Right-sided diaphragmatic hernia causing gastric outlet obstruction 1 month after trauma

Diaphragmatic hernias arising from trauma are rare, and scarcely present in a delayed manner. This case report highlights a case of delayed presentation of a right-sided post-traumatic hernia in a woman in her early 70s following a fall. The aim of this report is to shed light on the diagnostic peculiarities and management. The woman presented with a 3-day history of abdominal pain and coffee-ground vomiting. This followed a fall a month ago. CT confirmed the diagnosis of a gastric outlet obstruction secondary to a right-sided diaphragmatic rupture. At surgery, the herniated abdominal contents were reduced, and the diaphragmatic defect was fixed. The postoperative recovery was unremarkable, and the patient was discharged on day 4. This case highlights that diaphragmatic hernias should be considered as differential diagnoses following recent trauma.

Validation of Point-of-Care ultrasound in the diagnosis of a diaphragmatic hernia

Point-of-care ultrasound (POCUS) is a sensitive, specific tool for early diagnosis of diaphragm pathology in critically ill patients. We report the case of a patient with a history of iatrogenic diaphragmatic hernia who was admitted to the Resuscitation Unit after an emergency exploratory laparotomy. As the diagnosis of diaphragmatic hernia had already been confirmed, we determined the POCUS features that establish the diagnosis of diaphragmatic hernia: (1) normal bilateral diaphragmatic shortening fraction; (2) decreased diaphragmatic excursion; and (3) cephalic position of the diaphragmatic dome (4) greater in supine than in sitting position. We also outline a systematic ultrasound examination of the diaphragm and a POCUS-based differential classification of diaphragmatic dysfunction based on the functional integrity of the peripheral muscle and central diaphragmatic tendon in critically ill patients.

Right-Side Acquired Diaphragmatic Hernia in an Adult 15 Years After Living Donor Liver Transplant

Cases of adult liver transplant recipients with a postoperative right-side acquired diaphragmatic hernia are extremely rare. In this report, we describe an adult case of right-side acquired diaphragmatic hernia 15 years after living donor liver transplant. A 27-year-old woman was diagnosed with pancreatic insulinoma with multiple metastases in the liver. To treat the liver failure, she underwent left lobe living donor liver transplant and distal pancreatectomy with splenectomy 3 years after the transcatheter arterial chemoembolization. As a result of the liver abscesses that reached the diaphragm, the delicate diaphragm was injured, which required repair during the transplant surgery. At the age of 46 years, she developed a cough and intermittent abdominal pain. One month later, she went to another hospital's emergency room with complaints of epigastric pain. The computed tomography scan revealed colon and small intestine prolapse into the right thoracic cavity. She was referred to our hospital and underwent surgery the next day. Two adjacent right diaphragm defects were successfully sutured with nonabsorbable sutures. The patient was discharged on postoperative day 11.

Diaphragmatic hernia after radiofrequency ablation of liver tumor case report and literature review

INTRODUCTION

Radiofrequency ablation is an effective management modality for irresectable primary and secondary liver tumors. Some serious complications have been reported including diaphragmatic hernia. Diaphragmatic hernia is the protrusion of abdominal viscera into the thoracic cavity through a diaphragmatic defect and usually classified into congenital and acquired. After RFA, diaphragmatic hernia is a rarely-reported complication.

CASE REPORT

A 62-year-old male patient, known to have liver cirrhosis on top of hepatitis C virus, presented to the emergency department with generalized abdominal pain and vomiting four months after having a RFA procedure for a liver tumor in segment VIII. Computed tomography showed diaphragmatic hernia with strangulated terminal ileum in the chest. Emergency laparotomy was performed with resection of an ileal segment and creation of double barrel ileostomy. The patient was discharged in a good condition after tolerating oral intake.

CONCLUSION

Radiofrequency ablation is an effective modality for management of the primary and secondary liver tumors. Despite its safety, some complication may happen owing to its thermal effect and the associated patients general condition. Many techniques have been described to decrease its thermal injury. Diaphragmatic hernia is a rare complication after RFA. Its clinical presentation may be confusing and it may occur as early as one month after RFA. Its diagnosis depends mainly on computed tomography. Emergency surgical management is the standard approach.

