A simple thoracoscopic plication technique for diaphragmatic eventration in neonates and infants: technical details and initial results

Experience of Minimally Invasive Surgery in Neonates with Congenital Malformations in a Tertiary Care Pediatric Hospital

Aim:

The aim of this study is to report the experience with minimally invasive surgery (MIS) in neonates with congenital malformations in a tertiary care pediatric hospital.

Materials and Methods:

Design: descriptive study. All neonates undergoing MIS from 2013 to 2018 were included in the study. Perinatal data, characteristics of surgery, type and duration of analgesia, postoperative mechanical ventilation duration, postoperative hospitalization, and postoperative morbidity and mortality surgery-related rates were recorded.

Results:

Seventy-one neonates were included. Gestational age and weight at surgery ranged from 24 to 41 weeks and from 1350 g to 4830 g, respectively. Procedures performed were esophageal atresia/tracheoesophageal fistula repair, congenital diaphragmatic hernia repair, diaphragmatic plication, fundoplication/gastrostomy, intestinal atresia repair, and pancreatectomy. The median follow-up period was 14 months. Five neonates (7%) were converted to open, for surgical difficulties. Nine (12.6%) neonates had intraoperative complications, with decreased oxygen saturation as the most common complication. The median duration of analgesia and postoperative mechanical ventilation was 3 days in most procedures. The morbidity and mortality rates were 36.6% and 2.8%, respectively.

Conclusions:

In this first experience with MIS in neonates, the duration of analgesia and hospitalization was shorter for some procedures. However, intraoperative and postoperative complications were still high, which was possibly attributed to the learning curve. Thus, it is expected that the frequency of the complications presented in this study will be reduced in future.

Thoracoscopic repair of diaphragmatic eventration in children: a comparison of two repair techniques

BACKGROUND

Thoracoscopic plication has gained popularity in the management of diaphragmatic eventration, and several suturing techniques have been described. However, the superiority of one technique over the other has not been demonstrated. The purpose of this study is to report our experience with diaphragmatic plication and to compare the thoracoscopic interrupted and pleated suture techniques in pediatric patients with diaphragmatic eventration.

METHODS

This is a retrospective cohort study (level of evidence: 3) performed on 14 patients with diaphragmatic eventration. All patients were symptomatic and had diaphragmatic plication via thoracoscopy. The patients were further divided into two groups according to the repair technique; interrupted repair (n = 9) and pleated repair (n = 5). Preoperative, operative and postoperative data were compared between the two groups.

RESULTS

The median age was 9.5 months (25th- 75th percentiles: 6 to 15 months), and 8 (57%) were males. Twelve patients (85.71%) had right side eventration, and nine patients (64.29%) had congenital diaphragmatic eventration. One case was converted to open thoracotomy because of adhesions. There was no difference in the preoperative characteristics between both groups. Median operative time was 117 min (25th- 75th percentiles: 101-129 min) and 77 min (25th- 75th percentiles: 73-83 min) in the interrupted and pleated groups, respectively (p = 0.004). One patient had a postoperative elevation of the diaphragm (incomplete repair) in the pleated group (p = 0.357). No recurrence was reported during the follow-up.

CONCLUSION

Thoracoscopic plication is an effective technique for management of diaphragmatic eventration in children. Pleating technique is easy, fast, and associated with a marked reduction in operative time.

TYPE OF THE STUDY

Retrospective cohort study.

LEVELS OF EVIDENCE

Level of evidence: 3.

Double purse-string suturing: An easy plication technique in thoracoscopic repair of diaphragmatic eventration

OBJECTIVE

The aim of this study was to describe a new double purse-string suturing plication method that was developed to minimize difficulties experienced in thoracoscopic plication in pediatric patients.

METHODS

We retrospectively analyzed the data of patients that underwent diaphragmatic eventration repair with new technique developed in our clinic. In this technique, we perform diaphragm plication with continuous double layer purse-string suturing. A third suturing may be necessary in case of wide eventrations. Thoracic drainage catheter is inserted into the thorax on a routine basis.

RESULTS

Thoracoscopic plication was performed using the double purse-string suturing technique on 16 cases that presented with diaphragmatic eventration between April 2012 and December 2018. The patients' mean age was 2.2 years (6 months-17 years). The main causes of admission were recurrent respiratory system infections (n: 14), respiratory distress with effort (n: 4), ventilator dependence (n: 1), and gastrointestinal complaints such as nutritional problems (n: 1). Diaphragmatic eventration was incidentally detected in 1 patient. No complications were observed during the postoperative period, except for 1 patient that developed pneumothorax. The mean duration of hospital stay was 4.9 days (2-7 days), except for 1 patient who had ventilator dependence and congenital myopathy. The mean descending distance of the diaphragm was 2.3 intercostal spaces at postoperative first month. The clinical outcomes were satisfactory and all patients experienced symptom improvements.

