Intrathoracic Herniation Of Liver Research Articles

Dynamics of pulmonary hypertension severity in the first 48 h in neonates with prenatally diagnosed congenital diaphragmatic hernia.

Pulmonary hypertension (PH) is one of the major contributing factors to the high morbidity and mortality in neonates with congenital diaphragmatic hernia (CDH). The severity and duration of postnatal PH are an established risk factor for patient outcome; however, the early postnatal dynamics of PH have not been investigated. This study aims to describe the early course of PH in CDH infants, and its relation to established prognostic markers and outcome measures. We performed a monocentric retrospective review of neonates with prenatally diagnosed CDH, who received three standardized echocardiographic examinations at 2-6 h, 24, and 48 h of life. The degree of PH was graded as one of three categories: mild/no, moderate, or severe PH. The characteristics of the three groups and their course of PH over 48 h were compared using univariate and correlational analyses. Of 165 eligible CDH cases, initial PH classification was mild/no in 28%, moderate in 35%, and severe PH in 37%. The course of PH varied markedly based on the initial staging. No patient with initial no/mild PH developed severe PH, required extracorporeal membrane oxygenation (ECMO)-therapy, or died. Of cases with initial severe PH, 63% had persistent PH at 48 h, 69% required ECMO, and 54% died. Risk factors for any PH included younger gestational age, intrathoracic liver herniation, prenatal fetoscopic endoluminal tracheal occlusion (FETO)-intervention, lower lung to head ratio (LHR), and total fetal lung volume (TFLV). Patients with moderate and severe PH showed similar characteristics, except liver position at 24- (p = 0.042) and 48 h (p = 0.001), mortality (p = 0.001), and ECMO-rate (p = 0.035). To our knowledge, this is the first study to systematically assess the dynamics of PH in the first postnatal 48 h at three defined time points. CDH infants with initial moderate and severe PH have a high variation in postnatal PH severity over the first 48 h of life. Patients with mild/no PH have less change in PH severity, and an excellent prognosis. Patients with severe PH at any point have a significantly higher risk for ECMO and mortality. Assessing PH within 2-6 h should be a primary goal in the care for CDH neonates.

Sex-Specific Differences in Congenital Diaphragmatic Hernia Mortality

To compare disease severity and mortality differences between female and male patients with congenital diaphragmatic hernia (CDH). We queried the CDH Study Group (CDHSG) database for CDH neonates managed between 2007 and 2018. Female and males were compared in statistical analyses using t tests, χ² tests, and Cox regression, as appropriate (P≤.05). There were 7288 CDH patients, of which 3048 (41.8%) were female. Females weighed less on average at birth than males (2.84kg vs 2.97kg, P<.001) despite comparable gestational age. Females had similar rates of extracorporeal life support (ECLS) utilization (27.8% vs 27.3%, P=.65). Although both cohorts had equivalent defect size and rates of patch repair, female patients had increased rates of intrathoracic liver herniation (49.2% vs 45.9%, P=.01) and pulmonary hypertension (PH) (86.6% vs 81.1%, P<.001). Females had lower survival rates at 30-days (77.3% vs 80.1%, P=.003) and overall lower survival to discharge (70.2% vs 74.2%, P<.001). Subgroup analysis revealed that increased mortality was significant among those who underwent repair but were never supported on ECLS (P=.005). On Cox regression analysis, female sex was independently associated with mortality (adjusted hazard ratio 1.32, P=.02). After controlling for the established prenatal and postnatal predictors of mortality, female sex remains independently associated with a higher risk of mortality in CDH. Further study into the underlying causes for sex-specific disparities in CDH outcomes is warranted.

Intrathoracic liver herniation after pericardial fenestration – a case report

BackgroundPericardial effusions with its potential life threatening progression towards cardiac tamponade have to be often managed with surgical intervention. In our case study we describe a complication after a common surgical procedure which has only scarce literature mentions.Case presentationWe present a case of a 22-year-old male patient who underwent subxiphoidal pericardial fenestration, due to symptomatic pericardial effusion with the Chamberlain procedure and biopsy of enlarged mediastinal lymph nodes. The histology report confirmed classical Hodgkin lymphoma and subsequently the patient underwent oncological treatment. Later on he was admitted to the hospital with dyspnoea and chest pain. The initial examinations stated a suspicion for intrathoracic tumour arising from the pericardium or liver. Further investigation revealed symptomatic intrathoracic liver herniation for which the patient underwent laparoscopic surgery with the mobilisation of liver and placement of a perforated Parietene™ composite mesh.ConclusionThe purpose of this case report is to describe a rare complication after pericardial fenestration with its potential clinical implications.

