RESUMO

INTRODUCTION: Congenital diaphragmatic hernia (CDH) remains a therapeutic challenge. The surgical classification recommended by the Congenital Diaphragmatic Hernia study group (CDHSG), based on the size of the defect, is used for staging in reference centres. Larger defects are associated with poorer outcomes. Our aim was to describe and compare the morbidity at hospital discharge of newborns who underwent surgical correction of CDH at the Juan P. Garrahan, according to the surgical staging of the defect proposed by the CDHSG. MATERIAL AND METHODS: The study included patients with CDH admitted to the Juan P. Garrahan Hospital between 2012 and 2020, and we analysed the distribution, morbidity and mortality associated with the size of the defect. We carried out a descriptive analysis, calculating measures of central tendency and dispersion, and bivariate and multivariate analyses. RESULTS: A total of 230 patients with CDH were admitted and 158 underwent surgery. We found that defect sizes C and D sizes were associated with an increased risk of chronic pulmonary disease (CPD) (OR, 5.3; 95% CI, 2.2-13.4; P<.0000), need of extracorporeal membrane oxygenation (OR 3.9; 95% CI, 1.3-12.8; P<.005) and chylothorax (OR, 2.1; 95% CI, 0.8-6.4; P<.10]. The multivariate analysis revealed that a large defect size (C-D) was independently and significantly associated with CPD (OR 4.19; 95% CI, 1.76-9.95). CONCLUSION: Staging the defect according to de CDHSG classification during surgery allows the application of uniform management criteria and the prediction of patient outcomes and complications during the hospital stay.

Assuntos

RESUMO

La hernia diafragmática congénita es una discontinuidad del diafragma con herniación de los órganos abdominales a la cavidad torácica, actualmente se postula una hipótesis dual para su origen. Su fisiopatología está determinada por la hipoplasia pulmonar, la hipertensión pulmonar y la disfunción ventricular, entender estos elementos es necesario para un adecuado manejo y la mejoría del pronóstico.

Congenital diaphragmatic hernia is a discontinuity of the diaphragm with herniation of the abdominal organs into the thoracic cavity, currently a dual hypothesis for its origin is postulated. Its pathophysiology is determined by pulmonary hypoplasia, pulmonary hypertension and ventricular dysfunction, understanding these elements is necessary for adequate management and improve prognosis.

Assuntos

RESUMO

Resumen Una hernia diafragmática congénita ocurre cuando existe un defecto estructural en el diafragma que permite la migración de los órganos abdominales a la cavidad torácica. Se considera de presentación tardía cuando se diagnostica después de los 30 días de vida extrauterina. Más del 60% de los pacientes con hernia diafragmática congénita cuentan con un diagnóstico erróneo al momento del nacimiento, encontrándose dentro de los diagnósticos más frecuentes al derrame pleural, neumonía, neumotórax, neumatocele y absceso pulmonar. Presentamos el caso de una paciente del sexo femenino de 3 años que acudió a urgencias por dolor abdominal, náuseas, vómito, intolerancia a la vía oral y dificultad respiratoria. La radiografía de tórax evidenció migración de la cámara gástrica hacia el tórax, dessplazamiento de la silueta cardiaca y las estructuras del mediastino hacia la derecha con la punta de la sonda nasogástrica ubicada en el hemitórax izquierdo. Se concluyó el diagnóstico de hernia diafragmática de presentación tardía. La paciente recibió tratamiento quirúrgico, el cual fue exitoso. Este trabajo destaca la importancia de sospechar el diagnóstico de hernia diafragmática congénita de presentación tardía cuando se abordan pacientes pediátricos con dificultad respiratoria sin otra causa aparente, dolor abdominal, náuseas y vómito.

