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Keyes S, Spouge RJ, Kennedy P, Rai S, Abdellatif W, Sugrue G, Barrett SA, Khosa F, Nicolaou S, Murray N. Approach to Acute Traumatic and Nontraumatic Diaphragmatic Abnormalities. Radiographics 2024; 44:e230110. [PMID: 38781091 DOI: 10.1148/rg.230110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Acute diaphragmatic abnormalities encompass a broad variety of relatively uncommon and underdiagnosed pathologic conditions, which can be subdivided into nontraumatic and traumatic entities. Nontraumatic abnormalities range from congenital hernia to spontaneous rupture, endometriosis-related disease, infection, paralysis, eventration, and thoracoabdominal fistula. Traumatic abnormalities comprise both blunt and penetrating injuries. Given the role of the diaphragm as the primary inspiratory muscle and the boundary dividing the thoracic and abdominal cavities, compromise to its integrity can yield devastating consequences. Yet, diagnosis can prove challenging, as symptoms may be vague and findings subtle. Imaging plays an essential role in investigation. Radiography is commonly used in emergency evaluation of a patient with a suspected thoracoabdominal process and may reveal evidence of diaphragmatic compromise, such as abdominal contents herniated into the thoracic cavity. CT is often superior, in particular when evaluating a trauma patient, as it allows rapid and more detailed evaluation and localization of pathologic conditions. Additional modalities including US, MRI, and scintigraphy may be required, depending on the clinical context. Developing a strong understanding of the acute pathologic conditions affecting the diaphragm and their characteristic imaging findings aids in efficient and accurate diagnosis. Additionally, understanding the appearance of diaphragmatic anatomy at imaging helps in differentiating acute pathologic conditions from normal variations. Ultimately, this knowledge guides management, which depends on the underlying cause, location, and severity of the abnormality, as well as patient factors. ©RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Sarah Keyes
- From the Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (S.K., R.J.S., S.R., G.S., S.A.B., F.K., S.N., N.M.); Department of Radiology, Vancouver General Hospital, Jim Pattison Pavilion South, 899 W 12th Ave, Room G861, Vancouver, BC, Canada V5Z 1M9 (R.J.S., P.K., S.R., G.S., S.A.B., F.K., S.N., N.M.); and Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (W.A.)
| | - Rebecca J Spouge
- From the Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (S.K., R.J.S., S.R., G.S., S.A.B., F.K., S.N., N.M.); Department of Radiology, Vancouver General Hospital, Jim Pattison Pavilion South, 899 W 12th Ave, Room G861, Vancouver, BC, Canada V5Z 1M9 (R.J.S., P.K., S.R., G.S., S.A.B., F.K., S.N., N.M.); and Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (W.A.)
| | - Padraic Kennedy
- From the Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (S.K., R.J.S., S.R., G.S., S.A.B., F.K., S.N., N.M.); Department of Radiology, Vancouver General Hospital, Jim Pattison Pavilion South, 899 W 12th Ave, Room G861, Vancouver, BC, Canada V5Z 1M9 (R.J.S., P.K., S.R., G.S., S.A.B., F.K., S.N., N.M.); and Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (W.A.)
| | - Shamir Rai
- From the Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (S.K., R.J.S., S.R., G.S., S.A.B., F.K., S.N., N.M.); Department of Radiology, Vancouver General Hospital, Jim Pattison Pavilion South, 899 W 12th Ave, Room G861, Vancouver, BC, Canada V5Z 1M9 (R.J.S., P.K., S.R., G.S., S.A.B., F.K., S.N., N.M.); and Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (W.A.)
| | - Waleed Abdellatif
- From the Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (S.K., R.J.S., S.R., G.S., S.A.B., F.K., S.N., N.M.); Department of Radiology, Vancouver General Hospital, Jim Pattison Pavilion South, 899 W 12th Ave, Room G861, Vancouver, BC, Canada V5Z 1M9 (R.J.S., P.K., S.R., G.S., S.A.B., F.K., S.N., N.M.); and Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (W.A.)
| | - Gavin Sugrue
- From the Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (S.K., R.J.S., S.R., G.S., S.A.B., F.K., S.N., N.M.); Department of Radiology, Vancouver General Hospital, Jim Pattison Pavilion South, 899 W 12th Ave, Room G861, Vancouver, BC, Canada V5Z 1M9 (R.J.S., P.K., S.R., G.S., S.A.B., F.K., S.N., N.M.); and Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (W.A.)
| | - Sarah A Barrett
- From the Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (S.K., R.J.S., S.R., G.S., S.A.B., F.K., S.N., N.M.); Department of Radiology, Vancouver General Hospital, Jim Pattison Pavilion South, 899 W 12th Ave, Room G861, Vancouver, BC, Canada V5Z 1M9 (R.J.S., P.K., S.R., G.S., S.A.B., F.K., S.N., N.M.); and Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (W.A.)
| | - Faisal Khosa
- From the Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (S.K., R.J.S., S.R., G.S., S.A.B., F.K., S.N., N.M.); Department of Radiology, Vancouver General Hospital, Jim Pattison Pavilion South, 899 W 12th Ave, Room G861, Vancouver, BC, Canada V5Z 1M9 (R.J.S., P.K., S.R., G.S., S.A.B., F.K., S.N., N.M.); and Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (W.A.)
| | - Savvas Nicolaou
- From the Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (S.K., R.J.S., S.R., G.S., S.A.B., F.K., S.N., N.M.); Department of Radiology, Vancouver General Hospital, Jim Pattison Pavilion South, 899 W 12th Ave, Room G861, Vancouver, BC, Canada V5Z 1M9 (R.J.S., P.K., S.R., G.S., S.A.B., F.K., S.N., N.M.); and Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (W.A.)
| | - Nicolas Murray
- From the Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (S.K., R.J.S., S.R., G.S., S.A.B., F.K., S.N., N.M.); Department of Radiology, Vancouver General Hospital, Jim Pattison Pavilion South, 899 W 12th Ave, Room G861, Vancouver, BC, Canada V5Z 1M9 (R.J.S., P.K., S.R., G.S., S.A.B., F.K., S.N., N.M.); and Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Tex (W.A.)
