A review of patch options in the repair of congenital diaphragm defects

The use of biological membranes for correction of congenital malformations

Many congenital malformations often require a multidisciplinary and multistep surgical treatment, including the use of biological membranes. Aims of the study were to describe the use of these membranes for the correction of malformations, their clinical performance at follow-up, and patient's tolerance to them. The study included patients treated between 2009 and November 2020 in two referral centers. They were affected by abdominal wall defects (AWD), esophageal atresia/tracheo-esophageal fistula (EA/TEF), diaphragmatic hernia (CDH), spinal defects (SD), and anorectal malformations (ARM). The human origin membranes used during surgery were amniotic membrane, fascia lata, and pericardium provided by the local tissue bank and the porcine-derived membrane available on the market. Thirty-one patients were retrieved. The sample included 10 AWD, 7 EA/TEF, 5 CDH, 4 SD, 2 ARM, and 3 miscellaneous defects. The median age at repair was 139 days (range: 10,5–1494). The median follow-up was 1021 days (range: 485,5–1535). Two patients were lost at follow-up. The defects were successfully repaired and the membranes perfectly tolerated in 28/29 cases. In 1 case of CDH the fascia lata was replaced with a Goretex patch due to recurrence of the defect. This is the largest series on the use of biological membranes in congenital malformations. The variety of tissues allows to choose the best material for each malformation. The excellent tolerance and performance of this first series of patients encourage the use of these membranes to correct different type of malformations at any age.

Biological versus synthetic patch for the repair of congenital diaphragmatic hernia: 8-year experience at a tertiary center

PURPOSE

The aim of this study is to compare outcome between small intestinal submucosal (SIS) and polytetrafluoroethylene (PTFE) patches in patients with congenital diaphragmatic hernia (CDH) with large muscular defects.

MATERIAL AND METHODS

We performed a retrospective review of prospectively collected data of patients who underwent CDH repair from January 2011 to June 2019, with a minimum follow-up of 1 year. Data were collected regarding length of stay (LOS), mortality and recurrence. Kaplan-Meier analyses was used.

RESULTS

In the study period, 195 patients with CDH were admitted, 176 underwent surgical repair and 19 died before surgery. Sixty-two (35%) required a patch. Over the last 5 years, our institution transitioned from the use of all SIS to all PTFE. SIS was used in 18 cases and PTFE in 25. Overall survival rate was 89% (174/195). There was no significant difference regarding LOS and mortality. Nine patients (50%) of SIS and 1 (4%) of PTFE repairs recurred (P < 0.01; log-rank test P <  0.01), with a time course of recurrence of 18 (SD = 13) and 8 months, respectively. Median follow-up was 60 months (SD: 23) for the SIS group and 26 (SD: 10) for the PTFE group.

CONCLUSION

A significant lower recurrence was found using PTFE patches instead of SIS for the repair of large CDH.

LEVEL OF EVIDENCE

Level 3. Retrospective comparative study.

A systematic review and meta-analysis of surgical morbidity of primary versus patch repaired congenital diaphragmatic hernia patients

Large studies comparing the surgical outcome of primary versus patch repair in congenital diaphragmatic hernia (CDH) patients are rare. This study aims to evaluate the incidence of surgical complications in both types of CDH repair. PubMed, EMBASE, Cochrane and Web of Science were searched for peer-reviewed articles. Studies on CDH between 1991 and August 2020 were systematically screened and meta-analyses were performed. Primary outcomes of this review were: haemorrhage, chylothorax, recurrences and small bowel obstruction (SBO). A total of 6436 abstracts were screened, after which 25 publications were included (2910 patients). Patch repaired patients have a 2.8 times higher risk on developing a recurrence (20 studies) and a 2.5 times higher risk on developing a chylothorax (five studies). Moreover, they have a two times higher risk on developing a SBO. No studies could be included that evaluated the incidence of surgical haemorrhage between these patients. Although the quality of the studies was relatively low, patch repaired patients have a higher risk on developing a recurrence, chylothorax and small bowel obstruction. Large prospective studies are required to adjust for severity of disease, to reveal the true causative factors in order to minimize the risk on these surgical complications in both types of patients.

