Right-sided diaphragmatic hernia in an adult after living donor liver transplant: a rare cause of post-transplant recurrent abdominal pain

Incidence and outcomes of post-hepatectomy diaphragmatic hernia: a systematic review

BACKGROUND

Post-hepatectomy diaphragmatic hernia is the second most common cause of acquired diaphragmatic hernia. This study aims to review the literature on this complication's incidence, treatment and prognosis.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically searched PubMed for all studies related to acquired diaphragmatic hernias after hepatectomy.

RESULTS

We included 28 studies in our final analysis, comprising 11,368 hepatectomies. The incidence of post-hepatectomy diaphragmatic hernia was 0.75% (n = 86). The most frequent type of hepatectomy performed was right hepatectomy (79%, n = 68), and the indications for liver resection were a liver donation for living donor transplantation (n = 40), malignant liver tumors (n = 13), and benign tumors (n = 11). The mean onset between liver resection and the diagnosis of diaphragmatic hernia was 25.7 months (range, 1-72 months), and the hernia was located on the right diaphragm in 77 patients (89.5%). Pain was the most common presenting symptom (n = 52, 60.4%), while six patients were asymptomatic (6.9%). Primary repair by direct suture was the most frequently performed technique (88.3%, n = 76). Six patients experienced recurrence (6.9%), and three died before diaphragmatic hernia repair (3.5%).

CONCLUSION

Diaphragmatic hernia is a rare complication occurring mainly after right liver resection. Repair should be performed once detected, given the not-negligible associated mortality in the emergency setting.

Right-Side Acquired Diaphragmatic Hernia in an Adult 15 Years After Living Donor Liver Transplant

Cases of adult liver transplant recipients with a postoperative right-side acquired diaphragmatic hernia are extremely rare. In this report, we describe an adult case of right-side acquired diaphragmatic hernia 15 years after living donor liver transplant. A 27-year-old woman was diagnosed with pancreatic insulinoma with multiple metastases in the liver. To treat the liver failure, she underwent left lobe living donor liver transplant and distal pancreatectomy with splenectomy 3 years after the transcatheter arterial chemoembolization. As a result of the liver abscesses that reached the diaphragm, the delicate diaphragm was injured, which required repair during the transplant surgery. At the age of 46 years, she developed a cough and intermittent abdominal pain. One month later, she went to another hospital's emergency room with complaints of epigastric pain. The computed tomography scan revealed colon and small intestine prolapse into the right thoracic cavity. She was referred to our hospital and underwent surgery the next day. Two adjacent right diaphragm defects were successfully sutured with nonabsorbable sutures. The patient was discharged on postoperative day 11.

Acquired diaphragmatic hernia after hepatectomy and liver transplantation in adults and children: A case series and literature review

Backgrounds/Aims

Acquired diaphragmatic hernia is a rare complication following liver surgery in adult and pediatric patients. This study aims to describe main features occurring in adult and pediatric patients after liver surgery and report an up-date review of the literature.

Methods

All adult and pediatric patients who were diagnosed with postoperative acquired diaphragmatic hernia in Lyon and Marseille University Hospitals were included in this study. Diagnosis, clinical, radiologic, and therapeutic data were analysed retrospectively from medical papers and/or electronic records.

Results

Thirteen adults with a median age of 50 years (range, 30–67 years) and 5 children aged 2.4 years (range, 0.9–4 years) were diagnosed with acquired diaphragmatic hernia after a median time of 65.1 (range, 1.8–244.7) and 2 (range, 0.33–10.9) months, respectively, following surgeries (5 live-donor right hepatectomies, 5 right and 1 left hepatectomies for tumors and cysts, and 2 whole liver transplantations in adults; and 5 liver transplantations with left lateral section in children). Eleven patients presented digestive and/or thoracic symptoms whereas seven were asymptomatic and diagnosed by routine imaging follow-up. All patients were re-operated with a median delay of 2.4 months (range, 0–25.3 months) for adults and 1 day (range, 0–2 days) for children. Two recurrences resulted in a secondary surgical repair.