Abstract A congenital diaphragmatic hernia occurs when the diaphragm has a structural defect that allows the migration of abdominal organs into the chest cavity. It is called late presentation when its diagnosis does after 30 days of life. More than 60% of patients with congenital diaphragmatic hernia are misdiagnosed. The most common misdiagnoses are pleural effusion, pneumonia, pneumothorax, pneuma tocele, and lung abscess. We present a case of a 3-year-old female who attended the emergency room due to abdominal pain, nausea, vomiting, intolerance to the oral route, and respiratory distress. The chest X-ray showed migration of the gastric chamber towards the thorax, displacement of the cardiac silhouette and the mediastinal structures to the right, and the tip of the nasogastric tube located in the left hemithorax. The doctors concluded a late presentation diaphragmatic hernia. The patient received surgical treatment, which was successful. This paper highlights the importance of suspecting the diagnosis of late-onset congenital diaphragmatic hernia when treating pediatric patients with respiratory distress without another apparent cause, abdominal pain, nausea, and vomiting.

RESUMO

Background: Peritoneopericardial diaphragmatic hernia is a rare pathogenesis of congenital origin, which occurs due to a failure in the communication between the diaphragm and the pericardium during embryogenesis. Symptoms may be non-existent or non-specific, depending on the herniated organ involved and, in most cases, the diagnosis is incidental. Regarding the most indicated treatment, there are still divergences in the literature concerning the indication of conservative or surgical treatment. This study reports the case of a feline peritoneopericardial hernia, for which surgical correction was the treatment of choice. Case: A 3-month-old female kitten, no defined racial pattern, was referred to the Veterinary Hospital of the Federal Rural University of Pernambuco for treatment of a peritoneopericardial diaphragmatic hernia. This condition was diagnosed through radiographic examination after the patient having been submitted to pediatric castration and presented anesthetic complications in the transsurgery. Blood count, biochemical profile and Doppler echocardiogram were performed, which showed no significant changes. To obtain a better study and surgical planning, computed tomography was performed to observe the heart located cranially in the pericardial cavity. Caudally to the heart, hepatic parenchyma located in the pericardial cavity was observed; and hepatic vessels presenting slightly enlarged dimensions. These tomographic findings suggested peritoneopericardial diaphragmatic hernia; being the liver present in the pericardial cavity and signs of congestion in the hepatic parenchyma. Due to the likelihood of future worsening of the hernia, surgical correction was performed, with an abdominal midline incision in the preumbilical region to reposition the liver to its normal anatomy, followed by diaphragm reconstitution through a herniorrhaphy. After the surgical procedure, the patient was referred for observation in internment and, after 15 days, the skin sutures were removed. Complete correction of the hernial defect was observed on radiography performed 30 days after the surgical procedure. However, the examination showed the presence of deviation/ deformity in the topography of the sternum and costal cartilages, with slight cardiac displacement to the right hemithorax, suggesting the presence of pectus excavatum. Discussion: Peritoneopericardial diaphragmatic hernia is considered rare and, despite being one of the most common causes of congenital pericardial anomaly in felines, it has a low prevalence ranging from 0.06% to 1.45%. They are usually diagnosed from two years of age, with prevalence for older animals. However, due to having presented anesthetic changes, the patient of this case report could be diagnosed early. Among the most common organs that migrate to the thoracic cavity, the liver is the most commonly observed, which is also the hernia content of the present report. Peritoneopericardial hernia is often diagnosed through radiography and ultrasound, and these imaging tests proved to be sufficient for the diagnosis in this report. However, computed tomography was important for providing a better study of case and for the adoption of median celiotomy as a treatment. Associations with other malformations are described in the literature, with pectus excavatum being the most common and also observed in this report. Peritoneopericardial diaphragmatic hernia is a rare anomaly, rarely reported in the literature and with divergences regarding its treatment. The adoption of early surgical treatment performed in this report showed satisfactory evolution and the possibility of a favorable prognosis.

