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Pediatric Surgery International Dec 2023Three-dimensional (3D) printing is frequently used for surgical simulation and training, however, no widely available model exists for neonatal congenital diaphragmatic...
INTRODUCTION
Three-dimensional (3D) printing is frequently used for surgical simulation and training, however, no widely available model exists for neonatal congenital diaphragmatic hernia (CDH). The aim of this study was to develop a 3D-printed model of CDH and test interobserver variability in the simulated model for obtaining measurements of the diaphragmatic defect and ipsilateral diaphragm.
METHODS
A term fetal MRI (3.5 kg) of thorax, diaphragm and defect (15 mm × 5 mm) were delineated and segmented after parental consent to produce 3D-printed models. Consultant and trainee paediatric surgeons were invited to measure the posterior-lateral diaphragmatic defect and ipsilateral diaphragm. Mean measurement error was calculated (millimetres). Data are presented as median (range) and number/total (%).
RESULTS
An abdominal and thoracoscopic model were produced and tested by 52 participants (20 consultants and 32 trainees). Diaphragmatic defect via laparotomy measured 15 (10-20) mm (AP) × 16 (10-25) mm (ML) and thoracoscopically 14 (11-19) mm (AP) × 15 (11-22) mm (ML). Mean error per measurement was 4 (1-17) mm via laparotomy vs. 3 (0.5-9.5) mm thoracoscopically. Mean error was similar between consultants and trainees via laparotomy (4.3 vs. 3.9 mm, p = 0.70) and thoracoscopically (3 vs. 3 mm, p = 0.79). Error did not correlate with experience as operating surgeon via laparotomy (β = 13.0 [95% CI - 55.9 to 82.0], p = 0.71) or thoracoscopically (β = 1.4[95% CI - 6.4 to 9.2], p = 0.73.
CONCLUSIONS
We have designed and built simulation models for CDH repair via laparotomy and thoracoscopically. Operators can reliably measure the diaphragmatic defect and ipsilateral diaphragm, regardless of surgical experience and operative approach.
Topics: Child; Humans; Infant, Newborn; Computer Simulation; Diaphragm; Fetus; Hernias, Diaphragmatic, Congenital; Laparotomy; Printing, Three-Dimensional
PubMed: 38147130
DOI: 10.1007/s00383-023-05600-0 -
Wiadomosci Lekarskie (Warsaw, Poland :... 2021The aim of the study was to determine the possibility and effectiveness of simultaneous surgical interventions in umbilical and paraumbilical hernia repair.
OBJECTIVE
The aim of the study was to determine the possibility and effectiveness of simultaneous surgical interventions in umbilical and paraumbilical hernia repair.
PATIENTS AND METHODS
Material and methods: 148 case histories were analyzed concerning patients who were routinely admitted to the surgical department of the Kharkiv Regional Council's Municipal Non-Profit Enterprise «Regional Clinical Hospital» between 2017 and 2019, and who underwent umbilical and paraumbilical hernia repair simultaneously with operations related to some other surgical pathology (group 1, n = 67) or in separate interventions (group 2, n = 81). All patients were routinely operated after a set of mandatory and additional general clinical, laboratory and instrumental research conducted in accordance with the existing guidelines. The structure and results of surgical interventions related to the underlying disease and simultaneous operations were studied.
RESULTS
Results: Simultaneous operations were performed for comorbid cholecystolithiasis, diaphragmatic esophageal hernia with gastroesophageal reflux, inguinal hernia, white line hernia, benign diseases of the uterus and uterine appendages et al. The frequency of complications and recurrences of hernia in patients with simultaneous and isolated of umbilical hernia repair did not differ significantly. The outcome of the operation mostly depended on the method of operation (postoperative complications were most often observed in open sutures repair and were absent in laparoscopic hernia repair). Additional risk factors were weight gain and diabetes.
CONCLUSION
Conclusions: Summarizing the data obtained, it can be concluded that application of modern endovideoscopic techniques in surgery makes simultaneous surgical interventions not only possible but also necessary in the presence of concomitant abdominal pathology that requires surgical treatment.
