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Vaughn AE, Lyttle BD, Louiselle AE, Cooper E, Niemiec SM, Phillips R, Hilton SA, Kinsella JP, Gien J, Derderian SC, Liechty KW. Muscle Flap Technique Safe for On-ECMO Congenital Diaphragmatic Hernia Repair. J Pediatr Surg 2024; 59:962-968. [PMID: 38160185 DOI: 10.1016/j.jpedsurg.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/08/2023] [Accepted: 11/28/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Prosthetic patches (patch) and muscle flaps (flap) are techniques used for repair of congenital diaphragmatic hernia (CDH) with a large defect unamenable to primary closure. We hypothesized that the flap technique for CDH repair while on extra-corporeal membrane oxygenation (on-ECMO) would have decreased bleeding complications compared to patch due to the hemostatic advantage of native tissue. METHODS A single-center retrospective comparative study of patients who underwent on-ECMO CDH repair between 2008 and 2022 was performed. RESULTS Fifty-two patients met inclusion criteria: 18 patch (34.6%) and 34 flap (65.4%). There was no difference in CDH severity between groups. On univariate analysis, reoperation for surgical bleeding was lower following flap repair compared to patch (23.5% vs 55.6%, respectively; p = 0.045), 48-h postoperative blood product transfusion was lower after flap repair (132 mL/kg vs 273.5 mL/kg patch; p = 0.006), and two-year survival was increased in the flap repair group compared to patch (53.1% vs 17.7%, respectively; p = 0.036). On multivariate analysis adjusting for CDH side, day on ECMO repaired, and day of life CDH repaired, flap repair was significantly associated with lower five-day postoperative packed red blood cell transfusion amount, improved survival to hospital discharge, and improved two-year survival. CONCLUSIONS Our experience suggests that the muscle flap technique for on-ECMO CDH repair is associated with reduced bleeding complications compared to prosthetic patch repair, which may in part be responsible for the improved survival seen in the flap repair group. These results support the flap repair technique as a favored method for on-ECMO CDH repair. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Alyssa E Vaughn
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States.
| | - Bailey D Lyttle
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Amanda E Louiselle
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Emily Cooper
- Research Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, United States
| | - Stephen M Niemiec
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Ryan Phillips
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Sarah A Hilton
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - John P Kinsella
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - Jason Gien
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - S Christopher Derderian
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Kenneth W Liechty
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Division of Pediatric Surgery, Department of Surgery, University of Arizona Tucson College of Medicine and Banner Children's Hospital at Diamond Children's Medical Center, Tucson, AZ, United States; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
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Puligandla P, Skarsgard E, Baird R, Guadagno E, Dimmer A, Ganescu O, Abbasi N, Altit G, Brindle M, Fernandes S, Dakshinamurti S, Flageole H, Hebert A, Keijzer R, Offringa M, Patel D, Ryan G, Traynor M, Zani A, Chiu P. Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative. Arch Dis Child Fetal Neonatal Ed 2024; 109:239-252. [PMID: 37879884 DOI: 10.1136/archdischild-2023-325865] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/02/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE The Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative sought to make its existing clinical practice guideline, published in 2018, into a 'living document'. DESIGN AND MAIN OUTCOME MEASURES Critical appraisal of CDH literature adhering to Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence accumulated between 1 January 2017 and 30 August 2022 was analysed to inform changes to existing or the development of new CDH care recommendations. Strength of consensus was also determined using a modified Delphi process among national experts in the field. RESULTS Of the 3868 articles retrieved in our search that covered the 15 areas of CDH care, 459 underwent full-text review. Ultimately, 103 articles were used to inform 20 changes to existing recommendations, which included aspects related to prenatal diagnosis, echocardiographic evaluation, pulmonary hypertension management, surgical readiness criteria, the type of surgical repair and long-term health surveillance. Fifteen new CDH care recommendations were also created using this evidence, with most related to the management of pain and the provision of analgesia and neuromuscular blockade for patients with CDH. CONCLUSIONS The 2023 Canadian CDH Collaborative's clinical practice guideline update provides a management framework for infants and children with CDH based on the best available evidence and expert consensus.
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Affiliation(s)
- Pramod Puligandla
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Erik Skarsgard
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Baird
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elena Guadagno
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexandra Dimmer
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Olivia Ganescu
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Nimrah Abbasi
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gabriel Altit
- Neonatology, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mary Brindle
- Department of Surgery, Section of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Sairvan Fernandes
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shyamala Dakshinamurti
- Department of Pediatrics and Child Health, Section of Neonatology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Helene Flageole
- Department of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Audrey Hebert
- Department of Pediatrics, Division of Neonatology, Laval University, Quebec City, Quebec, Canada
| | - Richard Keijzer
- Department of Pediatric Surgery and Manitoba Institute of Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Dylan Patel
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Greg Ryan
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Michael Traynor
- Department of Anesthesia, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Augusto Zani
- Department of Surgery, Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Priscilla Chiu
- Department of Surgery, Division of Pediatric General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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3
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Cimbak N, Buchmiller TL. Long-term follow-up of patients with congenital diaphragmatic hernia. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000758. [PMID: 38618013 PMCID: PMC11015326 DOI: 10.1136/wjps-2023-000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/28/2024] [Indexed: 04/16/2024] Open
Abstract
Neonates with congenital diaphragmatic hernia encounter a number of surgical and medical morbidities that persist into adulthood. As mortality improves for this population, these survivors warrant specialized follow-up for their unique disease-specific morbidities. Multidisciplinary congenital diaphragmatic hernia clinics are best positioned to address these complex long-term morbidities, provide long-term research outcomes, and help inform standardization of best practices in this cohort of patients. This review outlines long-term morbidities experienced by congenital diaphragmatic hernia survivors that can be addressed in a comprehensive follow-up clinic.
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Affiliation(s)
- Nicole Cimbak
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Terry L Buchmiller
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA, USA
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Management of the CDH patient on ECLS. Semin Fetal Neonatal Med 2022; 27:101407. [PMID: 36411199 DOI: 10.1016/j.siny.2022.101407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is the most common indication for respiratory extracorporeal life support (ECLS) in neonates. The survival rate of CDH neonates treated with ECLS is 50%, and this figure has remained relatively stable over the last few decades. This is likely because the current population of CDH neonates who require ECLS have a higher risk profile [1]. The management of neonates with CDH has evolved over time to emphasize postnatal stabilization, gentle ventilation, and multi-modal treatment of pulmonary hypertension. In order to minimize practice variation, many centers have adopted CDH-specific clinical practice guidelines, however care is not standardized between different centers and outcomes vary [3]. The purpose of this review is to summarize our current understanding of issues central to the care of neonates with CDH treated with ECLS and specifically highlight how the use of the Extracorporeal Life Support Organization (ELSO) data have added to our understanding of CDH.
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Study and development of electrospun (TPU, PA-6) / silicone bilayer membranes for congenital diaphragmatic hernia repair. Polym Bull (Berl) 2022. [DOI: 10.1007/s00289-022-04566-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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6
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Han XY, Selesner LT, Butler MW. Congenital Diaphragmatic Hernia. Surg Clin North Am 2022; 102:739-757. [DOI: 10.1016/j.suc.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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7
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Kamal TR, Tyraskis A, Ghattaura H, Fitchie A, Lakhoo K. Synthetic versus Biological Patches for CDH: A Comparison of Recurrence Rates and Adverse Events, Systematic Review, and Meta-Analysis. Eur J Pediatr Surg 2022; 33:198-209. [PMID: 36027899 DOI: 10.1055/s-0042-1748530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Our systematic review aims to compare recurrence rates and complications of biological versus synthetic patches for the repair of congenital diaphragmatic herniae. METHODS Studies from January 1, 1980 to April 25, 2020, with patients under the age of 16 years and with a minimum 6-month follow-up, were included from MEDLINE, Embase, and Cochrane databases. Funnel plots for recurrence rates were constructed for biological and synthetic patches. Subgroup analysis was performed for recurrence rate at the 1-year time-point and data were gathered on individual adverse events from relevant studies. RESULTS A total of 47 studies with 986 patients (226 biological, 760 synthetic) were included. Funnel plot analysis determined overall recurrence rates of 16.7% for synthetic and 30.3% for biological patches. Subgroup analysis of 493 and 146 patients with synthetic and biological patches, respectively, showed recurrence rates of 9.9 and 26%, respectively.The most commonly used patch types-PTFE (polytetrafluoroethylene) and SIS (small intestinal submucosa)-had 11.5 and 33.3% recurrence, respectively. Adhesive bowel obstruction rates ranged from 4 to 29% in studies that systematically reported it for synthetic, and 7 to 35% for biological patches. Gastroesophageal reflux rates ranged from 25 to 48% in studies that systematically reported it for synthetic, and 21 to 42% for biological patches. Pectus deformity rates were reported as high as 80% for synthetic patches. CONCLUSION Biological patches appear to have higher recurrence rates than synthetic patches, while skeletal deformities are associated more commonly with synthetic patches. Results of biological patches are mainly using SIS and this may overestimate complications of current superior biological patches.