Assuntos

RESUMO

Introducción: La hernia diafragmática surge como resultado del movimiento de los órganos abdominales hacia el tórax a través de un defecto del diafragma resultante de varios tipos de lesiones, que a menudo representan un desafío diagnóstico y terapéutico. La hernia diafragmática traumática es una enfermedad infrecuente. El trauma diafragmático rara vez es aislado, la mayoría de las veces se acompaña de otras lesiones toracoabdominales, cerebrales o musculoesqueléticas, siendo estas comorbilidades más graves responsables del mal pronóstico y aumento de la mortalidad. Caso clínico: Anciana de 90 años de edad, hipertensa, quien inicia cuadro clínico 48 horas previas a su ingreso, cuando posterior a caída del plano de bipedestación presenta disminución del estado de consciencia, náuseas, vómitos y disnea en reposo. Rx de tórax evidencia asas intestinales en hemitórax derecho. Se realizó laparotomía exploradora. Conclusión: Las hernias diafragmáticas traumáticas son infrecuentes, con incidencia <3%, sintomatología inespecífica y relacionadas generalmente con lesiones asociadas al trauma. Siempre se debe sospechar de una HD ante un paciente con antecedente de trauma cerrado de alto impacto o penetrante, en función de la cinética y mecanismo de lesión. El diagnóstico supone un reto para el cirujano, debiendo apoyarse en una firme sospecha y estudios radiológicos. Su tratamiento es quirúrgico, debiendo ser individualizado, con abordajes torácicos o abdominales en función del caso. La técnica a emplear dependerá de las características del defecto, de la fase del diagnóstico y la experiencia del equipo quirúrgico(AU)

Introduction: Diaphragmatic hernia arises as a result of the movement of the abdominal organs towards the thorax through a defect in the diaphragm resulting from various types of injuries, which often represent a diagnostic and therapeutic challenge. Traumatic diaphragmatic hernia is a rare disease. Diaphragmatic trauma is rarely isolated, most of the time it is accompanied by other thoracoabdominal, brain or musculoskeletal injuries, these more serious comorbidities being responsible for the poor prognosis and increased mortality. Clinical case: A 90-year-old woman with hypertension , who began a clinical picture 48 hours prior to admission, when after falling from the standing plane he presented a decreased state of consciousness, nausea, vomiting, and dyspnea at rest. Chest x-ray shows intestinal loops in the right hemithorax. Exploratory laparotomy was performed. Conclusion: Traumatic diaphragmatic hernias are rare, with an incidence of <3%, non-specific symptoms, and generally related to injuries associated with trauma. HD should always be suspected in a patient with a history of high-impact or penetrating blunt trauma, depending on the kinetics and mechanism of injury. Diagnosis is a challenge for the surgeon, and must be based on a firm suspicion and radiological studies. Its treatment is surgical, and must be individualized, with thoracic or abdominal approaches depending on the case. The technique to be used will depend on the characteristics of the defect, the diagnostic phase and the experience of the surgical team(AU)

Assuntos

RESUMO

Se presenta un caso clínico de diagnóstico ecográfico de hernia diafragmática realizado a partir de signos de sospecha. La paciente se presenta a control prenatal cursando 18 semanas de gestación, donde se visualiza alteración de la posición de la silueta cardiaca y cambios en la ecogenicidad en el campo pulmonar izquierdo. Se evalúan los signos pronósticos de las hernias diafragmáticas como la presencia de estómago e hígado en tórax y se calcula el índice pulmóncabeza ( LHR). En el presente caso el LHR arrojo un valor de 2,3 %, lo cual indica un buen pronóstico ya que el LHR mayor a 1,4 % se asocia a 93 % de posibilidades de sobrevivir

A clinical case of ultrasound diagnosis of diaphragmatic hernia performed from signs of suspicion is presented. The patient is presented to prenatal control studying 18 weeks gestation, where alteration of the position of the cardiac silhouette and changes in ecogenicity in the left pulmonary field is displayed. The prognostic signs of diaphragmatic hernias such as the presence of stomach and thorax liver and the lung-headed index (LHR) are evaluated. In the present case, the LHR shows a value of 2.3 %, which indicates a good prognosis since the LHR greater than 1.4 % is associated with 93 % possibilities to survive

