Case Report
Volume 8 Issue 3 - 2021
Congenital Diaphragmatic Hernia with Massive Abdominal Contents
José Alberto Martinez Valdes1*, Xóchitl Serna Velazquez2, Héctor Armando Miranda Blasnich1, Paul Ernesto Charis Trujillo1, Jennifer Itzel Jacobo Godínez1, Manuel Cornish Estrada1, Alfredo Leonardo Ortiz Nieto1, Leslie Azarel Callejas Reyes1 and Ivan Hernadez Cuevas1
1General Surgeon, Department of General Surgery in “Hospital General Ticomán” General Hospital of Mexico City’s Health Secretariat, Universidad Nacional Autónoma de México, Mexico City, Mexico
2Perioperative Nurse, Hospital General de México, Universidad Nacional Autónoma de México, Mexico City, Mexico
*Corresponding Author: José Alberto Martinez Valdes, General Surgeon, Department of General Surgery in “Hospital General Ticomán” General Hospital of Mexico City’s Health Secretariat, Universidad Nacional Autónoma de México, Mexico City, Mexico.
Received: February 03, 2021; Published: February 11, 2021




Abstract

Introduction: Congenital diaphragmatic hernia (CDH) is a congenital defect that occurs in about 1: 3000 to 5000 live births leading to communication between the abdominal and thoracic cavities during critical stages of development. The displacement of abdominal contents into the thoracic space during this time can cause pulmonary hypoplasia due to the mass effect of abdominal contents. The lung not only suffers from hypoplasia, but also lacks a normal vascular and bronchial branching pattern. This abnormal development leads to increased pulmonary vascular resistance and subsequent significant pulmonary hypertension. These two pathological conditions are the main source of morbidity and mortality in patients with CDH.

CDH can occur either on the right side of the diaphragm, on the left side or even in the least of cases may be bilateral. Within the most frequent hernias are left-sided and there are two main types: Morgani (anteromedial) and Bochdalek (posterolateral). Bochdalek hernias occur much more often and are usually associated with physiological disorders in the newborn.

While open surgery (thoracotomy or laparotomy) has traditionally been performed for patients with CDH, minimally invasive surgery (laparoscopy or thoracoscopy) has emerged as a safe and feasible alternative. Each technique has advantages and disadvantages. Minimally invasive surgery has a shorter duration of postoperative ventilation, less pain and short-term use of narcotics, faster recovery, shorter hospitalization, and less morbidity, such as thoracic wall deformities and small bowel obstruction unlike open surgery.

Purpose: Presentation of a clinical case at the Pediatric Hospital of Peralvillo, of the Health Secretariat in Mexico City, on a case of congenital diaphragmatic hernia with massive abdominal contents to the surgical community.

Results: We present a clinical case of a male patient with 35 weeks of pregnancy who experiences respiratory distress, having at physical examination, absence of respiratory noise in left hemithorax, heart noises predominantly in right hemithorax, as well as concave abdomen without auscultating peristaltic noises, is taken a chest X-ray, in which is evidenced a diaphragmatic hernia, as well as displacement of the cardiac silhouette to the right, and abdomen with ground glass image, so surgical management is decided, having as a finding a hernial defect in the posterolateral left face of the diaphragm with massive abdominal content, diaphragmatic plasty with tension is performed. Post surgery, its postoperative period is carried out in the neonatal ICU where gasometry is taken in which severe respiratory acidosis is reported, requiring invasive mechanical ventilation with increase in ventilatory parameters, use of aminergics and life support with drug products, with death 15 hours after surgery.

Discussion: Congenital diaphragmatic hernia (CDH) is a condition in which partial or complete agenesis of the diaphragm occurs, resulting in continuity between the chest and abdominal cavities, usually more common in males, occurs in about 1: 3,000 to 5000 live births. Left side CDH is more common than on the right side. The posterolateral left side of the diaphragm is the most common localization in 75 to 90% of cases (Bochdaleck's hernia) and 10% occurs in the anteromedial portion (Morgani's hernia); the defect on the right side occurs in 10 to 15%, it can even be bilateral in 1 to 2% of cases. The prevalence of CDH does not appear to be associated with maternal age.

The pathogenesis of CDH is not fully understood, however, the most accepted theory is failure in the closure of the pleuroperitoneal membrane or environmental factors altering the differentiation of mesenchymal cells during the formation of the diaphragm and other somatic structures.

