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 Table of Contents     
ORIGINAL ARTICLE
Year : 2022  |  Volume : 18  |  Issue : 3  |  Page : 431-437
 

Can invasive diagnostic methods be reduced by magnetic resonance imaging in the diagnosis of diaphragmatic injuries in left thoracoabdominal penetrating injuries?


1 Department of General Surgery, Istanbul University Faculty of Medicine, Istanbul, Turkey
2 Department of Radiology, Istanbul University Faculty of Medicine, Istanbul, Turkey

Date of Submission04-Aug-2021
Date of Acceptance26-Nov-2021
Date of Web Publication17-May-2022

Correspondence Address:
Dr. Mehmet İlhan
Istanbul University Istanbul Faculty of Medicine, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.jmas_259_21

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 ¤ Abstract 


Aim: In this study, we aimed to investigate the effect of magnetic resonance imaging (MRI) in detecting diaphragmatic injury by comparing preoperative computed tomography (CT) and MRI imaging results with diagnostic laparoscopy/thoracoscopy results in patients with left thoracoabdominal penetrating injury. We investigated whether MRI reduces the rate of unnecessary surgery by examining its sensitivity and specificity.
Materials and Methods: Patients with left thoracoabdominal penetrating injuries who applied to the Emergency Surgery Unit of Istanbul University Istanbul Faculty of Medicine between November 2017 and December 2020 were evaluated. Patients who underwent emergency surgery, who could not undergo MRI or CT for any reason or who could not be operated on were excluded from the study. Preoperative MRI and CT images of patients who underwent diagnostic laparoscopy/thoracoscopy due to left thoracoabdominal injury in our clinic were evaluated retrospectively by a radiologist who did not know the surgical results. MRI results of the cases were compared with surgical findings and CT images.
Results: A total of 43 (41 males, mean age: 31, range: 15–57) patients were included in the study. The most common physical examination finding was lateral injury. The diaphragmatic injury was detected in 13 (30%) cases during surgical interventions. Laparoscopic repair was performed in 11 (84%) cases and thoracoscopic repair was performed in 2 (15%) cases with diaphragmatic injuries. MRI images of 14 (32%) cases were found to be compatible with diaphragmatic injury, in 1 of them no injury was observed during surgical intervention. According to these data, the sensitivity of MRI was calculated as 100%, specificity 94%, positive predictive value 86%, and negative predictive value 100%. The mean hospital stay was 6 days (1–30) in all cases.
Conclusion: In our study, MRI was found to have high specificity and sensitivity in detecting diaphragmatic injuries. The number of negative laparoscopy/thoracoscopy can be reduced by performing surgical intervention only in cases with positive or suspected diaphragmatic injury on MRI. Results should be supported by conducting new studies with larger case series with normal MRI findings and long follow-ups.


Keywords: Diagnostic laparoscopy, diaphragmatic injury, magnetic resonance imaging, penetrating left thoracoabdominal injury


How to cite this article:
Alizade E, İlhan M, Durak G, Kaan Gok AF, Ertekin C. Can invasive diagnostic methods be reduced by magnetic resonance imaging in the diagnosis of diaphragmatic injuries in left thoracoabdominal penetrating injuries?. J Min Access Surg 2022;18:431-7

How to cite this URL:
Alizade E, İlhan M, Durak G, Kaan Gok AF, Ertekin C. Can invasive diagnostic methods be reduced by magnetic resonance imaging in the diagnosis of diaphragmatic injuries in left thoracoabdominal penetrating injuries?. J Min Access Surg [serial online] 2022 [cited 2022 Jul 5];18:431-7. Available from: https://www.journalofmas.com/text.asp?2022/18/3/431/345444





 ¤ Introduction Top


Traumatic diaphragmatic injuries are potentially life-threatening injuries and usually occur as a result of trauma to the thoracoabdominal region. The rate of development of diaphragmatic injury varies between 1% and 5% in all thoracoabdominal injuries.[1] There is a higher probability of diaphragmatic injury in penetrating injuries (10% and 15%) than in blunt injuries (1% and 7%).[2]

Traumatic diaphragmatic injuries are most commonly diagnosed in left-sided injuries and represent 75% of cases. The organs that herniate on the left side are usually the stomach, spleen, large intestine, liver, small intestine, and omentum. Because of the protection of the liver on the right side, herniation is not very common.

