Validación de la ecografía Point-of-Care para el diagnóstico de hernia diafragmática: a propósito de un caso / Validation of Point-of-Care ultrasound in the diagnosis of a diaphragmatic hernia

La ecografía Point-of-Care (POCUS) es una herramienta sensible y específica para diagnosticar de manera precoz la patología del diafragma en pacientes críticos. Presentamos un caso clínico de un paciente con antecedentes de hernia diafragmática iatrogénica que ingresó en la unidad de reanimación tras una laparotomía exploradora de emergencia. Aprovechando el diagnóstico conocido de hernia diafragmática, describimos los signos clínicos que debemos encontrar en la evaluación POCUS para establecer el diagnóstico de hernia diafragmática: 1)fracción de acortamiento diafragmático normal bilateral; 2)excursión diafragmática reducida, y 3)posición cefálica de la cúpula diafragmática 4)mayor en supino que en sedestación. Igualmente, proponemos una sistemática de exploración ecográfica del diafragma y una clasificación diferencial de la disfunción diafragmática evaluada mediante POCUS en función de la correcta integridad y el buen funcionamiento del músculo periférico y del tendón central diafragmáticos en el paciente crítico.(AU)

Point-of-care ultrasound (POCUS) is a sensitive, specific tool for early diagnosis of diaphragm pathology in critically ill patients. We report the case of a patient with a history of iatrogenic diaphragmatic hernia who was admitted to the Resuscitation Unit after an emergency exploratory laparotomy. As the diagnosis of diaphragmatic hernia had already been confirmed, we determined the POCUS features that establish the diagnosis of diaphragmatic hernia: (1)normal bilateral diaphragmatic shortening fraction; (2)decreased diaphragmatic excursion, and (3)cephalic position of the diaphragmatic dome (4)greater in supine than in sitting position. We also outline a systematic ultrasound examination of the diaphragm and a POCUS-based differential classification of diaphragmatic dysfunction based on the functional integrity of the peripheral muscle and central diaphragmatic tendon in critically ill patients.(AU)

Validation of Point-of-Care ultrasound in the diagnosis of a diaphragmatic hernia.

Point-of-care ultrasound (POCUS) is a sensitive, specific tool for early diagnosis of diaphragm pathology in critically ill patients. We report the case of a patient with a history of iatrogenic diaphragmatic hernia who was admitted to the Resuscitation Unit after an emergency exploratory laparotomy. As the diagnosis of diaphragmatic hernia had already been confirmed, we determined the POCUS features that establish the diagnosis of diaphragmatic hernia: (1) normal bilateral diaphragmatic shortening fraction; (2) decreased diaphragmatic excursion; and (3) cephalic position of the diaphragmatic dome (4) greater in supine than in sitting position. We also outline a systematic ultrasound examination of the diaphragm and a POCUS-based differential classification of diaphragmatic dysfunction based on the functional integrity of the peripheral muscle and central diaphragmatic tendon in critically ill patients.

Hernia diafragmática congénita de presentación tardía Reporte de caso con revisión de literatura / Late Presentation Congenital Diaphragmatic Hernia: Case Report with Literature Review

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.

Herniación gástrica por rotura de prótesis diafragmática en el postoperatorio de pleuroneumonectomía por mesotelioma: una complicación a tener en cuenta / Gastric herniation due to rupture of diaphragmatic prosthesis in the postoperative period of pleuropneumonectomy due to mesothelioma: A complication to consider

La neumonectomía extrapleural, habitualmente asociada a reconstrucción pericárdica y diafragmática con material protésico, es una de las técnicas quirúrgicas empleadas en el tratamiento del mesotelioma pleural maligno. La herniación de vísceras abdominales hacia el tórax a través del material protésico a nivel diafragmático es una complicación rara, pero potencialmente grave de estos procedimientos, que debe de ser diagnosticada rápidamente para su reparación urgente.Presentamos el caso de un paciente que presentó una herniación gástrica en el postoperatorio precoz de una neumonectomía izquierda por un mesotelioma pleural. Los hallazgos clínicos fueron leves, pero apoyados en las pruebas de imagen, confirmaron la hipótesis diagnóstica y facilitaron la solución del cuadro. Se revisan los posibles factores contribuyentes y se incide en la necesidad de un diagnóstico y tratamiento precoz para evitar la isquemia de las vísceras abdominales herniadas en la cavidad torácica, por el riesgo de necrosis y contaminación por material fecaloideo.(AU)

