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Diaphragm

  • Michel B. Aboutanos
  • Therèse M. Duane
  • Ajai K. Malhotra
  • Rao R. Ivatury

Abstract

A 29-year-old man presents to the emergency department with a 2-week history of worsening shortness of breath. The patient is alert and hemodynamically stable. Physical examination documents decreased breath sounds at the left base. Chest x-ray demonstrates a dense opacity in the base of the left lung field, along with a large air-fluid level. A computed tomography scan of the chest and abdomen confirms a diaphragmatic hernia. The patient’s only other hospitalization was for a left thoracoabdominal stab wound. He recalls having a computed tomography scan done at that time and being discharged the next day. Which of the following would be the most appropriate intervention?
  1. (A)

    Esophagogastroscopy

     
  2. (B)

    Laparoscopy

     
  3. (C)

    Celiotomy

     
  4. (D)

    Thoracostomy

     
  5. (E)

    Expectant management

     

Keywords

Hiatal Hernia Blunt Trauma Stab Wound Diaphragmatic Injury Diaphragmatic Rupture 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Kondo T, Kobayashi I, Taguchi Y, Ohta Y, Yanagimachi N. A dynamic analysis of chest wall motions with MRI in healthy young subjects. Respirology 2000; 5(1):19–25.PubMedCrossRefGoogle Scholar
  2. 2.
    Robotham JL, Takata M. Mechanical abdomino/heart/lung interaction. J Sleep Res 1995; 4(S1):50–52.PubMedCrossRefGoogle Scholar
  3. 3.
    Takata M, Robotham JL. Effects of inspiratory diaphragmatic descent on inferior vena caval venous return. J Appl Physiol 1992; 72(2):597–607.PubMedGoogle Scholar
  4. 4.
    Reber PU, Schmied B, Seiler CA, et al. Missed diaphragm injuries and their long-term sequelae. J trauma 1998; 44(1):183–188.PubMedCrossRefGoogle Scholar
  5. 5.
    Shah R, Sabanathan S, Mearns AJ, et al. Traumatic rupture of diaphragm. Ann Thorac Surg 1995; 60:1444–1449.PubMedCrossRefGoogle Scholar
  6. 6.
    Hamby WB. The Case Reports and Autopsy Records of Ambroise Paré. Springfield, IL: Charles C Thomas, 1960; 50–51.Google Scholar
  7. 7.
    Rodriguez-Morales G, Rodriguez A, Shatney CH. Acute rupture of the diaphragm in blunt trauma: analysis of 60 patients. J Trauma 1986; 26:438–444.PubMedCrossRefGoogle Scholar
  8. 8.
    Rosati C. Acute traumatic injury of the diaphragm. Chest Surg Clin North Am 1998; 8(2):371–379.Google Scholar
  9. 9.
    Johnson CD. Blunt injuries of the diaphragm. Br J Surg 1988; 75:226–230.PubMedCrossRefGoogle Scholar
  10. 10.
    Patselas T, Gallagher E. The diagnostic dilemma of diaphragm injuries. Am Surg 2002; 68:633–639.PubMedGoogle Scholar
  11. 11.
    Hood RM. Traumatic diaphragmatic hernia. Ann Thorac Surg, 1971; 12:311–324.PubMedGoogle Scholar
  12. 12.
    Bekassy SM, Dave KS, Wooler GH, et al. “Spontaneous” and traumatic rupture of the diaphragm: long-term results. Ann Surg 1973; 177:320–324.PubMedCrossRefGoogle Scholar
  13. 13.
    Gravier L, Freeark RJ. Traumatic diaphragmatic hernia. Arch Surg 1963; 86:363–373.Google Scholar
  14. 14.
    Andrus CH, Morton JH. Rupture of the diaphragm after blunt trauma. Am J Surg 1970; 119:686–693.PubMedCrossRefGoogle Scholar
  15. 15.
    Mihos P, Potaris K, Gakidis J, et al. Traumatic rupture of the diaphragm: experience with 65 patients. Injury 2003; 34:169–172.PubMedCrossRefGoogle Scholar