Conclusions

Acquired diaphragmatic hernia is a rare and potentially serious event after liver surgery. Recognition and surgical repair of this particular complication should be considered in the setting of unexplained abdominal and/or thoracic symptoms. Preventive measures should be taken intraoperatively.

Incarcerated diaphragmatic hernia after right hepatectomy: an autopsy case with a review of 45 previous cases

An iatrogenic diaphragmatic hernia after major hepatic resection is a rare complication. Incarceration of the abdominal organ through a diaphragmatic defect can have a fatal prognosis. Here, we report a case of incarcerated diaphragmatic hernia after right hepatectomy, which was diagnosed only after the autopsy. The deceased, who had right hepatectomy 1 year previously, complained of severe chest pain, and 4 days later was found dead. Localized decomposition in his chest and abdomen suggested a late complication of the surgery because the location was consistent with the prior surgical area. In the autopsy, there was a small defect in his right diaphragm, resulting in the herniation and incarceration of the small intestine. Gross and microscopic findings of the herniated small intestine were consistent with ischemic enteritis. Different from our case, most of the previously reported cases showed a good prognosis after surgical repair, except one lethal one. Even though its overall incidence is very low, an incarcerated diaphragmatic hernia is one of the critical complications of major hepatic resection. The clinicians should warn the patients to avoid preventable morbidity and mortality. Reviewing this fatal complication would be also helpful for forensic pathologists and death investigators.

Postoperative Diaphragmatic Liver Herniation Diagnosed by Point-of-Care Ultrasound

Point-of-care ultrasound (PoCUS) is a sensitive and specific tool in early identification of malignant pathologies in unstable patients leading to improved outcomes. Postoperative diaphragmatic rupture is rare, can be life-threatening, and is difficult to diagnose. This report describes a 62-year-old women undergoing thoracoscopic right hemidiaphragm plication with acute postoperative hemodynamic instability. Bedside PoCUS identified hepatic herniation into the thorax causing cardiac compression and lateral displacement, which lead to expedited imaging and surgical reexploration.

Postnephrectomy diaphragmatic hernia presenting as progressive dyspnoea

The diagnosis of diaphragmatic hernia (DH) in adults is rare and may be due to missed congenital DH or acquired DH from trauma or as a postoperative complication of certain thoracic and abdominal surgeries. We present a case of a patient with well-controlled chronic obstructive pulmonary disease who presented to the hospital with progressive dyspnoea, 6 months after laparoscopic nephrectomy. The patient was initially misdiagnosed and treated for empyema after plain radiographic images were reported as consolidation with gas locules. Multislice CT imaging undertaken before diagnostic thoracocentesis confirmed the presence of a right-sided DH, which was subsequently surgically repaired in the outpatient setting, given her haemodynamic stability. As patients with DH usually present in the emergency setting, requiring urgent inpatient surgical repair, there are currently no guidelines on the method and urgency of management of asymptomatic or mildly symptomatic, stable patients. Furthermore, while plain radiography is the usual first-line imaging modality used, misdiagnosis of DH as pleural effusion or empyema can lead to unnecessary and potentially harmful procedures such as diagnostic thoracocentesis. These risks can potentially be minimised with early utilisation of multislice CT imaging in patients with high clinical suspicion.

Enterothorax After Hepatic Surgery: A Single-Center Experience

BACKGROUND

Enterothorax (ET) is a rare complication after hepatic surgery. The literature in this field is limited and mainly based on case reports. The aim of this study was to review our department's experience.

PATIENTS AND METHODS

We retrospectively analyzed 602 patients who underwent hepatic resection between November 2008 and December 2016. Major hepatic surgery (n = 321) was defined as right or extended right hepatectomy (n = 227), left or extended left hepatectomy (n = 63), trisegmentectomy (n = 13), and living donor liver transplantation (n = 18). ET cases were identified by analyzing clinical courses and radiological imaging.

