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King S, Carr BDE, Mychaliska GB, Church JT. Surgical approaches to congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151441. [PMID: 38986242 DOI: 10.1016/j.sempedsurg.2024.151441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
Surgical repair of the diaphragm is essential for survival in congenital diaphragmatic hernia (CDH). There are many considerations surrounding the operation - why the operation matters, optimal timing of repair and its relation to extracorporeal life support (ECLS) use, minimally invasive versus open approaches, and strategies for reconstruction. Surgery is both affected by, and affects, the physiology of these infants and is an important factor in determining long-term outcomes. Here we discuss the evidence and provide insight surrounding this complex decision making, technical pearls, and outcomes in repair of CDH.
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Affiliation(s)
- Sarah King
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA
| | - Benjamin D E Carr
- Doernbecher Children's Hospital, Division of Pediatric Surgery, Department of Surgery, Oregon Health and Science University. Portland, OR, USA
| | - George B Mychaliska
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA
| | - Joseph T Church
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA.
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2
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Pollack JC, Hollinger LE, Buchmiller TL, Jancelewicz T. Long-term follow-up in congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151443. [PMID: 38972214 DOI: 10.1016/j.sempedsurg.2024.151443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
With improvements in initial care for patients with congenital diaphragmatic hernia (CDH), the number of CDH patients with severe disease who are surviving to discharge has increased. This growing population of patients faces a unique set of long-term challenges, multisystem adverse outcomes, and post-intervention complications requiring specialized multidisciplinary follow-up. Early identification and intervention are essential to mitigate the potential morbidity associated with these challenges. This manuscript outlines a general framework for long-term follow-up for the CDH patient, including cardiopulmonary, gastrointestinal, neurodevelopmental, surgical, and quality of life outcomes.
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Affiliation(s)
- Jessica C Pollack
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, USA; Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, USA
| | - Laura E Hollinger
- Division of Pediatric Surgery, Department of Surgery, Medical University of South Carolina, USA
| | | | - Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, USA.
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3
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Shibuya S, Paraboschi I, Giuliani S, Tsukui T, Matei A, Olivos M, Inoue M, Clarke SA, Yamataka A, Zani A, Eaton S, De Coppi P. Comprehensive meta-analysis of surgical procedure for congenital diaphragmatic hernia: thoracoscopic versus open repair. Pediatr Surg Int 2024; 40:182. [PMID: 38980431 PMCID: PMC11233350 DOI: 10.1007/s00383-024-05760-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 07/10/2024]
Abstract
PURPOSE Previous studies have shown a higher recurrence rate and longer operative times for thoracoscopic repair (TR) of congenital diaphragmatic hernia (CDH) compared to open repair (OR). An updated meta-analysis was conducted to re-evaluate the surgical outcomes of TR. METHODS A comprehensive literature search comparing TR and OR in neonates was performed in accordance with the PRISMA statement (PROSPERO: CRD42020166588). RESULTS Fourteen studies were selected for quantitative analysis, including a total of 709 patients (TR: 308 cases, OR: 401 cases). The recurrence rate was higher [Odds ratio: 4.03, 95% CI (2.21, 7.36), p < 0.001] and operative times (minutes) were longer [Mean Difference (MD): 43.96, 95% CI (24.70, 63.22), p < 0.001] for TR compared to OR. A significant reduction in the occurrence of postoperative bowel obstruction was observed in TR (5.0%) compared to OR (14.8%) [Odds ratio: 0.42, 95% CI (0.20, 0.89), p = 0.02]. CONCLUSIONS TR remains associated with higher recurrence rates and longer operative times. However, the reduced risk of postoperative bowel obstruction suggests potential long-term benefits. This study emphasizes the importance of meticulous patient selection for TR to mitigate detrimental effects on patients with severe disease.
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Affiliation(s)
- Soichi Shibuya
- Stem Cell and Regenerative Medicine Section, Developmental Biology and Cancer Research & Teaching Department, Zayed Centre for Research Into Rare Disease in Children, Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1E, UK.
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo City, Tokyo, 113-8431, Japan.
| | - Irene Paraboschi
- Department of Biomedical and Clinical Science, University of Milano, Milan, Italy
| | - Stefano Giuliani
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Takafumi Tsukui
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo City, Tokyo, 113-8431, Japan
| | - Andreea Matei
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Mikihiro Inoue
- Department of Pediatric Surgery, Fujita Health University, Aichi, Japan
| | - Simon A Clarke
- Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo City, Tokyo, 113-8431, Japan
| | - Augusto Zani
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Simon Eaton
- Stem Cell and Regenerative Medicine Section, Developmental Biology and Cancer Research & Teaching Department, Zayed Centre for Research Into Rare Disease in Children, Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1E, UK
| | - Paolo De Coppi
- Stem Cell and Regenerative Medicine Section, Developmental Biology and Cancer Research & Teaching Department, Zayed Centre for Research Into Rare Disease in Children, Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1E, UK.
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.
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Sferra SR, Penikis AB, Guo M, Baschat AA, Mogayzel PJ, Burton VJ, Kunisaki SM. Neurodevelopmental Outcomes in Children After Fetoscopic Endoluminal Tracheal Occlusion for Severe Congenital Diaphragmatic Hernia: Results From a Multidisciplinary Clinic. J Pediatr Surg 2024; 59:1271-1276. [PMID: 38599907 DOI: 10.1016/j.jpedsurg.2024.03.041] [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: 03/12/2024] [Accepted: 03/12/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND We compared early neurodevelopmental morbidity in young children with severe CDH who underwent FETO to those without fetal therapy. METHODS We conducted a prospective study of severe CDH patients undergoing FETO (n = 18) at a single North American center from 2015 to 2021 (NCT02710968). Outpatient survivors (n = 12) were evaluated by a multidisciplinary team and compared to expectantly managed CDH patients. Neurodevelopmental outcomes were assessed using the Capute Scales [Clinical Linguistic and Auditory Milestone Scales (CLAMS) and Cognitive Adaptive Test (CAT)], with a developmental quotient (DQ) < 85 indicative of at-risk for delay. RESULTS At one year, 58% (n = 7) of FETO patients underwent evaluation, with notable concern for language delay (CLAMS median DQ, 80.1 [interquartile range, 67.6-86.7]). FETO scores improved by 24-months, whereas high severity/non-FETO scores declined [CLAMS median DQ (Difference in DQ), 92.3 (+12.2) vs. 77.1 (-13.4), respectively; p = 0.049]. On the initial CAT, FETO patients had concern for visual motor and problem-solving delays, with a median DQ of 81.3 (62.1-89.4). At 24-months, FETO patients had improving scores [Median CAT DQ, 90.8 (+9.5)], whereas high severity/non-FETO [87.5 (-3.0), p = 0.28] had declining scores. CONCLUSION These initial data suggest that FETO is associated with favorable neurodevelopmental outcomes at 24-months compared to severe CDH under expectant management. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Shelby R Sferra
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Annalise B Penikis
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Matthew Guo
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA
| | - Peter J Mogayzel
- Eudowood Division of Pediatric Pulmonary, Department of Pediatrics, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Baltimore, MD 21287, USA
| | - Vera Joanna Burton
- Neurology and Developmental Medicine, Department of Neurology, Johns Hopkins University School of Medicine, 801 N. Broadway Baltimore, MD 21205, USA
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA.
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Shah NR, Criss CN, Burgi K, Matusko N, Geiger JD, Perrone EE, Mychaliska GB, Ralls MW. Thoracoscopic Patch Repair of Congenital Diaphragmatic Hernia: Can Smaller Incisions Treat Larger Defects? J Pediatr Surg 2024; 59:1083-1088. [PMID: 37867043 DOI: 10.1016/j.jpedsurg.2023.09.040] [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: 08/22/2023] [Revised: 09/14/2023] [Accepted: 09/26/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Thoracoscopic CDH repair is increasingly performed for Type A and small Type B defects that are amenable to primary repair. However, the thoracoscopic approach is controversial for larger defects necessitating a patch due to technical complexity, intraoperative acidosis, and recurrence risk. We aim to compare clinical outcomes between thoracoscopic and open patch repair of Type B/C defects, using a standardized technique. METHODS This is a single-center retrospective review of thoracoscopic and open CDH patch repairs January 2017-December 2021. We excluded primary repairs, Type D hernias, repairs on ECMO, recurrent repairs. Various preoperative, intraoperative, and postoperative variables were compared. Primary outcome was recurrence rate. Secondary outcomes included intraoperative pH and pCO2, operative time, and complication rates. RESULTS Twenty-nine patients met inclusion criteria (open = 13, thoracoscopic = 16). The open cohort had lower o/e total fetal lung volume (29 vs 41.2%, p = 0.042), higher preoperative peak inspiratory pressures (24 vs 20 cm H2O, p = 0.007), were more frequently Type C defects (92.3 vs 31%, p = 0.002) and had liver "up" in left-sided hernias (46 vs 0%, p < 0.0001). Intraoperatively, median lowest pH and highest pCO2 did not differ; neither did overall median pH or pCO2. Operative times were similar (153 vs 194 min, p = 0.113). No difference in recurrence rates was identified, however postoperative complications were higher in the open group. There were no mortalities. CONCLUSIONS Although we demonstrate higher disease severity of patients undergoing open repair, thoracoscopic patch repair for Type B/C defects is safe and effective in patients with favorable physiologic status, alleviating concerns for intraoperative acidosis, operative length, and risk of recurrence. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Nikhil R Shah
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA.