Risk Stratification by Percent Liver Herniation in Congenital Diaphragmatic Hernia

IntroductionCongenital diaphragmatic hernia is associated with pulmonary hypoplasia, pulmonary hypertension, and significant neonatal morbidity. Although intrathoracic liver herniation (LH) >20% is associated with adverse outcomes, the relationship between LH <20% and outcomes is poorly characterized. MethodsA single-center retrospective cohort study was performed from 2011 to 2020 of 80 fetuses with left-sided congenital diaphragmatic hernia that were delivered and repaired at our institution. Perinatal, perioperative, and postoperative data were collected. We evaluated the association of %LH with outcomes as a stratified ordinal variable (0%-10% LH, 10%-19% LH, and >20% LH) and as a continuous variable. Data were analyzed by analysis of variance with Bonferroni post hoc analysis, chi-square analyses, and univariate logistic regression. ResultsExtracorporeal membrane oxygenation (ECMO) (P < 0.001), repair on ECMO (P = 0.002), repair with patch (P < 0.001), length of stay (P = 0.002), inhaled nitric oxide use (P < 0.001), and sildenafil use at discharge (P < 0.001), showed significant differences among LH groups. There were no differences among the groups concerning survival (at discharge, 6 mo, and 1 y) and tracheostomy. On further analysis there was no difference between 10% and 19% LH and ≥20% LH patients concerning ECMO (P = 0.55), repair on ECMO (P = 0.54), repair with patch (P = 1.00), length of stay (P = 1.00), and inhaled nitric oxide use (P = 0.33). Logistic regression analysis displayed a significant association with LH and ECMO, repair on ECMO, repair with patch, inhaled nitric oxide use, and sildenafil use. ConclusionsOur analysis displays no significant difference in perinatal management between patients with 10%-19% and ≥20% LH. These findings suggest that the historical cutoff of ≥20% LH may not be sufficient alone to guide perinatal counseling and decision-making.

Long-Term Evaluation of Gastroesophageal Reflux in Neonates with and without Preventive Anti-reflux Surgery at the Time of Congenital Diaphragmatic Hernia Repair.

One potential comorbidity after congenital diaphragmatic hernia (CDH) is gastroesophageal reflux (GER), which can have a substantial effect on patients’ quality of life, thriving, and complications later in life. Efforts have been made to reduce gastroesophageal reflux with a preventive anti-reflux procedure at the time of CDH repair. In this follow-up study of neonates participating in a primary RCT study on preventive anti-reflux surgery, symptoms of GER were assessed longitudinally. Long-term data with a median follow-up time of ten years was available in 66 patients. Thirty-one neonates received an initial fundoplication. Secondary anti-reflux surgery was necessary in 18% and only in patients with large defects. It was required significantly more often in patients with intrathoracic herniation of liver (p = 0.015) and stomach (p = 0.019) and patch repair (p = 0.03). Liver herniation was the only independent risk factor identified in multivariate regression analysis. Primary fundopexy and hemifundoplication did not reveal a protective effect regarding the occurrence of GER symptoms, the need for secondary antireflux surgery or the gain of body weight regardless of defect size neither in the short nor in the long term. Symptoms of GER must be assessed carefully especially in children with large defects, as these are prone to require secondary anti-reflux surgery in the long-term. Routine evaluation of GER including endoscopy and impedance measurement should be recommended especially for high-risk patients.

Single-Center Outcome of Fetoscopic Tracheal Balloon Occlusion for Severe Congenital Diaphragmatic Hernia

(Obstet Gynecol. 2020;135:511–521) Congenital diaphragmatic hernia, caused by the absence of the diaphragm or part of the diaphragm, leads to impaired fetal lung development as the abdominal contents move into the chest cavity. This is commonly managed with high-frequency oscillatory ventilation, pulmonary vasodilators, and extracorporeal membrane oxygenation, but the survival rate is &lt;20% in cases with an observed lung/head ratio of &lt;25% and intrathoracic liver herniation. In temporary fetoscopic tracheal balloon occlusion (FETO), the lungs are stretched and increase growth in airways and lung vasculature takes place. FETO has demonstrated increased survival rates, but is also associated with adverse outcomes such as preterm labor, rupture of membranes, and preterm birth. This study aimed to determine feasibility of FETO in cases of severe congenital diaphragmatic hernia.