Diaphragmatic hernia following esophagectomy for esophageal cancer: A systematic review

PURPOSE

Diaphragmatic hernia following an esophagectomy for esophageal cancer (EC) can be both an early and late complication. The esophageal hiatus within the diaphragm is disrupted during the operation. However, the incidence of Post-Esophagectomy Diaphragmatic Hernia (PEDH) is unknown. PEDH can be life-threatening and surgical treatment is challenging. However, all PEDH do not require surgery. The rate of EC diagnosis is rising. Therefore, esophageal surgery, particularly esophagectomy, is gradually increasing. Undoubtedly, the numbers of PEDH increase as well.

METHODS

This review describes the presentation and diagnosis of PEDH after surgery for esophageal malignancy, as well as the management options for PEDH.

RESULTS

Fifteen papers regarding PEDH have been published. There are many different surgical approaches to complete an esophagectomy, while there are different approaches to repair PEDH.

CONCLUSION

Upper GI surgeons need to have an index of suspicion for PEDH. They must investigate and operate these patients if this complication develops, since an immediate surgery has a high mortality and poor outcome.

Laparoscopic extracorporeal repair without a mesh of parasternal diaphragmatic hernia in an elderly woman: A case report

RATIONALE

The case of parasternal diaphragmatic hernia is relatively rare in adults. The best way for the treatment of diaphragmatic hernia is to receive operation, yet which surgical method is the best remains unclear.

PATIENT CONCERNS

An elderly woman in the hospital was complaining about upper abdominal pain that was complicated by the parasternal diaphragmatic hernia. Such state was found accidentally in a car accident and diagnosed by a computed tomography (CT) scan.

DIAGNOSIS

Parasternal diaphragmatic hernia.

INTERVENTIONS

Laparoscopic surgery was performed. The hernial component was easily drawn back into the abdominal cavity, and hernia sac was resected. Closure hernia sac underwent full-thickness U-shaped transabdominal wall sutures with 3-0 Prolene (ETHICON) after straightening the needle without a mesh.

OUTCOMES

The patient recovered quickly without postoperative complication. The hospital stay was 2 days. There was no recurrence and symptoms at a 6-month follow-up.

LESSONS

Laparoscopic extracorporeal repair without using a mesh is a safe, quick, and effective approach. It seems to be an effective treatment of the parasternal diaphragmatic hernia, in particular for elderly patients.

Iatrogenic Incarcerated Diaphragmatic Hernia after Nissen Fundoplication

Postoperative iatrogenic diaphragmatic hernias have been reported sparingly after several thoracic and abdominal surgeries. Although rare, a delay in diagnosis can lead to life-threatening cases of strangulation or perforation, as well as cardiovascular and respiratory insufficiency. This is a case of a 78-year-old female who developed acute obstructive symptoms secondary to herniation of the distal stomach through a defect in the central tendon of the diaphragm. The diaphragmatic defect was presumed to be iatrogenically acquired after Nissen fundoplication one year prior. Other etiologies were not as likely considering that she had never had any trauma to her chest or abdomen and had no history suggestive of a congenital nature for the diaphragmatic hernia. The hernia was successfully decompressed laparoscopically with the stomach having ischemic changes along the greater curvature, necessitating gastric wedge resection. The diaphragmatic defect, which was lengthened to reduce the edematous incarcerated stomach, was repaired primarily. The patient had an uneventful postoperative course. This case highlights the potential complication of incarcerated diaphragmatic hernia after Nissen fundoplication. Late diagnosis of iatrogenic diaphragmatic hernias is frequent because of nonspecific symptoms and surgery is indicated at the time of diagnosis.

Acquired diaphragmatic hernia in pediatrics after living donor liver transplantation: Three cases report and review of literature

RATIONALE

Diaphragmatic hernia (DH) in pediatrics following living donor liver transplantation (LDLT) has been seldom reported in the past.

PATIENT CONCERNS

We report successful diagnosis and treatment of three pediatric cases with DH secondary to LDLT, discuss the possible etiology, and review the relevant literature.

DIAGNOSES

The primary disease was biliary atresia and DH was diagnosed by computed tomography scan or x-ray of chest.

INTERVENTIONS

Laparotomy was performed successfully to repair the DH.

OUTCOMES

The respiratory and digestive function was gradually recovered in 1 to 2 weeks after repair operation. In 2 to 8 months follow-up, patients were asymptomatic without any respiratory or digestive complications.

LESSONS

DH post-LDLT should be recognized as a possible complication when a left lateral segment graft is used. Careful clinical examination and prompt surgery could minimize complications.