RESULTS

ET was observed in five out of 602 patients (0.8%). All patients developed the complication after major hepatic surgery (five out of 321, 1.6%). ET exclusively occurred after right (n = 3) or extended right hepatectomy (n = 2). Median time to diagnosis was 22 months. Radiological imaging showed herniation of small (n = 2), large bowel (n = 2), or omental fat (n = 1) with a median diaphragmatic defect of 3.9 cm. Two patients presented with acute incarceration and underwent emergency surgery, one patient reported recurrent pain and underwent elective repair, and two patients refused surgery. Follow-up imaging in two operated patients showed no recurrence of ET after 36 and 8 months.

CONCLUSIONS

Patients after right hepatectomy have a substantial risk of ET. Acute right upper quadrant pain and/or dyspnea after hepatectomy should be investigated with adequate radiological imaging. Elective surgical repair of ET is recommended to avoid emergency surgery in case of incarceration.

Case series and systematic review of acquired diaphragmatic hernia after liver transplantation

BACKGROUND

ADH is a rare and potentially fatal complication following LT. In this study, a systematic review was completed to identify risk factors which may contribute to ADH.

METHODS

Transplant databases at three LT programs were reviewed. Four pediatric and zero adult cases were identified. Next, a systematic review was completed. Fourteen studies describing 41 patients with ADH were identified. Patient demographics, transplant characteristics, and features of ADH diagnosis were examined.

RESULTS

The majority (90.2%) of ADH were in children. In pediatric LT, 95.1% received a segmental allograft. ADH occurred in the right P diaphragm 92.7% of the time, and 87.8% were repaired primarily. Patient demographics, post-transplant complications, and immunosuppression regimens were broad and failed to predict ADH. Most patients presented with either respiratory or gastrointestinal symptoms. There were two pediatric deaths related to undiagnosed ADH. The combined worldwide incidence of ADH in pediatric LT is 1.5% (34/2319 patients).

CONCLUSION

ADH is a rare complication post-LT that primarily occurs in pediatric recipients. When diagnosed early, ADH can be repaired primarily with good outcomes.

Diaphragmatic herniation following donor hepatectomy for living donor liver transplantation: a serious complication not given due recognition

A clear appreciation of benefits and risks associated with living donor hepatectomy is important to facilitate counselling for the donor, family, and recipient in preparation for living donor liver transplant (LDLT). We report a life-threatening complication occurring in one of our live liver donors at 12 weeks following hemi-liver donation. We experienced five donor complications among our first 50 LDLT: Clavien Grade 1, n=1; Clavien grade 2, n=3; and Clavien grade 3B, n=1. The one with Clavien grade 3B had a life-threatening diaphragmatic hernia occurring 12 weeks following hepatectomy. This was promptly recognized and emergency surgery was performed. The donor is well at 1-year follow-up. Here we provide a review of reported instances of diaphragmatic hernia following donor hepatectomy with an attempt to elucidate the pathophysiology behind such occurrence. Life-threatening donor risk needs to be balanced with recipient benefit and risk on a tripartite basis during the counselling process for LDLT. With increasing use of LDLT, we need to be aware of such life-threatening complication. Preventive measures in this regard and counselling for such complication should be incorporated into routine work-up for potential live liver donor.

A rare diaphragmatic hernia with a delayed presentation of intestinal symptoms following spleno-distal pancreatectomy: a case report

Acquired diaphragmatic hernia, non-related to trauma, is a very rare condition. It can constitute a therapeutic problem and the surgical solution is not always immediately clear. We report the case of a 73-year-old woman with a history of spleno-distal pancreatectomy for a neuroendocrine tumour performed in 2009, who came back to Emergency Room 2 years later, complaining of abdominal pain. Chest radiography and computed tomography were performed; they showed a diaphragmatic hernia with visceral migration into the thorax. The diaphragmatic defect was surgically repaired and the patient had an uneventful post-operative recovery.

