Congenital diaphragmatic hernia: the neonatologist's perspective

Improving outcome in congenital diaphragmatic hernia - experience of a tertiary center without ECMO

BACKGROUND

Congenital diaphragmatic hernia (CDH) has a high mortality rate, representing a therapeutic challenge. Prenatal diagnosis (PND) is essential in defining optimal perinatal strategy, particularly delivery planning. Hospital Pediátrico de Coimbra is the referral centre for all neonatal surgery, particularly CDH, for the central region of Portugal. The aim was to evaluate clinical management and outcome of newborns with CDH.

METHODS

An exploratory retrospective study made up of newborns admitted to PICU with CDH was undertaken between January 1995 and December 2014. Two groups were formed based on their year of admission: group A (1995- 2004) and group B (2005- 2014) and were compared.

RESULTS

The mean birth weight of the 69 newborns admitted was 2.762 ± 696 g; the median of the gestational age was 38 weeks. Associated malformations were observed in 28 (40.5%) and 15 (21.7%) had a right-sided diaphragm defect. The global mortality was 13.0%; in group A was significantly higher than in group B (22.2 vs 3.0%; p = 0.029). A reduction in mortality throughout the years was confirmed after adjusting for POS score (OR = 0.77; 95% CI: 0.62- 0.96, p = 0.021). PND was made in 30.6% of cases in the group A and 66.7% in the group B (p = 0.03). Tertiary perinatal hospital birth was achieved in 60% of newborns in the group A versus 84.8% in group B (p = 0.022). Maximum fraction of inspired oxygen showed a statistically significant difference between the two study groups (60% vs 40%; p = 0.009).

CONCLUSIONS

A significant decrease in mortality was observed throughout the study. The authors highlight the increase in prenatal diagnosis and an improvement in perinatal care with planning delivery as important contributors to these results.

Multidetector computed tomography evaluation of secondary hepatopulmonary fusion in a neonate

Hepatopulmonary fusion is a rare condition in which a dense adhesion occurs between the right lung and herniated hepatic parenchyma in patients with right-sided congenital diaphragmatic hernia. Plain radiographic and magnetic resonance imaging (MRI) findings of hepatopulmonary fusion in a neonate have been reported in a retrospective study with a small patient population and a case report. However, to our knowledge, there is no report regarding the secondary hepatopulmonary fusion (after right-sided congenital diaphragmatic hernia repair) evaluated with multidetector computed tomography (MDCT) in a neonate. We report a case of secondary hepatopulmonary fusion in a neonate, in which multiplanar and three-dimensional (3D) images were helpful in delineating the precise anatomy for preoperative evaluation. Understanding the diagnostic limitations of plain radiographs and MRI, the use of MDCT with its multiplanar and 3D imaging may emerge as a useful noninvasive imaging modality in the evaluation of possible hepatopulmonary fusion in pediatric patients with right-sided congenital diaphragmatic hernia.

Congenital diaphragmatic hernia: outcome review of 2,173 surgical repairs in US infants

Congenital diaphragmatic hernia (CDH) remains one of the most challenging conditions to treat within the pediatric surgical and medical communities. In spite of modern treatment modalities, including extracorporeal membrane oxygenation (ECMO) and improved ventilatory support, mortality remains high. The present study analyzes a US database containing information from nearly 93 million discharges in the US. Infants with congenital diaphragmatic hernia who underwent surgical repair were identified by ICD-9 procedure code and inclusion criteria including an age at admission of less than 1 year. Variables of gender, race, age, geographic region, co-existing diagnoses and procedures, hospital type, hospital charges adjusted to 2006 dollars, length of stay, and inpatient mortality were collected. A total of 89% of patients were either treated initially or rapidly transferred to urban teaching hospitals for definitive treatment of CDH. The inpatient mortality rate was 10.4% with a median length of stay of 20 days (interquartile range of 9-40 days). The median inflation-adjusted total hospital charge was $116,210. Respiratory distress was the most common co-existing condition (68.8%) followed by esophageal reflux (27.8%). The most common concomitant procedures performed were ECMO (17.8%) and fundoplication (17.6%). This study, which represents the largest characterization of US infants who have undergone CDH repair using data from a nationally representative non-voluntary database, demonstrates that surgical repair is associated with significant mortality and morbidity.