  16. 16.
    Bergeron E, Clas D, Ratte S, et al. Impact of deferred treatment of blunt diaphragmatic rupture: a 15-year experience in six trauma centers in Quebec. J Trauma 2002; 52(4):633–640.PubMedCrossRefGoogle Scholar
  17. 17.
    Reiff D, McGwin G, Metzger J, et al. Identifying injuries and motor vehicle collision characteristics that together are suggestive of diaphragmatic rupture. J Trauma 2002; 53(6):1139–1145.PubMedCrossRefGoogle Scholar
  18. 18.
    Desforges G, Strieder JW, Lynch JP, et al. Traumatic rupture of the diaphragm. J Thorac Surg 1957; 34:779–799.PubMedGoogle Scholar
  19. 19.
    Andrus C, Morton JU. Rupture of the diaphragm after blunt trauma. Am J Surg 1970; 119:686–693.PubMedCrossRefGoogle Scholar
  20. 20.
    Grage T, Maclean L, Campbell G. Traumatic rupture of the diaphragm. Surgery 1959; 46:669–681.PubMedGoogle Scholar
  21. 21.
    Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice, 2nd ed. Baltimore: Williams & Wilkins, 1996.Google Scholar
  22. 22.
    Feliciano DV, Moore EE, Matox KL, eds. Trauma, 3rd ed. Stanford, CT: Appleton-Lange, 1996.Google Scholar
  23. 23.
    Meyers BF, McCabe CJ. Traumatic diaphragmatic hernia. Ann Surg 1993; 218:783–790.PubMedCrossRefGoogle Scholar
  24. 24.
    Ilgenfritz FM, Stewart DE. Blunt trauma of the diaphragm: a 15 county private hospital experience. Am Surg 1992; 58:334–339.PubMedGoogle Scholar
  25. 25.
    Boulanger BR, Milzman DP, Rosati C, et al. A comparison of right and left blunt traumatic diaphragmatic rupture. J Trauma 1993; 35:255–260.PubMedCrossRefGoogle Scholar
  26. 26.
    Murray JG, Aioli E, Cruden JF, et al. Acute rupture of the diaphragm due to blunt trauma: diagnostic sensitivity and specificity of CT. AJR Am J Roentgenol 1996; 166(5): 1035–1039.PubMedGoogle Scholar
  27. 27.
    Guth AA, Pachter HL, Kim U. Pitfalls in the diagnosis of blunt diaphragmatic injury. Am J Surg 1995; 170:5–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Spann JC, Mariachi FE, Wait M. Evaluation of video assisted thoracoscopic surgery in the diagnosis of diaphragmatic injuries. Am J Surg 1995; 170:628–631.PubMedCrossRefGoogle Scholar
  29. 29.
    Arak T, Solheim K, Pillgram-Larsen J. Diaphragmatic injuries. Injury 1997; 28:113–117.PubMedCrossRefGoogle Scholar
  30. 30.
    Brasel KJ, Borgstrom DC, Meyer P, et al. Predictors of outcome in blunt diaphragmatic rupture. J Trauma 1996; 4:484–487.CrossRefGoogle Scholar
  31. 31.
    Gouin A, Garson AA. Diagnostic problems in traumatic diaphragmatic hernia. J Trauma 1974; 14:20–31.CrossRefGoogle Scholar
  32. 32.
    Bow ditch HI. Diaphragmatic hernia. Buffalo Med J 1853; 9(1):65.Google Scholar
  33. 33.
    Beal SL, McKennan M. Blunt diaphragmatic rupture: a morbid injury. Arch Surg 1988; 123:828–832.PubMedGoogle Scholar
  34. 34.
    Kearney PA, Ohana SW, Burney RE. Blunt rupture of the diaphragm: mechanism, diagnosis, and treatment. Ann Emerg Med 1989; 18:1326–1330.PubMedCrossRefGoogle Scholar
  35. 35.
    Kim HH, Shin YR, Kim KJ, et al. Blunt traumatic rupture of the diaphragm: Sonographic diagnosis. J Ultrasound Med 1997; 16:593–598.PubMedGoogle Scholar
  36. 36.
    Mansouri KA. Trauma to the diaphragm. Chest Surg Clin North Am 1997; 7:373–383.Google Scholar
  37. 37.
    Killeen KL, Mirvis SE, Shanmuganathan K. Helical CT of diaphragmatic rupture caused by blunt trauma. AJR Am J Roentgenol 1999; 173(6):1611–1616.PubMedGoogle Scholar