Diaphragmatic hernia in a pet chinchilla (Chinchilla lanigera)

A 10-year-old pet chinchilla (Chinchilla lanigera) was referred for ultrasound investigation of a thoracic mass. The mass was initially believed to be a pulmonary abscess or tumor based on radiographs and ultrasound. Cytological examination suggested the presence of a gastrointestinal structure in the thorax, and necropsy revealed a true diaphragmatic hernia subdividing the stomach into thoracic and abdominal portions.

Sternotomy Reconstruction with Omentum Followed by Large Diaphragmatic Hernia

Poststernotomy mediastinitis carries significant morbidity and mortality. Aggressive wound debridement combined with a pedicled omental flap, with or without a pedicled muscle flap, has gained acceptance in the management of difficult sternal wound infections. Two cases of poststernotomy mediastinitis and sternal wound reconstruction with a pedicled omental flap were complicated by a large anterior diaphragmatic hernia containing the large bowel.

Successful Management of a Perforated Interposed Substernal Ileocolon Caused by Right Pleural Hernia

A 73-year-old man underwent esophagectomy and reconstruction with interposition of the ileocolon through the substernal tract. Ten months later he presented with sudden pain in the right side of his chest that developed after vomiting. Emergency surgical intervention revealed a right pleural hernia of the esophageal substitute and a 3-cm perforation in the cecum. After suturing the perforation directly, we made the redundant ileum straight and pulled down the repaired cecum into the abdominal cavity to prevent intrathoracic leakage, successfully preserving the reconstructed organ. This rare case emphasizes the importance of careful dissection of the pleura and the use of a suitable length of ileocolon for reconstruction.

A fatal complication of an incarcerated diaphragmatic hernia Pyo-pneumopericardium due to a gastro-pericardial fistula, case report and literature review

A fatal complication of an incarcerated diaphragmatic hernia: pyo-pneumopericardium due to a gastro-pericardial fistula, case report and literature review

INTRODUCTION

The pyo-pneumopericardium is a very rare complication of an incarcerated diaphragmatic hernia. Usually, it depends on the existence of a gastropericardial fistula and, in most cases, it is a deadly complication.

CASE REPORT

We present the case of a 65 year old man who was admitted to our emergency service with clinical signs of septic shock. With the help of the CT scan a pyo-pneumopericardium and incarcerated diaphragmatic hernia was diagnosed. He was subjected to emergency surgical intervention with double approach (thoracic and abdominal), discerning during surgery the existence of a pericardial abscess due to a gastro-pericardial fistula due to an incarcerated diaphragmatic hernia. The gastric fundus was resected with abolition of the gastro-pericardial fistula, evacuation of the pericardial abscess, performing the splenectomy (in order to have a better surgical access) and adequate treatment of the diaphragmatic hernia. Despite the medical efforts, the patient died on the 10th postoperative day due to septic complications. To our knowledge this is the first case reported in the literature of gastro-pericardial fistula complicated with pyo-pneumo-pericardium due to an incarcerated diaphragmatic hernia. In such cases we consider that only by performing a double surgical approach (thoracic and abdominal) we can provide a proper resolution of the case, also based on the objective situation found during surgery, where the splenectomy can provide an easier approach to the diaphragmatic hernia.

Diaphragmatic Hernia After Pediatric Liver Transplant

Diaphragmatic hernia is an unusual complication after pediatric liver transplant. Nearly half of bowel obstruction cases, which require surgical intervention in liver transplant patients, are caused by diaphragmatic hernia. The smaller patients are at risk for higher rates of diaphragmatic complication after pediatric liver transplant, but diaphragmatic hernia has not been reported as a unique occurrence. Here, we report 3 cases of diaphragmatic hernia after liver transplant and discuss the possible contributing factors. Diaphragmatic hernia should nevertheless be added to the list of potential complications after liver transplant in the pediatric population. Pediatric transplant physicians and surgeons should be aware of this complication so that it is recognized promptly in both acute and nonacute settings and appropriate action is taken.

Thoracoscopic Approach for Repair of Diaphragmatic Hernia Occurring After Pediatric Liver Transplant

