Acute presentation of congenital diaphragmatic hernia past the neonatal period: a life threatening emergency

Purpose

Major gastric distension in the left hemithorax can threaten life in patients with congenital diaphragmatic hernia (CDH) presenting after the neonatal period. After presentation of two paediatric cases, guidelines for the optimal care of these patients are given.

Clinical features

Both children had respiratory and cardiocirculatory compromise on arrival. The diagnosis of late presenting CDH was made and the severity of symptoms was related to a voluminous distension of an intrathoracic stomach. Successful placement of an naso-gastric tube in the first patient, lead to a rapid clinical improvement, allowing surgical repair. In the second patient, oroor naso-gastric decompression was not possible and, while the lungs were mechanically ventilated and the patient was prepared for surgery, a sudden cardiocirculatory arrest was managed by external chest compressions and rescuscitation drugs. Transthoracic percutaneous decompression of the stomach was the sole treatment allowing spontaneous cardiac activity to reappear, and haemodynamic condition to normalize. However, the child died from brain death after this episode.

Conclusion

Gastric decompression is the key for the treatment of patients with CDH who present respiratory and/or cardiocirculatory distress due to the intrathoracic distension of the stomach. If an oroor naso-gastric decompression is not possible, then radiologically directed percutaneous decompression under local anaesthesia is required. After decompression, the patient is prepared for surgery, with particular emphasis on fluids infusion, in order to correct the frequently associated hypovolaemia:     

Iatrogenic gastric perforation in a misdiagnosed case of late presenting congenital diaphragmatic hernia: Report of an avoidable complication

IntroductionCongenital diaphragmatic hernia (CDH) is a defect in diaphragm which usually presents with severe respiratory distress in neonatal period.Presentation of caseWe present a case of congenital diaphragmatic hernia presenting at an age of 2.5 years in a male child. It was misdiagnosed as a case of pyothorax for which chest tube was attempted on left side resulting in iatrogenic gastric perforation. The patient was managed by early and prompt surgery.DiscussionLate presentation is usually rare with vast array of respiratory and gastrointestinal symptoms. It often leads to clinical and radiological misdiagnosis.ConclusionSurgical intervention in misdiagnosed cases can lead to catastrophic iatrogenic complications.     

Late Presentation of Bochdalek-Type Congenital Diaphragmatic Hernia in Children: A 23-Year Experience at a Single Center

Purpose The purpose of this article is to report on our 23-year experience of treating children with late-presenting congenital diaphragmatic hernia (CDH), focusing on diagnostic difficulties, associated anomalies, and morbidity. Method We reviewed 19 children in whom Bochdalek-type CDH was diagnosed after the neonatal period, between 1983 and 2005. Results There were 14 boys and 5 girls, with a mean age of 18.3 months (range, 5 weeks–14 years). Ten (52.6%) of the patients presented with respiratory symptoms and five (26.3%) with gastrointestinal symptoms. The diagnosis of CDH was based on the findings of chest X-rays, gastrointestinal tract contrast radiographs, and computerized tomography findings. The CDH was on the left side in 16 patients and on the right side in three patients. A hernia sac was present in seven (36.8%) patients. The only postoperative complications were intestinal obstruction caused by adhesions, incisional hernia, and eventration of the diaphragm in one patient each. None of the patients died within this study period. Conclusion The possibility of a delayed presentation of CDH should be considered in the differential diagnosis of recurrent non-specific respiratory or gastrointestinal tract symptoms in a child. A plain roentgenogram with a swallowed nasogastric tube might assist in the diagnosis. Early surgical correction of the diaphragmatic defect is crucial for preventing life-threatening complications.     