Longitudinal Follow-Up With Radiologic Screening for Recurrence and Secondary Hiatal Hernia in Neonates With Open Repair of Congenital Diaphragmatic Hernia-A Large Prospective, Observational Cohort Study at One Referral Center

Objective: After neonatal repair of congenital diaphragmatic hernia (CDH) recurrence is the most severe surgical complication and reported in up to 50% after patch implantation. Previous studies are difficult to compare due to differences in surgical techniques and retrospective study design and lack of standardized follow-up or radiologic imaging. The aim was to reliably detect complication rates by radiologic screening during longitudinal follow-up after neonatal open repair of CDH and to determine possible risk factors. Methods: At our referral center with standardized treatment algorithm and follow-up program, consecutive neonates were screened for recurrence by radiologic imaging at defined intervals during a 12-year period. Results: 326 neonates with open CDH repair completed follow-up of a minimum of 2 years. 68 patients (21%) received a primary repair, 251 (77%) a broad cone-shaped patch, and 7 a flat patch (2%). Recurrence occurred in 3 patients (0.7%) until discharge and diaphragmatic complications in 28 (8.6%) thereafter. Overall, 38 recurrences and/or secondary hiatal hernias were diagnosed (9% after primary repair, 12.7% after cone-shaped patch; p = 0.53). Diaphragmatic complications were significantly associated with initial defect size (r = 0.26). In multivariate analysis left-sided CDH, an abdominal wall patch and age below 4 years were identified as independent risk factors. Accordingly, relative risks (RRs) were significantly increased [left-sided CDH: 8.5 (p = 0.03); abdominal wall patch: 3.2 (p < 0.001); age ≤4 years: 6.5 (p < 0.002)]. 97% of patients with diaphragmatic complications showed no or nonspecific symptoms and 45% occurred beyond 1 year of age. Conclusions: The long-term complication rate after CDH repair highly depends on surgical technique: a comparatively low recurrence rate seems to be achievable in large defects by implantation of a broad cone-shaped, non-absorbable patch. Longitudinal follow-up with regular radiologic imaging until adolescence is essential to reliably detecting recurrence to prevent acute incarceration and chronic gastrointestinal morbidity with their impact on prognosis. Based on our findings and literature review, a risk-stratified approach to diaphragmatic complications is proposed.

Innovative, Stabilizing Self-Expandable Patch for Easier and Safer Thoracoscopic Repair of Congenital Diaphragmatic Hernia

Introduction: Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has become a popular approach and several benefits have been published. Patch closure requires demanding thoracoscopic skills and therefore primary closure with tight sutures is often pursued, which increases the risk of recurrence. The purpose of this study was to create and assess the performance of a new technique for thoracoscopic repair of CDH, which facilitates the surgical procedure. Materials and Methods: An innovative system for thoracoscopic repair of CDH with a novel patch was developed. The patch is self-expandable and offers a traction suture for stabilization, isolating and protecting the viscera. Its performance was assessed and compared with a conventional patch in an inanimate model of the disease through a quantitative and qualitative multivariate analysis. Results: Nine cases of CDH were repaired with each patch. The duration of the procedure was shorter (P < .05) and the level of difficulty was reported to be lower (P < .001) when using the self-expandable patch (SeP). The number of good quality knots was higher and adverse events were less common with this new technique. Conclusions: The stabilizing SeP offers safe and ergonomic performance for thoracoscopic CDH repair, facilitating the surgical technique. The main advantage is that it keeps the viscera isolated into the abdomen while offering a flap on the thoracic side for suturing in a practical manner, minimizing the risk of visceral injury and saving surgical time.

Transdiaphragmatic-pericardial Hernia: Case Report of an Unusual Condition Managed by Utilization of a Robotic Surgical System

Transdiaphragmatic hernia via the central tendon in the pericardium is a rare entity. Most often, these hernias are acquired and related to the iatrogenic creation of a transdiaphragmatic-pericardial defect. We would like to present a case of a 62-year-old male who presented with acute chest pain and was diagnosed to have a transdiaphragmatic-pericardial hernia on computed tomography. He has a history of cardiac intervention via an abdominal approach 12 years earlier. A segment of jejunum was found strangulated in the defect. We used DaVinci Xi® (Intuitive Surgical, Sunnyvale, CA) robot and were able to successfully reduce the hernia, repair the defect, and resect a short segment of jejunum which was non-viable. The utilization of a minimally invasive approach may be feasible, and the use of a robotic surgical system may enhance the surgeon’s ability to repair the defect.

