Multivariate model for predicting recurrence in congenital diaphragmatic hernia

Evaluation of a biodegradable polyurethane patch for repair of diaphragmatic hernia in a rat model: A pilot study

INTRODUCTION

Congenital diaphragmatic hernia (CDH) repair is an area of active research. Large defects requiring patches have a hernia recurrence rate of up to 50%. We designed a biodegradable polyurethane (PU)-based elastic patch that matches the mechanical properties of native diaphragm muscle. We compared the PU patch to a non-biodegradable Gore-Tex™ (polytetrafluoroethylene) patch.

METHODS

The biodegradable polyurethane was synthesized from polycaprolactone, hexadiisocyanate and putrescine, and then processed into fibrous PU patches by electrospinning. Rats underwent 4 mm diaphragmatic hernia (DH) creation via laparotomy followed by immediate repair with Gore-Tex™ (n = 6) or PU (n = 6) patches. Six rats underwent sham laparotomy without DH creation/repair. Diaphragm function was evaluated by fluoroscopy at 1 and 4 weeks. At 4 weeks, animals underwent gross inspection for recurrence and histologic evaluation for inflammatory reaction to the patch materials.

RESULTS

There were no hernia recurrences in either cohort. Gore-Tex™ had limited diaphragm rise compared to sham at 4 weeks (1.3 mm vs 2.9 mm, p = 0.003), but no difference was found between PU and sham (1.7 mm vs 2.9 mm, p = 0.09). There were no differences between PU and Gore-Tex™ at any time point. Both patches formed an inflammatory capsule, with similar thicknesses between cohorts on the abdominal (Gore-Tex™ 0.07 mm vs. PU 0.13 mm, p = 0.39) and thoracic (Gore-Tex™ 0.3 mm vs. PU 0.6 mm, p = 0.09) sides.

CONCLUSION

The biodegradable PU patch allowed for similar diaphragmatic excursion compared to control animals. There were similar inflammatory responses to both patches. Further work is needed to evaluate long-term functional outcomes and further optimize the properties of the novel PU patch in vitro and in vivo.

LEVEL OF EVIDENCE

Level II, Prospective Comparative Study.

Ingrowing Liver as Atypical Recurrent Diaphragmatic Hernia Presentation-Diagnostic and Treatment Difficulties: A Case Report

(1) Introduction: Recurrent diaphragmatic hernia is a relevant diagnostic and treatment dilemma. We have presented a patient with ingrowing liver as an atypical diaphragmatic hernia recurrence and discussed major aspects of diagnostic methods and the selection of an appropriate operative treatment. (2) Case description: We discuss a case of a patient with right-sided recurrent CDH (Congenital Diaphragmatic Hernia) who had primary thoracoscopic repair in newborn period. During infancy and early childhood, the patient presented recurrent upper and lower respiratory tract infections and bronchial hyperreactivity. The clinical picture was initially unclear. A CT scan was inconclusive to diagnose a recurrence. The patient was scheduled to have a re-thoracoscopy. A part of the liver was herniated into the pleural cavity. This fragment of 'ingrowing' liver was removed, and the diaphragmatic secondary defect was repaired. (3) Conclusions: This case proved that thoracoscopy can be a preferred technique in the diagnosis and treatment of CDH recurrence.

Recurrence of Congenital Diaphragmatic Hernia: Risk Factors, Management, and Future Perspectives

Recurrence is one of the most common surgical complications in Congenital Diaphragmatic Hernia (CDH). It could remain clinically silent for a long time or present as an acute complication week, months, or even years after the primary surgery. Several risk factors have been identified so far. An extended diaphragmatic defect represents one of the leading independent risk factors, together with indirect signs of large defect such as the liver position related to the diaphragm and the use of the prosthetic patch and with the use of a minimally invasive surgical (MIS) approach. However, the exact contribution of each factor and the overall risk of recurrence during the life span still need to be fully understood. This mini-review aims to give an overview of the current knowledge regarding CDH recurrence, focusing on predisposing factors, clinical presentation, management and follow-up of high-risk patients, and future perspectives.

