Evaluation of intrapleural contrast-enhanced abdominal pelvic CT-scan in detecting diaphragm injury in stable patients with thoraco-abdominal stab wound: A preliminary study
Hamid Reza Abbasy
a, Farzad Panahi
b, Sepideh Sefidbakht
c, Majid Akrami
a, Shahram Paydar
a, Sedighe Mirhashemi
b, Shahram Bolandparvaz
a, Kambiz Asaadi
c, Roohollah Salahi
b,*
aShirazUniversityofMedicalSciences–TraumaResearchCenter,Iran
bBaqiyatallahUniversityofMedicalSciences–TraumaResearchCenter,Iran
cShirazUniversityofMedicalSciences–RadiologyResearchCenter,Iran
Diaphragm injury (DI) may result from blunt trauma or penetratingthoraco-abdominalinjury.1IfdiagnosisofDIismissed, itmightresultinthestrangulationoftheabdominalorgansthrough diaphragmdefectintothechestcavity,whichis associatedwith gangreneof organsand, consequently, 30–60% mortalityrate.2,3 AlthoughthefirstreportofDIgoesbackto1941,4diagnosisofDIhas remainedacontroversialaspectofsurgery.1Upto1980,allpatients withpenetratingthoraco-abdominalinjuryunderwentdiagnostic laparotomy or thoracotomy,5,6 procedures associated with 70%
negativeresults.7,8Therefore,effortsfocussedontestingnoninva- sive methods of diagnosis of DI. Nowadays, haemodynamically unstablepatientswithpenetratingthoraco-abdominalstabwound (TASW)shouldbetakenforeitherlaparotomyorthoracotomy.9,10 However,manyofthepatientswithTASWremainasymptomatic;
previous studies reported that 7–48% of asymptomatic patients mighthaveDI.9,11Differenttypesofprotocolsweresuggestedto diagnoseDIinasymptomaticpatientsintraumacentres.
Nowadays, cliniciansconsiderthoracoscopyor multidetector computedtomography(MDCT) scanas thestandardmethodto diagnose DI.6 However, theyare notaccessible in many of the trauma centres in our country and other developing trauma centres.Thismadeustoconsideramethodcompatiblewithour Injury,Int.J.CareInjured43(2012)1466–1469
ARTICLE INFO
Articlehistory:
Accepted6June2011
Keywords:
CTscan Thoracoscopy Stable Stab Approach
ABSTRACT
Background: Manyofthepatientswiththoraco-abdominalstabwoundremainasymptomatic;inthis regard,previous studiesreportedthat7–48% ofasymptomaticpatientshaddiaphragm injury(DI).
Thoracoscopyormultidetectorcomputedtomography(MDCT)scanisthebestmethodtodetectDI.We aimedtoevaluatetheroleofCTscanwithintrapleuralcontrasttoruleoutDIinstablethoraco-abdominal stabwounds.
Method: In aprospective study, we evaluated allhaemodynamicallystable patientswith thoraco- abdominalstabwound,fromOctober2009to2010.Exclusioncriteriaincludedpatientswhoneeded emergencythoracotomyorlaparotomy,thosewhowerehaemodynamicallyunstableandthosewith blunttraumaorgunshotinjury.IntheCT-scandepartment,500ccofdilutedmegluminediatrozatewas transfusedintothepleuralspaceviaachesttubeandtheCTscanwasperformedfromthedomeofthe diaphragmtothepelviccavity.Inthesecondstep,allpatientsweretakenforthoracoscopywithin24h afteradmission.TheCT-scanslidewasconsideredpositiveifoneofthefollowingsignswasfound:(1)the diaphragmwasobviouslyinjured asseeninCT-scanslidesand(2)contrastagentwasseen inthe peritonealcavity.SensitivityandspecificitywerecalculatedforCTscanandthoracoscopy.
Results:Fouroutof40patientshadDIaccordingtothoracoscopy.CTscanwithintrapleuralcontrast predicteddiaphragmaticinjurycorrectlyinallfourpatients.Consideringthoracoscopyasthegold- standardmethod,theCTscanhadtwofalse-positivecases.Thesensitivityoftheintrapleural-contrastCT scanwas100%anditsspecificitywas94.4%.
Conclusion:OurstudyshowedthatCTscanwithintrapleuralcontrastcanbeanacceptableapproachto ruleoutDIandlimittheuseofthoracoscopyforfinaldiagnosisandrepairofDIincaseswithsuspiciousor positiveCT-scanresults, especiallyin traumacentres with highload oftraumapatients andlittle accessibleequipment.
ß2011ElsevierLtd.Allrightsreserved.
*Correspondingauthor.Tel.:+989173147009;fax:+987116269136.
E-mailaddresses:[email protected],[email protected](R.Salahi).