| | - Cory N Criss
- Nationwide Children's Hospital, Department of Surgery, Section of Pediatric Surgery, 700 Childrens Dr., Columbus, OH 43205, USA
| | - Keerthi Burgi
- University of Michigan School of Medicine, 1301 Catherine St., Ann Arbor, MI 48109-4211, USA
| | - Niki Matusko
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA
| | - James D Geiger
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA
| | - Erin E Perrone
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA
| | - George B Mychaliska
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA
| | - Matthew W Ralls
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA
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Streibel C, Willers CC, Bauman G, Pusterla O, Bieri O, Curdy M, Horn M, Casaulta C, Berger S, Dekany GM, Kieninger E, Bartenstein A, Latzin P. Long-term pulmonary outcome of children with congenital diaphragmatic hernia: functional lung MRI using matrix-pencil decomposition enables side-specific assessment of lung function. Eur Radiol 2024; 34:3773-3785. [PMID: 37982833 PMCID: PMC11166819 DOI: 10.1007/s00330-023-10395-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/23/2023] [Accepted: 08/30/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVES In patients with congenital diaphragmatic hernia (CDH) the exact functional outcome of the affected lung side is still unknown, mainly due to the lack of spatially resolved diagnostic tools. Functional matrix-pencil decomposition (MP-) lung MRI fills this gap as it measures side-specific ventilation and perfusion. We aimed to assess the overall and side-specific pulmonary long-term outcomes of patients with CDH using lung function tests and MP-MRI. METHODS Thirteen school-aged children with CDH (seven with small and six with large defect-sized CDH, defined as > 50% of the chest wall circumference being devoid of diaphragm tissue) and thirteen healthy matched controls underwent spirometry, multiple-breath washout, and MP-MRI. The main outcomes were forced expiratory volume in 1 second (FEV1), lung clearance index (LCI2.5), ventilation defect percentage (VDP), and perfusion defect percentage (QDP). RESULTS Patients with a large CDH showed significantly reduced overall lung function compared to healthy controls (mean difference [95%-CIadjusted]: FEV1 (z-score) -4.26 [-5.61, -2.92], FVC (z-score) -3.97 [-5.68, -2.26], LCI2.5 (TO) 1.12 [0.47, 1.76], VDP (%) 8.59 [3.58, 13.60], QDP (%) 17.22 [13.16, 21.27]) and to patients with a small CDH. Side-specific examination by MP-MRI revealed particularly reduced ipsilateral ventilation and perfusion in patients with a large CDH (mean difference to contralateral side [95%-CIadjusted]: VDP (%) 14.80 [10.50, 19.00], QDP (%) 23.50 [1.75, 45.20]). CONCLUSIONS Data indicate impaired overall lung function with particular limitation of the ipsilateral side in patients with a large CDH. MP-MRI is a promising tool to provide valuable side-specific functional information in the follow-up of patients with CDH. CLINICAL RELEVANCE STATEMENT In patients with congenital diaphragmatic hernia, easily applicable MP-MRI allows specific examination of the lung side affected by the hernia and provides valuable information on ventilation and perfusion with implications for clinical practice, making it a promising tool for routine follow-up. KEY POINTS • Functional matrix pencil decomposition (MP) MRI data from a small sample indicate reduced ipsilateral pulmonary ventilation and perfusion in children with large congenital diaphragmatic hernia (CDH). • Easily applicable pencil decomposition MRI provides valuable side-specific diagnostic information on lung ventilation and perfusion. This is a clear advantage over conventional lung function tests, helping to comprehensively follow up patients with congenital diaphragmatic hernia and monitor therapy effects.
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Affiliation(s)
- Carmen Streibel
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
| | - C Corin Willers
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Department of Paediatrics, Kantonsspital Aarau, Aarau, Switzerland
| | - Grzegorz Bauman
- Department of Radiology, Division of Radiological Physics, University of Basel Hospital, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Orso Pusterla
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Radiology, Division of Radiological Physics, University of Basel Hospital, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Oliver Bieri
- Department of Radiology, Division of Radiological Physics, University of Basel Hospital, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - Marion Curdy
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Horn
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carmen Casaulta
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Steffen Berger
- Department of Paediatric Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Gabriela Marta Dekany
- Department of Paediatric Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Elisabeth Kieninger
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Bartenstein
- Department of Paediatric Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Philipp Latzin
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Cullis PS, Fouad D, Goldstein AM, Wong KKY, Boonthai A, Lobos P, Pakarinen MP, Losty PD. Major surgical conditions of childhood and their lifelong implications: comprehensive review. BJS Open 2024; 8:zrae028. [PMID: 38776252 PMCID: PMC11110943 DOI: 10.1093/bjsopen/zrae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/18/2023] [Accepted: 01/30/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND In recent decades, the survival of children with congenital anomalies and paediatric cancer has improved dramatically such that there has been a steady shift towards understanding their lifelong health outcomes. Paediatric surgeons will actively manage such conditions in childhood and adolescence, however, adult surgeons must later care for these 'grown-ups' in adulthood. This article aims to highlight some of those rare disorders encountered by paediatric surgeons requiring long-term follow-up, their management in childhood and their survivorship impact, in order that the adult specialist may be better equipped with skills and knowledge to manage these patients into adulthood. METHODS A comprehensive literature review was performed to identify relevant publications. Research studies, review articles and guidelines were sought, focusing on the paediatric management and long-term outcomes of surgical conditions of childhood. The article has been written for adult surgeon readership. RESULTS This article describes the aforementioned conditions, their management in childhood and their lifelong implications, including: oesophageal atresia, tracheo-oesophageal fistula, malrotation, short bowel syndrome, duodenal atresia, gastroschisis, exomphalos, choledochal malformations, biliary atresia, Hirschsprung disease, anorectal malformations, congenital diaphragmatic hernia, congenital lung lesions and paediatric cancer. CONCLUSION The increasing survivorship of children affected by surgical conditions will translate into a growing population of adults with lifelong conditions and specialist healthcare needs. The importance of transition from childhood to adulthood is becoming realized. It is hoped that this timely review will enthuse the readership to offer care for such vulnerable patients, and to collaborate with paediatric surgeons in providing successful and seamless transitional care.
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Affiliation(s)
- Paul S Cullis
- Department of Paediatric Surgery, Royal Hospital for Children Edinburgh, Edinburgh, UK
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Dina Fouad
- Department of Paediatric Surgery, Leicester Children’s Hospital, Leicester, UK
| | - Allan M Goldstein
- Department of Paediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth K Y Wong
- Department of Paediatric Surgery, Queen Mary’s Hospital, University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Ampaipan Boonthai
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pablo Lobos
- Department of Paediatric Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mikko P Pakarinen
- The New Children’s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, University of Southern Denmark, Odense, Denmark
| | - Paul D Losty
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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Cimbak N, Zalieckas JM, Staffa SJ, Lemire L, Janeczek J, Sheils C, Visner G, Mullen M, Studley M, Becker R, Dickie BH, Demehri FR, Buchmiller TL. Disparities in Healthcare Utilization: An Analysis of Disease Specific and Patient Level Factors in a Congenital Diaphragmatic Hernia Clinic. J Pediatr Surg 2024:S0022-3468(24)00300-2. [PMID: 38806317 DOI: 10.1016/j.jpedsurg.2024.04.023] [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: 02/23/2024] [Revised: 04/03/2024] [Accepted: 04/29/2024] [Indexed: 05/30/2024]
Abstract
OBJECTIVES Our study examines if the disease severity profile of our Congenital Diaphragmatic Hernia (CDH) patient cohort adherent to long-term follow-up differs from patients lost to follow-up after discharge and examines factors associated with health care utilization. METHODS Retrospective review identified CDH survivors born 2005-2019 with index repair at our institution. Primary outcome was long-term follow-up status: "active" or "inactive" according to clinic guidelines. Markers of CDH disease severity including CDH defect classification, oxygen use, tube feeds at discharge, and sociodemographic factors were examined as exposures. RESULTS Of the 222 included patients, median age [IQR] was 10.2 years [6.7-14.3], 61% male, and 57 (26%) were insured by Medicaid. Sixty-three percent (139/222) of patients were adherent to follow-up. Seventy-six percent of patients discharged on tube feeds had active follow-up compared to 55% of patients who were not, with similar findings for oxygen at discharge (76% vs. 55%). Kaplan-Meier analysis showed patients with smaller defect size had earlier attrition compared to patients with larger defect size. Other race (Hispanic, Asian, Middle Eastern) patients had 2.87 higher odds of attrition compared to white patients (95% CI 1.18-7.0). Medicaid patients had 2.64 higher odds of attrition compared to private insurance (95% CI 1.23-5.66). CONCLUSION Loss to follow-up was associated with race and insurance type. Disease severity was similar between the active and inactive clinic cohorts. Long-term CDH clinic publications should examine attrition to ensure reported outcomes reflect the discharged population. This study identified important factors to inform targeted interventions for follow-up adherence. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Nicole Cimbak
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA.
| | - Jill M Zalieckas
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA
| | - Steven J Staffa
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA
| | - Lindsay Lemire
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA
| | - Joslyn Janeczek
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA
| | - Catherine Sheils
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gary Visner
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mary Mullen
- Department of Cardiology and Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mollie Studley
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Ronald Becker
- Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Belinda Hsi Dickie
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA 02115, USA
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9
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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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10
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Yaremenko AV, Pechnikova NA, Porpodis K, Damdoumis S, Aggeli A, Theodora P, Domvri K. Association of Fetal Lung Development Disorders with Adult Diseases: A Comprehensive Review. J Pers Med 2024; 14:368. [PMID: 38672994 PMCID: PMC11051200 DOI: 10.3390/jpm14040368] [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: 02/22/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
Fetal lung development is a crucial and complex process that lays the groundwork for postnatal respiratory health. However, disruptions in this delicate developmental journey can lead to fetal lung development disorders, impacting neonatal outcomes and potentially influencing health outcomes well into adulthood. Recent research has shed light on the intriguing association between fetal lung development disorders and the development of adult diseases. Understanding these links can provide valuable insights into the developmental origins of health and disease, paving the way for targeted preventive measures and clinical interventions. This review article aims to comprehensively explore the association of fetal lung development disorders with adult diseases. We delve into the stages of fetal lung development, examining key factors influencing fetal lung maturation. Subsequently, we investigate specific fetal lung development disorders, such as respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD), congenital diaphragmatic hernia (CDH), and other abnormalities. Furthermore, we explore the potential mechanisms underlying these associations, considering the role of epigenetic modifications, transgenerational effects, and intrauterine environmental factors. Additionally, we examine the epidemiological evidence and clinical findings linking fetal lung development disorders to adult respiratory diseases, including asthma, chronic obstructive pulmonary disease (COPD), and other respiratory ailments. This review provides valuable insights for healthcare professionals and researchers, guiding future investigations and shaping strategies for preventive interventions and long-term care.
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Affiliation(s)
- Alexey V. Yaremenko
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Oncology Unit, Pulmonary Department, George Papanikolaou Hospital, School of Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (K.P.); (S.D.)
| | - Nadezhda A. Pechnikova
- Laboratory of Chemical Engineering A’, School of Chemical Engineering, Faculty of Engineering, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (N.A.P.); (A.A.)
