Recent advances in the management of congenital diaphragmatic hernia

Extracellular Vesicles Attenuate Nitrofen-Mediated Human Pulmonary Artery Endothelial Dysfunction: Implications for Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) leads to pathophysiologic pulmonary vasoreactivity. Previous studies show that mesenchymal stromal cell-derived extracellular vesicles (MSCEv) inhibit lung inflammation and vascular remodeling. We characterize MSCEv and human pulmonary artery endothelial cell (HPAEC) interaction, as well as the pulmonary artery (PA) response to MSCEv treatment. HPAECs were cultured with and without exposure to nitrofen (2,4-dichloro-phenyl-p-nitrophenylether) and treated with MSCEv. HPAEC viability, architecture, production of reactive oxygen species (ROS), endothelial dysfunction-associated protein levels (PPARγ, LOX-1, LOX-2, nuclear factor-κB [NF-κB], endothelial NO synthase [eNOS], ET-1 [endothelin 1]), and the nature of MSCEv-cellular interaction were assessed. Newborn rodents with and without CDH (nitrofen model and Sprague-Dawley) were treated with intravascular MSCEv or vehicle control, and their PAs were isolated. Contractility was assessed by wire myography. The contractile (KCL and ET-1) and relaxation (fasudil) responses were evaluated. HPAEC viability correlated inversely with nitrofen dose, while architectural compromise was directly proportional. There was a 2.1 × increase in ROS levels in nitrofen HPAECs (P < 0.001), and MSCEv treatment attenuated ROS levels by 1.5 × versus nitrofen HPAECs (P < 0.01). Nitrofen-induced alterations in endothelial dysfunction-associated proteins are shown, and exposure to MSCEv restored more physiologic expression. Nitrofen HPAEC displayed greater MSCEv uptake (80% increase, P < 0.05). Adenosine, a clathrin-mediated endocytosis inhibitor, decreased uptake by 46% (P < 0.05). CDH PA contraction was impaired with KCL (108.6% ± 1.4% vs. 112.0% ± 1.4%, P = 0.092) and ET-1 (121.7% ± 3.0% vs. 131.2% ± 1.8%, P < 0.01). CDH PA relaxation was impaired with fasudil (32.2% ± 1.9% vs. 42.1% ± 2.2%, P < 0.001). After MSCEv treatment, CDH PA contraction improved (125.9% ± 3.4% vs. 116.4 ± 3.5, P = 0.06), and relaxation was unchanged (32.5% ± 3.2% vs. 29.4% ± 3.1%, P = 0.496). HPAEC exposure to nitrofen led to changes consistent with vasculopathy in CDH, and MSCEv treatment led to a more physiologic cellular response. MSCEv were preferentially taken up by nitrofen-treated cells by clathrin-dependent endocytosis. In vivo, MSCEv exposure improved PA contractile response. These data reveal mechanisms of cellular and signaling alterations that characterize MSCEv-mediated attenuation of pulmonary vascular dysfunction in CDH-associated pulmonary hypertension.

Congenital Diaphragmatic Hernia: Experience and Results of Thoracoscopic Repair from a Tertiary Care Hospital

Introduction Congenital diaphragmatic hernia (CDH) is one of the most common congenital anomalies encountered by pediatric surgeons. With the advances in the pediatric minimal access surgery, its role in the repair of CDH has also increased. We have been using thoracoscopy for the repair for CDH since 2015. We herein report our experience of CDH repair in newborns.

Materials and Methods A retrospective review was conducted from July 2015 to December 2019 in the Department of Pediatric surgery after ethical approval from the institutional review board and included all the children with CDH who underwent thoracoscopic repair. The case records were used to assess the demographic details, type of defect, and early and late postoperative complications of thoracoscopy in CDH.

Results Thoracoscopic repair was attempted in 29 patients of CDH. Eight (27.5%) patients converted to open procedure and were excluded from the study. Primary closure of the diaphragmatic defect was performed in 90.4% (19) patients. Also, 9.5% (2) children required mesh repair. There was no intraoperative death. Postoperative ventilation was required in 57.1% (12) children. The mean time on the ventilator was 3.03 ± 0.9 days. The mean age of children requiring postoperative ventilation was less compared with children who were extubated in the postoperative period (p = 0.032). The median follow-up in our study was 12 months and 28.5% of patients developed recurrence of the diaphragmatic hernia. All the children underwent laparotomy and repair of the diaphragmatic defect.

Conclusion Thoracoscopic repair is a safe and effective option for the repair of CDH in children performed by surgeons with significant procedure experience.