  38. 38.
    Shapiro MJ, Heifer E, Durham M, et al. The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma-induced diaphragmatic rupture. Clin Radiol 1996; 51:27–30.PubMedCrossRefGoogle Scholar
  39. 39.
    Shanmuganathan K, Mirvis SE, White CS, et al. MR imaging evaluation of hemidiaphragms in acute blunt trauma: experience with 16 patients. AJR Am J Roentgenol 1996; 67:397–402.Google Scholar
  40. 40.
    Carter BN, Goosefish J. Traumatic diaphragmatic hernia. AJR Am J Roentgenol 1951; 65:56–72.Google Scholar
  41. 41.
    Shapiro MJ, Heifer E, Durham M, et al. The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture. Clin Radiol 1996; 51:27–30.PubMedCrossRefGoogle Scholar
  42. 42.
    Miller L, Bennett EV, Root HD, et al. Management of penetrating and blunt diaphragmatic injury. J Trauma 1984; 24:403–409.PubMedCrossRefGoogle Scholar
  43. 43.
    Demetriades D, Kakoyiannis S, Parekh D, et al. Penetrating injuries of the diaphragm. Br J Surg 1988; 75:824–826.PubMedCrossRefGoogle Scholar
  44. 44.
    Hood RM. Injuries involving the diaphragm. In Hood RM, Boyd AD, Culliford AT, eds. Thoracic Trauma. Philadelphia: WB Saunders, 1989; 267–289.Google Scholar
  45. 45.
    Payne JH, Yellin AE. Traumatic diaphragmatic hernia. Arch Surg 1982; 117:18–24.PubMedGoogle Scholar
  46. 46.
    Worthy SA, Kang EY, Hartman TE, et al. Diaphragmatic rupture: CT findings in 11 patients. Radiology 1995; 194(3):885–888.PubMedGoogle Scholar
  47. 47.
    Jones TK, Walsh JW, Maull KI. Diagnostic imaging in blunt trauma of the abdomen. Surg Gynecol Obstet 1983; 157:389–398.PubMedGoogle Scholar
  48. 48.
    Toombs BD, Sandler CM, Lester RG. Computed tomography of chest trauma. Radiology 1981; 140:733–738.PubMedGoogle Scholar
  49. 49.
    Nau T, Seitz H, Mousavi M, Vecsei V. The diagnostic dilemma of traumatic rupture of the diaphragm. Surg Endosc 2001; 15:992–996.PubMedCrossRefGoogle Scholar
  50. 50.
    Somers JM, Gleeson FV, Flower CDR. Rupture of the right hemidiaphragm following blunt trauma: the use of ultrasound in diagnosis. Clin Radiol 1990; 42:97–101.PubMedCrossRefGoogle Scholar
  51. 51.
    Mirvis SE, Keramati B, Buckman R, et al. MR imaging of traumatic diaphragmatic rupture. J Comput Assist Tomogr 1988; 12:147–149.PubMedCrossRefGoogle Scholar
  52. 52.
    Kurata K, Kubota K, Oosawa H, et al. Thoracoscopic repair of traumatic diaphragmatic rupture. Surg Endosc 1996; 10:850–851.PubMedCrossRefGoogle Scholar
  53. 53.
    Martin I, O’Rourke N, Gotley D, et al. Laparoscopy in the management of diaphragmatic rupture due to blunt trauma. Aust N Z J Surg 1998; 68:584–586.PubMedCrossRefGoogle Scholar
  54. 54.
    Ivatury RR, Simon RJ, Weksler B, et al. Laparoscopy in the evaluation of the intrathoracic abdomen after penetrating injury. J Trauma 1992; 33:101–109.PubMedCrossRefGoogle Scholar
  55. 55.
    Edington HD, Evans S, Sindelar WF. Reconstruction of a functional hemidiaphragm with use of omentum and latissimus dorsi flaps. Surgery 1989; 105:442–445.PubMedGoogle Scholar
  56. 56.
    Hirsch EF. Repair of an abdominal wall defect after a salvage laparotomy for sepsis. J Am Coll Surg 2004; 198(2):324–328.PubMedCrossRefGoogle Scholar
  57. 57.
    Bender JS, Lucas CE. Management of close-range shotgun injuries to the chest by diaphragmatic transposition: case reports. J Trauma 1990; 30:1581–1584.PubMedCrossRefGoogle Scholar