Traumatic diaphragmatic injuries alone rarely cause death, but gastrointestinal herniations occurring in the late period may cause serious complications and death due to failure to diagnose at the time of admission. Mortality rates in cases of visceral herniation and drowning are reported to vary between 30% and 60%. All these show that traumatic diaphragmatic injuries are important injuries with vital importance, and early diagnosis and subsequent repair of the injury are of vital importance.

Detection of hemidiaphragm damage poses a diagnostic challenge for both radiologists and surgeons. Injury may initially be ignored unless there are obvious signs of diaphragmatic injury on imaging at presentation. Postponing the diagnosis causes morbidity and mortality. In order not to ignore diaphragmatic damage, especially in left thoracoabdominal penetrating injuries, all available radiological examinations are used today. Computed tomography (CT) detects life-threatening lung, spleen, liver and kidney injuries in left thoracoabdominal traumas and assists in the management of subsequent follow-ups of the trauma patient. However, it has been reported that 6% of CT results are false-negative in the detection of diaphragmatic injury.[3] Magnetic resonance imaging (MRI) has superiority over CT in the evaluation of soft tissues. Using this feature of MR, diaphragmatic damage can be examined more deeply and injury can be detected in patients with thoracoabdominal penetrating trauma.[4],[5],[6],[7] Diagnostic laparoscopy/thoracoscopy is used in both diagnosis and treatment.

When we analyze the studies focused on traumatic diaphragmatic injuries, we see that the majority of these studies are aimed at determining the diagnostic efficacy of CT for injuries by retrospectively examining CT scans in patients diagnosed with diaphragmatic damage by diagnostic laparoscopy. We can see the benefit of MRI in demonstrating diaphragmatic damage mostly in studies conducted on patients with congenital diaphragmatic defects.[8],[9],[10],[11],[12],[13]

In our study, we aimed to investigate the effectiveness of MR in detecting diaphragmatic injury by comparing the results of preoperative CT and MRI scans with the results of diagnostic laparoscopy/thoracoscopy in patients with left thoracoabdominal penetrating trauma.


 ¤ Materials and Methods Top


In our hospital, CT is used for patients with left thoracoabdominal injuries to exclude solid organ injuries, as in other major traumas. Moreover, routinely, diagnostic surgery, which we accept as the gold standard, is performed after 48 h for patients with hemodynamically stable follow-ups. Aiming to investigate the effectiveness of MRI in detecting diaphragmatic injury in left thoracoabdominal injuries, we planned to apply MRI to stable preoperative patients and created a new protocol.

Cases brought to Istanbul University Istanbul Medical Faculty Emergency Surgery Unit between November 2017 and December 2020 with penetrating injuries were evaluated. Patients with other penetrating trauma such as isolated thorax, abdominal, extremity and right thoracoabdominal were excluded from the study. The left thoracoabdominal penetrating injury was observed in 63 (17%) of 381 penetrating trauma cases. Amongst these cases, a total of 17 hemodynamically unstable patients, who underwent emergency surgery due to additional organ injuries, who could not undergo MRI, whose surgery was delayed due to pregnancy and who did not want to have surgery by signing a test treatment rejection form were excluded from the study and the remaining 43 patients were included in the study [Table 1].
Table 1: Patient flow chart

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The initial evaluation of all cases was managed following the advanced trauma life support protocol.[14] The patients were grouped as anterior, lateral and posterior according to the thoracoabdominal injury site:

  1. Anterior left thoracoabdominal injury: Injuries located anterior to the axillary line (below the nipple in front, left superior quadrant of the abdomen)
  2. Lateral left thoracoabdominal injury: Left thoracoabdominal injuries between the anterior axillary line and the posterior axillary line (below the sixth intercostal space, left superior quadrant of the abdomen)
  3. Posterior left thoracoabdominal injury: Injuries located posterior to the posterior axillary line (the eighth intercostal space at the back, left superior quadrant of the abdomen).


The wounds of all patients were closed with single sutures after the first physical examination. All cases were evaluated in terms of tetanus prophylaxis; one dose of tetanus vaccine was administered to those whose last vaccination date was older than 5 years. CT was performed in patients who were hemodynamically stable after a physical examination and had CT indication. Upper abdomen MRI was performed for the patients who were hemodynamically stable in the follow-up and did not have any obstacle for MRI, to evaluate the diaphragm. Axial, coronal and sagittal t2w_haste sequences and T1-weighted dynamic axial fat-suppressed sequences were taken during MRI. The images of the patients were stored in the picture archiving and communication system (Picture Archiving Communication System) of our hospital. Diagnostic laparoscopy/thoracoscopy was performed 48 h after admission to the patients. Cases with intra-abdominal solid organ injuries were followed longer before surgery and were operated on 6–7 days of their arrival. All patients were hospitalised until surgical intervention and were followed up by physical examination, hemoglobin/hematocrit control and vital signs.