Diaphragmatic hernias (DH) occurring after pediatric liver transplantation (LT) are rare. However, such complications have been previously reported in the literature and treatment has always been surgical repair via laparotomy. We report our experience of minimally invasive thoracoscopic approach for repair of DH occurring after LT in pediatric recipients.From April 2010 to December 2014, 7 cases of DH were identified in pediatric LT recipient in Samsung Medical Center. Thoracoscopic repair was attempted in 3 patients. Patients' medical records were retrospectively reviewed.Case 1 was a 12-month-old boy, having received deceased donor LT for biliary atresia (BA) 5 months ago. He presented with dyspnea and left-sided DH was detected. Thoracoscopic repair was successfully done and the boy was discharged at postoperative day 7. Case 2 was a 13-month-old boy, having received deceased donor LT for BA 2 months ago. He presented with vomiting and right-sided DH was detected. Thoracoscopic repair was done along with primary repair of herniated small bowel that was perforated while attempting reduction into the peritoneal cavity. The boy recovered from the surgery without complications and was discharged on the 10th postoperative day. Case 3 was a 43-month-old girl, having received deceased donor LT for Alagille syndrome 28 months ago. She was diagnosed with right-sided DH during steroid pulse therapy for acute rejection. Thoracoscopic repair was attempted but a segment of necrotic bowel was noticed along with bile colored pleural effusion and severe adhesion in the thoracic cavity. She received DH repair with small bowel resection and anastomosis via laparotomy.Thoracoscopic repair was attempted in 3 cases of DH occurring after LT in pediatric recipients. With experience and expertise in pediatric minimally invasive surgery, thoracoscopic approach is feasible in this rare population of patients.

Laparoscopic features and repair of a combined left Spigelian hernia and left Morgagni diaphragmatic hernia

Both Spigelian and Morgagni hernias cause serious morbidity so early diagnosis and timely treatment are necessary. These two types of hernia are more commonly found on the right side of patients. They are rare individually in adults and even rarer in combination. So far, an association between the two hernias has only been reported on the right. We describe the first case of a Spigelian hernia and a Morgagni hernia in a 62-year-old woman, both occurring on the left side. Our accompanying video describes several laparoscopic features that will help lead to early detection and diagnosis.

Incarcerated diaphragmatic hernia--differential diagnoses

The incarceration of diaphragmatic hernia is very rare. We present a case of a four-year-old girl who developed the incarceration of left-sided diaphragmatic hernia, who, until then, was completely asymptomatic. This incarceration of the hernia represented a surgical emergency presenting as obstructive ileus and a severe respiratory distress which developed from what appeared to be full health. During a brief pre-operative examination a number of differential diagnoses were suggested. Along with the laboratory blood analysis (complete blood count and acid-base balance) a plain thoracic and abdominal radiography was done (babygram). After that, through an inserted nasal-gastric tube, barium meal of the upper gastrointestinal tract was done, showing abdominal organs in the left half of the thorax and a significant shift of the mediastinum to the right. With an urgent upper medial laparotomy we accessed the abdominal cavity and made the correct diagnosis. An opening was shown in the rear part of the left hemi-diaphragm with thickened and edematous edges, approx. 6 cm in diameter with incarcerated content. The incarcerated abdominal organs (stomach, transversal colon, small intestine and spleen) gradually moved into the abdominal cavity. The opening was closed with nonresorptive sutures (TiCron) size 2-0 with aprevious control and ventilated expansion of the well-developed left lung. In postoperative course the acid-base balance quickly recovered, as well as the general state of the patient and radiography showed a good expansion and lucency of the lung parenchyma and a return of the mediastinum into the middle part of the thorax.

Clinicoradiological correlation of scoliosis in children with Jarcho-Levin and Escobar syndromes: associated "flat bone or wing-like" imaging findings

Congenital or early onset scoliosis may be the lead clinical feature in several rare syndromes. In this paper, we present the imaging findings in two children with early onset scoliosis related to the Jarcho-Levin and Escobar syndromes and an osseous plate or wing-like bar extending along the posterior elements of the spine on computed tomography. The clinical phenotypes in these syndromes are variable. A thorough clinical evaluation with imaging correlation is essential. The recognition of underlying spinal anomalies is essential in planning treatment and estimating prognosis. In young children with progressive scoliosis, cross-sectional imaging plays a major role in the diagnostic work-up.

CONCLUSION

Congenital scoliosis requires a comprehensive clinical evaluation and imaging work-up. The presence of an osseous plate or wing-like fusion of posterior elements of the spine may suggest the diagnosis of Jarcho-Levin and Escobar syndromes.

[Diaphragmatic lipoma needed to distinguish from Bochdalek hernia; report of a case]

A 69-year-old woman had been followed up for an abnormal shadow on the left diaphragm at a nearby hospital, which showed gradual increase in size and she was referred to our hospital for treatment. Chest computed tomography(CT) showed a dome-shaped and homogeneous mass with smooth surface on the left diaphragm. CT showed 50×60 mm hypodense mass and partly interrupted diaphragm. Magnetic resonance imaging( MRI) revealed fat signal intensity on both T1 and T2 weighted image and fat suppressed T1 image. Bochdalek hernia or diaphragm lipoma was suggested and surgery was done. Yellowish round tumor on the diaphragm was resected. The omentum was easily separated from the tumor. Histopathological finding revealed the lipoma cell invading into striated muscle of diaphragm, and the tumor was diagnosed as a mature lipoma originated from diaphragm.

