Images for surgeons
References 1. Oien KA. Pathologic evaluation of unknown primary cancer. Semin. Oncol. 2009; 36: 8–37. 2. Cheville JC, Lohse CM, Zincke H et al. Sarcomatoid renal cell carcinoma: an examination of underlying histologic subtype and an analysis of associations with patient outcome. Am. J. Surg. Pathol. 2004; 28: 435–41. 3. de Peralta-Venturina M, Moch H, Amin M et al. Sarcomatoid differentiation in renal cell carcinoma: a study of 101 cases. Am. J. Surg. Pathol. 2001; 25: 275–84. 4. Akhtar M, Tulbah A, Kardar AH et al. Sarcomatoid renal cell carcinoma: the chromophobe connection. Am. J. Surg. Pathol. 1997; 21: 1188–95. 5. Maldazys JD, deKernion JB. Prognostic factors in metastatic renal carcinoma. J. Urol. 1986; 136: 376–9.
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6. Shuch B, Bratslavsky G, Linehan WM, Srinivasan R. Sarcomatoid renal cell carcinoma: a comprehensive review of the biology and current treatment strategies. Oncologist 2012; 17: 46–54. 7. Steiner T, Mickisch GH. Metastatic renal cell carcinoma: primary and follow-up treatment. Urologe A. 2013; 52: 1529–30.
Yit Leang, MBBS Nieroshan Rajarubendra, MBBS Stephen Brough, MBChB, FRACS Urology Department, Launceston General Hospital, Launceston, Tasmania, Australia doi: 10.1111/ans.12592
Delayed presentation of a traumatic diaphragmatic hernia presenting as a large bowel obstruction: a case report A 71-year-old man presented to our emergency department with a 2-day history of intermittent left-sided abdominal pain and nausea, preceded by 5 days of constipation. His past medical history included hypertension and hypercholesterolaemia, but no previous abdominal surgery. He described a change in his bowel habit tending towards diarrhoea over several months but no passage of blood or mucus. On examination, he appeared uncomfortable and restless but with normal vital observations. His abdomen was grossly distended but soft with minimal left-sided tenderness. There were no peritoneal signs and no visible or palpable hernia. Digital rectal examination revealed a collapsed, empty rectum and no palpable mass. His white blood cell count was elevated at 18 × 109/L with a left shift. His haemoglobin was within normal limits. A plain supine abdominal X-ray revealed dilatation of proximal large bowel to the region of the splenic flexure, with minimal small bowel dilatation (Fig. 1). A chest X-ray revealed an elevated left hemi-diaphragm, but no free air beneath the hemi-diaphragms (Fig. 2). A diagnosis of large bowel obstruction was made. The underlying aetiology was thought likely to be a malignant obstructing tumour of the splenic flexure colon. A computed tomography scan was ordered which demonstrated his splenic flexure colon herniating through a defect in the left hemi-diaphragm with transition point clearly visible (Fig. 3). The patient was taken to the operating theatre for an urgent laparotomy. The diaphragmatic defect was seen and incarcerated splenic flexure colon was reduced from within it. An underwater seal intercostal drain was inserted into the left hemi-thorax and the diaphragmatic defect was closed with prolene sutures. Serosal tears of the incarcerated splenic flexure colon were oversewn but the colon remained viable and did not require resection. The patient was discharged from hospital 10 days later and made a full recovery. Of interest, on further questioning, the patient described an accident 5 years before, where he fell more than 1 m off a fence onto the left side of his lower chest impacting with a tree stump. He fractured his left 9–11th ribs posterolaterally at that time and was treated in the emergency department and discharged home. Traumatic diaphragmatic hernia is a well described but rare consequence of blunt thoracoabdominal trauma.1,2 It has been reported © 2014 Royal Australasian College of Surgeons
Fig. 1. Supine abdominal X-ray. Grossly dilated large bowel is visible. The lower arrow points to the caecal distension. The upper arrow points to the distal portion of the dilatation at the splenic flexure.
