Thoracoabdominal compartment syndrome complicating right-sided diaphragmatic eventration with co-existent unilateral renal agenesis

Diaphragmatic eventration (DE) associated with intestinal malrotation and renal agenesis is a rare entity. The authors report a case of a 69-year-old man who had symptoms of heart failure. He had a previous imaging diagnosis of right diaphragmatic eventration and dilated cardiomyopathy. He died on the second day after the hospital admission and had a post mortem examination that confirmed complete right diaphragmatic eventration, intestinal malrotation, left renal agenesis, dilated cardiomyopathy, and anteriorly rotated right kidney and had findings suggestive of a thoracoabdominal compartment syndrome. Thoracoabdominal compartment syndrome is described as transmission of abdominal pressure through a defective diaphragm causing compression of the hemithorax viscera and mediastinal shift with a hemodynamic alteration. The association of these anomalies is rare, and the possibility of this finding in a patient with eventration should always be considered.

Minimally invasive surgery for diaphragmatic diseases in neonates and infants.

Owing to recent advances in minimally invasive surgery (MIS), laparoscopic and thoracoscopic surgery have been gradually introduced for use in neonates and infants. This review focuses on two popular MIS procedures for diaphragmatic diseases in neonates and infants: congenital diaphragmatic hernia (CHD) repair and plication for diaphragmatic eventration. While several advantages of MIS are proposed for CDH repair in neonates, there are also some concerns, namely intraoperative hypercapnia and acidosis and a higher recurrence rate than open techniques. Thus, neonates with severe CDH, along with an unstable circulatory and respiratory status, may be unsuitable for MIS repair, and the use of selection criteria is, therefore, important in these patients. It is generally believed that a learning curve is associated with the higher recurrence rate. Contrary to CDH repair, no major disadvantages associated with the use of MIS for diaphragmatic eventration have been reported in the literature, other than technical difficulty. Thus, if technically feasible, all pediatric patients with diaphragmatic eventration requiring surgical treatment are potential candidates for MIS. Due to a shortage of studies on this procedure, the potential advantages of MIS compared to open techniques for diaphragmatic eventration, such as early recovery and more rapid extubation, need to be confirmed by further studies.

[EXPERIENCE OF RELAPAROTOMY APPLICATION IN SURGICAL TREATMENT OF THE ABDOMINAL CAVITY ORGANS DISEASES].

During 2011 - 2014 yrs in Surgical Clinic of The First City Clinic (Poltava) a relaparotomy was performed in 127 patients. There was established, that relaparotomy constitutes the only one procedure for such life threatening states, as intraabdominal bleeding, ileus in a decompensation stage, eventration, progressing peritonitis, abdominal compartment syndrome stages III - IV. The rate of relaparotomy application after performance of urgent operative interventions is bigger than after planned operations (ratio 4:1). Individual estimation of a state and choice of optimal surgical tactics during primary and secondary operative interventions are needed to improve the results of treatment.

Imaging of the diaphragm: anatomy and function.

The diaphragm is the primary muscle of ventilation. Dysfunction of the diaphragm is an underappreciated cause of respiratory difficulties and may be due to a wide variety of entities, including surgery, trauma, tumor, and infection. Diaphragmatic disease usually manifests as elevation at chest radiography. Functional imaging with fluoroscopy (or ultrasonography or magnetic resonance imaging) is a simple and effective method of diagnosing diaphragmatic dysfunction, which can be classified as paralysis, weakness, or eventration. Diaphragmatic paralysis is indicated by absence of orthograde excursion on quiet and deep breathing, with paradoxical motion on sniffing. Diaphragmatic weakness is indicated by reduced or delayed orthograde excursion on deep breathing, with or without paradoxical motion on sniffing. Eventration is congenital thinning of a segment of diaphragmatic muscle and manifests as focal weakness. Treatment of diaphragmatic paralysis depends on the cause of the dysfunction and the severity of the symptoms. Treatment options include plication and phrenic nerve stimulation. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.322115127/-/DC1.

Congenital diaphragmatic eventration in two closely related British Shorthair cats.