Assuntos

RESUMO

RESUMEN La hernia diafragmática traumática se define como el paso del contenido abdominal a la cavidad torácica a través de un defecto en el diafragma producido por un trauma. Su diagnóstico es difícil, a menudo puede pasar inadvertido, debido a la gravedad de las lesiones que le acompañan. Las claves para el diagnóstico son un alto grado de sospecha y el conocimiento de los distintos signos en la tomografía computarizada. Una vez diagnosticada la ruptura diafragmática, se repara quirúrgicamente para evitar complicaciones. Se presenta el caso de un paciente masculino, de 88 años de edad con antecedentes de haber sufrido trauma toracoabdominal cerrado hacía 35 años, que acudió con un cuadro clínico de oclusión intestinal. Se publica este caso porque, además de ser una entidad poco frecuente, resulta importante el conocimiento de esta enfermedad, para valorarla dentro de las posibilidades diagnósticas en aquellos pacientes que aquejen síntomas relacionados con sus complicaciones.

ABSTRACT Traumatic diaphragmatic hernia is defined as the passage of abdominal contents into the thoracic cavity through a defect in the diaphragm caused by trauma. The diagnosis of traumatic diaphragmatic hernia is difficult, it can often go unnoticed, due to the seriousness of the accompanying injuries. The keys to diagnosis are a high degree of suspicion and knowledge of the various signs on computed tomography. Once the diaphragmatic rupture is diagnosed, it is surgically repaired in order to avoid complications. The case of an 88-year-old male patient with a history of having suffered closed thoracoabdominal trauma 35 years earlier, who presented with a clinical picture of intestinal obstruction is presented. This case is published because, in addition to being a rare entity, knowledge of this disease is important, in order to assess it within the diagnostic possibilities, in those patients who suffer from symptoms related to its complications

RESUMO

ABSTRACT Introduction: diaphragmatic injury is a challenge for surgeons. It is an injury that can be isolated. It is frequent in penetrating thoracoabdominal trauma. It represents a diagnostic challenge and the ideal approach is not yet well established. The occurrence of spontaneous healing of these injuries is still much discussed and even more, if it does, what is the healing mechanism? Objective: to macroscopically and histologically evaluate the natural evolution of perforation and cutting wounds equivalent to 30% of the left diaphragm. Method: 50 specimens of rats underwent a surgical procedure and, after 30 days, were euthanized and those that presented scar tissue in the diaphragm, the samples were submitted to histopathological study, using the hematoxylin and eosin stains, Massons trichrome and Picrosirius to assess the presence of collagen or muscle fibers (hyperplasia) in the scar. Results: it was found that healing occurred in diaphragmatic injuries in 90% of rats. We also observed the presence of fibrosis in all analyzed samples. Conclusion: Spontaneous healing occurred in most diaphragmatic injuries and the inflammatory reaction represented by the presence of fibrosis and collagen deposition was observed in all our samples. Muscle fiber hyperplasia did not occur.

RESUMO Introdução: o ferimento diafragmático é um desafio para os cirurgiões. É uma lesão que pode ser isolada. É frequente nos traumas penetrantes toracoabdominais. Representa um desafio diagnóstico e a conduta ideal ainda não está bem estabelecida. A ocorrência da cicatrização espontânea dessas lesões é ainda muito discutida e mais ainda, se ocorre, qual o mecanismo de cicatrização? Objetivo: avaliar macroscopicamente e histologicamente a evolução natural das feridas perfuro cortantes equivalentes a 30% do diafragma esquerdo. Método: 50 espécimes de ratos, foram submetidos a procedimento cirúrgico e, após 30 dias, foram submetidos à eutanásia e aqueles que apresentaram tecido cicatricial no diafragma, as amostras foram submetidas a estudo histopatológico, usando as colorações de hematoxilina e eosina, tricrômico de Masson e Picrossirius para avaliar a presença de colágeno ou de fibras musculares (hiperplasia) na cicatriz. Resultados: verificou-se que ocorreu nas lesões diafragmáticas, a cicatrização em 90% dos ratos. Observamos também, a presença de fibrose em todas as amostras analisadas. Conclusão: ocorreu cicatrização espontânea na maioria das lesões diafragmáticas e a reação inflamatória representada pela presença de fibrose e deposição de colágeno foi observada em todas as nossas amostras. Não ocorreu hiperplasia de fibras musculares.