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Affiliation(s)
- Tasnim Rowshan Kamal
- Medical Science Division, Green Templeton College, University of Oxford, Oxford, Oxfordshire, United Kingdom of Great Britain and Northern Ireland
| | - Athanasios Tyraskis
- Department of Paediatric Surgery, John Radcliffe Hospital, Oxford, Oxfordshire, United Kingdom of Great Britain and Northern Ireland
| | - Harmit Ghattaura
- Department of Paediatric Surgery, John Radcliffe Hospital, Oxford, Oxfordshire, United Kingdom of Great Britain and Northern Ireland
| | - Angus Fitchie
- Department of Paediatric Surgery, John Radcliffe Hospital, Oxford, Oxfordshire, United Kingdom of Great Britain and Northern Ireland
| | - Kokila Lakhoo
- Department of Paediatric Surgery, John Radcliffe Hospital, Oxford, Oxfordshire, United Kingdom of Great Britain and Northern Ireland
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Verla MA, Style CC, Lee TC, Menchaca AD, Lau PE, Mehollin-Ray AR, Fernandes CJ, Keswani SG, Olutoye OO. Does creating a dome reduce recurrence in congenital diaphragmatic hernia following patch repair? J Pediatr Surg 2022; 57:637-642. [PMID: 34836640 DOI: 10.1016/j.jpedsurg.2021.10.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 09/23/2021] [Accepted: 10/13/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To develop a quantifiable approach to identify a dome shape of the repaired diaphragm using post-operative chest radiograph and to determine if a dome-shaped prosthetic patch repair is associated with a decreased rate of CDH recurrence. METHODS We conducted a retrospective review of all neonates evaluated at our institution from January 2004 to August 2017 with left- and right-sided CDH with at least 6 months of follow-up after CDH repair. Patch use, post-operative imaging and postnatal outcomes were analyzed. Neonates with patch repair were divided into two groups based on the presence of a dome. Using postoperative chest radiographs, the presence of a dome was classified as having a vertical-horizontal diaphragm ratio (VHDR) greater than 20%. Primary outcome was CDH recurrence after repair. RESULTS We identified 192 neonates who met our inclusion criteria. Cohort survival was 96%, recurrence rate was 15%, 78% had a left-sided CDH; 54% received a patch repair, of which 58% had a type C defect. Of the 104 infants with patch repairs, the CDH recurrence rate was 22% (n = 23) at a median age of 8.5 months (3.8, 20.1). Although neonates with a dome repair had more ECMO use and longer hospital stay, their recurrence rate was about half of those with a non-dome repair (14% vs 28%, p = 0.07). CONCLUSIONS A dome-shaped repair may reduce recurrence following prosthetic patch repair of congenital diaphragmatic hernia. A larger, multi-institutional study is needed to statistically validate this clinically significant observation. TYPE OF STUDY Retrospective review. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Mariatu A Verla
- Texas Children's Fetal Center, Houston, TX, USA; Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Candace C Style
- Center for Regenerative Medicine, Nationwide Children's Hospital, 575 Children's Drive, Columbus, OH 43205, USA.
| | - Timothy C Lee
- Texas Children's Fetal Center, Houston, TX, USA; Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Alicia D Menchaca
- Center for Regenerative Medicine, Nationwide Children's Hospital, 575 Children's Drive, Columbus, OH 43205, USA
| | - Patricio E Lau
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Amy R Mehollin-Ray
- Texas Children's Fetal Center, Houston, TX, USA; Texas Children's Hospital, Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Caraciolo J Fernandes
- Texas Children's Fetal Center, Houston, TX, USA; Texas Children's Hospital, Department of Pediatrics - Newbowrn Section, Baylor College of Medicine, Houston, TX, USA
| | - Sundeep G Keswani
- Texas Children's Fetal Center, Houston, TX, USA; Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Oluyinka O Olutoye
- Center for Regenerative Medicine, Nationwide Children's Hospital, 575 Children's Drive, Columbus, OH 43205, USA
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Horiguchi K, Lee SW, Shimizu T, Arima J, Taniguchi K, Hagihara S, Komeda K, Uchiyama K. Recurrence of a congenital diaphragmatic hernia 57 years postoperatively: A case report and review of the literature. Medicine (Baltimore) 2022; 101:e28650. [PMID: 35060556 PMCID: PMC8772697 DOI: 10.1097/md.0000000000028650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/04/2022] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Postoperative recurrence of congenital diaphragmatic hernia (CDH) in adults is very rare. There is currently no precedent and no established treatment. We encountered a case of CDH which recurred 57 years, postoperatively. PATIENT CONCERNS A 57-year-old man with dyspnea on exertion was referred to our hospital. He had undergone surgery at the same hospital for CDH when he was 46 days old. DIAGNOSIS AND INTERVENTIONS Laboratory studies, except diagnostic imaging and spirometry, were otherwise within normal limits. He was diagnosed with recurrent CDH based on computed tomography and underwent laparoscopic surgery. OUTCOMES His postoperative course was uneventful, and there was no recurrence on follow-up. LESSONS We reported our encounter with a case of recurrent CDH, more than 50 years after the initial surgery. When managing diaphragmatic hernias, prompt surgical treatment, with consideration to prior surgical history for CDH, leads to satisfactory results.
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Affiliation(s)
- Kohei Horiguchi
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, Japan
| | - Sang-Woong Lee
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, Japan
| | - Tetsunosuke Shimizu
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, Japan
| | - Jun Arima
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, Japan
| | - Kohei Taniguchi
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, Japan
- Translational Research Program, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, Japan
| | - Seita Hagihara
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, Japan
| | - Koji Komeda
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, Japan
| | - Kazuhisa Uchiyama
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, Japan
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Macchini F, Raffaeli G, Amodeo I, Ichino M, Encinas JL, Martinez L, Wessel L, Cavallaro G. Recurrence of Congenital Diaphragmatic Hernia: Risk Factors, Management, and Future Perspectives. Front Pediatr 2022; 10:823180. [PMID: 35223699 PMCID: PMC8864119 DOI: 10.3389/fped.2022.823180] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/17/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Genny Raffaeli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Ilaria Amodeo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Martina Ichino
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - José Luis Encinas
- Department of Pediatric Surgery, La Paz Children's Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Leopoldo Martinez
- Department of Pediatric Surgery, La Paz Children's Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Lucas Wessel
- Department of Pediatric Surgery, Faculty of Medicine Mannheim at Heidelberg University, Mannheim University Medical Center, Mannheim, Germany
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Tamura R, O'Connor E, Jaffray B. Surgeon level variation in outcome of repair of congenital diaphragmatic hernia with particular reference to the management of recurrence. J Pediatr Surg 2021; 56:2207-2214. [PMID: 33775404 DOI: 10.1016/j.jpedsurg.2021.02.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/10/2021] [Accepted: 02/24/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Ryo Tamura
- Department of Paediatric Surgery, The Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Elizabeth O'Connor
- Department of Paediatric Surgery, The Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Bruce Jaffray
- Department of Paediatric Surgery, The Great North Children's Hospital, Newcastle upon Tyne, UK.
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12
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Biological versus synthetic patch for the repair of congenital diaphragmatic hernia: 8-year experience at a tertiary center. J Pediatr Surg 2021; 56:1957-1961. [PMID: 33745743 DOI: 10.1016/j.jpedsurg.2021.02.052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/05/2021] [Accepted: 02/19/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE The aim of this study is to compare outcome between small intestinal submucosal (SIS) and polytetrafluoroethylene (PTFE) patches in patients with congenital diaphragmatic hernia (CDH) with large muscular defects. MATERIAL AND METHODS We performed a retrospective review of prospectively collected data of patients who underwent CDH repair from January 2011 to June 2019, with a minimum follow-up of 1 year. Data were collected regarding length of stay (LOS), mortality and recurrence. Kaplan-Meier analyses was used. RESULTS In the study period, 195 patients with CDH were admitted, 176 underwent surgical repair and 19 died before surgery. Sixty-two (35%) required a patch. Over the last 5 years, our institution transitioned from the use of all SIS to all PTFE. SIS was used in 18 cases and PTFE in 25. Overall survival rate was 89% (174/195). There was no significant difference regarding LOS and mortality. Nine patients (50%) of SIS and 1 (4%) of PTFE repairs recurred (P < 0.01; log-rank test P < 0.01), with a time course of recurrence of 18 (SD = 13) and 8 months, respectively. Median follow-up was 60 months (SD: 23) for the SIS group and 26 (SD: 10) for the PTFE group. CONCLUSION A significant lower recurrence was found using PTFE patches instead of SIS for the repair of large CDH. LEVEL OF EVIDENCE Level 3. Retrospective comparative study.