Agenesis of right diaphragm in the adults: a diagnostic dilemma

Diaphragmatic agenesis is the most extreme form of congenital diaphragmatic defect, and it may be unilateral or bilateral. Diaphragmatic agenesis is a rare diagnosis, typically made early in infancy and is generally associated with other genetic anomalies, especially anueploidy syndromes. It is associated with a high mortality, if not treated in infancy. However, a few patients have survived till adulthood. In this report, we describe the case of an adult female who presented with progressive shortness of breath during third trimester of pregnancy with complete agenesis of the right side of the diaphragm. A new diaphragm was created using polypropylene mesh after which she improved symptomatically and the lung showed good expansion.

Morgagni hernia: transabdominal or transthoracic approach?

BACKGROUND

Morgagni hernias are rare and constitute less than 2% of all diaphragmatic hernias. Treatment is primarily surgical and transthoracic or transabdominal route approach methods are amenable. In this study, we compared the results of our Morgagni hernia cases, which underwent either transabdominal or transthoracic method of surgery.

METHODS

We retrospectively analyzed the records of 20 patients we operated on for Morgagni hernias between 1997 and 2011 in our clinic. Age, sex, presenting symptoms, lesion location, diagnoses, applied surgical method, duration of the hospital stay, morbidity and mortality rates were reviewed. Six of the cases were (30%) approached via thoracotomy and 14 (70%) were laparotomy. The hernial sac was resected in all cases. Diaphragmatic defects were repaired using nonabsorbable sutures in all cases except in one case where prolen mesh used.

RESULTS

Thirteen cases (65%) were female and seven (35%) were male. Mean age was 44.1 +/- 25.3 years (1-73 years). Hernias were located on the right side in 18 cases, the left side in one, and bilaterally located in one case. Herniated organs were: omentum in 19 (95%), transverse colon in 18 (90%), small bowel in 4 (20%), stomach in 3 (15%), and left lobe of the liver in one (5%) case. No complication was observed in patients who underwent laparotomy, and wound infection occurred in one patient who underwent thoracotomy. Hospital stays in thoracotomy and laparotomy groups are 7 and 6.2 days, respectively. There were no mortalities observed. There was no recurrence during the follow-up of 36.4 months (10-116 months).

CONCLUSION

Our findings showed that both surgical methods have similar and satisfactory results. Although transthoracic approach was preferred in previous cases, the transabdominal approach was preferred in later ones because we assumed that the later procedure is less invasive for the patient. We prefer and propose the abdominal approach for the surgical management of Morgagni hernias.

[Laparoscopic repair of incarcerated diaphragmatic hernia as a late complication of laparoscopic right hepatectomy: a case report]

Incarcerated diaphragmatic hernia after laparoscopic right hepatectomy is very rare. An 81-year-old man underwent laparoscopic right hepatectomy for giant hepatic hemangioma. Twenty months after the surgery, he began to complain of nausea and abdominal pain and was brought to our hospital. Chest X-ray showed an abdominal gas shadow above the right diaphragm and computed tomography showed herniation of the colon into the right thoracic cavity. We diagnosed ileus due to incarcerated diaphragmatic hernia and performed emergency operation under laparoscopic surgery. After successfully reducing the prolapsed colon back to the abdominal cavity, the diaphragmatic hernia orifice was repaired. Incarcerated diaphragmatic hernia sometimes causes the fatal state. Clinicians must therefore consider such findings a late complication of laparoscopic hepatectomy.

Diagnosis and treatment of pulmonary hypertension in infancy

Normal pulmonary vascular development in infancy requires maintenance of low pulmonary vascular resistance after birth, and is necessary for normal lung function and growth. The developing lung is subject to multiple genetic, pathological and/or environmental influences that can adversely affect lung adaptation, development, and growth, leading to pulmonary hypertension. New classifications of pulmonary hypertension are beginning to account for these diverse phenotypes, and or pulmonary hypertension in infants due to PPHN, congenital diaphragmatic hernia, and bronchopulmonary dysplasia (BPD). The most effective pharmacotherapeutic strategies for infants with PPHN are directed at selective reduction of PVR, and take advantage of a rapidly advancing understanding of the altered signaling pathways in the remodeled vasculature.