- Saint Petersburg Pasteur Institute, Saint Petersburg 197101, Russia
| | - Konstantinos Porpodis
- Oncology Unit, Pulmonary Department, George Papanikolaou Hospital, School of Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (K.P.); (S.D.)
| | - Savvas Damdoumis
- Oncology Unit, Pulmonary Department, George Papanikolaou Hospital, School of Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (K.P.); (S.D.)
| | - Amalia Aggeli
- Laboratory of Chemical Engineering A’, School of Chemical Engineering, Faculty of Engineering, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (N.A.P.); (A.A.)
| | - Papamitsou Theodora
- Laboratory of Histology-Embryology, School of Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Kalliopi Domvri
- Oncology Unit, Pulmonary Department, George Papanikolaou Hospital, School of Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (K.P.); (S.D.)
- Laboratory of Histology-Embryology, School of Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
- Pathology Department, George Papanikolaou Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
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11
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Rivas JFG, Clugston RD. The etiology of congenital diaphragmatic hernia: the retinoid hypothesis 20 years later. Pediatr Res 2024; 95:912-921. [PMID: 37990078 PMCID: PMC10920205 DOI: 10.1038/s41390-023-02905-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 10/16/2023] [Accepted: 10/30/2023] [Indexed: 11/23/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a severe birth defect and a major cause of neonatal respiratory distress. Impacting ~2-3 in 10,000 births, CDH is associated with a high mortality rate, and long-term morbidity in survivors. Despite the significant impact of CDH, its etiology remains incompletely understood. In 2003, Greer et al. proposed the Retinoid Hypothesis, stating that the underlying cause of abnormal diaphragm development in CDH was related to altered retinoid signaling. In this review, we provide a comprehensive update to the Retinoid Hypothesis, discussing work published in support of this hypothesis from the past 20 years. This includes reviewing teratogenic and genetic models of CDH, lessons from the human genetics of CDH and epidemiological studies, as well as current gaps in the literature and important areas for future research. The Retinoid Hypothesis is one of the leading hypotheses to explain the etiology of CDH, as we continue to better understand the role of retinoid signaling in diaphragm development, we hope that this information can be used to improve CDH outcomes. IMPACT: This review provides a comprehensive update on the Retinoid Hypothesis, which links abnormal retinoic acid signaling to the etiology of congenital diaphragmatic hernia. The Retinoid Hypothesis was formulated in 2003. Twenty years later, we extensively review the literature in support of this hypothesis from both animal models and humans.
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Affiliation(s)
- Juan F Garcia Rivas
- Department of Physiology, University of Alberta, Edmonton, AB, Canada
- Women and Children's Health Research Institute, Edmonton, AB, Canada
| | - Robin D Clugston
- Department of Physiology, University of Alberta, Edmonton, AB, Canada.
- Women and Children's Health Research Institute, Edmonton, AB, Canada.
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12
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Bethell GS, Eastwood MP, Neville JJ, Harwood R, Ali S, Ooi SZY, Brown J, Tullie L, Hotonu S, Bradnock TJ, Hall NJ, Chacon S, Osgouei RH, Neville JJ. Development of a 3D-printed neonatal congenital diaphragmatic hernia model and standardisation of intra-operative measurement. Pediatr Surg Int 2023; 40:28. [PMID: 38147130 PMCID: PMC10751268 DOI: 10.1007/s00383-023-05600-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 12/27/2023]
Abstract
INTRODUCTION Three-dimensional (3D) printing is frequently used for surgical simulation and training, however, no widely available model exists for neonatal congenital diaphragmatic hernia (CDH). The aim of this study was to develop a 3D-printed model of CDH and test interobserver variability in the simulated model for obtaining measurements of the diaphragmatic defect and ipsilateral diaphragm. METHODS A term fetal MRI (3.5 kg) of thorax, diaphragm and defect (15 mm × 5 mm) were delineated and segmented after parental consent to produce 3D-printed models. Consultant and trainee paediatric surgeons were invited to measure the posterior-lateral diaphragmatic defect and ipsilateral diaphragm. Mean measurement error was calculated (millimetres). Data are presented as median (range) and number/total (%). RESULTS An abdominal and thoracoscopic model were produced and tested by 52 participants (20 consultants and 32 trainees). Diaphragmatic defect via laparotomy measured 15 (10-20) mm (AP) × 16 (10-25) mm (ML) and thoracoscopically 14 (11-19) mm (AP) × 15 (11-22) mm (ML). Mean error per measurement was 4 (1-17) mm via laparotomy vs. 3 (0.5-9.5) mm thoracoscopically. Mean error was similar between consultants and trainees via laparotomy (4.3 vs. 3.9 mm, p = 0.70) and thoracoscopically (3 vs. 3 mm, p = 0.79). Error did not correlate with experience as operating surgeon via laparotomy (β = 13.0 [95% CI - 55.9 to 82.0], p = 0.71) or thoracoscopically (β = 1.4[95% CI - 6.4 to 9.2], p = 0.73. CONCLUSIONS We have designed and built simulation models for CDH repair via laparotomy and thoracoscopically. Operators can reliably measure the diaphragmatic defect and ipsilateral diaphragm, regardless of surgical experience and operative approach.
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13
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Moskowitzova K, Zalieckas JM, Sheils CA, Studley M, Lemire L, Zurakowski D, Buchmiller TL. Impact of bowel rotation and fixation on obstructive complications in congenital diaphragmatic hernia. J Pediatr Surg 2023; 58:209-212. [PMID: 36396471 DOI: 10.1016/j.jpedsurg.2022.10.019] [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: 10/05/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
AIM OF THE STUDY Small bowel obstruction (SBO) is a known complication after congenital diaphragmatic hernia (CDH) repair, which can require surgery and even extensive bowel resection causing short bowel syndrome (SBS). We investigate whether specific bowel rotation and fixation can be used as a predictor for SBO including volvulus. METHODS A retrospective review of 256 CDH survivors following repair from 2003 to 2020 was performed. Operative notes and upper gastrointestinal series (UGI) were screened to determine the rotation and fixation of the bowel. Primary outcomes included SBO occurrence, SBO treated surgically, and volvulus. For statistical analysis Fisher's exact test was utilized. RESULTS Twenty-two (9%) patients presented with SBO and majority, 19 (86%), required surgery. Adhesion were observed in 10 (45%), recurrence in 5 (23%), and extensive volvulus leading to SBS in 3 (14%). Both rotation and fixation were recorded in 117 (46%). Presence of left CDH with malrotation and nonfixation was a significant predictor for SBO requiring surgery (P<0.05 vs all other groups). All 3 patients with extensive volvulus had left CDH with nonfixed bowel (100%), however only 1 had malrotation (33%). CONCLUSIONS Malrotation and nonfixation are associated with increased SBO in CDH. Normal rotation is not protective and patients are still at risk for volvulus resulting in SBS. SBO requiring surgical intervention is common in CDH. Bowel rotation and fixation are important determinants that, should be routinely documented and education about the risk of SBO should be included in family counseling. LEVEL OF EVIDENCE Level IV - Case Series.
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Affiliation(s)
- Kamila Moskowitzova
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Jill M Zalieckas
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Catherine A Sheils
- Division of Pulmonary Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Mollie Studley
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Lindsay Lemire
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Terry L Buchmiller
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.
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14
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Quigley CP, Folaranmi SE. A Systematic Review Comparing the Surgical Outcomes of Open Versus Minimally Invasive Surgery for Congenital Diaphragmatic Hernia Repair. J Laparoendosc Adv Surg Tech A 2023; 33:211-219. [PMID: 36445735 DOI: 10.1089/lap.2022.0348] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Surgical intervention is the definitive management for congenital diaphragmatic hernia (CDH) repair from 1902. Since this time, two mainstay approaches have been used, open and minimally invasive surgical (MIS) repair. An invasive laparotomy is used in around 91% of cases. So, this systematic review of the published literature will compare the surgical outcomes of open (CDH) repair vs MIS for CDH repair and will determine which approach is superior. Material and Methods: Our literature search across MEDLINE and EMBASE included articles from 2004 to 2022, incorporating pediatric CDH repairs, human subjects only, and English language articles. Primary outcomes analyzed were rate of recurrence, length of surgery, length of hospital stay, use of diaphragmatic patch, mortality, postoperative chylothorax, and extracorporeal membrane oxygenation (ECMO) use postoperatively. Results: After application of exclusion criteria, 32 articles were reviewed. Comparison of MIS repair versus open repair had a rate of recurrence at 8.6% versus 1.6% (P < .00001). Length of hospital stay was 19.6 days versus 33.6 days (P = .0012), mortality rate at 4.6% versus 16.6% (P < .0001), patch repair required in 19.6% versus 55.4% (P = < .00001), and postoperative ECMO use of 3.7% versus 12.3% (P < .00001), respectively. Conclusion: MIS repair is associated with decreased length of hospital stay, reduced mortality rate, and postoperative ECMO usage. Hernia recurrence is still high among MIS repair groups compared to the open repair groups. Large, multicentered randomized control trials are recommended for further analysis to decipher the true superior surgical intervention.
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Affiliation(s)
| | - Semiu E Folaranmi
- Cardiff University School of Medicine, Cardiff, United Kingdom.,Department of Paediatric Surgery, University Hospital of Wales, Cardiff, United Kingdom
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15
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Molino J, Guillén G, Rocha O, Oliver B, López Fernández S, Khan H, de Mir I, Iglesias I, López M. Analysis of perceived risk and satisfaction with telematic follow-up in patients and families of congenital diaphragmatic hernia patients during SARS-CoV-2 pandemia. J Healthc Qual Res 2023; 38:20-25. [PMID: 35835633 PMCID: PMC9221794 DOI: 10.1016/j.jhqr.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/23/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The impact of COVID-19 in families and patients with congenital diaphragmatic hernia (CDH) is unknown, this situation has generated uncertainty not only in family members but also in the optimal outpatient follow-up. Telehealth has become a fundamental tool for the follow-up during the pandemic. The objective of this survey is to evaluated the impact of SARS-CoV-2 in families and patients with CDH and the satisfaction with telematic follow-up. METHODS Telephone survey of patient's caregivers with CHD, aged 1-16 years, followed in neonatal surgery outpatients, from January 31, 2020 to November 15, 2020. The ethical clearance for this study was taken from the Clinical Research Ethics Committee of our Research Institute vide letter number VHIR/239283/01.01.2021. RESULTS 81 surveys of 100 patients with active follow-up were carried out. There were no refusals in any contacted parents. There were 30 contacts (37%), 44.8% at school and 27.6% from cohabiting family members. Four infections (4.9%) were diagnosed, half symptomatic. In 40 patients (49.4%) the follow-up was telematic, with a mean score of 3.1±1.3 out of 5. For future controls, 65% prefer presential follow-up, 25% alternate and 10% telematics. 50.6% reported greater anxiety and 34.6% (28/81) extreme measures of isolation, being more accentuated in the group of 3-6 years (p<0.05). CONCLUSION The impact of COVID19 in patients with CHD is not greater than in the general pediatric population. Although the incorporation of the telehealth was well valued, most of the caregivers prefer the face-to-face outpatient follow-up.