to occur in up to 5% of patients presenting with blunt abdominal trauma.3 The mechanism proposed is an increase in intra-abdominal pressure at the time of impact which results in shearing forces to the stretched diaphragm and avulsion from its points of attachment.1 The result is abdominal contents which protrude through a weakness in the diaphragm and into the chest. The most common viscera involved in the hernia are omentum, stomach, colon and spleen.1,2,4,5 Left-sided hernias are more common than right due to the liver shielding the diaphragmatic defect from the abdominal organs.1–4 The diagnosis is often missed at the time of the injury with a diagnosis only being made in 40–62% of cases.3 The time until diagnosis in cases of delayed presentation has been reported up to 50 years following injury.6 Most delayed cases reported in the literature,
98
Images for surgeons
Fig. 2. An erect chest X-ray. The arrow points to the splenic flexure colon above the hemi-diaphragm, interpreted and reported as an elevated left hemi-diaphragm with dilated colon beneath it. Old rib fractures are noted of the left lower ribs.
however, present 3 to 5 years later.1,2,7 Cases of delayed diagnosis usually present with abdominal or chest pain, dyspnoea and a clinical picture of bowel obstruction or occasionally bowel ischaemia.1–3 Bowel perforation and pleural contamination can cause severe sepsis and mortality. Chest X-ray has a low sensitivity for detecting diaphragmatic rupture with a sensitivity of only 46%.1 Computed tomography has a much higher sensitivity of 71% and is the preferred diagnostic imaging modality.1,3 Laparotomy with reduction and repair of the hernia defect is the standard treatment for traumatic diaphragmatic hernia.1–3 Other surgical interventions include thoracotomy, laparoscopy and thoracoscopy.1,3 Laparotomy has the advantage of allowing the surgeon to evaluate the integrity of the abdominal organs.8 This is particularly important in cases of suspected strangulation and ischaemia of bowel. Non-absorbable suture material is generally recommended to repair the diaphragmatic defect, and mesh is also advised for larger defects.1,3,4 Large bowel obstruction is usually caused by an obstructing colonic tumour, volvulus or diverticular disease.8,9 Herniation of colon through a traumatic diaphragmatic defect is a rare cause of large bowel obstruction and is unlikely to be suspected by clinicians and radiologists, especially when there has been a considerable delay between the initial injury and the presentation.9 This case highlights the significance of previous thoracoabdominal injury in patients presenting with bowel obstruction and the important role of computed tomography in cases of large bowel obstruction.
References 1. Rashid F, Chakrabarty MM, Singh R, Iftikhar SY. A review on delayed presentation of diaphragmatic rupture. World J. Emerg. Surg. 2009; 4: 32. 2. Saber WL, Moore EE, Hopeman AR, Aragon WE. Delayed presentation of traumatic diaphragmatic hernia. J. Emerg. Med. 1986; 4: 1–7.
Fig. 3. A sagittal slice computed tomography abdomen. The upper arrow points to a closed loop of splenic flexure colon above the left hemidiaphragm. The middle arrow points the transition point of the obstruction. The lower arrow points to dilated colon proximal to the obstruction.
3. Crandall M, Popowich D, Shapiro M, West M. Posttraumatic hernias: historical overview and review of the literature. Am. Surg. 2007; 73: 845–50. 4. Kishore GSB, Gupta V, Doley RP et al. Traumatic diaphragmatic hernia: tertiary centre experience. Hernia 2010; 14: 159–64. 5. Strug B, Noon GP, Beall AC. Traumatic diaphragmatic hernia. Ann. Thorac. Surg. 1974; 17: 444–9. 6. Singh S, Kalan MM, Moreyra CE, Buckman RF Jr. Diaphragmatic rupture presenting 50 years after the traumatic event. J. Trauma Acute Care Surg. 2000; 49: 156–9. 7. Lal S, Kailasia Y, Chouhan S, Gaharwar APS, Shrivastava GP. Delayed presentation of post traumatic diaphragmatic hernia. J. Surg. Case Rep. 2011; 2011: 6. 8. Williams NS, Bulstrode CJ, Ronan P, O’Connell MD (eds). Bailey & Love’s Short Practice of Surgery 26E. Houston Tex.: CRC Press, 2013. 9. Cruz CJ, Minagi H. Large-bowel obstruction resulting from traumatic diaphragmatic hernia: imaging findings in four cases. AJR Am. J. Roentgenol. 1994; 162: 843–5.
