Comparison of the Surgical Outcomes in Neonates with Left-sided Congenital Diaphragmatic Hernia with Only Skin Closure versus Abdominal Muscle Closure

Aim

This study aims to compare the outcome of neonatal left congenital diaphragmatic hernia (CDH, Bochdalek type) repair through laparotomy with and without abdominal muscle closure.

Materials and Methods

This retrospective study was conducted between January 2012 and May 2021 at a neonatal surgical unit of a Tertiary Care Center. Demographic details, preoperative management, Two-dimensional-echo, intra-operative findings, postoperative course, and follow-up data were collected and analyzed.

Results

The study group comprised 50 neonates with a mean standard deviation (SD) age at admission: 4.44 (5.12) days, male: female ratio of 3:2, and mean (SD) weight: 2.73 (0.51) kg. Following repair of the diaphragmatic defect through laparotomy, 26 (52%) underwent skin closure alone, whereas 24 (48%) underwent abdominal muscle closure. Postoperatively, there was a significant fall in the level of platelets (P = 0.021), increase in pressure support by at least 4-5 cm H2O (P = 0.027), and increase in the blood urea (P < 0.001), creatinine (P = 0.005), lactate (P = 0.019), and acidosis (P = 0.048) in the muscle closure group. Although not statistically significant, there was a fall in the urine output and blood pressure in this group. There was no significant difference in the duration of inotropes. Mortality was 8 (32%) in the skin closure group, and 14 (61%) in the muscle closure group (P = 0.05).

Conclusions

Neonates undergoing left CDH repair through the abdominal route with skin closure alone, had better survival, as well as hematological, renal, and ventilatory parameters than those who underwent muscle closure. It is a useful surgical modification to improve outcome in centers with limited facilities.

Treprostinil in Neonates with Congenital Diaphragmatic Hernia-Related Pulmonary Hypertension

OBJECTIVE

To describe our experience with treprostinil, evaluate correlations with cardiac function, and assess for adverse effects in neonates with congenital diaphragmatic hernia-related pulmonary hypertension (CDH-PH).

STUDY DESIGN

A retrospective review of a single-center prospective registry at a quaternary care children's hospital. Patients included in the study had CDH-PH treated with treprostinil between April 2013 and September 2021. Assessed outcomes were brain-type natriuretic peptide levels and quantitative echocardiographic parameters collected at baseline, 1 week, 2 weeks, and 1 month after treprostinil initiation. Right ventricular (RV) function was assessed by tricuspid annular plane systolic excursion Z-score and speckle tracking echocardiography (global longitudinal and free wall strain). Septal position and left ventricular (LV) compression were assessed by eccentricity index and M-mode Z-scores.

RESULTS

Fifty-one patients were included, with an average expected/observed lung-to-head ratio of 28.4 ± 9.0%. Most patients required extra-corporeal membrane oxygenation (n = 45, 88%). Survival to hospital discharge was 31/49 (63%). Treprostinil was initiated at a median age of 19 days with a median effective dose of 34 ng/kg/minute. Median baseline brain-type natriuretic peptide level decreased from 416.9 pg/mL to 120.5 pg/mL after 1 month. Treprostinil was associated with improved tricuspid annular plane systolic excursion Z-score, RV global longitudinal strain, RV free wall strain, LV eccentricity index, and LV diastolic and systolic dimensions, reflecting less compression by the RV, regardless of ultimate patient survival. No serious adverse effects were recorded.

CONCLUSIONS

In neonates with CDH-PH, treprostinil administration is well tolerated and is associated with improved RV size and function.

Survival after a two-stage surgical approach in hepatopulmonary fusion: A case report

INTRODUCTION

Congenital diaphragmatic hernias are a rare developmental defect. Pulmonary complications are more frequently seen in right sided defects (Partridge et al., 2016). Hepatopulmonary fusion is a rare and highly mortal malformation exclusively seen in right sided congenital diaphragmatic hernias marked by the fibrovascular fusion of the liver and lung.

