Exploring the clinical characteristics and prevalence of the annular pancreas: a meta-analysis

BACKGROUND

The annular pancreas (AP) is a rare gastrointestinal congenital malformation, in which malrotation of the pancreatic ventral bud in the seventh week of embryonic development manifests in a partial or complete ring of tissue around the second part of the duodenum.

METHODS

The main online medical databases such as PubMed, ScienceDirect, Wiley online library, Web of Science, and EBSCO discovery service were used to gather all relevant studies on the AP.

RESULTS

A total of 12,729,118 patients were analyzed in relation to the prevalence of AP. The pooled prevalence of AP was 0.0045% (95% CI: 0.0021%-0.0077%). The most frequent comorbidity in adults and children was duodenal obstruction, with a pooled prevalence of 24.04% and 52.58%, respectively (95% CI: 6.86%-46.48% and 35.56%-69.31%, respectively). The most frequent operation in adult patients with AP was duodenojejunostomy, with pooled prevalence established at 3.62% (95% CI: 0.00%-10.74%).

CONCLUSION

The diagnostic complexity of AP is accentuated by its nonspecific clinical symptoms, making accurate identification reliant on imaging studies. Therefore, having a thorough knowledge of the clinical characteristics of the AP and its associated anomalies becomes paramount when faced with this rare congenital condition.

Prenatal MRI assessment of mediastinal shift angle as a feasible and effective risk stratification tool in isolated right-sided congenital diaphragmatic hernia

OBJECTIVES

To develop a mediastinal shift angle (MSA) measurement method applicable to right-sided congenital diaphragmatic hernia (RCDH) in fetal MRI and to validate the predictive value of MSA in RCDH.

METHODS

Twenty-seven fetuses with isolated RCDH and 53 controls were included in our study. MSA was measured on MRI axial image at the level of four-chamber view of the fetal heart. The angle between the sagittal midline landmark line and the left boundary landmark line touching tangentially the lateral wall of the left ventricle was used to quantify MSA for RCDH. Appropriate statistical analyses were performed to determine whether MSA can be regarded as a valid predictive tool for postnatal outcomes. Furthermore, predictive performance of MSA was compared with that of lung area to head circumference ratio (LHR), observed/expected LHR (O/E LHR), total fetal lung volume (TFLV), and observed/expected TFLV (O/E TFLV).

RESULTS

MSA was significantly higher in the RCDH group than in the control group. MSA, LHR, O/E LHR, TFLV, and O/E TFLV were all correlated with postnatal survival, pulmonary hypertension (PH), and extracorporeal membrane oxygenation (ECMO) therapy (p < 0.05). Value of the AUC demonstrated good predictive performance of MSA for postnatal survival (0.901, 95%CI: (0.781-1.000)), PH (0.828, 95%CI: (0.661-0.994)), and ECMO therapy (0.813, 95%CI: (0.645-0.980)), which was similar to O/E TFLV but slightly better than TFLV, O/E LHR, and LHR.

CONCLUSIONS

We developed a measurement method of MSA for RCDH for the first time and demonstrated that MSA could be used to predict postnatal survival, PH, and ECMO therapy in RCDH.

CLINICAL RELEVANCE STATEMENT

Newly developed MRI assessment method of fetal MSA in RCDH offers a simple and effective risk stratification tool for patients with RCDH.

KEY POINTS

• We developed a measurement method of mediastinal shift angle for right-sided congenital diaphragmatic hernia for the first time and demonstrated its feasibility and reproducibility. • Mediastinal shift angle can predict more prognostic information other than survival in right-sided congenital diaphragmatic hernia with good performance. • Mediastinal shift angle can be used as a simple and effective risk stratification tool in right-sided congenital diaphragmatic hernia to improve planning of postnatal management.