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Dimmer A, Meehan M, Beauseigle S, Koclas L, Paquette K, Michel Macias C, Moore SS, Sant'Anna A, Shapiro A, Simoneau J, Villegas Martinez D, Altit G, Puligandla P. Disease severity impacts perceived quality of life in congenital diaphragmatic hernia: a prospective observational study. Arch Dis Child 2024; 109:510-514. [PMID: 38589198 DOI: 10.1136/archdischild-2024-326906] [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: 01/19/2024] [Accepted: 03/21/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND While research indicates comparable quality of life (QOL) in congenital diaphragmatic hernia (CDH) and healthy populations, the effect of CDH severity on patients' health perceptions remains unexplored. We aimed to assess QOL perception in CDH, hypothesising a decline correlated with increased disease severity. METHODS In this prospective observational study, we analysed patients with CDH aged 5 years and above participating in a longitudinal outpatient programme. We excluded bilateral CDH, genetic/syndromic conditions, prematurity and late diagnosis. Participants self-administered the age-adapted Pediatric Quality of Life Inventory (PedsQL) survey, covering four domains (physical, emotional, social, school). After enrolment, data were collected blind to severity status (larger defects denoting significant/'severe' disease). Repeated measurements were managed using a random mixed-effects model. RESULTS Of 34 participants (50% males) who completed the PedsQL, 10 provided measurements at two visits. Eight required a patch (type C), while 26 had primary repairs (type A=8; type B=18). Age at first evaluation was comparable across groups (no patch: median 11 (7-16), patch: 13 (8-15) years, p=0.78). Severe CDH correlated significantly with lower PedsQL scores (adjusted β: -18%, 95% CI -28%; -7%, adjusted for age at visit and sex). Lower scores specifically occurred in walking, exercising, social and academic functioning. CONCLUSION Severe CDH significantly lowers QOL. This finding is crucial for resource allocation in long-term CDH health surveillance and advocates for regular inclusion of patient experiences in quality improvement efforts.
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Affiliation(s)
- Alexandra Dimmer
- Harvey E Beardmore Division of Pediatric Surgery, Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Madison Meehan
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Sabrina Beauseigle
- Harvey E Beardmore Division of Pediatric Surgery, Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Louise Koclas
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Katryn Paquette
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Carolina Michel Macias
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Shiran S Moore
- Division of Neonatology, Dana-Dwek Children's Hospital, Tel Aviv, Israel
| | - Ana Sant'Anna
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Adam Shapiro
- Division of Respiratory Medicine, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Jessica Simoneau
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Daniela Villegas Martinez
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Gabriel Altit
- Division of Neonatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Québec, Canada
| | - Pramod Puligandla
- Harvey E Beardmore Division of Pediatric Surgery, Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, Québec, Canada
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Ding W, Gu Y, Wang H, Wu H, Zhang X, Zhang R, Wang H, Huang L, Lv J, Xia B, Zhong W, He Q, Hou L. Prenatal MRI assessment of mediastinal shift angle as a feasible and effective risk stratification tool in isolated right-sided congenital diaphragmatic hernia. Eur Radiol 2024; 34:1524-1533. [PMID: 37644150 DOI: 10.1007/s00330-023-10178-1] [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: 12/05/2022] [Revised: 06/21/2023] [Accepted: 07/07/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVES To develop a mediastinal shift angle (MSA) measurement method applicable to right-sided congenital diaphragmatic hernia (RCDH) in fetal MRI and to validate the predictive value of MSA in RCDH. METHODS Twenty-seven fetuses with isolated RCDH and 53 controls were included in our study. MSA was measured on MRI axial image at the level of four-chamber view of the fetal heart. The angle between the sagittal midline landmark line and the left boundary landmark line touching tangentially the lateral wall of the left ventricle was used to quantify MSA for RCDH. Appropriate statistical analyses were performed to determine whether MSA can be regarded as a valid predictive tool for postnatal outcomes. Furthermore, predictive performance of MSA was compared with that of lung area to head circumference ratio (LHR), observed/expected LHR (O/E LHR), total fetal lung volume (TFLV), and observed/expected TFLV (O/E TFLV). RESULTS MSA was significantly higher in the RCDH group than in the control group. MSA, LHR, O/E LHR, TFLV, and O/E TFLV were all correlated with postnatal survival, pulmonary hypertension (PH), and extracorporeal membrane oxygenation (ECMO) therapy (p < 0.05). Value of the AUC demonstrated good predictive performance of MSA for postnatal survival (0.901, 95%CI: (0.781-1.000)), PH (0.828, 95%CI: (0.661-0.994)), and ECMO therapy (0.813, 95%CI: (0.645-0.980)), which was similar to O/E TFLV but slightly better than TFLV, O/E LHR, and LHR. CONCLUSIONS We developed a measurement method of MSA for RCDH for the first time and demonstrated that MSA could be used to predict postnatal survival, PH, and ECMO therapy in RCDH. CLINICAL RELEVANCE STATEMENT Newly developed MRI assessment method of fetal MSA in RCDH offers a simple and effective risk stratification tool for patients with RCDH. KEY POINTS • We developed a measurement method of mediastinal shift angle for right-sided congenital diaphragmatic hernia for the first time and demonstrated its feasibility and reproducibility. • Mediastinal shift angle can predict more prognostic information other than survival in right-sided congenital diaphragmatic hernia with good performance. • Mediastinal shift angle can be used as a simple and effective risk stratification tool in right-sided congenital diaphragmatic hernia to improve planning of postnatal management.