Longitudinal Follow-Up with Radiologic Imaging Is Essential for Detection of Recurrence in Patients with Congenital Diaphragmatic Hernia - Results from a Large Prospective Cohort-Study at a Single Referral Centre

Background: Congenital diaphragmatic hernia is a rare and still challenging malformation with long-term-morbidity gaining more importance. Recurrence is reported in up to 50% after patch-implantation. Previous studies are difficult to compare, because surgical techniques differ, most are retrospective and do neither offer longitudinal follow-up nor radiologic imaging to all survivors. This is a large prospective cohort-study from one institution with a standardized surgical treatment-algorithm and a structured long-term follow-up to allow a reliant detection of recurrence-rate and determination of risk-factors. Methods: Data was collected over 12 years with a minimal follow-up of two years. 508 neonates with congenital diaphragmatic hernia were treated, 410 patients survived, and 90% were followed longitudinally. Findings: In open surgery 68 patients received a primary repair and 251 a cone-shaped patch. Recurrence after open surgery occurred in three patients until discharge, in 28 children thereafter. Six patients developed re-recurrences. Overall 38 recurrences were diagnosed (24 ‘true’ recurrences, eight hiatal hernias, six combined recurrences). Recurrence-rate after primary repair was 8.8% and 12.7% after repair with a cone-shaped patch (p=0.53). Recurrence was significantly associated with initial defect-size. Independent risk-factors for recurrence were a left-sided defect, intrathoracic liver-herniation, and the need for an abdominal wall patch. Interpretation: Long-term-results after diaphragmatic reconstruction highly depend on surgical technique. A reduced recurrence-rate in open surgery can even be achieved in a referral centre with predominantly large defects by implantation of a cone-shaped patch. It is essential to follow all patients longitudinally with regular radiologic imaging – since most showed no or minimal symptoms (97%) and because 45% of recurrences were diagnosed beyond one year of age. Only longitudinal follow-up with radiologic imaging of all patients allows a reliant detection of recurrence to prevent acute incarceration and chronic failure to thrive with their impact on prognosis. Funding Statement: There was no funding for this study. Declaration of Interests: KBZ, TS, MW and CW do not disclose any financial or personal conflict of interests. LMW received personal fees for his work in the Advisory Board Shire (intestinal failure in children due to short bowel syndrome) and for his lecture on pediatric surgery in neonatology (Chiesi). Ethics Approval Statement: This study was approved by our local ethic committee and informed consent was obtained from parents.

Secondary Imaging Findings Aid in Prenatal Diagnosis and Characterization of Congenital Diaphragmatic Hernia: Role of an Abnormal Orientation of Vascular Structures and Gallbladder Position.

To determine whether an abnormal orientation of the abdominal or hepatic vasculature and an abnormal gallbladder position on prenatal ultrasound (US) imaging are associated with intrathoracic liver herniation and postnatal outcomes in cases of congenital diaphragmatic hernia (CDH). Children who underwent prenatal US examinations and postnatal CDH repair at our institution were eligible. Prenatal US images were reviewed, and the orientation of the superior mesenteric artery (SMA) and hepatic veins as well as gallbladder position were recorded. Findings were correlated with prenatal US measurements (lung-to-head ratio and calculated observed-to-expected lung-to-head ratio) and postnatal outcomes, including intrathoracic liver herniation, an extracorporeal membrane oxygenation (ECMO) requirement, and mortality. A total of 175 patients met inclusion criteria. The SMA was shown in 168 cases and had a cephalad orientation in 95.4% (161 of 168), which was not associated with outcome measures and represented bowel herniation. A cephalad orientation of the hepatic veins was identified in 52.6% (90 of 171) and was associated with intrathoracic liver herniation, an ECMO requirement, and mortality (P < .01). In right-sided CDH, the gallbladder was intrathoracic in 91.3% (21 of 23). In left-sided CDH, an abnormal gallbladder position was seen in 51.3% (76/152) and was associated with intrathoracic liver herniation, an ECMO requirement, mortality, and lower lung-to-head ratio and observed-to-expected lung-to-head ratio values. When combined, abnormal hepatic vein and gallbladder positions showed good sensitivity and specificity in predicting intrathoracic liver herniation (area under the curve, 0.93). Abnormal SMA, hepatic vein, and gallbladder positions can be used to improve prenatal characterization of CDH. Accurate depiction of these structures on prenatal US images may aid in patient counseling and postnatal management.

