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Query: UMLS:C0019270 (hernia)
 15,856 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Infants with congenital diaphragmatic hernia (CDH) show a wide range of anatomic and physiological abnormalities, making it difficult to compare the efficacy of management protocols between institutions. The purpose of this study was twofold: (1) to analyze the results of treatment of CDH in a large tertiary care pediatric center using conventional mechanical ventilation (CMV) with extracorporeal membrane oxygenation (ECMO) as rescue therapy, and (2) to compare these results with those of a parallel study by a similar large urban center that used high-frequency oscillating ventilation (HFOV) as rescue therapy without ECMO. All patients who had CDH diagnosed within the first 12 hours of life and were referred for treatment before repair (between 1981 and 1994) were included in the analysis (n = 196). CMV was used initially in all patients, with conversion to ECMO for refractory hypoxemia or hypercapnea. Between 1981 and 1984, ECMO was not available. Between 1984 and 1987, ECMO was offered postoperatively. Between 1987 and 1991, ECMO was offered preoperatively. In all three groups, aggressive hyperventilation and alkalosis was the norm. Since 1991, permissive hypercapnia has been used. HFOV was used in three patients as stand-alone therapy with one survivor. Twenty patients died without repair: Ten had other lethal anomalies, eight died before ECMO could be instituted, and two died of ECMO-related complications. Overall, 104 patients (53%) survived and 92 (47%) died. Ninety-eight patients (50%) received ECMO, and 43 (44%) survived. Survivors had significantly higher 1- and 5-minute Apgar scores and higher postductal Po2s than did nonsurvivors. Associated anomalies were present in 39%, who had a significantly lower survival than those with isolated CDH. Antenatal diagnosis and side of the defect had no impact on outcome. Survival was not improved with the institution of ECMO or delayed repair but rose significantly to 69% (84% with isolated CDH, P = .007) with the introduction of permissive hypercapnea. Autopsy results from nonsurvivors showed other lethal anomalies and significant barotrauma as the primary causes of death. Comparisons between the Boston and Toronto series showed similar patient demographics and no significant differences in survival in any time period. The two series differed in the number of associated anomalies, their impact on survival, and in the prognosis of right-sided CDH. From the individual and combined analyses the authors concluded: (1) CMV with ECMO as rescue produced an overall survival in CDH patients equivalent to CMV with HFOV in a parallel series, (2) neither HFOV nor ECMO has significantly improved outcome in CDH patients, (3) institution of permissive hypercapnia has resulted in a significant increase in survival, and (4) the leading causes of death in CDH patients appear to be associated anomalies and pulmonary hypoplasia, which are currently untreatable. Barotrauma, which may contribute in up to 25% of deaths in CDH patients is avoidable.
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PMID:Congenital diaphragmatic hernia--a tale of two cities: the Boston experience. 909 2

Congenital diaphragmatic hernia (CDH) is associated with pulmonary hypoplasia. The pulmonary vascular bed may be extremely reactive to various stimuli, and in the treatment it is important to avoid pulmonary vasospasm. The strategy in our institution since 1990 has involved a prolonged preoperative stabilization with gentle mechanical ventilation. Pressures have been kept as low as possible, and slight hypercarbia has been accepted. Peak inspiratory pressures exceeding 35 cm H2O have been avoided. Extracorporeal membrane oxygenation (ECMO) has been used according to standard inclusion criteria. Nitric oxide and high-frequency oscillation have been added to the therapeutic modalities during the study period. When the patient was considered stabilized, surgical repair was undertaken after a delay of 24 to 96 hours. In patients on ECMO who could not be decannulated, surgical repair was undertaken while on ECMO. From 1990 through 1995, 52 patients were admitted with a diagnosis of CDH. Forty-three of these were risk group patients presenting with respiratory distress within 6 hours after birth. A total of 48 patients survived (survival rate 92%), and 39 of the risk group patients (survival rate 91%). There were only four hospital deaths, all with contraindications to ECMO. It is suggested that the adopted protocol is beneficial in the treatment of CDH and that the fraction of patients who have pulmonary hypoplasia incompatible with life is smaller than previously believed.
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PMID:Improved results in patients who have congenital diaphragmatic hernia using preoperative stabilization, extracorporeal membrane oxygenation, and delayed surgery. 926 67