PRESENTATION OF CASE

A newborn male presented with respiratory distress and a 1-minute APGAR score of 7. A chest radiograph showed complete opacification of the right hemithorax, and a CT-Scan confirmed a congenital diaphragmatic hernia, an intrathoracic location of the liver and secondary pulmonary hypoplasia. 48 h after, intraoperative findings showed fusion of diaphragm, lung and liver tissue. Four months after, complete tissue division of the lower lobe from the fused liver segments VII/VIII and correction of the hernia defect was achieved. The patient was discharged from the hospital six months after.

DISCUSSION

Partial division of tissues is described as the safest and most successful approach to hepatopulmonary fusion. The tally of all cases reported worldwide until 2020 shows higher survival rates with complete division of tissues (Ferguson DM; Congenital Diaphragmatic Hernia Study Group, 2020) Reported cases lean towards one-session surgical interventions. A two-stage surgical approach allows an initial low surgical trauma to manage compressive effects on intrathoracic structures by herniary contents and a second time for tissue division in a non-critical patient, in this case leading to long-term survival.

CONCLUSION

Hepatopulmonary fusion is a rare and highly lethal malformation with scarce information available. Future multicenter studies should compare different therapeutic options and search for outcomes including but not limited to mortality.

Giant Bochdalek Hernia: A Minimally Invasive Transabdominal Approach

A Bochdalek hernia is the most common congenital diaphragmatic hernia (CDH). It can rarely evade prenatal detection and persist into adulthood with minimal symptoms. Large CDH repair has often required an open approach in the past. In this article, we present a case of a patient with large CDH who was asymptomatic until later in her adult life who subsequently developed symptoms and sought a surgical evaluation. A minimally invasive transabdominal approach was used to effectively reduce and repair this rare giant hernia. The patient has remained free of recurrence and has had resolution of her symptoms after 18 months of follow-up. This case illustrates that even the largest of these can be handled in a minimally invasive fashion and achieve durable results.

Congenital Diaphragmatic Hernia: Core Review and Novel Updates

Congenital diaphragmatic hernia (CDH) is a developmental defect in the diaphragm that allows abdominal viscera to herniate into the thoracic cavity. Pulmonary hypoplasia and pulmonary hypertension are consequences of this disease process. The incidence is approximately 2.4-4.1/10,000 births, and survival rate is estimated at 70-90 percent. To avoid potentially devastating delays in care, it is crucial that neonatal nurses and care providers in both tertiary and nontertiary care centers be familiar with the pathogenesis of CDH and the standard of care for initial stabilization of the neonate. Novel fetal and postnatal surgical repair techniques are also described here.

Bochdalek hernia with retrocardiac spleen - Diagnostic dilemma for emergency care physicians-A case report

INTRODUCTION

Physicians working as first-level responders in emergency departments (ED) often encounter patients, of any age group with shortness of breath (SOB). Definitive diagnosis is quite challenging once the underlying pathology is rare and unusual and/or the ED physicians recommend and rely on non-specific investigations.

PRESENTATION OF CASE

A 29-year-old female presented to the emergency department with sudden onset of shortness of breath and upper abdominal pain radiating to the left shoulder. Diagnosis of Bochdalek hernia was made clinically coupled with radiological findings of CXR and computed tomography (CT) by the surgeon on-call, while it was missed by an emergency care physician on her first visit.

DISCUSSION

Herniation of the abdominal contents into the thoracic cavity via the Bochdalek opening, commonly known as Bochdalek hernia is seen and diagnosed most commonly accidentally in early life. Adult cases of symptomatic Bochdalek hernia has been reported in the literature. These patients usually present with non-specific symptoms, thus pose a diagnostic challenge for an emergency care physician.

CONCLUSION

The report of this case highlights the notion that such rare causes of acute onset dyspnea and upper abdominal pain pose a diagnostic challenge for novice emergency care physicians especially in situations where he/she does not ask for second-line help in general and recommend and rely on a non-specific investigation in specific.

Strangulated Congenital Diaphragmatic Hernia of Bochdalek Diagnosed in Late Pregnancy: A Case Report and Review of the Literature

BACKGROUND

Congenital diaphragmatic hernia is an unusual condition in the adult population because it is mostly a neonatal diagnosis. This entity may be triggered by pregnancy and threaten the life of the mother and her fetus.