Clinical and echocardiographic risk factors for extubation failure in infants with congenital diaphragmatic hernia.

Infants after surgical correction of congenital diaphragmatic hernia are at high risk for extubation failure, but little is known about contributing factors. Therefore, our study aimed to analyze clinical and echocardiographic parameters. Data of 34 infants with congenital diaphragmatic hernia treated at our department (July 2013-December 2015) were analyzed. Inclusion criteria were: presence of congenital diaphragmatic hernia and echocardiography performed within 48hours before the first, and, in case of reintubation, the final extubation attempt. Infants were allocated to group A (extubation failure) and group B (extubation successful). Extubation failure occurred in 12/34 infants (35%). Infants in group A had a higher proportion of intrathoracic liver herniation (P=0.001, OR 17 [2.8/104.5]) and lower rates of the lung-to-head ratio (P=0.042, 95% CI [-0.4/20]), even as higher rates of extracorporeal membrane oxygenation (P=0.001, 95% CI [2.7/80.9]). The oxygenation index and the PaO2 /FiO2 ratio differed significantly between both groups (both P=0.000; 95% CI [-11/-4.1] and [79/215], respectively). The mean airway pressure and fraction of inspired oxygen prior to extubation was significantly higher in group A (P=0.008; 95% CI [-3.9/-1.4]; P=0.000; 95% CI [-0.6/-0.2], respectively). In addition, the respiratory severity score was higher in group A (P=0.000; 95% CI [-7.3/-2.6]). In group A, administration of sildenafil and the vasoactive inotropic score were significantly higher (P=0.037; OR 9 [0.9/88.6] and P=0.013; 95% CI [-14/-1.8], respectively). More infants in group A had need for a surgical patch repair of the diaphragm (P=0.017; OR 7.2 [1.3/41.1]) and showed higher rates of relevant pleural effusions prior the extubation (P=0.021; OR 6 [1.2/29.5]). The total duration of the ventilation and the length of hospital stay were longer in group A (P=0.004; 95% CI [-915/-190] and P=0.000; 95% CI [-110/-39], respectively). The prevalence of pulmonary hypertension was more frequent in group A (P=0.012; OR 12 [1.3/114]), the time to peak velocity in the main pulmonary artery was significantly lower in group A (P=0.024; 95% CI [2/25.6]), and these infants suffered more often from cardiac dysfunction (P=0.007; OR 10 [1.6/63.1]). Our results demonstrate that extubation failure in infants with a congenital diaphragmatic hernia is associated with several clinical and echocardiographic risk factors.

Three-dimensional assessment of umbilical vein deviation angle for prediction of liver herniation in left-sided congenital diaphragmatic hernia.

To introduce a new sonographic marker of intrathoracic liver herniation in fetuses with left-sided congenital diaphragmatic hernia (CDH). In a consecutive series of fetuses with isolated CDH, an ultrasound volume of the fetal abdomen was acquired. On this volume, offline calculation of the angle formed by the midline of the abdomen (joining the center of the vertebral body to the abdominal insertion of the umbilical cord) and a second line joining the center of the vertebral body to the intra-abdominal convexity of the umbilical vein was carried out to give the umbilical vein deviation angle (UVDA). The UVDA was measured in a group of normal fetuses selected as controls. At follow-up, the presence of liver herniation was investigated in all cases of CDH. UVDA values were compared between the CDH group and controls, and between CDH 'liver-up' vs 'liver-down' cases. A receiver-operating characteristics (ROC) curve was constructed to identify a cut-off value of the UVDA with the highest accuracy in predicting liver herniation in the CDH group. Between 2009 and 2015, 22 cases of left-sided CDH were included in the study group, of which nine cases had liver herniation. Eighty-eight normal fetuses were recruited as controls. The UVDA was significantly higher in the cases vs controls (15.25 ± 7.91° vs 7.68 ± 1.55°; P < 0.0001). Moreover, the UVDA was significantly increased in CDH fetuses with liver-up vs liver-down (21.77 ± 8.79° vs 10.75 ± 2.10°; P < 0.0001). On ROC curve analysis the UVDA showed good prediction of liver herniation (area under the ROC curve, 0.94; P < 0.0001) with the best cut-off of 15.2°, yielding a sensitivity of 89% and a specificity of 100% (P < 0.0001). In fetuses with CDH, umbilical vein bowing may be quantified by measuring the UVDA using three-dimensional ultrasound. This sonographic marker seems to be an accurate predictor of liver herniation in left-sided CDH. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Congenital diaphragmatic hernia: outcomes of neonates treated at Mayo Clinic with and without extracorporeal membrane oxygenation.

