Delayed presentation of congenital diaphragmatic hernia presenting with intrathoracic gastric volvulus: a case report and review

Displacement of Abdominal Organs Into the Thoracic Cavity: A Rare Case of Adult Bochdalek Hernia

Congenital diaphragmatic hernias are primarily found in infants and have a high mortality rate due to neonatal respiratory distress. The most common type of congenital diaphragmatic hernia is Bochdalek hernia, which occurs in the posterolateral diaphragm, with the left side being the most commonly affected. However, congenital diaphragmatic hernias are extremely rare in adults and are often misdiagnosed due to their subtle symptoms. Therefore, we suggest that a contrast-enhanced CT scan should be used for early screening and diagnosis in all patients with sudden severe pain or recurrent ambiguous symptoms in the chest and abdomen. This case report presents a rare occurrence of Bochdalek hernia in an adult male. The patient experienced nonspecific abdominal symptoms after eating. The hernia resulted in the displacement of the left kidney, the transverse colon of the splenic flexure, and most of the stomach into the thoracic cavity. This displacement led to atelectasis of the left lung, which reached three-fifths of its capacity. The patient underwent successful treatment using a combination of laparoscopy and open surgery. Follow-up CT scans conducted two weeks, three months, and one year later revealed a stable condition with no complications.

Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper

BACKGROUND

Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable.

METHODS

A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations.

RESULTS

CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients.

CONCLUSIONS

Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.

A Rare Complication in the Delayed Manifestation of Bochdalek Hernia During Pregnancy: A Case Report

Acute gastric volvulus is a surgical emergency and is known to occur secondary to diaphragmatic hernia and eventration. Adult presentation of congenital diaphragmatic hernia is rare, with an estimated incidence of around 0.17%, and pregnancy may predispose to the development of symptoms due to increased intra-abdominal pressure. Pregnancy complicated by diaphragmatic hernia is associated with a high risk of maternal and fetal mortality, necessitating timely diagnosis and treatment. We present the case of a 23-year-old female presenting with a symptomatic left Bochdalek hernia complicated by organo-axial gastric volvulus during her second trimester (27 weeks). Emergency laparotomy was performed, with Caesarean section, reduction of gastric volvulus, and mesh repair of the left posterolateral defect.

When to proceed to surgical rib fixation?-A single-institution clinical experience

Background

Surgical rib fixation for multiple rib fractures and flail chest has become more common in the 2000s with interesting results in selected patients. However, surgical rib fixation lacks a consensus on the delay to surgery and the benefits on postoperative clinical outcomes. Our goal was to determine if delay to surgery can affect postoperative outcomes.

Methods

We analyzed a retrospective database including all consecutive patients referred for surgical rib fixation. All outcomes were explored according to trauma mechanism, associated lesions, initial ventilatory status, delay to surgery, surgical technique and a specific focus was made towards post-operative care and pulmonary complications. Logistic regressions were performed to evaluate the association between delay to surgery [before 48 hours (early group), 48 hours to 7 days (mid group), more than 7 days (late group)] and pneumonia and failure of extubating.

Results

From 2010 to 2020, 159 patients underwent surgical rib fixation. The median hospital length of stay was 18 days (interquartile range, 13-30 days). Pulmonary infections were encountered in 67 patients (42.2%) with about two third of early pneumonia (<5 days). The one-month mortality rate was 1.9%. Delay to surgery was not associated with either pneumonia (P>0.05) or failure of extubating (P>0.05).

Conclusions

Surgical rib fixation can be delayed without increasing the risk of pulmonary complications. Stabilizing other clinical situations can be safely prioritized if needed. A global evaluation including characteristics of trauma and lung evaluation must be considered before surgical stabilization of rib fracture.

Laparoscopic management of symptomatic congenital diaphragmatic hernia of Morgagni in the adult

BACKGROUND

Currently, there is a relative paucity of literature regarding the management of symptomatic congenital diaphragmatic hernia of the foramen of Morgagni in the adult. This study aims to describe our unique surgical technique and outcomes in adult patients undergoing laparoscopic repair of symptomatic Morgagni hernia.

METHODS

This is a retrospective review of adult patients from 2003 to 2020 who underwent a laparoscopic Morgagni hernia repair at our institution. All patients underwent a similar laparoscopic approach, utilizing the surgical principles of reduction of intra-abdominal contents, complete resection of the hernia sac, followed by primary repair of the hernia defect and mesh reinforcement with permanent mesh if the primary repair was subjectively under tension.

RESULTS

The study population consisted of 12 consecutive patients with a Morgagni hernia. Patients presented with a variety of symptoms attributed to the hernia, including pain 83% (n = 10), respiratory symptoms and shortness of breath 58% (7), and gastrointestinal obstruction 25% (3). Other complaints included: nausea 33% (4), reflux 50% (6), early satiety 8% (1), palpitations 16% (2), a gurgling sensation in the chest 8% (1), and weight loss 8% (1). Primary repair was possible in all patients following complete reduction of hernia contents including the hernia sac. Mesh reinforcement was used in 5 of 12 patients. Average surgical operative time was 93 (± 37) min. Median length of stay was 1.3 days (range 0.5-5.5 days). At a median follow-up of 10.9 months (IQR 8.0-41.5 months), all symptoms attributed to the hernia had resolved. No recurrences were identified.

CONCLUSIONS

Adults with symptomatic Morgagni hernia should undergo surgical repair. A laparoscopic approach utilizing the surgical principles of reduction of intra-abdominal contents, complete resection of the hernia sac, followed by primary repair of the hernia defect (when possible), with or without mesh reinforcement can be performed safely and effectively.

Massive gastric necrosis associated with delayed presentation of congenital diaphragmatic hernia—is salvage possible?

