is more frequent than the abdominal one. The requirement to open the second cavity was similar in both approaches.

Assuntos

RESUMO

Purpose: To evaluate the most used approach to treat traumatic diaphragmatic ruptures, and in which one the requirement to assess the second cavity is more frequent.Methods: Systematic review, observational studies. Outcomes: moment of approach, most commonly via addressed and the requirement to open the other cavity. Bases searched: Lilacs, Pubmed, Embase, Clinicaltrials.gov and Web of Science. Statistical analysis: StatsDirect 3.0.121 software. Results: Sixty eight studies (2023 participants) were included. Approach in acute phase was performed four times more than in chronic phase. Approach: abdominal 65% (IC 95% 63-67%), thoracic 23% (IC 95% 21-24%), abdominal in the acute phase 75% (IC 95% 71-78%), and chronic 24% (IC 95% 19-29%), thoracic in the acute phase 12% (IC 95% 10-14%) and chronic 69% (IC 95% 63-74%). Thorax opening in the abdominal approach: 10% (95% CI 8-14%). Abdomen opening in the thoracic approach: 15% (95% CI 7-24%). Conclusions: The most common approach was the abdominal. The approach in the acute phase was more common. In the acute phase the abdominal approach is more frequent than the thoracic approach. In the chronic phase the thoracic approach is more frequent than the abdominal one. The requirement to open the second cavity was similar in both approaches.(AU)

Assuntos

RESUMO

El trauma diafragmático se produce de forma secundaria tras lesiones penetrantes y trauma cerrado del abdomen y tórax. La hernia diafragmática traumática representa una entidad poco frecuente en la clínica. Cuando se presenta constituye un verdadero reto diagnóstico para el internista, cirujano y el radiólogo. Requiere de un alto índice de sospecha y el uso adecuado de las imágenes diagnósticas. El tratamiento siempre es quirúrgico. Por tales razones se presenta el caso de un paciente que fue operado debido a una herida por arma blanca en el tórax y que con posterioridad se le diagnosticó una hernia diafragmática traumática en el lado izquierdo del torax. Volvió a ser operado y la evolución posquirúrgica resultó satisfactoria.

Diaphragmatic trauma is secondary to penetrating injuries and blunt abdominal and thoracic trauma. Traumatic diaphragmatic hernia is an uncommon entity. Its diagnosis poses a real challenge to internists, surgeons and radiologists since it requires a high level of suspicion and appropriate use of diagnostic imaging. Surgical treatment is always needed. For these reasons, we present the case of a patient operated on due to a stab wound to the chest who was subsequently diagnosed with a traumatic diaphragmatic hernia on the left side of the chest. He underwent surgery again and had a successful postoperative recovery.

RESUMO

Objective: to evaluate natural evolution of right diaphragmatic injury after the surgical removal of a portion from hemi diaphragm. Methods: the animals were submitted to a surgical removal of portion from right hemi diaphragm by median laparotomy. The sample consists of 42 animals being 2 animals from pilot project and 40 operated animals. And the variables of the study were herniation, liver protection, healing, persistent diaphragm injury, evaluation of 16 channels tomography and the variables "heart rate" and "weight". Results: we analyzed 40 mice, we had two post-operative deaths; we had 17 animals in this group suffered from herniation (42.5%) and 23 animals didn't suffer from herniation (57.5%). Analyzing the tomography as image method in the evaluation of diaphragmatic hernia, we had as a method with good sensitivity (78.6%), good specificity (90.9%), and good accuracy (86.1%) when compared to necropsy. Conclusion: there was a predominance of healing of right hemi diaphragm, the size of initial injury didn't have influence on occurrence of the liver protection or hernia in mice.