Extrapleural pneumonectomy, usually associated with pericardial and diaphragmatic reconstruction with prosthetic material, is one of the surgical techniques used in the treatment of malignant pleural mesothelioma. Herniation of the abdominal viscera towards the thorax through the prosthetic material at the diaphragmatic level is a rare but potentially serious complication of these procedures, which must be diagnosed quickly for urgent repair.We present the case of a patient who presented with gastric herniation in the early postoperative period of a left pneumonectomy due to pleural mesothelioma. The clinical findings were mild, but supported by imaging tests, they confirmed the diagnostic hypothesis and facilitated the solution of the condition. Possible contributing factors are reviewed and the need for early diagnosis and treatment is emphasized to avoid ischemia of herniated abdominal viscera in the thoracic cavity, due to the risk of necrosis and contamination by fecaloid material.(AU)

Gastric herniation due to rupture of diaphragmatic prosthesis in the postoperative period of pleuropneumonectomy due to mesothelioma: A complication to consider.

Extrapleural pneumonectomy, usually associated with pericardial and diaphragmatic reconstruction with prosthetic material, is one of the surgical techniques used in the treatment of malignant pleural mesothelioma. Herniation of the abdominal viscera towards the thorax through the prosthetic material at the diaphragmatic level is a rare but potentially serious complication of these procedures, which must be diagnosed quickly for urgent repair. We present the case of a patient who presented with gastric herniation in the early postoperative period of a left pneumonectomy due to pleural mesothelioma. The clinical findings were mild, but supported by imaging tests, they confirmed the diagnostic hypothesis and facilitated the solution of the condition. Possible contributing factors are reviewed and the need for early diagnosis and treatment is emphasized to avoid ischemia of herniated abdominal viscera in the thoracic cavity, due to the risk of necrosis and contamination by fecaloid material.

Diaphragmatic hernia after radiofrequency ablation of liver metastases: a case report and review of the literature.

A diaphragmatic hernia is the protrusion of abdominal tissues into the thoracic cavity secondary to a defect in the diaphragm. Reviewing the literature, we found only 44 references to diaphragmatic hernia secondary to percutaneous radiofrequency treatment. The vast majority of these cases were secondary to the treatment of hepatocellular carcinoma in segments V and VIII. Nevertheless, to date, this is the first reported case of diaphragmatic hernia after radiofrequency ablation of a liver metastasis from colorectal cancer. Complications secondary to diaphragmatic hernias are very diverse. The principal risk factor for complications is the contents of the hernia; when small bowel or colon segments protrude in the thoracic cavity, they can become incarcerated. Asymptomatic cases have also been reported in which the diaphragmatic hernia was discovered during follow-up. The pathophysiological mechanism is not totally clear, but it is thought that these diaphragmatic hernias might be caused by locoregional thermal damage. Given that most communications correspond to asymptomatic and/or treated cases, it is likely that the incidence is underestimated. However, due to the advent of percutaneous treatments, this complication might be reported more often in the future. Most cases are treated with primary herniorrhaphy, done with a laparoscopic or open approach at the surgeon's discretion; no evidence supports the use of one approach over the other. Nevertheless, it seems clear that surgery is the only definitive treatment, as well as the treatment of choice if complications develop. However, in asymptomatic patients in whom a diaphragmatic hernia is discovered in follow-up imaging studies, management should probably be guided by the patient's overall condition, taking into account the potential risks of complications (contents, diameter of the opening into the thoracic cavity …).

