Congenital diaphragmatic hernia and chromosomal abnormalities: report of a lethal association

Congenital diaphragmatic hernia carries a high mortality which is often the consequence of associated anomalies. A chromosomal abnormality of the long arm of chromosome 8 resulted in a fatal combination of anomalies associated with CDH.     

Laparoscopic repair of chronic traumatic diaphragmatic hernia: case report and review of the literature

This study compared the efficacy and tolerability of nisoldipine coat core (CC) 10-40 mg o.d. and hydrochlorothiazide (HCTZ) 25-50 mg o.d. Patients with mild-to-moderate essential hypertension received either nisoldipine CC 10 mg o.d. or HCTZ 25 mg o.d. Treatment was titrated at two-weekly intervals as necessary. The primary efficacy endpoint was a defined reduction in diastolic blood pressure (DBP). Response rates were similar for both the nisoldipine CC- and HCTZ-treated groups (74% and 70%, respectively). Secondary efficacy endpoints were reductions in both diastolic and systolic blood pressures (SBP). At treatment endpoint, the change from baseline in SBP was 16.2 mmHg for the nisoldipine CC group and 14.9 mmHg for the HCTZ group. Both drugs were well tolerated, and adverse events were generally minor and typical of these antihypertensive agents. Drug-related adverse events were greater in the nisoldipine CC- than the HCTZ-treated patients (50% and 37%, respectively). Nisoldipine CC was shown to demonstrate antihypertensive efficacy similar to HCTZ in the treatment of mild-to-moderate hypertension.     

Renal cyst rupture following blunt abdominal trauma: case report

HLA typing was performed on 18 patients suffering from sarcoidosis and 30 patients suffering from diffuse interstitial pulmonary fibrosis. One hundred normal healthy people ethnically matched served as the controls. On statistical analysis, the corrected 'p' value of all the HLA antigens for both the patient groups was non significant. The results therefore suggest that there is no particular HLA antigen associated with sarcoidosis and diffuse interstitial pulmonary fibrosis.     

Jejunum perforation following blunt abdominal trauma--a case report

We describe an intestinal perforation in a football player who had been hit with the knee in the abdomen. Perforation of the small bowel, following blunt abdominal trauma, is relatively rare. Its most frequent cause is a deceleration trauma, usually from a traffic accident. Clinical signs are frequently discrete and nonspecific. The most frequent symptom is abdominal pain. Lack of bowel sounds is reported in 64% oft the cases. Enteric lesions should be suspected in the presence of a corresponding history (deceleration trauma) and of other pathologies (fractures of vertebrae and/or pelvis). Sonography and computed tomography are rarely helpful. Delayed perforations have been described, necessitating prolonged observation for 48 to 72 h. after painful abdominal trauma. Repeated examinations are essential to rule out enteric perforation. Initially, less than 50% of the cases show free air, thus limiting the usefulness of thoracic and abdominal radiography. Mortality reaches 30%. This rate is adversely affected by concomitant lesions in other organs and by delay (more than 10 h.) in diagnosis. When laparotomy has been delayed and peritonitis is present, antibiotic treatment should be started immediately during surgical intervention (cephalosporin, aminoglycoside, metronidazole). Postoperative complications include septicaemia, wound infection and, rarely, enterocutaneous fistulae.     

Acute traumatic abdominal hernia: case reports

Traumatic abdominal hernia is a rare injury with most reports documenting only one or two such cases. We describe five cases that were recognized during a 22-year period at a single trauma center. Physical examination often revealed abdominal wall tenderness and ecchymosis, but confirmation of hernia required additional testing in four of five patients. Two patients sustained muscle avulsion from the iliac crest which was likely a result of obesity and high riding seatbelts. In three of the patients a computed tomographic scan of the abdomen was instrumental in making the diagnosis. Surgical repair of the hernia was accomplished in three patients. The other two patients were managed nonsurgically. This report documents that an individualized approach to these patients is appropriate. Diagnosis may be difficult and immediate surgery does not prevent late sequelae. Management guidelines based upon a review of the English language literature on traumatic abdominal wall hernias are presented.     

Intestinal obstruction as late presentation of traumatic diaphragmatic hernia: report of a case and review of the literature

Until recently, tumours involving the pelvis were usually treated by hemipelvectomy, otherwise called "hindquarter amputation". A more recent approach of treating these tumours is the 'conservative hemipelvectomy', which consists of removing the tumour and sparing the lower extremity. A patient with Ewing's sarcoma of the pelvis underwent such a procedure. The femoral head was fixed temporarily to the remaining parts of the acetabulum and the iliac wing by a Steinman pin. The Steinman pin was removed 6 weeks after the operation and the patient was then put into traction for another 6 weeks. Weight-bearing was gradually allowed after 3 to 6 months. The patient remodelled a neoacetabulum, which gave sufficient stability to the hip joint. Walking without external help was possible. The patient presented with a 2 cm limb-shortening. No local recurrence was observed during a follow-up of 30 months. This experience with internal hemipelvectomy shows an encouraging result in terms of tumour control and gait function.     