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Affiliation(s)
- Wen Ding
- Department of Fetal Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yuanyuan Gu
- Department of Fetal Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
| | - Haiyu Wang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Huiying Wu
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Xiaochun Zhang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Rui Zhang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Hongying Wang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Li Huang
- Department of Medical Imaging, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Junjian Lv
- Surgical Neonatal Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Bo Xia
- Surgical Neonatal Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Wei Zhong
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Qiuming He
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Longlong Hou
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
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Inoue S, Muta Y, Takeuchi Y, Odaka A. Two cases of right congenital diaphragmatic hernia with stable respiratory condition: Two case reports. Int J Surg Case Rep 2024; 114:109036. [PMID: 38039568 PMCID: PMC10730737 DOI: 10.1016/j.ijscr.2023.109036] [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: 10/03/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 12/03/2023] Open
Abstract
INTRODUCTION Right congenital diaphragmatic defect (CDH) has been reported poor prognosis. However, laterality of the defect as the prognostic factor is recent controversial topic. We experienced two cases of right CDH with relatively stable respiratory condition and good clinical course. PRESENTATION OF CASES Case 1 was a girl diagnosed with right CDH by fetal ultrasonography and delivered by planned caesarian section at 37 weeks, 3 days. Fetal MRI showed liver herniation into the right thoracic cavity. High frequency oscillatory ventilation with nitric oxide gas was administered until day 5. At surgery on day 8, we found defects in the right posterolateral diaphragm and sac herniation of the right side of the liver into the right thoracic cavity. The postsurgical course was uneventful, and she was discharged on day 41. Case 2 was a girl with suspected congenital jejunal atresia after fetal ultrasonography detected polyhydramnios and dilatation. She was delivered by normal vaginal delivery at 38 weeks, 5 days, and thoraco-abdominal X ray showed right CDH but no small intestinal atresia. Surgery performed on day 3 found liver herniation into the diaphragmatic defect. Subsequently, bacterial infection occurred and was treated with the antibiotics, but her respiratory condition remained stable. She was discharged on day 49. DISCUSSION The volume of herniated abdominal organs is affected by the presence of a hernia sac or the size of the diaphragmatic defect. CONCLUSION The size of diaphragmatic defect, but not the laterality of the diaphragmatic defect, may be an important prognostic factor in right CDH.
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Affiliation(s)
- Seiichiro Inoue
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan.
| | - Yuki Muta
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
| | - Yuta Takeuchi
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
| | - Akio Odaka
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
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Nakagawa Y, Uchida H, Hinoki A, Shirota C, Sumida W, Makita S, Amano H, Masamune O, Takimoto A, Ogata S, Takada S, Kato D, Gohda Y, Guo Y. Rare case of a right Bochdalek hernia with retroperitoneal prolapse of organs into the thoracic cavity in infancy: A case report. Asian J Endosc Surg 2022; 16:284-288. [PMID: 36336788 DOI: 10.1111/ases.13139] [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: 08/11/2022] [Revised: 10/11/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
We report an extremely rare case of a right Bochdalek hernia with a sac, in which the retroperitoneal and intra-abdominal organs prolapsed into the thoracic cavity at the same time. The patient was a 7-month-old female with no comorbidities. She presented with cough and fever, and chest radiography revealed a right diaphragmatic hernia. Computed tomography showed that the right kidney, intestine, colon, and liver had prolapsed into the thoracic cavity. The patient underwent thoracoscopic surgery, which showed that the abdominal and retroperitoneal organs prolapsed into the thoracic cavity through the Bochdalek hernia. The herniated organs were spontaneously reduced using thoracoscopic insufflation. The defect hole was closed with artificial mesh. We adopted a thoracoscopic approach, in terms of easy reduction of herniated organs and accurate evaluation of the hernia orifice, which was useful.
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Affiliation(s)
- Yoichi Nakagawa
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Akinari Hinoki
- Department of Rare/Intractable Cancer Analysis Research, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Wataru Sumida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Hizuru Amano
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Okamoto Masamune
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Aitaro Takimoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Seiya Ogata
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Shunya Takada
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Daiki Kato
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yousuke Gohda
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yaohui Guo
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Okamoto M, Amano H, Uchida H, Hinoki A, Tainaka T, Shirota C, Sumida W, Yokota K, Makita S, Takimoto A, Yasui A, Nakagawa Y. Clinical characteristics and outcomes of the right congenital diaphragmatic hernia compared to the left: a 10-year single-center experience. Pediatr Surg Int 2021; 37:1675-1681. [PMID: 34436672 DOI: 10.1007/s00383-021-04999-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The features of right-sided congenital diaphragmatic hernias (RCDHs) are quite different from those of left-sided CDHs (LCDHs). We have summarized the features of RCDHs experienced in our institution. METHODS This retrospective study analyzed the cases of patients with CDH registered at our institution between 2011 and 2020. Defects on each side were compared based on prenatal diagnosis, medical treatment, type of surgery, and outcomes. RESULTS A total of 101 patients underwent surgery at our institution during the neonatal period, and 11 had RCDHs. RCDHs and LCDHs were significantly different in terms of extracorporeal membrane oxygenation (36% vs. 6%, p = 0.002), patch repair (81% vs. 28%, p < 0.001), recurrence rate (36% vs. 11%, p = 0.022), and length of hospital stay (117 days vs. 51 days, p = 0.012). The severity of the fetal diagnosis did not reflect postnatal severity. All patients with RCDH survived to discharge, and there was no significant difference in survival rate between the right and left sides. CONCLUSION Neonates with RCDH required more intensive treatments; however, the survival rate was comparable between RCDH and LCDH. RCDH was significantly different from LCDH and an optimal treatment strategy for RCDHs should be established.