Diaphragmatic hernia in the fetus: prenatal diagnosis and outcome in 94 cases

Most babies born with congenital diaphragmatic hernia (CDH) die after birth. The natural course of CDH in the human fetus is not known. We found 94 cases of fetal CDH in the records of surgeons and obstetricians surveyed in the United States and Canada. We found the following: (1) prenatal diagnosis of CDH is accurate and current techniques can detect lethal nonpulmonary anomalies and prevent diagnostic errors; (2) despite optimal conventional therapy, most fetuses with detectable CDH will die in the neonatal period (80% mortality); (3) polyhydramnios is both a common prenatal marker for CDH (present in 76% of fetuses) and a predictor for poor clinical outcome (only 11% survived); (4) fetal CDH is a dynamic process--nonsurvivors have larger defects and may have more viscera displaced into the chest at an earlier stage of development. Surgical intervention before birth may be necessary to improve survival of the fetus with CDH and polyhydramnios.     

Presentation of congenital diaphragmatic hernia past the neonatal period

Congenital diaphragmatic hernias (CDHs) presenting beyond the neonatal period are a rare and unusual problem; they occurred in 11 of 83 children at our institution. Two discrete clinical groups were apparent: (1) younger children, with mainly respiratory symptoms; and (2) older children with gastrointestinal (GI) complaints. Chest roentgenograms suggested CDHs, but GI contrast studies were necessary for confirmation in eight patients. The diagnosis was made preoperatively in ten of 11 children. At operation, no peritoneal sacs were found, the hernial contents were viable in all patients, and malrotation was present in six of 11 patients. None had evidence of pulmonary hypoplasia. Congenital diaphragmatic hernias do present beyond the neonatal age group in a significant number of cases (13% in our series), and a diagnosis of CDH should be considered in any child with persistent GI or respiratory problems and abnormal chest x-ray film findings. The mortality rate in these patients is small, but morbidity may be significant.     

Treatment evolution in high-risk congenital diaphragmatic hernia: ten years' experience with diaphragmatic agenesis

OBJECTIVE: The objective of this study was to evaluate the impact of newer therapies on the highest risk patients with congenital diaphragmatic hernia (CDH), those with agenesis of the diaphragm. SUMMARY BACKGROUND DATA: CDH remains a significant cause of neonatal mortality. Many novel therapeutic interventions have been used in these infants. Those children with large defects or agenesis of the diaphragm have the highest mortality and morbidity. METHODS: Twenty centers from 5 countries collected data prospectively on all liveborn infants with CDH over a 10-year period. The treatment and outcomes in these patients were examined. Patients were followed until death or hospital discharge. RESULTS: A total of 1,569 patients with CDH were seen between January 1995 and December 2004 in 20 centers. A total of 218 patients (14%) had diaphragmatic agenesis and underwent repair. The overall survival for all patients was 68%, while survival was 54% in patients with agenesis. When patients with diaphragmatic agenesis from the first 2 years were compared with similar patients from the last 2 years, there was significantly less use of ECMO (75% vs. 52%) and an increased use of inhaled nitric oxide (iNO) (30% vs. 80%). There was a trend toward improved survival in patients with agenesis from 47% in the first 2 years to 59% in the last 2 years. The survivors with diaphragmatic agenesis had prolonged hospital stays compared with patients without agenesis (median, 68 vs. 30 days). For the last 2 years of the study, 36% of the patients with agenesis were discharged on tube feedings and 22% on oxygen therapy. CONCLUSIONS: There has been a change in the management of infants with CDH with less frequent use of ECMO and a greater use of iNO in high-risk patients with a potential improvement in survival. However, the mortality, hospital length of stay, and morbidity in agenesis patients remain significant.     