Surgeon level variation in outcome of repair of congenital diaphragmatic hernia with particular reference to the management of recurrence

INTRODUCTION

The aim of this study is to investigate firstly, the rate of recurrence following primary repair of a congenital diaphragmatic hernia (CDH) and secondly, the rate of recurrence following revisional surgical repair. The primary outcome is rate of recurrence. Secondary outcomes are to establish whether recurrence is related to surgeon, surgeon volume, side of defect, the use of a patch, or a thoracopscopic approach METHODS: All repairs performed in an English regional center over 22 years were recorded. Possible explanatory variables were whether the repair was itself of a recurrence, the surgeon's identity, the surgeon's volume of prior repairs, the side of the defect, the use of a patch.

RESULTS

198 repairs were performed; 170 primary repairs and 28 of recurrences. Failure occurred significantly more commonly among recurrences (32%) than primary repairs (11%), p = 0.005. Failure of the primary repair was significantly more common where a patch was used 8/34 (23%) rather than a sutured repair 10/136 (7%), p = 0.006, or where a thoracoscopic technique was used 4/13 (31%) rather than laparotomy 14/157 (9%) p = 0.01. Failure of the primary repair was unrelated to the identity of the surgeon (Χ² = 5, p = 0.9) or the volume of prior repairs (t = 0.3, p = 0.6). However, failure of repair of a recurrence was significantly related to the surgeon's volume of prior repairs (t = 2.3, p = 0.01) and the identity of the surgeon (Χ² = 17, p = 0.014), but not the use of a patch (Χ² = 1.6, p = 0.2).

CONCLUSIONS

Repair of a recurrence of a CDH has a higher probability of failure than the original repair and is related to both the identity of the surgeon and the prior volume of experience. There is a volume outcome relationship for the repair of recurrence, but not the primary repair of CDH. Our study suggests the repair of recurrence of CDH should be restricted to surgeons with proven outcomes for this procedure.

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

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

Recurrent congenital diaphragmatic hernia: A single center experience

Congenital Diaphragmatic Hernia (CDH) occurs in 1:4000 live births. It's morbidity and mortality rates are significant. Recurrence is one of the recognized complications occurring after a successful initial repair. Poorly known are the rate of recurrence and factors that may influence the re-herniation. Poorly described are its morphology and treatment. Medical records of 95 neonates with CDH who had undergone repair at tertiary pediatric teaching hospital between 2007-2018 were retrospectively reviewed. Prior to surgery, peri-operative and recurrence data were collected. The follow-up was 1 to 12 years after the initial repair. Recurrence occurred in 22/84 (26%) patients. In 5 patients we observed more than one recurrence, total number of 27 (32%) re-herniations; 16/22 (72%) recurrences occurred within first 12 months; 7/27 (26%) recurrences were symptomatic which gives the symptomatic recurrence rate 8.3%; 20/27 (74%) were asymptomatic. There were no significant differences between groups considering LHR, gestational age, birth weight, severity of pre-surgery and post-surgery stabilization period. Significantly higher Apgar scores were in the group without recurrence. Among subjects with recurrent CDH majority had a left-sided defect, no hernia sac, no liver herniation, diaphragm was primarily sutured, abdominal wall primarily closed. Even though none of those factors was significantly related with the recurrence. Recurrence in CDH remains a significant issue for long-term surgical morbidity, especially more apparent in the first year of life. As long as the risk factors of re-herniation remains unclear, the most important seems to be routine follow-up protocol allowing for CDH recurrence detection.

NeoAPACHE II. Relationship Between Radiographic Pulmonary Area and Pulmonary Hypertension, Mortality, and Hernia Recurrence in Newborns With CDH

Congenital diaphragmatic hernia is a rare disease with high mortality and morbidity due to pulmonary hypoplasia and pulmonary hypertension. The aim of the study is to investigate the relationship between radiographic lung area and systolic pulmonary artery pressure (sPAP) on the first day of life, mortality, and hernia recurrence during the first year of life in infants with a congenital diaphragmatic hernia (CDH). A retrospective data collection was performed on 77 CDH newborns. Echocardiographic sPAP value, deaths, and recurrence cases were recorded. Lung area was calculated by tracing the lung's perimeter, excluding mediastinal structures, and herniated organs, on the preoperative chest X-ray performed within 24 h after birth. Logistic and linear regression analyses were performed. Deceased infants showed lower areas and higher sPAP values. One square centimeter of rising in the total, ipsilateral, and contralateral area was associated with a 22, 43, and 24% reduction in mortality risk. sPAP values showed a decreasing trend after birth, with a maximum of 1.84 mmHg reduction per unitary increment in the ipsilateral area at birth. Recurrence patients showed lower areas, with recurrence risk decreasing by 14 and 29% per unit increment of the total and ipsilateral area. In CDH patients, low lung area at birth reflects impaired lung development and defect size, being associated with increased sPAP values, mortality, and recurrence risk. Clinical Trial Registration: The manuscript is an exploratory secondary analysis of the trial registered at ClinicalTrials.gov with identifier NCT04396028.