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Affiliation(s)
- Masamune Okamoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hizuru Amano
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Akinari Hinoki
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takahisa Tainaka
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Wataru Sumida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Kazuki Yokota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Aitaro Takimoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Akihiro Yasui
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yoichi Nakagawa
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Hofer A, Huber G, Greiner R, Pernegger J, Zahedi R, Hornath F. Congenital diaphragmatic hernia: a single-centre experience at Kepler University Hospital Linz. Wien Med Wochenschr 2021; 172:296-302. [PMID: 34613518 PMCID: PMC8493772 DOI: 10.1007/s10354-021-00885-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/26/2021] [Indexed: 11/28/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is found in about 1 of 3000 live births and is often complicated by pulmonary hypoplasia and alteration of the pulmonary arterial wall with resulting pulmonary hypertension. Since 2005, with the fusion of the children’s hospital and the maternity clinic of the Kepler University Hospital Linz, affected neonates have been treated according to a standard protocol at our perinatal centre. Some prenatally measured parameters have been used to predict mortality, e.g., observed-to-expected lung-to-head ratio or lung volume measurements by nuclear magnetic resonance imaging. We performed a retrospective chart review of 67 new-borns with CDH treated at our institution to detect any predictors of hospital mortality from parameters routinely collected within the first 24 h of life. The term “liver up” was identified as a predictor of hospital mortality; OR 9.2 (95% CI 1.9–51.1, p = 0.002, sensitivity 79%, specificity 71%). In addition, the need for application of high-frequency oscillatory ventilation during the first 24 h was associated with mortality; OR 44.4 (95% CI 6.3–412.1, p = 0.001, sensitivity 85.7%, specificity 88%).
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Affiliation(s)
- Anna Hofer
- Department of Anaesthesiology and Intensive Care, Kepleruniversitätsklinikum, Linz, Austria. .,, Kirchfeldweg 8, 4073, Wilhering, Austria.
| | - Gudrun Huber
- Department of Anaesthesiology and Intensive Care, Kepleruniversitätsklinikum, Linz, Austria
| | - Regina Greiner
- Department of Anaesthesiology and Intensive Care, Kepleruniversitätsklinikum, Linz, Austria
| | - Julia Pernegger
- Department of Anaesthesiology and Intensive Care, Kepleruniversitätsklinikum, Linz, Austria
| | - Reza Zahedi
- Department of Anaesthesiology and Intensive Care, Kepleruniversitätsklinikum, Linz, Austria
| | - Franz Hornath
- Department of Anaesthesiology and Intensive Care, Kepleruniversitätsklinikum, Linz, Austria
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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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9
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Pinton A, Boubnova J, Becmeur F, Kuhn P, Senat MV, Stirnemann J, Capelle M, Rosenblatt J, Massardier J, Vaast P, Le Bouar G, Desrumaux A, Connant L, Begue L, Parmentier B, Perrotin F, Diguet A, Benoist G, Muszynski C, Scalabre A, Winer N, Michel JL, Casagrandre-Magne F, Jouannic JM, Gallot D, Coste Mazeau P, Sapin E, Maatouk A, Saliou AH, Sentilhes L, Biquard F, Mottet N, Favre R, Benachi A, Sananès N. Is laterality of congenital diaphragmatic hernia a reliable prognostic factor? French national cohort study. Prenat Diagn 2020; 40:949-957. [PMID: 32279384 DOI: 10.1002/pd.5706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/07/2019] [Accepted: 03/21/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The objective of this study was to assess whether the laterality of congenital diaphragmatic hernia (CDH) was a prognostic factor for neonatal survival. METHODS This was a cohort study using the French national database of the Reference Center for Diaphragmatic Hernias. The principal endpoint was survival after hospitalization in intensive care. We made a comparative study between right CDH and left CDH by univariate and multivariate analysis. Terminations and stillbirths were excluded from analyses of neonatal outcomes. RESULTS A total of 506 CDH were included with 67 (13%) right CDH and 439 left CDH (87%). Rate of survival was 49% for right CDH and 74% for left CDH (P < .01). Multivariate analysis showed two factors significantly associated with mortality: thoracic herniation of liver (OR 2.27; IC 95% [1.07-4.76]; P = .03) and lung-to-head-ratio over under expected (OR 2.99; IC 95% [1.41-6.36]; P < .01). Side of CDH was not significantly associated with mortality (OR 1.87; IC 95% [0.61-5.51], P = .26). CONCLUSION Rate of right CDH mortality is more important than left CDH. Nevertheless after adjusting for lung-to-head-ratio and thoracic herniation of liver, right CDH does not have a higher risk of mortality than left CDH.
