Congenital diaphragmatic hernia

Morgagni Hernia: A Rare Presentation in a Young Adult

Morgagni hernia is the rarest diaphragmatic hernia, occurring in only about 2% of all cases. Despite its infrequent presentation, it poses significant morbidity once the diagnosis is missed. We present a rare case of a young adult female with no predisposing factors who experienced dyspnea and retrosternal pain with unremarkable clinical findings. A posteroanterior view of the chest roentgenogram revealed a nonspecific triangular opacity at the right cardiophrenic angle. A computed tomography (CT) scan of the thorax confirmed the suspicion of a right anteromedial diaphragmatic defect with omental herniation. Exploratory laparoscopic primary repair of the hernia orifice was performed with non-absorbable sutures. CT helps in confirming the condition, and surgical repair is recommended. Morgagni hernia can present as asymptomatic or with respiratory symptoms. There is no consensus on the type of approach, but a minimally invasive approach is being preferred even in asymptomatic cases.

Agenesis of the left hemi-diaphragm, the cause of a neglected dyspnea in a 65-year-old female; case report and literature review

Introduction and importance

In its complex way of embryonic evolvement, the diaphragmatic membrane can be involved with various disorders that may partially or entirely not develop. Agenesis of the diaphragm is the term that refers to this maldevelopment. It is the more severe form of congenital diaphragmatic hernia in which intra-abdominal viscera protrude into the thoracic cavity, causing respiratory and gastrointestinal problems. Most neonates delivered with diaphragmatic agenesis do not live more than hours to days of the severity of lung immaturity. However, less than 20 affected cases have been reported so far that survived to childhood and even their adulthood period treated surgically or conservatively. We have reported a case of neglected left hemi-diaphragmatic agenesis for more than six decades, then reviewed all adult diaphragmatic agenesis cases available in the literature for 74 years.

Case presentation

A 65-year-old female complaining of worsened dyspnea during the last four months, a chronic history of short breath since her fourth decade of life, and recent surgery with the diagnosis of a diaphragmatic hernia, underwent the thoracotomy twice in which unilateral diaphragmatic hernia was diagnosed then repaired.

Clinical discussion

For the recurrence of her symptoms, she underwent a second thoracotomy, in which the final diagnosis of left hemi-diaphragmatic agenesis was made. A dual mesh patch constructed the defect. The post-operation period was uneventful. We only found 17 cases of adult hemi or bilateral agenesis of the diaphragm reviewing the main medical literature such as Medline and Web of Science. The conservative and operative treatment managements were equal for eight patients in each of them. One of them refused therapy, and one was non-declared in the study. As in congenital diaphragmatic hernia, the most typical side was the left in 10 out of 18. The most complaints patients had followed by coughing and bowel obstruction was dyspnea and dyspepsia.

Conclusion

Near the total of the diaphragmatic agenesis cases die in the neonatal population; remained undiagnosed or during an autopsy found. However, typically rare in the adult population, respiratory and digestive disorders are the most prevalent. It is difficult initially because diagnosing is intraoperatively, and no modality is available to help the examiner physician diagnose perinatally.

Morgagni hernia in adult: A case report

INTRODUCTION AND IMPORTANCE

Morgagni Hernia is a congenital diaphragmatic hernia but can rarely present in adults. It occurs due to a congenital defect in the development of the diaphragm. Here we present a case of symptomatic Morgagni hernia diagnosed in a 53 years' female.

CASE PRESENTATION

A 53 years' female presented with recurrent chest symptoms and was found to have bowel contents herniated into the right hemithorax on chest X-ray and CECT. Reduction of hernia was done laparoscopically and the hernia was repaired with non-absorbable suture in an interrupted manner.

CLINICAL DISCUSSION

Morgagni hernias are mostly diagnosed incidentally on a chest radiograph or can present with cardiorespiratory or abdominal symptoms. Our case was an adult who was diagnosed to have Morgagni hernia presenting with chest symptoms. The investigation of choice to diagnose and evaluate this condition is CECT of chest and repair of hernia without the use mesh is advised in asymptomatic cases also due to feared complications like strangulation and incarceration.

CONCLUSION

The treatment of Morgagni Hernia is primary surgical repair which can be done either transthoracically or transabdominally. It is advised that surgical repair should be done even in asymptomatic cases.

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.

Congenital retrosternal hernias of Morgagni: Manifestation and treatment in children

BACKGROUND

Due to scarcity of congenital diaphragmatic hearnias of Morgagni (CDHM), non-specific clinical presentation in the pediatric age group, we aimed to investigate the incidence, clinical manifestations, anatomical characteristics, and develop diagnostic algorithm and treatment of CDHM in children.

MATERIALS AND METHODS

The patients' records of children with CDHM treated in our hospital during past 20 years were retrospectively reviewed for the age at diagnosis, gender, clinical findings, anatomical features, operative details and outcome.

RESULTS

Since 1995 to 2014 we observed 6 (3 boys, 3 girls) patients with CDHM, that comprise 3.2% of all congenital diaphragmatic hernia cases (n = 185). Age at diagnosis varied from 3 mo. to 10y.o. Failure to thrive was main symptom in 4 patients, followed by recurrent respiratory infections (n = 3), dyspnea (n = 3), and gastrointestinal manifestations: constipation (n = 2), abdominal pain (n = 1). Work-up consisted of plain X-ray for all (n = 6), upper GI (n = 3), barium enema (n = 2), sonography (n = 6) and CT (n = 2). Abdominal approach used in 5 patients, and thoracotomy in one. Herniated contents were: liver lobes (n = 4), transverse colon (n = 3) and greater omentum (n = 1). 5 had right-sided lesion, 1- left-sided. Defect repaired using local tissues. Post-operative course was uneventful; all patients appeared well during follow-up.

CONCLUSION

CDHM is very uncommon anomaly, very occasionally diagnosed at the early age. Failure to thrive and recurrent respiratory infections are most frequent clinical manifestations. In suspected CDHM we advocate the following work-up: plain chest and abdominal X-ray, contrast study (upper GI series or barium enema), ultrasonographic screen and CT scan. Surgical repair via abdominal approach, using local tissues and hernia sac removal is preferred.

Presence of hernia sac in prediction of postoperative outcome in congenital diaphragmatic hernia

We conducted this study to assess the value of presence of hernia sac in prediction of postoperative outcome in congenital diaphragmatic hernia (CDH). Data were obtained form medical records of 70 children operated for CDH between 2002-12. Postoperative neonatal death occurred in 1/10 (10%) of infants with a hernia sac and 26/60 (43.3%) in cases without a hernia sac, respectively (P =0.04). Perinatal morbidity in surviving infants was lower in the group with a hernia sac although not significantly. We conclude that the presence of a hernia sac is associated with better postoperative outcome and overall prognosis of CDH.

Prognostic value of a hernia sac in congenital diaphragmatic hernia

OBJECTIVE

To investigate the prognostic value of a hernia sac in isolated congenital diaphragmatic hernia (CDH).

METHODS

Our database was searched to identify all consecutive cases of CDH referred to our fetal medicine unit between January 2004 and August 2011. Presence or absence of a hernia sac was assessed in liveborn cases using surgery or postnatal autopsy reports. We studied the correlation between the presence of a hernia sac and prenatal findings and perinatal morbidity and mortality.

