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King S, Carr BDE, Mychaliska GB, Church JT. Surgical approaches to congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151441. [PMID: 38986242 DOI: 10.1016/j.sempedsurg.2024.151441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
Surgical repair of the diaphragm is essential for survival in congenital diaphragmatic hernia (CDH). There are many considerations surrounding the operation - why the operation matters, optimal timing of repair and its relation to extracorporeal life support (ECLS) use, minimally invasive versus open approaches, and strategies for reconstruction. Surgery is both affected by, and affects, the physiology of these infants and is an important factor in determining long-term outcomes. Here we discuss the evidence and provide insight surrounding this complex decision making, technical pearls, and outcomes in repair of CDH.
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Affiliation(s)
- Sarah King
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA
| | - Benjamin D E Carr
- Doernbecher Children's Hospital, Division of Pediatric Surgery, Department of Surgery, Oregon Health and Science University. Portland, OR, USA
| | - George B Mychaliska
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA
| | - Joseph T Church
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA.
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Shah NR, Criss CN, Burgi K, Matusko N, Geiger JD, Perrone EE, Mychaliska GB, Ralls MW. Thoracoscopic Patch Repair of Congenital Diaphragmatic Hernia: Can Smaller Incisions Treat Larger Defects? J Pediatr Surg 2024; 59:1083-1088. [PMID: 37867043 DOI: 10.1016/j.jpedsurg.2023.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/14/2023] [Accepted: 09/26/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Thoracoscopic CDH repair is increasingly performed for Type A and small Type B defects that are amenable to primary repair. However, the thoracoscopic approach is controversial for larger defects necessitating a patch due to technical complexity, intraoperative acidosis, and recurrence risk. We aim to compare clinical outcomes between thoracoscopic and open patch repair of Type B/C defects, using a standardized technique. METHODS This is a single-center retrospective review of thoracoscopic and open CDH patch repairs January 2017-December 2021. We excluded primary repairs, Type D hernias, repairs on ECMO, recurrent repairs. Various preoperative, intraoperative, and postoperative variables were compared. Primary outcome was recurrence rate. Secondary outcomes included intraoperative pH and pCO2, operative time, and complication rates. RESULTS Twenty-nine patients met inclusion criteria (open = 13, thoracoscopic = 16). The open cohort had lower o/e total fetal lung volume (29 vs 41.2%, p = 0.042), higher preoperative peak inspiratory pressures (24 vs 20 cm H2O, p = 0.007), were more frequently Type C defects (92.3 vs 31%, p = 0.002) and had liver "up" in left-sided hernias (46 vs 0%, p < 0.0001). Intraoperatively, median lowest pH and highest pCO2 did not differ; neither did overall median pH or pCO2. Operative times were similar (153 vs 194 min, p = 0.113). No difference in recurrence rates was identified, however postoperative complications were higher in the open group. There were no mortalities. CONCLUSIONS Although we demonstrate higher disease severity of patients undergoing open repair, thoracoscopic patch repair for Type B/C defects is safe and effective in patients with favorable physiologic status, alleviating concerns for intraoperative acidosis, operative length, and risk of recurrence. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Nikhil R Shah
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA.
| | - Cory N Criss
- Nationwide Children's Hospital, Department of Surgery, Section of Pediatric Surgery, 700 Childrens Dr., Columbus, OH 43205, USA
| | - Keerthi Burgi
- University of Michigan School of Medicine, 1301 Catherine St., Ann Arbor, MI 48109-4211, USA
| | - Niki Matusko
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA
| | - James D Geiger
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA
| | - Erin E Perrone
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA
| | - George B Mychaliska
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA
| | - Matthew W Ralls
- University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA
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Cimbak N, Buchmiller TL. Long-term follow-up of patients with congenital diaphragmatic hernia. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000758. [PMID: 38618013 PMCID: PMC11015326 DOI: 10.1136/wjps-2023-000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/28/2024] [Indexed: 04/16/2024] Open
Abstract
Neonates with congenital diaphragmatic hernia encounter a number of surgical and medical morbidities that persist into adulthood. As mortality improves for this population, these survivors warrant specialized follow-up for their unique disease-specific morbidities. Multidisciplinary congenital diaphragmatic hernia clinics are best positioned to address these complex long-term morbidities, provide long-term research outcomes, and help inform standardization of best practices in this cohort of patients. This review outlines long-term morbidities experienced by congenital diaphragmatic hernia survivors that can be addressed in a comprehensive follow-up clinic.
