Chronic hepatothorax due to right diaphragmatic rupture: an anesthetic challenge in a rare case

Abstract

Background: Diaphragmatic rupture is an uncommon condition, with 90% of ruptures occurring on the left side. However, its incidence on the right side is increasing along with the increase in traffic accidents. Liver herniation may become progressive causing severe atelectasis of the right lung, resulting in impaired respiratory status and hemodynamic changes. Case report: We report the case of a 40 years old female, ASA III, scheduled for hepatothorax repair that evolved from right diaphragmatic hernia after a car accident when she was 8 years old. Clinically, she had severe restrictive respiratory syndrome caused by the hepatothorax. The anesthetic evaluation was normal, except for the chest X-ray showing elevation of the dome of the right hemidiaphragm without tracheal deviation. Diagnosis was confirmed by CT scan. After liver replacement in the abdominal cavity, a transient increase in central venous pressure, stroke volume index and flow time corrected (35%), and a decrease in systemic vascular resistance were observed. After complete hemodynamic and hepatosplenic stabilization, as well as ventilation, the patient was transferred intubated, under controlled ventilation and monitored, to the liver transplant unit. Conclusions: Hepatothorax is a rare condition and its repair may represent an anesthetic challenge. After liver replacement in the abdominal cavity during corrective surgery under general anesthesia complications may occur, particularly associated with pulmonary re-expansion. Effective teamwork and careful planning of surgery, between the surgical and anesthetic teams, are the key to success. Chronic hepatothorax due to right diaphragmatic rupture: an anesthetic challenge in a rare case 191 PALAVRAS-CHAVEHepatotórax; Anestesia; Lesão diafragmática Hepatotórax crônico devido à ruptura do diafragma direito: um desafio anestésico em um caso raro Resumo Justificativa: A ruptura diafragmática é uma condição incomum e ocorre em 90% no lado esquerdo. No entanto, a incidência de ruptura à direita tem vindo a aumentar junto com o aumento dos acidentes automobilísticos. A herniação do fígado pode tornar-se progressiva, causar atelectasia grave do pulmão direito, resultar num débil estado respiratório e alterações hemodinâmicas. Relato de caso: Mulher de 40 anos, estado físico ASA 3, marcada para reparação de hepatotórax que evoluiu de hérnia diafragmática direita, adquirida aos 8 anos, após um acidente automobilístico. Clinicamente apresentava síndrome respiratória restritiva grave, causada pelo hepatotórax. A avaliação anestésica era normal, com exceção da radiografia do tórax, que evidenciava elevação da hemicúpula diafragmática direita, sem desvio traqueal. Diagnóstico foi confirmado por tomografia computadorizada. Depois da recolocação do fígado na cavidade abdominal foram observados um aumento transitório da pressão venosa central, do Stroke Volume Index e Flow Time Corrected (35%) e uma diminuição da resistência vascular sistêmica. Uma vez alcançada a estabilização hemodinâmica geral e hepatoesp...

Post-Traumatic Right Diaphragmatic Hernia with Hepatothorax

“…Rupture of the left hemidiaphragm is more common, but has increased owing to road-traffic accidents [9].…”

“…Diaphragmatic rupture is an uncommon condition, and in 80% of cases occurs to the left side. However, the incidence of rupture to the right side has risen due to an increase in road-traffic accidents [8] [9]. Results of blood work-up were within normal parameters.…”

The hepatothorax: An unusual complication of right sided diaphragmatic injuries

“…Une hernie secondaire des viscères abdominaux dans la cavité pleurale n'est observée que dans 19% des cas [4]. L'atteinte diaphragmatique est souvent asymptomatique et peut passer inaperçue [4].…”