Congenital diaphragmatic hernia (CDH) is a rare anomaly with high mortality and long-term comorbid conditions. Our aim was to describe the presenting characteristics, treatment, and outcomes of consecutive patients with CDH treated at our institution. We performed a retrospective cohort study and identified consecutive neonates treated for CDH from 2001 to 2015 at our institution. For all patients identified, we reviewed hospital and postdischarge data for neonatal, disease, and treatment characteristics. We determined hospital survival overall and also according to the presence of prenatal diagnosis, liver herniation into the chest (liver up), and the use of extracorporeal membrane oxygenation (ECMO) in addition to surgery. We evaluated postdischarge chronic conditions in patients with at least one year of follow-up. Thirty-eight neonates were admitted for treatment during the study period. In three who were in extremis, life support was withdrawn. The other 35 underwent surgical repair, of whom eight received ECMO. The overall survival was 79% (30/38). Survival for those who had surgical correction of CDH but did not need ECMO was 89% (24/27); it was 75% (6/8) for those who received ECMO and had surgery. Hospital survival was lower for liver-up vs liver-down CDH (61% [11/18] vs 95% [19/20]; odds ratio, 0.08; 95% CI, 0.01-0.77; P = 0.01). Among survivors, the median duration of hospitalization was 31 (interquartile range, 20-73) days. Major chronic pulmonary and gastrointestinal disorders, failure to thrive, and neurodevelopmental delays were the most noted comorbid conditions after discharge, and all were more prevalent in those who required ECMO. The overall survival of neonates with CDH was 79%. Intrathoracic liver herniation was associated with more frequent use of ECMO and greater mortality. A substantial number of survivors, especially those who required ECMO, experienced chronic conditions after discharge.

Hernia Sac Presence Portends Better Survivability of Isolated Congenital Diaphragmatic Hernia with "Liver-Up".

Objective The objective of this study was to investigate the prognostic value of a hernia sac in isolated congenital diaphragmatic hernia (CDH) with intrathoracic liver herniation ("liver-up"). Study Design A retrospective study from the single tertiary center. Isolated "liver-up" CDH neonates referred to our institution between 2000 and 2015 were reviewed for the presence or absence of a hernia sac. Association between the presence of a hernia sac and survival was assessed. Results Over the study period, there were 29 isolated CDH patients with "liver-up" who were treated, 7 (24%) had a sac, and 22 (76%) did not. Demographics were similar between groups. However, disease acuity, assessed from lower Apgar scores (p = 0.044), lower probability of survival (p = 0.037), and lower admission oxygenation (p = 0.027), was higher in neonates without a sac. Hospital survival was significantly higher for those with sac compared with those without (7/7, 100 vs. 7/22, 32%, p = 0.002). Conclusion The presence of a hernia sac may be associated with better survival for isolated "liver-up" CDH. As the presence of sac can be prenatally detected, it may be a useful marker to aid perinatal decision making.