Prospective study to assess vocal cord palsy investigations

OBJECTIVES: To assess the investigation and clinical outcome of patients presenting with unexplained vocal cord palsy (VCP). STUDY DESIGN AND METHODS: A prospective cohort study designed to evaluate 86 patients with unexplained VCP presenting to our tertiary referral center. RESULTS: Twenty-four (36%) patients had positive findings on CT scanning. Twenty-one (24%) cases showed mediastinal adenopathy +/- pulmonary mass. The other three cases were a thoracic aneurysm, prostatic metastasis below the skull base, and a postcricoid tumor. Follow-up period was 18 to 66 months. Fifteen (24%) of the 62 patients with negative radiology recovered full vocal cord movement. CONCLUSION: CT neck +/- chest plays an important role in the evaluation of VCP patients. The majority of pertinent radiologic findings involve malignant neoplasm.     

Effect of PEEP and suction via chest drain on functional residual capacity and lung compliance after surgical repair of congenital diaphragmatic hernia: preliminary observations in 5 patients

BACKGROUND/PURPOSE: Congenital diaphragmatic hernia (CDH) is associated with pulmonary hypoplasia that limits survival. The authors' knowledge on lung mechanics and lung volumes in these patients with hypoplastic lungs is still limited. Therefore, the authors performed measurements of functional residual capacity (FRC), compliance of the respiratory system (CRS), and tidal volume in 5 full-term infants (gestational age, 38 to 40 weeks; birth weight, 2,800 to 3,530 g) before and after surgical repair of neonatal CDH. METHODS: The authors studied the influence of different levels of positive end-expiratory pressure (PEEP) and suction via inserted ipsilateral chest tube connected to a water seal on lung volume and lung mechanics. A computerized tracer gas (SF6) washout method was used for serial measurements of FRC. Compliance of the respiratory system was determined according to insufflatory method. RESULTS: The authors found a preoperative compliance between 1.5 and 3.9 mL/kPa/kg and a preoperative FRC between 9.1 and 12.9 mL/kg indicating severe hypoplasia of the lungs in all patients. Immediately after surgical repair of CDH, compliance decreased to 85% (78% to 91%) of preoperative value, and FRC increased to 132% (110% to 150%) of preoperative value under mechanical ventilation while at 4 cm of water of PEEP and at -10 cm of water of suction via chest drain with the need of high fraction of inspired oxygen. After reduction of PEEP from 4 to 2 or 1 cm of water and lowering suction from -10 cm of water to -2 or 0 cm of water FRC decreased to 103% (80% to 122%) of preoperative value and compliance, and tidal volume improved to 135% (110% to 147%) of preoperative value resulting in increased alveolar ventilation, correction of acidosis and improvement in oxygenation. During the first days after surgery inadequate high PEEP or strong suction via chest tube drainage resulted in increase in FRC paralleled by decrease in compliance indicating overdistension of these hypoplastic lungs. CONCLUSIONS: The data show that overdistension of hypoplastic lungs in infants with CDH can be detected and excluded by repeated measurements of FRC and compliance in these critical ill infants. These data might help setting appropriate ventilator parameters, adequate suction via chest drain, and thereby improve gas exchange and outcome.     

Impact of a current treatment protocol on outcome of high-risk congenital diaphragmatic hernia

Background

There is considerable debate regarding the optimal management of congenital diaphragmatic hernia (CDH) in high-risk infants (those cases presenting with respiratory distress within 2 hours of birth or those diagnosed prenatally). The aim of this study was to analyze patient outcomes using a new treatment protocol for CDH in a tertiary care non-extracorporeal membrane oxygenation (ECMO) neonatal unit.

Methods

The records of 78 consecutive neonates with CDH presenting to Bambino Gesù Children’s Hospital from 1996 to 2001 were analyzed retrospectively. Of these infants, 70 high-risk patients were identified (prenatal diagnosis or respiratory distress requiring intubation and assisted ventilation within 2 hours after birth), regardless of associated anomalies, medical condition on presentation, or degree of pulmonary hypoplasia. A prenatal diagnosis was made in 46 of 70 (66%) patients. Associated lethal malformations were present in 6 of the children (8.5%). The patients were placed in 3 historical groups: group 1, 19 patients from 1996 to 1997, group 2, 22 patients from 1998 to 1999, and group 3, 29 patients from 2000 to 2001. In the first 2 groups, a new protocol was introduced using inhaled nitric oxide (iNO) and high-frequency oxygen ventilation (HFOV). In the third group, gentle ventilation and permissive hypercarbia were also used routinely. Mortality and severe morbidity—defined as O₂ requirement at discharge, need for a tracheostomy, neurologic impairment, or bilateral hearing loss—were evaluated when the patients were at 6 months old. Univariate analysis was performed.