Objetivo: avaliar a evolução natural do ferimento diafragmático à direita após a retirada cirúrgica de uma porção do hemidiafragma. Métodos: os animais foram submetidos à ressecção de uma porção do hemidiafragma à direita através da laparotomia mediana. Foram operados 40 ratos. As variáveis analisadas foram: herniação, proteção hepática, cicatrização, lesão persistente do diafragma, avaliação da tomografia computadorizada, frequência cardíaca e peso. Resultados: foram analisados 40 ratos. Houve duas mortes no pós-operatório. Dezessete animais tiveram herniação (42,5%) e 23 (57,5%), não. Analisando emprego da tomografia computadorizada na avaliação da hérnia diafragmática, tivemos um método com boa sensibilidade (78,6%), boa especificidade (90,9%) e boa acurácia (86,1%) quando comparados com a necrópsia. Conclusão: houve predomínio de cicatrização do hemidiafragma à direita e o tamanho da lesão inicial não influenciou na ocorrência de proteção hepática ou hérnia em ratos.

Assuntos

RESUMO

A hérnia diafragmática congênita é um defeito de formação do diafragma que acomete entre 1:2.000 e 1:4.000 nascidos vivos e constitui 8% das principais anomalias congênitas. Avanços médicos nos últimos 30 anos envolvendo diagnóstico pré-natal, intervenção fetal, manejo clinico e cirúrgico neonatal têm mudado a sobrevivência dos seus portadores. A evolução histórica desses avanços ajuda a compreender o esforço na busca de melhores resultados desse defeito muitas vezes fatal. Perspectivas na utilização de bioengenharia e terapia envolvendo células tronco podem trazer novas esperanças para os fetos com hérnia diafragmática congênita.

The congenital diaphragmatic hernia is a defect in the formation of the diaphragm, which affects between 1:2,000 and 1:4,000 live births and represents 8% of major congenital anomalies. Medical advances in the last 30 years involving prenatal diagnosis, fetal intervention, neonatal surgical and clinical management have changed the survival of these patients. The historical evolution of these advances helps us to understand the effort in pursuit of better results of this defect, which is often lethal. Perspectives on the use of bioengineering and therapy involving stem cells may bring new hope for fetuses with congenital diaphragmatic hernia.

Assuntos

RESUMO

CONTEXT: Intrathoracic cystic lesions have been diagnosed in a wide variety of age groups, and the increasing use of prenatal imaging studies has allowed detection of these defects even in utero. CASE REPORT: A 17-year-old pregnant woman in her second gestation, at 23 weeks of pregnancy, presented an ultrasound with evidence of a cystic anechoic image in the fet al left hemithorax. A morphological ultrasound examination performed at the hospital found that this cystic image measured 3.7 cm x 2.1 cm x 1.6 cm. Polyhydramnios was also present. At this time, the hypothesis of cystic adenomatoid malformation was raised. Fet al echocardiography showed only a dextroposed heart. Fet al magnetic resonance imaging produced an image compatible with a left diaphragmatic hernia containing the stomach and at least the first and second portions of the duodenum, left lobe of the liver, spleen, small intestine segments and portions of the colon. The stomach was greatly distended and the heart was shifted to the right. There was severe volume reduction of the left lung. Fet al karyotyping showed the chromosomal constitution of 47,XXY, compatible with Klinefelter syndrome. In our review of the literature, we found only one case of association between Klinefelter syndrome and diaphragmatic hernia. CONCLUSIONS: We believe that the association observed in this case was merely coincidental, since both conditions are relatively common. The chance of both events occurring simultaneously is estimated to be 1 in 1.5 million births. .

