Patch repair for congenital diaphragmatic hernia: is it really a problem?

doi:10.1016/j.jpedsurg.2011.11.054

Journal of Pediatric Surgery

Volume 47, Issue 4, April 2012, Pages 637-641

https://doi.org/10.1016/j.jpedsurg.2011.11.054 Get rights and content

Abstract

Background

Large congenital diaphragmatic hernia (CDH) defects often require the use of synthetic patches for tension-free repair. Although high rates of recurrence and other morbidities have been previously reported, our favorable perception of patch repair prompted this review.

Methods

A single-center retrospective chart review of CDH cases repaired between January 1, 1999, and October 1, 2010. Patch repairs were performed by multiple surgeons with an effort to construct a tension-free dome-shaped patch.

Results

One hundred eighty-four children underwent CDH repair of whom 99 (53.8%) required a patch. Seventy-four (74.7%) of the 99 patients who underwent patch repair survived to discharge and were compared with 75 primary repair survivors. Of those undergoing patch repair, 88% were prenatally diagnosed, 55% had liver herniation, and 22 (29.9%) were repaired on extracorporeal membrane oxygenation. Two patients experienced a recurrence after a patch repair and 3 after a primary repair for a rate of 5.4% and 4.0%, respectively (P = 1.0).

Conclusions

These results demonstrate that synthetic patch repair for CDH can be performed with a very low rate of recurrence challenging the need for alternative approaches to diaphragmatic replacement. High rates of recurrence reported for patch repair may be technical rather than intrinsic to the patch.

Section snippets

Materials and methods

After approval of the study by the Children's Hospital of Philadelphia (CHOP) Institutional Review Board (IRB no. 10-007917), a retrospective search of the databases of both the CHOP Center for Fetal Diagnosis and Treatment and Pulmonary Hypoplasia Program was performed for patients with a diagnosis of CDH who underwent initial surgery at CHOP between January 1, 1999, and October 30, 2010. Patients who were diagnosed with CDH but did not undergo repair, had a repair performed at a different

Results

We identified 184 consecutive patients with CDH who underwent surgical repair at CHOP of whom 149 (81%) patients survived to discharge and became the study cohort. Ninety-nine (53.8%) of the 184 patients required prosthetic patch repair and 85 (46.2%) underwent primary repair. Twenty-five patch repair patients and 4 primary repair patients did not survive to discharge; 6 patients with primary repair had no documented follow-up. Of the 149 survivors with follow-up, 75 (50.3%) were repaired

Discussion

Advances in neonatal management have led to improved survival of patients with severe CDH and their associated large diaphragmatic defects. Diaphragmatic defects too large for primary repair are most commonly closed using a synthetic patch although the surgical technique used for patch repair varies widely. The literature is replete with studies citing a very high recurrence rate for synthetic patch repairs (Table 2) ranging from 14% to 50% [3], [4], [5], [6], [7], [8], [9], [10]. In addition,

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Cited by (84)

