Post-traumatic diaphragmatic rupture with pericardial denudation: A case report

INTRODUCTION: Post-traumatic diaphragmatic rupture is a lesion of variable severity. It is a rare and difficult to diagnose pathology, it has been found in 0.4% of all traumatized patients and in 1.9% of blunt traumas. It can be associated with abdominal andthoracic lesions, particularly cardiac, which can be life-threatening. MATERIALS AND METHODS: Our work is a retrospective case report with a descriptive aim concerning a patient operated for a post-traumatic diaphragmatic rupture within the department of general surgery of CHU Ibn Rochd Casablanca. This work has been reported in line with the SCARE 2020 criteria (17). CASE PRESENTATION: A 60-year-old patient was admitted to the visceral surgical emergency department following a work accident (crushing between two carts) causing a thoraco-abdominal impact point trauma without initial loss of consciousness, nor externalized digestive hemorrhage or associated signs, but with a general condition alteration. The patient was conscious, dyspneic with a blood pressure of 100/50 mmHg and afebrile. Physical examination showed diffuse abdominal sensibility. The thoraco-abdomino-pelvic CT scan revealed the presence of a left thoracic hernia with gastric, colic and epiploic contents through a lateral defect of the left diaphragmatic dome. The decision was to directly send the patient to the operating room. Exploration found a large left diaphragmatic breach of 20 cm, a denudation of the pericardia, a medium-abundant hemoperitoneum and a hematoma of the right mesocolon. The procedure consisted of right hemicolectomy with ileocolic anastomosis, treatment of a diaphragmatic breach with a 2-silk raphia, thoracic drainage with a Joly drain, pericardial drainage with a Joly drain, pre-anastomotic drainage with 2 delbet slides, drainage of the Douglas and left subthreshold with 2 Salem catheters. The post-operative follow-up was simple. DISCUSSION: Diaphragmatic rupture is a rare and difficult to diagnose condition. Traumatic diaphragmatic rupture (TDR) was found in 0.4% of all traumatized patients and in 1.9% of blunt trauma. Associated lesions of the spleen, liver and/or lungs were found in more than 30% of cases, with an overall mortality rate of 26.8% (1). Pericardial rupture following blunt chest trauma is rare and associated with a high mortality rate ranging from 30% to 64% (9). The physiopathology of this type of injury is not well understood, but the most accepted hypothesis describes an increase in intra-abdominal pressure due to a blunt creating a sufficiently high-pressure gradient between the chest and the abdomen to cause a diaphragmatic rupture. The common clinical symptoms of a diaphragmatic rupture are a marked respiratory distress and diffuse abdominal pain but it can be asymptomatic. Medical imaging exams visualize the ascended organs but it's more difficult to visualize the rupture itself. The chest X-ray is currently the first examination to be requested (4) and also helps in the diagnosis of injuries and diaphragm rupture (13). Surgical treatment includes the reduction of any visceral hernia, repair of the diaphragm and restoration of circulation, breathing and digestive functions. Laparotomy is generally used because of the complete exploration of the abdominal viscera, although it is easier to reduce herniated tissue and repair the diaphragm. CONCLUSION: Diaphragmatic rupture with denudation of the heart is rare with poor prognosis and requires emergency surgery with close postoperative monitoring in the intensive care setting. SUMMARY: Post-traumatic diaphragmatic rupture is a lesion of variable severity. It is a rare and difficult to diagnose pathology, it has been found in 0.4% of all traumatized patients and in 1.9% of blunt traumas. The lesions are more frequent in the left diaphragmatic dome compared to the right one, and exceptionally bilateral. Pericardial rupture following blunt chest trauma is rare and associated to a high mortality rate. It is often unrecognized and goes unnoticed in the acute phase. The most common clinical symptoms of diaphragmatic ruptures are respiratory distress and diffuse abdominal pain, as it can be asymptomatic. Its diagnosis is essentially radiological using CT scan, and requires emergency surgical treatment as soon as the diagnosis is suspected, in order to avoid the dreaded complications. Traumatic diaphragmatic rupture remains a diagnostic and therapeutic challenge. We report the case of a patient who presented a post-traumatic diaphragmatic rupture with pericardial damage operated in the visceral emergency department at the Ibn Rochd Hospital c in Casablanca, Morocco.