Over the last two decades there has been a constant improvement in the understanding of the pathophysiology of Congenital Diaphragmatic Hernia (CDH) and its management. However, the ideal treatment remains elusive. The earlier management strategy of immediate surgery is replaced by the principle of physiological stabilisation and delayed surgery. Conventional mechanical ventilatory techniques, with high pressures and hyperventilation to reverse ductal shunting and cause alkalinization, are being questioned because of the risks of barotrauma and consequent broncho-pulmonary dysplasia. It has also been shown that paralysis with pancuronium bromide for patients on conventional mechanical ventilation results in increased incidence of sensorineural hearing loss in childhood survivors of CDH. With the introduction of the concept of permissive hypercapnia and high frequency oscillation ventilation, the complications of pulmonary barotrauma are circumvented. Although ECMO therapy is invasive, yet has improved survival by about 15% independently, especially in critically ill infants who have the predictive mortality rate of more than 80%. Further insights into the pathophysiology of CDH and the introduction of less invasive therapeutic techniques in the form of high frequency oscillation ventilation, inhalation nitric oxide, surfactant, and perfluorocarbon liquid ventilation may even make the need for ECMO redundant.
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PMID:Congenital diaphragmatic hernia. 1102 21

Management of congenital diaphragmatic hernia has changed dramatically over the past couple of decades. Until the early 1980s, it was felt that the abdominal contents should be returned to the abdomen as soon as possible to allow the lungs to expand. It is now known that it is not the defect that causes respiratory distress, but the infant's hypoplastic lungs and accompanying pulmonary hypertension. Advances in treatment and technology have contributed to changes in management. Ultrasonography now allows for early prenatal detection. Prenatal treatment modalities include in utero tracheal ligation and maternal antenatal steroids. Postnatal modalities have expanded to include permissive hypercapnia, high-frequency ventilation, inhaled nitric oxide, pharmacologic support, exogenous surfactant, and extracorporeal membrane oxygenation. Liquid ventilation and lobar lung transplantation have also been tried. In spite of these advances, the overall survival rate remains about 63 percent.
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PMID:Current and emerging treatment for congenital diaphragmatic hernia. 1214 12

Congenital diaphragmatic hernia (CDH) is a lethal human birth defect. Hypoplastic lung development is the leading contributor to its 30-50% mortality rate. Efforts to improve survival have focused on fetal surgery, advances in intensive care and elective delivery at specialist centres following in utero diagnosis. The impact of abnormal lung development on affected infants has stimulated research into the developmental biology of CDH. Traditionally lung hypoplasia has been viewed as a secondary consequence of in utero compression of the fetal lung. Experimental evidence is emerging for a primary defect in lung development in CDH. Culture systems are providing research tools for the study of lung hypoplasia and the investigation of the role of growth factors and signalling pathways. Similarities between the lungs of premature newborns and infants with CDH may indicate a role for antenatal corticosteroids. Further advances in postnatal therapy including permissive hypercapnia and liquid ventilation hold promise. Improvements in our basic scientific understanding of lung development may hold the key to future developments in CDH care.
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PMID:Congenital diaphragmatic hernia. 1245 5

A number of new techniques have been studied for managing newborns with congenital diaphragmatic hernia and respiratory insufficiency. Among these have been the techniques of delayed approach to the repair of the diaphragmatic hernia; permissive hypercapnia; nitric oxide and surfactant administration; intratracheal pulmonary ventilation; liquid ventilation; perfluorocarbon-induced lung growth; and lung transplantation. These interventions are at various stages of development and evaluation of effectiveness. All, however, are being explored in the hopes of improving outcome in patients with congenital diaphragmatic hernia who continue to have significant morbidity and mortality in the newborn period.
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PMID:New approaches to managing congenital diaphragmatic hernia. 1528 98