Two closely related British Shorthair cats, which died after surgery performed in the dorsal position, were presented for dissection. In both, a thin, flaccid, enlarged transparent tendinous diaphragmatic portion protruded cranially into the thoracic cavity, forming a cupola in which left, right medial and quadrate hepatic lobes were encased in both cats and the stomach in one cat. Microscopically, no muscle fibres were observed in the membrane, but numerous hepatocytes and bile ducts were incorporated in its central part. The anomaly was diagnosed as a congenital diaphragmatic eventration.

Mediastinal lipoblastoma causing diaphragmatic eventration: a case report and review of the literature.

Lipoblastomatous tumors are quite rare neoplasms derived from embryonic white fatty tissues. The majority is seen in infancy and early childhood. Generally they arise in extremities. Here, we present a 12-month-old female infant presenting with a mediastinal and cervical mass, showing left diaphragmatic eventration. We reviewed these cases and discussed clinical manifestations, radiologic, and histopathologic findings and treatment of these tumors.

Técnica de las eventroplastias con malla protésica / Surgical technique for eventroplasty with prosthetic mesh

La mayor parte de los estudios prospectivos mostraron clara superioridad de la reparación con malla protésica sobre los procedimientos anatómicos en el tratamiento de las eventraciones, y apoyaron el concepto del uso de material protésico aun en los defectos eventrógenos de menor tamaño. En este trabajo se va a describir la técnica de la eventroplastía con malla en las eventraciones más frecuentes

Prediction of outcome in infants with congenital diaphragmatic hernia or severe diaphragmatic eventration.

Congenital diaphragmatic hernia (CDH) and severe congenital diaphragmatic eventration (SDE) still have high mortality. Our aims were to identify clinical prognostic factors for CDH and SDE, and to determine whether the size or area of the proximal bilateral pulmonary arteries (PA) correlate with the clinical outcome. We retrospectively analyzed medical charts of 26 patients--20 with CDH and 6 with SDE, but no obvious other associated anomalies--admitted over a 12-year period. We compared prenatal history, clinical manifestations, blood gas, and echocardiography before surgery in the survivors and the non-survivors. Ten patients (8 CDH, 2 SDE) died 2 to 16 days after birth, including 2 patients without surgery due to progressive hypoxemia. The survivors had significantly higher 1- and 5-min Apgar scores, higher the worst preductal arterial blood gas pH levels, lower oxygen indices, and lower PaCO2 (P < 0.05). The McGoon index of PA size measured by echocardiography was higher in survivors, but not statistically significant. Nakada PA index results, however, were statistically significant (93.07 +/- 32.02 vs. 121.07 +/- 27.08, P < 0.05) In conclusion, Apgar scores, preductal PaCO2, oxygen index, and pH level can predict prognosis in infants with CDH and SDE. The Nakada PA index, however, might be a useful prognostic marker for patients with CDH and SDE.

Congenital eventration of the diaphragm in children: 25 years' experience in three pediatric surgery centers.

Eventration of the diaphragm is generally defined as an abnormal elevation of all or a portion of an attenuated but otherwise intact diaphragmatic leaf. Previous studies have indicated that eventration is a relatively rare condition, which can be symptomatic and requires surgery. We aimed to evaluate our patients with diaphragmatic eventration, and to discuss their characteristics in the light of the relevant literature. We retrospectively analyzed age, sex, incidence, location of the eventration, symptoms, associated anomalies, surgical technique, complications and survival in our patients. Between 1974 and 1999, 33 patients were treated in the Pediatric Surgery Departments of Ege University, SSK Children's Hospital and Behçet Uz Children's Hospital, 18 of them boys and 15 girls. The ages of our patients ranged from three days to 12 years. All of the patients had at least one of the respiratory symptoms such as cough, respiratory distress and fever; 3 newborns were admitted with severe respiratory distress while children belonging to higher age groups had symptoms of acute or recurrent pulmonary infections and failure to thrive. The eventration was right-sided in 22, 11 eventrations were left-sided. Diagnosis was performed with the help of a number of radiological studies such as fluoroscopic investigation, contrast study of the upper gastrointestinal system, direct X-ray graphies of the thorax, CT scan and ultrasonography, as necessary. Surgery was performed via thoracotomy in 20 patients and the 12 other patients underwent laparotomy for plication. One patient underwent thoracoabdominal plication. Two patients died because of cardio-respiratory complications in the early postoperative period and the rest of them survived to annual follow-ups. In conclusion, diaphragmatic eventration is an important condition which can eventually be mortal. Early diagnosis is necessary and plication is the treatment of choice.

