Gastroesophageal reflux after repair of congenital diaphragmatic hernia

Do FETO CDH survivors need the same follow-up program as non-FETO patients?

Congenital diaphragmatic hernia (CDH) survivors are at risk of developing significant chronic health conditions and disabilities. The main purpose of this study was to compare the outcomes of CDH infants at 2 years of age (2y) according to whether the infants had undergone fetoscopic tracheal occlusion (FETO) during the prenatal period and characterize the relationship between morbidity at 2y and perinatal characteristics. Retrospective cohort single center study. Eleven years of clinical follow-up data (from 2006 to 2017) were collected. Prenatal and neonatal factors as well as growth, respiratory, and neurological evaluations at 2y were analyzed. One hundred and fourteen CDH survivors were evaluated. Failure to thrive (FTT) was present in 24.6% of patients, gastroesophageal reflux disease (GERD) in 22.8%, 28.9% developed respiratory problems, and 22% had neurodevelopment disabilities. Prematurity and birth weight < 2500 g were related to FTT and respiratory morbidity. Time to reach full enteral nutrition and prenatal severity markers seemed to influence all outcomes, but FETO therapy itself only had an effect on respiratory morbidity. Some variables related to postnatal severity (ECMO, patch closure, days on mechanic ventilation, and vasodilator treatment) were associated with almost all outcomes.  Conclusion: CDH patients have specific morbidities at 2y, most of them related to lung hypoplasia severity. Only respiratory problems were related to FETO therapy itself. The implementation of a specific multidisciplinary follow-up program for CDH patients is essential to provide them the best standard of care, but, more severe patients, regardless of whether they received prenatal therapy, need a more intensive follow-up. What is Known: • Antenatal fetoscopic endoluminal tracheal occlusion (FETO) increases survival in more severe congenital diaphragmatic hernia patients. • Congenital diaphragmatic hernia survivors are at risk of developing significant chronic health conditions and disabilities. Very limited data are available about the follow-up in patients with congenital diaphragmatic hernia and FETO therapy. What is New: • CDH patients have specific morbidities at 2 years of age, most of them related to lung hypoplasia severity. • FETO patients present more respiratory problems at 2 years of age but they don't have an increased incidence of other morbidities. More severe patients, regardless of whether they received prenatal therapy, need a more intensive follow-up.

Long-Term Evaluation of Gastroesophageal Reflux in Neonates with and without Preventive Anti-reflux Surgery at the Time of Congenital Diaphragmatic Hernia Repair

One potential comorbidity after congenital diaphragmatic hernia (CDH) is gastroesophageal reflux (GER), which can have a substantial effect on patients’ quality of life, thriving, and complications later in life. Efforts have been made to reduce gastroesophageal reflux with a preventive anti-reflux procedure at the time of CDH repair. In this follow-up study of neonates participating in a primary RCT study on preventive anti-reflux surgery, symptoms of GER were assessed longitudinally. Long-term data with a median follow-up time of ten years was available in 66 patients. Thirty-one neonates received an initial fundoplication. Secondary anti-reflux surgery was necessary in 18% and only in patients with large defects. It was required significantly more often in patients with intrathoracic herniation of liver (p = 0.015) and stomach (p = 0.019) and patch repair (p = 0.03). Liver herniation was the only independent risk factor identified in multivariate regression analysis. Primary fundopexy and hemifundoplication did not reveal a protective effect regarding the occurrence of GER symptoms, the need for secondary antireflux surgery or the gain of body weight regardless of defect size neither in the short nor in the long term. Symptoms of GER must be assessed carefully especially in children with large defects, as these are prone to require secondary anti-reflux surgery in the long-term. Routine evaluation of GER including endoscopy and impedance measurement should be recommended especially for high-risk patients.

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.