Image-based prenatal predictors of postnatal survival, extracorporeal life support, and defect size in right congenital diaphragmatic hernia

OBJECTIVE

To determine the association between prenatal ultrasound (US) and magnetic resonance imaging (MRI) characteristics in right congenital diaphragmatic hernia (RCDH) with postnatal outcome.

STUDY DESIGN

CDH Study Group data were reviewed for all RCDH infants (n = 156) born between 2015 and 2019. Prenatal US and MRI lung size measurements were correlated with survival, extracorporeal life support (ECLS), and defect size.

RESULT

Overall survival was 64.1%. ECLS was required in 40.4%. US and MRI-based prenatal assessment of pulmonary hypoplasia does not predict survival. Prenatal measurement of lung size using either US or MRI correlates with ECLS use. Only MRI-based measures of lung size are associated with defect size.

CONCLUSION

Image-based prenatal predictors of survival, ECLS, and defect size are of limited value in RCDH. Extrapolation of prenatal survival and morbidity indicators from left to right-sided CDH is not appropriate. There is an urgent need to develop RCDH prenatal prediction models.

In-Hospital Morbidities for Neonates with Congenital Diaphragmatic Hernia: The Impact of Defect Size and Laterality

OBJECTIVE

To determine in-hospital morbidities for neonates with right-sided congenital diaphragmatic hernia (R-CDH) compared with those with left-sided defects (L-CDH) and to examine the differential effect of laterality and defect size on morbidities.

STUDY DESIGN

This retrospective, multicenter, cohort study from the international Congenital Diaphragmatic Hernia Study Group registry collected data from neonates with CDH surviving until hospital discharge from 90 neonatal intensive care units between January 1, 2007, and July 31, 2020. Major pulmonary, cardiac, neurologic, and gastrointestinal morbidities were compared between neonates with L-CDH and R-CDH, adjusted for prenatal and postnatal factors using logistic regression.

RESULTS

Of 4123 survivors with CDH, those with R-CDH (n = 598 [15%]) compared with those with L-CDH (n = 3525 [85%]) had an increased odds of pulmonary (1.7; 95% CI, 1.4-2.2, P < .0001), cardiac (1.4; 95% CI, 1.1-1.8; P = .01), gastrointestinal (1.3; 95% CI, 1.1-1.6; P = .01), and multiple (1.6; 95% CI, 1.2-2.0; P < .001) in-hospital morbidities, with a greater likelihood of morbidity with increasing defect size. There was no difference in neurologic morbidities between the groups.

CONCLUSIONS

Neonates with R-CDH and a larger defect size are at an increased risk for in-hospital morbidities. Counseling and clinical strategies should incorporate knowledge of these risks, and approach to neonatal R-CDH should be distinct from current practices targeted to L-CDH.

Bochdalek hernia with intrathoracic spleen treated by robotic-assisted mesh repair utilizing indocyanine green contrast media intraoperatively. A case report

Bochdalek hernias are usually diagnosed in newborns. However, they can occur in adults. Few reports exist regarding robotic repair of such hernias. We present a case of a female patient with symptomatic Bochdalek hernia, including the spleen. Patient was successfully treated by robotic-assisted surgical mesh with the use of indocyanine green (ICG). An 80-year-old female patient presented with dyspnea, angina and intermittent abdominal pain. She had loss of appetite and 15-kg weight loss within 3 months. Past medical history was unremarkable. Imaging revealed a left Bochdalek hernia. The patient underwent robotic-assisted surgery; hernia contents included stomach, parts of colon, omentum and remarkably the spleen. Sac was dissected free. Patency of organs was assessed with ICG. Diaphragmatic defect was repaired with mesh. Bochdalek hernias should be surgically repaired. Minimally invasive therapy is safe and effective. Intraoperative ICG use can provide excellent results with favorable clinical outcomes.

Laparoscopic cholecystectomy in adult with asymptomatic partial agenesis of the right diaphragm: Case report and the literature

•

Diaphragmatic agenesis is a rare condition.