ContentslistsavailableatScienceDirect
Injury
j ou rna l h ome p a ge : w ww . e l se v i e r. co m/ l oc a te / i n j ury
0020–1383/$–seefrontmatterß2011ElsevierLtd.Allrightsreserved.
doi:10.1016/j.injury.2011.06.017
resources, accessible in our centres and, more importantly, sensitiveenoughtoruleoutDIinasymptomaticpatients.Having a sensitive and practical method in our centre will decrease durationofhospitaladmissionandthereforethecostimposedon thesystem.
Our hypothesis was based on theidea that a water-soluble contrast agenttransfused intothe pleural space will enter the peritoneal cavity through diaphragm defect, if it exists. We evaluatedtheaccuracyofanintrapleuralCTscantoruleoutDIin asymptomaticTASWs.AfterextensivesearchinEnglishjournals,it appearsthatitisthefirsttimethattransfusionofasolublecontrast agentthroughachesttubehasbeenusedtodetectDIs.
Method
In a prospective study, we evaluated all haemodynamically stablepatientswithTASWfromOctober2009toOctober2010.The thoraco-abdominalarea was definedas inferiorto thethoracic cavity(belowthenippleinfront,belowthesixthintercostalspace laterallyandtheeighthintercostalspaceattheback)andsuperior quadrantsof the abdomen.Exclusion criteriaincluded patients who neededemergency thoracotomyor laparotomy,haemody- namicallyunstablepatients,patientsforwhomchesttubewasnot neededandblunt-traumapatients.Asinourhospital,theprotocol ofmanagementofgunshotwoundsissurgicalexploration,these patients werealso excluded.Theprotocolwas approvedby our universityethicscommittee.Themethodofthestudy,objectives andcomplicationswerecompletelydescribedforthepatients,and theysignedtheconsentform.
Allthe patients wereexamined by a senior general-surgery resident to detectpleural injury by digital-wound exploration.
Reactiontoiodine-containingcontrastwasnotreportedbyanyof ourpatients.Thechesttubewasclampedandthepatientswere transferredtotheCT-scan department.There, 500ccof diluted megluminediatrozate(including100ccmegluminand400ccof normalsaline0.9%)wastransfusedintothepleural spaceviaa chest tube. During injection, vital signs of the patients were repeatedly checked, and they were requested to report any symptoms, such as dyspnoea, sweating and chills, to detect reactiontocontrastagent.Nointravenousororalcontrastagent wasused.Duringinjectionofthecontrast,weaskedthepatientsto eithercoughorperformtheValsalvamanoeuvre.ACTscanwas performed from the dome of diaphragm to the pelvic cavity (GeneralElectricMedicalSystemMilwaukee,WI,USA).Theslide thicknesswas3mminthedomeofthediaphragmand7mminthe abdomenandpelviccavities.AftertheCTscanwasfinished,the clampofthechesttubewasopenedandnearlytheentirecontrast agentwasdrainedintothechestbottlethroughthechesttube.
Inthesecondstep,allthepatientsweretakenforthoracoscopy within 24h after admission. It was performed under general anaesthesia by a trauma surgeon with at least 10 years of experience.Theradiologistandtraumasurgeonwereunawareof thethoracoscopyorradiologyresults,respectively.CTscanswere reviewed by an attending radiologist. CT-scan slides were consideredpositive ifoneofthefollowingsignswasfound:(1) thediaphragmwasobviouslyinjuredinCT-scanimagesor(2)the contrast agent was seen in the peritoneal cavity. Due to the importanceofnegativepredictivevalue(NPV)inoursubjects(DI), all positive or equivalent reports were considered positive.
Sensitivity, specificity, positive predictivevalue (PPV) and NPV werecalculatedforCTscanandthoracoscopy.
Results
From October 2009 to October 2010, 42 patients met our inclusioncriteriatoenterthestudy.Twopatients refusedtobe
takenforthoracoscopy;therefore,theywereexcludedfromour study.Ourpatientsincludedonefemaleand39males,withthe meanageof23.2years(range:18–37years).Thesiteofthestab wound was right sided in 31 patients and left sided in nine patients. During injection of the contrast agent, none of our patientsdevelopedreactiontotheagent.
Thoracoscopy reports confirmedDI in fourpatients. Wound characteristics,sizeandsiteofDIaresummarised.Inthecase1,the CT scan showed a 5-mm partial tearingin the left diaphragm (Fig. 1(a)). Thoracoscopy confirmed partial tearing of the dia- phragm;however,itwasnotrepairedduetointactperitoneum.In thecase2,theCTscanshowedextravasationofthecontrastagent anteriortotheleftcrusofthediaphragmandaroundthespleen (Fig.1(b)).Thethoracoscopyreportshowed1cmleftDI,whichwas notrepairedduetothesmallsizeoftheinjury.