Hernia diafragmática tras radiofrecuencia de metástasis hepática. Reporte de caso clínico y revisión de la literatura / Diaphragmatic hernia after radiofrequency ablation of liver metastases: a case report and review of the literature

La hernia diafragmática (HD) es la protrusión de los tejidos abdominales a la cavidad torácica secundaria a un defecto en el diafragma. Tras una revisión de la bibliografía, únicamente se han identificado 44 referencias al respecto, donde se describen 35 casos de HD secundarias a tratamientos percutáneos con radiofrecuencia (RF). En su gran mayoría son secundarias a lesiones por carcinoma hepatocelular en los segmentos V y VIII. No obstante, hasta la fecha, este es el primer caso comunicado de HD tras RF para el tratamiento de una metástasis hepática por carcinoma colorrectal. Las complicaciones secundarias a las HD son muy diversas. El principal factor de riesgo para ello es su contenido; así se describen casos incarceración de colon e intestino delgado. Igualmente, se describen casos asintomáticos en los que la HD ha sido un hallazgo en el seguimiento de los pacientes. El mecanismo fisiopatológico no está del todo esclarecido, pero se especula con la posibilidad de un daño térmico locorregional. Dado que la mayoría de las comunicaciones corresponden a casos sintomáticos y/o tratados, probablemente la incidencia esté infraestimada. No obstante, debido al advenimiento de los tratamientos percutáneos, esta complicación podría verse comunicada en mayor número en los próximos años. Respecto a los tratamientos descritos, en la mayoría de los casos se ha optado por una herniorrafia primaria, con una vía de abordaje abierta o laparoscópica a discreción del cirujano. No se dispone de evidencia que apoye ninguna actitud al respecto, si bien parece claro que el tratamiento quirúrgico es el único definitivo y el de elección en caso de complicación. Sin embargo, en pacientes asintomáticos en quienes la HD sea un hallazgo radiológico de control, el manejo quizá deba guiarse por el estado general del paciente, así como los riesgos potenciales de complicación (contenido, diámetro del orificio herniario…). (AU)

A diaphragmatic hernia is the protrusion of abdominal tissues into the thoracic cavity secondary to a defect in the diaphragm. Reviewing the literature, we found only 44 references to diaphragmatic hernia secondary to percutaneous radiofrequency treatment. The vast majority of these cases were secondary to the treatment of hepatocellular carcinoma in segments V and VIII. Nevertheless, to date, this is the first reported case of diaphragmatic hernia after radiofrequency ablation of a liver metastasis from colorectal cancer. Complications secondary to diaphragmatic hernias are very diverse. The principal risk factor for complications is the contents of the hernia; when small bowel or colon segments protrude in the thoracic cavity, they can become incarcerated. Asymptomatic cases have also been reported in which the diaphragmatic hernia was discovered during follow-up. The pathophysiological mechanism is not totally clear, but it is thought that these diaphragmatic hernias might be caused by locoregional thermal damage. Given that most communications correspond to asymptomatic and/or treated cases, it is likely that the incidence is underestimated. However, due to the advent of percutaneous treatments, this complication might be reported more often in the future. Most cases are treated with primary herniorrhaphy, done with a laparoscopic or open approach at the surgeon's discretion; no evidence supports the use of one approach over the other. Nevertheless, it seems clear that surgery is the only definitive treatment, as well as the treatment of choice if complications develop. However, in asymptomatic patients in whom a diaphragmatic hernia is discovered in follow-up imaging studies, management should probably be guided by the patient's overall condition, taking into account the potential risks of complications (contents, diameter of the opening into the thoracic cavity …). (AU)

Analysis of perceived risk and satisfaction with telematic follow-up in patients and families of congenital diaphragmatic hernia patients during SARS-CoV-2 pandemia.