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Affiliation(s)
- Anne Pinton
- Department of Obstetrics and Gynecology, Hôpital Trousseau, AP-HP, Paris, France.,Sorbonne Université, boulevard de l'Hôpital, Paris, France
| | - Julia Boubnova
- Department of Obstetrics and Gynecology, Maternité de la Conception, Gynepole, Marseille, France
| | - François Becmeur
- Department of Pediatric Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Pierre Kuhn
- Department of Neonatal Intensive Care Unit, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Institut des Neurosciences Cellulaires et Intégratives, UPR 3212, CNRS et Université de Strasbourg, Strasbourg, France
| | - Marie-Victoire Senat
- Department of Obstetrics and Gynecology, Maternal-fetal medicine, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Julien Stirnemann
- Department of Obstetrics and Gynecology, Maternal-fetal medicine, Hôpital Necker-Enfants malades, AP-HP, Paris, France.,EHU7328, Université de Paris and Institut IMAGINE, Paris, France
| | - Marianne Capelle
- Department of Obstetrics and Gynecology, Maternité de la Conception, Gynepole, Marseille, France
| | - Jonathan Rosenblatt
- Department of Obstetrics and Gynecology, Maternal-fetal medicine, Hôpital Universitaire Robert-Debré, AP-HP, Paris, France
| | - Jérôme Massardier
- Department of Obstetrics and Gynecology, Maternal-fetal medicine, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, University Claude Bernard, Lyon, France
| | - Pascal Vaast
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Lille, Lille, France
| | - Gwenaelle Le Bouar
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Rennes, University of Rennes 1, Rennes, France
| | - Amélie Desrumaux
- Department of Pediatrics, Centre Hospitalo-Universitaire de Grenoble, Grenoble, France
| | - Laure Connant
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Toulouse, Toulouse, France
| | - Laetitia Begue
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Montpellier, Montpellier, France
| | - Benoit Parmentier
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Poitiers, Poitiers, France
| | - Franck Perrotin
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Tours, François Rabelais University, Tours, France
| | - Alain Diguet
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Rouen, Rouen, France
| | - Guillaume Benoist
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Caen, Normandie University, Caen, France
| | - Charles Muszynski
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire d'Amiens, Amiens, France
| | - Aurélien Scalabre
- Department of Pediatric Surgery, Centre Hospitalo-Universitaire de Saint Etienne, Saint-Etienne, France
| | - Norbert Winer
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Nantes, Nantes, France.,NUN, INRAE, UMR 1280, PhAN, Université de Nantes, CIC Femme enfant adolescent, Nantes, France
| | - Jean-Luc Michel
- Department of Pediatric Surgery, Centre Hospitalo-Universitaire de Félix Guyon, Bellepierre Saint-Denis, Saint-Denis, France
| | | | - Jean-Marie Jouannic
- Department of Obstetrics and Gynecology, Fetal Medicine Department, Hôpital Trousseau AP-HP, Paris, France.,Sorbonne université, boulevard de l'Hôpital, Paris, France
| | - Denis Gallot
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire Estaing, Pole FEE, Clermont-Ferrand, France
| | - Perrine Coste Mazeau
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Limoges, Limoges, France
| | - Emmanuel Sapin
- Department of Pediatric Surgery, François-Mitterrand Teaching Hospital, LE2I UMR CNRS 6306, Arts et Métiers, University of Burgundy, Dijon, France
| | - Alexis Maatouk
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Nancy, Nancy, France
| | - Anne-Hélène Saliou
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Brest, Hôpital Morvan, Brest, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Bordeaux, Bordeaux, France
| | - Florence Biquard
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire d'Angers, Angers, France
| | - Nicolas Mottet
- Department of Obstetrics and Gynecology, Centre Hospitalo-Universitaire de Besançon, Université de Franche-Comté, Besançon, France
| | - Romain Favre
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Alexandra Benachi
- Department of Obstetrics and Gynecology and Reproductive Medicine, AP-HP, Antoine Béclère Hospital, University Paris Saclay, Clamart, France
| | - Nicolas Sananès
- Department of Obstetrics and Gynecology, Hôpitaux universitaires de Strasbourg, Strasbourg, France.,INSERM UMR-S 1121 "Biomatériaux et bioingénierie", Université de Strasbourg, Strasbourg, France
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10
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Chaudhary J, Shivprasad B, Lakshmi V, Shanmughsundaram R, Nandhini G, Balamourougane P. Analysis of Prognostic Factors in Congenital Diaphragmatic Hernia in Neonates. J Indian Assoc Pediatr Surg 2019; 24:176-179. [PMID: 31258265 PMCID: PMC6568153 DOI: 10.4103/jiaps.jiaps_47_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Aim: The aim is to study the demographic characteristics of neonates with congenital diaphragmatic hernia (CDH) and to analyze the prognostic factors determining mortality. Settings and Design: A retrospective cohort of CDH admitted at a tertiary level hospital during January 2005–December 2017. Materials and Methods: All cases of CDH admitted to our tertiary care neonatal intensive care unit before undergoing surgery were included in the study. Babies admitted after surgery and those with eventration of the diaphragm were excluded from the study. Results: Thirty cases (66.66% males, 53.33% inborn, and 63.3% >37 weeks) formed the study cohort. Mean birth weight was 2762 ± 579.67 g and mean gestational age was 37.12 ± 1.76 weeks. About 56.66% of the cases were detected antenatally. The survival rate was 60%. Predictors of poor survival included herniation of the liver or stomach (P < 0.05), low Apgar score at 5 min (<5), presence of moderate-to-severe persistent pulmonary hypertension of the newborn (PPHN) (P < 0.001), presence of shock (P < 0.003), low partial pressure of oxygen, high alveolar–arterial oxygen gradient, and high oxygenation index during first 24 h. Conclusions: Majority of the neonates with CDH at our center were >37 weeks and survival was 60%. The predictors of adverse outcome were low Apgar score, presence of moderate-to-severe PPHN, need for higher ventilatory settings, and shock. Antenatal detection of diaphragmatic hernia did not impact survival rates.