A systematic review with meta-analysis of the prevalence of gastroesophageal reflux in congenital diaphragmatic hernia pediatric survivors

Congenital diaphragmatic hernia survivors are a well-known group at risk for developing gastroesophageal reflux disease that may be particularly long-term severe. The aim of this study is to provide a systematic review of the prevalence of gastroesophageal reflux in infant and children survivors treated for congenital diaphragmatic hernia.Electronic and manual searches were performed with keywords related to congenital diaphragmatic hernia, gastroesophageal reflux disease, and epidemiology terms. Summary estimates of the prevalence were calculated. Effect model was chosen depending on heterogeneity (I2). Factors potentially related with the prevalence, including study quality or the diagnostic strategy followed, were assessed by subgroup and meta-regression analyses. Risk of publication bias was studied by funnel plot analysis and the Egger test.The search yielded 140 articles, 26 of which were included in the analyses and provided 34 estimates of prevalence: 21 in patients aged 12 months or younger, and 13 in older children. The overall prevalence of gastroesophageal reflux disease in infants was 52.7% (95% confidence interval [CI]: 43.2% to 62.1%, I2 = 88.7%) and, in children over 1 year old, 35.1% (95% CI: 25.4% to 45.3%, I2 = 73.5%). Significant clinical and statistical heterogeneity was found. The strategy chosen for gastroesophageal reflux diagnosis influenced the reported prevalence. The only estimate obtained with a systematic use of multichannel intraluminal impedance provided a higher prevalence in both age groups: 83.3% (95% CI: 67.2% to 93.6%) and 61.1% (95% CI: 43.5% to 76.9%) respectively. This last prevalence did not significantly differ from that obtained using only low risk of bias estimates.As a conclusion, gastroesophageal reflux disease is commonly observed after congenital diaphragmatic hernia repair and is almost constantly present in the first months of life. It may be underdiagnosed if systematically esophageal monitoring is not performed. This should be considered when proposing follow-up and management protocols for congenital diaphragmatic hernia survivors.

Prognostic factors of gastroesophageal reflux disease in congenital diaphragmatic hernia: a multicenter study

PURPOSE

Gastroesophageal reflux disease (GERD) is one of the concomitant problems in infants with congenital diaphragmatic hernia (CDH). We assessed risk factors of GERD in CDH patients.

METHODS

The retrospective observational study for CDH infants was conducted. Cases of CDH who were born between January 2006 and December 2010, were operated in the 9 participating institutions, and survived to discharge were included. Completion of medical therapy for GERD and incidence of surgery were primary outcomes. Kaplan-Meier survival analysis and Cox proportional hazards regression were used.

RESULTS

In 182 cases of CDH, the medical therapies for GERD were performed in 23.8% (40/168), and were completed in 60.0% (24/40). Prenatal detection of CDH (HR 5.87, CI 1.6-18.8, p = 0.012) and tube feeding at discharge (HR 5.04, 95% CI 1.3-33.1, p = 0.016) were significantly correlated with unsuccessful weaning from medical therapy. Surgery for GERD was performed in 10.7% (18/169). Gestational age (HR 4.78, 95% CI 1.5-21.1, p = 0.006) and diaphragmatic defect of more than 75% (HR 4.3, 95% CI 1.6-12.9, p = 0.005) were significantly correlated with need for antireflux surgery.

CONCLUSION

Diaphragmatic defect of more than 75% was risk factor of future need for antireflux surgery.

Growth in children with congenital diaphragmatic hernia during the first year of life

PURPOSE

Infants with congenital diaphragmatic hernia (CDH) have high rates of mortality and long-term morbidity, including poor growth and failure to thrive. The aim of this study was to describe growth patterns during the first year of life in infants with congenital diaphragmatic hernia in a non-ECMO cohort.

METHODS

Medical records of infants with CDH admitted to our center between January 2005 and December 2011 were reviewed. Infants with anthropometric measurements at 3, 6 and 12months were included. Anthropometric measurements were obtained for the first year of life. Logistic regression analyses were performed to find predictive associations with failure to thrive (FTT).

