Zahn Katrin B, Schaible Thomas, Rafat Neysan, Weis Meike, Weiss Christel, Wessel Lucas
Department of Pediatric Surgery, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany.
ERNICA-Center, Mannheim, Germany.
Front Pediatr. 2021 Dec 17;9:796478. doi: 10.3389/fped.2021.796478. eCollection 2021.
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. 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. 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; = 0.53). Diaphragmatic complications were significantly associated with initial defect size ( = 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 ( = 0.03); abdominal wall patch: 3.2 ( < 0.001); age ≤4 years: 6.5 ( < 0.002)]. 97% of patients with diaphragmatic complications showed no or nonspecific symptoms and 45% occurred beyond 1 year of age. 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.
先天性膈疝（CDH）新生儿修复术后复发是最严重的手术并发症，在植入补片后复发率高达50%。由于手术技术、回顾性研究设计的差异以及缺乏标准化的随访或影像学检查，以往的研究难以进行比较。本研究旨在通过对CDH新生儿开放修复术后的长期随访期间进行影像学筛查，可靠地检测并发症发生率，并确定可能的危险因素。在我们拥有标准化治疗方案和随访计划的转诊中心，在12年期间，按照规定的时间间隔，对连续的新生儿进行影像学检查以筛查复发情况。326例接受CDH开放修复术的新生儿完成了至少2年的随访。68例患者（21%）接受了一期修复，251例（77%）接受了宽锥形补片修复，7例（2%）接受了平片修复。出院前有3例患者（0.7%）复发，此后有28例（8.6%）出现膈肌并发症。总体而言，共诊断出38例复发和/或继发性食管裂孔疝（一期修复后为9%，锥形补片修复后为12.7%；P = 0.53）。膈肌并发症与初始缺损大小显著相关（P = 0.26）。多因素分析显示，左侧CDH修复、腹壁补片修复以及年龄小于4岁是独立的危险因素。相应地，相对风险（RRs）显著增加[左侧CDH修复：8.5（P = 0.03）；腹壁补片修复：3.2（P < 0.001）；年龄≤4岁：6.5（P < 0.002）]。97%的膈肌并发症患者无或仅有非特异性症状，45%的并发症发生在1岁以后。CDH修复术后的长期并发症发生率高度依赖于手术技术：通过植入宽锥形、不可吸收的补片，似乎可以在大缺损修复中实现相对较低的复发率。定期进行影像学检查直至青春期的长期随访对于可靠地检测复发、预防急性嵌顿和慢性胃肠道疾病及其对预后的影响至关重要。基于我们的研究结果和文献综述，提出了一种针对膈肌并发症的风险分层方法。