Prenatal diagnosis of CDH is based on ultrasound. Usually, diagnosis is based on the presence of a mediastinal displacement and a fluid-filled stomach next to or just behind the heart. In some cases, the fetal liver may herniate into the chest and appear as an intrathoracic homogeneous mass at heart level. The defect in the right hemidiaphragm is more difficult to diagnose since on ultrasound the liver is similar in appearance to the fetal lung.

Patients with CDH management before surgery may take several different forms, but all maintain several basic principles: permissive hypercapnia (PaCO2, 45 - 60 mm Hg), maintaining oxygen saturation between 85% - 95%, minimizing the volutrauma index and barotrauma with conventional ventilatory strategies aimed at maintaining a positive inspiratory pressure less than 25 cm H2O with a positive pressure at the end of expiration between 2 and 5 cm H2O. The addition of inhaled nitric oxide can further decompress the pulmonary vascular bed. If these goals cannot be achieved with maximum medical therapy, extracorporeal membrane oxygenation (ECMO) is required to deliver oxygen and eliminate CO2. However, in terms of hernia repair surgically, it has several modalities, with an open or minimally invasive technique, with or without mesh and approached from the abdomen or chest.

Conclusion: Congenital diaphragmatic hernia is a rare entity, whose clinical presentation varies from mild symptoms to incompatible with life, depending on the degree of pulmonary hypoplasia and concomitant diseases. One of the main problems related to anesthetic management of these patients is ventilation. According to the severity of symptoms, it is used from pressure-controlled respiratory assistance to high-frequency oscillatory respiratory assistance and extracorporeal membrane oxygenation. Congenital diaphragmatic hernia remains a challenging condition with a little-known etiology and pathogenesis.

