Right Sided Enterothroax: A Rare Long-term Complication of Donor Hepatectomy

A 41-year-old  male patient who had no chronic disease, no family history  and had undergone donor right-hepatectomy 3 years ago  was admitted to the  tertiary emergency department with complaints of  abdominal pain, nausea and vomiting for two days.  The patient emphasized that the abdominal pain increased from the beginning and was continuous throughout the day. The patient  also stated that he vomited dark colored and foul-smelling from the second day of his complaints. 

Vital signs of the patient were blood pressure 110/70 mm Hg, heart rate 110 beats/minute, breathing rate 25/minute,  saturation  94, fever 37.2 celcius.  The patient's BMI was 37 kg/m2.  Increased bowel sounds on auscultation; diffuse abdominal tenderness, rebound and minimal distension were detected in the comprehensive examination performed by the Emergency Service Doctors. On rectal examination, the ampulla was found to be empty. There was no significant finding other than leukocytosis in blood tests. A mild blunting was observed in the right sinus on chest X-ray. Abdominal X-ray showed several small intestinal air-fluid levels. Computed tomography (CT) showed air-fluid level in the distal small intestine and a herniated  rightcolon  in the thorax (Figure 1-2) .

Figure 1 CT Image at Coronal section. The right colon herniated to the thorax is seen

Figure 2 CT Image at Axial section

The patient  who was evaluated as acute abdomen by the emergency physicians  was consulted to us after the patient's anamnesis, physical examination, laboratory and radiological examinations. As a general surgery clinic, we diagnosed strangulated incarcerated incisional diaphragmatic hernia. 

The patient was admitted to the hospital after obtaining consent for further examination, treatment and data to be used for academic study. We decided for emergency laparatomybecause  systemic inflammatory response due to strangulation of the right colon started in the patient  and his hemodynamics was unstable. 

It was seen that there was bleeding in the small intestine mesentery which was stretched due to the hernia  and the blood supply to the cecum and ascending colon was impaired in the examination during the operation . After bleeding control is provided herniation of approximately 5 cm colon segment was detected from the 2 cm diaphragmatic defect in the case with donor right hepatectomy history. After enlarging the defect approximately 1 cm, the hernia was reduced. There was no significant adhesion with the major structures and pleura in the thorax. The diaphragmatic defect was closed transabdominally with non-absorbable sutures . Right hemicolectomy was performed, lateral anastomosis was performed with surgical staples. 

The patient was followed up in the intensive care unit one day after the operation and oral intake was started on the 3rd postoperative day. The patient who was treated with meropenem and vancomycin due to bilateral lower lobe pneumonia  was also followed up by the Pulmonary Diseases and Infectious Diseases  Clinic. The patient was discharged uneventfully on the 7th postoperative day. 

Studies have reported that the morbidity rate for a healthy donor in LDLT is 12-26%  with this it has been emphasized that incisional diaphragmatic hernia develops in 5-62% of cases in different series.  Direct  or thermal damage  of the diaphragm are presented as  hypothesis for diaphragmatic hernia, which is one of the morbidities ^4-5.  The congenital thin structure of the posterior diaphragm and the pressure difference between the thorax and abdomen were additionally emphasized as risk factors for diaphragmatic hernia after liver surgery. It was stated that the median time for the formation of an incisional diaphragmatic hernia after the surgery was 14 months ³. We diagnosed diaphragmatic hernia in our patient 3 years after liver surgery. 

Symptoms for diaphragmatic hernia are non-specific. Chest pain, recurrent abdominal pain, and early feeling of fullness after eating are some of the symptoms ⁶.

In the study, it was stated that there are four stages for the development of diaphragmatic hernia: 1) asymptomatic 2) minimal symptom 3) obstruction 4) Strangulation. Surgical treatment is essential in the strangulation period.  If not diagnosed early  it causes strangulation and severe lung disease, and the mortality rate reaches 32% ⁶.  

Computed tomography is the most commonly used modality for diagnosis. The radiography accuracy for diagnosis is approximately 40%. Definitive diagnosis is made on the basis of clinical examination and radiological examinations. Basically  the curative treatment of strangulated diaphragmatic hernias is emergency surgery. Primary repair is sufficient for small defects in diaphragmatic hernias ^2-6. 

In accordance with the data and experiences expressed in the literature; we diagnosed our patient who presented with strangulated incarcerated diaphragmatic hernia with CT and examination and performed an emergency operation on our patient. In the operation, we repaired the small diaphragmatic defect with primary suture. 

As a result, diaphragmatic hernias should be kept in mind as long-term complications in patients who have undergone liver surgery. Early diagnosis is important for good consequences ; symptoms, signs and general condition should be taken into consideration for patient  ^6-7. In addition liver surgeons should pay attention to the integrity of adjacent organs ⁵.