Background

Delayed presentation of congenital diaphragmatic hernia is an uncommon event. Occurrence of gastric volvulus with massive necrosis in this setting is unusual. In this difficult scenario, the surgeon is faced with the dilemma of conservation or resection.

Case presentation

A 1-year-old boy with vague gastrointestinal symptoms was found to have congenital diaphragmatic hernia with gastric volvulus, on imaging. The stomach showed massive necrosis secondary to volvulus, and after removal of the necrotic body of the stomach, the remnant was sutured together.

Conclusion

Congenital diaphragmatic hernia is difficult to diagnose in late presenters beyond the neonatal period due to lack of respiratory symptoms. Stomach salvage is feasible even in severe vascular compromise due to extensive collaterals.

Gastric Volvulus: A Rare Entity Case Report and Literature Review

Gastric volvulus is a rare entity defined as an abnormal rotation of the stomach around itself. It is a diagnosis of exclusion; the clinical index of suspicion is always low and is mostly diagnosed on imaging or on the surgery table. When it occurs, it is an emergency due to the risk of strangulation and consequent gangrene of the stomach. Mesentero-axial (MA) gastric volvuli constitute one-third of all cases. Here, we are present an interesting case of acute MA gastric volvulus diagnosed with imaging and treated subsequently.

Emergency surgery due to diaphragmatic hernia: case series and review

Background

Congenital diaphragmatic hernia (CDH) is a congenital abnormality, rare in adults with a frequency of 0.17–6%. Diaphragmatic rupture is an infrequent consequence of trauma, occurring in about 5% of severe closed thoraco-abdominal injuries. Clinical presentation ranges from asymptomatic cases to serious respiratory or gastrointestinal symptoms. Diagnosis depends on anamnesis, clinical signs and radiological investigations.

Methods

From May 2013 to June 2016, six cases (four females, two males; mean age 58 years) of diaphragmatic hernia were admitted to our Academic Department of General Surgery with respiratory and abdominal symptoms. Chest X-ray, barium studies and CT scan were performed.

Results

Case 1 presented left diaphragmatic hernia containing transverse and descending colon. Case 2 showed left CDH which allowed passage of stomach, spleen and colon. Case 3 and 6 showed stomach in left hemithorax. Case 4 presented left diaphragmatic hernia which allowed passage of the spleen, left lobe of liver and transverse colon. Case 5 had stomach and spleen herniated into the chest. Emergency surgery was always performed. The hernia contents were reduced and defect was closed with primary repair or mesh. In all cases, post-operative courses were uneventful.

Conclusion

Overlapping abdominal and respiratory symptoms lead to diagnosis of diaphragmatic hernia, in patients with or without an history of trauma. Chest X-ray, CT scan and barium studies should be done to evaluate diaphragmatic defect, size, location and contents. Emergency surgical approach is mandatory reducing morbidity and mortality.

Wandering Spleen and Organoaxial Gastric Volvulus after Morgagni Hernia Repair: A Case Report and Review of the Literature

Wandering spleen and gastric volvulus are two rare entities that have been described in association with congenital diaphragmatic hernia. The diagnosis is difficult and any delay can result in ischemia and necrosis of both organs. We present a case of a 13-year-old girl, previously operated on for anterior diaphragmatic hernia and intrathoracic gastric volvulus, that presented to our service for a subdiaphragmatic gastric volvulus recurrence associated with a wandering spleen. In this report we reviewed the literature, analyzing the clinical presentation, diagnostic assessment, and treatment options of both conditions, in particular in the case associated with diaphragmatic hernia.

Hypersplenism Associated With Late-Presenting Congenital Diaphragmatic Hernia: A Rare Combination. Case Report

Congenital diaphragmatic hernia (CDH) is a rare developmental anomaly of the diaphragm that mainly presents mainly in newborns. Even less common is late-onset CDH associated with hypersplenism. We report a 10-year-old male who presented with coughing, blood-stained sputum, and fever. He was diagnosed with CDH complicating hypersplenism after computed tomography was done. The patient was treated by CDH repair and splenectomy, and remained asymptomatic at 6-month follow-up. Computed tomography can be an important diagnostic option in this rare combination of CDH and hypersplenism, and surgical intervention is strongly recommended.

Possibility of visualization of gastrothorax based on unenhanced postmortem computed tomography/PMCT

We present a fatal case of a gastrothorax due to an acute gastric volvulus resulting from a Bochdalek hernia. A 5-year-old boy without previous medical history was brought to our institution in a state of cardiopulmonary arrest and was subsequently pronounced dead. Postmortem computed tomography (PMCT) of the torso showed abdominal organs involving the lower section of the esophagus up to the entire stomach, the left side of the transverse colon, the entire spleen, and the tail of the pancreas herniated into the left thoracic cavity. The stomach was markedly expanded and a mesentero-axial (rotation along the short axis) volvulus was observed, displacing mediastinal structures to the right side and depressing the diaphragmatic contour. A PMCT of the thorax at the lung window setting revealed displacement of bilateral lungs. The bilateral lungs were severely atelectatic and congested. The PMCT findings mentioned above were consistent with the autopsy findings. PMCT can provide useful information for the diagnosis in cases we initially cannot predict any significant changes, for example, organ displacement.

Acute gastric volvulus and congenital diaphragmatic hernia, case report and review

Congenital diaphragmatic hernia (CDH) is the result of the incomplete fusion and closure of the pleuroperitoneal canal during the fetal development. CDH is usually diagnosed prenatally but, if undiagnosed, the clinical presentation ranges from asymptomatic children to serious respiratory or gastrointestinal symptoms. Acute gastric volvulus associated with CDH is a rare surgical emergency in children. We report two cases of acute gastric volvulus associated with CDH and review the literature.