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Late-Presenting Congenital Diaphragmatic Hernia in Children

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Bagłaj M., Ładogórska J., Czernik J.
Polish Journal of Surgery
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2007
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vol. 79
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issue 4
305-311
EN
Congenital diaphragmatic hernia (CDH) is a typical neonatal emergency. There is, however, a subset of patients who manifest this congenital anomaly in infancy and early childhood. Late-presenting diaphragmatic hernia is characterized by a variety of gastrointestinal and respiratory symptoms with acute or chronic modes of manifestation.The aim of the study. Analysis of the clinical course, diagnosis, and surgical management of latepresenting CDH in children.Material and methods. A retrospective study of medical charts and diagnostic studies was performed for children older than 1 month of age with CDH, treated in the University Department of Pediatric Surgery and Urology in Wroclaw between 1975 and 2005.Results. In a 30-year period, 23 children with late-presenting CDH were treated. In one case, paraoesophageal hernia was diagnosed; Morgagni hernia was diagnosed in 2 cases. Among 20 children with postero-lateral CDH, 12 were younger than 1 year of age at diagnosis. In this group, left-sided CHD was noted in 17 children, while a right-sided defect was noted in 3. Nine infants with left CDH presented mainly respiratory symptoms; in 3 cases gastrointestinal symptoms prevailed. In the group of children beyond 1 year of age, 6 manifested chronic respiratory symptoms and 2 had mainly acute gastrointestinal complaints. In all children, CDH was diagnosed preoperatively. The most accurate diagnostic modality in 17 cases was a contrast upper GI study. Intraoperative findings revealed the presence of a hernial sac in only 3 patients. A complicated course of CHD with torsion of the stomach was noted in 2 children; intestinal necrosis was seen in one patient. Small and large bowel were the organs most commonly displaced into the thoracic cavity (noted in 12 and 11 children, respectively). In all children, surgical management of CDH was successful.Conclusions. Lack of typical clinical signs and symptoms of late-presenting CDH seems to be a factor responsible for delayed diagnosis of this anomaly in older children. Late presentation of CDH should be taken into differential diagnosis in all children presenting with gastrointestinal or respiratory symptoms. Late-presenting diaphragmatic hernia is an unequivocal indication for surgical management as soon as its diagnosis has been established.
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Clinical Spectrum of Malrotation in Children

100%
Bagłaj M., Patkowski D., Czernik J., Hilger T.
Polish Journal of Surgery
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2007
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vol. 79
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issue 4
286-296
EN
The aim of the study. Retrospective analysis of diagnosis, surgical management and final outcome of malrotation in children.Material and methods. Clinical charts, operative notes and imaging studies of all children operated on for malrotation in years 1985-2005 were studied. Children in whom malrotation was diagnosed incidentally during an operation performed because of other indications were excluded. A detailed analysis of the presentation, signs and symptoms, clinical course, and diagnostic modalities used in affected patients was carried out. Anatomical variants of malrotation and their operative management were evaluated as well.Results. In the period from 1985 to 2005 forty children with malrotation were treated. There were 25 neonates, 10 infants and 5 children older than 1 year of age. Thirty-five children were referred directly as inpatients from other hospitals. An acute or urgent clinical presentation was noted in 32 children, while in 8 patients as the presentation was subacute or chronic. In all children bile-stained vomiting was the predominant sign. In 21 children, ileus was the referral diagnosis. Only 5 children were admitted with an established diagnosis of malrotation. In six cases duodenal atresia was suspected. Delay in diagnosis of congential intestinal anomaly was identified in 15 children. In five newborns, the initial diagnosis was enterocolitis. Four other patients, including one infant and three older children, were admitted to the pediatric departments several times before receiving the final diagnosis. In 18 children, the only pre-operative imaging was abdominal plain X-ray. In 22 patients, contrast studies were performed as well. All children underwent operative management. Ladd's syndrome was diagnosed in 16 patients, and in another 7 children was associated with small bowel torsion. Isolated small bowel torsion was noted in 7 patients. In 6 patients, midgut volvulus with strangulation was found intraoperatively. Two children with typical anatomical features of non-rotation presented with recurrent episodes of ileus. In single cases, mesocolic internal hernia and sigmoid torsion were noted. 5 children died postoperatively, four of whom had midgut volvulus with massive small bowel necrosis.Conclusions. Malrotation is a rare congenital anomaly that can present with a wide anatomical and clinical spectrum but should be considered in the differential diagnosis for all children, regardless of age, manifesting with bile-stained vomiting. Suspicion of malrotation seems to be an obvious indication for referral to a tertiary pediatric surgical department where necessary imaging should be undertaken with the participation of an experienced radiologist. Regardless of its clinical presentation, malrotation should be considered an unequivocal indication for surgical treatment due to risk of midgut volvulus with its serious sequelae.
3
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Minimally Invasive Surgery in Newborns and Infants - Own Experience

76%
Patkowski D., Rysiakiewicz K., Rysiakiewicz J., Koziełł A., Apoznański W., Czernik J.
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EN
The aim of the study was to present own experience in utilisation of minimally invasive techniques in newborn and infant.Material and methods. It is retrospective analysis of minimally invasive procedures conducted in Department of Pediatric Surgery and Urology with focus on patients group up to age of one year.Results. In total 1791 minimally invasive procedures were conducted of which 234 (13.1%) operations were performed on 227 (7 patients underwent procedure twice) children in age group of up to one year in period from 01.04.1995 till 30.06.2008. There were 28 (11.97%) thoracoscopic and 206 (88.03%) laparoscopic procedures. No complications related to creation of pneumoperitoneum or surgical pneumothorax were observed. The commonest indications to surgery were inguinal hernia (116 children) oesophageal atresia with tracheoesophageal fistula (23 cases) and prolonged neonatal jaundice (18 patients).In total in 29 cases it was necessary to convert to open surgery, 2 cases due to intraoperative complications (bleeding, duodenal wall perforation) and in 14 cases due to poor visualisation of operating field.Conclusions. There is broad spectrum of indications to minimally invasive surgery in newborn and infant patients. Results indicate good tolerability of the procedure even in patients with low weight, safety and efficacy in typical conditions. Limited number of procedures performed in various conditions does not allow to draw uniform conclusions and requires further study.
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