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13
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Porcine bladder extracellular matrix as a tissue regenerative strategy in a neonate with omphalocele and diaphragmatic agenesis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2021.101993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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14
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Heiwegen K, de Blaauw I, Botden SMBI. A systematic review and meta-analysis of surgical morbidity of primary versus patch repaired congenital diaphragmatic hernia patients. Sci Rep 2021; 11:12661. [PMID: 34135386 PMCID: PMC8209041 DOI: 10.1038/s41598-021-91908-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 05/26/2021] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Kim Heiwegen
- Division of Pediatric Surgery, Department of Surgery, Radboudumc-Amalia Children's Hospital, route 618, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Ivo de Blaauw
- Division of Pediatric Surgery, Department of Surgery, Radboudumc-Amalia Children's Hospital, route 618, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Sanne M B I Botden
- Division of Pediatric Surgery, Department of Surgery, Radboudumc-Amalia Children's Hospital, route 618, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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15
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Zahn KB, Schaible T, Rafat N, Weis M, Weiss C, Wessel L. 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. Front Pediatr 2021; 9:796478. [PMID: 34976900 PMCID: PMC8719630 DOI: 10.3389/fped.2021.796478] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Katrin B Zahn
- Department of Pediatric Surgery, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany.,ERNICA-Center, Mannheim, Germany
| | - Thomas Schaible
- ERNICA-Center, Mannheim, Germany.,Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Neysan Rafat
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Meike Weis
- Department of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christel Weiss
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany.,ERNICA-Center, Mannheim, Germany
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16
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Nakamura H, Doi T, Puri P, Friedmacher F. Transgenic animal models of congenital diaphragmatic hernia: a comprehensive overview of candidate genes and signaling pathways. Pediatr Surg Int 2020; 36:991-997. [PMID: 32591848 PMCID: PMC7385019 DOI: 10.1007/s00383-020-04705-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 01/10/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a relatively common and life-threatening birth defect, characterized by incomplete formation of the diaphragm. Because CDH herniation occurs at the same time as preacinar airway branching, normal lung development becomes severely disrupted, resulting almost invariably in pulmonary hypoplasia. Despite various research efforts over the past decades, the pathogenesis of CDH and associated lung hypoplasia remains poorly understood. With the advent of molecular techniques, transgenic animal models of CDH have generated a large number of candidate genes, thus providing a novel basis for future research and treatment. This review article offers a comprehensive overview of genes and signaling pathways implicated in CDH etiology, whilst also discussing strengths and limitations of transgenic animal models in relation to the human condition.
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Affiliation(s)
- Hiroki Nakamura
- National Children’s Research Centre, Our Lady’s Children’s Hospital, Dublin, Ireland ,Department of Pediatric Surgery, Kansai Medical University, Osaka, Japan
| | - Takashi Doi
- National Children’s Research Centre, Our Lady’s Children’s Hospital, Dublin, Ireland ,Department of Pediatric Surgery, Kansai Medical University, Osaka, Japan
| | - Prem Puri
- National Children’s Research Centre, Our Lady’s Children’s Hospital, Dublin, Ireland ,Beacon Hospital, University College Dublin, Dublin, Ireland
| | - Florian Friedmacher
- National Children’s Research Centre, Our Lady’s Children’s Hospital, Dublin, Ireland ,Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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17
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Aydın E, Nolan H, Peiró JL, Burns P, Rymeski B, Lim FY. When primary repair is not enough: a comparison of synthetic patch and muscle flap closure in congenital diaphragmatic hernia? Pediatr Surg Int 2020; 36:485-491. [PMID: 32130491 DOI: 10.1007/s00383-020-04634-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2020] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Emrah Aydın
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA.
| | - Heather Nolan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Jose Luis Peiró
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Patricia Burns
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Beth Rymeski
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
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18
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Kirby E, Keijzer R. Congenital diaphragmatic hernia: current management strategies from antenatal diagnosis to long-term follow-up. Pediatr Surg Int 2020; 36:415-429. [PMID: 32072236 DOI: 10.1007/s00383-020-04625-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2020] [Indexed: 12/16/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a developmental birth defect consisting of a diaphragmatic defect and abnormal lung development. CDH complicates 2.3-2.8 per 10,000 live births. Despite efforts to standardize clinical practice, management of CDH remains challenging. Frequent re-evaluation of clinical practices in CDH reveals that management of CDH is evolving from one of postnatal stabilization to prenatal optimization. Translational research reveals promising avenues for in utero therapeutic intervention, including fetoscopic endoluminal tracheal occlusion. These remain highly experimental and demand improved antenatal diagnostics. Timely diagnosis of CDH and identification of severely affected fetuses allow time for delivery planning or in utero therapeutics. Optimal perinatal care and surgical treatment strategies are highly debated. Improved CDH mortality rates have placed increased emphasis on identifying and monitoring the long-term sequelae of disease throughout childhood and into adulthood. We review the current management strategies for CDH, highlighting where progress has been made, and where future developments have the potential to revolutionize care in this vulnerable patient population.
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Affiliation(s)
- Eimear Kirby
- Trinity College Dublin School of Medicine, Trinity Biomedical Sciences Institute, Dublin, Ireland
| | - Richard Keijzer
- Thorlakson Chair in Surgical Research, Division of Pediatric Surgery, Department of Surgery and Children's Hospital Research Institute of Manitoba, University of Manitoba, AE402-820 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada. .,Department of Pediatrics and Child Health and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada. .,Department of Physiology and Pathophysiology and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada.
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19
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Dewberry L, Hilton S, Gien J, Liechty KW, Marwan AI. Flap repair in congenital diaphragmatic hernia leads to lower rates of recurrence. J Pediatr Surg 2019; 54:2487-2491. [PMID: 31515112 DOI: 10.1016/j.jpedsurg.2019.08.042] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 08/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) repair is technically challenging with different approaches for repair. The aim of this study was to compare outcomes between patch and flap repair. METHODS CDH repairs performed at a quaternary care children's hospital between 2008 and 2018 were reviewed. Seventy CDH repairs were analyzed after primary repairs were excluded (n = 52). Analysis included proportions or median with interquartile range and chi-square or Wilcoxon rank-sum test. RESULTS Comparing patch and flap repairs, demographic characteristics and hernia parameters were similar. Examining outcomes, length of stay, 30-day mortality, and 1-year mortality were all similar between groups, but total/symptomatic recurrence was higher in the patch group (10%/7% vs. 3%/0%), and the median time to recurrence was 3 months. A sub-analysis comparing those who recurred to those who did not demonstrated no significant difference between the two groups. CONCLUSION Patients who undergo flap repair have a lower risk of recurrence compared to those who undergo patch repair, and this may be due to the ability of the flap to grow over time with the child. TYPE OF STUDY Treatment Study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Lindel Dewberry
- University of Colorado, Department of Surgery, Aurora, (CO,) USA.
| | - Sarah Hilton
- University of Colorado, Department of Surgery, Aurora, (CO,) USA
| | - Jason Gien
- University of Colorado, Department of Pediatrics, Division of Neonatology, Aurora, (CO,) USA; University of Colorado School of Medicine, Colorado Fetal Care Center, Aurora, (CO,) USA
| | - Kenneth W Liechty
- University of Colorado School of Medicine, Colorado Fetal Care Center, Aurora, (CO,) USA; University of Colorado, Department of Surgery, Division of Pediatric Surgery, Aurora, (CO,) USA
| | - Ahmed I Marwan
- University of Colorado School of Medicine, Colorado Fetal Care Center, Aurora, (CO,) USA; University of Colorado, Department of Surgery, Division of Pediatric Surgery, Aurora, (CO,) USA
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20
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Aydın E, Özler O, Burns P, Lim FY, Peiró JL. Left congenital diaphragmatic hernia-associated musculoskeletal deformities. Pediatr Surg Int 2019; 35:1265-1270. [PMID: 31482324 DOI: 10.1007/s00383-019-04548-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2019] [Indexed: 11/30/2022]
Abstract
AIM With the advancement in the treatment strategies of congenital diaphragmatic hernia (CDH), there is an increase in the survival rates. This fact leads to an increase in the morbidity and extrapulmonary complications in the long term such as failure to thrive, hernia recurrence, neurodevelopmental delay, gastrointestinal problems, and musculoskeletal anomalies. Herein, we aim to investigate the association between the long-term musculoskeletal complications in CDH patients regarding the defect size, repair type, and perinatal parameters. METHODS After Institutional Review Board approval was obtained (2017-6361), a retrospective chart review was performed on CDH patients from 2003 to 2016. Patients who were operated due to left-sided isolated congenital diaphragmatic hernia and survived to date were included in the study. Data were collected on demographics, preoperative characteristics, operative interventions, and postoperative outcomes. Statistical analysis was performed with IBM SPSS Statistics 20.0.0 (Chicago, IL). RESULTS There were 98 patients with left CDH of whom 33 (33.7%) had primary repair, 25 (25.5%) had patch repair, and 40 (40.8%) had muscle flap repair. The median age of the patients was 6.00 ± 3.83 years. 45 patients (45.9%) had large diaphragmatic defects, 28 patients (28.6%) had at least one type of musculoskeletal deformities, 2 of which were pectus carinatum, 16 were pectus excavatum, and 18 were scoliosis. CDH patients who had small diaphragmatic defects and repaired with a patch were less likely develop musculoskeletal deformities while who had primary abdominal closure after ventral hernia significantly have more pectus excavatum. CONCLUSION Although there was a trend towards an increased risk of the pectus deformity and scoliosis in patients repaired with muscle flap, it did not reach statistical significance. There is a correlation between musculoskeletal deformities and the severity of the CDH.