Results

The 3 groups were comparable with respect to predictive risk factors such as side of hernia, prenatal diagnosis, polyhydramnios, stomach and liver in the thorax, associated lethal malformations, and patch. Overall survival rate significantly increased from 47% (9 of 19) in group 1 and 50% (11 of 22) in group 2 to 90% (26 of 29) in group 3 (P = .02). None of the 19 patients in group 1 had severe morbidity compared with 2 of 22 (9%) patients in group 2 and 2 of 29 (7%) patients in group 3. Hearing loss was observed in 4 patients. Mortality rate and preoperative pneumothorax significantly decreased in group 3 compared with groups 1 and 2 (P = .03 and P = .00, respectively).

Conclusions

(1) The application of new treatment protocol for CDH, using gentle ventilation and permissive hypercarbia, produced a significant increase in survival with concomitant decrease in morbidity. (2) The rate of pneumothorax was significantly decreased by the introduction of permissive hypercarbia and gentle ventilation. (3) As more infants survive CDH without the use of ECMO, severe long-term sequelae of CDH can be recognized in these children.     

Chest trauma in a developing country.

In a developing country with inadequate clinical facilities a conservative method of management of a major clinical problem is often the only rational approach. This policy was adopted in the management of 145 patients with chest trauma in a teaching hospital in Nigeria. Automobile accidents were the cause of the thoracic injuries in 73.1% of the patients; 71.7% of the patients were managed as in-patients. The management of the patients was essentially aimed at correction of hypovolaemia, tube drainage of pleural collections, and relief of pain by intercostal nerve block. Major operative procedures were adopted in 11 cases (7.6%) for persistent haemothorax or for pyothorax, ruptured diaphragm, ruptured abdominal viscus, and subdural haematona. No operative reduction of rib fractures was performed and only 1 of the 12 patients with flail chest was mechanically ventilated. The hospital mortality was 9.7% and, despite a high rate of default at follow-up attendances, no late death or serious complication was recorded. Th aspects peculiar to chest trauma in Nigeria are discussed.     

Continuous intrapulmonary distension with perfluorocarbon accelerates lung growth in infants with congenital diaphragmatic hernia: initial experience

BACKGROUND/PURPOSE: The authors have shown previously in an animal model that neonatal lung growth can be accelerated by continuous intrapulmonary distension with a perfluorocarbon (PFC). The authors now describe a preliminary clinical experience with this therapeutic concept in a select group of infants with congenital diaphragmatic hernia (CDH). METHODS: Neonates with very high predicted mortality rate caused by CDH had their lungs completely filled with PFC while on extracorporeal life support (ECLS); (n = 5). A continuous positive pressure of 7 to 10 cm H2O was maintained via the endotracheal tube for 3 to 7 days (mean, 5.6 +/- 0.87 days). The areas of both lungs (L) then were measured daily from digitized chest x-rays and divided by the area of the corresponding L1 vertebrae (V), to create an L/V index, so as to control for variable roentgenographic techniques. Immediately after removal of PFC, blood gas data were collected off ECLS. RESULTS: At the end of continuous pulmonary distension, all patients showed improvements in oxygenation and ventilation. The ipsilateral lungs showed significant increase of the L/V index with time (P =.003) and of L/V's daily change (P <.0001), suggesting accelerated lung growth. Overall survival rate was 40% (2 of 5). Of the 3 patients that had 7 days of distension, 2 survived. CONCLUSIONS: Continuous intrapulmonary distension with PFC for up to 1 week accelerated ipsilateral lung growth, improved gas exchange, and increased survival of CDH infants with profound pulmonary hypoplasia marooned on ECLS. Additional trials of PFC-based pulmonary distension in similar infants are warranted.     

