In cats and dogs with traumatic diaphragmatic rupture, does surgical timing affect outcome?

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Appraisal, application and reflection

Overall, there is low quality of evidence assessing if performing herniorrhaphy within 24 hours of presentation affects the outcome of cats and dogs with traumatic diaphragmatic hernia. In the studies that assessed the time between trauma or hospital admission and surgical repair the timing of herniorrhaphy was not associated with survival to hospital discharge (Gibson et al., 2005; Legallet et al., 2017; and Schmiedt et al., 2003).

In one study assessing surgical repair of chronic diaphragmatic hernia, defined as being present for over 2 weeks prior to surgical repair, in-hospital mortality was 7/50 (14%) (Minihan et al., 2004). Another study found no difference in mortality in cats undergoing surgical repair within 24 hours, 1–7 days or over 7 days since trauma, with overall mortality of 6/34 (17.6%) (Schmiedt et al., 2003). Overall mortality is variable, with the lowest reported rate 3/44 (6.8%) (Ozer et al., 2007). The highest reported mortality rate was 27/53 (50.9%) (Garson et al., 1980); survival in this population was markedly worse that the cases in the remainder of the studies. This may reflect a change in approach to case management and treatment options available since publication. However, another older publication reported a mortality rate similar to more recent studies (Wilson et al., 1971).

The published data are retrospective studies with many clinical variables, with differences in individual disease severity and case management (Besalti et al., 2011; Garson et al., 1980; Gibson et al., 2005; Igna et al., 2014, Legallet et al., 2017; Minihan et al., 2004; Ozer et al., 2007; Schmiedt et al., 2003; Wilson et al., 1971; and Yaygingül et al., 2019). Varied disease severity is to be expected in this condition as it has a traumatic aetiology, and many cases presented with concurrent soft tissue and orthopaedic injuries. Multiple injuries were associated with outcome in two studies (Legallet et al., 2017; and Schmiedt et al., 2003), with an increase in mortality of these patients. Animals with concurrent injuries that underwent herniorrhaphy also had other surgical procedures performed under the same general anaesthesia. Several also had elective procedures performed, such as neutering. Increased anaesthesia time was linked with an increase in mortality (Legallet et al., 2017). In the same study, animals that required oxygen supplementation prior to surgery were less likely to survive. These findings suggest that systemic disease severity is associated with outcome in cats and dogs with traumatic diaphragmatic rupture.

Variables not assessed was the association between number and type of organs herniated into the thorax or the location of diaphragmatic tear and outcome. These were not linked to the PICO question to assess the timing of surgical intervention, therefore were not investigated as part of this review.

In conclusion, in reviewing the available literature, there is no evidence to support that time to surgical intervention is associated with outcome in cats and dogs with traumatic diaphragmatic rupture.

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