Nicholas J. Fischer,* MBChB, MPHTM Semisi Aiono,† MSc, FRCS *Department of General Surgery, Dunedin Hospital, Dunedin, and †Department of General Surgery, Whanganui Hospital, Whanganui, New Zealand doi: 10.1111/ans.12596
© 2014 Royal Australasian College of Surgeons
References 1. Oien KA. Pathologic evaluation of unknown primary cancer. Semin. Oncol. 2009; 36: 8–37. 2. Cheville JC, Lohse CM, Zincke H et al. Sarcomatoid renal cell carcinoma: an examination of underlying histologic subtype and an analysis of associations with patient outcome. Am. J. Surg. Pathol. 2004; 28: 435–41. 3. de Peralta-Venturina M, Moch H, Amin M et al. Sarcomatoid differentiation in renal cell carcinoma: a study of 101 cases. Am. J. Surg. Pathol. 2001; 25: 275–84. 4. Akhtar M, Tulbah A, Kardar AH et al. Sarcomatoid renal cell carcinoma: the chromophobe connection. Am. J. Surg. Pathol. 1997; 21: 1188–95. 5. Maldazys JD, deKernion JB. Prognostic factors in metastatic renal carcinoma. J. Urol. 1986; 136: 376–9.
97
6. Shuch B, Bratslavsky G, Linehan WM, Srinivasan R. Sarcomatoid renal cell carcinoma: a comprehensive review of the biology and current treatment strategies. Oncologist 2012; 17: 46–54. 7. Steiner T, Mickisch GH. Metastatic renal cell carcinoma: primary and follow-up treatment. Urologe A. 2013; 52: 1529–30.
Yit Leang, MBBS Nieroshan Rajarubendra, MBBS Stephen Brough, MBChB, FRACS Urology Department, Launceston General Hospital, Launceston, Tasmania, Australia doi: 10.1111/ans.12592
Delayed presentation of a traumatic diaphragmatic hernia presenting as a large bowel obstruction: a case report A 71-year-old man presented to our emergency department with a 2-day history of intermittent left-sided abdominal pain and nausea, preceded by 5 days of constipation. His past medical history included hypertension and hypercholesterolaemia, but no previous abdominal surgery. He described a change in his bowel habit tending towards diarrhoea over several months but no passage of blood or mucus. On examination, he appeared uncomfortable and restless but with normal vital observations. His abdomen was grossly distended but soft with minimal left-sided tenderness. There were no peritoneal signs and no visible or palpable hernia. Digital rectal examination revealed a collapsed, empty rectum and no palpable mass. His white blood cell count was elevated at 18 × 109/L with a left shift. His haemoglobin was within normal limits. A plain supine abdominal X-ray revealed dilatation of proximal large bowel to the region of the splenic flexure, with minimal small bowel dilatation (Fig. 1). A chest X-ray revealed an elevated left hemi-diaphragm, but no free air beneath the hemi-diaphragms (Fig. 2). A diagnosis of large bowel obstruction was made. The underlying aetiology was thought likely to be a malignant obstructing tumour of the splenic flexure colon. A computed tomography scan was ordered which demonstrated his splenic flexure colon herniating through a defect in the left hemi-diaphragm with transition point clearly visible (Fig. 3). The patient was taken to the operating theatre for an urgent laparotomy. The diaphragmatic defect was seen and incarcerated splenic flexure colon was reduced from within it. An underwater seal intercostal drain was inserted into the left hemi-thorax and the diaphragmatic defect was closed with prolene sutures. Serosal tears of the incarcerated splenic flexure colon were oversewn but the colon remained viable and did not require resection. The patient was discharged from hospital 10 days later and made a full recovery. Of interest, on further questioning, the patient described an accident 5 years before, where he fell more than 1 m off a fence onto the left side of his lower chest impacting with a tree stump. He fractured his left 9–11th ribs posterolaterally at that time and was treated in the emergency department and discharged home. Traumatic diaphragmatic hernia is a well described but rare consequence of blunt thoracoabdominal trauma.1,2 It has been reported © 2014 Royal Australasian College of Surgeons
Fig. 1. Supine abdominal X-ray. Grossly dilated large bowel is visible. The lower arrow points to the caecal distension. The upper arrow points to the distal portion of the dilatation at the splenic flexure.