Providing direction improves function: Comparison of a radial pore-orientated acellular collagen scaffold to clinical alternatives in a surgically induced rabbit diaphragmatic tissue defect model

Gore-Tex® is a widely used durable patch for repair of congenital diaphragmatic defects yet may result in complications. We compared Gore-Tex with a composite of a radial pore-orientated collagen scaffold (RP-Composite) and clinically used porcine small intestinal submucosa (SIS; Surgisis®) in a rabbit model for diaphragmatic hernia. The growing rabbit mimics the rapid rib cage growth and reherniation rates seen in children. We created and immediately repaired left hemidiaphragmatic defects in 6-week-old rabbits with Gore-Tex, SIS, and an RP-Composite scaffold. An additional group of rabbits had a sham operation. At 90 days, survivors more than doubled in weight. We observed few reherniations or eventrations in Gore-Tex (17%) and RP-Composite (22%) implanted animals. However, SIS failed in all rabbits. Maximum transdiaphragmatic pressure was lower in Gore-Tex (71%) than RP-Composite implanted animals (112%) or sham (134%). Gore-Tex repairs were less compliant than RP-Composite, which behaved as sham diaphragm (p < 0.01). RP-Composite induced less foreign body giant cell reaction than Gore-Tex (p < 0.05) with more collagen deposition (p < 0.001), although there was a tendency for the scaffold to calcify. Unlike Gore-Tex, the compliance of diaphragms reconstructed with RP-Composite scaffolds were comparable with native diaphragm, whereas reherniation rates and transdiaphragmatic pressure measurements were similar.

A finite element analysis of diaphragmatic hernia repair on an animal model

The diaphragm is a mammalian skeletal muscle that plays a fundamental role in the process of respiration. Alteration of its mechanical properties due to a diaphragmatic hernia contributes towards compromising its respiratory functions, leading to the need for surgical intervention to restore the physiological conditions by means of implants. This study aims to assess via numerical modeling biomechanical differences between a diaphragm in healthy conditions and a herniated diaphragm surgically repaired with a polymeric implant, in a mouse model. Finite Element models of healthy and repaired diaphragms are developed from diagnostic images and anatomical samples. The mechanical response of the diaphragmatic tendon is described by assuming an isotropic hyperelastic model. A similar constitutive model is used to define the mechanical behavior of the polymeric implant, while the muscular tissue is modeled by means of a three-element Hill's model, specifically adapted to mouse muscle fibers. The Finite Element Analysis is addressed to simulate diaphragmatic contraction in the eupnea condition, allowing the evaluation of diaphragm deformation in healthy and herniated-repaired conditions. The polymeric implant reduces diaphragm excursion compared to healthy conditions. This explains the possible alteration in the mechanical functionality of the repaired diaphragm. Looking to the surgical treatment of diaphragmatic hernia in human neonatal subjects, this study suggests the implementation of alternative approaches based on the use of biological implants.

A rare case report of Morgagni Hernia with Organo-Axial Gastric Volvulus and concomitant Para-esophageal hernia, repaired laparoscopically in a Septuagenarian

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These two forms of a hernia form a very rare association.

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Laparoscopic management of two different pathologies in one setting.

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Till now only four cases have been reported in English literature with successful Laparoscopic management of this condition.

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Patients may present with acute life-threatening complications viz. Incarceration, volvulus, etc.

Introduction

Simultaneous occurrence of Morgagni and the Para-esophageal hernia is a rare clinical condition with eight case reports in the English-language literature and only four managed laparoscopically. We describe a case of a Septuagenarian patient with Morgagni and concomitant Para-esophageal hernia treated laparoscopically.

Presentation of a case

A 71-year-old male patient, presented with a one-month history of regurgitation of acid, retrosternal burning and vomiting after eating. Computed tomography (CT) imaging demonstrated a large anterior diaphragmatic hernia, with herniation of bowel loops and anterosuperior displacement of the gastric antrum along with a grade III Para-esophageal hernia. The patient underwent simultaneous laparoscopic repair of Morgagni and Para-esophageal hernia with mesh reinforcement with Nissen’s total anti-reflux fundoplication. The patient’s postoperative recovery was uneventful.

