OBJECTIVES:

The purpose of this retrospective study was to determine whether objective assessment of cardiac shifting on two-dimensional ultrasonography can predict postnatal outcome in fetuses with isolated left-sided congenital diaphragmatic hernia (CDH).

MATERIALS AND METHODS:

Still images at the level of the four-chamber view were obtained in 23 fetuses with left-sided CDH. A group of 12 fetuses (3 non-survivors and 9 survivors) were examined at two periods, between 20 and 30 weeks and between 31 and 40 weeks. A further 11 fetuses (2 non-survivors and 9 survivors) were examined between 31 and 40 weeks. Fetal heart axis and position were determined manually and associated with postnatal outcome.

RESULTS:

The cardiac axis remained constant in the 9 survivors (15.5 +/- 3.2 versus 17.2 +/- 3.3, p = 0.71) and 3 non-survivors (19.0 +/- 11.5 versus 18.5 +/- 11.8, p = 0.97). There was no statistical difference between the 9 survivors and 3 non-survivors at the two periods. Cardiac displacement remained constant in the 9 survivors (0.2 +/- 0.02 versus 0.2 +/- 0.02, p = 0.32) but increased significantly in the 3 non-survivors (0.2 +/- 0.04 versus 0.4 +/- 0.02, p = 0.015). The difference between survivors and non-survivors was statistically significant between the18 survivors and 5 non-survivors examined between 31 and 40 weeks of gestation (0.2 +/- 0.02 versus 0.4 +/- 0.02, p = 0.037).

CONCLUSION:

This study does not support the hypothesis that objective assessment of mediastinal shift in fetuses with left-sided CDH has a role in predicting postnatal outcome before fetal viability, which is when it would be more useful for counseling patients regarding whether to continue with the pregnancy or to opt for termination.

Background: Hiatal and paraesophageal hernia (HH/PEH) recurrence is the most common cause of failure after gastroesophageal anti-reflux surgery. Crural reinforcement with mesh has been suggested to address this issue, but its efficacy remains debated. In this study, we aimed to determine the impact of biosynthetic mesh reinforcement compared to suture cruroplasty on anatomic and symptomatic hernia recurrence. Method: Data of patients who underwent robotic HH/PEH repair with suture cruroplasty with or without biosynthetic mesh reinforcement between January 2012 and April 2024 were retrospectively reviewed. Gastroesophageal reflux disease symptoms and anatomic hernia recurrence were assessed at short-term (3 months to 1 year) and longer-term (≥ 1 year) follow-up. Symptomatic hernia recurrence was defined as having both anatomic recurrence and symptoms. Results: Out of the 503 patients in the study, 308 had undergone biosynthetic mesh repair, while 195 had suture-only repair. After the surgery, both groups demonstrated comparable improvements in symptoms. Short-term anatomic hernia recurrence rates were 11.8% and 15.6% for mesh and suture groups, respectively (p = 0.609), while longer-term rates were 24.7% and 44.9% (p = 0.015). The rates of symptomatic hernia recurrence in the same group were 8.8% and 14.6% in the short-term (p = 0.256), and 17.2% and 42.2% in longer-term follow-ups (p = 0.003). In the repair of medium and large-size hernias, mesh reinforcement resulted in a 50.0% relative risk reduction in anatomic hernia recurrences and a 59.2% reduction in symptomatic hernia recurrences at ≥ 1-year follow-up. Conclusion: After more than a year of follow-up, it has been found that using biosynthetic mesh for medium and large hiatal or paraesophageal hernia repair significantly reduces the likelihood of both anatomic and symptomatic recurrence compared to using only suture cruroplasty. These findings strongly support the use of biosynthetic mesh to manage larger hernias. However, further long-term multicenter randomized studies are needed to provide more conclusive evidence.

This article has no abstract

Background: Repair of ventral hernia is associated with pain after operation. We wanted to study the influence of ultrasound‐guided (US) erector spine plane (ESP) block on postoperative pain and diaphragmatic dysfunction in obese cases undergoing repair of epigastric hernia. Methods: This prospective randomized‐controlled double‐blinded research was conducted on 50 obese cases with body mass index (30–40), aged (21–65) and scheduled for elective open repair of epigastric hernia. Cases were randomized into two equal groups to receive either general anesthesia alone (Controls) or general anesthesia combined with bilateral ultrasound‐guided ESP block. Postoperative pain, 24 h postoperative analgesic dose, and postoperative diaphragmatic excursion were assessed. Results: There was a statistically evident decrease in NRS score in the ESP versus controls (30 min, 2 hr, 6 hr, 12 hr)(p < 0.001). There was a statistically evident decrease in the total intraoperative fentanyl (p < 0.001) and total 24 h morphine dose (p < 0.001) in the ESP versus controls. There was a statistically evident decrease in the postoperative diaphragmatic excursion in controls versus the ESP (p = 0.001). Conclusions: The ESP block in obese cases undergoing open repair of epigastric hernia provided efficient postoperative analgesia. It decreased postoperative pain, reduced intraoperative and postoperative analgesic dose, and maintained diaphragmatic excursion.