•

In adults with partial diaphragmatic agenesis, laparoscopic cholecystectomy can be performed successfully.

•

A conservative management only with gallstones dissolution therapy can be used if laparoscopy cannot be done.

Introduction

The importance of unilateral diaphragmatic agenesis (DA) in adults for performing a laparoscopic cholecystectomy has not been well described in literature.

Presentation of case

A 60-year-old female patient entered our ward in March 2019 for laparoscopic cholecystectomy after 6 months history of epigastric pain and multiple episodes of biliary colic treated conservatively. She never complained of pulmonary symptoms. Preoperative chest Computed tomography (CT) was negative for diaphragmatic or pulmonary pathologies. Laparoscopic cholecystectomy was performed in 60 min with intraoperative detection of a thoracoabdominal communication with partial right hemidiaphragm agenesis. A chest CT and x-ray were performed in the postoperative period with progressive reduction of an asymptomatic small pneumothorax. The patient was discharged at home without complications on the fifth postoperative day. Thoracopulmonary surgery examination was performed without indications for diaphragmatic repair.

Discussion

DA is a rare condition and usually occurs in early neonatal period. The congenital form occurs in 1 out of 2200–12500 live births and is traditionally divided into anterior (Morgagni’s: 10%) and posterolateral (Bochdalek’s: 90%) hernias. Chest and abdomen CT with coronal and sagittal reconstructions is the most effective and useful imaging technique for the diagnosis of diaphragmatic hernia. In literature there are former two case reports of asymptomatic DA in cholelithiasis in which laparoscopic cholecystectomy was performed effectively.

Conclusion

In adults with partial DA, laparoscopic cholecystectomy can be performed successfully. A conservative management only with gallstones dissolution therapy can be used if laparoscopy cannot be done. Further studies with a higher level of evidence are needed.

Comparative outcomes of right versus left congenital diaphragmatic hernia: A multicenter analysis

BACKGROUND

Congenital diaphragmatic hernia (CDH) occurs in 1 out of 2500-3000 live births. Right-sided CDHs (R-CDHs) comprise 25% of all CDH cases, and data are conflicting on outcomes of these patients. The aim of our study was to compare outcomes in patients with right versus left CDH (L-CDH).

METHODS

We analyzed a multicenter prospectively enrolled database to compare baseline characteristics and outcomes of neonates enrolled from January 2005 to January 2019 with R-CDH vs. L-CDH.

RESULTS

A total of 588, 495 L-CDH, and 93 R-CDH patients with CDH were analyzed. L-CDHs were more frequently diagnosed prenatally (p=0.011). Lung-to-head ratio was similar in both cohorts. R-CDHs had a lower frequency of primary repair (p=0.022) and a higher frequency of need for oxygen at discharge (p=0.013). However, in a multivariate analysis, need for oxygen at discharge was no longer significantly different. There were no differences in long-term neurodevelopmental outcomes assessed at two year follow up. There was no difference in mortality, need for ECMO, pulmonary hypertension, or hernia recurrence.

CONCLUSION

In this large series comparing R to L-CDH patients, we found no significant difference in mortality, use of ECMO, or pulmonary complications. Our study supports prior studies that R-CDHs are relatively larger and more often require a patch or muscle flap for repair.

TYPE OF STUDY

Prognosis study LEVEL OF EVIDENCE: Level II.

Congenital heart disease associated with congenital diaphragmatic hernia: A systematic review on incidence, prenatal diagnosis, management, and outcome

PURPOSE

The purpose of this study was to evaluate the impact of congenital heart disease (CHD) on infants with congenital diaphragmatic hernia (CDH).

METHODS

Using a defined search strategy (PubMed, Cochrane, Embase, Web of Science MeSH headings), we searched studies reporting the incidence, management, and outcome of CDH infants born with associated CHD.

