The late presentation of postero-lateral congenital diaphragmatic hernias

Bochdalek hernias in the adult population: a systematic review of the literature

BACKGROUND

Bochdalek hernia (BH) is characterized by the protrusion of viscera into thorax through the posterolateral section of the diaphragm. The aim of this study was to systematically review current literature concerning Bochdalek hernias in adults and elucidate their clinical characteristics and preferable treatment approach.

METHODS

A search of PubMed and Cochrane bibliographical databases for studies regarding BHs was conducted (last search: 31st March 2021).

RESULTS

Predefined inclusion criteria were met by 173 articles and concerned collectively 192 patients (50.5% males) with a mean age of 45.41 ± 20.26 years. Abdominal pain (62.0%) and pulmonary symptoms (41.1%) were the predominant symptomatology of included cases. BHs protruded mainly through the left side of the diaphragm (70.7%), with large intestine (42.7%) and stomach (37.1%) being the most commonly herniated abdominal organs. Most patients (53.8%) underwent an open surgical approach, while abdominal approach was preferred (64.8%). to the thoracic one. Thirty-day postoperative complication were encountered at 21.5% of patients, while 30-day mortality reached 4.4%.

CONCLUSION

BH is an extremely rare type of congenital diaphragmatic hernia. It rarely concerns adults, and it manifests with vague gastrointestinal or pulmonary symptoms. Surgical approach is the preferred method for their management with open procedures being preferable at emergency cases, while minimal invasive approach necessitates experienced centers. Further research is needed in order to clarify their true incidence and optimal therapeutic strategy.

A late presenting left-sided congenital diaphragmatic hernia repair complicated by postoperative chylothorax: A case report

Management of chylothorax after repair of late presenting congenital diaphragmatic hernia is debatable. Conservative management in the form of close monitoring of chylous output with nutritional support appears convincing to surgery.

Laparoscopic Repair of Giant Bochdalek Hernia in Adults

INTRODUCTION

Bochdalek hernia is a congenital diaphragmatic defect that results from improper fusion of the septum transversum and the pleuroperitoneal folds. It rarely persists asymptomatic until adulthood. The reported incidence is as low as 0.17%. Surgical repair of the defect can be performed through the abdomen or through the chest, and in both cases open or through laparoscopy/thoracoscopy.

CASE REPORT

We present 2 cases of fully laparoscopic repair of giant Bochdalek hernia in adults. In both cases we used a GORE^® DUALMESH^® and we had neither complications nor recurrence. It is worthy of mention that hernia sac was not found in any of the cases. This has been described as a distinct characteristic that confirms diagnosis.

CONCLUSION

Bochdalek hernia in the adult is a rare entity that requires surgical treatment to avoid complications. CT scan of the abdomen and chest with oral and IV contrast is the gold standard for diagnosis.

Laparoscopic Repair of Bochdalek Diaphragmatic Hernia in Adults

Bochdalek hernia (BH) is an uncommon form of diaphragmatic hernia. The rarity of this hernia and its nonspecific presentation leads to delay in the diagnosis, with the potential risk of complications. This review summarizes the relevant aspects of its presentation and management, based on the present evidence in the literature. A literature search was performed on PubMed, Google Scholar, and EMBASE for articles in English on BH in adults. All case reports and series from the period after 1955 till January 2015 were included. A total of 180 articles comprising 368 cases were studied. The mean age of these patients was 51 years (range 15-90 years) with a male preponderance of 57% (211/368). Significantly, 6.5% of patients were above 70 years, with 3.5% of these being above 80 years. The majority of the hernias were on the left side (63%), with right-sided hernias and bilateral occurring in 27% and 10%, respectively. Precipitating factors were noted in 24%, with 5.3% of them being pregnant. Congenital anomalies were seen in 11%. The presenting symptoms included abdominal (62%), respiratory (40%), obstructive (vomiting/abdominal distension; 36%), strangulation (26%); 14% of them were asymptomatic (detected incidentally). In the 184 patients who underwent surgical intervention, the surgical approach involved laparotomy in 74 (40.27%), thoracotomy in 50 (27.7%), combined thoracoabdominal approach in 27 (14.6%), laparoscopy in 23 (12.5%), and thoracoscopic repair in 9 (4.89%). An overall recurrence rate of 1.6% was noted. Among these patients who underwent laparoscopic repair, 82% underwent elective procedure; 66% underwent primary repair, with 61% requiring interposition of mesh or reenforcement with or without primary repair. The overall mortality was 2.7%. Therefore, BH should form one of the differential diagnoses in patients who present with simultaneous abdominal and chest symptoms. Minimal access surgery offers a good alternative with short hospital stay and is associated with minimum morbidity and mortality.