The demographic data of our cases, thoracoabdominal injury site, trauma mechanism, presence of additional trauma findings, hemodynamic parameters, diagnostic methods used in the evaluation of the diaphragmatic injury, treatment method and hospital stay were evaluated retrospectively. In our hospital, MRI scans are reported not immediately after the imaging procedure but together with the surgical results and reported by different radiologists. Therefore, computed tomography and magnetic resonance imaging of all patients were then retrospectively reviewed by a single radiologist over the picture archiving and communication system, without knowing the surgical evaluation results.

The obtained qualitative data were compared using the Fisher test. Diagnostic values were calculated using probability tables. Positive and negative predictive values were calculated by considering the disease prevalence in the main cluster equal to that in the sample. The results had a 95% confidence interval and were statistically significant with P < 0.05. Findings obtained in the study were calculated by entering IBM SPSS (SPSS Inc., ver. 21. Chicago, IL, USA).

Ethics committee

The study titled 'Effectiveness of magnetic resonance imaging in detecting diaphragmatic injury in left thoracoabdominal stab wounds\ with file number 2017/653 was discussed at the meeting of our committee, dated 09/08/2017 and numbered 13, and was found ethically appropriate.


 ¤ Results Top


Forty-three of 63 patients with left thoracoabdominal injury were included in the study. CT and MRI could not be performed because emergency laparotomy was performed in seven patients who were excluded from the study, and resuscitative thoracotomy was performed in two patients. Diagnostic laparoscopy of another case was delayed due to pregnancy after MRI was performed. Angioembolisation was applied to the patient who developed retroperitoneal and intra-abdominal hematoma due to spleen, kidney and lumbar artery injury, and then she was discharged with a diagnostic thoracoscopy planned by the thoracic surgeon.

40 (95%) of our cases were male and 3 (5%) were female, with a mean age of 31 (15–57). Stab wounds were detected in forty patients and gunshot wounds in three patients [Table 2].
Table 2: Characteristics of patients presenting with penetrating left thoracoabdominal injur

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Multiple incisions were observed in 26 (60%) patients with stab wounds. In 23 of these, incisions due to more than one stab wound were seen on the extremities. In others, incisions of different sizes were observed in the cranial, thorax, abdomen and lumbar regions. Pneumothorax in 13 cases (30%), hemothorax in 4 cases (9%), hemopneumothorax in 5 cases (12%), rib fracture in 10 cases (23%), spleen injury in 6 cases (14%), kidney injury in 2 cases (4%) and gastric injury were accompanying in 1 case (3%). Six patients with solid organ injury were treated conservatively [Table 3].
Table 3: Additional organ injury in patients with left thoracoabdominal injury

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The most common physical examination finding was lateral left thoracoabdominal injury. Nineteen (44%) of the cases were lateral, 12 (28%) posterior and 10 (23%) anterior thoracoabdominal injuries. Two patients had simultaneous injuries from two localisations (lateral + anterior, lateral + posterior). Injury findings were observed on MRI in 3 (25%) of 12 patients with posterior injuries, 7 (36%) of 19 patients with lateral injuries, 3 (30%) of 10 patients with anterior injuries, and one patient with anterior + lateral injuries [Table 4].
Table 4: Diaphragmatic injury findings according to injury localisation

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Diagnostic laparoscopy was performed in forty patients, and diagnostic thoracoscopy was performed in three patients. The diaphragmatic injury was detected in only 13 (30%) patients who underwent surgical intervention, and primary repair was performed.

Organ herniation accompanying the diaphragmatic defect was observed in only two cases as a surgical finding. The herniated organ was the omentum in both cases. No mortality was observed in any of the cases. The mean hospital stay was 6 (1–30) days. The injury area was evaluated at intercostal intervals in patients. It was observed that 22% of the injuries (14 patients) were at the level of the 7th intercostal space [Table 5].
Table 5: Correlation between injury localisation and diaphragmatic injury and the effectiveness of magnetic resonance imaging in demonstrating injury