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Affiliation(s)
- J.A. Molino
- Pediatric Surgery and Urology Department, Neonatal Surgery Unit, Universitat Autónoma de Barcelona, Vall d’Hebron Hospital Campus, Barcelona, Spain,Corresponding author
| | - G. Guillén
- Pediatric Surgery and Urology Department, Neonatal Surgery Unit, Universitat Autónoma de Barcelona, Vall d’Hebron Hospital Campus, Barcelona, Spain
| | - O. Rocha
- Pediatric Surgery and Urology Department, Universitat Autónoma de Barcelona, Vall d’Hebron Hospital Campus, Barcelona, Spain
| | - B. Oliver
- Pediatric Surgery and Urology Department, Universitat Autónoma de Barcelona, Vall d’Hebron Hospital Campus, Barcelona, Spain
| | - S. López Fernández
- Pediatric Surgery and Urology Department, Neonatal Surgery Unit, Universitat Autónoma de Barcelona, Vall d’Hebron Hospital Campus, Barcelona, Spain
| | - H.A. Khan
- Pediatric Surgery and Urology Department, Universitat Autónoma de Barcelona, Vall d’Hebron Hospital Campus, Barcelona, Spain
| | - I. de Mir
- Pediatric Pulmonolocy Department, Universitat Autónoma de Barcelona, Vall d’Hebron Hospital Campus, Barcelona, Spain
| | - I. Iglesias
- Pediatric Pulmonolocy Department, Universitat Autónoma de Barcelona, Vall d’Hebron Hospital Campus, Barcelona, Spain
| | - M. López
- Pediatric Surgery and Urology Department, Universitat Autónoma de Barcelona, Vall d’Hebron Hospital Campus, Barcelona, Spain
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16
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Sullivan GA, Skertich NJ, Kwong J, Owen G, Pillai S, Madonna MB, Shah AN, Gulack BC. Minimally Invasive Approaches and Use of a Patch Are Not Associated with Increased Recurrence Rates After Congenital Diaphragmatic Hernia Repair. J Laparoendosc Adv Surg Tech A 2022; 32:1228-1233. [PMID: 36161877 DOI: 10.1089/lap.2022.0236] [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: 12/14/2022] Open
Abstract
Background: Minimally invasive surgery (MIS) is increasingly used for repair of congenital diaphragmatic hernia (CDH). Reported recurrence after MIS repair varies and is limited by short follow-up and low volume. Our objective was to compare recurrence after MIS versus open repair of CDH. Materials and Methods: Infants who underwent CDH repair between 2010 and 2020 were identified using the PearlDiver Mariner database, a national patient claims data set allowing longitudinal follow-up of patients across systems. Kaplan-Meier analysis and Cox proportional hazards regression models were used to evaluate the association of surgical approach (MIS versus open) and use of a patch with time to recurrence while adjusting for comorbidities (congenital heart disease and pulmonary hypertension) and length of stay (LOS). Results: In a cohort of 629 infants, 25.6% (n = 161) underwent MIS repair with a median follow-up of 4.8 years and recurrence rate of 38.6% (n = 243). Rates of recurrence after MIS repair were lower than open (5 years: 38.6% versus 44.3%; P = .03) and higher with use of patch (5 years: 60.1% versus 40.1%; P = .02). After adjustment for comorbidities and LOS as a proxy for patient complexity, there was no significant difference in recurrence based on approach (adjusted hazard ratio [aHR]: 0.79; confidence interval [95% CI]: 0.57-1.10; P = .16) or use of patch (aHR: 1.22; 95% CI: 0.83-1.79; P = .32). Conclusions: Recurrence rates after repair of CDH were not different based on surgical approach or use of patch after adjustment. Previous data were likely biased by patient complexity, and surgeons should consider these factors in determining approach.
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Affiliation(s)
- Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Nicholas J Skertich
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jacky Kwong
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Grant Owen
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Srikumar Pillai
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Mary Beth Madonna
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Ami N Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian C Gulack
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
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17
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Abstract
Congenital diaphragmatic hernia (CDH) is a challenging surgical disease that requires complex preoperative, perioperative, and postoperative care. Survival depends on successful reduction and repair of the defect, and numerous complex decisions must be made regarding timing and preparation for surgery. This review describes the challenges and controversies inherent to surgical CDH care and provides recommendations for management based on the most recent evidence.
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Affiliation(s)
- Matthew T Harting
- Department of Pediatric Surgery, Children's Memorial Hermann Hospital, University of Texas McGovern Medical School, 6431 Fannin Street, MSB: 5.233, Houston, TX 77030, USA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap Street Second Floor, Memphis, TN 38105, USA.
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18
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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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19
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Long-Term Outcomes of Congenital Diaphragmatic Hernia: Report of a Multicenter Study in Japan. CHILDREN 2022; 9:children9060856. [PMID: 35740795 PMCID: PMC9222080 DOI: 10.3390/children9060856] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/02/2022] [Accepted: 06/07/2022] [Indexed: 12/04/2022]
Abstract
Background: Treatment modalities for neonates with congenital diaphragmatic hernia (CDH) have greatly improved in recent years, with a concomitant increase in survival. However, long-term outcomes restrict the identification of optimal care pathways for CDH survivors in adolescence and adulthood. Therefore, we evaluated the long-term outcomes within the Japanese CDH Study Group (JCDHSG). Methods: Participants were born with CDH between 2006 and 2018 according to the JCDHSG. Participants were enrolled in the database at 1.5, 3, 6, and 12 years old. Follow-up items included long-term complications, operations for long-term complication, and home medical care. Results: A total of 747 patients were included in this study, with 626 survivors (83.8%) and 121 non-survivors (16.2%). At 1.5, 3, 6, and 12 years old, 45.4%, 36.5%, 34.8%, and 43.6% developed complications, and 20.1%, 14.7%, 11.5%, and 5.1% of participants required home care, respectively. Recurrence, pneumonia, pneumothorax, gastroesophageal reflux disease, and intestinal obstruction decreased with age, and thoracic deformity increased with age. Conclusions: As CDH survival rates improve, there is a need for continued research and fine-tuning of long-term care to optimize appropriate surveillance and long-term follow-up.
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20
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Zani A, Chung WK, Deprest J, Harting MT, Jancelewicz T, Kunisaki SM, Patel N, Antounians L, Puligandla PS, Keijzer R. Congenital diaphragmatic hernia. Nat Rev Dis Primers 2022; 8:37. [PMID: 35650272 DOI: 10.1038/s41572-022-00362-w] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/09/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. .,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Wendy K Chung
- Department of Paediatrics, Columbia University, New York, NY, USA
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child and Clinical Department of Obstetrics and Gynaecology, University Hospitals, KU Leuven, Leuven, Belgium.,Institute for Women's Health, UCL, London, UK
| | - Matthew T Harting
- Department of Paediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.,The Comprehensive Center for CDH Care, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shaun M Kunisaki
- Division of General Paediatric Surgery, Johns Hopkins Children's Center, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Lina Antounians
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pramod S Puligandla
- Department of Paediatric Surgery, Harvey E. Beardmore Division of Paediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard Keijzer
- Department of Surgery, Division of Paediatric Surgery, Paediatrics & Child Health, Physiology & Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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21
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Lewis L, Sinha I, Losty PD. Clinical trials and outcome reporting in congenital diaphragmatic hernia overlook long-term health and functional outcomes-A plea for core outcomes. Acta Paediatr 2022; 111:1481-1489. [PMID: 35567507 PMCID: PMC9542300 DOI: 10.1111/apa.16409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/09/2022] [Accepted: 05/12/2022] [Indexed: 11/27/2022]
Abstract
Aim To review the selection, measurement and reporting of outcomes in studies of interventions in Congenital Diaphragmatic Hernia (CDH). Methods We searched the Cochrane Central Register of Controlled Trials from 2000–2020 for randomised trials and observational studies. Outcomes reported were classified into seven key domains modelled on the patient journey. Results Our search yielded 118 papers; 27 were eligible. The most frequent domains measured were ‘short‐term markers of disease activity’ (17/27), whereas long‐term outcomes (3/27) and outcomes relating to functional health status (8/27) were reported infrequently. There was heterogeneity in the methods and timing of outcome reporting. Primary outcomes were varied and not always clearly stated. Conclusion Long‐term health and functional outcomes involving interventional studies in CDH are infrequently reported, which hinders the process of shared decision‐making and evidence‐based healthcare. A CDH core outcome set is needed to standardise outcome reporting that is relevant to both families and healthcare teams.
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Affiliation(s)
- Leonie Lewis
- Institute of Life Course and Medical Sciences University of Liverpool Liverpool UK
| | - Ian Sinha
- Department of Paediatric Respiratory Medicine Alder Hey Children's Hospital NHS Foundation Trust Liverpool UK
| | - Paul D. Losty
- Institute of Life Course and Medical Sciences University of Liverpool Liverpool UK
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22
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Musculoskeletal deformities in children with congenital thoracic malformations: a population-based cohort study. Pediatr Surg Int 2022; 38:731-736. [PMID: 35235016 DOI: 10.1007/s00383-022-05101-6] [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] [Accepted: 02/02/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE It is unclear if musculoskeletal deformities observed in patients with congenital diaphragmatic hernia (CDH), congenital lung lesion (CLL) and esophageal atresia/tracheoesophageal fistula (EA/TEF) are associated with the anomaly or are a result of the surgery required to treat the anomaly. This study compared the prevalence of musculoskeletal deformities for: (1) children with congenital thoracic anomalies to controls; (2) CLL to EA/TEF both repaired via thoracotomy; and (3) CLL and EA/TEF to CDH repaired via laparotomy. METHODS We performed a retrospective study of children with CLL, CDH or EA/TEF between 1990 and 2016. Date-of-birth-matched control groups were generated from a population-based dataset. International Classification of Disease codes were used to identify scoliosis and pectus anomalies. We determined Hazard ratios (HR) for cases versus controls. RESULTS We included 167 cases (CDH n = 82; CLL n = 29; EA/TEF n = 56) and 1670 controls. EA/TEF had a greater risk of scoliosis (HR 5.52, 95%CI 1.49,13.73) and pectus deformities (HR 4.07, 95%CI 1.96,8.45). CDH showed more scoliosis (HR 5.03, 95%CI 1.99,12.74) but not pectus anomalies. Musculoskeletal deformities were not more common in CLL. CONCLUSION Children born with CDH or EA/TEF, but not CLL, had more musculoskeletal deformities than controls. The inconsistent association between musculoskeletal deformities and the surgical approach suggested a congenital predisposition.