Pediatric incidental appendectomy: a systematic review

Incidental appendectomy is the removal of the vermiform appendix accompanying another operation, without evidence of acute appendicitis. It is generally performed to eliminate the risk of future appendicitis. The risks and benefits of incidental appendectomy during various operations in children have been debated for over a century, but need to be revisited in light of innovations in medical practice, including minimally invasive surgery, improved imaging techniques, and use of the appendix as a tubular conduit for reconstruction. A detailed review was undertaken of the techniques, pathology, risks of appendectomy, utility of the appendix, and incidental appendectomy in the treatment of specific pediatric medical conditions. A comprehensive literature search was performed, and retrieved results were reviewed for relevance to the topic. The decision to perform a pediatric incidental appendectomy relies on informed consideration of the individual patient's co-morbid conditions, the indication for the initial operation, the future utility of the appendix, and the risk of future appendiceal pathology. The discussion includes a variety of situations and comorbid conditions that may influence a surgeon's decision to perform incidental appendectomy.

Gastric volvulus complication in an infant with undiagnosed congenital diaphragmatic hernia presenting with acute respiratory distress

INTRODUCTION

Congenital diaphragmatic hernia is an embryologic defect that creates a passage for herniation of abdominal structures into the thoracic cavity. This can lead to a variety of complications, including gastric volvulus that can present acutely with epigastric distention and vomiting. In cases of late-onset congenital diaphragmatic hernia, symptoms may be vague and often necessitate further investigation.

CASE

Our patient is a 12-month-old previously healthy female infant who presented to the emergency department with a history of vomiting and acute onset respiratory distress. Her SaO(2) was 94% to 98% on room air, her respiratory rate was in the 80s breaths per minute, and she was noted to have severe retractions. Her chest examination revealed absent breath sounds on the left side. Her abdominal examination was unremarkable. The acute presentation of respiratory distress was initially concerning for a foreign body aspiration, but a chest radiograph demonstrated left-sided opacification and mediastinal shift to the right. The patient required intubation for respiratory decompensation and a subsequent computed tomographic scan showed diaphragmatic hernia with gastric volvulus.

CONCLUSIONS

This patient's presentation highlights one of the complications that may occur owing to congenital diaphragmatic hernia. Computed tomographic scan is the confirmatory test for diaphragmatic hernia and, in this case, also uncovered a concomitant gastric volvulus. Treatment includes early resuscitation, a definitive airway, and emergent surgery to prevent ischemic necrosis of the stomach owing to strangulation, gastric perforation, and serious cardiorespiratory decompensation.

Congenital diaphragmatic hernia: review of current concept in surgical management

CONGENITAL DIAPHRAGMATIC HERNIAS (CDHS) OCCUR MAINLY IN TWO LOCATIONS: the foramen of Morgagni and the more common type involving the foramen of Bochdalek. Hiatal hernia and paraesophageal hernia have also been described as other forms of CDH. Pulmonary hypertension and pulmonary hypoplasia have been recognized as the two most important factors in the pathophysiology of congenital diaphragmatic hernia. Advances in surgical management include delayed surgical approach that enables preoperative stabilization, introduction of fetal intervention due to improved prenatal diagnosis, the introduction of minimal invasive surgery, in addition to the standard open repair, and the use of improved prosthetic devices for closure.

Bochdalek hernia in the adult: demographics, presentation, and surgical management

BACKGROUND

Bochdalek hernias are a very rare form of diaphragmatic hernias. There are no robust studies that reveal the true natural history of this disease process. The aim of this study was to summarize clinically relevant data for the purpose of assisting surgeons with the work-up, diagnosis, and treatment of adult patients with Bochdalek hernia.