Porcine dermal patches as a risk factor for recurrence after congenital diaphragmatic hernia repair

PURPOSE

Recurrence of congenital diaphragmatic hernia (CDH) is a treatment-related morbidity which can be preventable. There is no consensus about the ideal material for diaphragmatic substitution. The aim of our study is to identify if the use of porcine dermis patches increases the risk of CDH recurrence.

METHODS

Retrospective review of medical records of CDH patients treated between 2013 and 2017 in our center was carried out. Demographic, clinical and surgical variables were collected. Regression analysis was performed to identify which factors increase the risk of recurrence.

RESULTS

50 patients entered the study. 94% of the patients had a left CDH, mean observed/expected lung-to-head ratio was 46%. 17 patients underwent a primary closure, the rest a patch closure: 25 Gore-Tex^® and 8 porcine dermis patches were used. Seven patients presented recurrence (14%). Median follow-up time was 3.5 years (1.2-6.2). Univariate analysis revealed that the use of a porcine dermis patch (75%) increased the risk of recurrence compared with Gore-Tex^® patch (4%) and primary closure (0%) p < 0.001 (HR 58.7; IC 95%: 6.9-501.2; p < 0.001).

CONCLUSION

The main risk factor for CDH recurrence is the use of a porcine dermis patch. We do not recommend the use of these patches for CDH repair.

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

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

Short bowel syndrome as an unusual complication of strangulated congenital diaphragmatic hernia: Case report

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Congenital diaphragmatic hernia is a rare cause of neonatal bowel obstruction.

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Congenital diaphragmatic hernia is associated with many long-term complications involving multiple systems.

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Only few cases in the literature has reported a strangulated congenital diaphragmatic hernia and even a fewer ones required bowel resection.

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Short bowel syndrome is an unlikely outcome of strangulated congenital diaphragmatic hernia, requiring feeding by total parenteral nutrition.

Introduction

Strangulation is a rare complication of congenital diaphragmatic hernia (CDH). There are few cases in the literature describing strangulated CDH. However, none of them was a recurrence of a previously repaired defect nor resulted in short bowel syndrome.

Presentation of case

We report an unusual case of newborn presenting with CDH that was repaired shortly after birth but developed recurrence with strangulation few months after, requiring a massive resection, resulting in short bowel syndrome (SBS). It was managed via total parenteral nutrition feeding for three months until the patient was able to tolerate orally.

Discussion

There were one familiar case in the reported literature by Woolley of an infant developing bowel infraction as a result of CDH where he later developed short bowel syndrome.

Conclusion

Short bowel syndrome is an unlikely outcome of strangulated CDH. Early repair of the defect should be promoted to avoid the devastating consequences of an CDH similar to the ones encountered in our case. High index of suspicion should be kept during the follow-up of patients with CDH post repair to detect early signs of recurrences.

When primary repair is not enough: a comparison of synthetic patch and muscle flap closure in congenital diaphragmatic hernia?

PURPOSE

Primary closure is often inadequate for large congenital diaphragmatic hernia (CDH) and necessitates repair by prosthetic patch or autologous muscle flap. Our aim was to evaluate outcomes of open patch versus flap repair, specifically diaphragmatic reherniation.

METHODS

A retrospective review (IRB #2017-6361) was performed on all CDH patients repaired from 2005 to 2016 at a single academic children's hospital. Patients were excluded from final analysis if they had primary or minimally invasive repair, expired, or were lost to follow-up.