A rare case of hepatopulmonary fusion associated with a right congenital diaphragmatic hernia: Case report and review of the literature
2023, International Journal of Surgery Case Reports
Hepatic-pulmonary fusion is a very rare condition that occurs in the right congenital diaphragmatic hernia and appears to affect both sexes equally. There are no specific diagnostic methods before surgery for this anomaly. Most cases are discovered during surgical repair of the right congenital diaphragmatic hernia. This anomaly is considered to have a poor prognosis because of the associated vascular abnormalities and pulmonary hypoplasia.
We present the case of a neonate who suffered from respiratory distress since birth. Later, a congenital right diaphragmatic hernia was diagnosed. At surgery, it was found that hepatic-pulmonary fusion was present, accompanied by an anomaly of pulmonary venous outflow. A complete detachment of the connective tissue was performed and a patch was placed to close the defect in the diaphragm.
The few cases of hepatic pulmonary fusion reported in the medical literature make it difficult to develop a clear plan for diagnosis and surgical management. However, this anomaly should be considered when right-sided congenital diaphragmatic hernia is present, and the case should be well investigated and the surgical decision should not be rushed.
Hepatic-pulmonary fusion has a poor prognosis and a high mortality rate. No pathological mechanism for this anomaly has been identified, so we could not identify a specific diagnostic mechanism or a specific surgical method to treat this anomaly.
Laparoscopic repair of recurrent congenital diaphragmatic hernia: A case report
2023, Journal of Pediatric Surgery Case Reports
Recurrent herniation is a well-recognised complication following the repair of a congenital diaphragmatic hernia (CDH). There is no consensus on the optimal surgical approach to manage recurrent CDH. We present a case of laparoscopic correction of recurrent herniation using a non-absorbable patch.
A 13-month old girl presented to the outpatients department with constipation and breath-holding attacks, previously having undergone left CDH surgery on the 7th day of life. The original operation was performed via a subcostal incision and a primary repair was carried out with interrupted non-absorbable sutures. Chest X-ray demonstrated elevation of the left hemi diaphragm with a posterior ‘bulge’ suggesting a recurrence. An elective diagnostic laparoscopy was performed confirming the recurrence with transverse colon herniation through a left postero-lateral diaphragmatic defect size 5 × 5 cm and complete absence of the previously noted posterior rim. There were significant adhesions to the anterior abdominal wall, including the spleen, which were divided and mobilised haemostatically to allow complete assessment of the defect. A patch repair was performed using synthetic mesh anchored with interrupted non-absorbable sutures. Total operating time was under 120 minutes. The patient was discharged on the 3rd post-operative day with minimal analgesic requirements and no evidence of recurrence on follow-up radiographs.
Laparoscopic repair is a safe and effective option for cases of CDH recurrence and is technically feasible despite the operative challenges that the surgeon will inevitably face as demonstrated in this case.
Survival after a two-stage surgical approach in hepatopulmonary fusion: A case report
2023, International Journal of Surgery Case Reports
Congenital diaphragmatic hernias are a rare developmental defect. Pulmonary complications are more frequently seen in right sided defects (Partridge et al., 2016). Hepatopulmonary fusion is a rare and highly mortal malformation exclusively seen in right sided congenital diaphragmatic hernias marked by the fibrovascular fusion of the liver and lung.
A newborn male presented with respiratory distress and a 1-minute APGAR score of 7. A chest radiograph showed complete opacification of the right hemithorax, and a CT-Scan confirmed a congenital diaphragmatic hernia, an intrathoracic location of the liver and secondary pulmonary hypoplasia. 48 h after, intraoperative findings showed fusion of diaphragm, lung and liver tissue. Four months after, complete tissue division of the lower lobe from the fused liver segments VII/VIII and correction of the hernia defect was achieved. The patient was discharged from the hospital six months after.
Partial division of tissues is described as the safest and most successful approach to hepatopulmonary fusion. The tally of all cases reported worldwide until 2020 shows higher survival rates with complete division of tissues (Ferguson DM; Congenital Diaphragmatic Hernia Study Group, 2020) Reported cases lean towards one-session surgical interventions. A two-stage surgical approach allows an initial low surgical trauma to manage compressive effects on intrathoracic structures by herniary contents and a second time for tissue division in a non-critical patient, in this case leading to long-term survival.
Hepatopulmonary fusion is a rare and highly lethal malformation with scarce information available. Future multicenter studies should compare different therapeutic options and search for outcomes including but not limited to mortality.