Absolute vs relative improvements in congenital diaphragmatic hernia survival: what happened to “hidden mortality”

Purpose

The aim of this study is to determine if there has been a true, absolute, or apparent relative increase in congenital diaphragmatic hernia (CDH) survival for the last 2 decades.

Method

All neonatal Bochdalek CDH patients admitted to an Ontario pediatric surgical hospital during the period when significant improvements in CDH survival was reported (from January 1, 1992, to December 31, 1999) were analyzed. Patient characteristics were assessed for CDH population homogeneity and differences between institutional and vital statistics-based population survival outcomes. SAS 9.1 (SAS Institute, Cary, NC) was used for analysis.

Result

Of 198 cohorts, demographic parameters including birth weight, gestational age, Apgar scores, sex, and associated congenital anomalies did not change significantly. Preoperative survival was 149 (75.2%) of 198, whereas postoperative survival was 133 (89.3%) of 149, and overall institutional survival was 133 (67.2%) of 198. Comparison of institution and population-based mortality (n = 65 vs 96) during the period yielded 32% of CDH deaths unaccounted for by institutions. Yearly analysis of hidden mortality consistently showed a significantly lower mortality in institution-based reporting than population.

Conclusion

A hidden mortality exists for institutionally reported CDH survival rates. Careful interpretation of research findings and more comprehensive population-based tools are needed for reliable counseling and evaluation of current and future treatments.     

Abdominal approach to chronic diaphragmatic hernias: is it safe?

Standard teaching has been to approach chronic diaphragmatic hernias (CDH) via a thoracotomy. It has been our experience that CDH can be safely approached via an abdominal incision. The objective of this study was to evaluate the outcome of patients undergoing the transabdominal approach for repair of CDH and comparing the outcome with that of patients undergoing a transthoracic (TT) approach. This is a retrospective chart review and was performed of patients with CDH secondary to trauma. Patient demographics, presenting symptoms, operative approach, and complications were collected. Patients were stratified by the surgical approach, TA versus TT. The endpoints of analysis were need for second incision, intraoperative and postoperative complications (enterotomies, pneumonia), need for a chest tube, mechanical ventilation postoperatively, and ICU and hospital days. Twenty-eight patients with CDH repairs performed between Jan 1993 and Dec 2002 were identified. Nineteen patients were in the TA group, and nine were in the TT group. Patients in the TA group had a higher incidence of emergent surgery (68% vs 11%, P = 0.005) and had a lower incidence of postoperative pneumonia (0% vs 33%, P = 0.009). No case of enteric injury from lysis of adhesions in the chest was identified. The need for a second incision (11%), the mortality (11%), ICU stay, and hospital stay were the same between the two groups. It appears that repair of CDH can be performed safely through an abdominal approach.     

Current consequences of prenatal diagnosis of congenital diaphragmatic hernia

Background

Today, the diagnosis of congenital diaphragmatic hernia (CDH) can readily be made in the prenatal period during screening ultrasound examination. Patients ought to be referred to rule out associated anomalies, and in isolated cases, prognosis is poor when the liver is intrathoracic and the lung-to-head ratio (LHR) is less than 1. In these patients, prenatal intervention aiming to reverse pulmonary hypoplasia can be considered.

Methods

We present our current algorithm for counselling patients presenting with CDH. Patients with a poor prognosis are offered percutaneous fetal endoluminal tracheal occlusion (FETO) with a balloon, inserted at 26 to 28 weeks. We report on the evolution of technique and results in a consecutive homogeneous case series and compare outcome in cases with similar severity managed in the postnatal period.