CASE

This report presents the case of a maternal diaphragmatic hernia diagnosed at 35 weeks of pregnancy with epigastric pain, nausea, and vomiting. Patient developed respiratory distress, and a radiograph revealed left lung collapse. A chest tube was inserted for a presumed tension pneumothorax. The patient's condition deteriorated, and a diaphragmatic hernia containing the stomach, transverse colon, and small bowel was diagnosed. The patient underwent laparotomy with Caesarean section, hernia reduction, and diaphragmatic repair.

CONCLUSION

A high degree of suspicion is required to avoid misdiagnosis and management delay. Surgical treatment must be individualized according to gestational age and clinical setting.

Cardiac Function Assessments in Left Bochdalek's Hernia: Clinical Relevance

The objectives of this study were to characterize peri-operative echocardiographic (ECHO) assessments of right ventricular (RV) function and pulmonary hypertension (PH) and ascertain correlation with clinical outcomes in infants with left Bochdalek's hernia (LBH). This retrospective study in a quaternary neonatal intensive care unit involved electronic database search for infants with LBH during January 2009 to July 2017. Demographics, outcomes, and ECHO parameters were accessed from archived databases. Thirty-one infants with mean gestational age and birthweight (BW) 38.4 ± 1.4 weeks and 3079 ± 450 g were included. Postnatal age at surgery was 4.3 ± 2 days. Two infants died before surgery (none after surgery). The survival rate in this cohort of late preterm and term infants with LBH not accompanied by congenital heart disease was 29/31 (93.5%). PH was noted in 28 (90%). Significant changes in biventricular function and pulmonary vascular haemodynamics were noted when reassessed after surgery [RV area change (%), 28 ± 3 vs. 34 ± 4, p = 0.007 and pulmonary artery capacitance (PAC) (ml³ × mmHg^-1), 0.05 ± 0.03 vs. 0.09 ± 0.05, p = 0.02]. The median duration of all respiratory support in those who were operated was 14.7 days (8.5, 25). Significant correlations were noted between pre-operative ECHO assessments and the duration of respiratory support (tricuspid regurgitation, r = 0.63, p = 0.0001 and PAC, r = - 0.52, p = 0.004). Peri-operative functional ECHO provided information about the evolution of cardiac function in infants with LBH.

Vincenc Alexandr Bohdálek (1801-1883): Czech anatomist and neuroscientist of the nineteenth century

Vincenc Alexandr Bohdálek (Vincenz Alexander Bochdalek) was a well-known anatomist and pathologist in the nineteenth century. Today, however, his name is all but forgotten. Bohdálek described a number of anatomical structures; some of them became eponyms. Unfortunately, his findings concerning the innervation of the eye, upper jaw, hard palate, auditory system, and meninges are little known today. This current overview is based on available archival sources and provides an insight into his results in the field of nervous system research, which account for almost half his work. Bohdálek can clearly be considered a pioneer in the field we now call functional anatomy, as he tried to find a physiological explanation for the anatomical and pathological findings he observed. The work and results of this truly outstanding neuroscientist of his time are thus again available to current and future generations of neuroscientists and neuroanatomists.

Right posterior diaphragmatic hernia (Bochdalek) with liver involvement and alteration of hepatic outflow in adult: a case report

Introduction

Posterior right diaphragmatic hernia is rare in newborn patients but when present, is accompanied by high mortality. Pulmonary hypoplasia seems to be the main cause of death but the presence of liver involvement remains one of the reasons for poor prognosis even when intrauterine surgery is performed.

Case Description

In this article, we will present a rare case that was diagnosed by chance in a 65-year old adult presenting with an adenocarcinoma of the rectosigmoid junction and a right Bochdalek hernia with liver herniation and modification of the hepatic vein outflow with a natural right to left shunt.

Discussion

Diaphragmatic repair was performed on the patient with a mash and simultaneous colorectal resection. Intraoperatively, the exceptional natural modification of the hepatic outflow and alteration of the caval system was evident.

Conclusion

This case report represent an extremely rare anatomic variation and could be useful to give new important information on the evolution that occur in foetal life.

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.

Large Sized Left Inferior Phrenic Artery and Parahiatal Type of Diaphragmatic Hernia Generating Confusion During Robotic Surgical Repair

INTRODUCTION

As an advanced minimally invasive surgical procedure, the repair of the diaphragmatic hernia may sometimes be very challenging especially when the anatomy is unclear.

