Massive Spontaneous Diaphragmatic Rupture Induced by a Squatting Position
A 68-year-old male presented with chest pain similar to acute coronary syndrome. The patient had felt a substernal pain from a period of four days prior to examination, which had begun while carrying out farm work in a squatting position. The severity of the chest pain had fluctuated, and then the patient felt intolerable chest pain that lasted for two hours. An electrocardiogram showed normal sinus rhythm, and cardiac enzymes were normal. However, compared with another chest X-ray four months earlier (), a second chest X-ray revealed left diaphragmatic hernia with a markedly distended stomach and passive atelectasis of the left lower lung (). An abdomen computed tomography showed that the herniated stomach was significantly distended by ingested air due to severe pyloric compression. The diaphragmatic defect was approximately 5 cm in diameter ().\nWe performed an emergency operation because the patient suffered from continuing chest pain, which suggested a strangulation of the stomach. A left lateral thoracotomy was performed through the eighth intercostal space after intubation with a double-lumen endotracheal tube and insertion of a nasogastric tube for decompressing the stomach. We carefully inspected the stomach, which was entirely displaced into the thoracic cavity, including the greater omentum (), and we then reduced the stomach into the peritoneal cavity. A diaphragmatic defect was identified on the highest central tendon and had a round shape, half of which had a well-demarcated margin (). The diaphragm was thinned and unevenly rough owing to senile change. The remaining tissue of the fragile margin was completely excised () and was closed primarily using continuous running sutures and multiple interrupted sutures (). The patient was extubated before leaving the operating room. The chest X-rays before discharge showed complete reduction of the stomach and full re-expansion of the left lung (). The patient was uneventfully discharged and resumed a normal diet 10 days after the operation.