BACKGROUND: The impact of COVID-19 in families and patients with congenital diaphragmatic hernia (CDH) is unknown, this situation has generated uncertainty not only in family members but also in the optimal outpatient follow-up. Telehealth has become a fundamental tool for the follow-up during the pandemic. The objective of this survey is to evaluated the impact of SARS-CoV-2 in families and patients with CDH and the satisfaction with telematic follow-up. METHODS: Telephone survey of patient's caregivers with CHD, aged 1-16 years, followed in neonatal surgery outpatients, from January 31, 2020 to November 15, 2020. The ethical clearance for this study was taken from the Clinical Research Ethics Committee of our Research Institute vide letter number VHIR/239283/01.01.2021. RESULTS: 81 surveys of 100 patients with active follow-up were carried out. There were no refusals in any contacted parents. There were 30 contacts (37%), 44.8% at school and 27.6% from cohabiting family members. Four infections (4.9%) were diagnosed, half symptomatic. In 40 patients (49.4%) the follow-up was telematic, with a mean score of 3.1±1.3 out of 5. For future controls, 65% prefer presential follow-up, 25% alternate and 10% telematics. 50.6% reported greater anxiety and 34.6% (28/81) extreme measures of isolation, being more accentuated in the group of 3-6 years (p<0.05). CONCLUSION: The impact of COVID19 in patients with CHD is not greater than in the general pediatric population. Although the incorporation of the telehealth was well valued, most of the caregivers prefer the face-to-face outpatient follow-up.

Hernia diafragmática congénita de diagnóstico tardío / Late presenting congenital diaphragmatic hernia

La hernia diafragmática congénita es un defecto del desarrollo diafragmático que suele diagnosticarse prenatalmente o en el periodo neonatal. Aunque su presentación tardía se asocia a mejor pronóstico, el diagnóstico supone en ocasiones un reto debido a su curso inespecífico. Resulta interesante conocer su existencia ante cuadros clínicos de difícil diagnóstico (AU)

Congenital diaphragmatic hernia is a diaphragmatic developmental defect that usually presents prenatally or in the neonatal period. Although its late presentation is associated with a better prognosis, the diagnosis is sometimes a challenge due to its non-specific course. It is interesting to know its existence in clinical presentations that are difficult to diagnose. (AU)

Hernia Diafragmatica Izquierda. Reporte de un caso / Left Diaphragmatic Hernia: A case report

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

Hernia diafragmática derecha postraumática de presentación tardía. Un caso infrecuente / Post-traumatic right diaphragmatic hernia of late presentation. A rare case

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

Descripción de un caso de hernia diafragmática de Morgagni con derrame pericárdico masivo resuelto mediante pericardiocentesis intrauterina / Description of a case of Morgagni's diaphragmatic hernia with massive pericardial effusion resolved by intrauterine pericardiocentesis

Introducción: Las hernias diafragmáticas de Morgagni diagnosticadas prenatalmente son una rara entidad, con menor riesgo asociado de hipoplasia pulmonar y problemas respiratorios que las hernias diafragmáticas posteriores. Nuestro caso pone de manifiesto cómo en los casos de hernia diafragmática de Morgagni los pulmones tienden a desarrollarse completamente, a pesar del significativo derrame pericárdico o cuán disminuidos pueden aparentar. Principales síntomas y/o hallazgos clínicos: Hernia diafragmática de Morgagni diagnosticada a las 14 semanas de gestación, con derrame pericárdico masivo y herniación torácica anterior del hígado. Diagnósticos principales, intervenciones terapéuticas y resultados: No se identificaron otras malformaciones asociadas, se descartaron otras causas de derrame pericárdico y el cariotipo fetal analizado fue normal. A las 25 semanas, se realizó una pericardiocentesis fetal intrauterina, consiguiendo una significativa distensión pulmonar, con una adecuada vascularización. Tras el nacimiento, la recién nacida precisó soporte ventilatorio debido a una hipoxemia severa causada por la hipertensión pulmonar, corrigiéndose el defecto quirúrgicamente a los 6 días de vida. La evolución posterior fue favorable, sin presentar problemas respiratorios significativos. Conclusión: La detección ecográfica de esta rara anomalía resulta útil para el manejo óptimo, y el drenaje pericárdico puede favorecer una resolución prenatal del derrame pericárdico, permitiéndonos evaluar de forma adecuada el riesgo de hipoplasia pulmonar.(AU)

