The main risk factors for reoperations in children with congenital diaphragmatic hernias

Abstract

Congenital diaphragmatic hernia (CDH) occurs with a frequency of 3.5 per 10,000 live births and occurs due to a fusion disorder of the closure of the pleuroperitoneal fold and transverse septum during 8-12 weeks of gestation. In an isolated variant of this pathology, mortality is quite high and there are a number of controversial issues. Even in the best specialized prenatal intensive care centers, the mortality rate reaches 30%. The use of new technologies in the treatment of CDH has increased the survival rate of patients, however, against this background, there is an increase in surgical problems associated with CDH. Purpose - to describe the structure and incidence of reoperations in children with CDH, depending on the access, identification of the main risk factors for reoperations, pathogenetic justification of optimal surgical access. Materials and methods. A retrospective cohort study of surgical correction of CDH in 104 infants who were operated on the basis of the NCH «OKHMATDYT» during 2000-2020 was conducted. To homogenize the group and to maximally exclude selection bias in order to identify risk factors, we include a group of patients with left-sided CDH in the study. Correction of the left-sided CDH was performed through the laparotomic approach in 51 patients (61%). Thoracotomy for left-sided EDH was used in 33 (39%) patients. Results. In the study group of patients, 14 (16.7%) reoperations were performed in this group at different times of the long-term period. The indications for reoperations were: adhesive intestinal obstruction - 3 (21.5%), inc. strangulated intestinal obstruction with bowel necrosis - 2 (14%), obstruction caused by malrotation - 1 (7%), gastroesophageal reflux - 4 (29.5%), recurrent hernia - 2 (14%), pectus excavatum - 1 (7%), spleen torsion - 1 (7%). The number of reoperations in the study group during a certain observation period was slightly higher in the thoracotomy group (18% versus 14%, p=0.80). More than half of repeated interventions were associated with acute intestinal obstruction, more often after laparotomy (35.7 versus 7%; p=0.16). In this group, 5 reoperations were performed, the cause of which was intestinal obstruction, in contrast to the thoracic group, where one patient was operated for malrotation. Reoperations for recurrent diaphragmatic hernia occurred only in the thoracotomy group in one patient with agenesis of the left diaphragm dome. Early postoperative mortality was found slightly higher in the laparotomy group (27.4% versus 18.1%; p=0.167). Conclusions. The optimal method of surgical treatment of large defects and agenesis of the dome is surgical correction of the diaphragm through a thoracotomy approach using a synthetic patch and thoracalization of the abdominal cavity. The abdominal approach has a high risk of reoperations, which is associated with the development of the adhesive process and the likelihood of the formation of ventral hernias due to viscero-abdominal imbalance. The indications for the use of thoracic access and patches for plasty of the diaphragm defect should be expanded regardless of the side of the lesion and the size of the defect. The main factors determining the risk of recurrent CDH are the size of the hernial defect and the method of diaphragm correction. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local ethics committee of all participating institutions. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: congenital diaphragmatic hernia, reoperations, intestinal obstruction, gastroesophageal reflux, recurrence, malrotation, thoracatomy, laparotomy.