64-Year-old male patient with hepatocellular carcinoma (HCC), liver cirrhosis, chronic hepatitis C infection, and glottic cancer presented with acute progressive abdominal pain and palpable mass in right upper quadrant of the abdomen. Despite treatment with hyoscine and tramadol, the symptoms persisted. He had received three sessions of Transcatheter arterial chemoembolization (TACE) and two sessions of microwave ablation (MWA) for HCC treatment, with the last session being TACE 11 months prior. Plain film abdomen showed bowel gas pattern in the right hemithorax compatible with bowel obstruction. CT imaging revealed a right diaphragmatic hernia containing closed loop small bowel obstruction. An emergency exploratory laparotomy was performed. The patient improved and was discharged. There was no recurrence of diaphragmatic hernia or abdominal mass or pain at the 6-month follow-up visit. We herein demonstrate a catastrophic complication of TACE by using an IPA and MWA which leads to right diaphragmatic hernia.

INTERVENTION:

After delivery, the patient will be intubated immediately and receive the allocated ventilation strategy (high‐frequency oscillatory ventilation or conventional ventilation). Vital functions will be measured by a monitor. General laboratory measurements, blood gasses and urine samples will be taken regularly according to the standard care on the intensive care unit. An arterial line and a central venous line will be given. X‐rays of the thorax will be made on a regular basis. To exclude a vitium cordis and to measure pulmonary hypertension, an echocardiography will be performed and repeated on clinical indication. An echo of the brain will be performed. After the patient has stabilized, surgery will be performed. If necessary, an ECMo procedure will be performed. All the procedures described above are standard procedures in paediatric intensive care medicine. Mostly, every child born with a congenital diaphragmatic hernia will undergo these procedures.

CONDITION:

; Ventilation, Congenital diaphragmatic hernia, Neonates, Newborns, Bronchopulmonary dysplasia , High frequency oscillatory ventilation ; ;

PRIMARY OUTCOME:

Death at day 28 and/or oxygen dependency at day 28

SECONDARY OUTCOME:

• Severity of chronic lung disease according to the Bancalari definition: ; ; o Determined in children having oxygen use at day 28 ; ; o Point of assessment of severity of chronic lung disease at day 56 or discharge whichever comes first: ; ; § Mild: breathing room air ; ; § Moderate: need for < 30 % oxygen ; ; § Severe: need for = 30 % oxygen and/or positive pressure by mechanical ventilation or CPAP ; ; ; • Number of ventilator‐free days at day 30 ; ; • Number of ventilator‐free days at day 60 ;

INCLUSION CRITERIA:

1. Newborn children antenatally diagnosed with congenital diaphragmatic hernia 2. The children are born in one of the participating centres 3. The children are born at or after a gestational age of 34 weeks 4. Prenatal informed consent 5. High‐risk infants who received a fetal intervention may be included 6. Infants small for gestational age may be included

OBJECTIVE:

The long-term consequences of congenital diaphragmatic hernia (CDH), which include altered lung functions and compromised cardiopulmonary capacity, impact functional performance and quality of life. This study investigates the effects of virtual reality-based exercise programs on pulmonary functions, cardiopulmonary capacity, functional performance, and quality of life in children with repaired CDH.

PATIENTS AND METHODS:

A randomized controlled clinical trial was performed. Fifty-two children with repaired CDH (aged 6-10 years) were enrolled and randomly allocated to virtual reality-based exercises plus traditional physical therapy (VR-EX group, n = 26) or traditional physical therapy alone (control group, n = 26). Interventions were conducted three times a week for 12 weeks. Pulmonary functions, cardiopulmonary capacity, functional performance, and quality of life were assessed before and after the intervention.

RESULTS:

The VR-EX group demonstrated significantly enhanced post-treatment pulmonary functions and cardiopulmonary capacity compared to the control group after accounting for the pre-treatment values (p < 0.05). In addition, the values in functional performance and quality of life measures showed significantly larger improvements in the VR-EX group (p < 0.05).

CONCLUSIONS:

Children with repaired CDH may benefit more from VR-based exercises when combined with traditional physical therapy than from traditional physical therapy alone regarding their pulmonary functions, cardiopulmonary capacity, functional performance, and quality of life.