Topics: Female; Hernia, Hiatal; Hernia, Inguinal; Herniorrhaphy; Humans; Laparoscopy; Recurrence; Surgical Mesh
PubMed: 33813475
DOI: No ID Found -
Journal of Gastrointestinal Surgery :... Mar 2022Mesh implants are regularly used to help repair both hiatus hernias (HH) and diaphragmatic hernias (DH). In vivo studies are used to test not only mesh safety, but... (Review)
Review
INTRODUCTION
Mesh implants are regularly used to help repair both hiatus hernias (HH) and diaphragmatic hernias (DH). In vivo studies are used to test not only mesh safety, but increasingly comparative efficacy. Our work examines the field of in vivo mesh testing for HH and DH models to establish current practices and standards.
METHOD
This systematic review was registered with PROSPERO. Medline and Embase databases were searched for relevant in vivo studies. Forty-four articles were identified and underwent abstract review, where 22 were excluded. Four further studies were excluded after full-text review-leaving 18 to undergo data extraction.
RESULTS
Of 18 studies identified, 9 used an in vivo HH model and 9 a DH model. Five studies undertook mechanical testing on tissue samples-all uniaxial in nature. Testing strip widths ranged from 1-20 mm (median 3 mm). Testing speeds varied from 1.5-60 mm/minute. Upon histology, the most commonly assessed structural and cellular factors were neovascularisation and macrophages respectively (n = 9 each). Structural analysis was mostly qualitative, where cellular analysis was equally likely to be quantitative. Eleven studies assessed adhesion formation, of which 8 used one of four scoring systems. Eight studies measured mesh shrinkage.
DISCUSSION
In vivo studies assessing mesh for HH and DH repair are uncommon. Within this relatively young field, we encourage surgical and materials testing institutions to discuss its standardisation.
Topics: Hernia, Diaphragmatic; Hernia, Hiatal; Herniorrhaphy; Humans; Laparoscopy; Prostheses and Implants; Recurrence; Surgical Mesh
PubMed: 34935102
DOI: 10.1007/s11605-021-05227-3 -
Journal of Applied Physiology... Mar 2021Congenital diaphragmatic hernia (CDH) is characterized by incomplete partitioning of the thoracic and abdominal cavities by the diaphragm muscle (DIAm). The resulting in...
Congenital diaphragmatic hernia (CDH) is characterized by incomplete partitioning of the thoracic and abdominal cavities by the diaphragm muscle (DIAm). The resulting in utero invasion of the abdominal viscera into the thoracic cavity leads to impaired fetal breathing movements, severe pulmonary hypoplasia, and pulmonary hypertension. We hypothesized that in a well-established rodent model of Nitrofen-induced CDH, DIAm isometric force generation, and DIAm fiber cross-sectional areas would be reduced compared with nonlesioned littermate and Control pups. In CDH and nonlesioned pups at embryonic day 21 or birth, DIAm isometric force responses to supramaximal field stimulation (200 mA, 0.5 ms duration pulses in 1-s duration trains at rates ranging from 10 to 100 Hz) was measured ex vivo. Further, DIAm fatigue was determined in response to 120 s of repetitive stimulation at 40 Hz in 330-ms duration trains repeated each second. The DIAm was then stretched to , frozen, and fiber cross-sectional areas were measured in 10 μm transverse sections. In CDH pups, there was a marked reduction in DIAm-specific force and force following 120 s of fatiguing contraction. The cross-sectional area of DIAm fibers was also reduced in CDH pups compared with nonlesioned littermates and Control pups. These results show that CDH is associated with a dramatic weakening of the DIAm, which may contribute to poor survival despite various surgical efforts to repair the hernia and improve lung development. There are notable respiratory deficits related to congenital diaphragmatic hernia (CDH), yet the contribution, if any, of frank diaphragm muscle weakness to CDH is unexplored. Here, we use the well-established Nitrofen teratogen model to induce CDH in rat pups, followed by diaphragm muscle contractility and morphological assessments. Our results show diaphragm muscle weakness in conjunction with reduced muscle fiber density and size, contributing to CDH morbidity.
