Iatrogenic diaphragmatic hernia due to laparoscopic gastric banding

A patient developed a huge diaphragmatic hernia following laparoscopic gastric banding. Almost the entire stomach was incarcerated within the left chest. Segmental necrosis of the greater curvature of the stomach necessitated partial gastrectomy. The postoperative course was uneventful. The etiology, diagnosis and treatment of this previously undescribed complication of laparoscopic gastric banding are addressed in relation to the present case.     

Fate of the type II pneumocyte following tracheal occlusion in utero: a time-course study in fetal sheep

 Tracheal occlusion in utero has been shown to cause accelerated fetal lung growth and is now being considered as a therapeutic modality for pulmonary hypoplasia. We report the effects of tracheal ligation on the surfactant-producing type II pneumocyte population. Three groups of fetal lambs underwent tracheal ligation of 2 weeks’, 4 weeks’ and 6 weeks’ duration, respectively, and all were sacrificed at 136 days’ gestation (9 days pre-term). Nonoperated twins served as controls. The type II pneumocyte population was studied morphometrically using a combination of anti-surfactant protein B immunohistochemistry and computer-assisted stereologic morphometry at light and electron microscopic levels. Single-factor ANOVA was used for statistical analysis. Two weeks of tracheal ligation resulted in doubling of the total lung volume as a result of airspace distension and, to lesser extent, growth of the tissue compartment. With increasing duration of tracheal ligation, there was no additional lung growth. However, more prolonged tracheal occlusion was found to result in significant reduction of the surfactant system, as reflected in the marked decrease of total pneumocyte type II volume (3.14 cm³, 0.95 cm³, and 0.46 cm³, after 2, 4, and 6 weeks of ligation, compared with 5.96 cm³ for controls) and total pneumocyte type II number (13.9 × 10⁹, 3.8 × 10⁹, and 2.4 × 10⁹, compared with 53.2 × 10⁹ for controls). Ultrastructural analysis of the type II cells in obstructed lungs showed vacuolar degenerative changes that, after 6 weeks of ligation, were apparently irreversible. In utero tracheal ligation causes fetal lung hyperplasia, but results in reduction of and injury to the surfactant-producing cell population. Before tracheal occlusion can find widespread clinical application, its pathophysiology needs to be further elucidated. Received: 30 April 1997 / Accepted: 10 July 1997     

肺癌侵犯膈肌6例外科治疗体会

对6例侵犯膈肌的非小细胞肺癌进行回顾性分析,其中肺叶切除4例,双肺叶切除1例,左全肺切除1例,6例均伴受侵膈肌切除+膈肌修复术,术后辅助化疗。结果表明,6例切除标本病理证实均为肺鳞状细胞癌侵犯膈肌,术前均未疑诊。2例N_0病人术后14、31个月健在,1例N_1病人术后25个月死亡。3例N_2病人分别于术后9、10、18个月死亡。因此,正确评价纵隔状态以采取不同的治疗组合是改善预后的关键。     

创伤性膈疝误诊漏诊原因分析（附8例报告）

目的：探讨创伤性膈疝误诊漏诊的原因,方法：回顾性分析１９７６～１９９６年８例创伤性膈疝并结合有关文献进行探讨。结果：全组患者术前确诊５例,术前未明确膈肌破裂,因其它原因手术而确诊３例,结论：创俐性膈疝的诊断主要依靠临床动脉观察和Ｘ线的特异表现为追踪观察。     