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When the imaging of the patients was evaluated, it was observed that MRI was positive in 14 cases, MRI negative in 29 cases, CT positive in 17 cases and CT negative in 40 cases. When MRI and CT findings are compared with surgical results, MRI sensitivity is 100% (95% confidence interval [CI]: 75.3–100), specificity 96.6% (95% CI: 82.8–99.2) and positive predictive value (PPV) 92.8% (95% CI: 65.4–98.9) in demonstrating diaphragmatic injury. Negative predictive value (NPV) was calculated as 100%. CT sensitivity was 92.8% (95% CI: 66.1–99.8), specificity 96.7% (95% CI: 82.8–99.9), PPV 92.8% (95% CI: 65.3–98.9) and NPV 96.7% (95% CI: 81.4–99.4) [Table 6].
Table 6: Comparison of the efficacy of MRI and CT in detecting diaphragmatic injury

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The diagnosis of diaphragmatic damage was confirmed by surgery in 12 of 13 cases with CT showing a diaphragmatic defect and 13 of 14 cases with MRI showing a diaphragmatic defect. False-positive results were obtained in both MRI and CT in one patient. In this case, no finding indicating diaphragmatic damage was found in diagnostic laparoscopy. When the results were compared, MRI and CT findings were similar [Table 7].
Table 7: Comparison of the efficacy of MRI and CT in detecting diaphragmatic injury

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 ¤ Discussion Top


In the literature, the rate of development of diaphragmatic rupture in trauma patients varies between 1% and 5%.[1] Especially in cases of the left-sided thoracoabdominal penetrating device, the rate of development of the diaphragm is higher in the report. Traumatic diaphragms are 10 times more common in the left diaphragm than in the right.[15] In our study, the diaphragmatic injury was observed at a rate of 30% in left thoracoabdominal penetrating device cases.

In patients who are asymptomatic in the early period after injury, complaints begin with herniation of intra-abdominal organs into the thorax due to the enlargement of the defect in the later stages. After the development of hernia due to diaphragmatic injury, strangulation of herniated organs carries a serious life risk. When diaphragmatic injuries cannot be detected in the acute phase of trauma, the affected structures may strangulate into the thorax, and thus the mortality rate may increase from 20% to 80%.[16],[17],[18] In a study of 65 patients conducted by Peter et al. between 1989 and 2000, preoperative diaphragmatic damage was diagnosed in only 17 patients (26%).[19] In our study, the diaphragmatic injury was observed in 13 (30%) of 43 patients, and all of these cases could be diagnosed with preoperative MRI.

Therefore, diagnosis and surgical treatment of diaphragmatic injury in asymptomatic patients in thoracoabdominal injuries is an important task for surgeons. Surgery for the repair of diaphragmatic injury in other patients is a difficult decision unless there is no doubt that surgical intervention is necessary for the presence of signs of hemodynamic instability and peritonitis. Direct radiography, CT and MRI are used for diagnostic purposes. Diagnostic laparoscopy/thoracoscopy is used for both diagnostic and therapeutic purposes. Although therapeutic laparotomy was previously performed in symptomatic patients, with the widespread use of laparoscopy, surgeons began to move away from laparotomy, which has higher morbidity and mortality.[20],[21],[22],[23],[24] Over the last few years, laparoscopic equipment and techniques have been further developed. In a multicentric study using the data of our clinic, it is reported that the sensitivity, specificity and accuracy of laparoscopy in trauma are close to 100%. Regarding missed injuries, the rate during laparoscopy was as low as 0.12%, which was not statistically different from the rate during laparotomy.[25] Based on these studies, which our clinic also contributed, diagnostic surgery to be applied to cases with left thoracoabdominal penetrating injuries is performed by laparoscopic or thoracoscopic methods in our clinic.

There are previous studies comparing imaging studies to diagnose diaphragmatic injury in patients with left thoracoabdominal injury. Most radiological studies have focused on evaluating the accuracy of CT in diagnosing diaphragmatic injuries following trauma. Some studies report that the sensitivity of CT in the diagnosis of diaphragmatic injury is 80% and the specificity is 77%.[5],[26],[27],[28] In a previous study in our clinic, the sensitivity and specificity of CT in the diagnosis of diaphragmatic injury were 84% and 95%.[29]