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Affiliation(s)
- Emrah Aydın
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA. .,Department of Pediatric Surgery, Koç University School of Medicine, Istanbul, Turkey.
| | - Oğuz Özler
- Department of Pediatric Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Patricia Burns
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Jose Luis Peiró
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
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21
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Solé Cruz E, Rabattu PY, Todesco A, Bellier A, Chaffanjon PC, Faguet R, Piolat C, Robert Y. Study of abdominal wall muscle innervation applied to large-defect closure in congenital diaphragmatic hernia. Clin Anat 2019; 33:759-766. [PMID: 31625184 DOI: 10.1002/ca.23503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/23/2019] [Accepted: 10/12/2019] [Indexed: 11/07/2022]
Abstract
In large congenital diaphragmatic hernias (CDHs), direct suture of the diaphragm is impossible. Surgeons can use a triangular internal oblique muscle (IOM) plus transverse abdominis muscle (TAM) flap. Its caudal limit faces the medial extremity of the 11th rib. Clinical studies show that the flap is not hypotonic but that the procedure could expose patients already presenting a hypoplastic lung to external oblique muscle (EOM) hypotonia. The aims of this study were to study EOM innervation by the 10th intercostal nerve (ICN) and ICN innervation to the IOM and TAM. Forty cadaveric abdominal hemi-walls were dissected. The number of branches and the trajectory of each specimen's 10th ICN were studied medially to the medial extremity of the 11th rib (MEK11) using surgical goggles and a microscope (Carl Zeiss®). The 10th ICN was consistently found between the IOM and TAM. There was a median of nine branches from the 10th ICN to the EOM, 77% of them medial to the MEK11. Median values of nine and 12 branches for the IOM and TAM were found, 60% and 51%, respectively, medial to the MEK11. These results argue in favor of good innervation to the IOM plus TAM flap but also indicate postoperative abdominal weakness exposing patients to herniation risks, as more than 75% of the branches from the 10th ICN to the EOM were sectioned or pulled away during flap detachment. Clin. Anat., 33:759-766, 2020. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Eva Solé Cruz
- Univ. Grenoble Alpes, LADAF, Anatomical Laboratory, Grenoble University Hospital, Grenoble, France.,ID17 Biomedical Beamline, European Synchrotron Radiation Facility, Grenoble, France
| | - Pierre-Yves Rabattu
- Univ. Grenoble Alpes, LADAF, Anatomical Laboratory, Grenoble University Hospital, Grenoble, France.,Department of Pediatric Surgery, Children's Hospital, University Hospital of Grenoble, Grenoble, France
| | - Alban Todesco
- Department of Cardiothoracic and Vascular Surgery, AP-HM, Marseille, France
| | - Alexandre Bellier
- Univ. Grenoble Alpes, LADAF, Anatomical Laboratory, Grenoble University Hospital, Grenoble, France
| | - Philippe C Chaffanjon
- Univ. Grenoble Alpes, LADAF, Anatomical Laboratory, Grenoble University Hospital, Grenoble, France.,Univ. Grenoble Alpes, CNRS, Grenoble INP, GIPSA-lab, Grenoble, France
| | - Romain Faguet
- Department of Pediatric Surgery, Children's Hospital, University Hospital of Grenoble, Grenoble, France
| | - Christian Piolat
- Department of Pediatric Surgery, Children's Hospital, University Hospital of Grenoble, Grenoble, France
| | - Yohann Robert
- Univ. Grenoble Alpes, LADAF, Anatomical Laboratory, Grenoble University Hospital, Grenoble, France.,Department of Pediatric Surgery, Children's Hospital, University Hospital of Grenoble, Grenoble, France
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22
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Nolan H, Aydin E, Frischer JS, Peiro JL, Rymeski B, Lim FY. Hemorrhage after on-ECMO repair of CDH is equivalent for muscle flap and prosthetic patch. J Pediatr Surg 2019; 54:2044-2047. [PMID: 31103273 DOI: 10.1016/j.jpedsurg.2019.04.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 04/24/2019] [Accepted: 04/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND/PURPOSE Prosthetic patch (patch) and muscle flap (flap) techniques are utilized for severe congenital diaphragmatic hernia (CDH) repair; however, when performed on extracorporeal membrane oxygenation (ECMO), the risk of hemorrhage increases. We sought to compare bleeding complications between repair types. METHODS We retrospectively reviewed 2010-2016 on-ECMO CDH repairs. RESULTS Twenty-nine patients met criteria: 13 patch (44.8%) and 16 flap (55.2%). Eight patch (61.5%) and 13 flap (81.2%) patients had left-sided defects (p = 0.223). All defects were Type C or D (Type C: patch 53.8%, flap 56.2%, p = 0.596). There was no difference in gestational age at delivery (patch 37.5 ± 0.9 weeks, flap 37.2 ± 1.3 weeks, p = 0.390) or age at repair (patch 7.46 ± 6.6 days, flap 6.00 ± 4.3 days, p = 0.476). Seven patch (53.8%) and 9 flap (56.2%) patients survived to discharge (p = 0.596). Estimated intraoperative blood loss was equivalent (patch 35.3 ± 53.9 mL, flap 24.2 ± 18.4 mL, p = 0.443). One patch patient (7.6%) and two (12.5%) flap patients required reoperation in the first 48 h for bleeding (p = 0.580). 48-h postoperative transfusions were the same for those that required reoperation (patch 282.0 mL/kg, flap 208.5 ± 21.9 mL/kg, p = 0.054) and those that did not (patch 120.7 ± 111.7 mL/kg, flap 118.4 ± 89.9 mL/kg, p = 0.561). CONCLUSIONS On-ECMO bleeding complications are equivalent for both flap and patch CDH repair. LEVEL OF EVIDENCE Type III (retrospective comparative study).
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Affiliation(s)
- Heather Nolan
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Emrah Aydin
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Jason S Frischer
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Jose L Peiro
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Beth Rymeski
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Foong-Yen Lim
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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23
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Puligandla P, Skarsgard E, Offringa M, Adatia I, Baird R, Bailey M, Brindle M, Chiu P, Cogswell A, Dakshinamurti S, Flageole H, Keijzer R, McMillan D, Oluyomi-Obi T, Pennaforte T, Perreault T, Piedboeuf B, Riley SP, Ryan G, Synnes A, Traynor M. Diagnosis and management of congenital diaphragmatic hernia: a clinical practice guideline. CMAJ 2019; 190:E103-E112. [PMID: 29378870 DOI: 10.1503/cmaj.170206] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
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- Montreal Children’s Hospital, Montréal, Que
| | | | | | | | - Ian Adatia
- University of Alberta and Glenwood Radiology and Medical Centre, Edmonton, Alta
| | - Robert Baird
- British Columbia Children’s Hospital, Vancouver, BC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Anne Synnes
- British Columbia Women’s Hospital & Health Centre, Vancouver, BC
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24
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Defining outcomes following congenital diaphragmatic hernia using standardised clinical assessment and management plan (SCAMP) methodology within the CDH EURO consortium. Pediatr Res 2018; 84:181-189. [PMID: 29915407 DOI: 10.1038/s41390-018-0063-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/01/2018] [Accepted: 05/10/2018] [Indexed: 01/29/2023]
Abstract
Treatment modalities for neonates born with congenital diaphragmatic hernia (CDH) have greatly improved in recent times with a concomitant increase in survival. In 2008, CDH EURO consortium, a collaboration of a large volume of CDH centers in Western Europe, was established with a goal to standardize management and facilitate multicenter research. However, limited knowledge on long-term outcomes restricts the identification of optimal care pathways for CDH survivors in adolescence and adulthood. This review aimed to evaluate the current practice of long-term follow-up within the CDH EURO consortium centers, and to review the literature on long-term outcomes published from 2000 onward. Apart from having disease-specific morbidities, children with CDH are at risk for impaired neurodevelopmental problems and failure of educational attainments which may affect participation in society and the quality of life in later years. Thus, there is every reason to offer them long-term multidisciplinary follow-up programs. We discuss a proposed collaborative project using standardized clinical assessment and management plan (SCAMP) methodology to obtain uniform and standardized follow-up of CDH patients at an international level.