Diaphragmatic Hernia After Living Donor Right Hepatectomy: Proposal for a Screening Protocol

BACKGROUND

Living donor hepatectomy (LDH) is increasingly being used to improve access to liver transplantation for those with end-stage liver disease. Although recipient outcomes are equivalent, donor complication rates range from 10% to 41%. A rare, but potentially serious complication is occurrence of a diaphragmatic hernia (DH), of which 9 cases have been reported so far in the literature. The purpose of this work was to review the clinical impact of DH post-LDH, including risk factors (RF) in hope of mitigating impact.

METHODS

A literature review was performed identifying all previous reports of post-operative DH in living liver donors. Demographic and outcome data were gathered to help identify RF. We also report 2 cases from our own institution.

RESULTS

Reported incidences range from 0.6% to 2.3%, of which the majority are delayed (≥19 months). Obstruction or intestinal strangulation was present in 45%, 60% of whom required an intestinal resection. The most common RF was right lobe donation.

CONCLUSIONS

Postoperative DH is a rare but serious complication of LDH. The major RFs are right lobe donation and potentially conditions resulting in increased intraabdominal pressure. Diaphragmatic hernia frequently lead to intestinal obstruction and strangulation and should be repaired when identified. The implementation of a screening protocol for early identification could lead to repair before the development of complications. We propose the addition of screening chest x-ray to follow-up protocols to aid in the identification and subsequent repair of postoperative DH. Such a practice could hopefully reduce the clinical impact of this complication.

Early incarcerated diaphragmatic hernia following right donor hepatectomy: a case report

Right diaphragmatic hernia after donor hepatectomy is extremely rare. The occurrence is usually late. We present a case with early occurrence complicated with small bowel strangulation. Early detection and emergency surgical repair relieved the problem quickly. Predisposing factors are discussed. To avoid such a complication is very important.

Acquired right diaphragmatic hernia following pediatric living donor orthotopic liver transplantation

ADH following OLT is a rare entity. Herein, we report a case of Alagille syndrome who developed ADH secondary to OLT, and possible etiological causes are discussed in light of the literature.

Right diaphragmatic iatrogenic hernia after laparoscopic fenestration of a liver cyst: report of a case and review of the literature

Iatrogenic right diaphragmatic hernia is very rare. We report the first case of a patient who had a diaphragmatic hernia after laparoscopic fenestration of liver cyst. A herniorrhaphy of the diaphragmatic defect was carried out after reducing the herniated organ. The postoperative course was uneventful. Diaphragmatic hernias are not as common as the traumatic type. Surgeons can easily miss diaphragmatic injuries during the operation especially after laparoscopy. Late diagnosis of iatrogenic diaphragmatic hernias is frequent. Ct scan is helpful for diagnosis. Surgery is the treatment of diaphragmatic hernia at the time of diagnosis, even with asymptomatic patients. The incidence of iatrogenic diaphragmatic hernia after surgery may be reduced if the surgeon checks for the integrity of the diaphragm before the end of the operation. A review of the literature is also performed regarding this rare complication.

Diaphragmatic hernia in infants following living donor liver transplantation: report of three cases and a review of the literature

DH is a rare complication following LT. This report presents three cases of right-sided DH after LT using a left-sided graft. All of the patients were younger than one yr of age, and they were critically ill owing to their original disease, characterized by biliary atresia, progressive familiar intrahepatic cholestasis, and acute liver failure. DH occurred with sudden onset within three months after LT. All of the cases were promptly diagnosed and treated. A literature review of 24 cases of DH identified four factors associated with DH: left-sided graft, right-sided DH, relatively delayed onset of DH, and age-specific chief complaint. DH following LT should be considered as a potential surgical complication when a left-sided graft is used, especially in small infants with coagulopathy and malnutrition.