RESUMO

Resumen La hernia diafragmática congénita es un defecto en la formación del diafragma con una alta mortalidad y morbilidad para el recién nacido. La ubicación en el lado derecho corresponde a solo el 10% de todos los casos y se asocia con una menor supervivencia, especialmente cuando hay una herniación hepática. No se conoce con precisión el porcentaje de casos de hernia diafragmática congénita derecha que no implican una herniación hepática. Aun no hay certeza del tiempo estimado para obtener el mayor beneficio de la corrección quirúrgica, en nuestro caso realizado con éxito a los 2 días de vida, logrando previamente una adecuada estabilidad hemodinámica y ventilatoria. El manejo perioperatorio en unidad de cuidado intensivo neonatal, es fundamental para reducir la morbimortalidad asociada. Se presenta un caso de hernia diafragmática congénita derecha tratado con éxito y se exponen los aspectos más relevantes del manejo médico-quirúrgico de esta patología. MÉD.UIS.2021;34(3): 71-7.

Abstract Congenital diaphragmatic hernia is a congenital defect in the formation of the diaphragm with high mortality and morbidity for the newborn. The location on the right side corresponds to only 10% of all cases and is associated with a lower survival, especially when there is a liver herniation. The percentage of cases of right congenital diaphragmatic hernia that do not involve liver herniation is not known with precision. An estimated time to obtain the greatest benefit from surgical correction is not known with certainty, in our case it was carried out successfully at 2 days of life, previously achieving adequate hemodynamic and ventilatory stability. Perioperative management in the neonatal intensive care unit is essential to reduce the associated morbidity and mortality. A case of congenital right diaphragmatic hernia treated successfully is presented and the most relevant aspects of the medical-surgical management of this pathology are exposed. MÉD. UIS.2021;34(3): 71-7.

Assuntos

RESUMO

Introducción: La hernia diafragmática traumática es una complicación grave del traumatismo abdominal o torácico. Se considera una entidad poco frecuente. El diagnóstico es difícil y, a menudo, puede pasar inadvertido. Objetivo: El propósito de este caso clínico es demostrar la necesidad de sospechar la presencia de hernia diafragmática en los pacientes con trauma toracoabdomial. Presentación del Caso: Paciente de 75 años que sufre accidente de tránsito, con evaluación inicial sin alteraciones clínico-radiológicas, que posteriormente presentan evolución desfavorable con hallazgo radiográfico de una hernia diafragmática traumática. Conclusiones: La hernia diafragmática cuando se presenta constituye un verdadero reto para el diagnóstico por parte del personal médico; pues esta requiere de un alto índice de sospecha y el uso adecuado de las imágenes diagnósticas. Se considera una entidad importante para la evaluación del paciente traumatizado(AU)

Introduction: Traumatic diaphragmatic hernia is a serious complication of abdominal or thoracic trauma. It is considered a rare pathology. The diagnosis is difficult and can often go unnoticed. Objective: The purpose of this clinical case is to demonstrate the need to suspect the presence of diaphragmatic hernia in patients with thoracoabdomial trauma. Case Presentation: Seventy-five-year-old patient who suffers a traffic accident. At initial evaluation no clinical-radiological alterations were observed, but later the patient presented an unfavorable evolution with radiographic finding of a traumatic diaphragmatic hernia. Conclusions: Diaphragmatic hernia, when present, is a real challenge for the diagnosis by the medical staff since it requires a high index of suspicion and an adequate use of diagnostic images. It is considered an important entity in the evaluation of the trauma patient(AU)

Assuntos