RESULTS

Of 171 patients, 151 (88.3%) survived to discharge, 9 expired after discharge and 11 were lost to follow up, leaving 131 (86.8%) long-term survivors. Median follow-up was 5 years. Open repair was performed in 119 (90.8%) of which 28 (23.5%) underwent primary repair, 34 (28.6%) patch repair, and 57 (47.9%) flap repair. Overall, 6/119 (5%) patients reherniated, 1/28 (3.6%) in the primary group, 3/34 (8.8%) in the patch group, and 2/57 (3.5%) in the flap group. Comparing prosthetic patch to muscle flap repair, there was no significant difference in the number of patients who recurred nor time to reherniation (3 vs. 2, p = 0.295; 5.5 ± 0.00 months vs. 53.75 ± 71.06 months, p = 0.288). One patient in the patch group recurred twice.

CONCLUSIONS

Both muscle flap and patch repair of large CDH are feasible and durable with a relatively low risk of recurrence.

Functionalization of PTFE Materials Using a Combination of Polydopamine and Platelet-Rich Fibrin

BACKGROUND

The diaphragm, which forms a physical barrier between the thoracic and the abdominal cavities, is also the major part of the respiratory system. Congenital diaphragmatic hernia (CDH) is a malformation of that partition muscle. Expanded polytetrafluoroethylene (e-PTFE), a synthetic nondegradable biomaterial, is currently used for the repair of diaphragm defects. Indeed, this hydrophobic biomaterial does not promote rapid and dense cell colonization. Surface modifications are needed to favor or even guide cellular responses.

MATERIALS AND METHODS

In this context, we present here a practical and effective way of functionalization of the e-PTFE material. We investigated, by using electron microscopy, the coating with PRF (Platelet-Rich Fibrin) of PDA (Polydopamine) treated e-PTFE implant material.

RESULTS

We demonstrate that this straightforward chemical functionalization with PDA increases the hydrophilicity of e-PTFE and thus improves tissue integration. Then, we demonstrated that whatever the contact time between PRF and e-PTFE and the centrifugation speed, the PDA coating on the e-PTFE biomaterial promotes further biological events like cell adhesion and spreading.

CONCLUSIONS

Our findings clearly show that this composite coating (chemically by using PDA + biologically by using PRF) method of e-PTFE is a simple, interesting and promising way to favor tissular integration of such biomaterials.

Outcomes for thoracoscopic versus open repair of small to moderate congenital diaphragmatic hernias

INTRODUCTION

Indications for thoracoscopic versus open approaches to repair congenital diaphragmatic hernia (CDH) are unclear as the variability in defect size, disease severity and patient characteristics pose a challenge. Few studies use a patient and disease-matched comparison of techniques. We aimed to compare the clinical outcomes of open versus thoracoscopic repairs of small to moderate sized hernia defects in a low risk population.

METHODS

All neonates receiving CDH repair of small (type A) and moderate (type B) size defects at an academic children's hospital between 2006 and 2016 were retrospectively reviewed and analyzed. Patients <36weeks gestation, birth weight <1500g, or requiring extracorporeal life support were excluded. Demographics, including CDH severity index, and hernia characteristics were recorded. The primary outcome parameter was recurrence. Secondary outcomes included length of hospital stay, length of mechanical ventilation, time to goal feeds, and mortality.

RESULTS

The 51 patients receiving thoracoscopic (35) and open (16) repairs were similar in patient and hernia characteristics, with median 2-year follow-up for both groups. Patients with thoracoscopic repair had shorter hospital stay (16 vs. 23days, p=0.03), days on ventilator (5 vs. 12, p=0.02), days to start of enteral feeds (5 vs. 10, p<0.001), and days to goal feeds (11 vs. 20, p=0.006). Higher recurrence rates in the thoracoscopic groups (17.1% vs. 6.3%) were not statistically significant (p=0.28). Median time to recurrence was 88days for the open repair and 183days (IQR 165-218) for the thoracoscopic group. There were no mortalities in either group.

CONCLUSIONS

In low risk patients born with small to moderate size defects, a thoracoscopic approach was associated with decreased hospital length of stay, mechanical ventilation days, and time to feeding; however, there was a trend towards higher recurrence rates.

LEVEL OF EVIDENCE

Level III.

Factors associated with early recurrence after congenital diaphragmatic hernia repair

BACKGROUND

The purpose of this study was to identify patient and treatment characteristics associated with early (in hospital) hernia recurrence after congenital diaphragmatic hernia (CDH) repair.