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Affiliation(s)
- Jenisha Chaudhary
- Department of Neonatology, Mehta Children Hospital, Chennai, Tamil Nadu, India
| | - B Shivprasad
- Department of Neonatology, Mehta Children Hospital, Chennai, Tamil Nadu, India
| | - V Lakshmi
- Department of Neonatology, Mehta Children Hospital, Chennai, Tamil Nadu, India
| | - R Shanmughsundaram
- Department of Neonatology, Mehta Children Hospital, Chennai, Tamil Nadu, India
| | - G Nandhini
- Department of Pediatric Surgery, Mehta Children Hospital, Chennai, Tamil Nadu, India
| | - P Balamourougane
- Department of Pediatric Surgery, Mehta Children Hospital, Chennai, Tamil Nadu, India
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11
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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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12
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Long AM, Bunch KJ, Knight M, Kurinczuk JJ, Losty PD. Early population-based outcomes of infants born with congenital diaphragmatic hernia. Arch Dis Child Fetal Neonatal Ed 2018; 103:F517-F522. [PMID: 29305406 DOI: 10.1136/archdischild-2017-313933] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/07/2017] [Accepted: 12/08/2017] [Indexed: 11/04/2022]
Abstract
PURPOSE This study aims to describe short-term outcomes of live-born infants with congenital diaphragmatic hernia (CDH) and to identify prognostic factors associated with early mortality. DESIGN A prospective population cohort study was undertaken between April 2009 and September 2010, collecting data on live-born infants with CDH from all 28 paediatric surgical centres in the UK and Ireland using an established surgical surveillance system. Management and outcomes are described. Prognostic factors associated with death before surgery are explored. RESULTS Two hundred and nineteen live-born infants with CDH were reported within the data collection period. There were 1.5 times more boys than girls (n=133, 61%). Thirty-five infants (16%) died without an operation. This adverse outcome was associated with female sex (adjusted OR (aOR) 3.96, 95% CI 1.66 to 9.47), prenatal diagnosis (aOR 4.99, 95% CI 1.31 to 18.98), and the need for physiological support in the form of inotropes (aOR 9.96, 95% CI 1.19 to 83.25) or pulmonary vasodilators (aOR 4.09, 95% CI 1.53 to 10.93). Significant variation in practice existed among centres, and some therapies potentially detrimental to infant outcomes were used, including pulmonary surfactant in 45 antenatally diagnosed infants (34%). Utilisation of extracorporeal membrane oxygenation was very low compared with published international studies (n=9/219, 4%). Postoperative 30-day survival was 98% for 182 infants with CDH who were adequately physiologically stabilised and underwent surgery. CONCLUSION This is the first British Isles population-based study reporting outcome metrics for infants born with CDH. 16% of babies did not survive to undergo surgery. Factors associated with poor outcome included female sex and prenatal diagnosis. Early postoperative survival in those who underwent surgical repair was excellent.
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Affiliation(s)
- Anna-May Long
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK.,Academic Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - Kathryn J Bunch
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | | | - Paul D Losty
- Academic Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK.,Institute of Child Health, University of Liverpool, Liverpool, UK
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13
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Sperling JD, Sparks TN, Berger VK, Farrell JA, Gosnell K, Keller RL, Norton ME, Gonzalez JM. Prenatal Diagnosis of Congenital Diaphragmatic Hernia: Does Laterality Predict Perinatal Outcomes? Am J Perinatol 2018; 35:919-924. [PMID: 29304545 PMCID: PMC6033692 DOI: 10.1055/s-0037-1617754] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of this study was to examine laterality as a predictor of outcomes among fetuses with prenatally diagnosed congenital diaphragmatic hernia (CDH). METHODS This is a retrospective cohort study of pregnancies with CDH evaluated at our center from 2008 to 2016 compared cases with right-sided CDH (RCDH) versus left-sided CDH (LCDH). The primary outcome was survival to discharge. Secondary outcomes included ultrasound predictors of poor prognosis (liver herniation, stomach herniation, lung area-to-head circumference ratio [LHR]), concurrent anomalies, hydrops, stillbirth, preterm birth, mode of delivery, small for gestational age, use of extracorporeal membrane oxygenation, and length of stay. Terminations and stillbirths were excluded from analyses of neonatal outcomes. RESULTS In this study, 157 (83%) LCDH and 32 (17%) RCDH cases were identified. Survival to discharge was similar (64 vs. 66.4%, p = 0.49) with regard to laterality. RCDH had higher rates of liver herniation (90.6 vs. 72%, p = 0.03), hydrops fetalis (15.6 vs. 1.3%, p < 0.01), and lower LHR (0.87 vs. 0.99, p = 0.04). LCDH had higher rates of stomach herniation (69.4 vs. 12.5%, p < 0.01). Rates of other outcomes were similar in univariate analyses. Adjusting for microarray abnormalities, the odds for survival to discharge for RCDH compared with LCDH was 0.93 (0.38-2.30, p = 0.88). CONCLUSION Compared with LCDH, fetuses with RCDH had higher rates of adverse ultrasound predictors, but equivalent survival.