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Risk stratification helps identify congenital diaphragmatic hernia (CDH) infants in need of formal neurodevelopmental assessment: Observations from a structured, interdisciplinary long-term follow-up clinic. J Pediatr Surg 2022; 57:846-850. [PMID: 35090718 DOI: 10.1016/j.jpedsurg.2021.12.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 12/30/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND/PURPOSE Neurodevelopmental delay (NDD) affects congenital diaphragmatic hernia (CDH) infants. Initial assessment by experienced developmental pediatricians, supported by Bayley-3 tests, is a viable pathway for NDD identification and surveillance. We risk stratified CDH infants to observe differences in incidence and type of NDD based on disease severity. METHODS Patients from a CDH long-term follow-up database started in 2012 were reviewed (REB#2019-4583). Risk stratification into low, moderate, and high-risk cohorts was performed using the CDH Study Group Mortality Prediction Score. Patients requiring ECLS, supplemental oxygen at 30 days and patch repair were also considered high-risk (i.e. usual clinical criteria). Post-discharge NDD assessments by developmental pediatricians and occupational therapists (Bayley-3) were analyzed for all patients >18months. NDD incidence and type per risk group was determined using descriptive statistics. RESULTS Of 102 CDH patients included for study, 26% (27/102) had NDD. Risk stratification identified 2(2%), 7(7%), and 18(18%) patients with NDD in the low, moderate and high-risk groups, respectively. Language delay (2 low; 6 moderate; 10 high) was the most prevalent. Three patients had both expressive and receptive language delay. Motor deficits were observed almost exclusively in the high-risk group. CONCLUSION Based on our experience, NDD affects one-quarter of CDH infants. Risk stratification helped identify infants at increased risk of NDD. While language delays predominated across all risk groups, multiple deficits occurred in higher risk cohorts. These patients should receive structured NDD assessment as part of an optimal interdisciplinary CDH care pathway.
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24
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Customized bioreactor enables the production of 3D diaphragmatic constructs influencing matrix remodeling and fibroblast overgrowth. NPJ Regen Med 2022; 7:25. [PMID: 35468920 PMCID: PMC9038738 DOI: 10.1038/s41536-022-00222-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 03/01/2022] [Indexed: 02/06/2023] Open
Abstract
The production of skeletal muscle constructs useful for replacing large defects in vivo, such as in congenital diaphragmatic hernia (CDH), is still considered a challenge. The standard application of prosthetic material presents major limitations, such as hernia recurrences in a remarkable number of CDH patients. With this work, we developed a tissue engineering approach based on decellularized diaphragmatic muscle and human cells for the in vitro generation of diaphragmatic-like tissues as a proof-of-concept of a new option for the surgical treatment of large diaphragm defects. A customized bioreactor for diaphragmatic muscle was designed to control mechanical stimulation and promote radial stretching during the construct engineering. In vitro tests demonstrated that both ECM remodeling and fibroblast overgrowth were positively influenced by the bioreactor culture. Mechanically stimulated constructs also increased tissue maturation, with the formation of new oriented and aligned muscle fibers. Moreover, after in vivo orthotopic implantation in a surgical CDH mouse model, mechanically stimulated muscles maintained the presence of human cells within myofibers and hernia recurrence did not occur, suggesting the value of this approach for treating diaphragm defects.
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25
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Gerall CD, Stewart LA, Price J, Kabagambe S, Sferra SR, Schmaedick MJ, Hernan R, Khlevner J, Krishnan US, De A, Aspelund G, Duron VP. Long-term outcomes of congenital diaphragmatic hernia: A single institution experience. J Pediatr Surg 2022; 57:563-569. [PMID: 34274078 DOI: 10.1016/j.jpedsurg.2021.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/03/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND/PURPOSE As survival rates for patients with congenital diaphragmatic hernia (CDH) increase, long-term sequelae become increasingly prevalent. We present the outcomes of patients who underwent CDH repair at our institution and discuss standardization of follow-up care in our long-term multidisciplinary follow-up clinic. METHODS A retrospective review of patients followed in multidisciplinary clinic after CDH repair at our institution from January 1, 2005 to December 1, 2020. RESULTS A total of 193 patients met inclusion criteria, 73 females (37.8%) and 120 males (62.2%). Left-sided defects were most common (75.7%), followed by right-sided defects (20.7%). Median age at repair was 4 days (IQR 3-6) and 59.6% of all defects required patch repair. Median length of stay was 29 days (IQR 16.8-50.0). Median length of follow up was 49 months (IQR 17.8-95.3) with 25 patients followed for more than 12 years. Long-term outcomes included gastroesophageal reflux disease (42.0%), diaphragmatic hernia recurrence (10.9%), asthma (23.6%), neurodevelopmental delay (28.6%), attention deficit hyperactivity disorder (7.3%), autism (1.6%), chest wall deformity (15.5%), scoliosis (11.4%), and inguinal hernia (6.7%). CONCLUSION As survival of patients with CDH improves, long-term care must be continuously studied and fine-tuned to ensure appropriate surveillance and optimization of long-term outcomes.
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Affiliation(s)
- Claire D Gerall
- Division of Pediatric Surgery, Department of Surgery. Columbia University Vagelos College of Physicians and Surgeons / NewYork-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway CH2N, New York, NY 10032, USA
| | - Latoya A Stewart
- Division of Pediatric Surgery, Department of Surgery. Columbia University Vagelos College of Physicians and Surgeons / NewYork-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway CH2N, New York, NY 10032, USA
| | - Jessica Price
- Division of Pediatric Surgery, Department of Surgery. Columbia University Vagelos College of Physicians and Surgeons / NewYork-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway CH2N, New York, NY 10032, USA
| | - Sandra Kabagambe
- Division of Pediatric Surgery, Department of Surgery. Columbia University Vagelos College of Physicians and Surgeons / NewYork-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway CH2N, New York, NY 10032, USA
| | - Shelby R Sferra
- Division of Pediatric Surgery, Department of Surgery. Columbia University Vagelos College of Physicians and Surgeons / NewYork-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway CH2N, New York, NY 10032, USA
| | - Maggie J Schmaedick
- Division of Pediatric Surgery, Department of Surgery. Columbia University Vagelos College of Physicians and Surgeons / NewYork-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway CH2N, New York, NY 10032, USA
| | - Rebecca Hernan
- Division of Pediatrics, Department of Molecular Genetics. Columbia University Vagelos College of Physicians and Surgeons / NewYork-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway CH2N, New York, NY 10032, USA
| | - Julie Khlevner
- Division of Pediatric Gastroenterology, Department of Pediatrics. Columbia University Vagelos College of Physicians and Surgeons / NewYork-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway CH2N, New York, NY 10032, USA
| | - Usha S Krishnan
- Division of Pediatric Cardiology, Department of Pediatrics. Columbia University Vagelos College of Physicians and Surgeons / NewYork-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway CH2N, New York, NY 10032, USA
| | - Aliva De
- Division of Pediatric Pulmonology, Department of Pediatrics. Columbia University Vagelos College of Physicians and Surgeons / NewYork-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway CH2N, New York, NY 10032, USA
| | - Gudrun Aspelund
- Division of Pediatric Surgery, Department of Surgery. Columbia University Vagelos College of Physicians and Surgeons / NewYork-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway CH2N, New York, NY 10032, USA
| | - Vincent P Duron
- Division of Pediatric Surgery, Department of Surgery. Columbia University Vagelos College of Physicians and Surgeons / NewYork-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway CH2N, New York, NY 10032, USA.
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26
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Commentary on long-term outcomes of congenital diaphragmatic hernia: A single institution experience. J Pediatr Surg 2022; 57:570-571. [PMID: 34645568 DOI: 10.1016/j.jpedsurg.2021.09.033] [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: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 11/24/2022]
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27
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Sivarajah V, Bhatnagar P, Tom KN, Wong JP, Gerstle JT, Moodie RG, Wong PD. Late Complication of Congenital Diaphragmatic Hernia Repair: Recurrent Small Bowel Obstruction. Pediatr Emerg Care 2022; 38:e1028-e1029. [PMID: 33900715 DOI: 10.1097/pec.0000000000002345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Congenital diaphragmatic hernia (CDH) is associated with high early mortality. However, advances in newborn care have led to improved survival into adolescence and early adulthood. We report a 17-year-old adolescent boy with recurrent small bowel obstruction after CDH repair at 2 days of age. Emergency physicians should be aware of late complications after neonatal CDH repair.