Antenatal assessment of liver position, rather than lung-to-head ratio (LHR) or observed/expected LHR, is predictive of outcome in fetuses with isolated left-sided congenital diaphragmatic hernia

Objectives: Respiratory morbidity in congenital diaphragmatic hernia (CDH) is associated with high mortality and adverse outcome. Accurate prenatal diagnosis is essential for prognosis and potential treatment in utero. The aim was to evaluate the prenatal ultrasound findings in assessing the respiratory prognosis in fetuses with isolated left-sided CDH.Methods: We retrospectively analyzed the medical records of 59 prenatally diagnosed left-sided CDH cases managed at a tertiary perinatal center.Results: Survival rate in the study group was 73% (43/59). We found no statistically significant relationship between survival and the presence of polyhydramnios, gestational age at diagnosis, lung-to-head ratio (LHR) and observed/expected LHR (O/E LHR) values, gestational age at birth and birth weight. Intrathoracic liver herniation was a statistically significant parameter adversely affecting survival (37.2% in survivors, 68.8% in non-survivors, p = 0.031) and logistic regression confirmed this relationship. The presence of pneumothorax and severe pulmonary hypertension were significantly associated with mortality (82% non-survivors versus 15% in survivors, p = 0.0001).Conclusion: Intrathoracic liver herniation seems to be a reliable parameter in the prediction of survival and neonatal respiratory morbidity in fetuses with isolated left-sided CDH. In contrast, we found no significant correlation between perinatal outcome and LHR, O/E LHR values, birth weight and gestational age.

Right sided traumatic diaphragmatic hernia repair with intrathoracic herniation of liver, stomach and transverse colon

Traumatic rupture of the right dome of the diaphragm is an uncommon clinical entity. The diagnosis is difficult due to lack of specificity in clinical signs and chest film findings. Clinical incidence of rupture of the right dome of the diaphragm due to blunt trauma is much less common (10%) compared to the left (90%) and usually associated with more grievous injuries with very high pre hospital mortality thus accounting for rare clinical diagnosis. We report a case of 26year old male who had the blunt trauma chest referred to us after 7days of injury with complaints of shortness of breath and vomiting. On investigations the patient was diagnosed as a case of the ruptured right dome of the diaphragm with intrathoracic herniation of the stomach. The patient also had fracture pelvis. Surgical exploration was done through right 6th intercostal space which revealed intrathoracic herniation of the stomach, liver and transverse colon, which were healthy. Contents reduced into the abdomen and diaphragm was repaired. Post operative chest X-ray suggested complete expansion of the right lung with no residual herniation of abdominal contents. Post operative recovery was uneventful with the patient discharged on 14th post operative day.

Association of Intrathoracic Herniation of the Liver with Left Heart Hypoplasia in Fetuses with a Left Diaphragmatic Hernia but not in Fetuses with a Right Diaphragmatic Hernia

Predominant left heart hypoplasia is commonly observed in human fetuses with left diaphragmatic hernia and intrathoracic liver herniation ("liver-up"). In contrast, marked left/right heart disproportion has not been described in fetuses with right diaphragmatic hernia, despite intrathoracic herniation of large parts of the liver. We analyzed the data of 15 fetuses with left diaphragmatic hernia and 10 fetuses with right diaphragmatic hernia and all with intrathoracic liver herniation ("liver-up") that were examined with fetal echocardiography between 21 weeks + 1 day and 35 weeks + 0 days of gestation. The inflow and outflow dimensions and Z-scores of the two groups were statistically compared. In addition, ductus venosus streaming patterns were examined. Despite the presence of intrathoracic liver herniation, predominant left heart hypoplasia, defined as a mitral valve Z-score < - 2 in combination with a tricuspid valve Z-score that was at least 2 Z larger than the mitral valve Z-score in an individual fetus, was observed in 11 of the 15 fetuses with left diaphragmatic hernia but in none of the 10 fetuses (p < 0.001) with right diaphragmatic hernia. Preferential streaming to the right heart was observed in 14 of the 15 fetuses with left hernia but in none of the 7 fetuses with right diaphragmatic hernia in whom this flow information was available (p < 0.0001). Intrathoracic herniation of the liver ("liver-up") is associated with predominant left heart hypoplasia in left diaphragmatic hernia but not right fetal diaphragmatic hernia. Our observations indicate that this difference may result from different ductus venosus streaming sites in these conditions.

Intrathoracic Herniation of the Liver ("Liver-Up") is Associated with Predominant Left Heart Hypoplasia in Left but not Right Fetal Diaphragmatic Hernia

Predominant left heart hypoplasia is commonly observed in human fetuses with left diaphragmatic hernia and intrathoracic liver herniation (“liver-up”). In contrast, marked left/right heart dysproportion has not been described in fetuses with right diaphragmatic hernia, despite intrathoracic herniation of large parts of their liver.