Discussion

A Morgagni Hernia is a rare congenital condition consisting of a Subcosto-sternal defect in the diaphragm. A Para-esophageal hernia is a rare variant of a hiatus hernia. Morgagni and Para-esophageal hernia may present with gastric volvulus or incarceration, requiring emergency treatment. Minimally invasive surgery is the preferred treatment, particularly for elderly patients and patients with comorbidities. The laparoscopic operation can provide excellent exposure and repair the hernia defect easily with minimal invasiveness and fewer complications.

Conclusion

This case report highlights the co-existence of Morgagni and Para-esophageal hernias and validates the feasibility of laparoscopic repair of both hernias simultaneously.

A Rare Case of Bochdalek Hernia with Concomitant Para-Esophageal Hernia, Repaired Laparoscopically in an Octogenarian

Patient: Male, 81

Final Diagnosis: Bochdalex hernia

Symptoms: Chest pain • vomiting

Medication: —

Clinical Procedure: Laparoscopic repair of both diaphragmatic hernias

Specialty: Surgery

Complications in neonatal surgery

Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.

New insight in the biological integration of polytetrafluoroethylene from an explant used for diaphragm repair

Congenital diaphragmatic hernia is a severe disease requiring diaphragm replacement mostly with expanded polytetrafluoroethylene. Unfortunately, the recurrence rate is high due to prosthesis failure with significant morbidity for the child. To provide a better understanding of the integration and possible failure processes of the biomaterial implanted in humans, we conducted electron microscopical and mechanical assessments on a prosthesis explant from a child with congenital diaphragmatic hernia presenting a recurrence. Our findings show a major penetration of connective tissue into the expanded polytetrafluoroethylene on the rough side, whereas the smooth side presents few tissue colonization. This penetration is more important in the central area (area A) with large collagen bundles and layers, in comparison to the peripheral areas without prosthesis failure (area B), where few extracellular matrix is produced. The connective tissue penetrates the prosthesis in depth. In contrast, the peripheral areas with prosthesis failure (area C) show very few cells and extracellular matrix, with an oriented organization in comparison to areas A and B. Obviously, the forces applied on the implanted material modulate the cellular behavior of the newly developed tissues. Atomic force microscopic measurements of the biomaterials’ surfaces may explain some cellular behaviors according to areas with or without failure.

Diaphragm Repair with a Novel Cross-Linked Collagen Biomaterial in a Growing Rabbit Model

Background

Neonates with congenital diaphragmatic hernia and large defects often require patch closure. Acellular collagen matrices (ACM) have been suggested as an alternative to synthetic durable patches as they are remodeled by the host or could also be used for tissue engineering purposes.

Materials and Methods

2.0x1.0 cm diaphragmatic defects were created in 6-weeks old New-Zealand white rabbits. We compared reconstruction with a purpose-designed cross-linked ACM (Matricel) to 4-layer non-cross-linked small intestinal submucosa (SIS) and a 1-layer synthetic Dual Mesh (Gore-Tex). Unoperated animals or animals undergoing primary closure (4/0 polyglecaprone) served as age-matched controls. 60 (n = 25) resp. 90 (n = 17) days later, animals underwent chest x-ray and obduction for gross examination of explants, scoring of adhesion and inflammatory response. Also, uniaxial tensiometry was done, comparing explants to contralateral native diaphragmatic tissue.

Results

Overall weight nearly doubled from 1,554±242 g at surgery to 2,837±265 g at obduction (+84%). X-rays did show rare elevation of the left diaphragm (SIS = 1, Gore-Tex = 1, unoperated control = 1), but no herniation of abdominal organs. 56% of SIS and 10% of Matricel patches degraded with visceral bulging in four (SIS = 3, Matricel = 1). Adhesion scores were limited: 0.5 (Matricel) to 1 (SIS, Gore-Tex) to the left lung (p = 0.008) and 2.5 (Gore-Tex), 3 (SIS) and 4 (Matricel) to the liver (p<0.0001). Tensiometry revealed a reduced bursting strength but normal compliance for SIS. Compliance was reduced in Matricel and Gore-Tex (p<0.01). Inflammatory response was characterized by a more polymorphonuclear cell (SIS) resp. macrophage (Matricel) type of infiltrate (p<0.05). Fibrosis was similar for all groups, except there was less mature collagen deposited to Gore-Tex implants (p<0.05).