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25
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Regeneration of diaphragm with bio-3D cellular patch. Biomaterials 2018; 167:1-14. [DOI: 10.1016/j.biomaterials.2018.03.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 03/07/2018] [Accepted: 03/08/2018] [Indexed: 12/22/2022]
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26
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Janssen S, Heiwegen K, van Rooij IA, Scharbatke H, Roukema J, de Blaauw I, Botden SM. Factors related to long-term surgical morbidity in congenital diaphragmatic hernia survivors. J Pediatr Surg 2018; 53:508-512. [PMID: 28602525 DOI: 10.1016/j.jpedsurg.2017.05.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 05/24/2017] [Accepted: 05/24/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients born with a congenital diaphragmatic hernia (CDH) have a high mortality and morbidity. After discharge, complications and long-term morbidity are still encountered. This study describes the factors related to the surgical long-term outcomes in CDH survivors. METHODS A cohort of CDH patients born between 2000 and 2014, with a minimum of two years follow up, were included in this retrospective study. Demographics, CDH specific characteristics, treatment, and long-term surgical outcome were evaluated using multivariate logistic regression analyses. RESULTS 112 patients were included, with a mean follow up of 7.3 years (SD 3.8). The majority had primary repair, but 31% received patch repair. Recurrence was reported in 7% of all patients. However, recurrence risk increased for patients with extracorporeal membrane oxygenation (ECMO) treatment (ORadjusted: 6.3, 95% CI: 1.2-33.9). This risk was highest for patients needing both ECMO and patch repair (OR: 11.2, 95% CI: 2.3-54.1). Small bowel obstructions (SBO) were observed in 20% and was associated with patch repair (ORadjusted: 3.5, 95% CI: 1.2-10.0), but ECMO treatment seemed to reduce this risk (ORadjusted: 0.2, 95% CI: 0.0-1.0). Thoracic deformations (36%) was diagnosed most often after patch repair, especially when ECMO was needed (60%) as well. CONCLUSIONS This retrospective study shows that the incidence of surgical long-term morbidity of CDH is relatively high, with different factors accounting for this. Diaphragmatic hernia recurrence was strongest associated with ECMO treatment in combination with patch repair, while SBO's were associated with patch repair, with an unexpected protective effect of ECMO treatment. TYPE OF STUDY Retrospective comparative study - Level III evidence.
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Affiliation(s)
- Stan Janssen
- Department of Pediatrics, Jeroen Bosch Ziekenhuis's, Hertogenbosch, The Netherlands
| | - Kim Heiwegen
- Department of Surgery-Division of Pediatric Surgery, Radboudumc - Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Iris Alm van Rooij
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboudumc, Nijmegen, The Netherlands
| | - Horst Scharbatke
- Department of Surgery-Division of Pediatric Surgery, Radboudumc - Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Jolt Roukema
- Department of Pediatrics, Radboudumc-Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Ivo de Blaauw
- Department of Surgery-Division of Pediatric Surgery, Radboudumc - Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Sanne Mbi Botden
- Department of Surgery-Division of Pediatric Surgery, Radboudumc - Amalia Children's Hospital, Nijmegen, The Netherlands.
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Suzuki K, Komura M, Terawaki K, Kodaka T, Gohara T, Komura H, Nakayama Y. Engineering and repair of diaphragm using biosheet (a collagenous connective tissue membrane) in rabbits. J Pediatr Surg 2018; 53:330-334. [PMID: 29241962 DOI: 10.1016/j.jpedsurg.2017.11.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 11/08/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prosthetic patches can be used to repair large congenital diaphragmatic hernia defects but may be associated with infection, recurrence, and thoracic deformity. Biosheets (collagenous connective tissue membranes) have been used in regenerative medicine. We evaluated the efficacy of Biosheets in a rabbit model. METHODS Biosheets were prepared by embedding silicone plates in dorsal subcutaneous pouches of rabbits for 4weeks. In group 1 (n=11), Gore-Tex® sheets (1.8×1.8cm) were implanted into a diaphragmatic defect. In group 2 (n=11), Seamdura®, a bioabsorbable artificial dural substitute, was implanted in the same manner. In group 3 (n=14), biosheets were autologously transplanted into the diaphragmatic defects. All rabbits were euthanized 3months after transplantation to evaluate their graft status. RESULTS Herniation of liver was observed in 5 rabbits (45%) in group 1, 8 (73%) in group 2, and 3 (21%) in group 3. A significant difference was noted between groups 2 and 3 (P=0.017). Biosheets had equivalent burst strength and modulus of elasticity as native diaphragm. Muscular tissue regeneration in transplanted biosheets in group 3 was confirmed histologically. CONCLUSION Biosheets may be applied to diaphragmatic repair and replacement of diaphragmatic muscular tissue. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Keisuke Suzuki
- Department of Pediatric Surgery, Saitama Medical University, Saitama, Japan
| | - Makoto Komura
- Department of Pediatric Surgery, Saitama Medical University, Saitama, Japan.
| | - Kan Terawaki
- Department of Pediatric Surgery, Saitama Medical University, Saitama, Japan
| | - Tetsuro Kodaka
- Department of Pediatric Surgery, Saitama Medical University, Saitama, Japan
| | - Takumi Gohara
- Department of Pediatric Surgery, Saitama Medical University, Saitama, Japan
| | - Hiroko Komura
- Division of Tissue Engineering, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yasuhide Nakayama
- Division of Medical Engineering and Materials, National Cerebral and Cardiovascular Centre Research Institute, Osaka, Japan
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Kabagambe SK, Lankford L, Kumar P, Chen YJ, Herout KT, Lee CJ, Stark RA, Farmer DL, Wang A. Isolation of myogenic progenitor cell population from human placenta: A pilot study. J Pediatr Surg 2017; 52:2078-2082. [PMID: 28964407 DOI: 10.1016/j.jpedsurg.2017.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 08/28/2017] [Indexed: 01/07/2023]
Abstract
PURPOSE The purpose of this study was to demonstrate a method of isolating myogenic progenitor cells from human placenta chorionic villi and to confirm the myogenic characteristics of the isolated cells. METHODS Cells were isolated from chorionic villi of a second trimester male placenta via a combined enzymatic digestion and explant culture. A morphologically distinct subpopulation of elongated and multinucleated cells was identified. This subpopulation was manually passaged from the explant culture, expanded, and analyzed by fluorescence in situ hybridization (FISH) assay, immunocytochemistry, and flow cytometry. Myogenic characteristics including alignment and fusion were tested by growing these cells on aligned polylactic acid microfibrous scaffold in a fusion media composed of 2% horse serum in Dulbecco's modified Eagle medium/high glucose. RESULTS The expanded subpopulation was uniformly positive for integrin α-7. Presence of Y-chromosome by FISH analysis confirmed chorionic villus origin rather than maternal cell contamination. Isolated cells grew, aligned, and fused on the microfibrous scaffold, and they expressed myogenin, desmin, and MHC confirming their myogenic identity. CONCLUSION Myogenic progenitor cells can be isolated from human chorionic villi. This opens the possibility for translational and clinical applications using autologous myogenic cells for possible engraftment in treatment of chest and abdominal wall defects.
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Affiliation(s)
| | - Lee Lankford
- University of California, Davis Health, Sacramento, CA, USA
| | | | - Y Julia Chen
- University of California, Davis Health, Sacramento, CA, USA
| | - Kyle T Herout
- University of California, Davis Health, Sacramento, CA, USA
| | - Chelsey J Lee
- University of California, Davis Health, Sacramento, CA, USA
| | | | - Diana L Farmer
- University of California, Davis Health, Sacramento, CA, USA
| | - Aijun Wang
- University of California, Davis Health, Sacramento, CA, USA
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Morini F, Valfrè L, Bagolan P. Long-term morbidity of congenital diaphragmatic hernia: A plea for standardization. Semin Pediatr Surg 2017; 26:301-310. [PMID: 29110826 DOI: 10.1053/j.sempedsurg.2017.09.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Congenital diaphragmatic hernia (CDH) survivors present long-term morbidities in several systems, including the neurodevelopmental, gastrointestinal, pulmonary, and musculoskeletal ones, and CDH long-term sequelae are increasingly being recognized. Due to high co-morbidity, health related quality of life in a significant proportion of CDH patients might be compromised. As a consequence of consciousness on the long-term sequelae of CDH survivors, and their consequences for life, several follow-up programs were brought to life worldwide. In this review, we will summarize the long-term sequelae of CDH survivors, the impact of new treatments, and analyze the consistency of follow-up programs.