CONTEXTO: Lesões císticas intratorácicas são diagnosticadas em ampla variedade de faixas etárias, e o uso aumentado dos estudos de imagem pré-natal tem permitido a detecção desses defeitos ainda intraútero. RELATO DO CASO: Uma gestante de 17 anos que estava em sua segunda gravidez, com 23 semanas de gestação, apresentava ultrassom com evidência de imagem cística anecoica no hemitórax esquerdo fet al. O ultrassom morfológico realizado no hospital verificou que esta media 3,7 cm x 2,1 cm x 1,6 cm. Evidenciou-se também a presença de polidrâmnio. Neste momento, levantou-se a hipótese de malformação adenomatoide cística. A ecocardiografia fet al mostrou apenas coração desviado para a direita. A ressonância magnética fet al revelou imagem compatível com hérnia diafragmática à esquerda, contendo estômago e, pelo menos, primeira e segunda partes do duodeno, lobo esquerdo do fígado, baço, segmentos de intestino delgado e porções do cólon. O estômago mostrava-se muito distendido e o coração, deslocado para a direita. Havia redução importante do volume do pulmão esquerdo. O cariótipo fet al mostrou constituição cromossômica 47,XXY, compatível com a síndrome de Klinefelter. Em nossa revisão da literatura, encontramos apenas um caso de associação entre síndrome de Klinefelter e hérnia diafragmática. CONCLUSÃO: Acreditamos que a associação observada neste caso foi puramente uma coincidência, uma vez que ambas as condições são relativamente comuns. A chance de os dois eventos ocorrerem simultaneamente é estimada em 1 em 1,5 milhões de nascimentos. .

Assuntos

RESUMO

OBJECTIVE: To standardize a technique for ventilating rat fetuses with Congenital Diaphragmatic Hernia (CDH) using a volume-controlled ventilator. METHODS: Pregnant rats were divided into the following groups: a) control (C); b) exposed to nitrofen with CDH (CDH); and c) exposed to nitrofen without CDH (N-). Fetuses of the three groups were randomly divided into the subgroups ventilated (V) and non-ventilated (N-V). Fetuses were collected on day 21.5 of gestation, weighed and ventilated for 30 minutes using a volume-controlled ventilator. Then the lungs were collected for histological study. We evaluated: body weight (BW), total lung weight (TLW), left lung weight (LLW), ratios TLW / BW and LLW / BW, morphological histology of the airways and causes of failures of ventilation. RESULTS: BW, TLW, LLW, TLW / BW and LLW / BW were higher in C compared with N- (p <0.05) and CDH (p <0.05), but no differences were found between the subgroups V and N-V (p> 0.05). The morphology of the pulmonary airways showed hypoplasia in groups N- and CDH, with no difference between V and N-V (p <0.05). The C and N- groups could be successfully ventilated using a tidal volume of 75 ìl, but the failure of ventilation in the CDH group decreased only when ventilated with 50 ìl. CONCLUSION: Volume ventilation is possible in rats with CDH for a short period and does not alter fetal or lung morphology. .

OBJETIVO: padronizar uma técnica para ventilar fetos de rato com HDC usando um ventilador volume-controlado. MÉTODOS: ratas grávidas foram distribuídas em: a) Controle (C); e b) Expostos a Nitrofen com HDC e sem HDC (N-). Fetos dos três grupos foram divididos aleatoriamente em subgrupos ventilados (V) ou não ventilados (NV). Os fetos foram coletados no dia 21,5 da gestação, pesados e ventilados por 30 minutos usando um ventilador volume-controlado. A seguir os pulmões foram coletados para estudo histológico. Nós avaliamos: peso corporal (PC), peso pulmonar total (PPT), peso do pulmão esquerdo (PPE), razão PPT/PC e PPE/PC, histologia morfológica das vias aéreas e as causas das falhas da ventilação. RESULTADOS: PC, PPT, PPE, LLW, PPT/PC e PPE/PC foram maiores em C em relação a N- (p<0,05) e a HDC (p<0,05), mas não houve diferenças entre os subgrupos V e NV (p>0,05). A morfologia das vias aéreas pulmonares mostrou hipoplasia nos grupos N- e HDC, não havendo diferença entre V e NV (p<0,05). Os grupos C e N- puderam ser ventilados com sucesso usando o volume corrente de 75ìl, mas a falha de ventilação no grupo HDC só diminuiu quando ventilados com 50ìl. . CONCLUSÃO: a ventilação a volume de ratos com HDC por um curto período é possível e não altera a morfologia fetal ou pulmonar. .