RESULTS

Over the study period, there were 70 cases with isolated CDH born alive in which either a surgery or autopsy report was available. Neonatal death, either preoperative or postoperative, occurred in 1/18 (5.6%) infants with a hernia sac and in 17/52 (32.7%) cases without a hernia sac (P = 0.03). Patients with a hernia sac had a significantly higher observed to expected pulmonary volume on prenatal magnetic resonance imaging (51.9 vs 39.3%, P = 0.01). Neonatal morbidity in surviving infants was lower in the group with a hernia sac, although not significantly.

CONCLUSION

The presence of a hernia sac is associated with a higher pulmonary volume and a better overall prognosis for CDH.

Defect-diaphragmatic ratio: a new parameter for assessment of defect size in neonates with congenital diaphragmatic hernia

AIM

The aim of our study is to introduce a new objective method of perioperative evaluation of the size of diaphragmatic defect to enable comparison of results among various centres and methods used for diaphragmatic reconstruction.

MATERIALS AND METHODS

Prospective observational study of neonates with congenital diaphragmatic hernia (CDH) and respiratory distress within 24 h of birth operated on from January 2009 to December 2011. Weight, length, thoracic shape and the diameters of diaphragmatic defect were measured. To determine the relative size of the defect, a defect-diaphragmatic ratio (DDR = defect area:diaphragm area × 100) was calculated. The measured and calculated data were subsequently compared between Gore-Tex patch group (GT) and primary repair group (PR). Mann-Whitney U test was used for statistical analysis.

RESULTS

Forty-seven patients with CDH were admitted during study period. The overall survival rate was 79 % (37/47). Preoperative stabilization was achieved in 85 % (40/47). Survival of operated neonates was 93 % (37/40). Diaphragmatic reconstruction with Gore-Tex patch was used in 7 neonates (17 %), and primary repair in 33 (83 %). Mortality in Gore-Tex group was 29 %; mortality in primary repair group was 3 %. Data of anthropometric measurement were complete in 34 children (5 GT and 29 PR). Significant differences were found between GT group and PR group in the size of diaphragmatic defect with the transverse and sagittal diameters of defect (48.0 ± 5.7 vs. 30.1 ± 5.9, P < 0.00061; 34.0 ± 12.5 vs. 16.0 ± 7.3, P < 0.0022) and DDR (18.29 ± 4.60 vs. 5.77 ± 3.28, P < 0.0005), respectively.

CONCLUSION

The value of DDR as an objective criterion of the extent of diaphragmatic defect was confirmed by the close correlation between DDR and feasibility of primary repair in the study group. This objective assessment of defect size may improve comparing various surgical techniques and results of different centres, and thus facilitates sharing experience with management of neonates with CDH.

Insulinlike growth factor receptor type 1 and type 2 are downregulated in the nitrofen-induced hypoplastic lung

PURPOSE

In congenital diaphragmatic hernia (CDH), high mortality rates are attributed to severe pulmonary hypoplasia. The insulinlike growth factor receptor type 1 (IGF-1R) and type 2 (IGF-2R) play a critical role in the alveologenesis during lung development. The IGF-1R null mutation mice die after birth because of respiratory failure. The IGF-2R knockout mice showed retarded lungs with poorly formed alveoli. We hypothesized that IGF-1R and IGF-2R gene expression levels are downregulated in the nitrofen-induced CDH model.

METHODS

Pregnant rats were exposed to either olive oil or 100 mg of nitrofen on day 9.5 (D9.5) of gestation. Fetuses were harvested on D18 and D21 and divided into control and nitrofen groups. Relative messenger RNA (mRNA) levels of IGF-1R and IGF-2R were determined using real time reverse transcription polymerase chain reaction. Immunohistochemistry was performed to determine protein expression.

RESULTS

Relative levels of IGF-1R mRNA were significantly decreased in the nitrofen group (2.91 +/- 0.81) on D21 compared to controls (5.29 +/- 2.59) (P < .05). Expression levels of IGF-2R mRNA on D21 were also significantly decreased in nitrofen group (1.76 +/- 0.49) compared to controls (3.59 +/- 2.45) (P < .05). Immunohistochemistry performed on D21 showed decreased IGF-1R and also IGF-2R expression in nitrofen group.

CONCLUSION

Downregulation of IGF-1R and IGF-2R gene expression may interfere with normal alveologenesis causing pulmonary hypoplasia in the nitrofen-induced CDH model.

Downregulation of insulin-like growth factor binding protein 3 and 5 in nitrofen-induced pulmonary hypoplasia

PURPOSE

The high mortality in congenital diaphragmatic hernia (CDH) is mainly attributed to pulmonary hypoplasia. Recent studies suggest that retinoid signaling pathway (RSP) is inhibited in the nitrofen-induced hypoplastic lung. The insulin-like growth factor (IGF) system plays a crucial role in fetal lung development by interaction of IGFBP-3 and IGFBP-5 with RSP. We hypothesized that pulmonary IGFBP-3 and IGFBP-5 gene expression levels are downregulated in the nitrofen-induced pulmonary hypoplasia.

METHODS

Pregnant rats were exposed to either olive oil or 100 mg nitrofen on day 9.5 (D9.5) of gestation. Fetal lungs were harvested on D18 and D21 and divided into control and nitrofen groups. IGFBP-3 and IGFBP-5 pulmonary gene and protein expression were determined using real-time RT-PCR and immunohistochemistry.

RESULTS

Relative levels of IGFBP-3 mRNA were significantly decreased in the nitrofen group (8.00 +/- 14.44) in D21 compared to controls (14.81 +/- 16.11; p < 0.05). Expression levels of IGFBP-5 mRNA were also significantly decreased in nitrofen group (10.66 +/- 4.83) on D18 compared to controls (17.92 +/- 4.77). Immunohistochemistry showed decreased IGFBP-3 expression on D21 and decreased IGFBP-5 immunoreactivity on D18 in hypoplastic lungs compared to controls.

CONCLUSION

Downregulation of IGFBP-3 and IGFBP-5 gene expression may cause pulmonary hypoplasia in the nitrofen-induced CDH model by interfering with retinoid signaling pathway.

Congenital diaphragmatic hernia and retinoids: searching for an etiology

Congenital diaphragmatic hernia (CDH) is a major life-threatening cause of respiratory failure in the newborn. Recent data reveal the role of a retinoid-signaling pathway disruption in the pathogenesis of CDH. We describe the epidemiology and pathophysiology of human CDH, the metabolism of retinoids and the implications of retinoids in the development of the diaphragm and lung. Finally, we describe the existing evidence of a disruption of the retinoid-signaling pathway in CDH.

Fetal lung-head ratio is not related to outcome for antenatal diagnosed congenital diaphragmatic hernia

We asked if fetal lung-to-head ratio (LHR) of 1.0 or lower or liver herniation had a statistical effect on survival or need for extracorporeal membrane oxygenation (ECMO), compared with LHR above 1.0 in patients with congenital diaphragmatic hernia (CDH).