to occur in up to 5% of patients presenting with blunt abdominal trauma.3 The mechanism proposed is an increase in intra-abdominal pressure at the time of impact which results in shearing forces to the stretched diaphragm and avulsion from its points of attachment.1 The result is abdominal contents which protrude through a weakness in the diaphragm and into the chest. The most common viscera involved in the hernia are omentum, stomach, colon and spleen.1,2,4,5 Left-sided hernias are more common than right due to the liver shielding the diaphragmatic defect from the abdominal organs.1–4 The diagnosis is often missed at the time of the injury with a diagnosis only being made in 40–62% of cases.3 The time until diagnosis in cases of delayed presentation has been reported up to 50 years following injury.6 Most delayed cases reported in the literature,
98
Images for surgeons
Fig. 2. An erect chest X-ray. The arrow points to the splenic flexure colon above the hemi-diaphragm, interpreted and reported as an elevated left hemi-diaphragm with dilated colon beneath it. Old rib fractures are noted of the left lower ribs.
however, present 3 to 5 years later.1,2,7 Cases of delayed diagnosis usually present with abdominal or chest pain, dyspnoea and a clinical picture of bowel obstruction or occasionally bowel ischaemia.1–3 Bowel perforation and pleural contamination can cause severe sepsis and mortality. Chest X-ray has a low sensitivity for detecting diaphragmatic rupture with a sensitivity of only 46%.1 Computed tomography has a much higher sensitivity of 71% and is the preferred diagnostic imaging modality.1,3 Laparotomy with reduction and repair of the hernia defect is the standard treatment for traumatic diaphragmatic hernia.1–3 Other surgical interventions include thoracotomy, laparoscopy and thoracoscopy.1,3 Laparotomy has the advantage of allowing the surgeon to evaluate the integrity of the abdominal organs.8 This is particularly important in cases of suspected strangulation and ischaemia of bowel. Non-absorbable suture material is generally recommended to repair the diaphragmatic defect, and mesh is also advised for larger defects.1,3,4 Large bowel obstruction is usually caused by an obstructing colonic tumour, volvulus or diverticular disease.8,9 Herniation of colon through a traumatic diaphragmatic defect is a rare cause of large bowel obstruction and is unlikely to be suspected by clinicians and radiologists, especially when there has been a considerable delay between the initial injury and the presentation.9 This case highlights the significance of previous thoracoabdominal injury in patients presenting with bowel obstruction and the important role of computed tomography in cases of large bowel obstruction.
References 1. Rashid F, Chakrabarty MM, Singh R, Iftikhar SY. A review on delayed presentation of diaphragmatic rupture. World J. Emerg. Surg. 2009; 4: 32. 2. Saber WL, Moore EE, Hopeman AR, Aragon WE. Delayed presentation of traumatic diaphragmatic hernia. J. Emerg. Med. 1986; 4: 1–7.
Fig. 3. A sagittal slice computed tomography abdomen. The upper arrow points to a closed loop of splenic flexure colon above the left hemidiaphragm. The middle arrow points the transition point of the obstruction. The lower arrow points to dilated colon proximal to the obstruction.
3. Crandall M, Popowich D, Shapiro M, West M. Posttraumatic hernias: historical overview and review of the literature. Am. Surg. 2007; 73: 845–50. 4. Kishore GSB, Gupta V, Doley RP et al. Traumatic diaphragmatic hernia: tertiary centre experience. Hernia 2010; 14: 159–64. 5. Strug B, Noon GP, Beall AC. Traumatic diaphragmatic hernia. Ann. Thorac. Surg. 1974; 17: 444–9. 6. Singh S, Kalan MM, Moreyra CE, Buckman RF Jr. Diaphragmatic rupture presenting 50 years after the traumatic event. J. Trauma Acute Care Surg. 2000; 49: 156–9. 7. Lal S, Kailasia Y, Chouhan S, Gaharwar APS, Shrivastava GP. Delayed presentation of post traumatic diaphragmatic hernia. J. Surg. Case Rep. 2011; 2011: 6. 8. Williams NS, Bulstrode CJ, Ronan P, O’Connell MD (eds). Bailey & Love’s Short Practice of Surgery 26E. Houston Tex.: CRC Press, 2013. 9. Cruz CJ, Minagi H. Large-bowel obstruction resulting from traumatic diaphragmatic hernia: imaging findings in four cases. AJR Am. J. Roentgenol. 1994; 162: 843–5.
Nicholas J. Fischer,* MBChB, MPHTM Semisi Aiono,† MSc, FRCS *Department of General Surgery, Dunedin Hospital, Dunedin, and †Department of General Surgery, Whanganui Hospital, Whanganui, New Zealand doi: 10.1111/ans.12596
© 2014 Royal Australasian College of Surgeons