Topics: Animals; Animals, Newborn; Diaphragm; Disease Models, Animal; Hernias, Diaphragmatic, Congenital; Lung; Muscle Fibers, Skeletal; Rats; Rats, Sprague-Dawley
PubMed: 33507852
DOI: 10.1152/japplphysiol.00852.2020 -
European Journal of Pediatrics Oct 2022The use of inhaled nitric oxide (iNO) in treating pulmonary hypertension in infants with congenital diaphragmatic hernia (CDH) is controversial. Our aims were to...
UNLABELLED
The use of inhaled nitric oxide (iNO) in treating pulmonary hypertension in infants with congenital diaphragmatic hernia (CDH) is controversial. Our aims were to identify factors associated with survival in CDH infants and whether this was influenced by the response to iNO. Results of CDH infants treated in a tertiary surgical and medical perinatal centre in a ten year period (2011-2021) were reviewed. Factors affecting survival were determined. To assess the response to iNO, blood gases prior to and 30 to 60 min after initiation of iNO were analysed and PaO/FiO ratios and oxygenation indices (OI) calculated. One hundred and five infants were admitted with CDH; 46 (43.8%) infants died. The CDH infants who died had a lower median observed to expected lung to head ratio (O/E LHR) (p < 0.001) and a higher median highest OI on day 1 (HOId1) (p < 0.001). HOId1 predicted survival after adjusting for gestational age, Apgar score at 5 min and O/E LHR (odds ratio 0.948 (95% confidence intervals 0.913-0.983)). Seventy-two infants (68.6%) received iNO; 28 survived to discharge. The median PaO (46.7 versus 58.8 mmHg, p < 0.001) and the median PaO/FiO ratio (49.4 versus 58.8, p = 0.003) improved post iNO initiation. The percentage change in the PaO/FiO ratio post iNO initiation was higher in infants who survived (69.4%) compared to infants who died (10.2%), p = 0.018.
CONCLUSION
The highest OI on day 1 predicted survival. iNO improved oxygenation in certain CDH infants and a positive response was more likely in those who survived.
WHAT IS KNOWN
• The use of iNO is controversial in infants with CDH with respect to whether it improves survival.
WHAT IS NEW
• We have examined predictors of survival in CDH infants including the response to iNO and demonstrated that the highest oxygenation index on day 1 predicted survival (AUCROC =0.908). • Certain infants with CDH responded to iNO and those with a greater response were more likely to survive.
Topics: Administration, Inhalation; Gases; Hernias, Diaphragmatic, Congenital; Humans; Hypertension, Pulmonary; Infant; Nitric Oxide; Retrospective Studies
PubMed: 35900449
DOI: 10.1007/s00431-022-04568-8 -
European Journal of Pediatric Surgery :... Dec 2021Congenital diaphragmatic hernia (CDH) is a relatively common and severe birth defect with variable clinical outcome and associated malformations in up to 60% of... (Review)
Review
Congenital diaphragmatic hernia (CDH) is a relatively common and severe birth defect with variable clinical outcome and associated malformations in up to 60% of patients. Mortality and morbidity remain high despite advances in pre-, intra-, and postnatal management. We review the current literature and give an overview about the genetics of CDH to provide guidelines for clinicians with respect to genetic diagnostics and counseling for families. Until recently, the common practice was (molecular) karyotyping or chromosome microarray if the CDH diagnosis is made prenatally with a 10% diagnostic yield. Undiagnosed patients can be reflexed to trio exome/genome sequencing with an additional diagnostic yield of 10 to 20%. Even with a genetic diagnosis, there can be a range of clinical outcomes. All families with a child with CDH with or without additional malformations should be offered genetic counseling and testing in a family-based trio approach.
Topics: Child; Counseling; Hernias, Diaphragmatic, Congenital; Humans; Karyotyping
PubMed: 34911129
DOI: 10.1055/s-0041-1740337 -
Pediatric Surgery International Nov 2023Patch repair of congenital diaphragmatic hernia (CDH) using Gore-Tex is associated with infection, adhesions, hernia recurrence, long-term musculoskeletal sequels and...
BACKGROUND
Patch repair of congenital diaphragmatic hernia (CDH) using Gore-Tex is associated with infection, adhesions, hernia recurrence, long-term musculoskeletal sequels and poor tissue regeneration. To overcome these limitations, the performance of two novel biodegradable membranes was tested to repair CDH in a growing pig model.