Study of Lethal Congenital Malformations at a Tertiary-Care Referral Centre in North India

Lethal congenital malformations (LCMs) are fatal birth defects that are an important cause of fetal/neonatal death. There is a lack of informative data about these malformations in India, a country that shares the maximum burden of neonatal mortality due to congenital birth defects. Therefore, we conducted a retrospective analysis to know the prevalence of LCMs in late pregnancy, to find out associated factor/variables and to evaluate fetal/neonatal outcome of such anomalies; at a tertiary-care referral centre in North India. All deliveries with LCMs after 24 weeks of gestation were included in the study. Data about antepartum history (maternal age, parity, education, socioeconomic status, consanguineous marriage, folic acid intake, any chronic medical disorder, availability of anomaly scan, unplanned pregnancy); intrapartum events (gestational age at delivery, mode of delivery); postpartum events (weight of the baby, gender of the baby); newborn evaluation; and details of hospital stay were recorded from medical record sheet over the duration of one year. We found that anencephaly, severe meningomyelocele, multicystic dysplastic kidneys and non-immune hydrops with major cardiac defects were more prevalent among all LCMs. On the evaluation of the various studied variables, maximum babies with LCMs were born to mothers who were between 20 and 35 years of age, those who were illiterate, belonged to middle/lower socio-economic class, multigravida, and those who had no detailed anomaly scan. We feel that there is an urgent need to formulate a universally accepted definition of LCMs, to identify preventable risk factors and to formulate management strategy for both mother and liveborn baby with LCMs, in order to minimize the hidden burden of these defects in stillbirth/ perinatal/ neonatal mortality statistics.

Incidence and prevalence of congenital anomalies in low- and middle-income countries: A systematic review

BACKGROUND

In the absence of robust data from low- and middle-income countries (LMICs), most disease burden estimates and related resource allocation choices are based on historic Northern demographics. We hypothesize that significant discrepancies exist between directly reported LMIC data and surrogate high-income country (HIC) disease burden estimates of correctible congenital anomalies.

METHODS

Nine online databases were searched for studies reporting incidence and prevalence data on surgically correctible congenital anomalies in LMICs between 2006 and 2017. Two independent reviewers screened titles and abstracts, with a third adjudicating discrepancies. Selected studies were reviewed and analyzed.

RESULTS

Of 10,128 identified articles, 98 were extracted for full-text review, and 41 were included, representing 21 LMICs and 18 conditions. Study types included community surveys (34%), prospective (22%) and retrospective (17%) multi-site data, registries (12%), single-site data (12%), and systematic reviews (5%). Data collection periods were 1 to 10 years. The pooled epidemiologic data varied systematically from existing HIC literature, with the incidence of disease being generally lower in LMICs.

CONCLUSIONS

Marked discrepancies exist between reported epidemiological data in LMICs and HIC literature, in part owing to varying quality of data collection in LMICs. Robust population-based surveys are needed to accurately estimate the burden of surgically correctable congenital anomalies in LMICs.

LEVEL OF EVIDENCE

Level V, expert opinion without explicit critical appraisal.

Role of Ultrasound-Based Prenatal Prediction of Pulmonary Function in Congenital Diaphragmatic Hernia: Does It Have Prognostic Significance Postnatally?

BACKGROUND AND OBJECTIVES

The incidence of congenital diaphragmatic hernia (CDH) in India is 1 in 1000. About 60 % of these are isolated, and the survival prognosis in them depends upon the quantum of contralateral functional lung. Out of the various pulmonary and extrapulmonary sonological predictors, observed to expected lung-head ratio (O/E LHR) is an efficient gestation-independent predictor of pulmonary function. This study was carried out to see the correlation of this prenatal predictor with the postnatal outcome depending on the pulmonary function.

METHODOLOGY

This study was carried out at Apollo Center of Fetal Medicine, New Delhi, from January 2009 to December 2015. A total of 14 fetuses with isolated left-sided CDH were included. The contralateral lung area was measured in 2D transverse view of the thorax at the level of four-chamber view of the heart by tracing method. The obtained value (square mm) was then divided by the expected mean lung area at that gestation and multiplied with 100 to express O/E LHR as percentage. These were then classified as severe (O/E LHR <25 %), moderate (25-45 %) or mild (>45 %) varieties of CDH. The parents to be were counselled for termination or continuation of pregnancy based on severity of CDH and total lung area. The patients were followed up for obstetrical and neonatal outcome till the time of first postoperative visit (diaphragmatic repair).

RESULTS

The survival correlation in mild cases was 100 % (n = 5 out of 5) and 50 % in moderate cases (n = 2 out of 4), and both severe cases were terminated. There was a significant difference (p < 0.01) in the survival rate in the mild versus severe cases.

CONCLUSIONS

The prenatal predictor for postnatal pulmonary function correlates well with the neonatal outcome and hence is an important tool in prenatal counseling and triaging those who require termination of pregnancy versus expectant management. An obstetrician who is a first point of contact to the pregnant women can understand this and use it for counseling and differentiating the patients who need termination with regard to CDH.

Emergencies in pediatric surgery

Primary care physicians are often required to initially manage the children with surgical emergencies. Many neonates with congenital malformations delivered without supervision may also be managed initially by the family physicians. The role of the primary care physician in such cases should be to diagnose the condition correctly, provide immediate care and then refer the newborn or child to higher centre for appropriate management.

Congenital diaphragmatic hernia: review of current concept in surgical management

CONGENITAL DIAPHRAGMATIC HERNIAS (CDHS) OCCUR MAINLY IN TWO LOCATIONS: the foramen of Morgagni and the more common type involving the foramen of Bochdalek. Hiatal hernia and paraesophageal hernia have also been described as other forms of CDH. Pulmonary hypertension and pulmonary hypoplasia have been recognized as the two most important factors in the pathophysiology of congenital diaphragmatic hernia. Advances in surgical management include delayed surgical approach that enables preoperative stabilization, introduction of fetal intervention due to improved prenatal diagnosis, the introduction of minimal invasive surgery, in addition to the standard open repair, and the use of improved prosthetic devices for closure.