Assuntos

RESUMO

Transdiaphragmatic intercostal hernia is uncommon and mostly related to blunt or penetrating trauma. We report three similar cases of cough-induced transdiaphragmatic intercostal hernia, highlighting the anatomic findings obtained with different imaging modalities (radiography, ultrasonography, CT, and magnetic resonance) in each of the cases.

Hérnias intercostais transdiafragmáticas são eventos raros e são geralmente relacionadas a traumas abertos ou fechados, com risco de complicações. Relatamos três casos semelhantes, decorrentes de crises de tosse, destacando o aspecto das alterações anatômicas nos exames de imagem obtidos em cada situação (radiografia, ultrassonografia, TC e ressonância magnética).

Assuntos

RESUMO

OBJETIVO: Descrever as alterações do exame radiográfico de tórax em pacientes com diagnóstico de hérnia diafragmática pós-traumática (HDPT) confirmado no intraoperatório. MÉTODOS: No período entre janeiro de 1990 e agosto de 2008 foram tratados 45 pacientes com HDPT. Foram analisados dados demográficos, mecanismo de trauma, alterações na radiografia convencional de tórax (Rtx), extensão e localização da lesão do diafragma e órgãos herniados. Foram descritos os achados radiográficos mais frequentes identificados por assistentes da cirurgia e da radiologia. RESULTADOS: A Rtx foi realizada em 32 pacientes, com predomínio do sexo masculino (27 casos - 84,4%) e a média das idades foi 34 anos. O mecanismo de trauma mais frequente foi o contuso (25 casos - 78,1%). O exame radiográfico de tórax apresentava alterações sugestivas de HDPT em 26 casos (81,3%). Na laparatomia exploradora constatou-se HDPT à esquerda em 28 casos (87,5%) e à direita em 4 (12,5%). O órgão herniado mais frequente foi o estômago. CONCLUSÃO: O estudo mostrou que o Rtx é muito útil na pesquisa inicial no diagnóstico de HDPT. A dificuldade é que as lesões de diafragma, principalmente após trauma penetrante, podem passar inicialmente despercebidas, sem alterações nesse método de imagem, tornando o diagnóstico difícil.

OBJECTIVE: To describe changes in the radiographic examination of the chest in patients with post-traumatic diaphragmatic hernia (PTDH) confirmed intra-operatively. METHODS: Between January 1990 and August 2008 45 patients with PTDH were treated. We analyzed demographic data, cause of injury, changes in chest radiography (CXR), extent and location of the diaphragmatic lesion and herniated organs. We described the radiographic findings most frequently identified by surgeons and radiologists. RESULTS: CXR was performed on 32 patients, predominantly male (27 cases, 84.4%) and the mean age was 34 years. The most common cause of injury was blunt trauma (25 cases, 78.1%). Radiographic examination of the chest showed changes suggestive of PTDH in 26 cases (81.3%). During exploratory laparotomy, left PTDH was found in 28 cases (87.5%) and right in four (12.5%). The most frequently herniated organ was the stomach. CONCLUSION: The study showed that CXR is very useful in the initial diagnostic approach to PTDH. The difficulty is that diaphragmatic injuries, particularly after penetrating trauma, may initially go unnoticed, and without changes in the CXR images, diagnosis is made difficult.

Assuntos

RESUMO

Introducción: la hernia diafragmática congénita (HDC) plantea un reto por la amplia variabilidad de presentación clínica, la falla respiratoria y la posibilidad de hipertensión pulmonar grave. El objetivo de esta revisión fue describir el tratamiento de la HDC y sus resultados, entre 1999 y 2009, en la Sección de Cirugía Infantil del Hospital Universitario San Vicente de Paúl, de Medellín. Materiales y métodos: se estudiaron en 36 pacientes variables socioeconómicas, tiempo de estabilización preoperatoria, tipo de tratamiento y sus resultados, complicaciones, tiempo de permanencia en la UCI, necesidad de soporte ventilatorio y duración de la estancia hospitalaria. Resultados: fue más frecuente la HDC izquierda y en hombres. Veintidós pacientes presentaron malformaciones asociadas. Se hizo tratamiento médico y quirúrgico en 31 pacientes. El tiempo de estabilización preoperatoria fue en promedio cuatro días. La mediana de días de ventilación mecánica fue cuatro, la de estancia en UCI, seis y la de estancia hospitalaria, 12,5. La sepsis fue la complicación más frecuente, en seis pacientes hubo infección del sitio operatorio y en igual número, secuelas. Murieron 10 pacientes; los factores asociados con la mortalidad fueron: inestabilidad hemodinámica, Apgar menor de 5, tratamiento exclusivamente médico, diagnóstico prenatal, uso de parche para la reparación y las malformaciones asociadas.