Retinol status of newborn infants with congenital diaphragmatic hernia

The etiology of congenital diaphragmatic hernia (CDH) is not yet known. Studies in the literature from 1941 have reported that nutritional deficiency of vitamin A during pregnancy could lead to CDH, associated or not with other malformations in young rats. More recently, possible correlations between expression patterns of cellular retinoid-binding protein and retinoic-acid receptors and morphologic effects of vitamin A deficiency have been suggested. The purpose of this study was to verify in human newborns the possible link between vitamin A deficiency and CDH previously observed in experimental animals. Blood samples were obtained during the first hours after birth from 11 term CDH newborns and 11 healthy controls matched for gestational age, and also from 7 mothers in each group, for a total of 7 newborn-mother pairs of matched CDH-controls. Plasma retinol was measured by high-performance liquid chromatography and retinol-binding protein (RBP) by nephelometry. In the 11 matched CDH-control newborns, plasma retinol and RBP levels in CDH newborns were 50% less than control values (P< 0.0002 and <0.006, respectively); in contrast, retinol levels in CDH mothers were significantly higher than those of control mothers (P < 0.005). The observation that the plasma concentrations of retinol and RBP are low in infants with CDH relative to controls may be clinically very relevant and may help to elucidate the mechanism of development of this congenital anomaly.     

Respiratory Failure Secondary to Diaphragmatic Paralysis from Acute Exacerbation of Dermatomyositis

Dermatomyositis (DM) is an idiopathic inflammatory disorder that presents with proximal muscle weakness and typical DM skin changes. DM can involve other organs such as the lung, esophagus, and heart. Diaphragmatic muscle paralysis is an unrecognized clinical presentation of acute DM exacerbation. A 58-year-old man with a history of DM presented to the hospital after sustaining a cardiorespiratory arrest. Before arrest, he had been suffering from progressive dyspnea and muscle weakness. Immunosuppressive therapy of tacrolimus for DM was recently discontinued due to renal toxicity. Bedside ultrasound of the diaphragm while intubated revealed evidence of bilateral diaphragmatic paralysis. After extubation, supine and upright pulmonary function tests (PFT) and sniff test results strengthened the diagnosis of diaphragmatic paralysis. The patient was worked up for an acute DM exacerbation as the likely etiology of the severe diaphragmatic muscle weakness (diaphragmatic paralysis) and ventilatory failure. Skin and muscle biopsy confirmed the diagnosis of active DM. The patient was treated with high dose steroids and mycophenolate mofetil, following which he soon recovered.     

胎儿磁共振在先天性膈疝患儿预后评估中的应用研究CSCD

目的回顾性分析先天性膈疝患儿产前胎儿磁共振图像,探讨磁共振测量和评价参数与患儿预后的关系,初步探讨胎儿磁共振参数在先天性膈疝患儿预后评估中的应用价值。方法收集西安交通大学第二附属医院2011—2020年胎儿磁共振图像结果,收集诊断为先天性膈疝的50例胎儿磁共振图像,包括左侧膈疝37例,右侧膈疝13例,检测并分析观察-预期肺容积比、肺肝比、纵膈移位角、肺底基线的完整性、肝脏及胃泡位置等与患儿预后的关系。结果50例患儿中,存活35例(为存活组),死亡15例(为死亡组)。胎儿磁共振图像观察-预期肺容积比:存活组比死亡组为(35.09±10.87)比(24.29±6.86);肺肝比:存活组比死亡组为(2.68±1.01)比(1.93±0.93);纵膈移位角:存活组比死亡组为(30.88±7.07)比(39.05±4.21);差异均有统计学意义(P<0.05)。图像分析结果显示,胎儿磁共振肺底基线不完整、肝脏及胃泡位置疝入胸腔患儿的预后较差,差异具有统计学意义(P<0.05)。受试者操作特征曲线分析结果显示,联合应用观察-预期肺容积比、肺肝比、纵膈移位角、肺底基线的完整性、肝脏及胃泡位置等判断患儿预后,较单一参数判断更为准确,差异具有统计学意义(P<0.05)。结论胎儿磁共振观察-预期肺容积比、肺肝比、纵膈移位角、肺底基线完整性、肝脏及胃泡位置均可作为判断先天性膈疝患儿预后的评价指标,联合应用上述六项参数可以更加准确地判断患儿预后,以上述参数为基础构建先天性膈疝的评估体系,有助于先天性膈疝患儿的肺发育评估、体外膜肺氧合的应用判断以及手术方式的选择。     

Diaphragm ultrasound in the diagnosis of respiratory dysfunction in patients with amyotrophic lateral sclerosis