CONCLUSIONS

Diaphragm plication with double purse-string suturing method enables symmetrical stretching of the diaphragmatic muscles. Therefore, the diaphragmatic surface and costophrenic sinium are protected and remain functional. The advantages of this new double purse-string suturing method are easy application and durability. We believe that this method can become a preferred thoracoscopic plication technique for treatment of diaphragmatic eventration.

Thoracic versus abdominal approach to correct diaphragmatic eventration in children

BACKGROUND

Plication of diaphragm (DP) for eventration (DE) can be done using thoracic or abdominal approaches. The purpose of our study was to compare outcomes between these approaches based on our experience and on systematic literature review.

METHODS

Retrospective records of children <16 years who underwent DP (single-center, 2004-2018) were recorded and analyzed. Systematic review and meta-analysis of related studies was undertaken. Data are reported as median (range).

RESULTS

Eighty-nine cases were identified in thoracic (Congenital = 5, Acquired = 84) and 13 (Congenital = 10, Acquired = 3) in abdominal group aged 5.88 (0.36-184.44) and 10.0 (0.12-181.8) months. Improvement in diaphragm level post-DP was significantly higher in abdominal [2(0-4)] than chest [1.5(0-5)] group (p = 0.04). On Cox regression analysis, there was a non-significant trend to a longer time to extubation in the chest group (Hazard ratio (HR) = 0.539[0.208-1.395], p = 0.203). Patients operated transthoracically left intensive care unit after a significantly longer time (HR = 0.339[0.119-0.966], p = 0.043). Patients operated transabdominally tended to be fed later, although this was not significant (HR = 1.801[0.762-4.253], p = 0.043). On Kaplan-Meier analysis, there was a non-significant trend to a lower rate of recurrence in the abdominal group (HR = 0.3196[0.061-1.675], p = 0.1876). In the meta-analysis including three published studies as well as our data (total n = 181, Thoracic = 139, Abdominal = 42), no difference was found in the incidence of recurrence amongst the 2 groups (RD = -0.04, 95%CI = -0.25, 0.18, p = 0.74).

CONCLUSION

This is one of the largest reports on outcomes of children undergoing DP for DE. There is no significant difference in recurrence rate, even though all recurrences in our series (15.7%) were in the acquired cases operated using a thoracic approach.

TYPE OF STUDY

Treatment Retrospective Comparative Study.

LEVEL OF EVIDENCE

Level III.

Advanced minimal access surgery in infants weighing less than 3kg: A single center experience

BACKGROUND

Minimal access surgery (MAS) has gained popularity in infants less than 5kg, however, significant challenges still arise in very low weight infants.

STUDY DESIGN

A retrospective chart review was performed to identify all infants weighing less than 3kg who underwent an advanced MAS or equivalent open procedure from 2009 to 2016. Advanced case types included Nissen fundoplication, duodenal atresia repair, Ladd procedure, congenital diaphragmatic hernia repair, esophageal atresia/tracheoesophageal fistula repair, diaphragmatic plication, and pyloric atresia repair. A comparative analysis was performed between the MAS and open cohorts.

RESULTS

A total of 45 advanced MAS cases and 17 open cases met the inclusion criteria. Gestational age and age at operation were similar between the cohorts, while infants who underwent open procedures had significantly lower weight at operation (p=0.003). There were no deaths within 30days related to surgery in either group. Only 3 MAS cases required unintended conversion to open. There were 2 (4.4%) postoperative complications related to surgery in the MAS cohort and 2 (11.8%) in the open cohort.

CONCLUSION

Advanced MAS may be performed in infants weighing less than 3kg with low mortality, acceptable rates of conversion, and similar rates of complications as open procedures.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level III.

Early Thoracoscopic Plication of Diaphragm in a Newborn with Brachial Plexus Palsy and Concurrent Phrenic Nerve Palsy

Phrenic nerve palsy is a rare cause of respiratory distress in a newborn. When conservative measures fail to achieve adequate ventilation, then early surgical plication has been found to be associated with good outcome. We report a case of neonate with phrenic nerve palsy in whom an early thoracoscopic diaphragmatic plication was done.