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Affiliation(s)
- Nicole Cimbak
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Terry L Buchmiller
- Department of Pediatric Surgery, Boston Children's Hospital, Boston, MA, USA
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Chen KK, Edwards MJ. Delayed presentation of a right congenital diaphragmatic hernia following left congenital diaphragmatic hernia repair in infancy. Int J Surg Case Rep 2023; 105:108020. [PMID: 36963226 PMCID: PMC10053395 DOI: 10.1016/j.ijscr.2023.108020] [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: 01/03/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 03/26/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Congenital diaphragmatic hernias (CDH) affect variable portions of diaphragm, resulting in herniation of abdominal contents into the chest. CDH typically is diagnosed prenatally or presents soon after birth with respiratory distress and abnormal chest X-ray (CXR) findings. Presentation after infancy is rare but well described. We present a case of delayed presentation of a right CDH following left CDH repair. CASE PRESENTATION An 18-month-old boy with a history of a left CDH repaired in the newborn period presented with a newly elevated right hemidiaphragm presumed to be an eventration. He re-presented 9 months later with abdominal pain and respiratory distress. Xray was concerning for gastric volvulus within the right chest. Surgical exploration revealed a small right sided diaphragmatic hernia with an incarcerated liver and stomach. This was repaired without event. CLINICAL DISCUSSION Normal appearing CXR following L CDH repair led to delayed recognition of this right CDH. Delayed presentation was likely due to the liver covering the small diaphragmatic defect, preventing early migration of the intra-abdominal viscera into the chest. Recurrence of the CDH is the most common cause of respiratory and gastrointestinal symptoms following prior repair, but an unrecognized contralateral defect is a rare possibility. CONCLUSION In a patient with a prior history of a left CDH who presents with respiratory and gastrointestinal symptoms, along with a recurrence of the left sided CDH, the presence of a right sided defect should be considered if the right hemidiaphragm is newly elevated.
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Affiliation(s)
- Kaddie Kwok Chen
- Albany Medical College, 49 New Scotland Avenue, Albany, NY 12208, United States of America.
| | - Mary Jude Edwards
- Pediatric Surgery, Department of Surgery, Albany Medical Center, 50 New Scotland Avenue, Albany, NY 12208, United States of America.
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Theodorou CM, Taylor A, Lee SY, Cortez LM, Fu H, Pivetti CD, Zhang C, Stasyuk A, Hao D, Kumar P, Farmer DL, Liao J, Brown EG, Hong Y, Wang A. Evaluation of a biodegradable polyurethane patch for repair of diaphragmatic hernia in a rat model: A pilot study. J Pediatr Surg 2023; 58:964-970. [PMID: 36797111 PMCID: PMC10184880 DOI: 10.1016/j.jpedsurg.2023.01.036] [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: 01/06/2023] [Accepted: 01/08/2023] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Congenital diaphragmatic hernia (CDH) repair is an area of active research. Large defects requiring patches have a hernia recurrence rate of up to 50%. We designed a biodegradable polyurethane (PU)-based elastic patch that matches the mechanical properties of native diaphragm muscle. We compared the PU patch to a non-biodegradable Gore-Tex™ (polytetrafluoroethylene) patch. METHODS The biodegradable polyurethane was synthesized from polycaprolactone, hexadiisocyanate and putrescine, and then processed into fibrous PU patches by electrospinning. Rats underwent 4 mm diaphragmatic hernia (DH) creation via laparotomy followed by immediate repair with Gore-Tex™ (n = 6) or PU (n = 6) patches. Six rats underwent sham laparotomy without DH creation/repair. Diaphragm function was evaluated by fluoroscopy at 1 and 4 weeks. At 4 weeks, animals underwent gross inspection for recurrence and histologic evaluation for inflammatory reaction to the patch materials. RESULTS There were no hernia recurrences in either cohort. Gore-Tex™ had limited diaphragm rise compared to sham at 4 weeks (1.3 mm vs 2.9 mm, p = 0.003), but no difference was found between PU and sham (1.7 mm vs 2.9 mm, p = 0.09). There were no differences between PU and Gore-Tex™ at any time point. Both patches formed an inflammatory capsule, with similar thicknesses between cohorts on the abdominal (Gore-Tex™ 0.07 mm vs. PU 0.13 mm, p = 0.39) and thoracic (Gore-Tex™ 0.3 mm vs. PU 0.6 mm, p = 0.09) sides. CONCLUSION The biodegradable PU patch allowed for similar diaphragmatic excursion compared to control animals. There were similar inflammatory responses to both patches. Further work is needed to evaluate long-term functional outcomes and further optimize the properties of the novel PU patch in vitro and in vivo. LEVEL OF EVIDENCE Level II, Prospective Comparative Study.
