Right diaphragmatic hernia after liver transplant in pediatrics: A case report and review of the literature

Abstract

Diaphragmatic hernias (DH) are an unusual complication after pediatric liver transplantation; however, they have been reported with increased frequency in the past few years. DHs are responsible for nearly half of the small bowel obstructions requiring surgical intervention in this patient population. It has been suggested that the use of a left lobe liver graft, surgical trauma, malnourishment, elevated intra-abdominal pressures, and mTor inhibitors may predispose to development of DH. The use of a segmental graft may increase the recognition of diaphragmatic hernia because the surgically damaged right hemi-diaphragm often remains exposed to underlying viscera, instead of being covered by the right hepatic lobe. Treatment is surgical reduction, with up to 20% of the patients requiring resection of the herniated intestine. Herein we describe a case of DH after left segmental liver transplant in a two- yr-old boy that presented one month post left lobe split liver transplant with abdominal pain, anorexia, and respiratory distress. Just like in the majority of the reported cases, an urgent laparotomy with primary repair was performed. No resection of the herniated segment of intestine was required. For pediatric patients with otherwise unexplained respiratory or gastrointestinal symptoms after a left lateral segment liver transplant, right-sided diaphragmatic hernias should always be high in the differential diagnosis.

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“…First, small infants who are candidates for transplant are usually critically ill, with at least onehalf already hospitalized or on mechanical support while waiting for a transplant. 3,8 They have low weight and typically have severe malnutrition (as was the case with 2 of our reported patients) and have generalized reduced muscle bulk. 9 It is therefore likely that their diaphragm is quite thin and may be more sensitive to the effects of diathermy, resulting in an area of focal necrosis.…”

Case series and systematic review of acquired diaphragmatic hernia after liver transplantation

“…More recently, individual case reports have presented mTOR inhibitor‐based immunosuppression as a potential culprit contributing to ADH post‐LT . Indeed, mTOR inhibitors have been linked to delayed wound healing and higher rates of incisional hernia when used in the early post‐transplant period .…”

“…Although reported with increasing frequency over the past several years, ADH are still considered to be a rare surgical complication following LT. Only a small number of case reports or case series have been described . As a result, no risk factors to predict or etiology to clearly explain ADH post‐liver transplant have been identified.…”

Acquired right diaphragmatic hernia following pediatric living donor orthotopic liver transplantation

“…Management of ADH is always surgical, and every effort should be made for a stable diaphragmatic wall. Most of the cases, as in our case, may be repaired primarily, whereas prosthetic materials may also be used .…”

“…There are <30 cases of post‐transplant ADH reported in the literature . Several predisposing factors including surgical trauma during hepatectomy, left lobe liver transplant, malnutrition, increased post‐transplant intra‐abdominal pressure, postoperative ascites, or pleural effusion formation and immunosuppression have been proposed for the etiologies of ADH following OLT . Surgical trauma during hepatectomy and unprotected right diaphragm due to left lobe liver transplant may theoretically predispose to post‐transplant right‐side ADH; however, if this were the case, then ADH rate following right hepatectomy for any other purpose would be a much more common problem.…”