Results

Within a period of 28 months, FETO was performed between 26 and 28 weeks in 24 fetuses with severe left-sided CDH. Under general (n = 5), epidural (n = 17) or local (n = 2) anesthesia, the balloon was successfully positioned at first surgery (23/24) with a mean operation time of 20 minutes (range, 3-60 minutes). There were no serious maternal complications or direct fetal adverse effects. In the first 2 weeks after FETO, LHR increased from 0.7 to 1.7. Premature prelabour rupture of the membrane (PPROM) occurred in 16.7% and 33.3% at 28 and 32 weeks or earlier, respectively. Gestational age at delivery was 33.5 weeks. Patency of airways was restored either in the prenatal (n = 12) or perinatal period (n = 12). Early (7 days) and late (28 days) survival, and survival at discharge were 75% (18/24), 58.3% (14/24) and 50% (12/24), respectively. Half of nonsurvivors (n = 6) died of pulmonary hypoplasia and hypertension, in combination with PPROM and preterm delivery (n = 4) and balloon dislodgement (n = 2), which coincided with a short tracheal occlusion (TO) period (12 days). In the other 6, TO period was comparable to that in the 12 survivors (47 vs 42 days, respectively). In that group of 6 babies, only 2 died of pulmonary problems. Late neonatal survival (28 days) was higher with prenatal vs perinatal balloon retrieval 83.3% vs 33.3% (P = .013). In a multicentre study validating the criteria, survival till discharge in 37 comparable cases was 9% (3/32) and 13% (5/37) of parents opted for termination.

Conclusion

Fetuses with isolated left-sided CDH, liver herniation, and LHR of less than 1 have a poor prognosis. Percutaneous FETO is minimally invasive and may improve the outcome in these highly selected cases. Airways can be restored before birth, allowing vaginal delivery and return to the referring tertiary unit and may improve survival rate. The procedure carries a risk for PPROM, although that may decrease with experience.     

Risk-stratification enables accurate single-center outcomes assessment in congenital diaphragmatic hernia (CDH)

BackgroundManagement of CDH is highly variable from center to center, as are patient outcomes. The purpose of this study was to examine risk-stratified survival and extracorporeal membrane oxygenation (ECMO) rates at a single center, and to determine whether adverse outcomes are related to patient characteristics or management.MethodsA retrospective single-center review of CDH patients was performed, and outcomes compared to those reported by the CDH Study Group (CDHSG) registry. Patient demographics, disparities, and clinical characteristics were examined to identify unique features of the cohort. A model derived using the registry that estimates probability of ECMO use or death in CDH newborns was used to risk-stratify patients and assess mortality rates. Observed over expected (O/E) ECMO use rates were calculated to measure whether “excess” or “appropriate” ECMO use was occurring.ResultsThere were 81 CDH patients treated between 2004–2017, and 5034 in the CDHSG registry. Mortality in ECMO-treated patients was higher than the registry. Socioeconomic variables were not significantly associated with outcomes. The strongest predictors of mortality were ECMO use and early blood gas variables. The risk model accurately predicted ECMO use with a c-statistic of 0.79. Compared with the registry, the disparity in mortality rates was greatest for moderate-risk patients. O/E ECMO use was highest in low and moderate-risk patients.ConclusionsECMO use is a more consistent predictor of mortality than CDH severity at a single center, and there is relative overuse of ECMO in lower-risk patients. Risk stratification allows for more accurate institutional assessment of mortality and ECMO use, and other centers could consider such an adjusted analysis to identify opportunities for outcomes improvement.Level of EvidenceIII.     

Octreotide for chylous effusions in congenital diaphragmatic hernia

Background/Purpose

Chylothorax is a frequent complication in congenital diaphragmatic hernia (CDH) infants and is associated with significant morbidity. The optimal treatment strategy remains unclear. We hypothesize that octreotide decreases chylous effusions in infants with CDH.