Introduction: Congenital diaphragmatic hernia (CDH) remains a challenge because of the wide variability of its clinical presentation, severity of respiratory failure, and the possibility of severe pulmonary hypertension. The objective of this review was to describe the management and outcomes of patients with CDH between 1999 and 2009, in the pediatric surgery unit at Hospital Universitario San Vicente de Paul in Medellín, Colombia. Materials and methods: We studied in 36 patients the socioeconomic variables, preoperative stabilization time, type of treatment, outcomes, complications, length of stay in the ICU, need for ventilatory support, and length of hospital stay. Results: HDC was more frequent on the left side and in males. Twenty two patients had associated malformations. Surgical treatment was carried out in 31 patients. Preoperative stabilization time averaged four days. The median duration of mechanical ventilation was four days, average stay in the ICU was six days and average hospital stay, 12.5 days. Sepsis was the most common complication, six patients had surgical site infection and an equal number had sequels. Ten patients died. Factors associated with mortality were hemodynamic instability, prenatal diagnosis, Apgar <5, lack of surgical treatment, use of patch for repair, and the presence of associated malformations.

Assuntos

RESUMO

As hérnias diafragmáticas são decorrentes principalmente de traumas contusos e são mais comuns à esquerda. Essa menor frequência à direita é explicada pela contenção e proteção do fígado ao hemidiafragma homolateral. Entretanto, apesar de as lesões à esquerda serem mais frequentes, aquelas situadas à direita associam-se a lesões mais graves e resultam em mais instabilidade hemodinâmica, o que gera elevada mortalidade no momento do trauma. Além disso, a hérnia diafragmática direita, pode permanecer assintomática por longo tempo, favorecendo a aparecimento de complicações como isquemia e ruptura das vísceras herniadas dentro do tórax. Assim é fundamental um diagnóstico precoce, a fim de se realizar o tratamento cirúrgico, uma vez que o diafragma não cicatriza espontaneamente. (AU)

The diaphragmatic hernias are mainly due to blunt trauma and are more common on the left. This lower frequency on the right side is explained by liver protection of the ipsilateral hemidiaphragm. However, despite the injuries are more frequent on the left, those situated on the right are associated with more severe injuries and result in more hemodynamic instability, which leads to high mortality at the time of trauma. Furthermore, the right diaphragmatic hernia can remain asymptomatic for long time, favoring the onset of complications such as ischemia and rupture of the herniated organs inside the chest. Therefore early diagnosis is fundamental in order to perform surgical treatment, since the diaphragm does not heal spontaneously. (AU)