Keywords: Hernia; Congenital; Massive; Viscera; Bochdalek; Morgani; ECMO; FETO

References

  1. Dingeldein M. “Congenital Diaphragmatic Hernia”. Advances in Pediatrics1 (2018): 241-247.
  2. McHoney M. “Congenital diaphragmatic hernia, management in the newborn”. Pediatric Surgery International11 (2015): 1005-1013.
  3. Przemysław Kosiński and Mirosław Wielgoś. “Congenital diaphragmatic hernia: pathogenesis, prenatal diagnosis and management - literature review”. Ginekologia Polska 1 (2017): 24-30.
  4. Slavotinek AM. “The genetics of common disorders - congenital diaphragmatic hernia”. European Journal of Medical Genetics 8 (2014): 418-423.
  5. Kovler ML and Jelin EB. “Fetal Intervention for Congenital Diaphragmatic Hernia”. Seminars in Pediatric Surgery (2019): 150818.
  6. Jancelewicz T and Brindle ME. “Prediction tools in congenital diaphragmatic hernia”. Seminars in Perinatology (2019): 151165.
  7. Correia-Pinto J and Barroso C. “Perioperative Complications of Congenital Diaphragmatic Hernia Repair”. European Journal of Pediatric Surgery 28.02 (2018): 141-147.
  8. Graham G and Devine PC. “Antenatal diagnosis of congenital diaphragmatic hernia”. Seminars in Perinatology 2 (2005): 69-76.
  9. Benachi A., et al. “Advances in prenatal diagnosis of congenital diaphragmatic hernia”. Seminars in Fetal and Neonatal Medicine 6 (2014): 331-337.
  10. Sananes N., et al. “Improving the Prediction of Neonatal Outcomes in Isolated Left-Sided Congenital Diaphragmatic Hernia by Direct and Indirect Sonographic Assessment of Liver Herniation”. Institute of Ultrasound in Medicine 7 (2016): 1437-1443.
  11. Deprest JA., et al. “The making of fetal surgery”. Prenatal Diagnosis 7 (2010): 653-667.
  12. Peralta CF., et al. “Fetal lung volume after endoscopic tracheal occlusion in the prediction of postnatal outcome”. American Journal of Obstetrics and Gynecology 1 (2008).
  13. Done E., et al. “Predictors of neonatal morbidity in fetuses with severe isolated congenital diaphragmatic hernia undergoing fetoscopic tracheal occlusion”. Ultrasound in Obstetrics and Gynecology 1 (2013).
  14. Jani JC., et al. “Severe diaphragmatic hernia treated by fetal endoscopic tracheal occlusion”. Ultrasound in Obstetrics and Gynecology 3 (2009).
  15. DeKoninck P., et al. “Right-sided congenital diaphragmatic hernia in a decade of fetal surgery”. An International Journal of Obstetrics and Gynaecology 7 (2015): 940-946.
  16. Fayoux P., et al. “Neonatal tracheal changes following in utero fetoscopic balloon tracheal occlusion in severe congenital diaphragmatic hernia”. Journal of Pediatric Surgery 4 (2010): 687-692.
  17. Deprest J., et al. “Tracheal side effects following fetal endoscopic tracheal occlusion for severe congenital diaphragmatic hernia”. Pediatric Radiology 5 (2010): 670-673.
  18. Basurto D., et al. “Prenatal diagnosis and management of congenital diaphragmatic hernia”. Best Practice and Research Clinical Obstetrics and Gynecology 58 (2019): 93-106.
  19. Clifton MS and Wulkan ML. “Congenital Diaphragmatic Hernia and Diaphragmatic Eventration”. Clinics in Perinatology 4 (2017): 773-779.
  20. Logan JW., et al. “Congenital diaphragmatic hernia: a systematic review and summary of best-evidence practice strategies”. Journal of Perinatology 27 (2007): 535-549.
  21. Kays DW., et al. “Extracorporeal life-support of patients with congenital diaphragmatic hernia: how long should we treat?” Journal of the American College of Surgeons 4 (2014): 808-817.
  22. Seetharamaiah R., et al. “Factors associated with survival in children with congenital diaphragmatic hernia requiring extracorporeal membrane oxygen: a report from the Congenital Diaphragmatic Hernia Study Group”. Journal of Pediatric Surgery 44 (2009): 1315-1321.
  23. Kays DW., et al. “Extracorporeal life support in patients with congenital diaphragmatic hernia: how long should we treat?” Journal of the American College of Surgeons 218 (2014): 808-817.
  24. McHoney M and Hammond P. “Role of ECMO in congenital diaphragmatic hernia”. Archives of Disease in Childhood - Fetal and Neonatal Edition2 (2017): F178-F181.
  25. Partridge EA., et al. “Timing of repair of congenital diaphragmatic hernia in patients supported by extracorporeal membrane oxygenation (ECMO)”. Journal of Pediatric Surgery 50 (2015): 260-262.
  26. Desai AA., et al. “Optimal timing of congenital diaphragmatic hernia repair in infants on extracorporeal membrane oxygenation”. Seminars in Pediatric Surgery 24 (2015): 17-19.
  27. Grant H., et al. “Potential danger of 'trial of life' approach to congenital diaphragmatic hernia”. Journal of Pediatric Surgery 29 (1994): 399.
  28. Fallon SC., et al. “Repair of congenital diaphragmatic hernias on Extracorporeal Membrane Oxygenation (ECMO): does early repair improve patient survival?” Journal of Pediatric Surgery 48 (2013): 1172-1176.
  29. McHoney M. “Congenital diaphragmatic hernia, management in the newborn”. Pediatric Surgery International 11 (2015).
  30. Pacilli M., et al. “Absorption of carbon dioxide during laparoscopy in children measured using a novel mass spectrometric technique”. British Journal of Anaesthesia 97 (2006): 215-219.
  31. Bishay M., et al. “Decreased cerebral oxygen saturation during thoracoscopic repair of congenital diaphragmatic hernia and esophageal atresia in infants”. Journal of Pediatric Surgery 46 (2011): 47-51.
  32. McHoney M., et al. “Effect of patient weight and anesthetic technique on CO(2) excretion during thoracoscopy in children assessed by endtidal CO(2)”. Journal of Laparoendoscopic and Advanced Surgical Techniques 18 (2008): 147-151.
  33. McHoney M., et al. “Thoracoscopic repair of congenital diaphragmatic hernia: intraoperative ventilation and recurrence”. Journal of Pediatric Surgery 45 (2010): 355-359.
  34. Tsao K., et al. “Minimally invasive repair of congenital diaphragmatic hernia”. Journal of Pediatric Surgery 46 (2011): 1158-1164.
  35. Bruns NE., et al. “Approach to recurrent congenital diaphragmatic hernia: results of an international survey”. Journal of Laparoendoscopic and Advanced Surgical Techniques 11 (2016): 925-929.
Citation: José Alberto Martinez Valdes., et al. “Congenital Diaphragmatic Hernia with Massive Abdominal Contents". EC Gastroenterology and Digestive System 8.3 (2021): 94-102.