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Affiliation(s)
| | | | | | - Jonathan P Wong
- Department of Pediatrics, Faculty of Medicine, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - J Ted Gerstle
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rosemary G Moodie
- Department of Pediatrics, Faculty of Medicine, Hospital for Sick Children, University of Toronto, Toronto, Canada
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28
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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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29
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Zahn KB, Franz AM, Schaible T, Rafat N, Büttner S, Boettcher M, Wessel LM. Small Bowel Obstruction After Neonatal Repair of Congenital Diaphragmatic Hernia-Incidence and Risk-Factors Identified in a Large Longitudinal Cohort-Study. Front Pediatr 2022; 10:846630. [PMID: 35656380 PMCID: PMC9152166 DOI: 10.3389/fped.2022.846630] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE In patients with a congenital diaphragmatic hernia (CDH), postoperative small bowel obstruction (SBO) is a life-threatening event. Literature reports an incidence of SBO of 20% and an association with patch repair and ECMO treatment. Adhesions develop due to peritoneal damage and underly various biochemical and cellular processes. This longitudinal cohort study is aimed at identifying the incidence of SBO and the risk factors of surgical, pre-, and postoperative treatment. METHODS We evaluated all consecutive CDH survivors born between January 2009 and December 2017 participating in our prospective long-term follow-up program with a standardized protocol. RESULTS A total of 337 patients were included, with a median follow-up of 4 years. SBO with various underlying causes was observed in 38 patients (11.3%) and significantly more often after open surgery (OS). The majority of SBOs required surgical intervention (92%). Adhesive SBO (ASBO) was detected as the leading cause in 17 of 28 patients, in whom surgical reports were available. Duration of chest tube insertion [odds ratio (OR) 1.22; 95% CI 1.01-1.46, p = 0.04] was identified as an independent predictor for ASBO in multivariate analysis. Beyond the cut-off value of 16 days, the incidence of serous effusion and chylothorax was higher in patients with ASBO (ASBO/non-SBO: 2/10 vs. 3/139 serous effusion, p = 0.04; 2/10 vs. 13/139 chylothorax, p = 0.27). Type of diaphragmatic reconstruction, abdominal wall closure, or ECMO treatment showed no significant association with ASBO. A protective effect of one or more re-operations has been detected (RR 0.16; 95% CI 0.02-1.17; p = 0.049). CONCLUSION Thoracoscopic CDH repair significantly lowers the risk of SBO; however, not every patient is suitable for this approach. GoreTex®-patches do not seem to affect the development of ASBO, while median laparotomy might be more favorable than a subcostal incision. Neonates produce more proinflammatory cytokines and have a reduced anti-inflammatory capacity, which may contribute to the higher incidence of ASBO in patients with a longer duration of chest tube insertion, serous effusion, chylothorax, and to the protective effect of re-operations. In the future, novel therapeutic strategies based on a better understanding of the biochemical and cellular processes involved in the pathophysiology of adhesion formation might contribute to a reduction of peritoneal adhesions and their associated morbidity and mortality.
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Affiliation(s)
- Katrin B Zahn
- Department of Pediatric Surgery, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany.,ERNICA Centre, Mannheim, Germany
| | - Anna-Maria Franz
- Department of Pediatric Surgery, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany.,ERNICA Centre, Mannheim, Germany
| | - Thomas Schaible
- 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
| | - Sylvia Büttner
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Boettcher
- Department of Pediatric Surgery, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany.,ERNICA Centre, Mannheim, Germany
| | - Lucas M Wessel
- Department of Pediatric Surgery, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany.,ERNICA Centre, Mannheim, Germany
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30
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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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31
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Fry J, Antiel RM, Michelson K, Rowell E. Ethics in prenatal consultation for surgically correctable anomalies and fetal intervention. Semin Pediatr Surg 2021; 30:151102. [PMID: 34635274 DOI: 10.1016/j.sempedsurg.2021.151102] [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: 10/20/2022]
Abstract
Pediatric surgeons play an essential role in prenatal consultation for congenital anomalies likely to require surgery in the newborn period. The involvement of pediatric surgeons during multi-disciplinary prenatal meetings has been an important part of the evolution of comprehensive fetal care, characterized by detailed prenatal evaluation, diagnosis, prognosis, and planned perinatal and post-natal care. Advances in fetal diagnostics and treatments, as well as complex postnatal medical care and decision-making create a broad range of care options for pregnant women with fetal surgical anomalies. Ethical challenges involve the availability and risks/benefits of maternal-fetal surgery, and diagnostic and prognostic uncertainty for the newborn. Clinical scenarios illustrate cases that pediatric surgeons may encounter in practice, with discussions highlighting the ethical principles involved as well as considerations for management.
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Affiliation(s)
- Jessica Fry
- Division of Neonatology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, United States; Northwestern University, Feinberg School of Medicine, United States
| | - Ryan M Antiel
- Division of Pediatric Surgery, Riley Children's Hospital, Department of Surgery, Indiana University School of Medicine, United States
| | - Kelly Michelson
- Division of Critical Care Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, United States; Northwestern University, Feinberg School of Medicine, United States
| | - Erin Rowell
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, United States; Northwestern University, Feinberg School of Medicine, United States.
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32
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One-year outcomes of congenital diaphragmatic hernia repair: Factors associated with recurrence and complications. J Pediatr Surg 2021; 56:1542-1546. [PMID: 33268050 DOI: 10.1016/j.jpedsurg.2020.09.018] [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: 07/09/2020] [Revised: 09/03/2020] [Accepted: 09/17/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Congenital diaphragmatic hernia (CDH) is a congenital anomaly associated with lifelong multisystem morbidity. This study sought to identify factors contributing to hospital readmission after CDH repair. METHODS The Nationwide Readmissions Database from 2010 to 2014 was used to identify patients with CDH who underwent surgical repair. Primary outcomes included all cause readmission at 30-days and 1 year and readmission for hernia recurrence. Patient and hospital factors were compared using chi-squared analysis. RESULTS Five hundred eleven patients were identified with neonatal CDH. All repairs were performed at teaching hospitals via laparotomy in 59% (n = 303), thoracotomy in 36% (n = 183), and minimally invasive (MIS) repair in 5% (n = 25). The readmission rate within 30-days was 32% (n = 163), and 97% (n = 495) within 1 year. The most common conditions surrounding readmission were for gastroesophageal reflux (20%), CDH recurrence (17%), and surgery for gastrostomy tube and/or fundoplication (16%). Recurrence was significantly higher after MIS repair (48%) compared to those with open repair via either approach (16%), p < 0.001. CONCLUSIONS This is the first study to evaluate nationwide readmissions in newborns with CDH. Readmission is commonly due to CDH recurrence and reflux-associated complications. The recurrence rate is higher than previously reported and is more common after MIS and repair via thoracotomy. LEVEL OF EVIDENCE Level III treatment study.
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33
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Tragesser CJ, Hafezi N, Kitsis M, Markel TA, Gray BW. Survivors of congenital diaphragmatic hernia repair face barriers to long-term follow-up care. J Surg Res 2021; 267:243-250. [PMID: 34171561 DOI: 10.1016/j.jss.2021.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/16/2021] [Accepted: 05/07/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) carries high morbidity and mortality, and survivors commonly have neurodevelopmental, gastrointestinal, and pulmonary sequela requiring multidisciplinary care well beyond repair. We predict that following hospitalization for repair, CDH survivors face many barriers to receiving future medical care. METHODS A retrospective review was conducted of all living CDH patients between ages 0 to 12 years who underwent repair at Riley Hospital for Children (RHC) from 2010 through 2019. Follow-up status with specialty providers was reviewed, and all eligible families were contacted to complete a survey regarding various aspects of their child's care, including functional status, quality of life, and barriers to care. Bivariate analysis was applied to patient data (P < 0.05 was significant) and survey responses were analyzed qualitatively. RESULTS After exclusions, 70 survivors were contacted. Thirty-three (47%) were deemed lost to follow up to specialist providers, and were similar to those who maintained follow-up with respect to defect severity type (A-D, P = 0.57), ECMO use (P = 0.35), number of affected organ systems (P = 0.36), and number of providers following after discharge (P = 0.33). Seventeen (24%) families completed the survey, of whom eight (47%) were deemed lost to follow up to specialist providers. Families reported distance and time constraints, access to CDH-specific information and care, access to CDH-specific resources, and access to healthcare as significant barriers to care. All respondents were interested in a multidisciplinary CDH clinic. CONCLUSIONS CDH survivors require multidisciplinary care beyond initial repair, but attrition to follow-up after discharge is high. A multidisciplinary CDH clinic may address caregivers' perceived barriers.
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Affiliation(s)
| | - Niloufar Hafezi
- Indiana University School of Medicine, Department of Surgery, Division of Pediatric Surgery, Riley Hospital for Children, Indianapolis, Indiana
| | - Michelle Kitsis
- University of Illinois At Chicago Metropolitan Group Hospitals, Department of Surgery, Chicago, Illinois
| | - Troy A Markel
- Indiana University School of Medicine, Department of Surgery, Division of Pediatric Surgery, Riley Hospital for Children, Indianapolis, Indiana
| | - Brian W Gray
- Indiana University School of Medicine, Department of Surgery, Division of Pediatric Surgery, Riley Hospital for Children, Indianapolis, Indiana.
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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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Video-Assisted Thoracic Surgery for Late Recurrence of Congenital Diaphragmatic Hernia. SURGERIES 2021. [DOI: 10.3390/surgeries2020014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is often diagnosed and treated in the perinatal period. Recurrence is a known complication that may very rarely occur years after the operation. We report here the case of a patient who had an operation for a CDH at birth that then recurred in adulthood. Given the risk of complications and the symptomatology of the patient, we decided to treat the patient surgically. We successfully performed a video-assisted thoracic surgery (VATS) procedure during which we reduced the hernia and closed the breach. Given the recurrent nature of the hernia, we decided to reinforce the repair with a mesh.
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Słowik-Moczydłowska Ż, Kamiński A. Recurrent congenital diaphragmatic hernia: A single center experience. LA PEDIATRIA MEDICA E CHIRURGICA 2021; 43. [PMID: 33666066 DOI: 10.4081/pmc.2021.228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 02/11/2021] [Indexed: 11/23/2022] Open
Abstract
Congenital Diaphragmatic Hernia (CDH) occurs in 1:4000 live births. It's morbidity and mortality rates are significant. Recurrence is one of the recognized complications occurring after a successful initial repair. Poorly known are the rate of recurrence and factors that may influence the re-herniation. Poorly described are its morphology and treatment. Medical records of 95 neonates with CDH who had undergone repair at tertiary pediatric teaching hospital between 2007-2018 were retrospectively reviewed. Prior to surgery, peri-operative and recurrence data were collected. The follow-up was 1 to 12 years after the initial repair. Recurrence occurred in 22/84 (26%) patients. In 5 patients we observed more than one recurrence, total number of 27 (32%) re-herniations; 16/22 (72%) recurrences occurred within first 12 months; 7/27 (26%) recurrences were symptomatic which gives the symptomatic recurrence rate 8.3%; 20/27 (74%) were asymptomatic. There were no significant differences between groups considering LHR, gestational age, birth weight, severity of pre-surgery and post-surgery stabilization period. Significantly higher Apgar scores were in the group without recurrence. Among subjects with recurrent CDH majority had a left-sided defect, no hernia sac, no liver herniation, diaphragm was primarily sutured, abdominal wall primarily closed. Even though none of those factors was significantly related with the recurrence. Recurrence in CDH remains a significant issue for long-term surgical morbidity, especially more apparent in the first year of life. As long as the risk factors of re-herniation remains unclear, the most important seems to be routine follow-up protocol allowing for CDH recurrence detection.