A leak too far--gastro-pleural fistula mimicking recurrence of repaired congenital diaphragmatic hernia following fundoplication

Recurrence rate after a congenital diaphragmatic hernia repair is high especially after a patch repair. Recurrence can be asymptomatic, followed by respiratory or gastrointestinal symptoms and the diagnosis is usually confirmed radiologically. We present an unusual case of radiologically diagnosed recurrent left diaphragmatic hernia but at surgery was found to be a gastro-pleural fistula that occurred as a complication following fundoplication surgery.

Late-presenting congenital diaphragmatic hernia in children: the experience of single institution in Korea

PURPOSE

Late-presenting congenital diaphragmatic hernia (CDH) beyond the neonatal period is rare and often misdiagnosed, with delayed treatment.

MATERIALS AND METHODS

We retrospectively reviewed our experience with late-presenting CDH over 30 years at a single institution to determine the characteristics of late-presenting CDH for early diagnosis.

RESULTS

Seven patients had operations due to late-presenting CHD in our institution over 30 years. The patients' ages ranged from 2.5 months to 16 years. There were six boys and one girl. Five hernias were left-sided, one was right-sided and one was a retrosternal hernia. All patients had normal intestinal rotation. Non-specific gastrointestinal or respiratory symptoms and signs were usually presented. Intestinal malrotations were absent; therefore, only organs adjacent to the defect or relatively movable organs such as the small bowel and transverse colon were herniated. Two cases were accompanied by stomach herniation with the volvulus and liver, respectively. The duration from presentation to diagnosis varied from 5 days to 1 year. Diagnoses were made by chest X-ray, upper gastrointestinal series and chest computed tomography. All patients underwent primary repair with interrupted non-absorbable sutures by a transabdominal approach. None had postoperative complications. The follow-up period in six patients ranged from 4 months to 20 years (median 3.8 years). There was no recurrence in any of the patients on follow-up.

CONCLUSION

A high index of suspicion is important for the diagnosis of late-presenting CDH because it can be a life-threatening condition such as CDH with a gastric volvulus. Early diagnosis and appropriate treatment can lead to a good prognosis.

Economics and ethics of paediatric respiratory extra corporeal life support

Extra corporeal membrane oxygenation (ECMO) is a form of life support, which facilitates gas exchange outside the body via an oxygenator and a centrifugal pumping system. A paediatric cardiac ECMO programme was established in 2005 at Our Lady's Children's Hospital, Crumlin (OLCHC) and to date 75 patients have received ECMO, the majority being post operative cardiac patients. The outcome data compares favourably with international figures. ECMO has been most successful in the treatment of newborn infants with life threatening respiratory failure from conditions such as meconium aspiration, respiratory distress syndrome and respiratory infections. There is no formal paediatric respiratory ECMO programme at OLCHC, or anywhere else in Ireland. Currently, neonates requiring respiratory ECMO are transferred to centres in Sweden or the UK at an average cost of 133,000 Euros/infant, funded by the Health Service Executive E112 treatment abroad scheme. There is considerable morbidity associated with the transfer of critically ill infants, as well as significant psycho-social impact on families. OLCHC is not funded to provide respiratory ECMO, although the equipment and expertise required are similar to cardiac ECMO and are currently in place. The average cost of an ECMO run at OLCHC is 65,000 Euros. There is now a strong argument for a fully funded single national cardiac and respiratory paediatric ECMO centre, similar to that for adult patients.

Prediction of mortality and the need for neonatal extracorporeal membrane oxygenation therapy by 3-dimensional sonography and magnetic resonance imaging in fetuses with congenital diaphragmatic hernias

OBJECTIVES

To compare different rotation angles for assessment of fetal lung volume by 3-dimensional (3D) sonography with magnetic resonance imaging (MRI) regarding prediction of mortality and the need for neonatal extracorporeal membrane oxygenation (ECMO) therapy in fetuses with congenital diaphragmatic hernias.

METHODS

One hundred patients with fetal congenital diaphragmatic hernias between 22 and 39 weeks' gestation were examined by 3D sonography and MRI. Sonographic contralateral fetal lung volumes were assessed by the rotational technique (virtual organ computer-aided analysis) at 3 different rotation angles: 6°, 15°, and 30°. The MRI fetal lung volumes were calculated based on multiplanar T2-weighted MRI. To eliminate the influence of gestational age, the observed to expected contralateral fetal lung volume on sonography and the observed to expected fetal lung volume on MRI were calculated. Receiver operating characteristic (ROC) curves were calculated for the statistical prediction of survival and need for ECMO therapy by the observed to expected contralateral fetal lung volume (sonography) and observed to expected fetal lung volume (MRI).

