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Sun Nov 23 22:18:03 GMT 2008

Dear Dr. Hardcastle,

Our group also has a series on TDH (traumatic diaphragmatic hernia) with
time from initial injury of up to 20 years. We also had one patient falling
on an exposed nail hitting the lower lateral chest developing TDH 10 years
later. Fortunately, most of them present with bowel incarceration, not
strangulation but we had 1 postoperative death ---septicemia from perforated
transverse colon in the chest.

We have the same views on this. I would be interested in your paper (in
press). What journal did you submit your paper?

Thanks.

Jose Luis J. Danguilan, MD
Division of Thoracic and CV Surgery
Philippine General Hospital

On 11/23/08, Dr Timothy Hardcastle <dr.tchardcastle at absamail.co.za> wrote:
>
> Norm
>
> it is exactly this group - the survivors of the 24 hour observation that
> with penetrating trauma can have an occult injury to the diaphragm. If
> they have a lower left chest stab, no signs of abdominal injury and maybe
> only a PTx or Htx then the risk for an occult hole in the diaphragm is
> still high. With a 50% mortality if they present late with dead colon in
> the chest (I've seen one 18 years after a minor stab chest with a simple
> PTx treated with a chest tube and then discharged - no abdominal signs at
> the time; dead colon thru a small diaphragm hole) I feel this is worth the
> effort in this group.
>
> Up to 30% of such patients had a hole in the diaphragm on either VATS or
> Lap-scope despite NO clinical findings. Our own series (currently not yet
> in press) found the same as the series by Demetriades and the recent
> Injury publication from Cowley.
>
> Don't get me wrong - I am not saying this is to be part of the INITIAL
> assessment, this is for later definitive treatment. There we agree -
> clinical management first, with directed imaging
>
> Tim
> Dr T C Hardcastle
> M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
> Principal Specialist Trauma Surgeon /
> Honorary Lecturer UKZN Dept Surgery
> Deputy Director - IALCH Trauma Service
> > Tim
> >
> > Yes it *can* be an indication but *should* it? A hole in the diaphragm
> > is just like a hole in the peritoneum from any other direction. This is
> > violation of the peritoneum, it is not sign of repairable injury. I have
> > not read those studies for a while, but using identification of
> > "repairable injury" as a positive outcome and no "repairable injury" as
> > a negative outcome, I do not believe that they showed any different
> > outcome than did Nance or Shafton. This would make the general
> > anesthesia and the insertion of the laparoscopy an unnecessary
> > operation.
> >
> > And Yes, I know that many of today's surgeons (or at least this is true
> > of the younger surgeons in the US), can (will) no longer do effective
> > abdominal examinations, and they VOMIT, but that does not make the
> > principle incorrect
> >
> > Use the indications that Nance described. 1) significant blood loss =
> > uncontrolled hemorrhage, 2) acute abdomen = hole in the GI tract go to
> > the OR  for a laparotomy. Otherwise after 24 hours of observation with
> > *serial physical examinations*, if neither #1 or #2 have developed then
> > discharge home without any operation
> >
> > Norman
> >
> > Norman McSwain Jr, MD FACS
> > Trauma Director Charity Hospital
> > Professor of Surgery
> > Tulane University School of Medicine
> > 504 988 5111
> >
> >
> > -----Original Message-----
> > From: trauma-list-bounces at trauma.org
> > [mailto:trauma-list-bounces at trauma.org] On Behalf Of Dr Timothy
> > Hardcastle
> > Sent: Saturday, November 22, 2008 12:12 PM
> > To: Trauma &amp; Critical Care mailing list
> > Subject: RE: Laparoscopy in trauma
> >
> >
> >> There is very little if any use for the laparoscopy in the primary
> >> assessment and management of either blunt or penetrating trauma of the
> >> abdomen.
> >>VATS is different. It can be used for the management of hemorrhage in
> >> most chest injuries. It can be used to identify diaphragmatic
> >> perforation ( and the potential need for a laparotomy). And it is
> >> cheaper in complications, time and money than a thoracotomy
> >>
> >> The chest and abdomen are two different cavities, two different types
> > of
> >> problems tow different kinds of complications and two different
> >> outcomes. Do not try to compare these in the same thought process
> >>
> >> Norman
> >>
> >> Norman McSwain Jr, MD FACS
> >> Trauma Director Charity Hospital
> >> Professor of Surgery
> >> Tulane University School of Medicine
> >> 504 988 5111
> > Norm
> >
> > Maybe one place for lap-scope is where VATS not available and there is
> > lower left chest stab (not GSW) looking for occult diaphragm injury. At
> > least three large series supporting this.
> >
> > Tim
> > Dr T C Hardcastle
> > M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
> > Principal Specialist Trauma Surgeon /
> > Honorary Lecturer UKZN Dept Surgery
> > Deputy Director - IALCH Trauma Service
> >
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>
>
>
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