Prenatal Imaging Features and Postnatal Factors Associated with Gastrointestinal Morbidity in Congenital Diaphragmatic Hernia

BACKGROUND

To perform a comprehensive assessment of postnatal gastrointestinal (GI) morbidity and determine the prenatal imaging features and postnatal factors associated with its development in patients with congenital diaphragmatic hernia (CDH).

MATERIALS AND METHODS

A retrospective review was conducted of all infants evaluated for CDH at a quaternary fetal center from February 2004 to May 2017. Prenatal imaging features and postnatal variables were analyzed. GI morbidity was the primary outcome. The Mann-Whitney U test, the Kruskal-Wallis test with Dunnett's T3 post hoc analysis and logistic regression, and the χ2 test were performed when appropriate.

RESULTS

We evaluated 256 infants; 191 (75%) underwent CDH repair and had at least 6 months of follow-up. Of this cohort, 60% had gastroesophageal reflux disease (GERD), 13% had gastroparesis, 32% received a gastrostomy tube (G-tube), and 17% needed a fundoplication. Large defect, patch repair, extracorporeal membrane oxygenation (ECMO), and prolonged use of mechanical ventilation were significantly associated with having GERD, gastroparesis, G-tube placement, and fundoplication (p < 0.05). Fetuses with stomach grades 3 and 4 were most likely to have GERD, a G-tube, and a long-term need for supplemental nutrition than fetuses with stomach grades 1 and 2 (p < 0.05).

CONCLUSION

Survivors of CDH with large defects, prolonged use of mechanical ventilation, or that have received ECMO may be at an increased risk for having GERD, gastroparesis, and major GI surgery. Marked stomach displacement on prenatal imaging is significantly associated with GI morbidity in left-sided CDH.

Clinical characteristics and outcomes of patients with right congenital diaphragmatic hernia: A population-based study

PURPOSE

The purpose of this study was to compare RCDH to LCDH from the perspective of prenatal diagnosis, illness severity, treatment, and outcome.

METHODS

A retrospective study of all cases of CDH registered in the Canadian Pediatric Surgery Network (CAPSNet) database from 2005 to 2013 was conducted. Side of defect comparisons were made by prenatal diagnostic features, birth demographic data, intensity of medical treatment, timing and type of surgery, and outcomes. Outcomes prediction with logistic regression modeling using side of defect as an exploratory covariate was performed.

RESULTS

The study cohort included 498 patients, of which 84 (17%) cases had RCDH. Prenatal diagnosis was more commonly made for LCDH. No difference existed in perinatal risk factors (GA, illness severity (SNAP-II) score, associated anomalies), preoperative treatment intensity (use of vasodilators, inotropes), timing of surgery, ventilation days, need for ECMO, LOS, and overall survival. Significant differences between RCDH and LCDH were detected for patch repair rate (48.2% vs. 30.6%; p=0.036) and recurrence (4.1% vs. 0.6%; p=0.038). Stepwise regression modeling identified side of hernia as independently predictive of need for patch.

CONCLUSIONS

Overall, little difference exists between RCDH and LCDH in terms of prognostic factors and outcomes.

Intrathoracic caudate lobe of the liver: A case report and literature review

Heterotopic supradiaphragmatic livers are rare. A total of 23 cases of primary supradiaphragmatic livers have been reported in the literature. The clinical presentations of heterotopic supradiaphragmatic liver are variable. The simultaneous detection of intrathoracic accessory liver and pulmonary sequestration is extremely rare, and only one case has previously been reported. It is difficult to make a correct diagnosis preoperatively. We presented a 53-year-old woman with complaints of an intermittent, productive cough and dyspnea for two months that was refractory to medical treatment. She had no previous history of trauma or surgery. A chest radiograph only showed a widening of the mediastinum. Contrast-enhanced computed tomography of the chest revealed a well-circumscribed homogenous soft-tissue mass, approximately 4.35 cm × 2.5 cm × 6.14 cm in size, protruding through the right diaphragmatic crura to the right pleural cavity, attached to the inferior vena cava, esophagus and liver. There was no conclusive diagnosis before surgery. After the operation, we discovered that this patient was the first case of a supradiaphragmatic heterotopic liver, which passed through the inferior vena cava foramen and was coincidentally combined with an intralobar pulmonary sequestration that was found intraoperatively. We discussed its successful management with surgical resection via a thoracic approach and reviewed the published literature.