REOPERATIONS IN HIGH RISK GROUP CHILDREN WITH CONGENITAL DIAPHRAGMATIC HERNIA

Abstract

Background. Nowadays the survival of newborns with congenital diaphragmatic hernia (CDH) is increasing. That’s why high frequency of chronic diseases and surgical complications is predictable.Purpose: determination of the structure and frequency of CDH reoperation in children with high risk, retrospective evaluation of perinatal clinical and intraoperative risk factors for repeat surgery.Materials and methods. Prospectively established group of 68 high-risk children with CDH, which were operated and survived during the period from 2000 to 2014. Left-sided hernias were dominated (82%) and right-sided CDH were diagnosed in 18% of newborns. Correction of left-sided CDH were performed by laparotomy in 51 patients (88%), including upper midline laparotomy in 43 cases and in 8 patients upper transverse laparotomy was performed. Thoracotomy was performed in 19 patients. Also thoracotomy was preferred in right-sided CDH (66.7%). Plastic of the diaphragm in case of left-sided CDH was performed by own tissues in 50 patients (73.5%). Plastic with using synthetic materials was made in 17 patients (26.5%): Medical Teflon ePTFE (n = 8), patch in the form of "sandwich" ("Tutoplast-pericardium" and mash) was used in four patients, Gor-Tex (n = 3) and with "Tutoplast-pericardium" was performed in two patients.Results. 23 operations in 20 of 68 patients were performed (29.4%). The reason of performing reoperations were such disease: adhesive bowel obstruction - 8 (40%), including strangulation obstruction with necrosis - 2 (10%), recurrent hernia - 6 (30%), gastroesophageal reflux - 5 (25%), obstruction caused by malrotation- 1 (5%), spleen torsion - 1 (5%), funnel chest deformation - 1 (5%). In patient with left diaphragmatic dome agenesis and primary plastics using synthetic ePTFE patch surgical treatment for recurrence was performed twice - at the age of 6 months and 1 year. Antireflux procedure was performed in the early postoperative period in two children, and in three children in the age of 5 years. In all children antireflux operation was performed by Nissen method. Correction of the funnel chest deformation by Nuss method was performed in patient after plastic CDH by own tissues, combined with recurrent hernia. The cause of postoperative intestinal obstruction in most patients were adhesions (n=8) and in one case was malrotation. Adhesive intestinal obstruction was occurred in 6 patients after using laparotomic access, including two of them with necrosis and intestinal resection. In two patients adhesive intestinal obstruction was occurred after using thoracotomic access and obstruction was caused by solitary threadlike adhesion.Conclusions. There is a high probability of surgical complications and reoperations in patients with high risk who survived after the CDH correction. The main factors that determine the risk of recurrence of CDH are the size of the hernia defect and the way of surgical plastic of the diaphragm. Laparotomic access increases the risk of postoperative adhesive intestinal obstruction. It is essential to long-term observation of these children to find out the risk factors of specific surgical complications.