Evaluation of a biodegradable polyurethane patch for repair of diaphragmatic hernia in a rat model: A pilot study
2023, Journal of Pediatric Surgery
Congenital diaphragmatic hernia (CDH) repair is an area of active research. Large defects requiring patches have a hernia recurrence rate of up to 50%. We designed a biodegradable polyurethane (PU)-based elastic patch that matches the mechanical properties of native diaphragm muscle. We compared the PU patch to a non-biodegradable Gore-Tex™ (polytetrafluoroethylene) patch.
The biodegradable polyurethane was synthesized from polycaprolactone, hexadiisocyanate and putrescine, and then processed into fibrous PU patches by electrospinning. Rats underwent 4 mm diaphragmatic hernia (DH) creation via laparotomy followed by immediate repair with Gore-Tex™ (n = 6) or PU (n = 6) patches. Six rats underwent sham laparotomy without DH creation/repair. Diaphragm function was evaluated by fluoroscopy at 1 and 4 weeks. At 4 weeks, animals underwent gross inspection for recurrence and histologic evaluation for inflammatory reaction to the patch materials.
There were no hernia recurrences in either cohort. Gore-Tex™ had limited diaphragm rise compared to sham at 4 weeks (1.3 mm vs 2.9 mm, p = 0.003), but no difference was found between PU and sham (1.7 mm vs 2.9 mm, p = 0.09). There were no differences between PU and Gore-Tex™ at any time point. Both patches formed an inflammatory capsule, with similar thicknesses between cohorts on the abdominal (Gore-Tex™ 0.07 mm vs. PU 0.13 mm, p = 0.39) and thoracic (Gore-Tex™ 0.3 mm vs. PU 0.6 mm, p = 0.09) sides.
The biodegradable PU patch allowed for similar diaphragmatic excursion compared to control animals. There were similar inflammatory responses to both patches. Further work is needed to evaluate long-term functional outcomes and further optimize the properties of the novel PU patch in vitro and in vivo.
Level II, Prospective Comparative Study.
Congenital Diaphragmatic Hernia: Considerations for the Adult General Surgeon
2022, Surgical Clinics of North America
Citation Excerpt :
For large CDH defects, a prosthetic patch, typically polytetrafluoroethylene (Gore-Tex Soft Tissue Patch, Flagstaff, AZ), may be needed for the diaphragm repair or to supplement or reinforce a repair that can only be partially approximated primarily without tension. Mesh repairs have historically been associated with higher rates of postoperative adhesive bowel obstructions and recurrences; however, some recent studies have not found a significant increase in the risk of recurrence with patch repair.35–38 Many have abandoned using biologic mesh alone due to high rates of recurrence.37,39
Does creating a dome reduce recurrence in congenital diaphragmatic hernia following patch repair?
2022, Journal of Pediatric Surgery
Citation Excerpt :
Hernia recurrence is a common morbidity that has been linked to both the size of defect and type of repair including a minimally invasive approach [4,5]. Large defect sizes such as types C and D are commonly repaired with a patch to achieve adequate closure, however, compared to primary repair, patch repair has been associated with a higher rate of CDH recurrence, from 14 to 50% [6–14]. It has been hypothesized that the recurrence rate in patch repair can be minimized with optimal surgical technique [14].
To develop a quantifiable approach to identify a dome shape of the repaired diaphragm using post-operative chest radiograph and to determine if a dome-shaped prosthetic patch repair is associated with a decreased rate of CDH recurrence.
We conducted a retrospective review of all neonates evaluated at our institution from January 2004 to August 2017 with left- and right-sided CDH with at least 6 months of follow-up after CDH repair. Patch use, post-operative imaging and postnatal outcomes were analyzed. Neonates with patch repair were divided into two groups based on the presence of a dome. Using postoperative chest radiographs, the presence of a dome was classified as having a vertical-horizontal diaphragm ratio (VHDR) greater than 20%. Primary outcome was CDH recurrence after repair.
We identified 192 neonates who met our inclusion criteria. Cohort survival was 96%, recurrence rate was 15%, 78% had a left-sided CDH; 54% received a patch repair, of which 58% had a type C defect. Of the 104 infants with patch repairs, the CDH recurrence rate was 22% (n = 23) at a median age of 8.5 months (3.8, 20.1). Although neonates with a dome repair had more ECMO use and longer hospital stay, their recurrence rate was about half of those with a non-dome repair (14% vs 28%, p = 0.07).
A dome-shaped repair may reduce recurrence following prosthetic patch repair of congenital diaphragmatic hernia. A larger, multi-institutional study is needed to statistically validate this clinically significant observation.
Retrospective review.
III.

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¹: These authors contributed equally to this work.

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Original articlePatch repair for congenital diaphragmatic hernia: is it really a problem?

Abstract

Background

Methods

Results

Conclusions

Section snippets

Materials and methods

Results

Discussion

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Surg Res

J Pediatr Surg

Original article
Patch repair for congenital diaphragmatic hernia: is it really a problem?