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Affiliation(s)
- Jeffrey D. Sperling
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Teresa N. Sparks
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Victoria K. Berger
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Jody A. Farrell
- Division of Pediatric Surgery, Department of Surgery, Fetal Treatment Center, University of California, San Francisco, San Francisco, California
| | - Kristen Gosnell
- Division of Pediatric Surgery, Department of Surgery, Fetal Treatment Center, University of California, San Francisco, San Francisco, California
| | - Roberta L. Keller
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Mary E. Norton
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Juan M. Gonzalez
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
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14
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Quinney M, Wellesley H. Anaesthetic management of patients with a congenital diaphragmatic hernia. BJA Educ 2018; 18:95-101. [PMID: 33456817 DOI: 10.1016/j.bjae.2018.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2018] [Indexed: 12/25/2022] Open
Affiliation(s)
- M Quinney
- University College London Hospitals NHS Foundation Trust, London, UK
| | - H Wellesley
- Great Ormond Street Hospital for Children NHS Trust, London, UK
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15
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Burgos CM, Frenckner B, Luco M, Harting MT, Lally PA, Lally KP. Right versus left congenital diaphragmatic hernia - What's the difference? J Pediatr Surg 2017; 53:S0022-3468(17)30649-8. [PMID: 29122292 DOI: 10.1016/j.jpedsurg.2017.10.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 10/05/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Right-sided congenital diaphragmatic hernias (CDH) and bigger defect sizes have been associated with poorer outcomes. AIM The aim of this study was to evaluate right- and left-sided CDH in terms of size, survival, associated anomalies, and morbidity. MATERIAL AND METHODS We used information from a multicenter, multinational database including patients with CDH born between 2007 and 2015. All infants with data on defect side were included for this analysis. We compared differences in outcomes between right- and left-sided CDH. Further analysis on the association between side, size of the defect, and outcome was performed. RESULTS A total of 3754 cases of CDH were entered in the registry between January 2007 and September 2015, with an overall survival of 71%. Of those, 598 (16%) were right-sided and 3156 left-sided, with a survival rate of 67% and 72%, respectively. Right-sided CDH had a larger proportion of C and D defects (p<0.001 and 0.04, respectively). Survival rates for the same size defect were similar, independent of the side of the defect. Multivariable logistic regression analysis with survival as dependent variable identified a significant correlation with defect size, but not side. CONCLUSIONS The higher proportion of large defects (C & D) in right-sided CDH, not the side itself, accounts for the reported poorer survival in right-sided CDH. LEVEL OF EVIDENCE Level I for a prognosis study - This is a high-quality, prospective cohort study with 99% of patients followed to the study end point (death or discharge).
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Affiliation(s)
| | - Björn Frenckner
- Department of Pediatric Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Matias Luco
- Department of Neonatology, School of Medicine, Pontificia Universidad Católica de, Chile
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at UT Health and Children's Memorial Hermann Hospital, Houston, TX, US
| | - Pamela A Lally
- Department of Pediatric Surgery, McGovern Medical School at UT Health and Children's Memorial Hermann Hospital, Houston, TX, US
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at UT Health and Children's Memorial Hermann Hospital, Houston, TX, US
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16
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Lally PA, Skarsgard ED. Congenital diaphragmatic hernia: The role of multi-institutional collaboration and patient registries in supporting best practice. Semin Pediatr Surg 2017. [PMID: 28641749 DOI: 10.1053/j.sempedsurg.2017.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Among congenital malformations, congenital diaphragmatic hernia (CDH) is distinguished by its relatively low occurrence rate, need for resource intensive, integrated multidisciplinary care, and widespread variation in practice and outcome. Although randomized controlled trials (RCTs) are considered the gold standard for generating evidence, they are poorly suited to the study of a condition like CDH due to challenges in illness severity adjustment, unpredictability in clinical course and the impact limitations of studying a single intervention at a time. An alternative to RCTs for comparative effectiveness research for CDH is the patient registry, which aggregates multi-institutional condition-specific patient level data into a large CDH-specific database for the dual purposes of collaborative research and quality improvement across participating sites. This article discusses patient registries from the perspective of structure, data collection and management, and privacy protection that guide the use of registry data to support collaborative, multidisciplinary research. Two CDH-specific registries are described as illustrative examples of the "value proposition" of registries in improving the evidence basis for best practices for CDH.
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Affiliation(s)
- Pamela A Lally
- Department of Pediatric Surgery, McGovern Medical School at UT Health and Children's Memorial Hermann Hospital, Houston, Texas
| | - Erik D Skarsgard
- Department of Pediatric Surgery, BC Children's Hospital, Vancouver, British Columbia, Canada; Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada.
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17
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Abstract
Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.
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Affiliation(s)
- Mauricio A Escobar
- Pediatric Surgery, Mary Bridge Children׳s Hospital, PO Box 5299, MS: 311-W3-SUR, 311 South, Tacoma, Washington 98415-0299.
| | - Michael G Caty
- Section of Pediatric Surgery, Department of Surgery, Yale-New Haven Children׳s Hospital, New Haven, Connecticut
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Donahoe PK, Longoni M, High FA. Polygenic Causes of Congenital Diaphragmatic Hernia Produce Common Lung Pathologies. THE AMERICAN JOURNAL OF PATHOLOGY 2016; 186:2532-43. [PMID: 27565037 DOI: 10.1016/j.ajpath.2016.07.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/20/2016] [Accepted: 07/13/2016] [Indexed: 12/12/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is one of the most common and lethal congenital anomalies, and significant evidence is available in support of a genetic contribution to its etiology, including single-gene knockout mice associated with diaphragmatic defects, rare monogenetic disorders in humans, familial aggregation, and association of CDH with chromosomal abnormalities. Structural lung defects in the form of lung hypoplasia are almost invariably seen in patients with CDH and frequently in animal models of this condition. Better understanding of the mechanisms of pulmonary defects in CDH has the potential for creating targeted therapies, particularly in postnatal stages, when therapeutics can have maximum clinical impact on the surviving cohorts. Successful treatment of CDH is dependent on the integration of human genomic and genetic data with developmental expression profiling, mouse knockouts, and gene network and pathway modeling, which have generated a large number of candidate genes and pathways for follow-up studies. In particular, defective alveolarization appears to be a common and potentially actionable phenotype in both patients and animal models.