METHODS

Data from the Congenital Diaphragmatic Hernia Study Group registry were queried from 2007 to 2015. Recurrence of the diaphragmatic hernia after initial repair and prior to death or discharge was determined at the time of reoperation. Minimally invasive surgery (MIS) approaches included laparoscopy or thoracoscopy, and open approaches consisted of laparotomy or thoracotomy. Multivariate regression analysis was performed.

RESULTS

Of 3984 patients, 3332 (84%) underwent CDH repair. 76 (2.3%) patients had an early recurrence. The rate of recurrence was less variable over time for patients undergoing laparotomy vs thoracoscopy (range: 1.1-3.7% vs 1.7-8.9% annually). Timing of repair, whether performed after, during, or before ECMO did not significantly alter recurrence rates (0% vs 4.2% vs 3.0%, p=0.116). Larger defect size (C: OR 4.3, 95% CI 1.2-15.4; D: OR 7.1, 95% CI 1.7-29.1) and an MIS approach (OR 3.2, 95% CI 1.7-6.0) were the only independent predictors of recurrence.

CONCLUSION

Larger defect size and an MIS approach were associated with higher rates of early recurrence, while ECMO use and timing of repair with ECMO were not.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

II.

Recurrent diaphragmatic hernia: Modifiable and non-modifiable risk factors

RATIONALE

The risk of recurrence of Congenital Diaphragmatic Hernia (CDH) in an era of thoracoscopic surgery is unclear.

OBJECTIVES

(1) estimate the incidence and (2) evaluate the perioperative factors associated with the symptomatic recurrence of CDH.

METHODS

Medical records of CDH infants operated on in the neonatal period at a single-tertiary hospital between January 2000 and January 2013 were retrospectively reviewed.

RESULTS

Of 119 infants with CDH, 34 (28.6%) were excluded: 17 (14.3%) died without recurrence and 17 (14.3%) presented beyond neonatal period or were followed elsewhere. Of 85 survivors, 71 infants had an open repair and 14 had a thoracoscopic repair. Eleven of 85 survivors (13%) developed a recurrence on average 19.8 weeks (range 15-34) after the initial repair. Of 11 recurrences, 6 had an initial thoracoscopic repair and 5 had an open repair (6/14 [43%] vs. 5/71 [7%]; P = 0.002). Two children had multiple recurrences. Statistically significant associations were found between recurrence and the presence of persistent pulmonary hypertension (PPHTN) (P = 0.006), severe PPHTN (P = 0.002), inhaled nitric oxide, or sildenafil use for treatment of PPHTN (P = 0.002), need for perioperative high frequency oscillatory ventilation (HFOV) (P = 0.0006), length of hospital stay (LOS) (P = 0.02), duration of ventilation (P = 0.016), and need for home oxygen (P = 0.003). In multivariate regression analysis both the closure type and home oxygen requirement were statistically significant, independent factors predicting a recurrence (P = 0.04 and 0.02, respectively) but the type of surgery (thoracoscopic vs. open) only approached significance (P = 0.052). The recurrence rate for the seven surgeons who performed at least 5 repairs ranged from 7% to 40%.

CONCLUSIONS

A high survival rate of 85% with a 13% incidence of symptomatic CDH recurrence was demonstrated. Potentially, improved selection of cases for thoracoscopic repair and concentrating the thoracoscopic technique amongst a dedicated team of experienced thoracoscopic surgeons may reduce the rate of recurrence of CDH.

Multidisciplinary long-term follow-up of congenital diaphragmatic hernia: a growing trend

This literature review discusses the growing trend toward multidisciplinary long term follow-up for congenital diaphragmatic hernia.

Outcomes following prosthetic patch repair in newborns with congenital diaphragmatic hernia

Background

The anatomical defect in congenital diaphragmatic hernia (CDH) can usually be closed primarily but prosthetic patch repair may be required in newborns with a deficient diaphragm. High rates of patch failure and hernia recurrence (up to 50 per cent) have been reported. This study evaluated contemporary outcomes following patch repair of CDH at a UK paediatric surgical centre.

Methods

Medical records of newborns undergoing surgery for CDH between 1 February 1990 and 1 November 2010, and attending a multidisciplinary follow-up clinic, were examined. Operative details and patch utilization are reported.