PubMed Indexed Article


EC Pharmacology and Toxicology
LC-UV-MS and MS/MS Characterize Glutathione Reactivity with Different Isomers (2,2' and 2,4' vs. 4,4') of Methylene Diphenyl-Diisocyanate.

PMID: 31143884 [PubMed]

PMCID: PMC6536005


EC Pharmacology and Toxicology
Alzheimer's Pathogenesis, Metal-Mediated Redox Stress, and Potential Nanotheranostics.

PMID: 31565701 [PubMed]

PMCID: PMC6764777


EC Neurology
Differences in Rate of Cognitive Decline and Caregiver Burden between Alzheimer's Disease and Vascular Dementia: a Retrospective Study.

PMID: 27747317 [PubMed]

PMCID: PMC5065347


EC Pharmacology and Toxicology
Will Blockchain Technology Transform Healthcare and Biomedical Sciences?

PMID: 31460519 [PubMed]

PMCID: PMC6711478


EC Pharmacology and Toxicology
Is it a Prime Time for AI-powered Virtual Drug Screening?

PMID: 30215059 [PubMed]

PMCID: PMC6133253


EC Psychology and Psychiatry
Analysis of Evidence for the Combination of Pro-dopamine Regulator (KB220PAM) and Naltrexone to Prevent Opioid Use Disorder Relapse.

PMID: 30417173 [PubMed]

PMCID: PMC6226033


EC Anaesthesia
Arrest Under Anesthesia - What was the Culprit? A Case Report.

PMID: 30264037 [PubMed]

PMCID: PMC6155992


EC Orthopaedics
Distraction Implantation. A New Technique in Total Joint Arthroplasty and Direct Skeletal Attachment.

PMID: 30198026 [PubMed]

PMCID: PMC6124505


EC Pulmonology and Respiratory Medicine
Prevalence and factors associated with self-reported chronic obstructive pulmonary disease among adults aged 40-79: the National Health and Nutrition Examination Survey (NHANES) 2007-2012.

PMID: 30294723 [PubMed]

PMCID: PMC6169793


EC Dental Science
Important Dental Fiber-Reinforced Composite Molding Compound Breakthroughs

PMID: 29285526 [PubMed]

PMCID: PMC5743211


EC Microbiology
Prevalence of Intestinal Parasites Among HIV Infected and HIV Uninfected Patients Treated at the 1o De Maio Health Centre in Maputo, Mozambique

PMID: 29911204 [PubMed]

PMCID: PMC5999047


EC Microbiology
Macrophages and the Viral Dissemination Super Highway

PMID: 26949751 [PubMed]

PMCID: PMC4774560


EC Microbiology
The Microbiome, Antibiotics, and Health of the Pediatric Population.

PMID: 27390782 [PubMed]

PMCID: PMC4933318


EC Microbiology
Reactive Oxygen Species in HIV Infection

PMID: 28580453 [PubMed]

PMCID: PMC5450819


EC Microbiology
A Review of the CD4 T Cell Contribution to Lung Infection, Inflammation and Repair with a Focus on Wheeze and Asthma in the Pediatric Population

PMID: 26280024 [PubMed]

PMCID: PMC4533840


EC Neurology
Identifying Key Symptoms Differentiating Myalgic Encephalomyelitis and Chronic Fatigue Syndrome from Multiple Sclerosis

PMID: 28066845 [PubMed]

PMCID: PMC5214344


EC Pharmacology and Toxicology
Paradigm Shift is the Normal State of Pharmacology

PMID: 28936490 [PubMed]

PMCID: PMC5604476


EC Neurology
Examining those Meeting IOM Criteria Versus IOM Plus Fibromyalgia

PMID: 28713879 [PubMed]

PMCID: PMC5510658


EC Neurology
Unilateral Frontosphenoid Craniosynostosis: Case Report and a Review of the Literature

PMID: 28133641 [PubMed]

PMCID: PMC5267489


EC Ophthalmology
OCT-Angiography for Non-Invasive Monitoring of Neuronal and Vascular Structure in Mouse Retina: Implication for Characterization of Retinal Neurovascular Coupling

PMID: 29333536 [PubMed]

PMCID: PMC5766278


EC Neurology
Longer Duration of Downslope Treadmill Walking Induces Depression of H-Reflexes Measured during Standing and Walking.