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Affiliation(s)
- Francesco Morini
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Laura Valfrè
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pietro Bagolan
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
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Rolli L, Leuzzi G, Girotti P, Duranti L, Pastorino U. Permeable Nonabsorbable Mesh for Total Diaphragmatic Replacement in Extended Pneumonectomy. Ann Thorac Surg 2017. [PMID: 28633250 DOI: 10.1016/j.athoracsur.2017.02.077] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
After complex thoracic exenterations, total diaphragmatic resection and reconstruction is challenging. We describe our novel technique for total diaphragmatic replacement with permeable nonabsorbable mesh after extended pneumonectomy.
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Affiliation(s)
- Luigi Rolli
- Thoracic Surgery Unit, IRCCS, Istituto Nazionale dei Tumori Foundation, Milan, Italy.
| | - Giovanni Leuzzi
- Thoracic Surgery Unit, IRCCS, Istituto Nazionale dei Tumori Foundation, Milan, Italy
| | - Paolo Girotti
- Thoracic Surgery Unit, IRCCS, Istituto Nazionale dei Tumori Foundation, Milan, Italy
| | - Leonardo Duranti
- Thoracic Surgery Unit, IRCCS, Istituto Nazionale dei Tumori Foundation, Milan, Italy
| | - Ugo Pastorino
- Thoracic Surgery Unit, IRCCS, Istituto Nazionale dei Tumori Foundation, Milan, Italy
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Abstract
Increased survival of patients with congenital diaphragmatic hernia has created a unique cohort of children, adolescent, and adult survivors with complex medical and surgical needs. Disease-specific morbidities offer the opportunity for multiple disciplines to unite together to provide long-term comprehensive follow-up, as well as an opportunity for research regarding late outcomes. These children can exhibit impaired pulmonary function, altered neurodevelopmental outcomes, nutritional insufficiency, musculoskeletal changes, and specialized surgical needs that benefit from regular monitoring and intervention, particularly in patients with increased disease severity. Below we aim to characterize the specific challenges that these survivors face as well as present an algorithm for a multidisciplinary long-term follow-up program.
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Affiliation(s)
- Laura E Hollinger
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, Texas 77030
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, Texas 77030
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, Texas 77030.
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Schlager A, Arps K, Siddharthan R, Clifton MS. Tube Thoracostomy at the Time of Congenital Diaphragmatic Hernia Repair: Reassessing the Risks and Benefits. J Laparoendosc Adv Surg Tech A 2017; 27:311-317. [DOI: 10.1089/lap.2016.0233] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Kelly Arps
- Emory University/Children's Healthcare of Atlanta, Department of Surgery, Atlanta, Georgia
| | - Ragavan Siddharthan
- Oregon Health and Science University, Department of Surgery, Portland, Oregon
| | - Matthew S. Clifton
- Emory University/Children's Healthcare of Atlanta, Department of Surgery, Atlanta, Georgia
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Huddleston CB, Greenspon J. Would you buy this car without a warranty? J Thorac Cardiovasc Surg 2016; 152:927-8. [PMID: 27325489 DOI: 10.1016/j.jtcvs.2016.05.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
Affiliation(s)
| | - Jose Greenspon
- Department of Surgery, Saint Louis University School of Medicine, St Louis, Mo
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Deeney S, Somme S. Prenatal consultation for foetal anomalies requiring surgery. Women Birth 2015; 29:e1-7. [PMID: 26321230 DOI: 10.1016/j.wombi.2015.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 08/07/2015] [Accepted: 08/09/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND During prenatal screening of pregnant women, foetal anomalies requiring surgery may be diagnosed. Healthcare providers should have a basic knowledge of these diseases, including their workup, comorbidities, prognosis, treatment options and any considerations that need to be made in planning for birth. AIM This article aims to provide this information by summarising the most recent literature for some of the most commonly diagnosed foetal anomalies requiring surgical correction. METHODS English language studies on prenatal diagnostic modalities, abdominal wall defects, congenital diaphragmatic hernias, surgical conditions leading to airway compromise, hydrops fetalis, intestinal obstruction and abdominal cysts were retrieved from the PubMed database. FINDINGS The most recent and relevant literature is summarised regarding the above listed paediatric conditions. The incidence and prevalence (when available), prognosis, workup, common comorbidities, foetal interventions and special birth considerations (when applicable), and postnatal surgical treatment options are reviewed. CONCLUSIONS Healthcare providers will occasionally encounter foetal anomalies which may require surgery while performing prenatal screening. They may need to provide early counselling to expectant parents to inform their expectations. When indicated, referrals should be made to a foetal care centre for prenatal consultation. For conditions which may cause danger or distress to the foetus in the immediate postnatal period, preparations should be made to ensure sufficient resources are available at the location of birth.
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Affiliation(s)
- Scott Deeney
- Department of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA.
| | - Stig Somme
- Department of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
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Zani A, Zani-Ruttenstock E, Pierro A. Advances in the surgical approach to congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2014; 19:364-9. [PMID: 25447986 DOI: 10.1016/j.siny.2014.09.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Congenital diaphragmatic hernia is a birth defect that affects about one in 2500 live births. Although the overall survival has improved over the last several decades thanks to advancements in postnatal resuscitation and intensive care treatment, morbidity and mortality remain high. The surgical management of these infants is far from being standardized, and many aspects are still disputed among experts. The timing of surgical repair remains controversial and the indications for the ideal time for surgery have not been validated. The main novelty in the surgical treatment is related to the use of minimally invasive techniques, although these have been associated with intraoperative blood gas disturbances and higher recurrence rates. Herein, we report and comment on the main controversies of postnatal CDH repair in this rapidly evolving field.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elke Zani-Ruttenstock
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Russell KW, Barnhart DC, Rollins MD, Hedlund G, Scaife ER. Musculoskeletal deformities following repair of large congenital diaphragmatic hernias. J Pediatr Surg 2014; 49:886-9. [PMID: 24888828 DOI: 10.1016/j.jpedsurg.2014.01.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 01/27/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE Large congenital diaphragmatic hernias (CDH) can be repaired with either a muscle flap or prosthetic patch. The purpose of this study was to assess the frequency and severity of scoliosis, chest wall, and abdominal wall deformities following these repairs. METHODS Neonates who underwent CDH repair (1989-2012) were retrospectively reviewed. We then validated our retrospective review by comparing results of a focused radiologic evaluation and clinical examination of patients with large defects seen in prospective follow-up clinic. Tests for association were made using Fisher's exact test. RESULTS 236 patients survived at least 1year. Of these patients, 30 had a muscle flap, and 13 had a patch repair. Retrospectively, we identified pectus in 9% of primary repairs, 47% of flap repairs, and 54% of patch repairs. We identified scoliosis in 7% of primary repairs, 13% of flap repairs, and 15% of patch repairs. Prospectively, 75% of flap patients and 67% of patch patients had pectus and 13% of flap patients and 33% of patch patients had scoliosis. There was no significant difference between flap and patch patients. CONCLUSIONS Scoliosis and pectus deformity were common in children with large CDH. The operative technique did not appear to affect the incidence of subsequent skeletal deformity.
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Affiliation(s)
- Katie W Russell
- University of Utah, Primary Children's Hospital, Division of Pediatric Surgery, Salt Lake City, UT, USA.
| | - Douglas C Barnhart
- University of Utah, Primary Children's Hospital, Division of Pediatric Surgery, Salt Lake City, UT, USA
| | - Michael D Rollins
- University of Utah, Primary Children's Hospital, Division of Pediatric Surgery, Salt Lake City, UT, USA
| | - Gary Hedlund
- University of Utah, Primary Children's Hospital, Division of Pediatric Surgery, Salt Lake City, UT, USA
| | - Eric R Scaife
- University of Utah, Primary Children's Hospital, Division of Pediatric Surgery, Salt Lake City, UT, USA
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Jawaid WB, Qasem E, Jones MO, Shaw NJ, Losty PD. Outcomes following prosthetic patch repair in newborns with congenital diaphragmatic hernia. Br J Surg 2013; 100:1833-7. [DOI: 10.1002/bjs.9306] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2013] [Indexed: 11/07/2022]
Abstract
Abstract
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.