METHODS
Twelve male pigs were randomly assigned to 3 different groups of 4 animals each, determined by the type of patch used during thoracoscopic diaphragmatic hernia repair (Gore-Tex, polycaprolactone electrospun membrane-PCLem, and decellularized human chorion membrane-dHCM). After 7 weeks, all animals were euthanized, followed by necropsy for diaphragmatic evaluation and histological analysis.
RESULTS
Thoracoscopic defect creation and diaphragmatic repair were performed without any technical difficulty in all groups. However, hernia recurrence rate was 0% in Gore-Tex, 50% in PCLem and 100% in dHCM groups. At euthanasia, Gore-Tex patches appeared virtually unchanged and covered with a fibrotic capsule, while PCLem and dHCM patches were replaced by either floppy connective tissue or vascularized and floppy regenerated membranous tissue, respectively.
CONCLUSION
Gore-Tex was associated with a higher survival rate and lower recurrence. Nevertheless, the proposed biodegradable membranes were associated with better tissue integration when compared with Gore-Tex.
Topics: Animals; Male; Diaphragm; Hernias, Diaphragmatic, Congenital; Herniorrhaphy; Polytetrafluoroethylene; Swine
PubMed: 37999778
DOI: 10.1007/s00383-023-05584-x -
Ultrasound in Obstetrics & Gynecology :... Jan 2021To investigate the efficacy and safety of the 'smart' tracheal occlusion (Smart-TO) device in fetal lambs with diaphragmatic hernia (DH).
OBJECTIVE
To investigate the efficacy and safety of the 'smart' tracheal occlusion (Smart-TO) device in fetal lambs with diaphragmatic hernia (DH).
METHODS
DH was created in fetal lambs on gestational day 70 (term, 145 days). Fetuses were allocated to either pregnancy continuation until term (DH group) or fetoscopic endoluminal tracheal occlusion (TO), performed using the Smart-TO balloon on gestational day 97 (DH + TO group). On gestational day 116, the presence of the balloon was confirmed on ultrasound, then the ewe was walked around a 3.0-Tesla magnetic resonance scanner for balloon deflation, which was confirmed by ultrasound immediately afterwards. At term, euthanasia was performed and the fetus retrieved. Efficacy of occlusion was assessed by the lung-to-body-weight ratio (LBWR) and lung morphometry. Safety parameters included tracheal side effects assessed by morphometry and balloon location after deflation. The unoccluded DH lambs served as a comparator.
RESULTS
Six fetuses were included in the DH group and seven in the DH + TO group. All balloons deflated successfully and were expelled spontaneously from the airways. In the DH + TO group, in comparison to controls, the LBWR at birth was significantly higher (1.90 (interquartile range (IQR), 1.43-2.55) vs 1.07 (IQR, 0.93-1.46); P = 0.005), while on lung morphometry, the alveolar size was significantly increased (mean linear intercept, 47.5 (IQR, 45.6-48.1) vs 41.9 (IQR, 38.8-46.1) μm; P = 0.03); whereas airway complexity was lower (mean terminal bronchiolar density, 1.56 (IQR, 1.0-1.81) vs 2.23 (IQR, 2.14-2.40) br/mm ; P = 0.005). Tracheal changes on histology were minimal in both groups, but more noticeable in fetal lambs that underwent TO than in unoccluded lambs (tracheal score, 2 (IQR, 1-3) vs 0 (0-1); P = 0.03).
CONCLUSIONS
In fetal lambs with DH, TO using the Smart-TO balloon is effective and safe. Occlusion can be reversed non-invasively and the deflated intact balloon expelled spontaneously from the fetal upper airways. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
Topics: Animals; Balloon Occlusion; Female; Fetoscopy; Hernias, Diaphragmatic, Congenital; Humans; Pregnancy; Sheep; Trachea
PubMed: 33012007
DOI: 10.1002/uog.23135 -
Annals of the American Thoracic Society Nov 2020Brain-type natriuretic peptide (BNP) correlates with pulmonary hypertension as demonstrated by echocardiogram in congenital diaphragmatic hernia (CDH); however, its...
