title: Evolution in the management of traumatic diaphragmatic injuries: a multicenter review.
abstract: BACKGROUND
  Traumatic diaphragmatic injury (TDI) is uncommon and has historically been identified by chest x-ray and repaired by laparotomy with nonabsorbable suture. Blunt TDI was more frequently (90%) detected on the left. With advances in imaging and operative techniques, our objective was to evaluate evolution in incidence, location, and management of TDI.
  
  
  METHODS
  The medical records of patients admitted to three Wisconsin regional trauma centers with TDI from 1996 to 2011 were reviewed. Patients were stratified into blunt and penetrating injury and early (1996-2003) and recent (2004-2011) periods. p < 0.05 was significant.
  
  
  RESULTS
  A total of 454 patients was included, 87% were men. Median Injury Severity Score (ISS) was 22 and 19 in the early and recent periods, respectively. Diagnostic modality for TDI did not change over time when comparing chest x-ray, computed tomography, or intraoperative diagnosis for blunt (p = 0.214) or penetrating (p = 0.119) TDI. More right-sided penetrating TDI were identified in the recent versus early group (49% vs. 27%). Perihiatal injury was rare (2%). Minimally invasive repairs increased in the recent versus early group of penetrating TDI (5.8% vs. 0.9%, p = 0.040). Complex repairs (mesh, transposition) were required in only three patients. In-hospital mortality was 15% and 4% for blunt and penetrating TDIs, respectively (p < 0.001).
  
  
  CONCLUSIONS
  A large increase in the frequency of both blunt and penetrating TDIs in our region was documented. While no difference was observed regarding diagnosis of blunt TDI during the two study periods, our data show a change from historical reports; more injuries were detected by computed tomography. An increase in right-sided penetrating TDI was also observed. A small but previously unreported incidence of perihiatal/pericardial injury occurred with both blunt and penetrating TDIs. While the majority of injuries were repaired with laparotomy, minimally invasive repairs were used more frequently in the recent period.
  
  
  METHODS
  Epidemiologic study, level III. Therapeutic study, level IV.
authors.affiliation: From the Department of Medical Education (J.S.T.), Gundersen Medical Foundation; Department of Research (M.A.M., K.J.K.), Gundersen Medical Foundation; and Department of General and Vascular Surgery (T.H.C.), Gundersen Health System, La Crosse; Departments of Medical Education (J.R.P.) and Surgery (K.J.B.), Medical College of Wisconsin, Milwaukee; Departments of Medical Education (A.M.) and Surgery (R.F.M.), Marshfield Clinic, Marshfield, Wisconsin.
authors.forename: Jill S
authors.initials: JS
authors.lastname: Ties
authors.forename: Jacob R
authors.initials: JR
authors.lastname: Peschman
authors.forename: Andres
authors.initials: A
authors.lastname: Moreno
authors.forename: Michelle A
authors.initials: MA
authors.lastname: Mathiason
authors.forename: Kara J
authors.initials: KJ
authors.lastname: Kallies
authors.forename: Ronald F
authors.initials: RF
authors.lastname: Martin
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Brasel
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Cogbill
mesh_terms: D000007:Abdominal Injuries / Q000175:diagnosis* / Q000401:mortality / Q000601:surgery; D000328:Adult; D003964:Diaphragm / Q000293:injuries*; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015601:Injury Severity Score; D007902:Length of Stay / Q000639:trends; D008297:Male; D009104:Multiple Trauma; D011379:Prognosis; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000379:methods*; D013898:Thoracic Injuries / Q000175:diagnosis* / Q000401:mortality / Q000601:surgery; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers; D014922:Wisconsin; D014949:Wounds, Nonpenetrating / Q000175:diagnosis* / Q000601:surgery