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Query: UMLS:C0019270 (hernia)
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The writers report a clinical series of 50 patients with traumatic diaphragmatic hernia. There were 36 hernias on the left side and 14 on the right. Stab or bullet wound was the cause of the hernia in 27 cases. The other 23 cases were due to traffic accidents or other blunt injuries. Immediate operative repair was done in 30 cases; in 20 cases the operation was carried out after a time interval of 11.5 years post trauma on an average. Plain chest X-ray, barium meal or enema and pneumoperitoneum were the most valuable diagnostic tools. Visceral injuries were discovered in 53% of cases caused by traffic accidents. The omentum, stomach, colon and spleen were the organs most frequently herniated. In two cases perforation of the stomach occurred before the operation. There were three cases of pericardial rupture associated with the diaphragmatic hernia in the series. The repair was done via thoracotomy in 28 cases, via laparotomy in 4 cases; and both thoracotomy and laparotomy were carried out in 18 cases. The hospital mortality was 2%. One of the patients died of peritonitis and renal failure following perforation of the stomach and intestines on the 9th postoperative day. Recurrence of the hernia occurred twice in one case. Re-examination revealed striction of the diaphragmatic movement in 11 cases. The clinical features, diagnosis and operative treatment are discussed.
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PMID:Traumatic diaphragmatic hernia. Report of 50 cases. 59 96

Three cases of spontaneous umbilical hernia rupture in patients with alcoholic liver disease and ascites are reported. Eighteen cases have been previously reported in the literature. These 21 cases are reviewed in an attempt to determine precipitating events, prognostic factors, complications, and the results of therapy. All patients had significant ascites prior to umbilical rupture. Ulceration of the umbilicus prior to rupture was common (81%). The subsequent presence of peritonitis, hypotension, renal failure, gastrointestinal hemorrhage or hepatic coma was associated with significant mortality (80%). All patients with a serum albumin above 2.4 gm./dl. survived. There were no survivors in those patients who did not receive surgical treatment. Based upon the outcome of these 21 patients optimal treatment of this disorder would seem to be early surgical repair of the umbilical hernia, appropriate fluid and electrolyte replacement, antiobiotics and measures to reduce intraabdominal pressure.
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PMID:Spontaneous umbilical hernia rupture: a report of three cases. 70 65

Extracorporeal membrane oxygenation (ECMO) is effective for newborns with pulmonary failure unresponsive to conventional therapy. However, ECMO for the older child and adult has been controversial and not widely utilized. Over 4 years, 24 patients (aged 4 months to 16 years; 11 boys, 13 girls) underwent venoarterial ECMO (duration, 7 to 19 days) for respiratory failure. The diagnoses were: viral pneumonia (7), hydrocarbon aspiration (6), sepsis with adult respiratory distress syndrome (ARDS) (2), bacterial pneumonitis (2), tracheal stenosis (1), bilateral pulmonary contusion (1), diaphragmatic hernia with ARDS (1), ketoacidosis with ARDS (1), pulmonary artery injection of hydrocarbon (1), drowning (1), and epiglottis with barotrauma (1). Pre-ECMO blood gas ranges (and means) were PO2 18 to 65 (46), and PCO2 47 to 112 (65). Nineteen patients received dopamine, dobutamine, or other inotrope for associated cardiac and/or renal failure. Cannulation for ECMO was through neck or groin vessels in 17, and sternotomy in 7. ECMO flow rates were 150 to 250 mL/kg/min, to maintain PO2 greater than 100 and PCO2 less than 40. Nine patients (41%) survived ECMO, with eight long-term survivors, (4 hydrocarbon aspiration or injection, 1 pulmonary contusion, 1 viral pneumonia, 1 ARDS, 1 barotrauma), three of whom have mild neurological deficit. All patients with sternotomy, and 8 of 15 with neck and/or groin cannulation, required 1 to 5 explorations for hemorrhage while on ECMO. All survivors had primarily pulmonary failure; patients with combinations of pulmonary, cardiac, and renal failure did not survive. ECMO can be life-saving in the child with isolated pulmonary failure, but its efficacy in patients with multiorgan failure is uncertain.
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PMID:Prolonged extracorporeal support for nonneonatal respiratory failure. 140 44