Brain-type natriuretic peptide (BNP) correlates with pulmonary hypertension as demonstrated by echocardiogram in congenital diaphragmatic hernia (CDH); however, its association with right ventricular (RV) function and mortality is unknown. To characterize the relationships between echocardiogram-derived RV strain, BNP, and mortality in diaphragmatic hernia. We performed a single-center retrospective cohort study of infants with CDH and at least one BNP-echocardiogram pair within a 24-hour period. RV global longitudinal strain (GLS) and free-wall strain (FWS) were measured on existing echocardiograms. Associations among strain, BNP, and mortality were tested using mixed-effect linear and logistic regression models. Survival analysis was stratified by BNP and strain abnormalities. There were 220 infants with 460 BNP-echocardiogram pairs obtained preoperatively ( = 237), ≤1 week postoperatively ( = 35), and >1 week postoperatively ("recovery"; = 188). Strain improved after repair ( < 0.0001 for all periods). Higher BNP level was associated with worse strain in recovery but not before or immediately after operation (estimate [95% confidence interval] for recovery: GLS, 1.03 [0.50-1.57]; = 0.0003; FWS, 0.62 [0.01-1.22]; = 0.047). BNP and strain abnormalities were associated with an extracorporeal-membrane oxygenation requirement. Higher BNP level in recovery was associated with greater mortality (odds ratio, 11.2 [1.2-571.3]; = 0.02). Abnormal strain in recovery had high sensitivity for detection of mortality (100% for GLS; 100% for FWS) but had low specificity for detection of mortality (28% for GLS; 48% for FWS). Persistent RV dysfunction after CDH repair may be detected by a high BNP level and abnormal RV strain.
Topics: Heart Ventricles; Hernias, Diaphragmatic, Congenital; Humans; Infant; Natriuretic Peptide, Brain; Retrospective Studies; Ventricular Dysfunction, Right
PubMed: 32730099
DOI: 10.1513/AnnalsATS.201910-767OC -
Annals of Pediatric Surgery 2021Right Bochdalek congenital diaphragmatic hernia (RB-CDH) is far less common than left Bochdalek congenital diaphragmatic hernia, accounting for only 13% of cases. There...
BACKGROUND
Right Bochdalek congenital diaphragmatic hernia (RB-CDH) is far less common than left Bochdalek congenital diaphragmatic hernia, accounting for only 13% of cases. There are limited published data on the outcomes and survival rate of RB-CDH.We aimed at investigating the clinical characteristics and analyzing the risk factors of survival in neonates with RB-CDH treated in our center over a period of 13 years.
RESULTS
Fifteen infants with RB-CDH were identified. Most of the patients were full term (74%). The mean birth weight was 2.90± 0.72 kg. The ratio of male to female was 2:1. The mean APGAR score at 1 min was 5.31±2.34, and 7.30±1.59 at 5 min. Ten patients (67%) were imaged by antenatal ultrasound. Eleven patients (73.33%) survived to go for surgical repair. The hernia sac was found in 5 patients (45%). Most hernial defects were closed in a primary fashion. The mean age at the operative repair was 8.11±9.90 days. The average NICU stay for all patients was 40.47±50.38 days. The mean follow-up period was 20.45±9.34 months. Three patients had postoperative complications. The total survival rate in neonates with RB-CDH was 9/15 (60%). Nine out of 11 (82%) neonates survived after surgical repair. Four patients (27%) died before surgical repair. Ventilation-related bilateral pneumothorax was a contributing cause of death in three patients. Birth weight was found lower in the non-survivor's group ( < 0.05). Moreover, the degree of pulmonary hypertension was more severe among non-survivors. No statistical significance was observed between other variables and mortality.
CONCLUSION
We found that low birth weight and the presence of severe PHTN were risk factors for mortality in neonates with RB-CDH. These results are in line with previous studies on prognostic factors in CDH. Ventilator-related pneumothorax appears to be a significant contributing cause of death. Long-term follow-up studies of infants born with RB-CDH are needed as small number of cases limits large-volume RB-CDH studies.
PubMed: 34899880
DOI: 10.1186/s43159-021-00081-z