ObjectiveIn this study, we aimed to select the best diaphragm ultrasonography (DUS) parameter as an alternative index for the diagnosis of lung function impairment in amyotrophic lateral sclerosis (ALS).MethodsTwenty-nine patients with ALS and 15 healthy subjects were enrolled in the study. DUS, lung function tests, phrenic nerve conduction study and arterial blood gas analysis were performed.ResultsPatients with respiratory dysfunction had a significantly lower level of ΔTmax than those without (P = 0.039). Significant correlations (P < 0.05) were found between forced vital capacity (FVC) and Tdi-ins (r = 0.665, P < 0.0001) and ΔTmax (r = ?0.748, P < 0.0001) and Δins-exp (r = 0.627, P < 0.0001) and ΔTdi (r = 0.485, P < 0.0001). Receiver Operating Curves analysis demonstrated that ΔTmax (AUC = 0.76, P = 0.044) had a better overall accuracy for detection of respiratory dysfunction compared with Tdi-ins (AUC = 0.27, P = 0.067), Δins-exp (AUC = 0.312, P = 0.139), and ΔTdi (AUC = 0.38, P = 0.359).ConclusionΔTmax is the most valuable DUS index in the diagnosis of diaphragmatic dysfunction.SignificanceDUS can provide functional and structural information of diaphragm and help to diagnose diaphragmatic dysfunction in ALS.     

A Simplified Formula Using Early Blood Gas Analysis Can Predict Survival Outcomes and the Requirements for Extracorporeal Membrane Oxygenation in Congenital Diaphragmatic Hernia

The aims of this study were to investigate whether early arterial blood gas analysis (ABGA) could define the severity of disease in infants with congenital diaphragmatic hernia (CDH). We conducted a retrospective study over a 21-yr period of infants diagnosed with CDH. Outcomes were defined as death before discharge, and extracorporeal membrane oxygenation requirements (ECMO) or death. A total 114 infants were included in this study. We investigated whether simplified prediction formula [PO₂-PCO₂] values at 0, 4, 8, and 12 hr after birth were associated with mortality, and ECMO or death. The area under curve (AUC) of receiver operating characteristic curve was used to determine the optimum ABGA values for predicting outcomes. The value of [PO₂-PCO₂] at birth was the best predictor of mortality (AUC 0.803, P < 0.001) and at 4 hr after birth was the most reliable predictor of ECMO or death (AUC 0.777, P < 0.001). The value of [PO₂-PCO₂] from ABGA early period after birth can reliably predict outcomes in infants with CDH.     

医源性膈疝MSCT多平面重组表现

目的 分析食管癌术后继发医源性膈疝(IDH)的MSCT多平面重组(MPR)表现,探讨其诊断价值.方法 回顾性分析2010年1月至2014年3月间食管癌术后继发IDH 16例.将其CT号随机混编入其他50例食管癌术后无食管裂孔(EH)扩大患者队列,由2名不知研究目的从事腹部影像诊断的高年资医师分别就横断位和MPR图像进行判断.对不同医师、不同方法判断结果及影像表现差异采用x2检验.结果 16例IDH中3例局限性于EH,横断位2例呈假“肠套叠”征,1例呈肠扭转表现;MPR直观显示肠管挤入EH顶压胸腔胃呈“壁贴壁征”.13例超出EH范围,横断位表现为胸腔内肠管于各方向汇聚于EH处胸腔胃,其中,前外、后外及前后外侧分别为9例、5例和2例,前外侧明显多于前后外侧(x2 =6.79,P＜0.05),2例并肠系膜扭转;MPR直观显示胸腔内管肠及其系膜血管通过EH与腹腔相应结构连通.由2名医师横断位提示IGH诊断分别为3例和4例,MPR全部提示IDH诊断,均显著高于横断位(x2=21.89,19.20,P值均＜0.05).结论 食管癌术后继发IDH横断位表现隐匿,仔细观察并及时辅以MPR,对诊断具有重要意义.