Methods

This is a retrospective study of all infants with CDH admitted to our institution from October 2006 to October 2011.

Results

Eleven (12%) infants developed a chylothorax. Five infants were managed conservatively with thoracostomy and total parenteral nutrition. Six infants were started on octreotide therapy. None of the infants required surgical intervention to stop the effusion. There was no significant difference in survival to discharge, length of stay, or average daily chest tube output between groups. There appeared to be a temporally associated drop in chest tube output upon initiation of octreotide in two infants; however, the overall rate of decline in chest tube drainage was unchanged. In addition, there were infants in the conservative group who demonstrated a similar drop in daily chest tube output despite the absence of octreotide.

Conclusions

Our data suggest that the majority of chylous effusions in CDH infants resolve with conservative therapy alone.     

Pneumothorax as a presenting manifestation of early sarcoidosis

Pneumothorax rarely develops sarcoidosis. A 21-year-old man with early sarcoidosis presenting as pneumothorax is reported. The patient came to our institute with severe chest pain and dyspnea. Plain chest roentgenograms revealed pneumothorax in the left lung. A chest tube was inserted to inflate the lung. Subsequent computed tomography demonstrated subpleural blebs in the upper lobe of the left lung. Continuous treatment with tube drainage was performed. However, surgical intervention was needed since long-term tube drainage turned out to be unsuccessful. Thoracoscopic partial extirpation on the left upper lobe was performed. The histology of the obtained lung tissue showed non-caseating granulomas composed of epithelioid cells and occasional giant cells. A diagnosis of sarcoidosis was made on the basis of the histological report. Although early sarcoidosis presenting as pneumothorax is rare in young patients, the possibility of a sarcoidosis should be considered.     

Thoracoscopic surgery for congenital diaphragmatic hernia: a report of nine cases

PURPOSE: To describe the surgical technique and early results of thoracoscopic repair of congenital diaphragmatic hernia (CDH) in children. MATERIALS AND METHODS: A retrospective review was undertaken of patients with CDH who underwent thoracoscopic surgery in our institution over a period of 15 months. There were nine patients, five boys and four girls, ranging in age from 7 days to 8 years. All nine patients underwent surgery under general anaesthesia. Reduction of the hernia contents was carried out using one optical trocar and two operating trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 2 to 4 mmHg. The hernia defect was repaired using non-absorbable interrupted sutures. RESULTS: The hernia was located on the left side in seven patients and on the right side in two. The mean operative time was 80 minutes. In all patients, the chest tube was removed on the first postoperative day. All patients were discharged on the fifth postoperative day. Chest X-ray and clinical examination 3 months after surgery were normal in all patients. CONCLUSION: The thoracoscopic approach for the repair of CDH in children, including small infants and newborns, is feasible and safe. The technique causes minimal trauma, results in good respiratory function, and promotes early recovery.     

13例新生儿气漏的病因分析和治疗

目的 探讨新生儿气漏的病因、临床特点和诊断治疗.方法 回顾性分析13例气漏患儿的临床资料,治疗使用中心静脉导管代替传统的穿刺针,一次性输液器延长管、灭菌输液瓶及中心负压吸引器组成的胸腔闭式引流装置代替胸管和传统的吸引装置进行闭式引流,呼吸机辅助呼吸.结果 13例气漏患儿中有7例患儿行胸腔闭式引流,中心静脉导管留置3～7d后,复查胸片,被压缩的肺组织基本复张.治愈10例,好转后放弃治疗1例,死亡2例,死亡率为15.4%.结论 新生儿气漏死亡率较高,呼吸窘迫综合征是导致新生儿气漏发生的常见原因.治疗气漏的一个重要方法是行胸腔闭式引流,笔者所在科室使用中心静脉导管代替传统的胸管行引流治疗的方法,具有方法简单、引流效果理想、不易造成后期发育畸形、价格低廉等优点.