METHODS

Antenatal records of all patients diagnosed with CDH from January of 2002 to June of 2005 were examined. Inclusion criteria were isolated left-sided CDH and absence of significant cardiac or other anomalies/syndromes, treated solely at this institution. Lung-to-head ratio values were compared based on the value currently proposed for fetal intervention: LHR of 1.0 or lower vs LHR above 1.0. Outcome was assessed as survival (discharge to home) or need for ECMO.

RESULTS

Twenty-eight patients met inclusion criteria. Overall survival was 86% (24/28). Postnatal survival in fetuses with LHR of 1.0 or lower (8/11) was not statistically different from LHR above 1.0 (16/17) (73% vs 94%, P = .114). The need for ECMO in the group with LHR of 1.0 or lower (3/11) was not significantly different from those with LHR above 1.0 (1/17) (27% vs 6%, P = .114). Herniation of the fetal liver into the chest did not affect survival or need for ECMO (P = .228).

CONCLUSION

Neither LHR of 1.0 or lower nor liver herniation identified a risk factor significant enough to warrant fetal intervention. Multicenter studies may be more appropriate to investigate this clinical problem.

Case report: Morgagni hernia

The case reported here is a 32-year-old man with a sudden onset of chest pain and an acute deterioration of lung function. An incarcerated Morgagni hernia was diagnosed with a computer tomographic CT scan, and repaired electively via a midline laparotomy. Morgagni hernia is a rare type of congenital diaphragmatic hernia, which may not be symptomatic until adulthood when the patient presents with acute symptoms or incarceration.

Expression of vasoactive mediators during mechanical ventilation in nitrofen-induced diaphragmatic hernia in rats

The high mortality in patients with congenital diaphragmatic hernia (CDH) has been attributed to pulmonary hypoplasia and persistent pulmonary hypertension (PPH). Endothelin-1 (ET-1), nitric oxide (NO), and calcitonin gene-related peptide (CGRP) have been reported to be important vasoactive mediators in the perinatal pulmonary circulation. The exact mechanism by which these vasoactive mediators interact to regulate the perinatal pulmonary vascular tone in CDH with PPH is not fully understood. We hypothesized that the altered pulmonary vascular reactivity in CDH is due to imbalance in vasoactive mediators. This study was designed to investigate mRNA expression of ET-1, eNOS, and CGRP in CDH lung in the perinatal period. A CDH model was induced in pregnant rats following administration of nitrofen. In control animals, the same dose of olive oil was given without nitrofen. Cesarean section was performed on day 21 of gestation. The newborn rats were intubated and ventilated, and ventilation was continued for 1-6 h. Left lungs were collected from both groups at 0, 1, and 6 h after ventilation (n=8 in each group). Reverse transcriptase-polymerase chain reaction on lung tissue was performed to evaluate the relative level of ET-1, eNOS, and CGRP mRNA expression. The results showed a significant increase in ET-1 mRNA in CDH lung at 1 and 6 h after ventilation compared with controls. In CDH lung, eNOS mRNA and CGRP mRNA levels were significantly increased at 1 h but were similar to control values at 6 h after ventilation. The increased expression of vasoconstrictor ET-1 mRNA and vasodilators eNOS mRNA and CGRP mRNA in the CDH lung at 1 h after ventilation suggests that pulmonary vascular tone is rapidly changing after birth. An imbalance in the production of vasoconstrictors and vasodilators by the CDH lung may contribute to high pulmonary vascular resistance.

Evaluation of the development of lung hypoplasia in the premature lamb

BACKGROUND

The death rate from human diaphragmatic hernia (CDH) ranges from 50 to 80%, mainly due to the associated lung hypoplasia. To prevent these irreversible pathological and physical defects, the question of intrauterine surgical intervention arises. The histological changes of the lung tissue after inducement of a diaphragmatic hernia were examined. Of special interest was the time elapsing until the development of lung hypoplasia.

METHODS

A model of intrauterine inducement of diaphragmatic hernia was established using five fetal lambs to study consecutive pulmonary hypoplasia. Inducement of a diaphragmatic hernia was undertaken between 105 and 108 days' gestation. Lung tissue was examined histologically on postoperative days 8, 17, 21, 22, and 25 after inducement of the defect.

RESULTS

On postoperative days 8, 17, and 21, no signs of pulmonary hypoplasia were found on histological examination. A pulmonary hypoplasia was found in two fetuses (on the 22nd and 25th postoperative day). The pathological and anatomical examination of a unilateral pulmonary hypoplasia after a short period of time shows that the artificially created diaphragmatic defect is a good model for producing a congenital diaphragmatic hernia.

DISCUSSION

The severity of the pulmonary hypoplasia is related to the duration of lung compression by the herniated organs. The time elapsing until the development of lung hypoplasia is shorter than expected. Tracheal occlusion seems to be an effective strategy for treatment of the defect CDH, but the best technique for achieving occlusion, and particularly the ideal point in time to carry out "Fetendo," are unknown. Further research into this congenital illness is required in order to treat it.

Genetic polymorphisms of angiotensin system genes in congenital diaphragmatic hernia associated with persistent pulmonary hypertension

BACKGROUND/PURPOSE

The renin-angiotensin system plays an important role in pulmonary artery remodelling. Several polymorphisms of genes encoding for components of the renin angiotensin system such as the angiotensin converting enzyme (ACE), the angiotensinogen (AGT) gene, and the angiotensin II type 1 receptor (ATIR) have been associated with the development of pulmonary hypertension. The aim of this study was to investigate the ACE I/D genotype, the M235 T polymorphism of the AGT gene and the A1166 C polymorphism of AT1R in the lungs of congenital diaphragmatic hernia (CDH) complicated by persistent pulmonary hypertension (PPH) in the newborn.

METHODS

Genomic DNA was extracted from archival paraffin-embedded lung tissue from 13 newborns with CDH complicated by PPH and from 9 controls. Genotyping for the I/D-ACE, the M235 T-AGT, and the A1166 C-ATIR gene polymorphisms were determined by a polymerase chain reaction-based method with appropriate restriction digest when required.

RESULTS

In controls, ACE genotype distribution of DD, ID, and II was 11%, 33%, and 55%, respectively, whereas in CDH it was 70%, 15%, and 15%, respectively. The ACE-DD genotype was significantly higher in CDH compared with controls (P <.05). In CDH samples, the prevalence of AGT-MM genotype was lower (8% v. 33%; P <.05), whereas the AGT-TT genotype was higher (61% v. 22%; P <.05) compared with controls. There were no differences in allele frequencies of AT1R between CDH patients and controls.

CONCLUSIONS

These data suggest that D allele of the ACE gene insertion/deletion polymorphism and angiotensinogen M235 T polymorphism may be associated with PPH in newborns with congenital diaphragmatic hernia.

Fetal Sheep with Tracheal Occlusion: Monitoring Lung Development with MR Imaging and B-Mode US

PURPOSE

To assess the accuracy of magnetic resonance (MR) imaging in determining fetal lung volume (FLV) and to observe fetal lung development with B-mode ultrasonography (US) and MR imaging.

MATERIALS AND METHODS

Seven sheep fetuses between 92 and 141 gestational days (term, 145 days) with and without tracheal occlusion (controls) underwent serial MR imaging and US. FLV at MR imaging was measured with true fast imaging with steady-state precession in coronal and transverse planes. The combined cross-sectional left- and right-lung area was measured with US at three transverse levels. FLV was measured at autopsy. Statistical evaluations included linear regression analysis and calculation of the mean and 95% CI.