Pectus excavatum: historical background, clinical picture, preoperative evaluation and criteria for operation

Pectus excavatum is a depression of the sternum and costal cartilages which may present at birth, or more commonly during the teenage growth spurt. Symptoms of lack of endurance, shortness of breath with exercise, or chest pain are frequent. Although pectus excavatum may be a component of some uncommon syndromes, patients usually are healthy. Evaluation should include careful anatomic description with photographs, radiography to demonstrate the depth of the depression, extent of cardiac compression, or displacement, measurement of pulmonary function, and echocardiography to look for mitral valve prolapse (in 15%) or diminished right ventricular volume. Indications for surgical treatment include two or more of the following: a severe, symptomatic deformity; progression of deformity; paradoxical respiratory chest wall motion; computer tomography scan with a pectus index greater than 3.25; cardiac compression/displacement and/or pulmonary compression; pulmonary function studies showing restrictive disease; mitral valve prolapse, bundle branch block, or other cardiac pathology secondary to compression of the heart; or failed previous repair(s). The developmental factors, genetics, and physiologic abnormalities associated with the condition are reviewed.

Long-term follow up of infants with congenital diaphragmatic hernia

With improving treatment strategies for congenital diaphragmatic hernia (CDH) infants, an increase in survival of more severely affected patients can be expected. Consequently, more attention is now focused on long-term follow up of these patients. Many reports have emphasized associated morbidity, including pulmonary sequelae, neurodevelopmental deficits, gastrointestinal disorders, and other abnormalities. Therefore, survivors of CDH remain a complex patient population to care for throughout infancy and childhood, thus requiring long-term follow up. Much information has been provided from many centers regarding individual institutional improvements in overall survival. Few of these, however, have reported long-term follow up. The aim of this review is to describe the long-term outcome of survivors with CDH and to suggest a possible follow-up protocol for these patients.

Long-term functional impact of congenital diaphragmatic hernia repair on children

BACKGROUND/PURPOSE

Congenital diaphragmatic hernia (CDH) is a malformation requiring neonatal surgical repair with in-hospital survival rates above 90%. We examined the long-term functional impact of CDH repair on a cross-sectional cohort of survivors.

METHODS

A cohort of 53 CDH families participated in this study. Functional impact was evaluated with parent report of the Functional Status IIR and the Child Health Ratings Inventories General Health Module. Parents also provided a clinical severity score, the child's medical history, and family demographic information. The primary outcome was the effect of medical morbidity on the Functional Status IIR total score.

RESULTS

Congenital diaphragmatic hernia survivors had a median age of 8 years; 50% were in third grade or above. Sixty-six percent had major medical issues at hospital discharge, whereas 48% had current clinical problems. Functional Status IIR total score was strongly correlated with child's clinical severity (r = -0.65; P < .0001) and was lower among children with ongoing medical morbidity, denoting worse functioning (P = .01). Child Health Ratings Inventories General Health Module scores followed a similar pattern.

CONCLUSIONS

A subset of long-term CDH survivors continues to have ongoing clinical problems a median of 8 years after surgery, translating to lower functional status. Affected children and their families may benefit from prospective identification and ongoing interventions.

Pleural and pericardial effusion: a potential ultrasonographic marker for the prenatal differential diagnosis between congenital diaphragmatic eventration and congenital diaphragmatic hernia

OBJECTIVES

To determine whether or not the presence of pleural and/or pericardial effusion can be used prenatally as an ultrasonographic marker for the differential diagnosis between diaphragmatic eventration and diaphragmatic hernia.

