Injury to the diaphragm following blunt or penetrating thoracoabdominal trauma is not uncommon. Recognition of this important complication of trauma continues to be a challenge because of the lack of specific clinical and plain radiographic features, the frequent presence of other serious injuries and the potential for delayed presentation. Delayed diaphragmatic herniation often presents with catastrophic bowel obstruction or strangulation. Early recognition of diaphragmatic injury is required to avoid this potentially lethal complication. The case of a 35-year-old man with a history of a knife wound to the left flank 15 years previously, who presented with unexplained acute hypoxemic respiratory failure and a unilateral exudative pleural effusion that was refractory to tube thoracostomy drainage, is reported. After admission to hospital, he developed gross dilation of his colon; emergency laparotomy revealed an incarcerated colonic herniation into the left hemithorax. Interesting clinical features of this patient's case included the patient's hobby of weightlifting, a persistently deviated mediastinum despite drainage of the pleural effusion and deceptive pleural fluid biochemical indices. Key Words: Acute ileus; Bowel obstruction; Deviated mediastinum; Pleural effusion; WeightliftingConfusion entre épanchement parapneumonique compliqué et hernie diaphragmatique tardive RÉSUMÉ : L'atteinte diaphragmatique n'est pas rare après un traumatisme thoraco-abdominal fermé ou pénétrant. La reconnaissance de cette importante complication des traumatismes continue de représenter un défi, compte tenu de l'absence de caractéristiques spécifiques sur les plans des symptômes cliniques et des clichés radiologiques simples, de la présence fréquente d'autres lésions graves et du risque que les manifestations apparaissent tardivement. L'hernie diaphragmatique tardive s'accompagne souvent d'une dangereuse obstruction ou strangulation intestinale. Le diagnostic précoce de cette lésion diaphragmatique est nécessaire pour éviter une complication potentiellement fatale. Le cas présenté ici est celui d'un homme de 35 ans ayant subi 15 ans auparavant une blessure à l'arme blanche au côté gauche; il se présente pour insuffisance respiratoire hypoxémique aiguë inexpliquée et épanchement pleural exsudatif bilatéral réfractaire au traitement par thoracotomie. Après son admission à l'hôpital, il a présenté une dilatation marquée du côlon. La laparotomie d'urgence a révélé une hernie irréductible du côlon dans l'hémithorax gauche. Parmi les caractéristiques intéressantes de ce cas, mentionnons le passetemps du patient, haltérophile, un médiastin présentant une déviation persistante malgré le drainage de l'épanchement pleural et les indices biochimiques trompeurs du liquide pleural.T raumatic injury and subsequent herniation through the diaphragm was first described over 400 years ago (1), and the first successful repair was reported in 1886 (2). Correct diagnosis of this potentially lethal condition continues to require a high index of suspic...

BackgroundOptimal management of pleurodesis for malignant pleural effusion (MPE) has not been defined either in terms of optimal analgesia or chest tube size. Non-steroidal anti-inflammatory drugs (NSAID) are highly effective analgesics, but are avoided in pleurodesis as they may reduce pleurodesis efficacy. Smaller (<14 French) chest tubes may be less painful compared to larger chest tubes, but their efficacy in MPE pleurodesis has not been proven. This study investigated chest tube size (large versus small) and analgesia (NSAID versus opiate) in this setting.MethodsA 2 × 2 factorial, phase 3 randomised controlled trial in 320 patients with MPE undergoing pleurodesis. Patients were randomised to opiate/NSAID and 24 French drain/12 French drain. Co-primary outcomes were; pain while tube in situ, measured on 100 mm visual analogue scale (VAS) over 5 days (superiority comparison) and pleurodesis efficacy at 3 months (non-inferiority comparison, margin of non-inferiority 15%). Secondary outcomes included use of rescue analgesia, pleurodesis success to 6 months, adverse events and mortality.Results320 patients were randomised (63% male, mean age 71.8 years), with similar baseline characteristics. Mean VAS scores in opiate and NSAID groups were similar (adjusted mean difference, -1.5 mm (95% confidence interval [CI], -5.0 to 2.0; p = 0.40). Patients receiving NSAID required more rescue analgesia (38% vs. 26%). Pleurodesis failure occurred in 33/144 (23%) NSAID patients compared with 30/150 (20%) of participants receiving opiate, meeting criteria (15%) for non-inferiority (difference 3%; (90% CI -5% to 10%)). Smaller chest tubes were modestly less painful than larger tubes (adjusted mean difference, -6.0 mm (95% CI, -11.7 to -0.2; p = 0.04)) and were associated with a higher pleurodesis failure rate which failed to meet non-inferiority criteria (pleurodesis failure 15/50 (30%) and 12/50 (24%) respectively, difference 6% (90% CI, -9% to 20%)). Adverse events did not differ between analgesic groups, but complications during insertion occurred more commonly with smaller drains (adjusted odds ratio, 1.91; 95% CI 0.71 to 5.13, p = 0.20).ConclusionNSAID and opiate analgesia were not significantly different in treatment of post-pleurodesis pain and neither was associated with impaired efficacy of pleurodesis. Smaller chest tubes were associated with less pain, but may be associated with reduced pleurodesis success compared with larger tubes. These results challenge current guidelines for pleurodesis of MPE, which advocate avoidance of NSAID and use of small chest tubes.

No abstract

No abstract

No abstract