Conclusions

Matricel induced a macrophage-dominated inflammatory response, more adhesions, had appropriate strength but a lesser compliance compared to native tissue. The herein investigated ACM is not a viable option for CDH repair.

Prenatal management of the fetus with isolated congenital diaphragmatic hernia in the era of the TOTAL trial

Congenital diaphragmatic hernia (CDH) may be isolated or associated with other structural anomalies, the latter with poor prognosis. The defect allows viscera to herniate through the defect into the chest, competing for space with the developing lungs. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension that is lethal in up to 30% of patients. When isolated, survival chances can be predicted by antenatal measurement of lung size and liver herniation. Chromosomal microarrays and exome sequencing contribute to understanding genetic factors underlying isolated CDH. Prenatal intervention aims at stimulating lung development, clinically achieved by percutaneous fetal endoscopic tracheal occlusion (FETO) under local anesthesia. The Tracheal Occlusion To Accelerate Lung growth trial (www.totaltrial.eu) is an international randomized trial investigating the role of fetal therapy for severe and moderate pulmonary hypoplasia. Despite an apparent increase in survival following FETO, the search for lesser invasive and more potent prenatal interventions must continue.

Advances in the surgical approach to congenital diaphragmatic hernia

Congenital diaphragmatic hernia is a birth defect that affects about one in 2500 live births. Although the overall survival has improved over the last several decades thanks to advancements in postnatal resuscitation and intensive care treatment, morbidity and mortality remain high. The surgical management of these infants is far from being standardized, and many aspects are still disputed among experts. The timing of surgical repair remains controversial and the indications for the ideal time for surgery have not been validated. The main novelty in the surgical treatment is related to the use of minimally invasive techniques, although these have been associated with intraoperative blood gas disturbances and higher recurrence rates. Herein, we report and comment on the main controversies of postnatal CDH repair in this rapidly evolving field.

Organ bioengineering for the newborn

Regenerative medicine has recently been established as an emerging interdisciplinary field focused on the repair; replacement or regeneration of cells, tissues and organs. It involves various disciplines, which are focused on different aspects of the regeneration process such as cell biology, gene therapy, bioengineering, material science and pharmacology. In this article, we will outline progress on tissue engineering of specific tissues and organs relevant to paediatric surgery.

Full thickness abdominal wall defect in growing rats as a model for congenital diaphragmatic hernia prosthetic repair

BACKGROUND

Large congenital diaphragmatic hernia may require prosthetic correction. Acellular collagen matrices were introduced to avoid complications owing to the use of synthetic patches. We tested 3 different ACM for reconstruction of an abdominal wall defect in an animal model that mimics the fast growth during infancy.

METHODS

Pelvisoft® (CR Bard, Covington, GA) and 2 investigational ACM were used for primary reconstruction of a full thickness abdominal wall defect. 3months-old rats (n=26) were allowed to survive for 90days after implantation. Anatomical, tensiometric and histological analyses were performed. Based on good outcomes, we did the same with 1month-old rats (n=54). Unoperated rats were used for obtaining reference tensiometric values of selected native tissues.

RESULTS

Major wound complications were exclusively observed in 1month-old rats. All explants in both groups thinned significantly (p<0.03) and had an elastic modulus increasing over time, far above that from native tissues at 90days of life. Both investigational ACM induced a more vigorous foreign body reaction than Pelvisoft(®).

CONCLUSIONS

The shift from 3 to 1month-old rats was associated with wound complications. Pelvisoft® showed a better biocompatibility than the 2 investigational ACM. Passive biomechanical properties of all explants were still not comparable to that of native tissues.

Laparoscopic repair of a postadrenalectomy left-sided diaphragmatic hernia complicated by chronic colon obstruction

Iatrogenic diaphragmatic hernias are a rarely reported complication of abdominal surgery. We present a case of an iatrogenic diaphragmatic hernia diagnosed 2 years after an adrenalectomy. Corrective laparoscopic surgery was performed, and the postoperative course was uneventful. The patient remained asymptomatic 6 months after the repair. To our knowledge, this is the first such case to be reported.