The CT scan showed focal extension of the contrast agent beneaththerightcrusofthediaphragminthecase3.Inthiscase, thetraumasurgeonreporteda1-cminjuryofthedomeoftheright diaphragm (Fig. 1(c)), which was not repaired. All the above patientswerefollowedupinclinic,andtheywereasymptomatic withnormalchestX-ray.Itwasonlyinthe4thcasethat,dueto existence of a 3-cm injury in the lateral side of the right hemidiaphragm, thoracoscopy shifted to thoracotomyto repair the diaphragm. Minimal amount of contrast extravasationwas seeninthesuprahepaticarea,anteriorandparalleltotherightcrus ofthediaphragm(Fig.1(d)).
Thoracoscopy reports were negative in the rest of the 36 patients;however,theCTscanwaspositiveintwofurthercases.
Thefirstcasewasa23-year-oldmanwithleft-sideTASWinjury.
TheCTscanshowedminimalamountofcontrastagentintheleft subdiaphragmatic and splenorenal areas(Fig.2(a)).The second case was a 28-year-old man with left TASW. The radiologist reportedextravasationofcontrastagentintheleftsubdiaphrag- maticareaandjustintheupperstomacharea(Fig.2(b)).
AftercomparingtheresultsoftheCTscanwiththoracoscopy, sensitivityandNPVoftheCTscanwerereported100%;however, its specificity and PPV were 94.4% and 66.6%, respectively.
Specificity, sensitivity, PPV and NPV of the thoracoscopy were 100%.
Inourstudy,twopatients(5%)developedairleakinthebottleof thechesttubeafterthoracoscopy,whichresolvedduring7days.
AssociatedinjuriesseenintheCTscan wereribfracture(n=2), soft-tissue haematoma (n=20) and subcutaneous emphysema (n=35).Extravasationofthecontrastagentfromthesiteofthe chesttubewasseeninthreecasesintheCTscan.Noneofthese patientsdevelopedskininflammationofthesiteofthechesttube.
Discussion
Our study showed that sensitivity and specificity of the intrapleural-contrastCTscanwere100%and94.4%,respectively, consideringthoracoscopyasthegoldstandard.Ourstudyshowed that CT scan with intrapleural contrast can be one of the approachestoruleoutDI,andlimittheuseofthoracoscopyfor finaldiagnosis and for repairof DI in caseswith suspiciousor positive CT-scanresults, especiallyin traumacentreswithhigh loadoftraumapatientsandlimitedaccessibleequipment.
Consideringthefactthatmanyofthepatientswithpenetrating TASW remain asymptomatic, having a practical and accessible methodtodiagnoseDIinbothdevelopinganddevelopedtrauma centresisdesirable.Recentinvestigationshavediscusseddifferent methods,includingconservativeapproach,digital-woundexplo- ration, deep peritoneal large (DPL), MDCT scan and, finally, thoracoscopytodiagnoseDIinhaemodynamicallystablepatients withTASW.
H.R.Abbasyetal./Injury,Int.J.CareInjured43(2012)1466–1469 1467
Theconservativeapproachandtheserialphysicalexamination failedtodiagnoseDIin20–45%ofthecases.9,11Ultrasonography wasnotaccurateinthediagnosisofDI.6Moreetal.usedDPLto detectDI.Ithadahighaccuracy(90%)inthedetectionofDI;12,13 however, it was not sensitive enough to reliably rule out DI (sensitivity:87.5%,specificity:96.6%).14,15Localwoundexplora- tionwasnotausefulmethodinthecasesofthoraco-abdominal wounds.16ChestX-ray(CXR),themostcommonfirstradiologic
investigation,failedtodetectDIsin12–66%ofthepatients.17,18 Magneticresonanceimaging(MRI)wasagoodmethodtovisualise theentireareaofthediaphragm;however,itwasnotasuitable methodinacutesettings.17ConventionalCTscanhadasensitivity of14–61%andspecificityof76–99%todetectDI.Moreover,itwas not able to differentiate between DI and adjacent pulmonary injuries.19,20PreviousstudiesshowedthatspiralCTscanwasnot reliabletodetectDIsresultingfromTASW21,22becausethistypeof Fig.1.IntrapleuralcontrastCT-scanin4caseswithdiaphragminjury.(A)CT-scanshoweda5mmpartialtearingintheleftdiaphragm,(B)CT-scanshowedextravasationof thecontrastagentanteriortotheleftcrusofthediaphragmandaroundthespleen,(C)CT-scanshowedfocalextentionofcontrastagentbeneaththerightcrusofthe diaphragm,(D)Minimalamountofcontrastextravasationwasseeninthesuprahepaticarea,anteriorandparalleltotherightcrusofthediaphragm.