RESULTS

No differences in FLV were observed on coronal or transverse MR images (r2 = 0.98; slope = 0.91; 95% CI: 0.82, 1.01). FLV at MR imaging at termination of the experiment was significantly related to FLV at autopsy (r2 = 0.96; slope = 1.27; 95% CI: 0.97, 1.57; n = 6). FLV at MR imaging increased more rapidly with gestational age in fetuses with tracheal occlusion (21.0 mL/d; 95% CI: 10.7, 31.3) than in controls (4.7 mL/d; 95% CI: 1.7, 7.7). Increase in left- and right-lung area at US was accelerated in fetuses with tracheal occlusion (1.60 cm2/d; 95% CI: 1.3, 1.9) compared with controls (0.38 cm2/d; 95% CI: 0.23, 0.53). Left- and right-lung area at US and FLV at MR imaging were significantly correlated (r2 = 0.82).

CONCLUSION

FLV can be measured with moderate accuracy at MR imaging on both coronal and transverse images. MR imaging and B-mode US are useful tools for monitoring and quantifying tracheal occlusion-stimulated fetal lung growth in sheep fetuses.

Fetal surgery for lung lesions, congenital diaphragmatic hernia, and sacrococcygeal teratoma

After more than 2 decades of experimental and clinical work, fetal surgery is an accepted treatment option for highly selected fetuses with life-threatening anomalies. Fetal lung masses associated with hydrops are nearly 100% fatal. These lesions can be resected in utero if they are predominantly solid or multicystic. Thoracoamniotic shunt placement may be effective in the setting of a single large cyst. Fetuses diagnosed with left congenital diaphragmatic hernia before 26 weeks' gestation with associated liver herniation and a low right lung to head circumference ratio have a relatively poor prognosis with conventional therapy after birth, but in utero therapeutic approaches have yet to show a comparative survival benefit. A prospective randomized trial is required to critically evaluate the efficacy of fetal tracheal occlusion for severe diaphragmatic hernia. Fetal sacrococcygeal teratoma complicated with progressive high output cardiac failure may benefit from in utero resection of the tumor.

Expression of heme oxygenase-1 and endothelial nitric oxide synthase in the lung of newborns with congenital diaphragmatic hernia and persistent pulmonary hypertension

BACKGROUND/PURPOSE

Heme oxygenase (HO-1), an inducible isoform of HO is a regulator of vascular tone and cell proliferation through the production of endogenous carbon monoxide (CO). Endothelium-derived nitric oxide (NO) occurs in the endothelial layers of blood vessels and mediates vasorelaxation. Both CO and NO have similar properties and are potent vasodilators. The aim of this study was to examine the expression of HO-1 and endothelial nitric oxide synthase (eNOS) in the Congenital diaphragmatic hernia (CDI) lung.

METHODS

RNA was extracted from archival formalin-fixed paraffin-embedded lung tissue from 11 patients with CDH complicated by persistent pulmonary hypertension (PPH). Five age-matched newborns served as controls. Reverse transcription polymerase chain reaction (RT-PCR) was performed using specific primers for human HO-1 and eNOS. Immunohistochemistry using HO-1 and eNOS antibodies was performed and examined using laser scanning microscope.

RESULTS

HO-1 and eNOS mRNA expression was significantly decreased in CDH lung compared with controls (P <.05). HO-1 and eNOS immunoreactivity was reduced markedly reduced in the endothelium and arterial wall in the CDH samples compared with normal lung.

CONCLUSIONS

Decreased expression of HO-1 and eNOS in the CDH lung suggests deficiency of endogenous NO and CO, which may contribute to altered vascular tone causing PPH.

A prospective, randomized pilot trial of perfluorocarbon-induced lung growth in newborns with congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Initial laboratory and clinical data suggest that partial liquid ventilation (PLV) can enhance pulmonary function and that lung growth can be induced via distension of the newborn lung using perfluorocarbon in patients with congenital diaphragmatic hernia (CDH). The authors, therefore, performed a prospective, randomized pilot study evaluating PLV and perfluorocarbon-induced lung growth (PILG) in newborns with CDH on extracorporeal life support (ECLS) at 6 medical centers.

METHODS

Patients were selected randomly using a permuted block design to PLV/PILG (n = 8) or conventional mechanical ventilation (CMV/control, n = 5). Patients in the PILG group received daily doses which filled the lungs with perflubron for up to 7 days and were placed on continuous positive airway pressure of 5 to 8 cm H2O. CMV patients were treated with standard mechanical ventilation while on extracorporeal membrane oxygenation (ECMO).

RESULTS

A total of 13 patients were evaluated in this study. All 3 patients enrolled without being on ECLS rapidly transitioned to ECLS. The study, therefore, effectively evaluated PILG (n = 8) versus standard ventilation (control, n = 5) on ECLS. Mean (+/- SE) gestational age was 37 +/- 1 weeks and weight was 3.1 +/- 0.1 kg. Time on ECMO was 9.8 +/- 2.3 days in the PILG and 14.5 +/- 3.5 days (P =.58) in the control group. Survival rate in the PILG group was 6 of 8 (75%), whereas survival rate was 2 of 5 (40%) in the control group (P =.50). The number of days free from the ventilator in the first 28 days (VFD) was 6.3 +/- 3.3 days with PILG and 4.6 +/- 4.6 days with control (P =.9). Causes of death in the PILG group included sepsis and renal failure in one patient and pulmonary hypertension in the other. There were no safety issues, and the deaths in the PILG group did not appear to be related to the administration of perflubron.

CONCLUSIONS

These data show that PILG can be performed safely. The survival rate, VFD, and time on ECMO data, although not conclusive, are encouraging and indicate the need for a definitive trial of this novel intervention in these neonates with high mortality.

Antenatal dexamethasone enhances endothelin-1 synthesis and gene expression in the heart in congenital diaphragmatic hernia in rats

BACKGROUND/PURPOSE

Although high levels of endothelin-1 (ET-1) in plasma may be relevant in certain pathophysiologic states, such as pulmonary hypertension accompanying congenital diaphragmatic hernia (CDH), experimental evidence favors a local, paracrine, or autocrine role for ET-1 in most tissues. Evidence of ET-1 production has been documented in fetal heart tissue where it exerts growth-enhancing and mitogenic effects. ET-1 also has a potent positive inotrope action on cardiac muscle. ET-1 -/- homozygous mice display a wide variety of cardiac anomalies, which also are features of the human and of the experimental CDH. Autopsy reports have shown that total heart weight is reduced significantly in the presence of CDH, and animal models have documented the presence of cardiac hypoplasia associated with CDH. Experimental and clinical studies have shown that prenatal exposure to corticosteroids improves cardiovascular function in the immediate newborn period. The aim of this study was to determine cardiac gene expression of ET-1 and of its receptor ET(A) and the cardiac ET-1 content in the heart of nitrofen-induced CDH in rats and to evaluate the effect of antenatal Dexamethasone (Dex) treatment.