In the 6 years before this paper, all children presenting with end-stage renal failure (ESRF) in Northern Ireland were electively commenced on continuous ambulatory peritoneal dialysis (CAPD). In that period, 22 patients were treated, 16 received renal transplants and 6 remained on CAPD. Active treatment was withdrawn in 1 child due to obliterative peritonitis. There were no deaths. One incident of peritonitis was documented per 11.6 patient treatment months. Recurring peritonitis lead to catheter replacement in 3 patients. Other problems encountered were catheter exit site infections, hernia formation and in one instance, hydrothorax. Peritonitis was more common in children under 2 years of age as was undernutrition, growth retardation and developmental delay. Home CAPD can be recommended as a viable first option treatment for childhood ESRF where suitable haemodialysis facilities are not easily accessible.
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PMID:Efficacy of CAPD as the primary treatment for end-stage renal failure in children. 147 95

This report describes a 7-year experience with acute peritoneal dialysis in 31 neonates and infants less than 60 days of age. There were 20 boys and 11 girls, ages 3 to 60 days. Tenckhoff catheters of modified length were placed in the newborn intensive care unit (ICU), pediatric ICU, or surgery suites, and hourly exchanges (20 cc/kg) were started immediately postoperatively. Diagnoses included congenital metabolic disorders (11), acute tubular necrosis (6), postcardiopulmonary bypass with renal failure (5), renal cortical necrosis (5), obstructive uropathy (2), renal agenesis (1), and bilateral renal dysplasia (1). Complications included: peritonitis (4), bowel perforation (1), exit site infection (3), leaking dialysate (4), catheter obstruction (2), inguinal hernias (3), umbilical hernia (1), and retroperitoneal hemorrhage (1). There were 19 deaths (61.3%) from 1 to 90 days postinsertion in this high risk group. The (1), and post liver transplant (1). Effective dialysis (lowering of blood urea nitrogen (BUN) or ammonia, correction of acidosis, decrease in fluid overload) was possible in all cases. Five of the 12 survivors remain on chronic dialysis awaiting renal transplantation. Peritoneal dialysis is effective in the newborn period in the management of metabolic disturbances as well as renal failure. Morbidity and mortality (61.3%) is related to the near-morbid condition of the baby at the time of insertion and the severity of the complex underlying diagnosis often associated with multiorgan failure.
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PMID:Peritoneal dialysis in the first 60 days of life. 229 35

Trends are changing in the management of infants and children with indirect inguinal hernias. Advances in neonatal intensive care have resulted in the survival of many small premature infants who have a high incidence of inguinal hernia. The rate of incarceration, strangulation, and gonadal infarction in these babies is twice that of the general pediatric age group. Respiratory immaturity, apnea, bradycardia, and associated neonatal conditions require special management at the time of hernia repair, usually performed just before discharge from the neonatal intensive care unit. New information concerning volume loss and depletion of germ cells beginning at 6 months of age in boys with undescended testes has stimulated the performance of orchiopexy when the patient is 1 year of age. More than 90% of boys with cryptorchid testes at the age of 1 year have an associated hernia that requires concomitant repair at the time of orchiopexy. The use of the peritoneal cavity for fluid absorptive purposes in hydrocephalus treated by venticuloperitoneal shunts or of peritoneal dialysis for renal failure and metabolic diseases such as hyperammonemia and lactic acidosis causes increased intraabdominal pressure and results in the appearance of a previously unrecognized hernia. Recognition of these and other conditions associated with a high incidence of hernial occurrence should allow early diagnosis and treatment before the development of complications. Most elective repairs of hernias are safely performed in the outpatient setting; however, some infants and children with concurrent illnesses are best managed in a "morning admissions" program, in which hospital admission occurs postoperatively.
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PMID:Current concepts in inguinal hernia in infants and children. 257