Iatrogenic perforation of perivaterian duodenal diverticulum: report of a case

The author reports a case of iatrogenic perforation of a duodenal diverticulum, an extremely rare occurrence, during percutaneous radiologic extraction of a retained common-bile-duct-stone. Perforation was related to the perivaterian location of the duodenal diverticulum. Because an inflammatory reactions was present, tube duodenostomy was chosen over excision, closure and drainage to prevent the complication of lateral duodenal fistula and sepsis. Whenever iatrogenic duodenal perforation is suspected, prompt radiologic documentation and early surgical consultation should be sought.     

Sliding colonic Maydl's hernia: report of a case

An unusual variety of Maydl's hernia (hernia-in-W) in which all the herniated loops were colon is reported. The unusual anatomy of the hernia and its variations are described. It is important to examine the intraperitoneal intestine between the incarcerated loops in an effort to avoid leaving a nonviable segment of intraperitoneal intestine after repair of the hernia.     

Intercostal incisional hernia: case report

The authors report a case of intercostal incisional hernia following marsupialization of liver hydatid cyst stressing the considerable rarity of the pathology and describing the restorative procedure by intercostal plastic with polypropilene Mesh and rib's approach with stainless steel wires.     

Congenital diaphragmatic hernia: developing a protocolized approach

BACKGROUND/PURPOSE: The purpose of this study was to evaluate the evolving outcome of newborns who have congenital diaphragmatic hernia (CDH) using a protocolized approach to management, which includes extracorporeal membrane oxygenation (ECMO) and to present the details of such a management protocol. METHODS: A retrospective chart review was conducted of the neonatal outcome of near-term (>34 weeks' gestation) newborns with CDH all referred to the Royal Alexandra Hospital either before or after delivery. A protocol was developed that included antenatal assessment, the use of antenatal steroids, planned delivery, use of prophylactic surfactant, pressure limited gentle ventilation, permissive hypercarbia and hypoxia, and venovenous ECMO, if indicated. RESULTS: Sixty-five infants with CDH were treated from February 1989 through August 1996. Twenty-three infants were inborn, 20 of whom were antenatal referrals. Overall, 51 of the 65 infants survived (78%). Thirteen of the 23 inborn infants survived with conservative management, and 10 required ECMO, of whom, eight were long-term survivors. Thirty-eight infants required ECMO, and 26 survived (68%), whereas there were only two deaths among the 27 conservatively treated infants. Eighteen of 20 inborn infants with an antenatal diagnosis survived, compared with 13 of 21 (62%) outborn infants. An antenatal diagnosis before 25 weeks' gestation was associated with a 60% survival rate. Sixty-three percent of infants whose best postductal PaO2 value before ECMO was less than 100 torr survived, and 7 of 11 infants with a best postductal PaO2 value of less than 50 torr before ECMO survived (64%). The average age at surgery progressively increased over time both for infants who did not require ECMO (1.3 days to 5.8 days; P = .01) and for infants who received ECMO (1.9 days to 8.2 days; P = .016). CONCLUSIONS: The use of a protocolized management for infants with CDH has been associated with improving outcome in a population at high risk. The components (either separately or combined) of these protocolized approaches need to be tested in prospective trials to determine their true benefit. In addition, there is a need to evaluate prospectively the outcomes of infants with CDH born in ECMO centers compared with those infants born in other tertiary care neonatal units to determine the most appropriate management of the fetus with CDH.     

Pyopneumopericardium from perforation of a hiatus hernia ulcer : a case report

Pyoneumopericardium developed secondary to perforation of an iatrogenic hiatus hernia ulcer. Eighteen cases of gastropericardial fistulae have been reported, but only one similar case has been described in the published literature. Currently employed medical and surgical treatment gives disappointing results, whether the site of perforation of the ulcer be thoracic or transdiaphragmatic.     

Congenital diaphragmatic hernia: Bochdalek type

Congenital Bochdalek hernias result in significant mortality in the newborn period. Forty-four cases over a nineteen year period are presented. The overall mortality is 34 per cent; however, it has decreased from 41 to 25 per cent in the last five years. The mortality of those patients less than 24 hours old remains high (33 per cent) but improved. We prefer the abdominal approach and believe that prolonged respiratory support will salvage a significant number of these critically ill infants.     