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de Haro Jorge I, Prat Ortells J, Martín-Solé O, Muñoz Fernandez E, Pertierra A, Martin-Lluis A, Tarrado X. Porcine dermal patches as a risk factor for recurrence after congenital diaphragmatic hernia repair. Pediatr Surg Int 2021; 37:59-65. [PMID: 33245446 DOI: 10.1007/s00383-020-04787-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Recurrence of congenital diaphragmatic hernia (CDH) is a treatment-related morbidity which can be preventable. There is no consensus about the ideal material for diaphragmatic substitution. The aim of our study is to identify if the use of porcine dermis patches increases the risk of CDH recurrence. METHODS Retrospective review of medical records of CDH patients treated between 2013 and 2017 in our center was carried out. Demographic, clinical and surgical variables were collected. Regression analysis was performed to identify which factors increase the risk of recurrence. RESULTS 50 patients entered the study. 94% of the patients had a left CDH, mean observed/expected lung-to-head ratio was 46%. 17 patients underwent a primary closure, the rest a patch closure: 25 Gore-Tex® and 8 porcine dermis patches were used. Seven patients presented recurrence (14%). Median follow-up time was 3.5 years (1.2-6.2). Univariate analysis revealed that the use of a porcine dermis patch (75%) increased the risk of recurrence compared with Gore-Tex® patch (4%) and primary closure (0%) p < 0.001 (HR 58.7; IC 95%: 6.9-501.2; p < 0.001). CONCLUSION The main risk factor for CDH recurrence is the use of a porcine dermis patch. We do not recommend the use of these patches for CDH repair.
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Affiliation(s)
- Irene de Haro Jorge
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain.
| | - Jordi Prat Ortells
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Oriol Martín-Solé
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Elena Muñoz Fernandez
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Africa Pertierra
- Department of Neonatology, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Alba Martin-Lluis
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Xavier Tarrado
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
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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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Chotzoglou E, Hedrick HL, Herkert LM, Goldshore MA, Rintoul NE, Panitch HB. Therapy at 30 days of life predicts lung function at 6 to 12 months in infants with congenital diaphragmatic hernia. Pediatr Pulmonol 2020; 55:1456-1467. [PMID: 32191392 DOI: 10.1002/ppul.24736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/09/2020] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Congenital diaphragmatic hernia (CDH) is associated with variable degrees of lung hypoplasia. Pulmonary support at 30 days postnatal age was found to be the strongest predictor of inpatient mortality and morbidity among CDH infants and was also associated with higher pulmonary morbidity at 1 and 5 years. It is not known, however, if there is a relationship between the need for medical therapy at 30 days of life and subsequent abnormalities in lung function as reflected in infant pulmonary function test (iPFT) measurements. OBJECTIVE We hypothesized that CDH infants who require more intensive therapy at 30 days would have more abnormal iPFT values at the time of their first infant pulmonary function study, reflecting the more severe spectrum of lung hypoplasia. METHODS A single-institution chart review of all CDH survivors who were enrolled in a Pulmonary Hypoplasia Program (PHP) through July 2019, and treated from 2002 to 2019 was performed. All infants were divided into groups based on their need for noninvasive (supplemental oxygen, high flow therapy, noninvasive mechanical ventilation) or invasive (mechanical ventilation, extracorporeal membrane oxygenation) respiratory assistance, bronchodilators, diuretic use, and pulmonary hypertension (PH) therapy (inhaled and/or systemic drugs) at 30 days. Descriptive and statistical analyses were performed between groups comparing subsequent lung function measurements. RESULTS A total of 382 infants (median gestational age [GA] 38.4 [interquartile range (IQR) = 37.1-39] weeks, 41.8% female, 70.9% Caucasian) with CDH were enrolled in the PHP through July 2019, and 118 infants underwent iPFT. The median age of the first iPFT was 6.6 (IQR = 5.3-11.7) months. Those requiring any pulmonary support at 30 days had a higher functional residual capacity (FRC) (z) (P = .03), residual volume (RV) (z) (P = .008), ratio of RV to total lung capacity (RV/TLC) (z) (P = .0001), and ratio of FRC to TLC (FRC/TLC) (z) (P = .001); a lower forced expiratory volume at 0.5 seconds (FEV0.5) (z) (P = .03) and a lower respiratory system compliance (Crs) (P = .01) than those who did not require any support. Similarly, those requiring diuretics and/or PH therapy at 30 days had higher fractional lung volumes, lower forced expiratory flows and Crs than infants who did not require such support (P < .05). CONCLUSIONS Infants requiring any pulmonary support, diuretics and/or PH therapy at 30 postnatal days have lower forced expiratory flows and higher fractional lung volumes, suggesting a greater degree of lung hypoplasia. Our study suggests that the continued need for PH, diuretic or pulmonary support therapy at 30 days can be used as additional risk-stratification measurements for evaluation of infants with CDH.
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Affiliation(s)
- Etze Chotzoglou
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of General Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Holly L Hedrick
- Department of General Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lisa M Herkert
- Department of General Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew A Goldshore
- Department of General Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Natalie E Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Howard B Panitch
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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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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Abstract
Survivorship of patients with congenital diaphragmatic hernia (CDH) has created a unique cohort of children, adolescents and adults with complex medical and surgical needs. Morbidities specific to this disease benefit from multi-specialty care, and the long term follow up of these patients offers a tremendous opportunity for research and collaboration. Herein we aim to offer an overview of the challenges that modern CDH survivors face, and include a risk-stratified algorithm as a general guideline for a multi-specialty follow up program.
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Affiliation(s)
- Laura E Hollinger
- Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas Street, MSC 613/CSB 417, Charleston SC 29425, USA.
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Long-term feeding issue and its impact on the daily life of congenital diaphragmatic hernia survivors: results of the first patient-led survey. Pediatr Surg Int 2020; 36:63-68. [PMID: 31696254 PMCID: PMC6976546 DOI: 10.1007/s00383-019-04570-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND CDH UK is a registered charity governed by a volunteer committee and providing informal support to patients, families and healthcare workers affected directly or indirectly with congenital diaphragmatic hernia (CDH) internationally. This is the first patient-led survey undertaken by CDH UK aiming for highlighting the feeding problems and their impact on the daily life of CDH survivors. METHODS Answers from CDH survivors were collected through an online questionnaire (SurveyMonkey®) undertaken by CDH UK. The questionnaire contained questions about their feeding problems and support they were receiving for it. MAIN RESULTS Overall, 151 patients answered some parts of the survey and 102 patients completed the questionnaire. Overall, 116 (76.8%) responders reported suffering from any type of feeding issue. Gastric acid reflux (GER) and growth retardation were the commonest symptoms experienced by 97 (91.5%) and 72 (62.2%) responders, respectively. Only 18 (17.0%) responders have received any written information on feeding or details of patient/parent support. Eighty (75.5%) responders are satisfied with the level of support they are receiving, but 78 (76.4%) answered that the whole experience associated with the disease has been very or extremely stressful. CONCLUSIONS CDH survivors frequently have various issues with feeding, which may not be adequately supported or discussed clinically. It is desirable to assist the patients to reliable resources of long-term support, including multidisciplinary team (MDT) approach.
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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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Long AM, Bunch KJ, Knight M, Kurinczuk JJ, Losty PD. One-year outcomes of infants born with congenital diaphragmatic hernia: a national population cohort study. Arch Dis Child Fetal Neonatal Ed 2019; 104:F643-F647. [PMID: 31154421 DOI: 10.1136/archdischild-2018-316396] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 02/28/2019] [Accepted: 03/02/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To report outcomes to 1 year, in infants born with congenital diaphragmatic hernia (CDH), explore factors associated with infant mortality and examine the relationship between surgical techniques and postoperative morbidity. DESIGN Prospective national population cohort study. SETTING Paediatric surgical centres in the UK and Ireland. METHOD Data were collected to 1 year for infants with CDH live-born between 1 April 2009 to 30 September 2010. Factors associated with infant mortality are explored using logistic regression. Postoperative morbidity following patch versus primary closure, minimally invasive versus open surgery and biological versus synthetic patch material is described. Data are presented as n (%) and median (IQR). RESULTS Overall known survival to 1 year was 75%, 95% CI 68% to 81% (138/184) and postoperative survival 93%, 95% CI 88% to 97% (138/148). Female sex, antenatal diagnosis, use of vasodilators or inotropes, being small for gestational age, patch repair and use of surfactant were all associated with infant death. Infants undergoing patch repair had a high incidence of postoperative chylothorax (11/54 vs 2/96 in infants undergoing primary closure) and a long length of hospital stay (41 days, IQR 24-68 vs 16 days, IQR 10-25 in primary closure group). Infants managed with synthetic patch material had a high incidence of chylothorax (11/34 vs 0/19 with biological patch). CONCLUSION The majority of infant deaths in babies born with CDH occur before surgical correction. Female sex, being born small for gestational age, surfactant use, patch repair and receipt of cardiovascular support were associated with a higher risk of death. The optimum surgical approach, timing of operation and choice of patch material to achieve lowest morbidity warrants further evaluation.
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Affiliation(s)
- Anna-May Long
- Department of Paediatric Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Kathryn J Bunch
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
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Talon I, Schneider A, Ball V, Hemmerle J. Polydopamine Functionalization: A Smart and Efficient Way to Improve Host Responses to e-PTFE Implants. Front Chem 2019; 7:482. [PMID: 31338362 PMCID: PMC6629787 DOI: 10.3389/fchem.2019.00482] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 06/24/2019] [Indexed: 11/24/2022] Open
Abstract
Among the different materials used as protheses for the treatment of Congenital Diaphragmatic Hernia, expanded polytetrafluoroethylene (e-PTFE) plays a leading role owing to its mechanical properties as explained in the first part of this review. However, this material is poorly cell adhesive, which is expected for its contact on the abdominal face, but should display specific tissue adhesion on its thoracic exposed faced. A side specific functionalization method is hence required. The deposition of a nanosized polydopamine film on PTFE is known to be possible but immersion of the e-PTFE membrane in an aerated dopamine solution leads to a functionalization not only on both faces of the membrane but also in its porous volume. The fact that polydopamine also forms at the water/air interface has allowed to transfer a polydopamine film on only one face of the e-PTFE membrane. The deposition method and applications of such Janus like membranes are reviewed in the second part of the review.