Laparoscopic repair of intrathoracic liver herniation after traumatic rupture of the diaphragm

Right diaphragmatic hernia after abdominal trauma is a rare injury. Most patients can be asymptomatic, and the diagnosis may be delayed for several years. The treatment of choice involves surgical repair via laparotomy. The authors treated a young patient with transdiaphragmatic herniation of the right hepatic lobe and delayed diagnosis using a laparoscopic approach and accomplished a successful complete repair. The 6-month radiologic follow-up assessment confirmed good results.

Intrathoracic herniation of the liver (‘liver‐up’) is associated with predominant left heart hypoplasia in human fetuses with left diaphragmatic hernia

Left heart hypoplasia is commonly observed in fetuses with left diaphragmatic hernia. Because in this condition intrathoracic herniation of the liver serves as an important predictor for postnatal disease severity, we studied its potential association with left heart hypoplasia. We prospectively assessed 32 fetuses with left diaphragmatic hernia between 19 + 6 and 38 + 6 weeks of gestation using echocardiography. The fetuses were divided into two groups: Group I exhibited an intrathoracic liver position ('liver-up') and Group II an intra-abdominal liver position ('liver-down'). Cardiac inflow and outflow diameter ratios and cardiac Z-scores were compared between the two groups. Eleven of the 15 Group I (liver-up) fetuses, but only three of the 17 Group II (liver-down) fetuses with left diaphragmatic hernia exhibited predominant left heart hypoplasia with disproportionately smaller left than right heart dimensions (P = 0.0036). In addition, 14 of the 15 Group I fetuses, but only five of the 17 Group II fetuses exhibited preferential streaming of the ductus venosus towards the right heart (P = 0.0003). In fetuses with left diaphragmatic hernia, intrathoracic liver herniation is commonly associated with predominant left heart hypoplasia, whereas an intra-abdominal liver position is not. This observation may be explained by preferential ductus venosus streaming towards the right heart from elevation and leftward distortion of the normal course of the ductus venosus and inferior vena cava.

Repair of right sided Traumatic Diaphragmatic Hernia with intrathoracic herniation of liver and a segment of ruptured jejunum—a case report and review of literature

We present this rare case of a 24 year old male who was knocked down by a slowly backing truck when the rear wheels climbed on to the right side of the abdomen and on hearing the shouts of people rolled forwards causing a partial run over injury. He was resuscitated and treated conservatively. An X Ray Chest done 24 h later showed right sided chest wall fracture, right basilar opacity suggesting chest injury with localized haemothorax/pulmonary contusion and a chest tube was inserted through Rt. 5th intercostal space. Initially some blood came out. But on the third day bile was seen coming out of the intercostal drain prompting a diagnosis of traumatic rupture of diaphragm with liver injury. A Magnetic Resonance Imaging (MRI) scan was done when the diagnosis of ruptured right dome of diaphragm with Traumatic Diaphragmatic Hernia (TDH) with herniation of liver into the right hemithorax was made. Surgical exploration on the 4th day through right thoraco- abdominal approach confirmed TDH with herniated liver into the right hemithorax without any injury to the liver, hepatic blood vessels or the bile ducts but an unsuspected rupture in a herniated loop of jejunum wedged into the right hemithorax anterior to the liver with biliary discharge into the right hemithorax but without any peritoneal soiling. Repair was done by resection anastomosis of the ruptured jejunum, reduction of the liver into the abdomen, suturing of the torn diaphragm effectively obliterating the hernia orifice and reinforcing it with a polypropylene mesh anchored to the chest wall. There was a stormy post operative phase involving burst thorax which was corrected by re-exploration of the thoracic portion of the thoraco abdominal wound, wound toileting and resutured. The wound healed after 2 months. The patient is doing well after 20 months of follow up.

Preferential ductus venosus streaming towards the right side of the heart may contribute to poorer outcomes in fetuses with left diaphragmatic hernia and intrathoracic liver herniation (‘liver‐up’)

Preferential ductus venosus streaming towards the right side of the heart may contribute to poorer outcomes in fetuses with left diaphragmatic hernia and intrathoracic liver herniation (‘liver‐up’)