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Affiliation(s)
- Patricia K Donahoe
- Pediatric Surgical Research Laboratories, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts; Broad Institute of the Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts.
| | - Mauro Longoni
- Pediatric Surgical Research Laboratories, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Frances A High
- Pediatric Surgical Research Laboratories, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts; Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
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19
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Puligandla PS, Skarsgard ED. The Canadian Pediatric Surgery Network Congenital Diaphragmatic Hernia Evidence Review Project: Developing national guidelines for care. Paediatr Child Health 2016; 21:183-6. [PMID: 27429569 DOI: 10.1093/pch/21.4.183] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The Canadian Pediatric Surgery Network (CAPSNet) has been collecting population-based data regarding congenital diaphragmatic hernia (CDH) across its 17 perinatal sites since 2005. With >500 infants registered to date, CAPSNet has addressed many critical knowledge gaps pertaining to CDH care. Most importantly, it has identified variability in both CDH practice and outcome across Canada. Using the successful Evidence-based Practice for Improving Quality (EPIQ) method, CAPSNet is undertaking a national, multidisciplinary effort to standardize best practices for CDH, from prenatal diagnosis to hospital discharge, based on the best available evidence. The present article outlines the value of clinical research networks and the process CAPSNet will undertake to produce national consensus guidelines for CDH care.
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Affiliation(s)
- Pramod S Puligandla
- Divisions of Pediatric General and Thoracic Surgery, Montreal Children's Hospital, Montreal, Quebec
| | - Erik D Skarsgard
- Divisions of Pediatric General and Thoracic Surgery, British Columbia Children's Hospital, Vancouver, British Columbia
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20
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Right- versus left-sided congenital diaphragmatic hernia: a comparative outcomes analysis. J Pediatr Surg 2016; 51:900-2. [PMID: 27342009 DOI: 10.1016/j.jpedsurg.2016.02.049] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 02/26/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Right-sided congenital diaphragmatic hernia (R-CDH) occurs in up to 25% of all CDH cases, but has been less widely studied compared to left-sided defects. We sought to compare characteristics and outcomes of left- versus right-sided defects in a large cohort of CDH patients who underwent standardized treatment and follow-up at a single institution. METHODS We retrospectively reviewed charts of all CDH patients in our pulmonary hypoplasia program from January 2002 through December 2014. Categorical variables were analyzed by Fisher's exact test and continuous variables by Mann-Whitney t-test (p≤0.05). RESULTS A total of 330 CDH patients were treated more than the 12-year study period, with 274 (83%) left-sided and 56 (17%) right-sided cases identified. Specific pulmonary morbidities were associated with R-CDH, with increased duration of nitric oxide therapy, increased requirement for tracheostomy, increased requirement for supplemental oxygen at the time of NICU discharge, and increased chronic pulmonary hypertension with requirement for long-term Sildenafil therapy. CONCLUSIONS In this series, R-CDH was not associated with increased mortality, but was associated with increased requirement for pulmonary vasodilatory therapy and requirement for tracheostomy. The high incidence of pulmonary complications indicates increased severity of pulmonary hypoplasia in R-CDH, supporting a role for delivery in tertiary centers with expertise in CDH management.
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21
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Impaction of an intrathoracic kidney acted as a shield against herniation of the abdominal viscera in a case of right congenital diaphragmatic hernia. Obstet Gynecol Sci 2016; 59:58-61. [PMID: 26866038 PMCID: PMC4742478 DOI: 10.5468/ogs.2016.59.1.58] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 07/14/2015] [Accepted: 07/20/2015] [Indexed: 01/13/2023] Open
Abstract
We describe a case of an intrathoracic kidney combined with right congenital diaphragmatic hernia (CDH) that was diagnosed at 32 weeks of gestation. Although it has been well established that a right CDH shows a poorer outcome than a left CDH, our present case showed a good outcome because there was no herniation of other abdominal viscera, except for the right kidney. Our findings in this case indicate that impaction of the intrathoracic kidney may act as a 'shield' against further herniation of other abdominal viscera into the thoracic cavity.
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22
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Snoek KG, Reiss IKM, Greenough A, Capolupo I, Urlesberger B, Wessel L, Storme L, Deprest J, Schaible T, van Heijst A, Tibboel D. Standardized Postnatal Management of Infants with Congenital Diaphragmatic Hernia in Europe: The CDH EURO Consortium Consensus - 2015 Update. Neonatology 2016; 110:66-74. [PMID: 27077664 DOI: 10.1159/000444210] [Citation(s) in RCA: 314] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 01/25/2016] [Indexed: 11/19/2022]
Abstract
In 2010, the congenital diaphragmatic hernia (CDH) EURO Consortium published a standardized neonatal treatment protocol. Five years later, the number of participating centers has been raised from 13 to 22. In this article the relevant literature is updated, and consensus has been reached between the members of the CDH EURO Consortium. Key updated recommendations are: (1) planned delivery after a gestational age of 39 weeks in a high-volume tertiary center; (2) neuromuscular blocking agents to be avoided during initial treatment in the delivery room; (3) adapt treatment to reach a preductal saturation of between 80 and 95% and postductal saturation >70%; (4) target PaCO2 to be between 50 and 70 mm Hg; (5) conventional mechanical ventilation to be the optimal initial ventilation strategy, and (6) intravenous sildenafil to be considered in CDH patients with severe pulmonary hypertension. This article represents the current opinion of all consortium members in Europe for the optimal neonatal treatment of CDH.
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Affiliation(s)
- Kitty G Snoek
- Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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