Assuntos

RESUMO

OBJETIVO: Comparar a sobrevida pós-natal de fetos com hérnia diafragmática congênita esquerda grave isolada, os quais foram submetidos à oclusão traqueal, com a de controles não randomizados contemporâneos. MÉTODOS: Estudo experimental não randomizado e controlado, conduzido de abril de 2007 a setembro de 2011. Fetos portadores de hérnia diafragmática congênita esquerda isolada com herniação hepática e relação pulmão/cabeça <1,0, que foram submetidos à oclusão traqueal (grupo de estudo) ou conduta expectante (controles não randomizados contemporâneos), foram comparados quanto à relação pulmão/cabeça e ao observado/esperado da relação pulmão/cabeça no diagnóstico, à idade gestacional por ocasião do parto e sobrevida neonatal com alta do berçário. A evolução da relação pulmão/cabeça e do observado/esperado da relação pulmão/cabeça depois da oclusão traqueal foi descrita. Testes de Fisher, Mann-Whitney e Wilcoxon foram usados na análise estatística. RESULTADOS: Não houve diferenças significativas entre o grupo de estudo (n=28) e o Controle (n=13) quanto à relação pulmão/cabeça (p=0,7) e ao observado/esperado da relação pulmão/cabeça (p=0,5), no momento do diagnóstico, nem à idade gestacional no parto (p=0,146). A sobrevida com alta do berçário foi maior (p=0,012) no grupo da oclusão traqueal (10/28=35,7 por cento) do que no Grupo Controle (0/13=0,0 por cento). Houve aumento da relação pulmão/cabeça (p<0,001) e do observado/esperado da relação pulmão/cabeça (p<0,001) entre o momento do diagnóstico da hérnia diafragmática congênita [relação pulmão/cabeça: 0,8 (0,4-0,9); observado/esperado da relação pulmão/cabeça: 27,0 (15,3-45,0)] e um dia antes da retirada do balão traqueal [relação pulmão/cabeça: 1,2 (0,5-1,8); observado/esperado da relação pulmão/cabeça: 40,0 (17,5-60,0)]. CONCLUSÕES: Houve melhora significativa na sobrevida pós-natal com alta do berçário de fetos com hérnia diafragmática congênita esquerda isolada grave, que foram submetidos à oclusão traqueal em relação a controles não randomizados contemporâneos.

PURPOSE: To compare postnatal survival to hospital discharge of fetuses with severe isolated left-sided congenital diaphragmatic hernia, who underwent tracheal occlusion, with that of nonrandomized contemporaneous controls. METHODS: Experimental nonrandomized controlled study, performed from April 2007 to September 2011. Fetuses with severe isolated left-sided congenital diaphragmatic hernia with liver herniation into the chest and lung area-to-head circumference ratio <1.0, who underwent tracheal occlusion (study group) or expectant management (non-randomized contemporaneous controls), were compared in terms of lung area-to-head circumference ratio and observed/expected lung area-to-head circumference ratio (observed/expected lung area-to-head circumference ratio) at the time of diagnosis, gestational age at birth, and survival to hospital discharge. Modifications in lung area-to-head circumference ratio and o/e lung area-to-head circumference ratio after tracheal occlusion were also analyzed. Fisher's exact test, Mann-Whitney's or Wilcoxon's tests were used for the comparisons. RESULTS: There were no significant differences between the Study Group (TO=28) and Controls (n=13) in terms of the lung area-to-head circumference ratio (p=0.709) and the observed/expected lung area-to-head circumference ratio (p=0.5) at the time of diagnosis and gestational age at birth (p=0.146). The survival to hospital discharge was higher (p=0.012) in the tracheal occlusion group (10/28=35.7 percent) than in controls (0/13=0.0 percent). There was a significant increase in lung area-to-head circumference ratio (p<0.001) and observed/expected lung area-to-head circumference ratio (p<0.001) between the diagnosis of the congenital diaphragmatic hernia [lung area-to-head circumference ratio: 0.80 (0.40-0.94); observed/expected lung area-to-head circumference ratio: 27.0 (15.3-45.0)], and the day before retrieval of the balloon [lung area-to-head circumference ratio: 1.2 (0.50-1.80); observed/expected lung area-to-head circumference ratio: 40.0 (17.5-60.0)]. CONCLUSIONS: There was a significant improvement in the survival rate to hospital discharge of fetuses with severe isolated left-sided congenital diaphragmatic hernia, who underwent tracheal occlusion in comparison to nonrandomized contemporaneous controls.

