Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 47, Num. 2, 2001, pp. 108-110

Journal of Postgraduate Medicine, Vol. 47, Issue 2, 2001 pp.108-110

Iatrogenic Gastric Fistula Due to Inappropriate Placement of Intercostal Drainage Tube in a Case of Traumatic Diaphragmatic Hernia

Rege SA, Narlawar RS*, Deshpande AA, Dalvi AN

Departments of Surgery and Radiology*, Seth G. S. Medical college and K.E.M. Hospital, Parel, Mumbai - 400 012, India.

Code Number: jp01032

Abstract

A 26-year-old, 30 weeks primigravida presented with a gastric fistula through a left intercostal drain, which was inserted for drainage of suspected haemopneumothorax following minor trauma. It was confirmed to be a diaphragmatic hernia, with stomach and omentum as its contents. On exploratory laparotomy, disconnection of the tube and fistulous tract, with reduction of herniated contents and primary suturing of stomach was carried out. Diaphragmatic reconstruction with polypropylene mesh was also carried out. Post-operative recovery was uneventful with full lung expansion by 3rd postoperative day. Patient was asymptomatic at follow-up 6 months.

Key Words:Gastric fistula, Diaphragmatic hernia, Intercostal drain.

Case History

A 26-year-old female, with 30 weeks pregnancy, had minor trauma over the left side of the chest. She visited a physician for chest pain. She was haemodynamically stable with no breathlessness. Radiograph of the chest showed hyperlucency on the left side with air fluid level (Figure 1). In the setting of trauma, this was diagnosed as haemo- pneumothorax by the attending physician and an intercostal drain (ICD) was inserted in 5(th) intercostal space in midaxillary line on the left side. Immediately following insertion of the tube, patient felt better but had food particles draining through the tube after meals. She was referred to us after 3 days.

On presentation, she was haemodynamically stable with normal respiratory rate. The abdomen was soft with normal bowel sounds. Air entry was decreased in the left lower zone. The ICD drain showed food particles. A contrast study was done which revealed filling of the fundus at 3(rd) intercostal space in erect position with ICD tube in its vicinity. There was no spillage of contrast in to the pleural cavity. Upper gastrointestinal endoscopy revealed presence of tube within the stomach and methylene blue was seen to enter the stomach when injected through the tube. Ultrasonography was not contributory. Computerised tomography (CT scan) was deferred in view of pregnancy. In view of haemodynamically stable patient, absence of sepsis, no spillage of contrast in pleural cavity and 30 weeks pregnancy, conservative management was planned for this patient, with intravenous fluids and nil by mouth.

Two weeks later, after the delivery of the baby, contrast enhanced CT scan of thorax done revealed stomach and omentum on the left side of the thorax with ICD tube entering the stomach (Figure 2). Exploratory laparotomy was done which revealed normal peritoneal cavity and a rent in the left dome of the diaphragm about 6 x 6 cm in diameter through which the fundus of the stomach had herniated along with omentum. The ICD was seen to enter the fundus of stomach and omentum was wrapped all around the shaft of the tube preventing spillage. The tube was disconnected and removed. Hernial contents were reduced. Opening in the fundus of the stomach was sutured after freshening of the edges. An ICD tube was placed in the pleural cavity under vision. A polypropylene mesh was used to cover the large diaphragmatic defect. Abdomen was closed. Patient had an uneventful postoperative recovery with complete lung expansion by the 3(rd) postoperative day. Patient was asymptomatic at 6 months follow up.

Discussion

Diaphragmatic hernias may be congenital or acquired due to trauma. Diaphragmatic tears due to blunt trauma are known to go unrecognised at the time of the accident.(2) Massively distended stomach and colon in traumatic diaphragmatic hernia may be easily mistaken as pneumothorax or hydropneumothorax as in our case. Hegarty et al have reported 2 cases where intercostal drainage of gastric contents provided a diagnosis of diaphragmatic hernia.(1) A diaphragmatic hernia should be suspected even after a trivial trauma if an erect plain radiograph of the chest shows absence of fundic bubble in its normal position. In such cases, lateral decubitus and true erect frontal chest radiographs can aid in the diagnosis.(3) When suspected, insertion of nasogastric tube aids in diagnosis as it is seen in the “gas bubble” in the thorax.(3) While left-sided posttraumatic hernias are common, liver or omentum delay the herniation of abdominal contents on the right side.(4)

Fluoroscopy, Ultrasonography (USG), CT scan, and Magnetic Resonance Imaging (MRI) are potentially useful in demonstrating lacerations and rupture of diaphragm directly. USG is useful in diagnosis of congenital diaphragmatic hernia where uninterrupted contours of the diaphragm are not seen and peristalsis of bowel can be observed in the thorax.(5) However it may be difficult in obese patients and with extensive chest and abdominal wall injuries, further complicated by the gas filled bowel loops. CT scan may readily demonstrate the herniation of the abdominal viscera in the thorax but, may not be able to directly image the diaphragmatic lacerations that lie in different scan planes.(6) MRI with it’s multiplanar ability and better soft tissue delineation demonstrates the rent in the diaphragm.(7) Intraperitoneal technetium has been successfully used in suspected cases of diaphragmatic injuries to detect hernia by Halldorsson et al.(8)

Repair of the diaphragmatic hernia can be done by classically open method or with minimally invasive methods. Open exploration can be done through the abdominal or the thoracic route. In cases of acute blunt abdominal trauma with suspected diaphragmatic tears, have high incidence of other intraabdominal injuries and hence transabdominal exploration is warranted. Delayed presentations with no intra-abdominal injuries and right-sided herniations are difficult to repair through abdominal approach and hence may require right thoracotomy.(9)

Minimally invasive surgery involves laparoscopic repair and thoracoscopic repair. In acute trauma, with availability of expertise, laparoscopic exploration is helpful not only to diagnose and repair the diaphragmatic hernia, but also to diagnose other intraabdominal injuries. However, in delayed uncomplicated presentations thoracoscopic method may be useful. Villavicencio et al have analysed thoracoscopy in 15 studies in cases of trauma and shown that thoracoscopy has a specificity of 97%, sensitivity of 100% and accuracy of 98%.(10) Ochsner et al have reported very high accuracy with thoracoscopy in diagnosis of diaphragmatic injuries in penetrating trauma.(11) However, large disruptions in the diaphragm may require thoracotomy or laparotomy not only to repair the defect but also to diagnose other injuries. Whatever approach is adopted, the surgeon must be prepared to perform a combined thoraco-abdominal operation with different incisions.(9)

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