RESULT

Of the 45 survivors, 38 were seen twice (84%) and 24 (53%) were seen on three occasions to age 12months. Poor growth was observed with weight being most affected. FTT was present in 63% during the first six months of life. Days of mechanical ventilation were the only predictor of FTT. Besides poor weight gain, height and head circumference were also reduced. However, catch-up growth occurred during the second half of infancy and at age 12months failure to thrive had reduced by two thirds to 21%.

CONCLUSIONS

Poor growth is a common early finding in CDH patients, which improves during infancy. This emphasizes the importance of close follow-up and aggressive nutritional management in CDH patients.

Surgical complications, especially gastroesophageal reflux disease, intestinal adhesion obstruction, and diaphragmatic hernia recurrence, are major sequelae in survivors of congenital diaphragmatic hernia

PURPOSE

This study aimed to characterize the surgical complications, especially gastroesophageal reflux disease (GERD), intestinal adhesion obstruction (IAO), and diaphragmatic hernia recurrence, in patients with congenital diaphragmatic hernia (CDH).

METHODS

Between January 1995 and December 2013, we determined the incidence of surgical complications and their predictors in CDH patients. We also examined whether the CDH repair and patch closure were associated with the incidence of IAO and the severity of adhesion.

RESULTS

Seventy-four CDH survivors were evaluated. GERD occurred in 28 patients (37.8%) and recurred in 8 patients (10.8%). Stomach herniation was a risk factor for GERD, and occurred in 25 patients. IAO occurred in 13 patients (17.6%). In 240 neonatal laparotomies in the same period, the incidence of IAO was significantly higher in patients who underwent CDH repair than in patients who underwent other neonatal laparotomy (p = 0.023). Surgical time and intraoperative bleeding were significantly greater following CDH repair with an artificial patch compared with CDH repair with direct closure.

CONCLUSION

Surgical complications are major sequelae in survivors of CDH repair. CDH repair and artificial patch closure were significantly associated with the incidence of IAO and the severity of adhesion.

[Congenital diaphragmatic hernia: respiratory and vascular outcomes]

Congenital diaphragmatic hernia (CDH) is a life-threatening anomaly associated with a variable degree of pulmonary hypoplasia (PH) and persistent pulmonary hypertension (PPH). Despite remarkable advances in neonatal resuscitation and intensive care, and new postnatal treatment strategies, the rates of mortality and morbidity in the newborn with CDH remain high as the result of severe respiratory failure secondary to PH and PPH. Later, lung function assessments show obstructive and restrictive impairments due to altered lung structure and lung damage due to prolonged ventilatory support. The long-term consequences of pulmonary hypertension are unknown. Other problems include chronic pulmonary aspiration caused by gastro-oesophageal reflux and respiratory manifestations of allergy such as asthma or rhinitis. Finally, failure to thrive may be caused by increased caloric requirements due to pulmonary morbidity. Follow-up studies that systematically assess long-term sequelae are needed. Based on such studies, a more focused approach for routine multidisciplinary follow-up programs could be established. It is the goal of the French Collaborative Network to promote exchange of knowledge, future research and development of treatment protocols.

Evaluation of esophageal motility and reflux in children treated for congenital diaphragmatic hernia with the use of combined multichannel intraluminal impedance and pH monitoring

BACKGROUND

Gastroesophageal reflux (GER) is frequently observed in children treated for congenital diaphragmatic hernia (CDH) at birth, as well as esophageal dysmotility, that has been hypothesized to be caused by innervatory anomalies. The aim of this study is to evaluate GER and dysmotility in young patients with CDH using pH-multichannel intraluminal impedance.

METHODS

Thirty children (17 boys and 13 girls) who underwent repair for CDH between 2002 and 2007 with a median age of 5.2 years (range, 3-10 years) were included in the study. All patients were operated on with a subcostal laparotomy incision and had a left-sided diaphragmatic defect. The defect repair required an artificial patch (Goretex, Gore Medical, Flagstaff, AZ) in 8 patients (27%) because of its size. We described impedance reflux parameters and some specific motility parameters studied on 10 standardized swallows.