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Affiliation(s)
- W B Jawaid
- Academic Paediatric Surgery Unit, Division of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - E Qasem
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - M O Jones
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
| | - N J Shaw
- Department of Respiratory Medicine, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
- Liverpool Women's Hospital, Liverpool, UK
| | - P D Losty
- Academic Paediatric Surgery Unit, Division of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK
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Bianchi E, Mancini P, De Vito S, Pompili E, Taurone S, Guerrisi I, Guerrisi A, D'Andrea V, Cantisani V, Artico M. Congenital asymptomatic diaphragmatic hernias in adults: a case series. J Med Case Rep 2013; 7:125. [PMID: 23668793 PMCID: PMC3668166 DOI: 10.1186/1752-1947-7-125] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 03/05/2013] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Congenital diaphragmatic hernia is a major malformation occasionally found in newborns and babies. Congenital diaphragmatic hernia is defined by the presence of an orifice in the diaphragm, more often to the left and posterolateral, that permits the herniation of abdominal contents into the thorax. The aim of this case series is to provide information on the presentation, diagnosis and outcome of three patients with late-presenting congenital diaphragmatic hernias. The diagnosis of congenital diaphragmatic hernia is based on clinical investigation and is confirmed by plain X-ray films and computed tomography scans. CASE PRESENTATIONS In the present report three cases of asymptomatic abdominal viscera herniation within the thorax are described. The first case concerns herniation of some loops of the large intestine into the left hemi-thorax in a 75-year-old Caucasian Italian woman. The second case concerns a rare type of herniation in the right side of the thorax of the right kidney with a part of the liver parenchyma in a 57-year-old Caucasian Italian woman. The third case concerns herniation of the stomach and bowel into the left side of the chest with compression of the left lung in a 32-year-old Caucasian Italian man. This type of hernia may appear later in life, because of concomitant respiratory or gastrointestinal disease, or it may be an incidental finding in asymptomatic adults, such as in the three cases featured here. CONCLUSIONS Patients who present with late diaphragmatic hernias complain of a wide variety of symptoms, and diagnosis may be difficult. Additional investigation and research appear necessary to better explain the development and progression of this type of disease.
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Affiliation(s)
- Enrica Bianchi
- Department of Anatomical, Histological, Forensic and Locomotor System Sciences, V, A, Borelli 50, Rome, 00161, Italy.
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Jancelewicz T, Chiang M, Oliveira C, Chiu PP. Late surgical outcomes among congenital diaphragmatic hernia (CDH) patients: why long-term follow-up with surgeons is recommended. J Pediatr Surg 2013; 48:935-41. [PMID: 23701763 DOI: 10.1016/j.jpedsurg.2013.02.005] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 02/03/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND CDH patients experience multi-system morbidity. Despite apparent health, late childhood complications do occur. We reviewed the long-term surgical morbidity of our CDH patients to determine whether protracted clinical surveillance is warranted. METHODS A single-institution retrospective chart review of all CDH survivors treated from 1999 to 2011 who are followed at our CDH multidisciplinary clinic was performed. Descriptive and statistical analyses were performed to show risk of surgical complications over time. RESULTS A total of 187 CDH patients were treated with 160 surviving to discharge (86%). Primary repair was performed in 115 (73%), and 42 (27%) underwent patch repair. CDH recurrence occurred in 23 (15%) at a median time of 0.7 (range 0-8.5) years (65% asymptomatic). Seventy percent of recurrences occurred before 2 years and 17% after 4 years. Bowel obstruction occurred in 12 (8%) at a median time of 0.7 (range 0.2-7.2) years post-repair, and chest deformity occurred in 13 (8%) at a median of 5 (range 1.1-6.8) years. For patch repairs, scoliosis occurred in 4 (10%) patients at a median age of 3 (range 0.6-5) years. CONCLUSION Surgical complications in CDH survivors are common, can occur many years later, and are frequently asymptomatic. Long-term surveillance of CDH patients is recommended for early identification and treatment of complications.
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Affiliation(s)
- Tim Jancelewicz
- Division of Pediatric Surgery, The Hospital for Sick Children, Toronto, ON, Canada M5G 1X8
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40
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Abstract
Congenital diaphragmatic hernia (CDH) is a congenital anomaly that presents with a broad spectrum of severity that is dependent upon components of pulmonary hypoplasia and pulmonary hypertension. While advances in neonatal care have improved the overall survival of CDH in experienced centers, mortality and morbidity remain high in a subset of CDH infants with severe CDH. Prenatal predictors have been refined for the past two decades and are the subject of another review in this issue. So far, all randomized trials comparing prenatal intervention to standard postnatal therapy have shown no benefit to prenatal intervention. Although recent non-randomized reports of success with fetoscopic endoluminal tracheal occlusion (FETO) and release are promising, prenatal therapy should not be widely adopted until a well-designed prospective randomized trial demonstrating efficacy is performed. The increased survival and subsequent morbidity of CDH survivors has resulted in the need to provide resources for the long-term follow up and support of the CDH population.
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Affiliation(s)
- Holly L Hedrick
- Perelman School of Medicine at the University of Pennsylvania, The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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41
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Kunisaki SM, Powelson IA, Bruch SW, Jarboe MD, Geiger JD, Mychaliska GB. Thoracoscopic Repair of Recurrent Bochdalek Diaphragmatic Hernias in Children. J Laparoendosc Adv Surg Tech A 2012; 22:1004-9. [DOI: 10.1089/lap.2012.0048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Shaun M. Kunisaki
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Ian A. Powelson
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Steven W. Bruch
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Marcus D. Jarboe
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - James D. Geiger
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - George B. Mychaliska
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, Michigan
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Rygl M, Kuklova P, Zemkova D, Slaby K, Pycha K, Stranak Z, Melichar J, Snajdauf J. Defect-diaphragmatic ratio: a new parameter for assessment of defect size in neonates with congenital diaphragmatic hernia. Pediatr Surg Int 2012; 28:971-6. [PMID: 22752200 DOI: 10.1007/s00383-012-3113-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2012] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- M Rygl
- Department of Pediatric Surgery, Second Faculty of Medicine and Teaching Hospital in Motol, Charles University in Prague, V úvalu 84, 15006, Prague 5, Czech Republic.
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Romao RLP, Nasr A, Chiu PPL, Langer JC. What is the best prosthetic material for patch repair of congenital diaphragmatic hernia? Comparison and meta-analysis of porcine small intestinal submucosa and polytetrafluoroethylene. J Pediatr Surg 2012; 47:1496-500. [PMID: 22901906 DOI: 10.1016/j.jpedsurg.2012.01.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Revised: 12/08/2011] [Accepted: 01/09/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Prosthetic patches are widely used for congenital diaphragmatic hernia (CDH) repair. We compared the complication rate of absorbable (Surgisis [SIS]; Cook Biotech, Inc, West Lafayette, IN) and nonabsorbable (polytetrafluoroethylene [PTFE]) materials for this purpose. METHODS This is a retrospective review of all neonates with CDH undergoing patch closure at our institution over 10 years. Meta-analysis was also performed combining our data with the published literature examining the effect of patch type on recurrence and small bowel obstruction (SBO). RESULTS Primary patch (13 SIS, 9 PTFE) repair was performed in 22 (26%) of 84 patients with CDH. Groups were comparable in terms of demographics, hospital stay, ventilator days, need for high frequency oscillation, age at surgery, and length of follow-up. Likewise, recurrence rate (SIS, 4 [31%]; PTFE, 3 [33%]; P, nonsignificant [NS]), incidence of postoperative SBO (SIS, 1 [7%] vs PTFE, 2 [22%]; P, NS), and mortality (SIS, 2 [15%] and PTFE, 2 [22%]; P, NS) were similar. Meta-analysis failed to find a significant difference between SIS and PTFE both for recurrence rate (odds ratio, 1.21 [0.51-2.84]; P, NS) and SBO (odds ratio, 1.47 [0.44-4.96]; P, NS). CONCLUSIONS There was no difference in the incidence of CDH recurrence, SBO, or mortality post-CDH patch repair using either SIS or PTFE in our series. Meta-analysis failed to show any difference in recurrence and SBO rates between the 2 materials.
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Affiliation(s)
- Rodrigo L P Romao
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Abstract
PURPOSE OF REVIEW Congenital diaphragmatic hernia (CDH) is a rare developmental defect resulting in variable degrees of lung and pulmonary vasculature hypoplasia. Whereas many high-volume centers have recently reported increased survival rates, this has not been the collective trend. One potential explanation for this is inconsistent perinatal care among centers. RECENT FINDINGS Significant efforts have been made to identify prenatally those fetuses that will be most severely affected. A number of radiologic features have shown promise for achieving this goal as well as identifying fetuses that may benefit from prenatal intervention. When CDH is antenatally diagnosed, early referral to a tertiary center is recommended. Centers that routinely use postnatal management protocols have demonstrated improved overall survival rates including increased survival in high-risk CDH patients. SUMMARY As a result of advancements in perinatal care, more severely affected newborns with CDH are now surviving. These patients may experience a number of associated morbidities which affect not only their health but overall quality of life. A multidisciplinary approach to the long-term care of these patients will allow early identification and management of these morbidities.