METHODS

We present two case reports of non-isolated diaphragmatic eventration associated with pleural and/or pericardial effusion. Additionally, we reviewed the literature for all cases of congenital diaphragmatic hernia (CDH) and diaphragmatic eventration that met the following criteria: (1) prenatal diagnosis of a diaphragmatic defect and (2) definitive diagnosis by autopsy or surgery. The frequencies of pleural effusion, pericardial effusion and hydrops were compared between the two conditions using Fisher's exact test. A subanalysis was conducted of cases with isolated diaphragmatic defects (i.e. diaphragmatic defects not associated with hydrops and other major structural or chromosomal anomalies).

RESULTS

A higher proportion of fetuses with diaphragmatic eventration had associated pleural and pericardial effusions compared with fetuses with diaphragmatic hernia (58% (7/12) vs. 3.7% (14/382), respectively, P < 0.001). This observation remained true when only cases of diaphragmatic defects not associated with hydrops and other major structural or chromosomal anomalies were compared (29% (2/7) with eventration vs. 2.2% (4/178) with CDH, P < 0.02).

CONCLUSIONS

The presence of pleural and/or pericardial effusion in patients with diaphragmatic defects should raise the possibility of a congenital diaphragmatic eventration. This information is clinically important for management and counseling because the prognosis and treatment for CDH and congenital diaphragmatic eventration are different. Published by John Wiley & Sons, Ltd.

Treatment of a case with right-sided diaphragmatic hernia associated with an abnormal vessel communication between a herniated liver and the right lung

We herein report a rare case of a newborn girl with a right-sided congenital diaphragmatic hernia where a herniated liver had an abnormal vessel communication with the right lung. A surgical repair was initially attempted through a thoracic approach at 4 days of age where only a plication of the hernia capsule was performed without a prominent improvement in the respiratory condition. At 1 year of age, an angiographic examination was performed, which revealed pulmonary hypertension and abnormal vessel communications where the right pulmonary flow returned to the herniated liver and the right lung also received an arterial supply from the liver. During the second surgical repair performed at 1 year and 1 month of age, an abdominal approach through a right subcostal incision was selected. The aberrant vessels between the lung and the liver were carefully identified and ligated. Because the right lobe of the liver was completely herniated, a hepatic segmentectomy of S6 and S7 was performed. The patient has been doing well for 21 months without any mechanical ventilation since 2 months after undergoing the radical second operation. When performing surgery on a right-sided diaphragmatic hernia, the potential presence of such a vessel anomaly should be carefully taken into consideration.

The current status of neonatal extracorporeal membrane oxygenation

Marked changes have occurred in the practice of neonatal extracorporeal membrane oxygenation (ECMO) since the first survivor in 1975. Coagulation management has been markedly refined, new catheters allow ECMO to be done either in a venoarterial or venovenous (VV) mode, depending on cardiac function in the infant. A new design of the VV catheter will allow this technique to be used in more infants in the future. New therapies for respiratory failure have changed the complexion of the population being treated with ECMO. The 34 to 36 week gestation infant with respiratory distress syndrome and/or pulmonary hypertension rarely needs ECMO therapy due to the effectiveness of surfactant and high frequency oscillation. Present day survival for infants treated with ECMO for many diagnostic categories ranges between 90% to 100%. The effects of new interventions must be evaluated with regard to their effect on morbidity when being considered prior to ECMO. Neuro-developmental outcome is encouraging, but does indicate that ECMO and the near-miss ECMO patients need to be followed closely into school age. The number of patients being treated per ECMO center has dropped significantly over the last 10 years from 18 to 9. This brings forward the question about regional needs for ECMO Centers and how to assure that centers have enough patients to maintain their clinical competencies. The challenge for the future is where to place ECMO as a therapy. Should it remain a rescue therapy? Or should there now be a trial comparing ECMO to conventional therapies, with morbidity and cost of care as the outcome variables?