RESULTS

The incidence of GER was 86%. Reflux was mainly nonacidic, postprandial, and short-term and reached only the distal esophagus. Esophageal dysmotility was observed only in the distal esophagus.

CONCLUSIONS

With the use of pH-multichannel intraluminal impedance, both GER and esophageal motility in patients with congenital malformations can be analyzed. In patients with CDH, impaired motility seems to involve only the distal esophagus. In this group, the specific pattern of reflux is probably caused by the involvement of gastroesophageal junction, without significant intrinsic innervation abnormalities as observed in patients with esophageal atresia.

Physiological and clinical characteristics of gastroesophageal reflux after congenital diaphragmatic hernia repair

BACKGROUND/PURPOSE

Gastroesophageal reflux (GER) is an important sequela of congenital diaphragmatic hernia (CDH) repair. This study investigated the physiological and clinical characteristics of GER in CDH survivors.

METHODS

A total of 52 CDH survivors were investigated retrospectively. Esophageal acid exposure was evaluated with 24-h esophageal pH monitoring in all patients, and esophageal anatomical and motor functional abnormalities were examined with videomanometry in 16 patients.

RESULTS

Fundoplication was necessary in 1 patient. Medical treatment with acid suppression or rikkunshito, a traditional Japanese medicine, was successful in nine patients, and the reflux symptoms were ameliorated at the age of 3 years. The percentage of total time the esophageal pH was below 4.0 (reflux index: RI) ranged from 0.1 to 44.3%. No patient with an RI < 10% had reflux symptoms requiring treatment. The basal lower esophageal sphincter (LES) tone ranged from 15 to 35 mmHg (median 25 mmHg). Esophageal peristalsis was preserved in all of the patients examined, except one who had failed peristalsis and poor clearance in the dilated esophagus.

CONCLUSION

The motor function of the esophageal body and LES is usually preserved in CDH survivors despite the wide range of esophageal acid exposure in early infancy. Those with symptomatic GER outgrow it, unless associated with advanced respiratory distress or neurological impairment.

Congenital diaphragmatic hernia: long-term risk of gastroesophageal reflux disease

OBJECTIVES

Gastroesophageal reflux disease (GERD) is a well-recognized consequence of congenital diaphragmatic hernia (CDH). Results of studies examining predictive factors for early and late GERD are inconclusive. The aim of this study was to assess the incidence of early (<2 years) and late GERD (≥6 years) following CDH repair and to identify predictive variables.

PATIENTS AND METHODS

Of 183 patients born with high-risk CDH, 107 survived and 38 were excluded. Perinatal and postnatal data of 69 eligible patients were analysed to identify variables predictive for early GERD. For the follow-up study, 58 patients (84%) (ages 12.1 ± 3.4 years; range 6-17) completed a standardised questionnaire. Results were compared with those from a healthy control group (n = 83). Patients who had a score indicating increased risk of GERD underwent further diagnostic assessment. Predictive factors for early and late GERD were identified using multivariate regression analysis.

RESULTS

Early GERD was demonstrated in 27 patients (39%). Patch closure and intrathoracic position of the stomach were independent predictive variables for early GERD. At the time of follow-up, 9 of 58 patients (16%) had symptoms suggestive of GERD. In 7 patients (12%), late GERD was confirmed. For late GERD, however, no perinatal or postnatal risk factors were identified.

CONCLUSIONS

Early GERD is more common in CDH patients with patch closure or intrathoracic position of the stomach. Predictive factors for late GERD could not be identified and screening for early GERD does not protect for future GERD; therefore, long-term follow-up for GERD in CDH survivors is mandatory.

