Surgical Management of Herniated Intrathoracic Gastric Perforation in Traumatic Diaphragmatic Rupture: An Unusual Two Rare Cases

Gastric perforation into the thoracic cavity through a diaphragmatic rupture is rare but, when it occurs, patients present in severe distress, with mortality approaching 50%. We present our experience of two rare and unusual cases of traumatic diaphragmatic rupture from penetrating chest injury associated with herniated intrathoracic gastric perforation over a five-year period from January 2015 to December 2020 at the cardiovascular and thoracic surgery department of the Komfo Anokye Teaching Hospital in Kumasi, Ghana. Both patients underwent successful surgical repair through standard posterolateral thoracotomy with one having earlier negative exploratory laparotomy. The essence of the paper is to share and discuss the clinical presentation, diagnostic challenges, surgical management and the postoperative care of this very rare complication of traumatic diaphragmatic rupture.


Introduction
Traumatic diaphragmatic rupture, either due to blunt or penetrating thoracic or How to cite this paper: Okyere, I., Singh, S., Okyere abdominal injuries, is a rare occurrence with reported incidence of less than 10%. Traumatic diaphragmatic rupture is usually associated with intrathoracic herniation of intraabdominal organs and intestines. However, the occurrence of traumatic diaphragmatic rupture with herniated gastric perforation is a rare presentation with few reported cases in literature [1]. The diagnosis is often difficult and a delay in diagnosis frequently results in increased morbidity and mortality. The purpose of this paper is to share our experience in the management of these cases, to sensitize the readers about this rare entity and also discuss the diagnostic dilemma along with potential challenges in its management.

Case 1
The first case was a 46-year old male who was allegedly attacked by assailants who stabbed him twice in the left posterior chest. He started bleeding profusely from the wound sites with associated left-sided pleuritic chest pain and abdominal pain. He was rushed to the accident and emergency centre with the impaled knife in-situ at the back. He was however fully conscious but tachycardic with pulse rate of 111 bpm, moderate volume, BP of 144/93 mmHg, respiratory rate of 22 cycles per minute with saturation of 96% in room air. Air entry was reduced at the left middle and lower zones with stony dull percussion note and vesicular breath sounds. He had a 5 cm laceration over the left suprascapular area which admitted the whole length of the middle finger as well as a 4 cm laceration 2 cm below the inferior angle of the left scapula with the dagger in situ.
Immediate resuscitation with IV fluids, antibiotics, and antitetanus prophylaxis was started and a size 28Fr left chest tube was inserted draining bubbles of air and 300 ml of non-clotting haemorrhagic effusion. He was thus consented for exploratory laparotomy and was wheeled immediately to the operating theatre after blood has been taken for grouping and matching against 4 units of blood, full blood count and chemistry.
Using an extended upper midline laparotomy, the abdomen was entered.       Patient made an uneventful recovery and was subsequently discharged home on postoperative day 7. He was followed up on out-patient basis at 2 weeks, 1 month and 3 months and has been well since. Later he reported of his hypertrophic scars and was subsequently referred to the plastic surgeon for management.  The fully expanded lungs from his chest X-ray shown in Figure 11 and the nicely healed thoracotomy scar four months after the surgery as observed at the clinic.

Background
Traumatic diaphragmatic rupture from either penetrating or blunt thoracic or abdominal injuries is a rare occurrence with incidence of less than 10%. Majority of the cases are from high velocity thoracic or abdominal injuries while 25% of Open Journal of Thoracic Surgery     ing trauma tend to cause smaller diaphragmatic defects than those seen in blunt trauma-related injuries. Therefore, they are more prone to complications such as bowel obstruction and strangulation [6]. The diaphragmatic rupture of our first case was missed during the initial exploratory laparotomy due to the small laceration from the knife. The subsequent leakage from the gastric perforation and mediastinitis led to the definite diagnosis leading to further investigation and the patient finally undergoing thoracotomy to repair both the stomach and the diaphragm and also to clean the thoracic cavity. Traumatic

Clinical Presentation
Traumatic diaphragmatic injuries tend to have an insidious course and as such require a high index of suspicion to be diagnosed clinically [3]. Most commonly presented symptoms associated with traumatic diaphragmatic injuries include abdominal pain, dyspnoea, epigastric pain, shoulder pain and vomiting [3] [4].
Accurate preoperative diagnosis of traumatic diaphragmatic herniation has been possible in less than 50% of cases. Clinical presentation has been described in three phases, that is acute, latent or delayed and obstructive phases. The acute phase is predominantly associated with immediately life-threatening conditions such as haemorrhagic shock, respiratory failure, severe head injury or significant visceral injury. Hence, diagnosis of concomitant diaphragmatic rupture and/or Open Journal of Thoracic Surgery herniation is frequently missed especially with a chest X-ray since they are usually inconclusive [1] [2]. The delayed phase usually presents with upper gastrointestinal symptoms, dyspnoea and chest pain or asymptomatic with abnormal chest X-ray [2]. The obstructive phase, a rare but potentially life-threatening event, usually is associated with incarceration and obstruction of herniated viscera [1] [4]. Clinical suspicion of traumatic diaphragmatic rupture should be raised in the event of a thoracic injury with concurrent abdominal symptoms.
The reverse also holds true for abdominal injuries with concurrent thoracic symptoms [2] [3].
Traumatic diaphragmatic rupture with intrathoracic gastric perforation was found in 19% of the 22 cases with diaphragmatic rupture analysed by Akar and Kaya in 2017 [8]. Mortality associated with traumatic diaphragmatic rupture with intra-thoracic gastric perforation has been quoted by Vinnicombe et al.
(2016) to be as high as 46% -52%. Clinically, traumatic diaphragmatic injuries should be suspected in any penetrating injury from the level of the nipple to the umbilicus laterally and below the inferior pole of the scapula posteriorly [5].

Diagnosis
Chest X-ray is the initial screening imaging of choice for the detection of traumatic diaphragmatic ruptures even though diagnostic accuracy is about 30% in left-sided injuries and 18% in right-sided injuries [1] [2]. Yilmaz et al. (2006) showed that chest X-rays could be diagnostic in 25% -50% of cases. Diagnostic accuracy is reduced in the event of an accompanying pleural space collection and in patients with injuries due to penetrating trauma [2] [6] [9]. The pathog-  [6]. Despite having chest tubes passed for the two patients before definite diagnosis and surgery, it is difficult to ascribe the perforation of the stomach to the chest tube since they were all penetrating knife stab wounds and the chest tubes were not found in the stomach when the chest was entered via thoracotomy.

Management
Traumatic diaphragmatic herniation is diagnosed incidentally at surgery or autopsy in 41.3% of cases while delayed diagnosis is seen in about 15% of cases [2]. successfully via thoracotomy [5]. Thoracotomy is also particularly invaluable in patients with delayed presentation of diaphragmatic herniation so as to allow adequate adhesiolysis and easy repair of the rupture [2].
Traumatic diaphragmatic herniation with perforated hollow viscus contributes significantly to intra-abdominal abscesses, empyema thoracis or lobar pneumonia. As such, copious irrigation of the cavity with sufficient drainage is mandatory to limit risk of development [6] as was done for the two cases.

Conclusion
The association of traumatic diaphragmatic rupture with herniated intrathoracic gastric perforation is extremely rare with an associated high morbidity and mortality. The diagnosis needs high index of suspicion. Rapid resuscitation and early surgery via thoracotomy save lifes even in less resource centres.