Intercostal hernias with abdominal viscera have rarely been reported following penetrating accidental or surgical trauma. We report herein a case of a traumatic rupture of the left hemidiaphragm, presenting as an intercostal hernia 2 years after a penetrating thoracoabdominal injury. The diaphragmatic rupture had been initially very small and could not be detected in the serial chest films and abdominal computed tomographic scans. The injury was also missed during an exploratory lateral thoracotomy. The patient was admitted with the chief complaint of a painful and gradually enlarging left-sided chest wall bulge of 8 months' duration. Surgery via an anterolateral thoracotomy along the axis of the intercostal hernia was performed, and the omentum and splenic flexura of the colon were reduced.
A 24-year-old woman with a right infraclavicular gunshot wound developed an axillary artery pseudoaneurysm. She was successfully treated by using a 5 cm Hemobahn stent-graft with a diameter of 6 mm. Postimplantation arteriography revealed normal flow through the axillary artery without evidence of leakage of contrast medium. Five months after the procedure, stenoses developed within the stent-graft owing to intimal hyperplasia and were treated by balloon angioplasty. The patient has been followed up symptom-free for 6 months after the second procedure.
Perforation of the thoracic esophagus can be fatal unless diagnosed promptly and treated effectively. The high mortality with delayed treatment is principally due to the inability of effectively closing the perforation and preventing the leakage. We operated one patient with a delayed diagnosis of thoracic esophageal perforation developed after a rigid esophagoscopic procedure. The perforation was closed with primary sutures and reinforced with a intercostal muscle flap wrap. Radical decortication and wide mediastinal and pleural toilet were also done. Total parenteral nutrition was begun and antibiotics were administered according to the results of cultures. Esophagography and esophagoscopy performed 10 days after the operation showed a well healed esophagus without stenosis or leakage. We conclude that primary closure of the perforation and muscle flap wrap can provide a one-stage operation with good results for repair of thoracic esophageal perforations which are not diagnosed on time.
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