Laparoscopic fundoplication after previous open abdominal operations in infants and children

BACKGROUND

There have been multiple reports in the adult literature stating that previous open operations should no longer be considered a contraindication to the laparoscopic approach. However, there are little data on this topic in the pediatric population, particularly in patients with neonatal abdominal pathology unique to the newborn population. Therefore, we reviewed our experience with laparoscopic fundoplication after a variety of previous abdominal conditions and operations in the pediatric population.

METHODS

An institutional review board-approved retrospective chart review was performed on all patients undergoing laparoscopic fundoplication after a previous open operation between October 2000 and December 2007. The data collected demographics, comorbid conditions, previous abdominal operations, gastrostomy tube placement, time interval between the initial operation and laparoscopic fundoplication, conversions, and complications.

RESULTS

Forty-five patients underwent a laparoscopic Nissen fundoplication after an open operation during the study interval. Mean age was 41.3 months (range, 1-233) with a mean weight of 14.3 kg (range, 2.9-63.6), and 31 were (78.9%) male. A total of 61 previous abdominal operations were performed (range, 1-4). Mean time between last open operation and laparoscopic fundoplication was 27.3 months (range, 0.5-147). Mean operative time was 161 minutes (range, 73-420). There were no conversions and 3 perioperative complications occurred (splenic hematoma, clogged gastrostomy tube, and liver bleed). Early reoperations were performed in 2 patients (4.4%): 1 for bleeding on day 2 and the other for leaking gastrostomy day 12.

CONCLUSION

Our data demonstrate that laparoscopic fundoplication after a previous open operation is feasible and safe.

Anterior fundoplication at the time of congenital diaphragmatic hernia repair

PURPOSE

The loss of normal anatomic barriers in neonates with congenital diaphragmatic hernia (CDH) can predispose children to gastroesophageal reflux (GER). In an attempt to improve post-operative feeding, we have added a modified anterior fundoplication to restore natural gastric and esophageal positioning.

METHODS

The institutional review board of both participating centers approved this study. Between 1997 and 2008, 13 neonates with high-risk anatomy underwent repair of CDH combined with an anterior fundoplication (Boix-Ochoa). The anatomic indications for concomitant fundoplication were absence of an intra-abdominal esophagus, an obtuse angle of His, and a small, vertically oriented stomach.

RESULTS

Ten patients survived to discharge and eight were on full oral nourishment. One required partial gastrostomy feedings for an improving oral aversion and quickly progressed to full oral feedings. One patient with chromosomal anomalies and swallowing dysfunction remained on long-term bolus gastrostomy feedings. Two with progressive symptoms of GER and failure to thrive required conversion to a 360 degrees wrap after 18 months of medical management. This was performed in conjunction with a planned, staged muscle flap reconstruction in one patient. There were no complications related to the fundoplication.

CONCLUSION

Anatomic predictors of severe GER can be efficiently countered at the time of CDH repair. A modified fundoplication should be considered in the operative management of high-risk infants.

Influence of extracorporeal membrane oxygenation on subsequent surgeries after congenital diaphragmatic hernia repair

PURPOSE

Congenital diaphragmatic hernia (CDH) is a complex anomaly requiring intensive pulmonary and hemodynamic management. Survival has increased in this population placing them at risk for subsequent morbidities including surgery. The purpose of this study is to review the need for subsequent surgeries in the CDH population.

METHODS

After receiving institutional review board approval, a retrospective chart review of all CDH patients between 1980 and 2007 was conducted noting subsequent surgeries and the impact of extracorporeal membrane oxygenation (ECMO) on the types of surgical procedures. Comparison of groups was done by Fisher's Exact test or nonparametric Wilcoxon rank-sum test where appropriate. A P value of less than .05 was considered significant.

RESULTS

Data were analyzed for 227 of 294 patients during this period. Extracorporeal membrane oxygenation support was used in 45% of patients. Subsequent surgery was required in 117 patients. Seventy patients in the ECMO group (69%) required a subsequent operation. The most common operative procedures included inguinal hernia/orchiopexy, antireflux, and recurrent diaphragmatic hernias.