Assuntos

RESUMO

Introducción: La hernia diafragmática del lado derecho es una variable poco frecuente de los defectoscongénitos diafragmáticos que permiten el paso del contenido abdominal a la cavidad torácica, causandograves trastornos en el desarrollo pulmonar fetal. Objetivo: Describir las características patológicasencontradas en la autopsia perinatal de un paciente con Hernia diafragmática congénita derecha en elHospital Universitario de Santander. Caso clínico: Neonato de 35 semanas de gestación con diagnósticoprenatal de Hernia Diafragmática Congénita, quien fallece minutos después de su nacimiento debido ainsuficiencia respiratoria aguda. En los hallazgos de autopsia se encuentra ausencia de la mayor parte delhemidiafragma derecho, herniación del contenido abdominal al tórax y una severa hipoplasia pulmonar.Conclusión: La Hernia diafragmática congénita del lado derecho se asocia con alta mortalidad neonataly los hallazgos encontrados en el presente caso se correlacionan con los graves defectos estructuralespulmonares que se describen en otros casos reportados en la literatura.

Introduction: The congenital diaphragmatic hernia of the right side is the least common type ofthe congenital diaphragmatic defects which allows the passage of abdominal contents to the thoraciccavity, causing serious disorders on lung development. Objective: To describe the pathological featuresfound in perinatal autopsy of a patient with Congenital Diaphragmatic Hernia of the right side at theHospital Universitario de Santander. Case report: 35 weeks gestation neonate with prenatal diagnosisof congenital diaphragmatic hernia, who died due to acute respiratory failure. In the autopsy be founda severe pulmonary hypoplasia and in the microscopic examination, the pulmonary alveoli collapsed.Conclusion: The congenital diaphragmatic hernia of the right side is associated with high neonatalmortality and the findings in this case are correlated with severe pulmonary structural defects that aredescribed in other cases reported in the literature.

Assuntos

RESUMO

OBJETIVO: descrever as complicações maternas decorrentes dos procedimentos endoscópicos terapêuticos em Medicina fetal, realizados em um centro universitário no Brasil. MÉTODOS: estudo observacional retrospectivo que incluiu gestantes atendidas no período de Abril de 2007 a Maio de 2010. Esses casos foram submetidos aos seguintes procedimentos: ablação vascular placentária com laser (AVPL) por síndrome de transfusão feto-fetal (STFF) grave; oclusão traqueal fetal (OTF) e retirada de balão traqueal por via endoscópica por hérnia diafragmática congênita (HDC) grave e AVPL, com ou sem cauterização bipolar do cordão umbilical, por síndrome da perfusão arterial reversa (SPAR) em gêmeo acárdico. As principais variáveis descritas para cada condição clínica/tipo de cirurgia foram as complicações maternas e a sobrevida (alta do berçário) do neonato/lactente. RESULTADOS: cinquenta e seis gestantes foram submetidas a 70 procedimentos: STFF grave (34 pacientes; 34 cirurgias); HDC grave (16 pacientes; 30 cirurgias) e SPAR (6 pacientes; 6 cirurgias). Entre as 34 gestantes tratadas com AVPL por STFF, duas (2/34=5,9 por cento) apresentaram perda de líquido amniótico para a cavidade peritoneal e sete (7/34=20,6 por cento) tiveram abortamento após os procedimentos. A sobrevida de pelo menos um gêmeo foi de 64,7 por cento (22/34). Entre as 30 intervenções realizadas para HDC, houve perda de líquido amniótico para a cavidade peritoneal materna em um caso (1/30=3,3 por cento) e rotura prematura pré-termo de membranas após três (3/30=30 por cento) fetoscopias para retirada do balão traqueal. A sobrevida com alta do berçário foi de 43,8 por cento (7/16). Entre os seis casos de SPAR, houve sangramento materno para a cavidade peritoneal após uma cirurgia (1/6=16,7 por cento) e a sobrevida com alta do berçário foi de 50 por cento (3/6). CONCLUSÕES: em concordância com os dados disponíveis na literatura, em nosso centro, os benefícios relacionados às intervenções endoscópicas terapêuticas em casos de STFF, HDC e SPAR parecem superar os riscos de complicações maternas que, raramente, foram consideradas graves.