RESULTS

One hundred cases were assessed for survival and 89 for ECMO necessity (11 neonates were not eligible for ECMO). For prediction of postpartum survival and ECMO necessity, the areas under the ROC curves (AUCs) showed very similar results for MRI and 3D sonography: observed to expected fetal lung volume by MRI, 0.819 (95% confidence interval, 0.730-0.909) and 0.835 (0.748-0.922), respectively; 6° sonography, 0.765 (0.647-0.883) and 0.820 (0.734-0.905); 15° sonography, 0.784 (0.672-0.896) and 0.811 (0.719-0.903); and 30° sonography, 0.732 (0.609-0.855) and 0.772 (0.671-0.872). Comparisons between the AUCs revealed no statistical differences.

CONCLUSIONS

We have shown the good prognostic value of 3D sonography in fetuses with congenital diaphragmatic hernias compared with MRI, particularly when using small rotation angles. Therefore, it can be an appropriate diagnostic tool when counseling patients for congenital diaphragmatic hernias.

Outcome of congenital diaphragmatic hernia: analysis of implicated factors

AIM

Congenital diaphragmatic hernia remains a significant challenge for neonatologists and pediatric surgeons. Over the last years, new therapeutic approaches, as high-frequency oscillatory ventilation, inhaled nitric oxide, permissive hypercapnia, extracorporeal membrane oxygenation, have been used for the management of these newborns. We conducted a retrospective study of all infants who were managed for congenital diaphragmatic hernia in our NICU in order to identify possible clinical characteristics which were predictive for survival.

METHODS

We reviewed a single institution's experience with 42 consecutive neonates with congenital diaphragmatic hernia admitted to our NICU from 1993 to 2009.

RESULTS

Prenatal data and side of congenital diaphragmatic hernia were similar in survivors and no-survivors infants except for the lung-to-head ratio (LHR), which was higher and measured later in survivors than non-survivors. Multiple regression analysis showed that a gestational age ≥39 weeks, Apgar score at 5 min ≥7, FiO2<0.35, MAP<13 cmH2O, OI<10 and AaDO2 >282 before surgical repair, and the absence of persistent pulmonary hypoplasia were independent predictive factors of survival.

CONCLUSION

Our study suggests that the outcome of newborns with congenital diaphragmatic hernia still depends on the severity of lung hypoplasia, despite the different respiratory and therapeutical approaches.

[A rare complication after a violent coughing attack]

A 85-year-old man presented to the emergency department with acute onset of right-sided chest pain after vigorous coughing. Physical examination revealed a progressive hematoma and a palpable bulge that enlarged with expiration. A CT-Scan confirmed a lateral lung herniation with a dissection of the intervertebral muscle. The Patient underwent a surgical reconstruction of the chest wall defect and an additional Mersilene Mesh repair of a consecutive diaphragmal rupture. The patient had an uneventful recovery and was discharged on postoperative day 11.

Abdominal wall closure in neonates after congenital diaphragmatic hernia repair

PURPOSE

Repair of Congenital Diaphragmatic Hernia (CDH) abruptly increases intra-abdominal pressure. This study sought to characterize the incidence and significance of ACS and delayed fascial closure (DFC) after CDH repair.

METHODS

We reviewed the CAPSNet database from 2006 to 2011, identifying the subset of patients that developed ACS or required DFC. Prenatal and demographic information, operative and physiologic details, and outcomes were investigated.

RESULTS

Of 349 patients with CDH, 3 (0.8%) were diagnosed with ACS, while 43 patients (12%) had DFC at the time of CDH repair. Patients more often had right-sided defects (26% vs 13%, p=0.04) and trended toward requiring a patch repair (41% vs 31.2%, p=0.23) and having a liver lobe above the diaphragmatic rim (47% vs 32.7, p=0.09). Patients with ACS or DFC had increased length of stay (47.5 vs 33.9, p=0.01), days fasting (8.2 vs 5.8, p=0.01), days on parenteral nutrition (23.6 vs 15.5, p=0.003), and days on mechanical ventilation (16.3 vs 9.0, p=0.001).