CONCLUSION

In this series, ECMO survivors are at a high risk for requiring subsequent surgeries compared to the total CDH group. This information can be used as an education tool for referring physicians and parents as they care for this group of children.

The long-term follow-up of patients with a congenital diaphragmatic hernia: a broad spectrum of morbidity

Congenital diaphragmatic hernia (CDH) is a life-threatening anomaly with a mortality rate of approximately 40-50%, depending on case selection. It has been suggested that new therapeutic modalities such as nitric oxide (NO), high frequency oxygenation (HFO) and extracorporal membrane oxygenation (ECMO) might decrease mortality associated with pulmonary hypertension and the sequelae of artificial ventilation. When these new therapies indeed prove to be beneficial, a larger number of children with severe forms of CDH might survive, resulting in an increase of CDH-associated complications and/or consequences. In follow-up studies of infants born with CDH, many complications including pulmonary damage, cardiovascular disease, gastro-intestinal disease, failure to thrive, neurocognitive defects and musculoskeletal abnormalities have been described. Long-term pulmonary morbidity in CDH consists of obstructive and restrictive lung function impairments due to altered lung structure and prolonged ventilatory support. CDH has also been associated with persistent pulmonary vascular abnormalities, resulting in pulmonary hypertension in the neonatal period. Long-term consequences of pulmonary hypertension are unknown. Gastro-esophageal reflux disease (GERD) is also an important contributor to overall morbidity, although the underlying mechanism has not been fully understood yet. In adult CDH survivors incidence of esophagitis is high and even Barrett's esophagus may ensue. Yet, in many CDH patients a clinical history compatible with GERD seems to be lacking, which may result in missing patients with pathologic reflux disease. Prolonged unrecognized GERD may eventually result in failure to thrive. This has been found in many young CDH patients, which may also be caused by insufficient intake due to oral aversion and increased caloric requirements due to pulmonary morbidity. Neurological outcome is determined by an increased risk of perinatal and neonatal hypoxemia in the first days of life of CDH patients. In patients treated with ECMO, the incidence of neurological deficits is even higher, probably reflecting more severe hypoxemia and the risk of ECMO associated complications. Many studies have addressed the substantial impact of the health problems described above, on the overall well-being of CDH patients, but most of them concentrate on the first years after repair and only a few studies focus on the health-related quality of life in CDH patients. Considering the scattered data indicating substantial morbidity in long-term survivors of CDH, follow-up studies that systematically assess long-term sequelae are mandatory. Based on such studies a more focused approach for routine follow-up programs may be established.

Gastrointestinal sequelae in survivors of congenital diaphragmatic hernia

BACKGROUND

Gastrointestinal sequelae have been sporadically reported in survivors of congenital diaphragmatic hernia (CDH). The aim of the present paper was to evaluate the gastrointestinal morbidity in infant, adolescent and adult patients who had undergone repair of CDH.

METHODS

Thirty-one of 38 survivors after left-side CDH repair were followed up. They were subdivided in two groups. Group A consisted of 12 patients (39%) with a mean age of 4.5 years and group B, 19 patients (61%) with a mean age of 21.0 years. Patients underwent physical examination, barium meal study, gastroesophageal scintigraphy, esophageal pH monitoring and manometry of the esophagus and stomach. Upper intestinal endoscopy was performed in patients with confirmed gastroesophageal reflux (GER).

RESULTS

All patients were within the normal range for height or weight. A total of 41.7% of group A and 15.8% of group B had typical symptoms suggesting GER. Barium meal study was pathological in 33.3% of group A and 21% of group B patients. In 58% of group A and 42% of group B, GER was documented on scintigraphy. In 41.7% of group A and 47% of group B the time taken for the stomach to empty half of its radioactive content (T(1/2)) was pathological. On 24 h pH monitoring pathological GER was documented in 54.5%, whereas in group B it was present in 33.3%. In 36.4% of group A and 46.7% of group B alteration of peristalsis of the stomach was recorded. Endoscopy showed esophageal pathology in 33%.