METHODS

A CDH model was induced in pregnant rats after administration of 100 mg of nitrofen on day 9.5 of gestation (term, 22 days). Dex (0.25 mg/kg) was given by intraperitoneal injection on days 18.5 and 19.5 of gestation. Cesarean section was performed on day 21 of gestation. The fetuses were divided into 3 groups: group I, control (n = 8); group II, nitrofen-induced CDH (n = 8); group III, nitrofen-induced CDH with antenatal Dex treatment (n = 8). ET-1 protein was measured using ELISA. RT-PCR was performed to evaluate the relative amount of ET-1 and ET(A) mRNA expression.

RESULTS

There was a reduction in ET-1 mRNA (P <.05) and in ET(A) mRNA (P <.01) in the heart of CDH group compared with controls. ET-1 protein level also was reduced in heart of CDH compared with controls. Antenatal Dex treatment increased significantly both ET-1 mRNA and protein levels in the heart of CDH animals (P <.05 and P <.01, respectively).

CONCLUSIONS

The reduced cardiac ET-1 gene expression and ET-1 synthesis may be responsible for the heart hypoplasia associated with CDH. Prenatal corticosteroids increase the cardiac production of ET-1, and this may enhance heart growth and cardiac inotropism at birth.

Laparoscopic repair of a Morgagni hernia presenting with syncope in an 85-year-old woman: case report and update of the literature

An 85-year-old woman was transferred from her local hospital for cardiac evaluation after presenting with repeated episodes of syncope during bowel movements. A thorough evaluation revealed no cardiac abnormalities but did reveal a Morgagni hernia with transverse colon in the mediastinum. She underwent laparoscopic reduction of the colon and repair of the hernia with mesh and had a rapid and uneventful recovery.

Congenital diaphragmatic hernia: prenatal evaluation with MR lung volumetry--preliminary experience

PURPOSE

To determine the interobserver variability of prenatal magnetic resonance (MR) lung volumetry and to assess the value of MR lung volumetric findings as predictors of outcome in fetuses with congenital diaphragmatic hernia.

MATERIALS AND METHODS

Prenatal MR imaging was performed in 26 fetuses with unilateral congenital diaphragmatic hernia. Two independent observers performed planimetric measurement of lung volume. Relative lung volume was calculated as the observed total lung volume expressed as a percentage of the total lung volume predicted from fetal size. Relative lung volume was correlated with the ultrasonographic lung-head ratio in left-sided congenital diaphragmatic hernias evaluated before 27 weeks gestation (n = 21) and with pregnancy outcome in all cases of isolated left-sided congenital diaphragmatic hernia without prenatal intervention (n = 11).

RESULTS

Observers demonstrated excellent agreement in total lung volume measurements at MR imaging, with an intraclass correlation coefficient of 0.95. Relative lung volume was positively correlated with lung-head ratio (r = 0.78, P <.001). By using rank order analysis in the pregnancy outcome group, relative lung volume was predictive of prognosis (P <.05) when adjusted for gestational age at delivery and birth weight. Three of four fetuses with a relative lung volume of less than 40% died.

CONCLUSION

Interobserver agreement is high at MR lung volumetry, and its findings are predictive of outcome in fetuses with isolated left-sided congenital diaphragmatic hernia.

Structural immaturity of the heart in congenital diaphragmatic hernia in rats

PURPOSE

The form and function of the heart are the final result of an integration of cells, tissues, and extracellular material. The extracellular matrix (ECM) is a complex array of different molecular components, and it plays an important role for the transfer of mechanical force in both contraction and relaxation phases in the cardiac cycle. ECM plays also a significant role in the development of the heart. The aim of this study was to evaluate the expression of important ECM components in the heart of rats with induced CDH to test the hypothesis that an alteration of ECM may contribute to the cardiac maldevelopment, which recently has been identified as a contributive factor for the high mortality rate in babies with congenital diaphragmatic hernia (CDH).

METHODS

CDH model was induced in pregnant rats after administration of 100 mg of nitrofen on day 9.5 of gestation (term, 22 days). In control animals the same dose of olive oil was given without nitrofen. Cesarean section was performed on day 21 of gestation. The fetuses were divided into 2 groups: normal control (n = 10) and nitrofen-induced CDH (n = 10). Reverse transcription polymerase chain reaction (RT-PCR) was performed to evaluate the relative amount of tropoelastin and alpha1 (I) procollagen mRNA expression. Elastin protein content was measured using enzyme-linked immunosorbent assay (ELISA).

RESULTS

There was a reduction in tropoelastin mRNA (P <.05) and procollagen mRNA (P <.05) in CDH compared with controls. The cardiac alpha-elastin content also was reduced in CDH (P <.01).

CONCLUSIONS

The reduced cardiac tropoelastin and procollagen gene expression and the reduced alpha-elastin content indicate that the heart in CDH structurally is immature. The reduced production of cardiac ECM may contribute to a contractile dysfunction, which makes the heart unable to respond to the hemodynamic load accompanying persistent pulmonary hypertension (PPH).

Antenatal dexamethasone enhances surfactant protein synthesis in the hypoplastic lung of nitrofen-induced diaphragmatic hernia in rats

BACKGROUND/PURPOSE

Pulmonary hypoplasia is one of the main causes for the high mortality rate in patients with congenital diaphragmatic hernia (CDH). The expression of surfactant protein A in the hypoplastic CDH lung is reduced, and its concentration is decreased in the amniotic fluid of pregnancies complicated by CDH. In a CDH experimental model, prenatal glucocorticoid treatment has proved its efficacy in correcting the parameters of pulmonary biochemical and morphologic immaturity. The aim of this study was to investigate whether maternal administration of dexamethasone has any effect on the expression of surfactant protein A and surfactant protein B in nitrofen-induced experimental CDH rat model.

METHODS

CDH was induced in pregnant rats after administration of 100 mg of nitrofen on day 9.5 of gestation (term, 22 days). Dexamethasone (Dex, 0.25 mg/kg) was given by intraperitoneal injection on days 18.5 and 19.5 of gestation. Cesarean section was performed on day 21 of gestation. The fetuses were divided into 3 groups: group I, control (n = 16); group II, nitrofen-induced CDH (n = 16); group III, nitrofen-induced CDH with antenatal Dex treatment (n = 16). Indirect immunohistochemistry was performed using alkaline-phosphatase-coagulated streptavidin using anti-SP-A and anti-SP-B polyclonal antibodies. Reverse transcription polymerase chain reaction (RT-PCR) was performed to evaluate relative amount of SP-A and SP-B mRNA expression.

RESULTS

In the CDH lung (group II) we observed a markedly reduced number of type II pneumocytes positive for SP-A, and SP-B was increased to a level close to that of the control group. The relative amount of SP-A and SP-B was reduced significantly in group II compared with controls (P < .05) and significantly increased in group III compared with group II animals (P < .01).

CONCLUSION

These results suggest that antenatal glucocorticoid treatment increases the production of surfactant proteins in the CDH hypoplastic lung.