Congenital diaphragmatic hernia: operative considerations

OBJECTIVE: To evaluate the results of a vaccination strategy on children under one year of age, aimed at increasing the coverage of the complete vaccination scheme, and at improving early entry into the program. MATERIAL AND METHODS: In Tixtla, Guerrero, Mexico, from April to December 1994, two basic geo-statistical areas (BGSA) were studied. Each area had an average number of 100 children under one year of age. In the area of intervention, people from the community were hired on a permanent basis for early recruitment of children (under two months of age) and for appropriate vaccination of children with incomplete vaccination schemes. In the control area vaccination campaigns were offered periodically. RESULTS: It was found that the strategy of intervention increased the percentage of completed vaccination schemes, from 21.1% to 93.5% among children under one year of age, as well as the recruitment rate. CONCLUSIONS: This strategy can help to achieve a better coverage of vaccination programs in urban areas where coverage is low.     

Ultrasound diagnosis of fetal diaphragmatic hernia and complex congenital heart disease at 12 weeks' gestation--a case report

Congenital diaphragmatic hernia is commonly associated with congenital heart disease. Their coexistence indicates a poor prognosis. Prenatal diagnosis of these conditions in early pregnancy allows the option of pregnancy termination. We present a case of left-sided fetal diaphragmatic hernia and complex congenital heart disease diagnosed by ultrasound examination at 12 weeks' gestation.     

Prenatal diagnosis of supernumerary chromosome derivative (22) due to maternal balanced translocation in association with diaphragmatic hernia: a case report

An aneuploid fetus was detected prenatally by cordocentesis at 27 weeks' gestation following ultrasonographic diagnosis of severe fetal growth retardation and a large diaphragmatic hernia. The fetal karyotype was revealed to be 47,XX,der(22)t(11;22)(q23.3;q11.2) after parental bloods confirmed a balanced reciprocal translocation in the mother. Approximately 85 cases with an unbalanced karyotype 47,XX(or XY),+der(22),t(11;22) due to 3:1 meiotic disjunction in the parental translocation carrier have been reported in the world literature and only one of them was diagnosed prenatally. This is the first detailed case report of a supernumerary derivative (22) chromosome abnormality diagnosed prenatally in association with diaphragmatic hernia.     

Current surgical management of congenital diaphragmatic hernia: a report from the Congenital Diaphragmatic Hernia Study Group

BACKGROUND: Repair of congenital diaphragmatic hernia (CDH) has changed from an emergent procedure to a delayed procedure in the last decade. Many other aspects of management have also evolved since the first successful repair. However, most reports are from single institutions. The lack of a large multicenter database has hampered progress in the management of congenital diaphragmatic hernia (CDH) and makes determination of the current standard difficult. METHODS: The CDH study group was formed in 1995 to collect data from multiple institutions in North America, Europe, and Australia. Participating centers completed a registry form on all live-born infants with CDH during 1995 and 1996. Demographic information, data about surgical management, and outcome were collected for all patients. RESULTS: Sixty-two centers participated, with 461 patients entered. Overall survival was 280 of 442 patients (63%) where survival was recorded. The defect was left-sided in 78%, right-sided in 21%, and bilateral in 1%. A subcostal approach was used in 91% of patients, with pleural drainage used in 76%. A patch of some kind was used in just over half (51%) of the patients, with polytetrafluoroethylene being the most commonly used material (81%) in those patients with a patch. The mean surgical time was 102 minutes, with an average blood loss of 14 mL (range, 0 to 500 mL). The overwhelming majority of patients underwent repair between 6:00 AM and 6:00 PM (289 of 329, 88%). Nineteen percent of patients had surgical repair on extracorporeal membrane oxygenation (ECMO) at a mean time of 170 hours into the ECMO course (range, 10 to 593 hours). The mean age at surgery in patients not treated with ECMO was 73 hours (range, 1 to 445 hours). CONCLUSIONS: The multicenter nature of this report makes it a snapshot of current management. The data would indicate that prosthetic patching of the defect has become common, that after-hours repair is infrequent, and that delayed surgical repair has become the preferred approach in many centers. Furthermore, the mean survival rate of 63% indicates that despite decades of individual effort, the CDH problem is far from solved. This highlights the need for a centralized database and cooperative multicenter studies in the future.     

Acquired umbilical fistula after repair of inguinal hernia: a case report

A 2-year, 9-month-old boy had an umbilical fistula after repair of an inguinal hernia at 8 months of age. Fistulography findings showed a duct running from the umbilicus toward the inguinal wound. Pathological finding of the surgically removed fistula demonstrated granulomatous tissues containing silk ligature. Acquired umbilical fistula is a rare complication of inguinal herniorrhaphy. Its clinical details as well as a review of the previously reported four cases are presented.