  58. 58.
    Zantut L, Ivatury R, Smith S, et al. Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicenter experience. J Trauma 1997; 42(5):825–831.PubMedCrossRefGoogle Scholar
  59. 59.
    Leppaniemi A, Haapiainen R. Occult diaphragmatic injuries caused by stab wounds. J Trauma 2003; 55:646–650.PubMedCrossRefGoogle Scholar
  60. 60.
    Martinez M, Briz JE, Carillo EH. Video thoracoscopy expedites the diagnosis and treatment of penetrating diaphragmatic injuries. Surg Endosc 2001; 15:28–33.PubMedCrossRefGoogle Scholar
  61. 61.
    Murray JA, Demetriades D, Cornwell EE 3rd, et al. Penetrating left thoracoabdominal trauma: the incidence and clinical presentation of diaphragm injuries. J Trauma 1997; 43:624–626.PubMedCrossRefGoogle Scholar
  62. 62.
    Chen JC, Wilson SE. Diaphragmatic injuries: recognition and management in sixty-two patients. Am Surg 1991; 57:810–815.PubMedGoogle Scholar
  63. 63.
    Stylianos S, King TC. Occult diaphragm injuries at celiotomy for left chest stab wounds. Am Surg 1992; 58:364–368.PubMedGoogle Scholar
  64. 64.
    Symbas PN, Vlasis SE, Hatcher C Jr. Blunt and penetrating diaphragmatic injuries with or without herniation of organs into the chest. Ann Thorac Surg 1986; 42(2):158.PubMedCrossRefGoogle Scholar
  65. 65.
    Wiencek RG Jr, Wilson RF, Steiger Z. Acute injuries of the diaphragm. An analysis of 165 cases. J Thorac Cardiovasc Surg 1986; 92(6):989–993.PubMedGoogle Scholar
  66. 66.
    Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic injuries: spectrum of radiographic findings. Radiographics 1998; 18:49–59.PubMedGoogle Scholar
  67. 67.
    Adegboye VO, Ladipo JK, Adebo OA, et al. Diaphragmatic injuries. Afr J Med Med Sci 2002; 31:149–153.PubMedGoogle Scholar
  68. 68.
    Karmy-Jones R, Carter Y, Stern E. The impact of positive pressure ventilation on the diagnosis of traumatic diaphragmatic injury. Am Surg 2002; 68:167–172.PubMedGoogle Scholar
  69. 69.
    Udobi KF, Rodriguez A, Chiu WC, Scalea TM. Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study. J Trauma 2001; 50:475–479.PubMedCrossRefGoogle Scholar
  70. 70.
    Chiu WC, Shanmuganathan K, Mirvis SE, et al. Determining the need for laparotomy in penetrating torso trauma: a prospective study using triple-contrast enhanced abdominopelvic tomography. J Trauma 2001; 51:860–869.PubMedCrossRefGoogle Scholar
  71. 71.
    Mirvis SE, Shanmuganathan K. MR imaging of thoracic trauma. Magn Reson Imaging Clin North Am 2000; 8:91–104.Google Scholar
  72. 72.
    Ochsner MG, Rozycki GS, Lucente F, et al. Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma: a preliminary report. J Trauma 1993; 34:704–710.PubMedCrossRefGoogle Scholar
  73. 73.
    Smith RS, Fry WR, Tsoi EK, et al. Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury. Am J Surg 1993; 166:690–695.PubMedCrossRefGoogle Scholar
  74. 74.
    Uribe RA, Pachon CE, Frame SB, et al. A prospective evaluation of thoracoscopy for the diagnosis of penetrat ing thoracoabdominal trauma. J Trauma 1994; 37:650–654.PubMedCrossRefGoogle Scholar
  75. 75.
    Nel JH, Warren BL. Thoracoscopic evaluation of the diaphragm in patients with knife wounds of the left lower chest. Br J Surg 1994; 81:713–714.PubMedCrossRefGoogle Scholar
  76. 76.