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Affiliation(s)
- Christina M Theodorou
- Center for Surgical Bioengineering, Department of Surgery, School of Medicine, University of California Davis, 4625 2nd Avenue, Room 3001, Sacramento, CA, 95817, USA
| | - Alan Taylor
- Department of Bioengineering, University of Texas at Arlington, 500 UTA Blvd, Arlington, TX 76019, USA
| | - Su Yeon Lee
- Center for Surgical Bioengineering, Department of Surgery, School of Medicine, University of California Davis, 4625 2nd Avenue, Room 3001, Sacramento, CA, 95817, USA
| | - Lia Molina Cortez
- Department of Bioengineering, University of Texas at Arlington, 500 UTA Blvd, Arlington, TX 76019, USA
| | - Huikang Fu
- Department of Bioengineering, University of Texas at Arlington, 500 UTA Blvd, Arlington, TX 76019, USA
| | - Christopher D Pivetti
- Center for Surgical Bioengineering, Department of Surgery, School of Medicine, University of California Davis, 4625 2nd Avenue, Room 3001, Sacramento, CA, 95817, USA; Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, 2425 Stockton Blvd, Sacramento, CA, 95817, USA
| | - Chaoxing Zhang
- Center for Surgical Bioengineering, Department of Surgery, School of Medicine, University of California Davis, 4625 2nd Avenue, Room 3001, Sacramento, CA, 95817, USA; Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, 2425 Stockton Blvd, Sacramento, CA, 95817, USA
| | - Anastasiya Stasyuk
- Center for Surgical Bioengineering, Department of Surgery, School of Medicine, University of California Davis, 4625 2nd Avenue, Room 3001, Sacramento, CA, 95817, USA
| | - Dake Hao
- Center for Surgical Bioengineering, Department of Surgery, School of Medicine, University of California Davis, 4625 2nd Avenue, Room 3001, Sacramento, CA, 95817, USA; Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, 2425 Stockton Blvd, Sacramento, CA, 95817, USA
| | - Priyadarsini Kumar
- Center for Surgical Bioengineering, Department of Surgery, School of Medicine, University of California Davis, 4625 2nd Avenue, Room 3001, Sacramento, CA, 95817, USA; Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, 2425 Stockton Blvd, Sacramento, CA, 95817, USA
| | - Diana L Farmer
- Center for Surgical Bioengineering, Department of Surgery, School of Medicine, University of California Davis, 4625 2nd Avenue, Room 3001, Sacramento, CA, 95817, USA; Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, 2425 Stockton Blvd, Sacramento, CA, 95817, USA
| | - Jun Liao
- Department of Bioengineering, University of Texas at Arlington, 500 UTA Blvd, Arlington, TX 76019, USA
| | - Erin G Brown
- Center for Surgical Bioengineering, Department of Surgery, School of Medicine, University of California Davis, 4625 2nd Avenue, Room 3001, Sacramento, CA, 95817, USA
| | - Yi Hong
- Department of Bioengineering, University of Texas at Arlington, 500 UTA Blvd, Arlington, TX 76019, USA.
| | - Aijun Wang
- Center for Surgical Bioengineering, Department of Surgery, School of Medicine, University of California Davis, 4625 2nd Avenue, Room 3001, Sacramento, CA, 95817, USA; Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, 2425 Stockton Blvd, Sacramento, CA, 95817, USA; Department of Biomedical Engineering, University of California Davis, One Shields Ave, Davis, CA, 95616, USA.