CONCLUSIONS

Foregut dysmotility and GER are major sequelae in survivors of CDH repair. Long-term follow up of patients with CDH is recommended.

The cumulative incidence of significant gastroesophageal reflux in patients with congenital diaphragmatic hernia-a systematic clinical, pH-metric, and endoscopic follow-up study

BACKGROUND

Gastroesophageal reflux (GER) is common in patients with congenital diaphragmatic hernia (CDH). Gastroesophageal reflux may occur early after the primary repair of CDH and require antireflux surgery (ARS). It is unknown how many patients will be severely affected later on. We conducted an objective long-term follow-up for the cumulative incidence of CDH-associated GER based on symptoms, pH-metry, and histology.

MATERIALS AND METHODS

From March 1990 to July 2006, we admitted 33 newborn patients with CDH. Twenty-six patients (79%) (male 13, left-sided 21) survived. Extracorporeal membrane oxygenation was required in one patient and patch closure in 10 patients. The follow-up consisted of assessment of GER symptoms at 6 months, 1 year, 3 years, 5 years, and 10 years; endoscopy; and pH-metry for all patients at 1 year and to selected patients (with symptoms or complications of GER) from 3 to 10 years after the primary closure of CDH. Gastroesophageal reflux was considered significant (sGER) when a symptomatic patient required ARS, had endoscopic biopsies showing at least moderate esophagitis, or total and preprandial reflux index of more than 10% and 5%, respectively.

MAIN RESULTS

The incidence of sGER (patients with sGER/total amount assessed) at 6 months, 1 year, 3 years, 5 years, and 10 years was 27% (7/26), 42% (11/26), 53% (8/15), 53% (8/15), and 55% (5/9), respectively. During a median follow-up of 60 months (range, 12-195 months), 12 (46%) of 26 patients had sGER and 4 (15%) required ARS. After the assessment at 1 year, only one new case of sGER appeared. Endoscopic and/or pH-metric assessment covered 100% of the patients at 1 year follow-up, but later on only 70%.

CONCLUSION

One year after the primary closure of CDH, the incidence of sGER was 42%. After 1 year follow-up, only one new case of sGER was found, and ARS was not required. In patients who required ARS manifested before 6 months.

Abdominal complications related to type of repair for congenital diaphragmatic hernia

BACKGROUND

Literature on congenital diaphragmatic hernia (CDH) over the past few decades has focused on prognostic factors and management of pulmonary hypertension/hypoplasia. Larger diaphragmatic defects may require patch closure, reported by some authors to be associated with poorer outcomes. In this study, we evaluate the impact synthetic material has on the need for subsequent abdominal operations, particularly recurrence and small bowel obstruction (SBO).

METHODS

After obtaining IRB approval, all patients undergoing repair of congenital diaphragmatic from January, 1994 to December, 2004 were investigated. Records from primary and subsequent admissions were reviewed to identify those patients who underwent major procedures after repair of the diaphragmatic defect. Subsequent abdominal operations in these series were recurrent CDH repair, exploration for SBO and fundoplication. Patients who died prior to hospital discharge were excluded. Statistical comparisons were made using Fisher's exact test: significance was defined as P<0.05.

RESULTS

During the study period, there were 81 survivors from CDH repair, 24 with a synthetic patch, and 57 without. Those with a patch repair had a significantly increased risk of recurrence, small bowel obstruction, and subsequent operation (Table 1). Eleven patients had nonabsorbable mesh patches, and 13 were repaired with absorbable (Surgisis-Gold; Cook Technology Inc., West Lafayette, IN). While there were no differences in recurrence between these two groups, four patients (31%) with Surgisis developed SBO compared with one patient (9%) repaired with a nonabsorbable synthetic.