METHODS

A literature search was performed using PubMed, Google scholar, EMBASE and the following keywords: Bochdalek hernia, congenital diaphragmatic hernia, and posterolateral hernia. All case reports and series after 1955 that pertained to adults were included in the review. The following data points were queried: age, sex, presentation, studies utilized during work-up, laterality, surgical approach, hernia sac management, specific minimally invasive surgical techniques, and follow-up.

RESULTS

A total of 124 articles comprising 173 patients met the inclusion criteria. Based on the data provided, several conclusions regarding this disease process can be made. Most patients present with symptoms related to their hernia (86%). Pain is the most common complaint (69%). While laparotomy is the most widely used surgical approach (38%), minimally invasive surgical techniques have gained popularity since their first report in 1995. Laparoscopic repair can be performed with a low complication rate (7%) and short hospital stay (4 days).

CONCLUSIONS

Using modern surgical techniques to include laparoscopy, repair can be performed safely, with a short hospital stay, and with minimal morbidity or mortality.

Late-presenting congenital diaphragmatic hernia in children: a literature review

This is a review of 122 articles published until December 2003 that describe 349 children with late-presenting postero-lateral congenital diaphragmatic hernia (CDH). Data regarding pre-operative diagnostic work-up were adequately reported in 177 patients with left CDH and in 41 with a right-sided defect. Chest radiography was the only diagnostic study in 92 (51.9%) children from the former group and in 17 (43.9%) from the latter group. In other patients, diagnostic work-up encompassed various combinations of two or more imaging modalities. Apart from chest radiography, contrast study of the upper gastrointestinal tract was the most frequently performed imaging modality. In 88 (25.2%) children, initial radiographic features of CDH were misinterpreted. Pneumothorax and pleural effusion were the most common initial findings. Analysis of the hernial content in this group of patients has shown that herniation of the stomach, spleen or omentum should be regarded as risk factors for misdiagnosis of left CDH, whereas for right CDH, the risk factor is the presence of liver in the chest. Late-presenting CDH may pose a significant diagnostic problem because of the great variability of radiographic appearance. Chest radiography following passage of a nasogastric tube and contrast studies of the gastrointestinal tract seem to be the most useful investigations for the diagnosis of left CDH. For patients with right CDH, owing to the high probability of liver herniation, a chest radiograph with liver scintigraphy or CT seems to be the best diagnostic option.

Late-presenting congenital diaphragmatic hernia in children: a clinical spectrum

Articles dealing with late-presenting congenital diaphragmatic hernia (CDH) in children published until 2003 were collectively reviewed. The main purpose of the presented study was to gain insight into the clinical spectrum of this variant of CDH and to discuss its clinical and surgical aspects. In 125 articles, 362 patients were reported. Left posterolateral hernia was the dominant anatomical type, found in 79.4% of the children. Male-to-female distribution was nearly 2:1 in both right- and left-sided CDH. Associated anomalies were noted in 8.6% of children. Sixty-five percent of children with right CDH presented within the 1st year of life, whereas only 41.7% of patients with left CDH belonged to this age group. The children with right CDH presented with chronic symptoms in 57.4% of cases, while among those with left CDH, acute presentation prevailed, constituting 60.5% of this group. No strict correlation between age and clinical symptoms was noted, although the youngest patients tended to present with respiratory symptoms. Late-presenting diaphragmatic hernia is associated with a wide range of clinical symptoms occurring in various constellations. Dyspnea and vomiting were the most frequent symptoms found in patients with either chronic or acute manifestation. Preoperative mortality was 3.9% (14 children). In 45 children (12.4%), complications resulting from diaphragmatic hernia were noted, and in a further 11 children iatrogenic preoperative complications were noted. Among 152 children with reported CDH, true hernia with sac was found in 32.7%. Eight children (2.2%) died in the early postoperative period, while a further 13 patients (3.6%) had postoperative complications requiring surgical management. Recurrence of hernia was noted in seven children (1.9%). This collective review of basic epidemiological and clinical data from a large group of patients seems to support a hypothesis for a congenital nature of the diaphragmatic defect and an acquired nature of "herniation" of the viscera. The wide clinical spectrum of late-presenting CDH seems to be conditioned by two factors: timing of herniation and type of intraabdominal viscera displaced into the chest.