RESULTS

Of 6410 abstracts, 117 met criteria. Overall, out of 28,974 babies with CDH, 4427 (15%) had CHD, of which 42% were critical. CDH repair was performed in a lower proportion of infants with CHD (72%) than in those without (85%; p < 0.0001). Compared to CDH babies without CHD, those born with a cardiac lesion were more likely to have a patch repair (45% vs. 30%; p < 0.01) and less likely to undergo minimally invasive surgery (5% vs. 17%; p < 0.0001). CDH babies with CHD had a lower survival rate than those without CHD (52 vs. 73%; p < 0.001). Survival was even lower (32%) in babies with critical CHD.

CONCLUSION

CHD has a strong impact on the management and outcome of infants with CDH. The combination of CDH and CHD results in lower survival than those without CHD or an isolated cardiac defect. Further studies are needed to address some specific aspects of the management of this fragile CDH cohort.

TYPE OF STUDY

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level III.

Mortality factors in infants with congenital diaphragmatic hernia: A systematic review

BACKGROUND

Congenital diaphragmatic hernia (CDH) is a malformation of the diaphragm accounting for 8% of all major congenital anomalies. Although many clinical factors of survival in children with CDH have been established, limited research exists on the role of sociodemographic and other factors. We aimed to systematically identify and summarize all available international literature, published from January 2000 to July 2017, evaluating specific mortality factors for children with prenatally diagnosed, isolated, left-sided CDH.

METHODS

MEDLINE, PROSPERO, EMBASE, Scopus, The Cochrane Library databases, and the table of contents for the past 5 years for relevant journals were searched systematically. The risk factors of interest were as follows: birth weight, gestational age (GA) at diagnosis, GA at birth, infant sex, maternal age, ethnicity, socioeconomic status (SES), and plurality. The primary outcome measure was survival. Data were extracted on study design, study quality, participant data, and survival-related effect estimates.

RESULTS

Seven studies fulfilled the inclusion criteria. In total, 347 children were included in the review. Birth weight, GA at diagnosis, and GA at birth were evaluated in five studies each, infant sex in two, and maternal age in one. None of these factors were significantly associated with survival. No studies evaluated the influence of plurality, ethnicity or SES.

CONCLUSION

Although the factors of interest showed no significant association with survival, more evidence is required to confirm these findings. Understanding whether sociodemographic factors are associated with survival may help inform the development of public health interventions to improve survival rates for children with CDH.

Pre- and neonatal imaging of gastrointestinal complications in congenital diaphragmatic hernia

The initial outcome in infants with congenital diaphragmatic hernia is mainly related to the associated lung hypoplasia. However, these patients frequently present with additional gastrointestinal pathology that also influences their quality of life and final prognosis. Congenital gastrointestinal anomalies are often observed and the displacement of the liver, the stomach and/or the intestines into the thorax may cause distortion of the vascular axis of these organs, increasing the risk of congestion and/or ischemia. Some of these gastrointestinal complications are already visible at imaging studies performed in utero and/or in newborns.This pictorial essay describes the imaging findings of the most frequently detected gastrointestinal complications in fetuses and infants with congenital diaphragmatic hernia, focusing on prenatal exams.

De Novo Duplication of 11p15 Associated With Congenital Diaphragmatic Hernia

Background: Congenital diaphragmatic hernia (CDH) is a rare defect of the diaphragm commonly associated with high morbidity and mortality due to lung hypoplasia and pulmonary hypertension. Although in 70% of patients the etiology of a CDH remains unknown, a multitude of causative chromosomal aberrations has been identified. Case presentation: We describe the first case of isolated 11p15 duplication with CDH. The 18.6 Mb large duplication affected 285 RefSeq genes and included the Beckwith-Wiedemann (BWS)-associated imprinting control region 2 (ICR2, KCNQ1OT1 TSS DMR), whereas the ICR1 (H19 TSS DMR) was not affected. We were able to demonstrate de novo occurrence of the duplication. The paternal origin of the chromosomal material was detected by methylation testing the ICR2. Corresponding to other patients with duplications of the paternal ICR2 copy, a BWS phenotype is not present. Conclusions: The patient presented here together with the review of four other cases from the literature indicate an association between duplications of the chromosomal region 11p15 and developmental defects of the diaphragm. Thus, we suggest duplications of 11p15 as a rare cause of CDH. This association may or may not appear in the context of BWS depending on the extent of the duplication and the imprinting status. Hence, a genetic workup should be performed in patients with CDH, particularly when other abnormalities are noted.