    Freeman RK, Al-Dossari G, Hutcheson KA, et al. Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma. Ann Thorac Surg 2001; 72:342–347.PubMedCrossRefGoogle Scholar
  77. 77.
    Ivatury RR, Simon RJ, Stahl WM. A critical evaluation of laparoscopy in penetrating abdominal trauma. J Trauma 1993; 34:822–828.PubMedCrossRefGoogle Scholar
  78. 78.
    Ivatury RR, Simon RJ, Stahl WM. Selective celiotomy for missile wounds of the abdomen based on laparoscopy. Surg Endosc 1994; 8:366–370.PubMedCrossRefGoogle Scholar
  79. 79.
    Ortega AE, Tang E, Froes ET, et al. Laparoscopic evaluation of penetrating thoracoabdominal traumatic injuries. Surg Endosc 1996; 10:19–22.PubMedCrossRefGoogle Scholar
  80. 80.
    Murray JA, Demetriades D, Asensio JA, et al. Occult injuries to the diaphragm: a prospective evaluation of laparoscopy in penetrating injuries to the left lower chest. J Am Coll Surg 1998; 187:626–630.PubMedCrossRefGoogle Scholar
  81. 81.
    Ertekin C, Onaran Y, Guloglu R, et al. The use of laparoscopy as a primary diagnostic and therapeutic method in penetrating wounds of lower thoracal region. Surg Laparosc Endosc 1998; 8:26–29.PubMedCrossRefGoogle Scholar
  82. 82.
    McQuay N Jr, Britt LD. Laparoscopy in the evaluation of penetrating thoracoabdominal trauma. Am Surg 2003; 69: 788–791.PubMedGoogle Scholar
  83. 83.
    Morales CH, Villegas MI, Angel W, et al. Value of digital exploration for diagnosing injuries to the left side of the diaphragm caused by stab wounds. Arch Surg 2001; 136: 1131–1135.PubMedCrossRefGoogle Scholar
  84. 84.
    DeMaria EJ, Dalton JM, Gore DC, et al. Complementary roles of laparoscopic abdominal exploration and diagnostic peritoneal lavage for evaluating abdominal stab wounds: a prospective study. J Laparoendosc Adv Surg Tech A 2000; 10:131–136.PubMedCrossRefGoogle Scholar
  85. 85.
    Simon RJ, Rabin J, Kuhls D. Impact of increased use of laparoscopy on negative laparotomy after penetrating trauma. J Trauma 2002; 53:297–302.PubMedCrossRefGoogle Scholar
  86. 86.
    Shatney CH, Sensaki K, Morgan L. The natural history of stab wounds of the diaphragm: implications for a new management scheme for patients with penetrating thoracoabdominal trauma. Am Surg 2003; 69:508–513.PubMedGoogle Scholar
  87. 87.
    Kozar RA, Kaplan LJ, Cipolla J, et al. Laparoscopic repair of traumatic diaphragmatic injuries. J Surg Res 2001; 15:164–171.CrossRefGoogle Scholar
  88. 88.
    Murray JA, Cornwell EE 3rd, Velmahos GC, et al. Healing of traumatic diaphragm injuries: comparison of laparoscopic versus open techniques in an animal model. J Surg Res 2001; 100:189–191.PubMedCrossRefGoogle Scholar
  89. 89.
    Frantzides CT, Carlson MA. Laparoscopic repair of a penetrating injury to the diaphragm: a case report. J Laparoendosc Surg 1994; 4:153–156.PubMedGoogle Scholar
  90. 90.
    Gonzalez-Rapado L, Collera-Rodriguez SA, Perez-Esteban M, et al. Diaphragmatic hernia caused by penetrating injury: emergency laparoscopic reconstruction. Rev Gastroenterol Mex 1997; 62:281–283.PubMedGoogle Scholar
  91. 91.
    Matthews BD, Bui H, Harold KL, et al. Laparoscopic repair of traumatic diaphragmatic injuries. Surg Endosc 2003; 17:254–258.PubMedCrossRefGoogle Scholar
  92. 92.
    Shaw JM, Navsaria PH, Nicol AJ. Laparoscopy-assisted repair of diaphragm injuries. World J Surg 2003; 27:671–674.PubMedCrossRefGoogle Scholar
  93. 93.