Effect of CGS 26303, an endothelin-converting enzyme-neutral endopeptidase inhibitor, on nitrofen-induced congenital diaphragmatic hernia in the rat

BACKGROUND/PURPOSE

The pathophysiology of congenital diaphragmatic hernia (CDH) associated with lung hypoplasia and pulmonary hypertension is not understood fully. Endothelins (ETs) are the most potent vasoconstrictors that also act as promitogenic agents. They may play a role during pregnancy in leading to the condition found at birth and ongoing mortality in CDH. Therefore, the authors studied the effect of CGS 26303, a nonselective endothelin-converting enzyme and neutral endopeptidase inhibitor, in the rat model of CDH.

METHODS

Pregnant Sprague-Dawley rats were divided into 3 groups: group 1 (n = 4) received CGS 26303 (50 mg/kg, subcutaneously, twice a day), from gestational day 12 until term (21 to 23 days); group 2 (n = 8) received nitrofen (100 mg/kg, orally) at gestational day 11.5; group 3 (n = 8) received both nitrofen and CGS 26303. The survival of the newborn rats was monitored up to 240 minutes. After natural death or euthanasia, they were weighed and microdissected. The degree of hernia was quantified as small, moderate, or severe, and lungs and liver were harvested and weighed.

RESULTS

Newborn rats from mothers of group 3 (n = 81) survived 196 +/- 8 minutes compared with 173 +/- 9 minutes of those of group 2 (n = 97). Severe CDH from group 3 (n = 20) had a mean survival time of 66 +/- 13 minutes compared with 26 +/- 4 minutes for those of group 2 (n = 27). Lung index in severe CDH pups of group 3 was increased by 13% compared with those from group 2 (P < .0001), whereas their liver index went down by 8% (P < .05).

CONCLUSIONS

These results suggest that CGS 26303 might have a beneficial effect when given during pregnancy in increasing survival at birth and reducing the severity of the pulmonary hypoplasia in newborn rats with nitrofen-induced CDH.

Adult presentation of agenesis of the hemidiaphragm

A 66-year-old woman presented with a 3-day history of classical features of large bowel obstruction. At emergency laparotomy, the transverse colon and splenic flexure were located in the left hemithorax. The entire left hemidiaphragm was absent, and there were no diaphragmatic remnants visible. This is the oldest reported case of an absent hemidiaphragm. Previous cases of "agenesis" of the hemidiaphragm in adults either reported diaphragmatic remnants intraoperatively or failed to rule them out radiologically when managed conservatively. We would suggest that this is the first reported case of an adult presenting with true agenesis of the hemidiaphragm.

Antenatal dexamethasone enhances endothelin receptorB expression in hypoplastic lung in nitrofen-induced diaphragmatic hernia in rats

BACKGROUND/PURPOSE

The hypoplastic lung and persistent pulmonary hypertension (PPH) are the principle causes of high mortality and morbidity in infants with congenital diaphragmatic hernia (CDH). Endothelin-1 (ET-1), which is produced by vascular endothelial cells and some leukocytes, plays a key role in modulating pulmonary vascular tone in PPH. Two different receptors (ET(A) and ET(B)) for ET-1 have been characterized. Binding of ET-1 to ET(A), which is present on smooth muscle cells in fetal lung, results in vasoconstriction. However, binding of ET-1 to ET(B), which is present on endothelial cells results in vasodilation mediated by endogenous nitric oxide. Antenatal glucocorticoid therapy has been shown to prevent abnormal pulmonary arterial structural changes in animal model with CDH. The aim of this study was to investigate the effect of antenatal glucocorticoid administration on ET-1 system in nitrofen-induced CDH hypoplastic lung in rats.

METHODS

A CDH model was induced in pregnant rats after administration of nitrofen on day 9.5 of gestation. Dexamethasone (Dex) was given intraperitoneally on days 18.5 and 19.5 of gestation. Cesarean section was performed on day 21 of gestation. Rat ET-1 protein expression was measured in solubilized lung tissue extracts, by sandwich type enzyme-linked immunosorbent assay (ELISA) analysis. Reverse transcription polymerase chain reaction was performed to evaluate the relative amount of ET-1, ET(A), and ET(B) mRNA expression.

RESULTS

The ET-1 protein and mRNA expression of ET-1 and both receptors were increased significantly in CDH lung compared with controls. Although there was no significant difference in ET(A) mRNA expression between CDH lung with Dex treatment and without Dex treatment, ET(B) mRNA expression was elevated significantly in CDH lung with Dex treatment compared with CDH lung without Dex treatment.

CONCLUSION

These findings suggest that antenatal glucocorticoid therapy may modulate pulmonary vascular tone in CDH hypoplastic lung by selectively upregulating local expression of ET(B).

Congenital diaphragmatic hernia "occulta"

Congenital diaphragmatic hernia usually presents with cyanotic attacks, dyspnoea and dextrocardia, a typical triad which is almost considered pathognomonic. The case records of 10 patients (out of a total of 20) of congenital diaphragmatic hernia presenting beyond the neonatal period were reviewed retrospectively. Age and symptoms at presentation and signs elicited were paid special attention. All the patients underwent operative repair of hernia under general anaesthesia. Given below is an explanation for such a high incidence of late presentation in our series. This nomenclature (Congenital Diaphragmatic Hernia "Occulta") will help clinicians in remembering this entity if and when such patients present to the clinicians.

Open fetal surgery for life-threatening fetal malformations

After more than two decades of experimental and clinical work, fetal surgery has become an accepted treatment modality for selected fetuses with life-threatening anomalies. Color Doppler ultrasound and ultrafast fetal magnetic resonance imaging have enhanced the accuracy of prenatal evaluation traditionally made by ultrasound alone. Fetal lung masses associated with hydrops are nearly 100% fatal. These lesions can be resected in utero if they are predominantly solid or multicystic. Thoracoamniotic shunting may be effective in the setting of a single large predominant cyst. Fetuses diagnosed with left congenital diaphragmatic hernia before 26 weeks' gestation with liver herniation and a sonographic right lung to head circumference ratio (LHR) of less than one may benefit from fetal tracheal occlusion. Fetal sacrococcygeal teratoma complicated with placentomegaly, hydrops, or progressive high output heart failure may benefit from in utero resection of the tumor. Although preterm labor still remains the Achilles heel of open fetal surgery, effective tocolysis may, in the future, expand the scope of fetal surgery.

Antenatal dexamethasone suppresses tumor necrosis factor-alpha expression in hypoplastic lung in nitrofen-induced diaphragmatic hernia in rats

The hypoplastic lung in congenital diaphragmatic hernia (CDH) has both a quantitative and qualitative reduction in surfactant. Tumor necrosis factor-alpha (TNF-alpha) drastically decreases surfactant phospholipids synthesis by isolated human type II pneumocytes. Recently, it was shown that TNF-alpha mRNA expression is increased in human hypoplastic CDH lung. Antenatal glucocorticoid therapy demonstrates improved surfactant biochemical immaturity in an animal CDH model. The aim of this study was to investigate the effect of antenatal dexamethasone (Dex) on TNF-alpha protein and gene expression in nitrofen-induced CDH hypoplastic lung in rats. A CDH model was induced in pregnant rats after the administration of nitrofen on d 9.5 of gestation. Dex was given intraperitoneally on d 18.5 and 19.5. Cesarean section was performed on d 21. In situ hybridization was performed with a rat TNF-alpha-specific and digoxigenin-labeled oligonucleotide probe. TNF-alpha level was measured in solubilized lung tissue extracts by ELISA. In control lung, TNF-alpha mRNA expression was weak or absent. In contrast, strong TNF-alpha mRNA expression was demonstrated in type II pneumocytes and bronchiolar epithelium in CDH lung. In Dex-treated CDH lung, TNF-alpha mRNA expression was weak in both type II pneumocytes and the bronchiolar epithelium. The level of TNF-alpha was elevated significantly in CDH lung compared with levels in control lung extracts (p < 0.01). In Dex-treated CDH lung, TNF-alpha protein was significantly decreased compared with CDH lung (p < 0.05). Our findings suggest that the reduction in the local production of TNF-alpha may be one contributing mechanism by which antenatal glucocorticoid therapy improves pulmonary parenchymal immaturity, including surfactant.