Introduction: Morgagni diaphragmatic hernia with prenatal diagnosis is a rare entity, with lower risk of pulmonary hypoplasia and respiratory problems than posterior diaphragmatic hernia. Our case highlights how in Morgagni diaphragmatic hernia cases lungs tend to develop properly, despite significant pericardial effusion or how greatly diminished they may seem. Main symptoms and/or clinical findings: Morgagni diaphragmatic hernia diagnosed at 14 weeks, with massive pericardial effusion and anterior thoracic herniation of the liver. Main diagnosis, therapeutic interventions, and results: No other malformations were identified, other causes of pericardial effusion were ruled out and foetal karyotype was normal. At 25 weeks, in-utero pericardiocentesis was performed, observing significant pulmonary distension and adequate vascularization. After delivery, the newborn required respiratory support due to severe hypoxaemia related to pulmonary hypertension. Six days later surgical diaphragm closure was performed. The newborn had no significant respiratory problems and progressed positively after surgery. Conclusion: Ultrasonographic detection of this rare anomaly is useful for optimal management, and pericardial drainage can provide prenatal resolution of pericardial effusion, enabling us to evaluate pulmonary hypoplasia risk.(AU)

Calidad de vida en adolescentes intervenidos de herniadiafragmática congénita / Quality of life in adolescents who underwent congenital diaphragmatic hernia surgical repair

Objetivo: Los avances en el tratamiento quirúrgico y posnatal hanmejorado significativamente la supervivencia de pacientes con herniadiafragmática congénita (HDC). La morbilidad asociada sigue siendosignificativa. El objetivo del estudio es evaluar el efecto de estas se-cuelas sobre la calidad de vida relacionada con la salud (CVRS) deadolescentes y adultos jóvenes supervivientes de HDC y compararlacon la población general. Material y métodos: Estudio descriptivo transversal de pacientesdiagnosticados de HDC entre 1997 y 2004. Supervivencia, localiza-ción, tamaño de la hernia, órganos herniados, necesidad de oxigenaciónpor membrana extracorpórea, tiempo de ventilación mecánica. Estudio comparativo de CVRS actual de pacientes supervivientes mediante laencuesta SF-36 (36-Item Health Survey Short Form): función física,rol físico, dolor corporal, salud general, vitalidad, función social, rolemocional, salud mental. Utilizamos datos de 24 adolescentes sanoscomo grupo control. Resultados: De los 29 supervivientes (70,7%), fueron localizados21 y contestaron la encuesta 16, que consideraron tener una calidad devida global buena o muy buena. El grupo de adolescentes intervenidostuvieron mejores resultados en las esferas de vitalidad (p = 0,001) ysalud mental (p < 0,05), pero la puntuación de la CVRS global y elresto de dimensiones de salud fueron similares. No se objetivaron diferencias significativas en relación con el tamaño diafragmático ni lanecesidad de ECMO. Conclusiones: Los adolescentes supervivientes intervenidos deHDC consideran tener una calidad de vida similar a jóvenes de su mis-ma edad. Los resultados de nuestro estudio son alentadores y permitenun mejor asesoramiento para futuros pacientes con HDC.(AU)

