Thoracic versus abdominal approach to correct diaphragmatic eventration in children.

BACKGROUND: Plication of diaphragm (DP) for eventration (DE) can be done using thoracic or abdominal approaches. The purpose of our study was to compare outcomes between these approaches based on our experience and on systematic literature review. METHODS: Retrospective records of children <16 years who underwent DP (single-center, 2004-2018) were recorded and analyzed. Systematic review and meta-analysis of related studies was undertaken. Data are reported as median (range). RESULTS: Eighty-nine cases were identified in thoracic (Congenital = 5, Acquired = 84) and 13 (Congenital = 10, Acquired = 3) in abdominal group aged 5.88 (0.36-184.44) and 10.0 (0.12-181.8) months. Improvement in diaphragm level post-DP was significantly higher in abdominal [2(0-4)] than chest [1.5(0-5)] group (p = 0.04). On Cox regression analysis, there was a non-significant trend to a longer time to extubation in the chest group (Hazard ratio (HR) = 0.539[0.208-1.395], p = 0.203). Patients operated transthoracically left intensive care unit after a significantly longer time (HR = 0.339[0.119-0.966], p = 0.043). Patients operated transabdominally tended to be fed later, although this was not significant (HR = 1.801[0.762-4.253], p = 0.043). On Kaplan-Meier analysis, there was a non-significant trend to a lower rate of recurrence in the abdominal group (HR = 0.3196[0.061-1.675], p = 0.1876). In the meta-analysis including three published studies as well as our data (total n = 181, Thoracic = 139, Abdominal = 42), no difference was found in the incidence of recurrence amongst the 2 groups (RD = -0.04, 95%CI = -0.25, 0.18, p = 0.74). CONCLUSION: This is one of the largest reports on outcomes of children undergoing DP for DE. There is no significant difference in recurrence rate, even though all recurrences in our series (15.7%) were in the acquired cases operated using a thoracic approach. TYPE OF STUDY: Treatment Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.

[Elevation of the diaphragma after cardiac surgery]. / Uniesienie przepony po operacjach kardiochirurgicznych.

Phrenic nerve injury and diaphragmatic dysfunction can be induced by cardiac operation. We evaluated nonconsecutive 34 patients (pts) with elevation of the diaphragma after cardiac operation. 27 pts have coronary artery bypass grafting, 7 pts have prosthetic valve implantation. We have impression that ice/saline slush used along with cold cardioplegia for heart arrest can cause hypothermic damage of phrenic nerve. Palsy of that nerve results in raised hemidiaphragm and delayed recovery of the pts. In our pts normalisation of the diaphragm we observed 6 months after operation in 41% pts and 12 month after in 93% pts. We suggest that results depends on early and well rehabilitation.

Eventraciones post-operatorigas y el uso de la malla de Marlex como su tratamiento / Post-operative eventrations and the use of marlex mesh as treatment

Se revisan las historias clínicas de 200 pacientes operados de eventraciones postoperatorias (EPO), en el Servicio de Cirugía del Centro Médico Naval, de Enero de 1974 a Marzo de 1986, de los cuales 150 pacientes fueron tratadas con técnicas usuales y 50 pacientes fueron tratados con la malla de Marlex, teniendo un total de 224 intervenciones quirúrgicas. Los resultados muestran una mayor incidencia de las eventraciones postoperatorias entre los 50 a 69 años con el 56,5 por ciento, tienen gran predominancia en el sexo femenino con 84,0 por ciento. Gran porcentaje de los pacientes presentaron patología asociada que llegó a un 40,5 por ciento. La evolución postoperatoria inmediata fue satisfactoria o buena en el 80,4 por ciento para todos los casos, tanto con Marlex o sin Marlex. En cambio en el control postoperatorio tardío nos dan un 87,3 por ciento de evolución satisfactoria, con un índice total de recidivas de eventración del 12,7 por ciento. La recidiva en los casos operados con Marlex fue solo del 5,9 por ciento, contra un 14, 8 por ciento de recidiva de los operados sin Marlex. Según el estudio estadístico, mediante el Chi cuadrado, demostró que el uso de la malla Marlex, tiene una alta significancia en la prevención de las recidivas en las EPO. Se realizó también un análisis de los factores causantes de recidiva encontrándo que tiene significancia o son factores directos, entre ellos tenemos: antecedente de cirugía de eventración, complicaciones postoperatorias inmediatas y los pacientes obesos, en cambio no encontramos significancia estadística en pacientes mayores de 60 años y en el tipo de incisión primaria