Characterization of limb differences in children with Cornelia de Lange Syndrome

Cornelia de Lange syndrome (CdLS) is a well-described multisystem developmental disorder characterized by dysmorphic facial features, growth and behavioral deficits, and cardiac, gastrointestinal, and limb anomalies. The limb defects seen in CdLS can be mild, with small feet or hands only, or can be severe, with variable deficiency defects involving primarily the ulnar structures and ranging from mild hypoplasia of the fifth digit to complete absence of the forearm. Interestingly, the upper limbs are typically much more involved than the lower extremities that generally manifest with small feet and 2-3 syndactyly of the toes and shortened fourth metatarsal. The upper limbs often manifest asymmetric involvement. The limb findings in our cohort of 378 individuals with CdLS demonstrate a consistent pattern of laterality and symmetry involvement (with increased severity of right-sided limb in individuals with asymmetric limb defects) and a correlation of more significant limb defects with an increased risk of other structural anomalies, and more severe behavioral outcomes. Additionally, we found that individuals with mutations in NIPBL were most likely to have limb defects compared to mutations in other genes with nonsense, exonic deletion, and frameshift mutations being most prevalent in those with limb defects. Characterization of the limb differences in children with CdLS may provide a tool to assist in genetic counseling and determining prognosis. This paper will review the limb involvement in a large cohort of individuals with CdLS assessing the correlation with molecular etiologies, symmetry, additional structural birth defects, and cognitive outcomes. © 2016 Wiley Periodicals, Inc.

Case series on anesthesia for video-assisted thoracoscopic surgery for congenital diaphragmatic hernia in children

Video-assisted thoracoscopic surgery (VATS) in the pediatric population is a challenging task for any anesthesiologist, moreover considering the high incidence of associated congenital anomalies which are individual predictors of poor prognosis. A thorough preoperative evaluation, knowledge of the physiology of one lung ventilation - pertaining to various methods of lung isolation, individualized meticulous planning, and continuous vigilance to detect any untoward event at the earliest with good communication between the anesthesiology and surgical teams contributes to a safe and successful surgery. We present a case series of anesthetic management of congenital diaphragmatic hernia with VATS.

Right- versus left-sided congenital diaphragmatic hernia: a comparative outcomes analysis

PURPOSE

Right-sided congenital diaphragmatic hernia (R-CDH) occurs in up to 25% of all CDH cases, but has been less widely studied compared to left-sided defects. We sought to compare characteristics and outcomes of left- versus right-sided defects in a large cohort of CDH patients who underwent standardized treatment and follow-up at a single institution.

METHODS

We retrospectively reviewed charts of all CDH patients in our pulmonary hypoplasia program from January 2002 through December 2014. Categorical variables were analyzed by Fisher's exact test and continuous variables by Mann-Whitney t-test (p≤0.05).

RESULTS

A total of 330 CDH patients were treated more than the 12-year study period, with 274 (83%) left-sided and 56 (17%) right-sided cases identified. Specific pulmonary morbidities were associated with R-CDH, with increased duration of nitric oxide therapy, increased requirement for tracheostomy, increased requirement for supplemental oxygen at the time of NICU discharge, and increased chronic pulmonary hypertension with requirement for long-term Sildenafil therapy.