Fig.2.IntrapleuralcontrastCT-scaninthe2falsepositivecases.(A)CT-scanshowedminimalamountofcontrastagentintheleftsubdiaphragmaticandsplenorenalareas.(B) Extravasationofcontrastagentinleftsubdiaphragmaticareaandjustupperstomachareawerenoted.
H.R.Abbasyetal./Injury,Int.J.CareInjured43(2012)1466–1469 1468
DIisverysmallinsizeandisnotassociatedwithherniationofthe abdominalorgansdespiteDIresultingfromblunttrauma.23
Few studies have evaluated the accuracy of CT scan with contrastagentinthediagnosisofDI.Bodanapallyetal.compared theresultsofMDCTscanwithsurgicaltechniques.Thesensitivity andspecificityofMDCTindetectingDIinTASWwere90%and68%, respectively.ThesignsofDIresultingfromblunttraumawerenot as sensitive for the diagnosis of the typically small-sized DI resultingfromTASW(collarsign:4%,herniationofviscera:17%, discontinuity of diaphragm: 40%).24 In our study, considering thoracoscopy results as gold standard, the CT scan was true positiveinfourcasesandfalsepositiveintwocases.Inthecase1, partialtearingofthediaphragmwasdetectedbyCTscan,which was evident as a focal accumulation of contrast in the site of tearing(Fig.1(a)).Inthecases2,3and4,thecontrastagentwas seen beneath the diaphragm and also around the abdominal organs.
In this study,we evaluated a newCT-scan signof DI(focal accumulationofcontrastalongthediaphragmaticsurface),which hasnotalreadybeendescribed(tothebestofourknowledge,no one has used intrapleural water-soluble contrast material to evaluateDI).Inourlimitednumberofpatients,focalsubpleural accumulationofthecontrastandexistenceofcontrastbeneaththe diaphragm weresensitive enough indicatorsto detectDIs as a screeningtest.The intrapleuralcontrastCTscan hadtwo false- positiveresults.
UndiagnosedcasesofDIremainasymptomaticuntiltheyreturn with life-threatening complications, such as gangrene of the abdominal organs associated with 30–60% mortality rate.2,3 However,previousstudiesfailedtoproposeasensitivenoninva- sivemethodtoruleoutDI.Someresearchershavedeclaredthat12 thereshouldbea standardmethodtoruleoutDIinthestable patients.Steinetal.9,25showedthatthesensitivityandsensitivity of MDCT scan to exclude DI in TASW were 94% and 95.9%, respectively.Unfortunately,theyarenotwidelyavailableyet.9,25 Although we supportthe idea proposed in recent articles that MDCTscan25orthoracoscopyisthebestmethodtodiagnoseDI, becauseofhavinganovercrowdedtraumacentre,wethinkitisnot practicalinourcentretoevaluateallthestablepatientswithTASW withthoracoscopy.Moreover,MDCTscanwasnotavailableinour centreatthetimeofstudyasinmanyofotherdevelopingtrauma centres.In ourcentre, thoracoscopyis usually limitedeither to stablepatientswhobecomesymptomaticduringtheobservation periodortopatientswithprolongedairleakinthechesttube.Itis recommendedthattraumaprotocolsshouldbeadjustedbasedon theavailabilityofmedicalpersonnel,modernmedicalequipment andloadoftraumapatients,althoughtheadvancedprotocolsin developedtraumacentresshouldbeconsidered.26Consequently,it seemsthatitislogicaltohaveasensitiveandpracticalmethodin ourcentretoruleoutDIinstablepatientsandusethoracoscopyfor final diagnosis of DI. Considering our preliminary study, this approach was sensitive enough to rule out DI, although its specificitywaslow.Ifcontinuedinlargerstudies,thisapproachcan decreasethedurationofhospitaladmissionandthereforethecost imposedonthesystem.
Thereweresomelimitationstoourstudy.Contrastwasinjected only in patients with established indications for chest-tube insertion,duetoethicalconcerns.Moreover, atthetime ofthis study,wedidnotpossessasidescopeforthoracoscopy,whichcan alsolimitthestudy’saccuracy.
Conclusion
OurstudyshowedthatCTscanwithintrapleuralcontrastcan be one of the approaches to rule out DI and limit the use of thoracoscopy for finaldiagnosis and repair ofDI in cases with
suspiciousorpositiveCT-scanresults,especiallyintraumacentres withhighloadoftraumapatientsandlittleaccessibleequipment.
Conflictofintereststatement Noconflictofinterest.
Acknowledgements
TheauthorswouldliketothankDr.NasrinShokrpouratCentre for Development of Clinical Research of Nemazee Hospital for editorialassistance.
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