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Affiliation(s)
- Isabelle Talon
- Service de Chirurgie Pédiatrique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Institut National de la Santé et de la Recherche Médicale, UMR_S 1121, Strasbourg, France
| | - Anne Schneider
- Service de Chirurgie Pédiatrique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Institut National de la Santé et de la Recherche Médicale, UMR_S 1121, Strasbourg, France
| | - Vincent Ball
- Institut National de la Santé et de la Recherche Médicale, UMR_S 1121, Strasbourg, France.,Faculté de Chirurgie Dentaire, Université de Strasbourg, Strasbourg, France
| | - Joseph Hemmerle
- Institut National de la Santé et de la Recherche Médicale, UMR_S 1121, Strasbourg, France
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Ali K, Dassios T, Khaliq SA, Williams EE, Tamura K, Davenport M, Greenough A. Outcomes of infants with congenital diaphragmatic hernia by side of defect in the FETO era. Pediatr Surg Int 2019; 35:743-747. [PMID: 31089883 DOI: 10.1007/s00383-019-04484-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To compare the outcomes of infants with a right (RCDH) versus a left-sided (LCDH) congenital diaphragmatic hernia (CDH) and whether these differed according to whether the infants had undergone fetoscopic tracheal occlusion (FETO). METHODS Demographics, the type of surgical repair, preoperative and postoperative courses and respiratory, gastrointestinal, surgical and skeletal morbidities at follow-up were compared between infants with a RCDH or LCDH. A sub-analysis was undertaken in those who had undergone FETO. RESULTS During the study period, there were 167 infants with a LCDH and 24 with a RCDH; 106 underwent FETO (15 RCDH). Overall, the need for inhaled nitric oxide (p = 0.036) was higher in the RCDH group and, at follow-up, infants with RCDH were more likely to have a hernia recurrence (p = 0.043), pectus deformity (p = 0.019), scoliosis (p = 0.029) and suffer chronic respiratory morbidity (p = 0.001). There were, however, no significant differences in short term or long term outcomes (hernia recurrence (p = 0.237), pectus deformity (p = 0.322), scoliosis (p = 0.0174) or chronic respiratory morbidity (p = 0.326)) between infants with a right or left sided CDH who had undergone FETO. CONCLUSION Overall, infants with a RCDH compared to those with a LCDH had greater long-term morbidity, but not if they had undergone FETO.
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Affiliation(s)
- Kamal Ali
- Neonatal Intensive Care Centre, 4th Floor Golden Jubilee Wing, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Theodore Dassios
- Neonatal Intensive Care Centre, 4th Floor Golden Jubilee Wing, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.,Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Syed Abdul Khaliq
- Neonatal Intensive Care Centre, 4th Floor Golden Jubilee Wing, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Emma E Williams
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kentaro Tamura
- Neonatal Intensive Care Centre, 4th Floor Golden Jubilee Wing, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.,Division of Neonatology, Maternal and Perinatal Centre, Toyama University Hospital, Toyama, Japan
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Neonatal Intensive Care Centre, 4th Floor Golden Jubilee Wing, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK. .,Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK. .,The Asthma UK Centre for Allergic Mechanisms of Asthma, King's College London, London, UK. .,NIHR Biomedical Centre at Guy's and St Thomas NHS Foundation Trust and King's College London, London, UK.
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47
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Requirement and Duration of Tube Feed Supplementation among Congenital Diaphragmatic Hernia Patients. J Pediatr Surg 2019; 54:895-898. [PMID: 30773392 DOI: 10.1016/j.jpedsurg.2019.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 01/27/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE Oral feeds pose a challenge for congenital diaphragmatic hernia (CDH) infants. Tube feed (TF) supplementation may be required to support the achievement of normal growth. The aim of this study was to determine the duration and factors associated with TF use in CDH infants at our institution. METHODS A single centre retrospective chart review was performed for CDH-born infants who underwent repair between 2000 to 2013 (REB #1000053124). Patient demographics, perinatal management, and feeding status of infants with at least 1-year follow-up were reviewed. RESULTS Of 160 CDH infants, 32 (20%) were discharged on partial or complete TF, and an additional 5 (3.1%) patients started TF post discharge. CDH infants with TF were more likely to have initial arterial blood pH < 7.25, patch repair, ECMO support, and prolonged ICU stay (p < 0.05). Time to TF discontinuation did not differ significantly between those partially or fully TF at discharge. Twelve patients (33.3%) remained TF at their last known follow-up. CONCLUSION High risk CDH patients are likely to require TF to support their nutritional intake. Parents and caregivers need to be informed and properly supported. Long-term monitoring of CDH patient oral intake, growth, and development will be required. LEVEL OF EVIDENCE/TYPE OF STUDY Level III Retrospective Study.
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48
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Abstract
Pathologic processes that involve the central nervous system, phrenic nerve, neuromuscular junction, and skeletal muscle can impair diaphragm function. When these processes are of sufficient severity to cause diaphragm dysfunction, respiratory failure may be a consequence. This article reviews basic diaphragm anatomy and physiology and then discusses diagnostic and therapeutic approaches to disorders that result in unilateral or bilateral diaphragm dysfunction. This discussion provides a context in which disorders of the diaphragm and their implications on respiratory function can be better appreciated.
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Affiliation(s)
- F Dennis McCool
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA.
| | - Kamran Manzoor
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA
| | - Taro Minami
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA
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49
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Kamran A, Zendejas B, Demehri FR, Nath B, Zurakowski D, Smithers CJ. Risk factors for recurrence after thoracoscopic repair of congenital diaphragmatic hernia (CDH). J Pediatr Surg 2018; 53:2087-2091. [PMID: 30017067 DOI: 10.1016/j.jpedsurg.2018.04.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 02/19/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE To identify technical modifications concerning factors that may lower the risk of recurrence following thoracoscopic repair of congenital diaphragmatic hernia (CDH). METHODS All CDH patients who underwent thoracoscopic repair from April 2003 to September 2017 were retrospectively reviewed. Some of the more recently treated patients underwent technically modified repairs with underlay and overlay buttresses. RESULTS Sixty-eight patients underwent thoracoscopic repair of a diaphragmatic hernia that presented either neonatally (n = 52) or beyond the neonatal period (>1 month) (n = 16). At our institution, the minimally invasive surgical approach is considered for clinically stable CDH patients, who are likely to have type A or B defects. 21 patients had a sac-type defect. Forty-seven patients with type A defect had primary closure, buttressed in 6 cases. In 21 patients, the type B defect was repaired with a patch, buttressed in 11 patients. Median follow-up was 36 months (IQR 9-45). Recurrence occurred in 13 patients (overall 19% recurrence rate); all had a neonatally presented defect (25% vs. 0%, p = 0.03). Patients with a sac-type defect had a lower recurrence rate than patients with no hernia sac (5% vs. 26%, p = 0.05). Recurrence complicated 7 of 47 (15%) patients after primary closure and 6 of 21 (29%) patients with patch repair; none of the 17 cases with buttressed repairs had a recurrence. CONCLUSIONS Due to a higher rate of recurrence following thoracoscopic CDH repair compared to the standard open approach, we suggest a sandwich-type buttress repair with underlay and overlay components for both primary and patch repairs. LEVEL OF EVIDENCE Level III cohort study.
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Affiliation(s)
- Ali Kamran
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Benjamin Zendejas
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Farokh R Demehri
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Bharath Nath
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - David Zurakowski
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Charles J Smithers
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States.
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50
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Eastwood MP, Daamen WF, Joyeux L, Pranpanus S, Rynkevic R, Hympanova L, Pot MW, Hof DJ, Gayan-Ramirez G, van Kuppevelt TH, Verbeken E, Deprest J. Providing direction improves function: Comparison of a radial pore-orientated acellular collagen scaffold to clinical alternatives in a surgically induced rabbit diaphragmatic tissue defect model. J Tissue Eng Regen Med 2018; 12:2138-2150. [PMID: 30055525 DOI: 10.1002/term.2734] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 06/14/2018] [Accepted: 07/11/2018] [Indexed: 12/26/2022]
Abstract
Gore-Tex® is a widely used durable patch for repair of congenital diaphragmatic defects yet may result in complications. We compared Gore-Tex with a composite of a radial pore-orientated collagen scaffold (RP-Composite) and clinically used porcine small intestinal submucosa (SIS; Surgisis®) in a rabbit model for diaphragmatic hernia. The growing rabbit mimics the rapid rib cage growth and reherniation rates seen in children. We created and immediately repaired left hemidiaphragmatic defects in 6-week-old rabbits with Gore-Tex, SIS, and an RP-Composite scaffold. An additional group of rabbits had a sham operation. At 90 days, survivors more than doubled in weight. We observed few reherniations or eventrations in Gore-Tex (17%) and RP-Composite (22%) implanted animals. However, SIS failed in all rabbits. Maximum transdiaphragmatic pressure was lower in Gore-Tex (71%) than RP-Composite implanted animals (112%) or sham (134%). Gore-Tex repairs were less compliant than RP-Composite, which behaved as sham diaphragm (p < 0.01). RP-Composite induced less foreign body giant cell reaction than Gore-Tex (p < 0.05) with more collagen deposition (p < 0.001), although there was a tendency for the scaffold to calcify. Unlike Gore-Tex, the compliance of diaphragms reconstructed with RP-Composite scaffolds were comparable with native diaphragm, whereas reherniation rates and transdiaphragmatic pressure measurements were similar.
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Affiliation(s)
- Mary Patrice Eastwood
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium.,Center for Surgical Technologies, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Willeke F Daamen
- Department of Biochemistry, RIMLS, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luc Joyeux
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium.,Center for Surgical Technologies, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Savitree Pranpanus
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium.,Center for Surgical Technologies, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Obstetrics and Gynecology, Prince of Songkla University, Hat Yai, Thailand
| | - Rita Rynkevic
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium.,NEGI, Faculdade de Engenharia da Universidade do Porto, Universidade do Porto, Porto, Portugal
| | - Lucie Hympanova
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium.,Center for Surgical Technologies, Katholieke Universiteit Leuven, Leuven, Belgium.,Institute for the Care of the Mother and Child, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michiel W Pot
- Department of Biochemistry, RIMLS, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Danique J Hof
- Department of Biochemistry, RIMLS, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Toin H van Kuppevelt
- Department of Biochemistry, RIMLS, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eric Verbeken
- Department of Pathology, Group Biomedical Sciences, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium.,Center for Surgical Technologies, Katholieke Universiteit Leuven, Leuven, Belgium.,Research Department of Maternal Fetal Medicine, Institute of Women's Health, University College London, London, UK
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