BACKGROUND:

Congenital diaphragmatic hernia (CDH) is a life-threatening condition with long-term complications including respiratory tract infections, respiratory muscle weakness, and abnormal lung functions. This study was designed to ascertain the effects of chest resistance and chest expansion exercises on respiratory muscle strength, lung function, and chest mobility in children with post-operative CDH.

METHODS:

This randomized controlled clinical study was conducted in the outpatient physiotherapy clinic at Prince Sattam bin Abdulaziz University. Thirty-two children with CDH aged 10-14 years between May 2020 and February 2021 were randomly allocated to the study group (n = 16) and the control group (n = 16). The control group underwent a usual chest physiotherapy program; however, the study group underwent a 12-week chest resistance exercise combined with chest expansion exercise in addition to usual chest physiotherapy, with three sessions per week. Respiratory muscle strength, lung function, and thoracic excursion were assessed pre- and post-treatment.

RESULTS:

Using the 2 × 2 repeated ANOVA, significant time × group interactions were detected in favor of the study group, FVC (F = 4.82, 95% CI = -15.6 to -0.97, p = 0.005, and η2 = 0.16), FEV1 (F = 4.54, 95% CI = -11.99 to -2.8, p ˂ 0.001, and η2 = 0.14), PImax (F = 5.12, 95% CI = -15.71 to -5.3, p ˂ 0.001, and η2 = 0.15), and thoracic excursion (F = 4.41, 95% CI = -2.04 to -0.16, p = 0.036, and η2 = 0.17).

CONCLUSIONS:

Concurrent chest resistance and expansion exercises may improve respiratory muscle strength, lung function, and thoracic excursion in children with post-operative CDH. The study findings suggest that concurrent chest and chest expansion exercises be part of an appropriate pulmonary rehabilitation program in children with a history of CDH.

PURPOSE:

In high-risk congenital diaphragmatic hernia (CDH), significant barotrauma or death can occur before extracorporeal membrane oxygenation (ECMO) can be initiated. We previously examined ex utero intrapartum treatment (EXIT)-to-ECMO in our most severe CDH patients, but demonstrated no survival advantage. We now report morbidity outcomes in survivors of this high-risk cohort to determine whether EXIT-to-ECMO conferred any benefit.

METHODS:

All CDH survivors with <15% predicted lung volume (PPLV) from September 1999 to December 2010 were included. We recorded prenatal imaging, defect size, and pulmonary, nutritional, cardiac, and neurodevelopmental outcomes.

RESULTS:

Seventeen survivors (8 EXIT-to-ECMO, 9 non-EXIT) had an average PPLV of 11.7%. Eight of 9 non-EXIT received ECMO within 2days. There were no significant defect size differences between groups, mostly left-sided (13/17) and type D (12/17). Average follow-up was 6.7years (0-13years). There were no statistically significant differences in outcomes, including supplemental oxygen, diuretics, gastrostomy, weight-for-age Z scores, fundoplication, pulmonary hypertension, stroke or intracranial hemorrhage rate, CDH recurrence, and reoperation. No survivor in our cohort was neurologically devastated. All had mild motor and/or speech delay, which improved in most.

CONCLUSIONS:

In this pilot series of severe CDH survivors, EXIT-to-ECMO confers neither significant survival nor long-term morbidity benefit.

LEVEL OF EVIDENCE:

Level III treatment study.

BACKGROUND:

The impact of COVID-19 in families and patients with congenital diaphragmatic hernia (CDH) is unknown, this situation has generated uncertainty not only in family members but also in the optimal outpatient follow-up. Telehealth has become a fundamental tool for the follow-up during the pandemic. The objective of this survey is to evaluated the impact of SARS-CoV-2 in families and patients with CDH and the satisfaction with telematic follow-up.

METHODS:

Telephone survey of patient's caregivers with CHD, aged 1-16 years, followed in neonatal surgery outpatients, from January 31, 2020 to November 15, 2020. The ethical clearance for this study was taken from the Clinical Research Ethics Committee of our Research Institute vide letter number VHIR/239283/01.01.2021.

RESULTS:

81 surveys of 100 patients with active follow-up were carried out. There were no refusals in any contacted parents. There were 30 contacts (37%), 44.8% at school and 27.6% from cohabiting family members. Four infections (4.9%) were diagnosed, half symptomatic. In 40 patients (49.4%) the follow-up was telematic, with a mean score of 3.1±1.3 out of 5. For future controls, 65% prefer presential follow-up, 25% alternate and 10% telematics. 50.6% reported greater anxiety and 34.6% (28/81) extreme measures of isolation, being more accentuated in the group of 3-6 years (p<0.05).

CONCLUSION:

The impact of COVID19 in patients with CHD is not greater than in the general pediatric population. Although the incorporation of the telehealth was well valued, most of the caregivers prefer the face-to-face outpatient follow-up.