Left diaphragmatic eventration with a suprapubic spleen: report of a case.

Diaphragmatic defects such as eventration and hernia are known to be associated with a high-sited, sometimes intrathoracic spleen. We report here a unique case of an 8-year-old boy found to have a left congenital diaphragmatic eventration and a suprapubic wandering spleen after presenting with symptoms of an "acute abdomen" due to torsion of the splenic pedicle. To our knowledge only one other case of a similar paradoxical association of these anomalies has been reported before; interestingly, in this patient splenic infarction had also resulted secondary to splenic torsion. We recommend careful evaluation of the location and vascular status of the spleen in all patients with congenital diaphragmatic defects due to the common occurrence of splenic vascular insult.

Surgical embryology and anatomy of the diaphragm with surgical applications.

This article reviews the development, surgical anatomy, and teratology of the diaphragm, and discusses the diagnostic procedures, surgical therapy, and prognosis of congenital disturbances. Special attention is paid to the traumatic rupture of the diaphragm, concerning incidence, cause, diagnosis, prognosis, and surgical repair.

[Myohyperplasia of the lung arterioles in congenital diaphragmatic defects]. / Myohyperplasie der Lungenarteriolen bei kongenitalem Zwerchfelldefekt.

The ratio of lumen/wall thickness of pulmonary arterioles was measured in patients who died post-operatively due to a congenital diaphragmatic defect. This was compared to normal arterioles in healthy newborn lungs. The wall musculature of pulmonary arterioles was 2.8 times thicker than in normal arterioles of newborn lungs. The main cause of this enormous wall thickness is a genuine growth of substance, i.e. myohyperplasia. Myohypertrophia can be an additional reason.

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

Eventration of the diaphragm in infants and children.

The study reviews 18 infants and children with eventration of the diaphragm who were treated over a period of eight years. The affected diaphragm and pulmonary tissue were examined by light and electron microscopy. The 18 patients, ranging in age from 10 days to 6 years, were divided according to Thomas' classification into a group with the congenital (10 patients) and a group with the acquired type (8 patients). Fifteen of these patients underwent surgery with diaphragmatic plication. On microscopic examination, biopsies of the lung showed atelectasis and pneumonia. These pathological changes became increasingly diffuse and severe with age. The diaphragm in patients with the congenital type of eventration was occupied by diffuse fibroelastic tissue. In patients with the acquired type, the cross-striated muscles of the diaphragm showed degenerative changes such as fragmentation, and interstitial fibrosis of the diaphragm became prominent with age. The results of this clinical study suggest that, in order to reduce the pathological changes in the lung, early surgical plication should be performed even in patients with the acquired type, if respiratory and digestive symptoms are noted.

Bilateral congenital eventration of the diaphragms: successful surgical management.

Bilateral congenital eventration of the diaphragms is a relatively rare occurrence, associated with an almost uniform mortality. We recently have had experience with three patients who underwent successful treatment of this anomaly. Each patient presented as a newborn with severe respiratory insufficiency. One had had a sibling who died shortly after birth with a congenital diaphragmatic hernia. One infant had associated respiratory distress syndrome. PA and lateral chest roentgenograms demonstrated the anomaly in each patient. In two, the use of ultrasound clearly demonstrated the presence of attenuated diaphragms and paradoxical motion. Each infant underwent transabdominal bilateral diaphragmatic plication, reinforced with transversus abdominis muscle, within the first 2 weeks of life. Two infants showed prompt improvement in arterial blood gases and were extubated following the operation. The infant with respiratory distress syndrome required a tracheostomy for continued mechanical ventilation. This infant developed a recurrent eventration of the left diaphragm 6 months after the initial operation and has undergone a secondary plication with clinical improvement. Unlike unilateral eventration, bilateral eventration of the diaphragms is associated with persistent and significant respiratory symptoms. Surgical plication should be performed urgently in all of these patients, before chronic pulmonary changes occur.