Longitudinal Follow-Up With Radiologic Screening for Recurrence and Secondary Hiatal Hernia in Neonates With Open Repair of Congenital Diaphragmatic Hernia—A Large Prospective, Observational Cohort Study at One Referral Center

Abstract

Objective: After neonatal repair of congenital diaphragmatic hernia (CDH) recurrence is the most severe surgical complication and reported in up to 50% after patch implantation. Previous studies are difficult to compare due to differences in surgical techniques and retrospective study design and lack of standardized follow-up or radiologic imaging. The aim was to reliably detect complication rates by radiologic screening during longitudinal follow-up after neonatal open repair of CDH and to determine possible risk factors.Methods: At our referral center with standardized treatment algorithm and follow-up program, consecutive neonates were screened for recurrence by radiologic imaging at defined intervals during a 12-year period.Results: 326 neonates with open CDH repair completed follow-up of a minimum of 2 years. 68 patients (21%) received a primary repair, 251 (77%) a broad cone-shaped patch, and 7 a flat patch (2%). Recurrence occurred in 3 patients (0.7%) until discharge and diaphragmatic complications in 28 (8.6%) thereafter. Overall, 38 recurrences and/or secondary hiatal hernias were diagnosed (9% after primary repair, 12.7% after cone-shaped patch; p = 0.53). Diaphragmatic complications were significantly associated with initial defect size (r = 0.26). In multivariate analysis left-sided CDH, an abdominal wall patch and age below 4 years were identified as independent risk factors. Accordingly, relative risks (RRs) were significantly increased [left-sided CDH: 8.5 (p = 0.03); abdominal wall patch: 3.2 (p < 0.001); age ≤4 years: 6.5 (p < 0.002)]. 97% of patients with diaphragmatic complications showed no or nonspecific symptoms and 45% occurred beyond 1 year of age.Conclusions: The long-term complication rate after CDH repair highly depends on surgical technique: a comparatively low recurrence rate seems to be achievable in large defects by implantation of a broad cone-shaped, non-absorbable patch. Longitudinal follow-up with regular radiologic imaging until adolescence is essential to reliably detecting recurrence to prevent acute incarceration and chronic gastrointestinal morbidity with their impact on prognosis. Based on our findings and literature review, a risk-stratified approach to diaphragmatic complications is proposed.

Recurrence of Congenital Diaphragmatic Hernia: Risk Factors, Management, and Future Perspectives

“…The goal of the patch is to allow closure of the defect without tension on the surrounding structures, despite a large defect size, granting a tension-free suture. This aims to reduce the risk of recurrence and seems effective, as shown by Zahn et al (27). Another advantage is the possibility to create an "over-sized" cone-or dome-shape for the new diaphragm, allowing for better respiratory physiology.…”

“…Another surgical PF is the use of an abdominal patch. Even if rapidly removed through staged closure, an abdominal prosthesis can predispose to recurrence by interfering with the integrity of the diaphragm at its connection to the anterior abdominal wall ( 16 , 27 ).…”

“…In case of minor recurrences, conservative management may represent a good choice, avoiding re-operation, provided that the patient remains stable at periodic plain CXR and clinical examination for a minimum follow-up of 5 years ( 5 , 6 , 15 , 27 ).…”

“…Sometimes, an acute bowel obstruction could be the presenting clinical picture of a misdiagnosed hernia recurrence. However, up to two-thirds of the patients are asymptomatic at the detection, and its diagnosis remains extremely difficult when no structured follow-up is offered ( 5 , 27 ).…”

“…Moreover, it provides additional abdominal volume during the significant growth of the first year of life, facilitating tissue ingrowth coming from folds of the redundant material sutured to the rims of the diaphragm (28). Nonetheless, some single-center studies do not report any significant difference in hernia recurrence rates between the patch and primary repair, while other authors even described a reduced recurrence rate in patients treated with a patch (6,27,29,30), in contrast with data of large series from high-volume centers (6,16,26).…”