Objective: The advances made in the surgical and postnataltreatment of congenital diaphragmatic hernia (CDH) have consid-erably improved patient survival, but morbidity remains significant.The objective of this study was to analyze the effect these sequelshave on the health-related quality of life (HRQL) of adolescents andyoung adults who have survived CDH, and to compare it with thatof the general population. Materials and methods: A transversal descriptive study of pa-tients diagnosed with CDH in our institution from 1997 to 2004 wascarried out. Survival, location, hernia size, herniated organs, need forextracorporeal membrane oxygenation, and mechanical ventilationtime were analyzed. In addition, a comparative study of the currentHRQL of survivors was conducted using the SF-36 survey (36-Item Health Survey Short Form), which assessed physical function,physical role, body pain, general health, vitality, social function,emotional role, and mental health. Data of 24 healthy adolescentswas used as a control group. Results: Of the 29 survivors (70.7%), 21 were successfullycontacted, and 16 responded to the survey. They all claimed theiroverall quality of life was good or very good. The group of ado-lescents who underwent CDH surgical repair had better results inthe vitality (p= 0.001) and mental health (p< 0.05) areas, but theoverall HRQL score and the remaining health areas were similar.No significant differences were found regarding diaphragmatic sizeor need for ECMO. Conclusions: According to adolescent survivors who underwentCDH surgical repair, their quality of life is similar to that of otherindividuals of their age. Our results are encouraging and may proveuseful for future parents of CDH patients.(AU)

Natural evolution of perforating wounds of 30% extension of the left diaphragm and the anatomopathological characteristics of its healing. Experimental Study / Evolução natural das feridas perfurocortantes de 30% de extensão do diafragma esquerdo e das características anatomopatológicas de sua cicatrização. Estudo Experimental

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.

Atresia duodenal con apple peel asociada a herniadiafragmática congénita: un caso excepcional yrevisión de la literatura / Duodenal atresia with apple peel associated with congenital diaphragmatic hernia: an exceptional case and a literature review

Introducción: La atresia duodenal asociada con appel peel es extremadamente infrecuente. La primera se produce por un defecto en larecanalización en etapas tempranas, mientras que la atresia intestinalparece deberse a causas vasculares en etapas más tardías. La presenciade anomalías asociadas a la hernia diafragmática es común, pero laasociación con la atresia duodenal apenas está descrita.Caso clínico: Presentamos un recién nacido de 31 semanas de gestación y sexo femenino, con atresia duodenal y apple peel, asociada ahernia diafragmática izquierda y cardiopatía mayor. Se realizó un flapmuscular abdominal para el cierre del defecto diafragmático y anastomosis duodenoyeyunal tras la resección de parte del apple peel inviable.Comentarios: A nuestro entender, es el primer caso descrito conesta asociación singular. La combinación de atresia duodenal con apple peel se ha descrito previamente en 11 ocasiones; la asociación de ambascon hernia diafragmática congénita no había sido descrita.

Introduction: Duodenal atresia associated with apple peel is extremely rare. Duodenal atresia occurs as a result of absence of recanali-zation at an early stage, whereas intestinal atresia is seemingly due tovascular causes at later stages. The presence of abnormalities associatedwith diaphragmatic hernia is frequent, but association with duodenalatresia has been little explored.Care report: This is the case of a female neonate born at gestational week 31, with duodenal atresia and apple peel, associated withleft diaphragmatic hernia and major heart disease. An abdominal muscle flap was performed for diaphragmatic defect closure purposes, and duodenojejunal anastomosis was carried out following resection of partof the non-viable apple peel.Discussion: To our knowledge, this is the first case described with this rare association. The combination of duodenal atresia and applepeel had been previously described 11 times. However, the associationof both with congenital diaphragmatic hernia had not been reported yet.

Hernia diafragmática congénita posterolateral derecha sin herniación hepática: presentación de caso con tratamiento exitoso / Right posterolateral congenital diaphragmatic hernia without liver herniation: presentation of a case with successful treatment

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.

Hernia diafragmática congénita en la gestación gemelar / Congenital diaphragmatic hernia in twin gestation

La hernia diafragmática congénita (HDC) en un feto de una gestación gemelar es una situación extremadamente infrecuente y de difícil manejo. La cirugía fetal no parece una opción válida debido al alto riesgo de rotura prematura de membranas y/o parto prematuro. La interrupción fetal selectiva debe hacerse antes de la semana 22, y tampoco está exenta de riesgos. El manejo expectante se asocia a la prematuridad y a fetos de bajo peso característicos de una gestación gemelar. Por tanto, el asesoramiento a los padres por parte de un equipo multidisciplinar es crucial en la toma de decisiones. La cesárea programada a término parece ser la vía más razonable en estos casos, sobre todo si es el segundo gemelo el afecto por HDC. Se presentan 6 casos de gestaciones gemelares bicoriales con uno de los fetos afecto de HDC con diferentes manejos y evoluciones obstétricas.(AU)