    Thal ER, Provost DA. Traumatic rupture of the diaphragm. In Nyhus LM, Baker RJ, Fischer JE, eds. Mastery of Surgery, 3rd ed. Boston: Little, Brown and Company, 1997; 686–693.Google Scholar
  94. 94.
    Asensio JA, Demetriades D, Rodriguez A. Injury to the diaphragm. In Mattox KL, Feliciano DV, Moore EE, eds. Trauma. New York: McGraw-Hill, 2000; 603–632.Google Scholar
  95. 95.
    Reber PU, Schmied B, Seiler CA, et al. Missed diaphragmatic injuries and their long-term sequelae. J Trauma 1998; 44:183–188.PubMedCrossRefGoogle Scholar
  96. 96.
    Sullivan RE. Strangulation and obstruction in diaphragmatic hernia due to direct trauma. J Thorac Cardiovasc Surg 1966; 52:725–784.PubMedGoogle Scholar
  97. 97.
    Williams M, Carlin AM, Tyburski JG, et al. Predictors of mortality in patients with traumatic diaphragmatic rupture and associated thoracic and/or abdominal injuries. Am Surg 2004; 70:157–163.PubMedGoogle Scholar
  98. 98.
    Mattila S, Jarvinen A, Mattila T, et al. Traumatic diaphragmatic hernia. Report of 50 cases. Acta Chir Scand 1977; 143:313–318.PubMedGoogle Scholar
  99. 99.
    Ivatury RR. Laparoscopy and thoracoscopy in penetrating thoraco-abdominal injuries. Eur Surg 2005; 37(1):19–27.CrossRefGoogle Scholar
  100. 100.
    Laine L. Upper gastrointestinal hemorrhage. West J Med 1991; 155:274–279.PubMedGoogle Scholar
  101. 101.
    Rockey DC. Gastrointestinal bleeding. In Feldman M, Friedman LS, Sleisenger MH, eds. Gastrointestinal and Liver Disease, 7th ed. Philadelphia: Saunders, 2002; 211–248.Google Scholar
  102. 102.
    Stabile BE, Stamos MJ. Gastrointestinal bleeding. In Zinner MJ, Schwartz SI, Ellis H, eds. Maingot’s Abdominal Operations, 10th ed. Stamford, CT: Appleton & Langer 1997; 289–313.Google Scholar
  103. 103.
    Rakic S, Hissink RJ, Schiff BW. Perforation of gastric ulcer associated with paraesophageal hernia causing diffuse peritonitis. Dig Surg 2000; 17:83–84.PubMedCrossRefGoogle Scholar
  104. 104.
    Riepe G, Braun S, Swoboda L. Perforation into the heart— a rare complication of stomach ulcer in hiatal hernia. Chirurg 1998; 69:475–476.PubMedCrossRefGoogle Scholar
  105. 105.
    Trojan I, Imre J, Kulka F. Gastro-pulmonary fistula as an unusual late complication of a hiatal hernia. Thoraxchir Vasik Chir 1971; 19:152–154.Google Scholar
  106. 106.
    Alvarez L, Blondiau JV, Scherpings P, et al. Pneumopericardium: a race against time! Case report and literature review. Rev Med Brux 1996; 17:143–146.PubMedGoogle Scholar
  107. 107.
    Borchardt M. Zur pathologie und therapie des magenvolvulus. Arch FJ Chir 1904; 74:243.Google Scholar
  108. 108.
    Carter R, Brewer LA, Hinshaw DB. Acute gastric volvulus. Am J Surg 1980; 140:99–106.PubMedCrossRefGoogle Scholar
  109. 109.
    Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: operation or observation? Ann Surg 2002; 236: 492–500.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Michel B. Aboutanos
    • 1
  • Therèse M. Duane
    • 1
  • Ajai K. Malhotra
    • 1
  • Rao R. Ivatury
    • 2
  1. 1.Division of Trauma, Critical Care, and Emergency Surgery, Virginia Commonwealth University Medical CenterMedical College of Virginia Hospitals and PhysiciansRichmondUSA
  2. 2.Department of Surgery, Virginia Commonwealth UniversityVirginia Commonwealth University Medical CenterRichmondUSA

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