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Goudarzi H, Hemmatizadeh M, Anbara T. Surgical technique of congenital diaphragmatic hernia following sleeve gastrectomy; a case report study. Int J Surg Case Rep 2022; 99:107671. [PMID: 36150329 PMCID: PMC9568777 DOI: 10.1016/j.ijscr.2022.107671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction and importance Congenital diaphragmatic hernia (CDH) is caused by a defect of diaphragm. The incidence of CDH is 1/3600 in new births in the US, causing pulmonary hypoplasia and pulmonary hypertension. In rare cases, the late presentation in adulthood is reported. Case presentation We report a 31-year-old female with respiratory distress and gastrointestinal disease, diagnosed on X-ray chest and abdomen CT scan as CDH case, which was in left-sided diaphragm. Clinical discussion Left posterolateral thoracotomy was performed for this patient. The patient with late diaphragmatic hernias presentation had a variety of symptoms, but diagnosis was very difficult. Conclusion In this super rare case, the patient had a mix of bariatric surgery complications such as excessive weight loss. Additional investigation and research are necessary to better detect this type of disease. A 31-year-old female with left-sided CDH, with BMI 44 kg/m2 who had underwent laparoscopic sleeve gastrectomy. Symptoms were cough, fever, shivering and excessive weight loss after 4 months. It is the first time a patient was diagnosed with CDH following surgery where the patient had no respiratory and gastrointestinal symptoms. We guess that the patient experienced severe weight loss after sleeve gastrectomy that may put this susceptible case at the risk of late occurring diaphragmatic hernia.
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Affiliation(s)
- Hamidreza Goudarzi
- Department of Surgery, Erfan Niayesh Hospital, PC 1476919491 Tehran, Iran
| | - Mahsa Hemmatizadeh
- Department of Surgery, Erfan Niayesh Hospital, PC 1476919491 Tehran, Iran
| | - Taha Anbara
- Department of Surgery, Erfan Niayesh Hospital, PC 1476919491 Tehran, Iran.
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Amodeo I, Borzani I, Raffaeli G, Persico N, Amelio GS, Gulden S, Colnaghi M, Villamor E, Mosca F, Cavallaro G. The role of magnetic resonance imaging in the diagnosis and prognostic evaluation of fetuses with congenital diaphragmatic hernia. Eur J Pediatr 2022; 181:3243-3257. [PMID: 35794403 PMCID: PMC9395465 DOI: 10.1007/s00431-022-04540-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/23/2022] [Indexed: 11/04/2022]
Abstract
UNLABELLED In recent years, magnetic resonance imaging (MRI) has largely increased our knowledge and predictive accuracy of congenital diaphragmatic hernia (CDH) in the fetus. Thanks to its technical advantages, better anatomical definition, and superiority in fetal lung volume estimation, fetal MRI has been demonstrated to be superior to 2D and 3D ultrasound alone in CDH diagnosis and outcome prediction. This is of crucial importance for prenatal counseling, risk stratification, and decision-making approach. Furthermore, several quantitative and qualitative parameters can be evaluated simultaneously, which have been associated with survival, postnatal course severity, and long-term morbidity. CONCLUSION Fetal MRI will further strengthen its role in the near future, but it is necessary to reach a consensus on indications, methodology, and data interpretation. In addition, it is required data integration from different imaging modalities and clinical courses, especially for predicting postnatal pulmonary hypertension. This would lead to a comprehensive prognostic assessment. WHAT IS KNOWN • MRI plays a key role in evaluating the fetal lung in patients with CDH. • Prognostic assessment of CDH is challenging, and advanced imaging is crucial for a complete prenatal assessment and counseling. WHAT IS NEW • Fetal MRI has strengthened its role over ultrasound due to its technical advantages, better anatomical definition, superior fetal lung volume estimation, and outcome prediction. • Imaging and clinical data integration is the most desirable strategy and may provide new MRI applications and future research opportunities.
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Affiliation(s)
- Ilaria Amodeo
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Irene Borzani
- grid.414818.00000 0004 1757 8749Pediatric Radiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Genny Raffaeli
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy ,grid.4708.b0000 0004 1757 2822Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Nicola Persico
- grid.4708.b0000 0004 1757 2822Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy ,grid.414818.00000 0004 1757 8749Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Simeone Amelio
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Silvia Gulden
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Mariarosa Colnaghi
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Eduardo Villamor
- grid.412966.e0000 0004 0480 1382Department of Pediatrics, School for Oncology and Reproduction (GROW), Maastricht University Medical Center, University of Maastricht, MUMC+), Maastricht, the Netherlands
| | - Fabio Mosca
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy ,grid.4708.b0000 0004 1757 2822Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy.
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