Tracheoscopic endoluminal plugging using an inflatable device in the fetal lamb model

OBJECTIVE

Intra-uterine tracheal occlusion has been proposed to reverse pulmonary hypoplasia, an important prognostic factor in congenital diaphragmatic hernia. We aimed to evaluate the feasibility and pulmonary effects of tracheoscopic tracheal obstruction with a detachable balloon.

STUDY DESIGN

Fourteen mid-trimester fetuses out of 24 in 13 ewes underwent tracheoscopic balloon obstruction. Ten non-operated fetuses served as controls. Plugging was performed under fiber-tracheoscopy using a detachable balloon. Outcome measures consisted of: total operating time, tracheoscopy time, fetal survival, efficiency of plugging, and pulmonary effects. The Mann-Whitney test and linear regression were used for statistical analysis.

RESULTS

Mean operating time and tracheoscopy time were 65+/-12 and 6.6+/-3.9 min, respectively. One intra-operative death occurred in each group. The post-operative mortality was 2/13 for cases and 2/9 for controls. In all 14 fetuses, the trachea was successfully obstructed. In the 11 treated animals born alive, the lung-to-body-weight ratio was 0.060+/-0.01, while in controls it was 0.031+/-0.01 (P = 0.0001). In a subset of six fetuses obstructed for 14-18 days, mean-terminal-bronchial density was 0.95+/-0.59, compared to 2.06+/-0.80 for controls (P = 0.046).

CONCLUSIONS

Using fetal tracheoscopy, the trachea can successfully be obstructed with an inflatable balloon. Pulmonary hyperplasia is achieved when the obstruction lasts 2 weeks.

Altered insulin-like growth factor I mRNA expression in human hypoplastic lung in congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Insulin-like growth factor I (IGF-I) is a peptide growth factor that is synthesized in many organs during human development and plays a role in the growth and differentiation of tissue. IGF-I has been shown to be produced in rat and human fetal lung and to be an important mitogen involved in lung growth and development. The cells responsible for the synthesis of IGF-I in lung in vivo have been demonstrated to be type II pneumocytes, alveolar macrophages, and mesenchymal cells. Recent studies have shown that IGF-I mRNA expression in the lung is predominant during fetal life and decreases before birth, becoming barely detectable in the neonatal lung. The aim of this study was to investigate IGF-I mRNA expression in CDH lung to understand the basis of pulmonary hypoplasia in newborns with CDH.

METHODS

Lung tissue samples were obtained during autopsy from 13 patients with CDH. Nine were full-term newborns (mean age, 3.8 days), and four were stillborns. Normal lung tissue from eight sudden infant death syndrome infants (mean age, 15.3 days) acted as controls. In situ hybridization was performed on frozen sections using IGF-I-specific and digoxigenin-labeled oligonucleotide probe and visualized by nitro blue tetrazolium staining.

RESULTS

In control lung, IGF-I mRNA expression was absent or weak in type II pneumocytes and alveolar macrophages. In contrast, there was strong IGF-I mRNA expression in type II pneumocytes and alveolar macrophages in hypoplastic CDH lung in newborns as well as stillborns.

CONCLUSION

The findings of strong IGF-I mRNA expression in the hypoplastic lung suggest that lung hypoplasia in CDH is a persistence of fetal stage of lung development.

Adventitial changes in pulmonary vasculature in congenital diaphragmatic hernia complicated by pulmonary hypertension

PURPOSE

The purpose of this study was to characterize structural changes in the pulmonary vasculature in congenital diaphragmatic hernia (CDH) complicated by persistent pulmonary hypertension (PPH) with particular emphasis on adventitial thickness.

METHODS

Victorian blue Van Gieson (VVG) staining and immunostaining with antialpha smooth muscle actin (ASMA) were performed on lung tissues obtained at autopsy from 23 patients with CDH complicated by PPH and 11 age-matched control tissues of sudden infant death syndrome patients (SIDS). The degree of medial and adventitial thickening was measured in pulmonary arteries with an external diameter (ED) of less than 75 microm, 75 to 100 microm, 100 to 150 microm, 150 to 250 microm, 250 to 500 microm, and greater than 500 microm by IPS-4.01 image analyzer and compared statistically. The degree of medial thickening and adventitial thickening was also measured in pulmonary veins with an ED of less than 100 microm, 100 to 200 microm, and greater than 200 microm. To determine whether the characteristic structural changes were size related, each was related to ED. The area of adventitia and media of the pulmonary arteries and veins was measured using image analyzer.

RESULTS

There was a significant increase in medial and adventitial thickness in arteries of all sizes in CDH patients compared with controls (P < .01). The degree of adventitial area was significantly increased for arteries of all sizes (P < .01) and the degree of medial area was significantly increased only for arteries less than 100 microm size (P < .05) in CDH patients compared with controls. Calculation of the areas of the various components in the wall of each artery showed that for small arteries (<100 microm ED), the area of the lumen was smaller, and the areas of the media and adventitia were larger in CDH patients compared with controls (P < .01). There was a significant increase in adventitial thickness and area in veins of all sizes in CDH patients compared with controls (P < .01). The adventitial thickness of pulmonary veins were ED of less than 100 microm: CDH, 13.5 microm +/- 3.5; control, 9.21 microm +/- 2.0; ED 100 to 200 microm: CDH, 21.3 microm +/- 7.5; control, 13.0 microm +/- 4.8; ED greater than 200 microm: CDH, 34.4 microm +/- 12.5; control, 22.3 microm +/- 4.2.

CONCLUSIONS

The present study provides the first quantitative demonstration of structural alterations in pulmonary veins in addition to pulmonary arteries in CDH complicated by PPH. The structural remodeling of the pulmonary vein is perhaps as a result of an increase in transvascular pressure in PPH.

Intrauterine tracheal obstruction, a new treatment for congenital diaphragmatic hernia, decreases amniotic fluid sodium and chloride concentrations in the fetal lamb

OBJECTIVE

To evaluate the effect of fetal tracheal occlusion on sodium and chloride concentrations in amniotic and tracheal fluid.

SUMMARY BACKGROUND DATA

Intrauterine tracheal occlusion has been proposed to reverse pulmonary hypoplasia, an important prognostic factor in congenital diaphragmatic hernia. In early human trials, technical failure of the obstructive device has been reported.