CONCLUSIONS

In this series, R-CDH was not associated with increased mortality, but was associated with increased requirement for pulmonary vasodilatory therapy and requirement for tracheostomy. The high incidence of pulmonary complications indicates increased severity of pulmonary hypoplasia in R-CDH, supporting a role for delivery in tertiary centers with expertise in CDH management.

Congenital Right Morgagni Hernia Presenting in an Adult-a Case Report

Patients with congenital diaphragmatic hernias (CDH) usually present in the neonatal period with respiratory distress. Delayed presentation of CDH in adults is rare and difficult to diagnose. We present a 42-year-old female patient who came with complaints of epigastric pain and breathlessness on exertion. X-ray and CT scan of the chest revealed a right-sided Morgagni hernia. The contents of the hernia were reduced and a primary tension free repair of the hernia defect was done through laparotomy. The postoperative course was uneventful. A strong clinical suspicion and good interpretation of radiological images help diagnose CDH which present late. Prompt surgical repair is mandatory and the outcomes are usually favorable. Primary repair is usually successful; however, mesh repair may be required for larger defects.

Laparoscopic cholecystectomy in an adult with agenesis of right hemidiaphragm and limb reduction defects: First report in literature

The importance of the complete absence of a hemidiaphragm or unilateral diaphragmatic agenesis in adulthood in relation to performing laparoscopic procedures has not been well documented. This article reports for the first time in literature a case of successful laparoscopic cholecystectomy in an adult with previously undiagnosed unilateral diaphragmatic agenesis. A 36-year-old female complaining of stubborn right upper abdominal pain radiating to her upper back was diagnosed as having cholelithiasis and was scheduled for laparoscopic cholecystectomy. There were also bilateral upper extremity malformations to a certain level. Routine diagnostic tests demonstrated that her entire liver and some bowel loops were in the right hemithorax, suggesting right-sided diaphragmatic hernia. Laparoscopic procedure was performed with the insertion of four trocars. Exploration of abdomen revealed total absence of the right hemidiaphragm. Cholecystectomy was completed laparoscopically in about 45 minutes without need for additional trocars. Patient had an uneventful recovery and was discharged on the second postoperative day without any complaint. Laparoscopic cholecystectomy in adults with diaphragmatic agenesis and intrathoracic abdominal viscera can be performed successfully. Nevertheless, any bile duct aberrations must be documented prior to surgery, and the surgeon should be able to convert to open procedure if necessary.

Rare case report - congenital diaphragmatic hernia presentation in adult

Congenital diaphragmatic hernia (CDH) which mainly occurs in the newborn or in childhood with severe respiratory distress and high mortality, is rarely found in adults (Yamaguchi et al. Ann Thorac Cardiovasc Surg 8:106-108, 2002; Dalencourt and Katlic Ann Thorac Surg 82:721-722, 2006; Fraser et al. Endosc Percutan Tech 19: e5-e7, 2009; Kanazawa et al. Surg Today 32:812-815, 2002). These patients are been accustomed to adjust their lifestyle to manage symptoms associated with frank herniation of the large bowel and liver inside the diaphragmatic hernial sac. Bowel above the liver surface especially the transverse colon is suggestive of a Chilaiditi's syndrome in these group of patients. Diagnostic laparoscopy plays an important role for diagnosis of diaphragmatic hernia in some cases over other investigations like CT scan and ultrasonography. Chilaiditi's syndrome has no surgical line of treatment but a symptomatic diaphragmatic hernia requires surgical correction. Liver as the main hernial content has been reported only in three cases throughout the world (Goh et al. Am J Surg 194: 390-391, 2007; Luo et al. Hepatobiliary Pancreat Dis Int 6: 219-221, 2007; Bosenberg and Brown RA Curr Opin Anaesthesiol 21: 323-331, 2008). A case of a 27 year old female patient presenting with a symptomatic congenital diaphragmatic hernia is reported.