CONCLUSIONS

Incidence of SBO and recurrent CDH in patients with a patch was higher than those who underwent primary repair. There may also be a difference in the rate of subsequent SBO depending on the type of mesh used. A prospective trial is under way at our institution to help define this issue.

Predicting the need for fundoplication at the time of congenital diaphragmatic hernia repair

PURPOSE

This study was conducted to examine the preoperative factors predictive of subsequent intervention for gastroesophageal reflux (GER) in children with congenital diaphragmatic hernia (CDH).

METHODS

We conducted a retrospective cohort study on children who underwent repair of a CDH between January 1, 1995, and December 31, 2002 with follow-up continuing to September 1, 2005. Excluded in the study were children who died during their first admission, or who underwent fundoplication at the time of CDH repair. Univariate and multivariate logistic regressions were performed to examine preoperative factors predictive of subsequent intervention (fundoplication or gastrojejunal tube placement).

RESULTS

Of 86 children, 13 underwent intervention (fundoplication, 10; gastrojejunal tube, 3) for GER. Univariate predictors included the following: right-sided CDH, use of nonconventional ventilation, liver within the chest, and patch closure of the CDH. However, only liver within the chest and patch closure of the CDH were significant predictors in a multiple variable analysis. The positive and negative predictive values of the multivariate model were 69.2% and 87.7%, respectively.

CONCLUSIONS

Infants with CDH who have liver within the chest or require patch closure of their hernia are at increased risk for subsequent intervention for GER. These children may represent a subpopulation that would benefit from fundoplication at the time of CDH repair.

Correlation between lung scintigraphy and long-term outcome in survivors of congenital diaphragmatic hernia

Lung scintigraphy has been used to evaluate the degree of pulmonary hypoplasia in infants with congenital diaphragmatic hernia (CDH). However, the relationship between lung scintigraphy and long-term outcome of CDH remains unclear. The aim of this study is to determine whether lung scintigraphy correlates with long-term pulmonary morbidity and nutritional status in survivors of CDH. Consecutive 31 survivors of CDH were enrolled in this study. The initial scan was performed at 1-2 months when the patients were ready for discharge and the follow-up scan was performed following an approximately 1-year interval. The regional ventilation and perfusion were evaluated using (133)Xe-inhalation and intravenous (99m)Tc-MAA injection, respectively. The ventilation and perfusion of the ipsilateral lung was expressed as a percentage of that of the contralateral lung. Physical growth at 1 and 2 years, and pulmonary morbidity were reviewed from medical records. The ventilation and perfusion of the ipsilateral lung at the follow-up scan increased significantly from those at the initial scan. Ten patients had pulmonary morbidity. The ventilation and perfusion of the ipsilateral lung was significantly lower in the patients with pulmonary morbidity compared to the patients without pulmonary morbidity. The initial ventilation and perfusion of the ipsilateral lung were strongly correlated with body weight at 1 and 2 years (ventilation: R = 0.503, P < 0.01; perfusion: R = 0.760, P < 0.0001). These results suggest that lung scintigraphy is useful to predict long-term pulmonary morbidity and poor nutritional status in survivors of CDH.

Endobronchial migration of prosthetic patch after congenital diaphragmatic hernia repair

Surgical repair of congenital diaphragmatic hernia (CDH) can be performed by means of either direct suturing of the diaphragm or positioning of a prosthetic patch. However, half of all prosthetic patches show evidence of reherniation. We describe the case of an 8-year-old girl who presented with prosthesis dislocation and fistulization in the right lower bronchus as a complication of a CDH repair that she underwent when she was 1 year old. Abdominal ultrasound and magnetic resonance imaging suggested a hernia relapse, whereas chest computed tomographic scan failed to identify the diaphragmatic defect. Only fibrobronchoscopy allowed fistulization of the prosthesis into the bronchi to be correctly diagnosed.