Congenital diaphragmatic hernia (CDH) in a twin gestation foetus is an extremely infrequent and difficult situation to manage. Foetal surgery does not seem to be an option due to the high risk of premature rupture of membranes and/or preterm delivery. Selective foetal termination must be done before 22 weeks and is also not without risk. Expectant management is associated with prematurity and low weight foetuses characteristic of twin gestation. Therefore, parental counselling by a multidisciplinary team is crucial in decision making. Programmed caesarean section at term seems to be the most reasonable route in these cases, especially if the second twin is affected by CDH. Six cases of bicornuate twin gestations with one of the foetuses affected by CDH are presented, with different management and obstetric outcomes.(AU)

Llanto inexplicable en un lactante sano. Hernia diafragmática congénita de presentación tardía / Unexplained crying in a healthy infant. Late-onset congenital diaphragmatic hernia

La hernia diafragmática congénita es un defecto simple del diafragma que permite el paso de los órganos abdominales al tórax. En la mayoría de los casos, se manifiesta en el periodo neonatal, con un cuadro de dificultad respiratoria grave, pero en algunos casos su presentación puede ser más tardía y con síntomas más diversos. Presentamos el caso de un lactante de seis meses que acude a Urgencias por irritabilidad y llanto persistente de una hora de evolución. La radiografía y ecografía torácica confirmaron el diagnóstico de hernia diafragmática (AU)

Congenital diaphragmatic hernia is a defect of the diaphragm that allows the passage of abdominal organs to the chest. Respiratory distress in the neonatal period is the most common presenting symptom, but in some cases its presentation may be later and with more diverse symptoms. We report a case of a 6-month-old infant who attended the emergency room due to irritability and persistent crying for one hour. Chest radiography and ultrasound confirmed the diagnosis of diaphragmatic hernia. (AU)

Hernia diafragmática: Un desafío diagnóstico / Diaphragmatic Hernia: A Diagnostic Challenge

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)

Benefit of video-assisted thoracic surgery in the emergency of a complicated postpartum diaphragmatic hernia / Beneficio de la cirugía torácica video-asistida en la emergencia de una hernia diafragmática posparto complicada

Abstract Diaphragmatic hernia during pregnancy or puerperium are rare entities that, in the event of a complication, represent a life-threatening emergency for both mother and the unborn child. Resolution in many cases requires a combined access through the thoracic and abdominal cavity to manage the complica tions of necrosis and/or perforation of an abdominal viscera. To treat the thoracic cavity, thoracotomy is the most described approach. Even more, the minimally invasive access by video-assisted thoracic surgery (VATS) is not widely referenced in the literature despite its clear benefits of this technique in the recovery of patients, even in emergencies. We present the case of a postpartum right diaphragmatic hernia, complicated by necrosis of the colonic wall, treated by combined VATS approach and laparotomy in the emergency.

Resumen Las hernias diafragmáticas durante el embarazo o puerperio son entidades raras que, en caso de complicación, representan una emergencia potencialmente mortal tanto para la madre como para el feto. La resolución en muchos casos requiere un acceso combinado a través de la cavidad torácica y abdominal para manejar las complicaciones de la necrosis o perforación de las vísceras abdominales. Para tratar la cavidad torácica, la toracotomía es la vía más descrita. Más aún, el acceso mínimamente invasivo mediante cirugía torácica video-asistida (VATS) no está ampliamente referenciado en la literatura a pesar de los claros beneficios de esta técnica en la recuperación de los pacientes, incluso en emergencias. Presentamos el caso de una hernia diafragmática derecha posparto, complicada por necrosis de la pared colónica, tratada combinado VATS y laparotomía en la urgencia.