CONCLUSIONS

While ACS in neonates after CDH repair is rare (<1%), DFC is required relatively commonly (>10%) and is associated with right-sided diaphragmatic hernias. Inability to close abdominal fascia is associated with increased morbidity. Clinicians caring for neonates with CDH should be facile with strategies to manage delayed abdominal fascia closure.

Agenesis of the hemidiaphragm: a rare presentation in an adult

Unilateral diaphragmatic agenesis is a rare finding in adult patients. We report a case of unilateral agenesis of diaphragm in a 22-year-old male patient to highlight the fact that a rare entity of agenesis of diaphragm can have a misleading presentation in adulthood due to both pulmonary and abdominal symptoms.

Prognostic value of a hernia sac in congenital diaphragmatic hernia

OBJECTIVE

To investigate the prognostic value of a hernia sac in isolated congenital diaphragmatic hernia (CDH).

METHODS

Our database was searched to identify all consecutive cases of CDH referred to our fetal medicine unit between January 2004 and August 2011. Presence or absence of a hernia sac was assessed in liveborn cases using surgery or postnatal autopsy reports. We studied the correlation between the presence of a hernia sac and prenatal findings and perinatal morbidity and mortality.

RESULTS

Over the study period, there were 70 cases with isolated CDH born alive in which either a surgery or autopsy report was available. Neonatal death, either preoperative or postoperative, occurred in 1/18 (5.6%) infants with a hernia sac and in 17/52 (32.7%) cases without a hernia sac (P = 0.03). Patients with a hernia sac had a significantly higher observed to expected pulmonary volume on prenatal magnetic resonance imaging (51.9 vs 39.3%, P = 0.01). Neonatal morbidity in surviving infants was lower in the group with a hernia sac, although not significantly.

CONCLUSION

The presence of a hernia sac is associated with a higher pulmonary volume and a better overall prognosis for CDH.

Recurrent left Bockdalek hernia in adult, a rare cause of subocclusive syndrome

To present a rare clinical case of a subocclusive syndrome caused by recurrence of a left Bockdalek hernia, with emphasis on the radiological diagnosis and surgical treatment. The current paper presents a 36 year old female with past surgical history of Bockdalek hernia repaired 7 years ago using a diaphragmorrhaphy by thoraco-abdominal approach who presented with a subocclusive syndrome and epigastric pain. Upper endoscopy showed a duodenal ulcer positive for H. pylori. Initial abdominal CT scan was read as negative. On a closer evaluation of the CT images, a small Bockdalek hernia was appreciated, with the elevation of the left colic angle through the diaphragm. Given the occlusive symptoms, the patient underwent surgical treatment with diaphragmorrhaphy and alloplasty with polypropylene mesh, using an open approach. Postoperatively, the patient had a favourable course, being discharged home two days later. To date, there are 173 cases of Bockdalek hernia in the the medical literature, but none with a recurrence. Bockdalek hernia is a rare disease, with non-specific symptoms. It has a broad differential diagnosis that may delay early identification and management. The surgical treatment, either open or laparoscopic, must follow the current recommendations of the surgical societies, including mesh alloplasty to prevent recurrences.

[A woman with acute abdominal pain in the night]

A 43-year-old woman came to the Emergency Room with acute abdominal pain during the night. CT examination of the abdomen showed ventral herniation of the stomach and parts of the small intestine and colon in the right hemithorax. We made the diagnosis 'symptomatic Morgagni hernia', a rare congenital defect that is usually diagnosed soon after birth.

Lethal Bochdalek hernia in a three-year-old: pathological findings and medicolegal investigation in accusation of malpractice

Diaphragmatic hernias can be a pitfall for paediatric diagnostics, especially in the cases of late presentation, which can also have medico-legal ramifications as exposed. A three-year-old boy was taken to a children's hospital after an episode of abdominal pain and vomiting of food. A physical examination proved normal, with mild ketonuria being found and he was discharged. Three months later for the same signs and symptoms, he was taken once more to hospital, where he arrived in a state of cardiac arrest and died. A lawsuit was begun against the doctors who had examined him three months earlier. The autopsy found herniation of the abdominal organs into the left pleural cavity through a defect in the left hemidiaphragm. The cause of death was identified as cardiac tamponade caused by mechanical compression of multiple herniated abdominal organs. The histopathological examination revealed marked atelectasis of the left lung, with non-expansion of 60-90% of the alveoli which suggested an acute mechanism that proved fatal, and the doctors were acquitted. The features of this disease and the possible difficulties in its diagnosis highlight the need for the utmost attention in differential diagnosis, even at an age where the discovery of a diaphragmatic hernia is exceedingly rare.