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Beres A, Christison-Lagay ER, Romao RLP, Langer JC. Evaluation of Surgisis for patch repair of abdominal wall defects in children. J Pediatr Surg 2012; 47:917-9. [PMID: 22595572 DOI: 10.1016/j.jpedsurg.2012.01.046] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 01/26/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Abdominal wall defects in children are not always amenable to primary repair and may require a patch. The ideal material has yet to be established. We sought to evaluate our experience using the bioabsorbable material Surgisis (Cook Surgical, Bloomington, IN) for abdominal closure. METHODS A retrospective chart review of abdominal wall defects repaired with Surgisis in our institution from 2000 to 2010 was performed. Data extracted included cause of defect, age at operation, possibility of skin coverage, recurrence, length of follow-up, and rate of wound infection. RESULTS Thirteen patients were identified. Cause of defect was gastroschisis (n = 2), ventral hernia after diaphragmatic hernia repair (n = 2), and omphalocele (n = 9). At median follow-up of 60 months (range, 10-90), 5 (38%) of 13 patients recurred, and 1 patient recurred twice. All recurrences required subsequent patch closure. Six instances of wound infection required antibiotics. None required patch removal. There was a trend toward more frequent recurrence among infants undergoing patch repair (3/4 recurrences in this group) than neonates (1/4 recurrences) or children older than 18 months (1/5 recurrences). CONCLUSION Our data suggest that Surgisis is moderately successful in the repair of pediatric abdominal wall defects. We noted a trend toward a higher recurrence rate in infants. Further studies investigating timing of repair and alternative biosynthetic materials are warranted.
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Affiliation(s)
- Alana Beres
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Samangaya RA, Choudhri S, Murphy F, Zaidi T, Gillham JC, Morabito A. Outcomes of congenital diaphragmatic hernia: a 12-year experience. Prenat Diagn 2012; 32:523-9. [PMID: 22499217 DOI: 10.1002/pd.3841] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine outcomes for babies with congenital diaphragmatic hernia (CDH) diagnosed prenatally and postnatally presenting to a tertiary unit. METHOD Fetal medicine database and neonatal surgical unit admission books were reviewed to identify cases of CDH over a 12-year period (Jan 1998- Dec 2009). RESULTS A total of 132 cases of CDH were diagnosed prenatally and 39 cases diagnosed postnatally. Mean gestation at diagnosis was 22 weeks (range 13-37 weeks). Karyotyping was abnormal in 15.9%; abnormal karyotype in 3.6% of fetuses without other structural anomalies compared with 38.9% when other anomalies were identified. In 45 cases (34.1%) pregnancy was terminated. Two stillbirths occurred (2.3% of ongoing pregnancies). One hundred twenty-four babies were live born, of whom 98 babies underwent surgery. Survival to discharge of all live born babies was 72.6%; survival following surgery was 91.8%. Birthweight had a significant effect on survival (odds ratio 0.22, 95% confidence intervals 0.08-0.66). Survival for live born babies prenatally diagnosed was significantly lower (65.9%) than those diagnosed postnatally (92.3%). CONCLUSION Abnormal karyotype was more common when CDH was associated with other anomalies. In multivariate analysis, lower birthweight and prenatal diagnosis had a significant impact on survival. Only prenatally diagnosed CDH survival figures should be utilised in prenatal counselling.
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Affiliation(s)
- Rebekah A Samangaya
- Fetal Medicine Unit, St Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.
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47
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Patch repair for congenital diaphragmatic hernia: is it really a problem? J Pediatr Surg 2012; 47:637-41. [PMID: 22498374 DOI: 10.1016/j.jpedsurg.2011.11.054] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 11/20/2011] [Accepted: 11/21/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Large congenital diaphragmatic hernia (CDH) defects often require the use of synthetic patches for tension-free repair. Although high rates of recurrence and other morbidities have been previously reported, our favorable perception of patch repair prompted this review. METHODS A single-center retrospective chart review of CDH cases repaired between January 1, 1999, and October 1, 2010. Patch repairs were performed by multiple surgeons with an effort to construct a tension-free dome-shaped patch. RESULTS One hundred eighty-four children underwent CDH repair of whom 99 (53.8%) required a patch. Seventy-four (74.7%) of the 99 patients who underwent patch repair survived to discharge and were compared with 75 primary repair survivors. Of those undergoing patch repair, 88% were prenatally diagnosed, 55% had liver herniation, and 22 (29.9%) were repaired on extracorporeal membrane oxygenation. Two patients experienced a recurrence after a patch repair and 3 after a primary repair for a rate of 5.4% and 4.0%, respectively (P = 1.0). CONCLUSIONS These results demonstrate that synthetic patch repair for CDH can be performed with a very low rate of recurrence challenging the need for alternative approaches to diaphragmatic replacement. High rates of recurrence reported for patch repair may be technical rather than intrinsic to the patch.
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Abstract
Congenital Diaphragmatic Hernia (CDH) is defined by the presence of an orifice in the diaphragm, more often left and posterolateral that permits the herniation of abdominal contents into the thorax. The lungs are hypoplastic and have abnormal vessels that cause respiratory insufficiency and persistent pulmonary hypertension with high mortality. About one third of cases have cardiovascular malformations and lesser proportions have skeletal, neural, genitourinary, gastrointestinal or other defects. CDH can be a component of Pallister-Killian, Fryns, Ghersoni-Baruch, WAGR, Denys-Drash, Brachman-De Lange, Donnai-Barrow or Wolf-Hirschhorn syndromes. Some chromosomal anomalies involve CDH as well. The incidence is < 5 in 10,000 live-births. The etiology is unknown although clinical, genetic and experimental evidence points to disturbances in the retinoid-signaling pathway during organogenesis. Antenatal diagnosis is often made and this allows prenatal management (open correction of the hernia in the past and reversible fetoscopic tracheal obstruction nowadays) that may be indicated in cases with severe lung hypoplasia and grim prognosis. Treatment after birth requires all the refinements of critical care including extracorporeal membrane oxygenation prior to surgical correction. The best hospital series report 80% survival but it remains around 50% in population-based studies. Chronic respiratory tract disease, neurodevelopmental problems, neurosensorial hearing loss and gastroesophageal reflux are common problems in survivors. Much more research on several aspects of this severe condition is warranted.
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Barnhart DC, Jacques E, Scaife ER, Yoder BA, Meyers RL, Harman A, Downey EC, Rollins MD. Split abdominal wall muscle flap repair vs patch repair of large congenital diaphragmatic hernias. J Pediatr Surg 2012; 47:81-6. [PMID: 22244397 DOI: 10.1016/j.jpedsurg.2011.10.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 10/06/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE Large congenital diaphragmatic hernias are commonly repaired with a prosthetic patch. We hypothesized that a split abdominal wall muscle flap would reduce the risk of recurrence. METHODS A retrospective review of neonates with congenital diaphragmatic hernia in whom primary repair was not possible was performed. Kaplan-Meier analyses and Cox proportional hazards modeling were performed. RESULTS Of 153 patients, 46 could not have repair with primary closure of the diaphragm. Thirty-three survived to discharge and were subjected to analysis for recurrence. Ten underwent repair with a patch, whereas 23 had a muscle flap (internal oblique and transversalis) patch. The groups were similar with regard to demographics, need for extracorporeal membrane oxygenation, repair on extracorporeal membrane oxygenation, and size of the defect. Fifty percent of patch repairs recurred with a median time of 0.5 years. Only one (4.3%) of the patients who had muscle flap patch developed a recurrence. This was significant on Kaplan-Meier analysis (P = .0009) and had a hazard ratio of 14.3 on Cox regression (P = .018). Median follow-up exceeded 4 years. No children required surgery for an abdominal wall hernia. CONCLUSIONS The split abdominal wall muscle flap allows for closure of large congenital diaphragmatic hernia defects with autologous tissue. This approach is associated with significantly fewer recurrences than patch repairs.
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Affiliation(s)
- Douglas C Barnhart
- Division of Pediatric Surgery, Primary Children's Medical Center, University of Utah, Salt Lake City, Utah 84113, USA
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Kesieme EB, Kesieme CN. Congenital diaphragmatic hernia: review of current concept in surgical management. ISRN SURGERY 2011; 2011:974041. [PMID: 22229104 PMCID: PMC3251163 DOI: 10.5402/2011/974041] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 10/26/2011] [Indexed: 11/23/2022]
Abstract
CONGENITAL DIAPHRAGMATIC HERNIAS (CDHS) OCCUR MAINLY IN TWO LOCATIONS: the foramen of Morgagni and the more common type involving the foramen of Bochdalek. Hiatal hernia and paraesophageal hernia have also been described as other forms of CDH. Pulmonary hypertension and pulmonary hypoplasia have been recognized as the two most important factors in the pathophysiology of congenital diaphragmatic hernia. Advances in surgical management include delayed surgical approach that enables preoperative stabilization, introduction of fetal intervention due to improved prenatal diagnosis, the introduction of minimal invasive surgery, in addition to the standard open repair, and the use of improved prosthetic devices for closure.
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Affiliation(s)
- Emeka B. Kesieme
- Department of Surgery, Irrua Specialist Teaching Hospital, PMB 8, Edo State, Irrua, Nigeria
| | - Chinenye N. Kesieme
- Department of Paediatrics, Irrua Specialist Teaching Hospital, PMB 8, Edo State, Irrua, Nigeria
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