Despite improvements in prenatal diagnosis and neonatal intensive care, the Congenital Diaphragmatic Hernia (CDH) Registry still records a 64% survival rate. Many reports demonstrate, however, that approximately 80% of CDH patients with no other malformations may survive if managed with permissive hypercapnia, gentle ventilation, high-frequency oscillatory ventilation (HFOV), surfactant, inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation (ECMO), and delayed surgical repair. We wished to define the evolving outcome of CDH newborns using a protocol approach to management, which includes surgery in the neonatal intensive care unit (NICU) or operating room (OR). From January 1996, data were collected prospectively on 42 consecutive live-born infants with CDH. Newborns symptomatic at birth were sedated and paralyzed in the delivery room, and treated with elective HFOV, iNO, surfactant, and ECMO as necessary, delaying surgical repair until their clinical conditions were stable. Once the CDH newborn was stabilized, a trial on conventional ventilation was started at least 24 hours before surgery; however, if the patient was unstable, therapy was switched back to HFOV and surgery was performed in the NICU. Demographic and clinical parameters were compared between CDH newborns who underwent surgery in the NICU and in the OR. The two groups were comparable in terms of clinical characteristics and baseline ventilatory and blood gas values. Mean age at surgery was 3 +/- 2 days. After surgery, the NICU group had more infectious complications. However, the survival rate of uncomplicated CDH was 78% and a low rate of chronic lung disease was reported. A prolonged phase of presurgery stabilization is proposed and strict control of infection is recommended for the CDH newborns who might benefit from an exclusive HFOV and NICU surgery.
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PMID:Congenital diaphragmatic hernia: intensive care unit or operating room? 1590 12

Severe obesity is a chronic condition that is difficult to treat through diet and exercise alone. Gastrointestinal surgery for obesity (bariatric surgery) alters the digestive process by either restrictive surgical alterations or malabsorptive operations. Some 10-20% of patients who have weight-loss surgery require follow-up operations to correct complications. Hypoxemia after gastric bypass surgery for morbid obesity, a reported complication, can occur as early as 24 h post surgery. Two patients presented with severe hypoxia and were placed on veno-venous extracorporeal membrane oxygenation (ECMO). Patient No. 1 had an obstruction of the alimentary limb of the gastric bypass due to suture adhesions, and patient No. 2 had an incarcerated diaphragmatic hernia. While on ECMO, ventilation using a protective strategy (60% FiO2, pressure-controlled ventilation inspiratory pressure (PCV) IP 25-27, positive end-expiratory pressure (PEEP) 10-14, permissive hypercapnia) was employed. An inflow cannula to the level of the right atrium served as arterial outflow from the circuit to the patient, while the femoral vein served as venous inflow to the ECMO circuit. Although ECMO in adult respiratory failure is often used as the last resort due to serious associated adverse events, we report two patients with life-threatening complications from gastric bypass who were rescued, resuscitated to day 7, and uneventfully discharged from the hospital to home.
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PMID:Respiratory failure of two sp gastric bypass patients and subsequent rescue with extracorporeal membrane oxygenation. 1648 3

We experienced an extremely rare complication during performance of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair for a 57-year-old healthy man. About 50 minutes after CO(2) insufflation, the patient developed tachycardia, hypoxemia, hypercapnia and an increased airway pressure. Right pneumothorax with subcutaneous emphysema was recognized on the emergency chest X-ray and this was successfully treated by chest tube insertion. Anesthesiologists should be aware of the possible occurrence of pneumothorax during laparoscopic TEP hernia repair.
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PMID:Pneumothorax during laparoscopic totally extraperitoneal inguinal hernia repair -A case report-. 2053 60

Thoracoscopic operations in neonates, such as repair of oesophageal atresia and tracheooesophageal fistula or congenital diaphragmatic hernia, can be associated with intraoperative acidosis and hypercapnia in the absence of hypoxia. These derangements in intraoperative gas exchanges seem to be related to the insufflation and absorption of medical CO2. The effects on the developing brain are unknown, and further prospective investigations are needed to elucidate whether different strategies should be implemented to avoid these intraoperative problems.
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PMID:Hypercapnia and acidosis during the thoracoscopic repair of oesophageal atresia and congenital diaphragmatic hernia. 2563 11


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