Associated malformations in delayed presentation of congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Delayed presentation of congenital diaphragmatic hernia (CDH) has been considered rare, and clinical manifestations differ from the more common newborn entity. Associated malformations in late-appearing CDH have been reported in a few patients. The authors reviewed their clinical experience to catalogue the frequency and clinical importance of associated malformations in patients with late-presenting CDH.

METHODS

The records of patients greater than 1 month of age with Bochdalek type CDH treated in the authors' clinic, from 1991 to 2001, were retrospectively reviewed. Twenty patients (age range, 1 month to 10 years) were included in the study.

RESULTS

Associated malformations were documented in 16 of the patients (80%) and included malrotation in 12 patients, umbilical hernia in 2, pulmonary hypoplasia in 4, pulmonary sequestration in 1, gastroesophageal duplication cyst coexisting with polysplenia in 1, atrial septal defect and ventricular septal defect in 1, hydronephrosis in 1, wandering spleen in 1, talipes equinovarus in 1, and type I diabetes mellitus in 1.

CONCLUSIONS

The results of this study show a significant incidence and a wide spectrum of associated malformations. These findings suggest that patients with late CDH should be evaluated carefully for additional anomalies that may help to establish correct diagnosis and treatment.

Laparoscopic treatment of Bochdalek hernia without the use of a mesh

Bochdalek hernia is a rare pathology. The preoperative diagnosis is difficult, and few reports are available regarding its treatment. Herein we report the case of a 25-year-old woman referred for symptoms of dyspepsia, dysphagia, and thoracic pain exacerbated by pregnancy. Preoperative radiography, EGD, and CT scan revealed a paraesophageal hiatal hernia. Laparoscopic exploration showed the complete thoracic migration of the stomach through a left posterolateral diaphragmatic foramen. The diagnosis of a Bochdalek hernia was then made. The diaphragmatic defect was repaired without inserting a prosthesis, using five separate non-reabsorbable stitches (Rieder technique). The procedure was completed with a Nissen-Rossetti fundoplication. The duration of the procedure was 150 min. Hospital stay was 12 days. There were no complications. Postoperative Gastrografin radiography of the esophagus and stomach showed a normal-shaped fundoplication and confirmed the subdiaphragmatic location of the stomach. We conclude that the laparoscopic approach represents the gold standard for the diagnosis and treatment of Bochdalek hernia and any associated complications.

Acute presentation of congenital diaphragmatic hernia past the neonatal period: a life threatening emergency

PURPOSE

Major gastric distension in the left hemithorax can threaten life in patients with congenital diaphragmatic hernia (CDH) presenting after the neonatal period. After presentation of two pediatric cases, guidelines for the optimal care of these patients are given.

CLINICAL FEATURES

Both children had respiratory and cardio-circulatory compromise on arrival. The diagnosis of late presenting CDH was made and the severity of symptoms was related to a voluminous distension of an intrathoracic stomach. Successful placement of an naso-gastric tube in the first patient, lead to a rapid clinical improvement, allowing surgical repair. In the second patient, oro- or naso-gastric decompression was not possible, and while the lungs were mechanically ventilated and the patient was prepared for surgery, a sudden cardiocirculatory arrest was managed by external chest compressions and rescuscitation drugs. Transthoracic percutaneous decompression of the stomach was the sole treatment allowing spontaneous cardiac activity to reappear, and haemodynamic condition to normalize. However, the child died from brain death after this episode.

CONCLUSION

Gastric decompression is the key for the treatment of patients with CDH who present respiratory and/or cardiocirculatory distress due to the intrathoracic distension of the stomach. If an oro- or naso-gastric decompression is not possible, then radiologically directed percutaneous decompression under local anesthesia is required. After decompression, the patient is prepared for surgery, with particular emphasis on fluids infusion, in order to correct the frequently associated hypovolaemia.