Results

Of 118 newborns with CDH, 37 required a patch to the diaphragmatic defect. Gore-Tex® patches were used in 35 and biological Surgisis® patches in two. Eight babies additionally required an abdominal wall patch. Seven infants had an abdominal patch alone with primary diaphragm repair. A total of 102 infants (86·4 per cent) survived after surgery. Two early recurrences were both related to the use of biological patches, leading to revisional surgery with Gore-Tex® patch reconstruction. Diaphragmatic patch use was associated with a greater requirement for intensive cardiovascular and respiratory support, although there was no significant difference in mortality between patch versus primary diaphragm repair. The mortality rate was significantly higher among infants requiring abdominal wall patching (with or without a diaphragmatic patch): 40 per cent (6 of 15) versus 9·7 per cent (10 of 103) (P = 0·006). Postoperative survival rates for infants with a diaphragmatic patch alone, abdominal wall patch alone, and both abdominal and diaphragmatic patches were 86 per cent (25 of 29), 57 per cent (4 of 7) and 63 per cent (5 of 8) respectively.

Conclusion

Prosthetic diaphragmatic hernia repair at this centre has a good outcome and low rate of recurrence (5 per cent). The recognition of an inadequate abdominal domain prenatally may additionally prove to be a useful marker for predicting increased mortality in newborns with CDH.

Early recurrence of congenital diaphragmatic hernia is higher after thoracoscopic than open repair: a single institutional study

INTRODUCTION

Experience in thoracoscopic congenital diaphragmatic hernia (CDH) repair has expanded, yet efficacy equal to that of open repair has not been demonstrated. In spite of reports suggesting higher recurrent hernia rates after thoracoscopic repair, this approach has widely been adopted into practice. We report a large, single institutional experience with thoracoscopic CDH repair with special attention to recurrent hernia rates.

METHODS

We reviewed the records of neonates with unilateral CDH repaired between January 2006 and February 2010 at Morgan Stanley Children's Hospital. Completely thoracoscopic repairs were compared to open repairs of the same period. In addition, successful thoracoscopic repairs were compared with thoracoscopic repairs that developed recurrence. Data were analyzed by Mann-Whitney U and Fisher exact tests.

RESULTS

Thirty-five neonates underwent attempted thoracoscopic repair, with 26 completed. Concurrently, 19 initially open CDH repairs were performed. Preoperatively, patients in the open repair group required more ventilatory support than the thoracoscopic group. Recurrence was higher after thoracoscopic repair (23% vs 0%; P = .032). In comparing successful thoracoscopic repairs to those with recurrence, none of the factors analyzed were predictive of recurrence.

CONCLUSIONS

Early recurrence of hernia is higher in thoracoscopic CDH repairs than in open repairs. Technical factors and a steep learning curve for thoracoscopy may account for the higher recurrence rates, but not patient severity of illness. In an already-tenuous patient population, performing the repair thoracoscopically with a higher risk of recurrence may not be advantageous.

Preclinical regulatory validation of an engineered diaphragmatic tendon made with amniotic mesenchymal stem cells

PURPOSE

Under a Food and Drug Administration directive, we examined definite long-term safety and efficacy aspects of an engineered diaphragmatic tendon graft as a regulatory prerequisite for clinical trials.

METHODS

Newborn lambs (N = 27) underwent partial diaphragmatic replacement with a Teflon patch, a composite acellular bioprosthesis, or the same bioprosthesis seeded with autologous amniotic mesenchymal stem cells processed under Good Manufacturing Practice guidelines. Multiple safety and efficacy analyses were performed at different time points up to 14 months of age (ovine adulthood).

RESULTS

There was no mortality. None of the blood tests or full body autopsy specimens showed any abnormality. There was a significantly higher failure rate in animals that received an acellular bioprosthetic graft vs an engineered graft, with no significant differences between Teflon and acellular bioprosthetic implants. Tensile strength and total collagen levels were significantly higher in engineered grafts than in acellular bioprosthetic grafts. On histology, lysozyme and myeloperoxidase stainings were unremarkable in all grafts.

CONCLUSIONS

Diaphragmatic repair with a clinically viable autologous tendon engineered with amniotic mesenchymal stem cells leads to improved outcomes when compared with an equivalent acellular bioprosthesis, with no local or systemic adverse effects. Clinical trials of engineered diaphragmatic repair appear practicable within regulatory guidelines.