MATERIALS AND METHODS

We are presenting a rare case of a parahiatal hernia defect repair where the understanding of the anatomy was complicated by the presence of an unusual large sized left inferior phrenic artery. The Da Vinci surgical platform was used to perform the entire procedure. Hernia sac dissection, identification of the crura, primary closure of the defect, and use of biologic mesh reinforcement were the main steps performed in the usual manner for hernia repair. In addition, the use of intraoperative ultrasound was of great utility to clarify the vascular anatomy.

RESULTS

The additional time required for the intraoperative ultrasound and identification of the vascular anatomy has increased the duration of the procedure that otherwise was uneventful. The accurate identification of the anatomy allowed for a safe surgical outcome. The postoperative course was favorable and patient was free of symptoms at 1-month follow-up.

CONCLUSION

The challenge of the repair of this rare, parahiatal type of diaphragmatic hernia where a large sized left inferior phrenic artery was also encountered was successfully mitigated by the use of the intraoperative Doppler ultrasound and by compliance with the basic steps of the procedure.

The First Case Report of Robotic Multivisceral Resection for Synchronous Liver Metastasis from Pancreatic Neuroendocrine Tumor: A Case Report and Literature Review

INTRODUCTION

Surgery for liver metastases in pancreatic neuroendocrine tumor (PNET) improves overall survival rate. We present the first case report for robotic multivisceral resection of distal pancreas, spleen, and left liver for metastatic PNET.

MATERIALS AND METHODS

We present a case of 52-year-old female diagnosed with PNET in the pancreatic neck metastatic to the liver, responding to somatostatin and bland embolization, who underwent surgical debulking using da Vinci robotic platform. Intraoperative Doppler ultrasound was used to define the vascular distribution and tumor extension. The parenchymal liver transection was performed with vessel sealer. The distal pancreas and the spleen were approached medial to lateral and resected in an en-bloc fashion. The left liver inflow, outflow, and splenic artery and vein were transected with vascular stapler device.

RESULTS

Da Vinci robot-assisted multivisceral resection has been performed with good postoperative outcome. Operative time was 369 minutes and the estimated blood loss was 100 mL. The patient had a short hospital stay with quick recovery and good outcome at 5 months follow-up after the surgery.

DISCUSSION

Liver metastases in PNETs are considered an adverse factor. Aggressive surgical management is a mainstay. The laparoscopic approach to pancreatic or hepatic surgery is difficult in inexperienced hands with steep learning curve. The recent robotic system seems to overcome many limitations. This is the first case of robotic multivisceral resection for synchronous liver metastasis from PNET. Concurrent primary tumor resection with hepatectomy offers potential curative intention.

Adult right-sided Bochdalek hernia with ileo-cecal appendix: Almeida-Reis hernia

INTRODUCTION

Bochdalek hernia is one of the most common congenital abnormalities manifested in infants. In the adult is a rarity, with a prevalence of 0.17-6% of all diaphragmatic hernias. Right-sided Bochdalek hernias containing colon are even more rare, with no case described in the literature with ileo-cecal appendix.

PRESENTATION OF CASE

The authors present a case of a right-sided Bochdalek hernia in an adult female of 49 years old, presented with severe respiratory failure. During laparotomy for hernia correction, were found in an intrathoracic position the cecum and ileo-cecal appendix, the right colon and the transverse colon.

DISCUSSION

Although useful in patient evaluation, clinical history and physical examination are not helpful in making diagnosis because of their nonspecific character. CT scan is the most accurate exam for making diagnosis. Most of the times there is no hernial sac. Surgery is the treatment of choice, and it is always indicated even if asymptomatic. In general suture of the defect is possible. Due to patient's weak respiratory function we chose laparotomy by Kocher incision.

CONCLUSION

Being the first case of a right-sided Bochdalek hernia in the adult with a herniated ileo-cecal appendix, we name it Almeida-Reis hernia.

Congenital diaphragmatic hernia in identical twins

Congenital diaphragmatic hernia (CDH, Bochdalek type) is rarely seen in both members of identical twins. Herein, we report a 37 weeks’ twins with CDH along with a brief review of the literature. Both the neonates survived.