METHODS

Eight fetal lambs (gestational age = 95 days) were subjected to fetal tracheoscopy, and amniotic and tracheal fluid samples were taken. In multiple pregnancies (n = 6), amniotic fluid was also sampled from the contralateral amniotic sac and used as a control. Subsequently, endotracheal obstruction, using a detachable balloon, was performed. After 14 days, all fetuses were delivered, and sodium and chloride concentrations in amniotic and tracheal fluid were measured again. Statistical analysis was done using a two-tailed Student's t test, paired or unpaired as appropriate.

RESULTS

In controls, between 95 and 109 days gestational age, no significant changes occurred in sodium or chloride concentrations in amniotic or tracheal fluid. After 2 weeks of tracheal obstruction, however, chloride and sodium concentrations in amniotic fluid decreased (chloride = 76.7 mEq/L vs. 107.6 mEq/L, p = 0.0003; sodium = 109.6 mEq/L vs. 125.9 +/- 5.2 mEq/L, p = 0.019). A concomitant increase in chloride and sodium concentration was observed in tracheal fluid (chloride = 145.4 mEq/L vs. 130.0 mEq/L, p = 0.047; sodium = 153.1 mEq/L vs. 142.9 mEq/L, p = 0.051). When comparing groups at 109 days, chloride and sodium concentrations in amniotic fluid were markedly lower in the treated group versus controls (p = 0.0004 and p = 0.05 for chloride and sodium, respectively).

CONCLUSION

Complete tracheal occlusion in ovine fetuses results in a significant decrease of amniotic fluid sodium and chloride concentrations.

Wandering spleen presenting as duodenal obstruction after repair of congenital diaphragmatic hernia

The most common presentation of the wandering spleen in children is torsion with infarction. Duodenal obstruction by the spleen has not been reported previously. Wandering spleen can accompany congenital diaphragmatic hernia (CDH) because of its loss of retroperitoneal fixation. If absence of normal splenic fixation is found during repair of CDH, splenopexy should be performed to eliminate the risk of torsion, infarction, or, as described here, duodenal obstruction.

Tracheoscopic endotracheal occlusion in the ovine model: technique and pulmonary effects

BACKGROUND/PURPOSE

The purpose of this study was to assess the tracheoscopic placement of a detachable balloon to obstruct the trachea in the fetal lamb model and to study the pulmonary effects 2 weeks later.

METHODS

Thirteen pregnant ewes carrying 27 fetuses were used in this trial. Thirteen fetuses underwent endotracheal plugging at a mean gestational age of 95 (90 to 100) days (term, 145). Fourteen nonoperated fetuses served as controls. The intended duration of obstruction was 15 days. Study parameters consisted of operating time, fetal survival, performance of the balloon, and pulmonary changes.

RESULTS

Hysterotomy time was 41 +/- 25 minutes and tracheoscopy time was 7.2 +/- 3.4 minutes. There were no intraoperative deaths in this series. Postoperative fatalities occurred in 2 of 13 plugged fetuses and 1 of 14 controls. At completion of the experiment, the balloon was recovered intact in the trachea of 12 of 13 (92.3%) fetuses. The lung weight/body weight ratio was 76 +/- 16 mg/kg for plugged animals, while in controls it was 34 +/- 8 mg/kg (P = .0001). The lung volume/body weight ratio was 101 +/- 17 mL/kg in plugged fetuses, compared with 47 +/- 4 mL/kg for controls (P = .0002). Mean-terminal-bronchial-density was 0.937 +/- 0.303 for plugged animals, compared with 1.911 +/- 0.441 for controls (P = .0002). Mean linear intercept was 60.9 +/- 5.2 microm in treated fetuses, and 46.3 +/- 5.8 microm for controls (P = .0004).

CONCLUSIONS

Fetal endotracheal occlusion, using a tracheoscopically placed detachable balloon, is reliable, and results in pulmonary hyperplasia after 2 weeks of obstruction. This technique may be beneficial in treating the pulmonary hypoplasia seen in congenital diaphragmatic hernia. Further studies using this balloon device are now required to corroborate these findings.

Active collagen synthesis by pulmonary arteries in pulmonary hypertension complicated by congenital diaphragmatic hernia

The high mortality rate for patients with congenital diaphragmatic hernia (CDH) has been attributed to pulmonary hypoplasia and persistent pulmonary hypertension (PPH). The factors that cause vasoconstriction and vascular remodeling in PPH are not fully understood. Immunohistochemistry was performed on lung tissue obtained from postmortem CDH patients with pulmonary hypoplasia and PPH (n = 21) using the following antibodies: alpha smooth muscle-actin (ASMA), transforming growth factor-beta (TGF-beta), isoform specific (TGF-beta 1, -beta 2, -beta 3), and M-57. Normal lung tissues from age-matched sudden infant death syndrome patients (SIDS, n = 8) were obtained as controls. TGF-beta 3 immunoreactivity was observed in the adventitia but not in the media of pulmonary muscular arteries in patients with CDH. TGF-beta 1, -beta 2 immunoreactivity was either absent or faintly expressed in pulmonary arteries in CDH patients. No TGF-beta staining was observed in the pulmonary vasculature of SIDS patients. Newly synthesized procollagen (M-57) was easily detected in the media and adventitia in a large number of pulmonary arteries in all patients with CDH and in the neointima in two patients with long standing PPH. No M-57 staining was seen in the media of pulmonary arteries of the lungs of SIDS patients. These observations suggest a potential role of TGF-beta 3 but not TGF beta 1 or TGF beta 2 in pulmonary vascular remodeling and that smooth muscle cells in muscular pulmonary arteries are actively synthesizing collagen in patients with CDH complicated by PPH.

Partial liquid ventilation in newborn patients with congenital diaphragmatic hernia

The authors evaluated the safety and efficacy of liquid ventilation with perfluorocarbon in four newborns with congenital diaphragmatic hernia and severe respiratory failure, who were on extracorporeal life support (ECLS). After 2 to 5 days on the ECLS, perflubron was administered into the trachea until the dependent zone of the lung was filled. The first dose was 6 +/- 1 mL/kg (range, 5 to 8 mL/kg). Gas ventilation of the perflubron-filled lung was performed (partial liquid ventilation). The administration of perflubron was repeated daily for 5 to 6 days, with total cumulative doses of 36 +/- 8 mL/kg (range, 26 to 44 mL/kg). A significant increase in PaO(2) (P = .027 by repeated-measures analysis of variance [ANOVA]), a trend toward an increase in arterial oxygen content (P = .052 by repeated-measures ANOVA), and a significant increase in specific static total pulmonary compliance (P = .007 by repeated-measures ANOVA) were observed after administration of the daily dose of perflubron. PaCO(2) data showed a decreasing trend (P = .08 by repeated measures ANOVA). The authors conclude that perflubron can be safely administered into the lungs of newborn patients with congenital diaphragmatic hernia and severe respiratory failure, and it may be associated with improvement in gas exchange and pulmonary compliance.

Prenatal and neonatal sonographic imaging of a central diaphragmatic hernia

A case of a central diaphragmatic hernia diagnosed prenatally is reported. The prenatal sonographic findings included central herniation of most of the liver into the chest and hydrops. The hernia was successfully repaired. However, the infant died secondary to respiratory distress syndrome.