Extracorporeal membrane oxygenation (ECMO) is an approved therapy for some neonates who have respiratory failure that is due to hyaline membrane disease, meconium aspiration, persistent pulmonary hypertension, congenital diaphragmatic hernia, or sepsis. The major complication of this therapy is hemorrhage, with intracranial hemorrhage having the highest morbidity and mortality. Seizures, incisional bleeding and bleeding in the pleural space, hypoxic-ischemic encephalopathy, renal failure, and cardiovascular complications account for most of the other complications. Cranial sonography provides an ideal imaging modality for baseline evaluation and daily follow-up; however, computed tomography and magnetic resonance imaging, because of better sensitivity, are important for assessment after ECMO. The changes in intracranial blood flow related to ECMO can be noninvasively evaluated by Doppler ultrasound modalities.
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PMID:Neurosonographic findings in infants treated by extracorporeal membrane oxygenation (ECMO). 268 79

Safe management of the newborn infant with congenital diaphragmatic hernia (CDH) requires precise fluid administration to avoid hypovolemia or fluid overload. Twenty-two CDH patients and 12 infants who underwent abdominal operations were studied for three postoperative days to determine whether the postoperative neonatal renal response to fluid administration was appropriate or inappropriate. Each response was categorized, on the basis of urine and blood measurements, as: (1) appropriate urine output and concentration, (2) inappropriate urine output and concentration with fluid retention or (3) renal failure. Fluid intake was similar in all groups. The CDH group had a significantly lower urine output, higher urine osmolarity, and lower serum osmolarity. All of the control group (100%) responded appropriately to intake. Sixty-four percent of the CDH group inappropriately retained water during the first 16 hours (appropriate, 27%; renal failure, 9%). By 24 hours, 34% still had inappropriate urine output and fluid retention. The majority of patients with CDH initially responded inappropriately to postoperative fluid intake. If this response is not recognized and fluid intake is not adjusted, serious fluid overload will result.
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PMID:Inappropriate fluid response in congenital diaphragmatic hernia: first report of a frequent occurrence. 285 19

Living related donor (LRD) nephrectomies are controversial due to the risks to the donor and improved cadaveric graft survival using cyclosporine A. Between December 22, 1970, and December 31, 1984, 1096 renal transplants were performed at a single institution, 314 (28.6%) from LRD. The average age was 34.3 years (range: 18-67); none had preoperative hypertension. All nephrectomies were performed transabdominally. Major perioperative complications occurred in 22 (7.0%). These include wound infections (3.5%), pancreatitis (1.0%), injuries to spleen (1.0%) or adrenal gland (0.3%) requiring removal, pneumonitis (0.6%), ulnar nerve palsy (0.6%), femoral artery thrombosis after arteriogram (0.3%), pulmonary embolus (0.3%), and upper pole infarct of contralateral kidney (0.3%). There are six known deaths in this series, none of which were related to the operation. Major late complications were seen in 50 (20.0%) of 250 patients followed for 6 to 175 months (mean 53.1 months). These included definite hypertension (5.6%), suture granuloma (4.4%), incisional hernia (3.6%), proteinuria (2.4%), bowel obstruction (2.0%), nephrolithiasis (1.2%), wound infection (0.4%), scrotal hydrocele (0.4%), and chronic pancreatitis (0.4%). While the risk of hypertension appears to increase as the interval from donation increases, no cases of renal failure after donation have been noted, and negligible proteinuria among those followed long-term has been seen in this series. It is felt that living related kidney donation is justified when the relative is sincerely motivated and well informed prior to donation.
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PMID:Living related kidney donors. A 14-year experience. 352 9

There is an increasing number of patients whose permanent renal failure is managed by chronic peritoneal dialysis. Four adult male patients developed symptomatic indirect inguinal hernias shortly after the institution of dialysis. The hernia sac in each of the patients was both narrow and elongated. We postulate that in each patient the hydrostatic pressure of the dialysis fluid converted a patient processus vaginalis into a symptomatic indirect hernia.
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PMID:Indirect inguinal hernia in patients undergoing peritoneal dialysis. 394 28


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