In the literature, the use of MRI mostly in congenital diaphragmatic hernias has been discussed.[11] However, there are few studies on the effectiveness of MRI in demonstrating diaphragmatic injury in trauma patients.[30],[31],[32] MRI has superiority over CT in the evaluation of soft tissues. Dynamic scanning in MRI imaging has the advantage of allowing the evaluation of diaphragmatic motion. The major advantage of MRI is its ability to directly acquire coronal and sagittal images that allow the evaluation of the entire diaphragm in both normal and pathological conditions.[33] In a study conducted in Italy, MRI showed the correct location and size of diaphragmatic rupture in all cases.[34] In a study by Daum et al., it was revealed that diaphragmatic ruptures can be ignored in traumas, and the role of MRI in diagnosing patients who present with delayed diaphragmatic rupture later on.[35] Most trauma centers have limited experience in evaluating diaphragmatic injuries with MRI. Some studies are showing that MRI is not practical, especially in multitrauma patients.[36] According to the experience, we gained while doing the study, it is possible to have MRI in third-level hospitals where the appropriate infrastructure is available, even for multitrauma patients with stable hemodynamics. This is a rare study demonstrating the efficacy of MRI in detecting diaphragmatic injury in penetrating traumas. In our study, MRI was performed in 26 hemodynamically stable patients with multitrauma (60% of all our patients).

MRI also has disadvantages such as accessibility, time and cost.[37],[38] Interpreting images require special expertise and may not be available in many centers. All these do not make MRI a second-line tool for examining the diaphragm. In hemodynamically stable patients, MRI imaging can be easily obtained in high-level trauma centers when there is no contraindication to MRI (incompatible prosthesis, pacemaker, etc.).

In our study, the diagnosis of diaphragmatic damage was generally made by the appearance of a direct defect in the diaphragm on MRI images. Since the images were taken in the earlier period, no organ herniation was observed in any of the patients. Apart from this, nonspecific findings such as edema and thickening in the diaphragm were also observed. Disruption of diaphragmatic integrity has the highest value of all symptoms, indicating that it is the most useful sign in diagnosing diaphragmatic injury in penetrating trauma.

Interventions and materials used during the first intervention may adversely affect the quality of MRI imaging.[39],[40] In our study, 19 (41%) patients were found to have a thoracic tube. This both impairs the quality of the imaging as an artifact and causes a poor quality image as it prevents the patients from holding their breath during the examination.

In our study, although findings consistent with diaphragmatic injury were detected in both MRI and CT scans in one patient, no evidence of diaphragmatic damage was found in the diagnostic laparoscopy. When the images of this patient, who had an injury associated with a 5 cm incision corresponding to the 9th intercostal space in the left anterior thoracoabdominal region were re-examined, it was concluded that, although the diaphragm was damaged, the diaphragm might not have been full-thickness incision and therefore no diaphragmatic injury could be observed in diagnostic laparoscopy. Although diagnostic laparoscopy/thoracoscopy are the gold standard diagnostic methods, when is used alone, only one side of the diaphragm is visualised, so diaphragmatic injuries without a full-thickness incision are not visible.

In our study, we evaluated the effectiveness of MRI in detecting diaphragmatic injury in patients with penetrating left thoracoabdominal injury. The performance of MRI in demonstrating diaphragmatic injury was sufficient (sensitivity 100% and specificity 96.6%). The efficacy of MRI in demonstrating diaphragmatic injury was similar when compared to CT and the gold standard diagnostic laparoscopy. Given these data, MRI alone is sufficient to detect diaphragmatic injury and may reduce the need for routine diagnostic laparoscopy/thoracoscopy to evaluate the diaphragmatic injury.

It is difficult to diagnose diaphragmatic injury without surgical exploration. In our study, it was demonstrated that MRI is a technique that succeeds in providing a comprehensive evaluation of the diaphragm, which is the main inspiratory muscle. Therefore, radiologists and clinicians should be aware of the diagnostic possibilities of this safe technique.

As a result of this study, diagnostic surgical methods, which we previously accepted as the gold standard in the detection of diaphragmatic injury in left thoracoabdominal traumas, are no longer routinely applied in our center. Patients with normal CT and MRI findings are followed up after detailed information is given.


 ¤ Conclusion Top


MR has high specificity and sensitivity in detecting diaphragmatic injuries, and its performance is similar to CT and the gold standard diagnostic laparoscopy/thoracoscopy.

Diaphragmatic injury can be excluded by performing MRI instead of CT, which has major side effects such as radiation and contrast nephropathy. CT findings applied to exclude organ injury in patients with suspected solid organ injury can also be supported by MRI. The number of negative laparoscopy/thoracoscopy can be reduced by performing surgical intervention only in cases with positive or suspected diaphragmatic injury on MRI. Results should be supported by conducting new studies with larger case series with normal MR findings and long follow-ups.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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© 2004 Journal of Minimal Access Surgery
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Online since 15th August '04