PURPOSE: to describe the maternal complications due to therapeutic endoscopic procedures in fetal Medicine performed at an university center in Brazil. METHODS: retrospective observational study including patients treated from April 2007 to May 2010 who underwent laser ablation of placental vessels (LAPV) for severe twin-twin transfusion syndrome (TTTS); fetal tracheal occlusion (FETO) and endoscopic removal of tracheal balloon in cases of severe congenital diaphragmatic hernia (CDH); LAPV with or without bipolar coagulation of the umbilical cord in cases of twin reversed arterial perfusion (TRAP) sequence. The main variables described for each disease/type of surgery were maternal complications and neonatal survival (discharge from nursery). RESULTS: fifty-six patients underwent 70 procedures: Severe TTTS (34 patients; 34 surgeries); severe CDH (16 patients; 30 surgeries), and TRAP sequence (6 patients; 6 surgeries). Among 34 women who underwent LAPV for TTTS, two (2/34=5.9 percent) experienced amniotic fluid leakage to the peritoneal cavity and seven (7/34=20.6 percent) miscarried after the procedure. Survival of at least one twin was 64.7 percent (22/34). Among 30 interventions performed in cases of CDH, there was amniotic fluid leakage into the maternal peritoneal cavity in one patient (1/30=3.3 percent) and premature preterm rupture of membranes after three (3/30=30 percent) fetoscopies for removal of the tracheal balloon. Infant survival with discharge from nursery was 43.8 percent (7/16). Among six cases of TRAP sequence, there was bleeding into the peritoneal cavity after surgery in one patient (1/6=16.7 percent) and neonatal survival with discharge from nursery was 50 percent (3/6). CONCLUSIONS: in agreement with the available data in literature, at our center, the benefits related to therapeutic endoscopic interventions for TTTS, CDH and TRAP sequence seem to overcome the risks of maternal complications, which were rarely considered severe.

Assuntos

RESUMO

INTRODUÇÃO: Lesões diafragmáticas traumáticas ainda permanecem como um grande desafio diagnóstico na sala de emergência. Essas injúrias são entidades incomuns cujos diagnósticos passam despercebidos, resultando em hérnias diafragmáticas crônicas, podendo evoluir para estrangulamento. RELATO DO CASO: Paciente com injúria diafragmática direita tardia associada a hepatotórax diagnosticada três anos após o trauma original. O comprometimento respiratório e dor abdominal em quadrante superior foram os principais sintomas que levaram à investigação diagnóstica. Ele foi manejado através de laparotomia e o defeito fechado mediante reparo primário, sem o uso de telas. Não houve complicações no pós-operatório, com alta após seis dias. CONCLUSÃO: As hérnias diafragmáticas tardias associadas a hepatotórax são raras. Estudos radiográficos e tomografias computadorizadas são os métodos de escolha para o correto diagnóstico. Tanto a toracotomia quanto a laparotomia podem ser realizadas para o reparo cirúrgico.

INTRODUCTION: Traumatic diaphragm lesions still remain problematic in diagnosis and handling. CASE REPORT: Patient with diaphragmatic hernia had the diagnosis made three years after car accident. At admission, he was with abdominal pain and respiratory distress. Submitted to image investigation, had the diagnosis done of a diaphragm herniation. Laparotomy revealed liver and adjacent viscera into the thorax and a diaphragm defect of 15 cm. The defect was closed without the use any mash. There was no complications and in an outclinic assistance, one year later, he was asymptomatic. CONCLUSION: Diaphragmatic herniations are rare entities. Image examination is indicated and can do correct diagnosis in all cases. Laparotomy or thoracotomy must be use in defect reparation.

RESUMO

Bochdalek´s hernia is a congenital malformation of the posterolateral diaphragm region. It is more common on the left and more frequently seen in newborns and rare in adults, with over a few 100 reported cases. We present a case of Bochdalek´s hernia in a 49-year-old patient with long term dyspeptic symptoms. The upper endoscopy showed a gastric fundus herniation sliding into the chest through the diaphragmatic defect. The patient also presented with a rare pulmonary malformation diagnosed during surgery. It was corrected through thoracic approach with no other complications.