PMID: 31032493 [PubMed]

PMCID: PMC6483108


EC Microbiology
Onchocerciasis in Mozambique: An Unknown Condition for Health Professionals.

PMID: 30957099 [PubMed]

PMCID: PMC6448571


EC Nutrition
Food Insecurity among Households with and without Podoconiosis in East and West Gojjam, Ethiopia.

PMID: 30101228 [PubMed]

PMCID: PMC6086333


EC Ophthalmology
REVIEW. +2 to +3 D. Reading Glasses to Prevent Myopia.

PMID: 31080964 [PubMed]

PMCID: PMC6508883


EC Gynaecology
Biomechanical Mapping of the Female Pelvic Floor: Uterine Prolapse Versus Normal Conditions.

PMID: 31093608 [PubMed]

PMCID: PMC6513001


EC Dental Science
Fiber-Reinforced Composites: A Breakthrough in Practical Clinical Applications with Advanced Wear Resistance for Dental Materials.

PMID: 31552397 [PubMed]

PMCID: PMC6758937


EC Microbiology
Neurocysticercosis in Child Bearing Women: An Overlooked Condition in Mozambique and a Potentially Missed Diagnosis in Women Presenting with Eclampsia.

PMID: 31681909 [PubMed]

PMCID: PMC6824723


EC Microbiology
Molecular Detection of Leptospira spp. in Rodents Trapped in the Mozambique Island City, Nampula Province, Mozambique.

PMID: 31681910 [PubMed]

PMCID: PMC6824726


EC Neurology
Endoplasmic Reticulum-Mitochondrial Cross-Talk in Neurodegenerative and Eye Diseases.

PMID: 31528859 [PubMed]

PMCID: PMC6746603


EC Psychology and Psychiatry
Can Chronic Consumption of Caffeine by Increasing D2/D3 Receptors Offer Benefit to Carriers of the DRD2 A1 Allele in Cocaine Abuse?

PMID: 31276119 [PubMed]

PMCID: PMC6604646


EC Anaesthesia
Real Time Locating Systems and sustainability of Perioperative Efficiency of Anesthesiologists.

PMID: 31406965 [PubMed]

PMCID: PMC6690616


EC Pharmacology and Toxicology
A Pilot STEM Curriculum Designed to Teach High School Students Concepts in Biochemical Engineering and Pharmacology.

PMID: 31517314 [PubMed]

PMCID: PMC6741290


EC Pharmacology and Toxicology
Toxic Mechanisms Underlying Motor Activity Changes Induced by a Mixture of Lead, Arsenic and Manganese.

PMID: 31633124 [PubMed]

PMCID: PMC6800226


EC Neurology
Research Volunteers' Attitudes Toward Chronic Fatigue Syndrome and Myalgic Encephalomyelitis.

PMID: 29662969 [PubMed]

PMCID: PMC5898812


EC Pharmacology and Toxicology
Hyperbaric Oxygen Therapy for Alzheimer's Disease.

PMID: 30215058 [PubMed]

PMCID: PMC6133268


News and Events


May Issue Release

We always feel pleasure to share our updates with you all. Here, notifying you that we have successfully released the May issue of respective journals and the latest articles can be viewed on the current issue pages.

Submission Deadline for upcoming Issue

Ecronicon delightfully welcomes all the authors around the globe for effective collaboration with an article submission for the upcoming issue of respective journals. Submissions are accepted on/before May 28, 2021.

Certificate of Publication

Ecronicon honors with a "Publication Certificate" to the corresponding author by including the names of co-authors as a token of appreciation for publishing the work with our respective journals.

Best Article of the Issue

Editors of respective journals will always be very much interested in electing one Best Article after each issue release. The authors of the selected article will be honored with a "Best Article of the Issue" certificate.

Certifying for Review

Ecronicon certifies the Editors for their first review done towards the assigned article of the respective journals.

Latest Articles

The latest articles will be updated immediately on the articles in press page of the respective journals.

Immediate Assistance

The prime motto of this team is to clarify all the queries without any delay or hesitation to avoid the inconvenience. For immediate assistance on your queries please don't hesitate to drop an email to editor@ecronicon.uk