Acquired diaphragmatic hernia after hepatectomy and liver transplantation in adults and children: A case series and literature review

A rare complication of pediatric liver transplantation: Post-transplant diaphragmatic hernia

AIM

Acquired post-transplant diaphragmatic hernia (PTDH) is a rare complication of liver transplantation (LT) in children. We aimed to present our experience in PTDH, and a possible causative background is discussed.

METHODS

Medical records of patients who had undergone diaphragmatic repair following LT between 2015 and 2023 were reviewed. Demographic information, details of primary diseases necessitating LT, transplantation techniques, and clinical findings associated with PTDH were evaluated.

RESULTS

There were seven patients with PTDH. Median age at transplantation was 69 (range: 9-200) months. Five patients received a left lateral sector, one patient had a right lobe, and one had a left lobe graft. Time between LT and PTDH was 9 (2-123) months. One patient who was diagnosed in the postoperative 10th year was asymptomatic. Respiratory distress and abdominal pain were the main symptoms among all. All patients underwent laparotomy, and primary repair was performed in six patients, and one patient required mesh repair because of a large defect. Small intestine herniated in most cases. There were two complicated cases with perforation of the stomach and colonic volvulus. There is no recurrence or long-term complications for the median 60 (20-119) month follow-up period.

CONCLUSION

PTDH is a rare but serious complication. Majority of symptomatic cases present within the first postoperative year, whereas some late-presenting cases may not be symptomatic. Inadvertent injury to the inferior phrenic vasculatures due to excessive use of cauterization for control of hemostasis may be a plausible explanation in those cases.

Incidence and outcomes of post-hepatectomy diaphragmatic hernia: a systematic review

BACKGROUND

Post-hepatectomy diaphragmatic hernia is the second most common cause of acquired diaphragmatic hernia. This study aims to review the literature on this complication's incidence, treatment and prognosis.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically searched PubMed for all studies related to acquired diaphragmatic hernias after hepatectomy.

RESULTS

We included 28 studies in our final analysis, comprising 11,368 hepatectomies. The incidence of post-hepatectomy diaphragmatic hernia was 0.75% (n = 86). The most frequent type of hepatectomy performed was right hepatectomy (79%, n = 68), and the indications for liver resection were a liver donation for living donor transplantation (n = 40), malignant liver tumors (n = 13), and benign tumors (n = 11). The mean onset between liver resection and the diagnosis of diaphragmatic hernia was 25.7 months (range, 1-72 months), and the hernia was located on the right diaphragm in 77 patients (89.5%). Pain was the most common presenting symptom (n = 52, 60.4%), while six patients were asymptomatic (6.9%). Primary repair by direct suture was the most frequently performed technique (88.3%, n = 76). Six patients experienced recurrence (6.9%), and three died before diaphragmatic hernia repair (3.5%).

CONCLUSION

Diaphragmatic hernia is a rare complication occurring mainly after right liver resection. Repair should be performed once detected, given the not-negligible associated mortality in the emergency setting.

Right-Side Acquired Diaphragmatic Hernia in an Adult 15 Years After Living Donor Liver Transplant

Cases of adult liver transplant recipients with a postoperative right-side acquired diaphragmatic hernia are extremely rare. In this report, we describe an adult case of right-side acquired diaphragmatic hernia 15 years after living donor liver transplant. A 27-year-old woman was diagnosed with pancreatic insulinoma with multiple metastases in the liver. To treat the liver failure, she underwent left lobe living donor liver transplant and distal pancreatectomy with splenectomy 3 years after the transcatheter arterial chemoembolization. As a result of the liver abscesses that reached the diaphragm, the delicate diaphragm was injured, which required repair during the transplant surgery. At the age of 46 years, she developed a cough and intermittent abdominal pain. One month later, she went to another hospital's emergency room with complaints of epigastric pain. The computed tomography scan revealed colon and small intestine prolapse into the right thoracic cavity. She was referred to our hospital and underwent surgery the next day. Two adjacent right diaphragm defects were successfully sutured with nonabsorbable sutures. The patient was discharged on postoperative day 11.

Development of diaphragmatic hernia following hepatectomy

BACKGROUND

The majority of the diaphragmatic hernias developing on the right side are hernias developing after right hepatectomy. We aimed to present the clinical presentation at the time of admission, surgical treatment, and postoperative course of patients that developed DH following a major liver resection in our center.

PATIENTS AND METHODS

Liver surgeries performed in Ataturk University Organ Transplant Center and Ataturk University Research Hospital General surgery Hepatopancreatobiliary ward between 2012 and 2021 were analysed retrospectively. Demographic information, admission types (emergency or elective), admission clinics, the process of diaphragmatic hernia formation following hepatectomy, imaging methods used for diagnosis, and surgical methods performed were recorded for the patients with diaphragmatic hernia. Qualitative values were tabulated and their percentages were calculated.

RESULTS

Six hundred and sixty patients who underwent major liver surgery in our center between 2012 and 2021 were analysed. It was found that diaphragmatic hernia developed in 9 (1.4%) of those patients. The incidence of diaphragmatic hernia after donor hepatectomy was 3.04% in our study. The mean time from the first surgery until the DH diagnosis was 47.33 ± 38.16 months. 1 (11.1%) patient had small intestine perforation and 1 patient had both small intestine and colon perforation. One patient died before to the surgery.

CONCLUSION

DH following liver resection can cause fatal complications and it should be intervened when diagnosed. Although it is rare, centers particularly focusing on hepatobiliary surgery should determine a follow-up protocol to detect DH that develops after major liver resections.