Right-sided congenital diaphragmatic hernia: high utilization of extracorporeal membrane oxygenation and high survival

PURPOSE

The purpose of the study was to assess the treatment strategies and outcome of right-sided congenital diaphragmatic hernia (R-CDH), particularly extracorporeal membrane oxygenation (ECMO).

METHODS

We reviewed the cases of 42 patients treated for R-CDH at our institution from 1991 to 2006. We gathered demographic information, documented ECMO use and the type of surgical repair, and compared outcomes with predicted survival as calculated by the CDH Study Group's equation.

RESULTS

Of the 35 patients included in our statistical analysis (7 were excluded), 12 (34%) were born at our institution, all of whom were prenatally diagnosed with R-CDH. Nineteen patients (54%) required ECMO therapy. Extracorporeal membrane oxygenation was initiated after repair of the R-CDH in 2 patients (11%). Of those patients who went on ECMO before repair, 4 patients (21%) were repaired on ECMO, 9 patients (47%) underwent repair after ECMO, and 4 patients (21%) underwent ECMO but died before their R-CDH could be repaired. Primary repair of the diaphragm was possible in 15 cases (56%), and primary closure of the abdominal incision was possible in 15 of the 23 open repairs (65%). The mean predicted survival for all 35 patients was 63%, whereas 28 (80%) actually survived. Logistic regression showed a significant association between the presence of cardiac defects and mortality (odds ratio = 0.008, P = .014).

CONCLUSIONS

Our data suggest that patients with R-CDH have high ECMO utilization and may experience greater relative benefit from ECMO as evidenced by their higher-than-expected overall survival. Extracorporeal membrane oxygenation may be found to have a distinctive role in managing R-CDH. More high-powered series are needed to elucidate differences between R-CDH and left-sided CDH that may dictate alternate forms of management.

Imaging of congenital diaphragmatic hernias

Congenital diaphragmatic hernias are complex and life-threatening lesions that are not just anatomic defects of the diaphragm, but represent a complex set of physiologic derangements of the lung, the pulmonary vasculature, and related structures. Imaging plays an increasingly important role in the care of these infants. Prenatal sonography and MRI have allowed early and accurate identification of the defect and associated anomalies. These tools have also been the key to defining the degree of pulmonary hypoplasia and to predicting neonatal survival and need for aggressive respiratory rescue strategies. In the postnatal period, conventional radiography supplemented by cross-sectional imaging in selected cases can be very useful in sorting out the differential diagnosis of intrathoracic masses, in the detection of associated anomalies, and in the management of complications. Understanding the pathogenesis of diaphragmatic defects, the underlying physiologic disturbances, and the strengths and limitations of current imaging protocols is essential to the effective and accurate management of these complex patients.

Management of congenital diaphragmatic hernia

PURPOSE OF REVIEW

To evaluate the impact of recent research on the management of congenital diaphragmatic hernia in the light of new theories on embryological development, earlier antenatal diagnosis, fetal and postnatal interventions together with advances in perinatal intensive care.

RECENT FINDINGS

The year 2007 provided in excess of 200 publications that address various aspects of congenital diaphragmatic hernia. The genetic basis and the causes of pulmonary hypoplasia at the molecular level are slowly being unravelled. Fetal MRI of lung volume, lung-head ratio, liver position and size of diaphragmatic defect have all been evaluated as early predictors of outcome and with a view to prenatal counselling. The impact of fetal interventions such as fetal endoluminal tracheal occlusion, the mode of delivery, the surgical techniques and agents for treating pulmonary hypertension were evaluated. The influence of associated anomalies and therapeutic interventions on the outcome and quality of life of survivors continue to be appraised.

SUMMARY

Deferred surgery after stabilization with gentle ventilation and reversal of pulmonary hypertension remain the cornerstones of management. Optimal presurgery and postsurgery ventilatory settings remain unproven. Continued improvement in neonatal intensive care raises the bar against which any intervention such as fetal endoluminal tracheal occlusion and extracorporeal membrane oxygenation will be judged.