Thoracic versus abdominal approach to correct diaphragmatic eventration in children

Alisha Gupta; Martin Sidler; Daan van Poll; Nikita Patel; Simon Eaton; Nagarajan Muthialu; Paolo De Coppi

doi:10.1016/j.jpedsurg.2019.10.040

Thoracic versus abdominal approach to correct diaphragmatic eventration in children

J Pediatr Surg. 2020 Feb;55(2):245-248. doi: 10.1016/j.jpedsurg.2019.10.040. Epub 2019 Nov 2.

Authors

Alisha Gupta¹, Martin Sidler², Daan van Poll¹, Nikita Patel¹, Simon Eaton³, Nagarajan Muthialu³, Paolo De Coppi⁴

Affiliations

¹ Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children NHS trust, London, UK.
² Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children NHS trust, London, UK; Stem Cells and Regenerative Medicine section, Developmental Biology and Cancer Programme, Institute of Child Health, University College London, London WC1N 1EH, UK.
³ Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children NHS Trust.
⁴ Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children NHS trust, London, UK; Stem Cells and Regenerative Medicine section, Developmental Biology and Cancer Programme, Institute of Child Health, University College London, London WC1N 1EH, UK. Electronic address: paolo.decoppi@gosh.nhs.uk.

PMID: 31761454
DOI: 10.1016/j.jpedsurg.2019.10.040

Abstract

Background: Plication of diaphragm (DP) for eventration (DE) can be done using thoracic or abdominal approaches. The purpose of our study was to compare outcomes between these approaches based on our experience and on systematic literature review.

Methods: Retrospective records of children <16 years who underwent DP (single-center, 2004-2018) were recorded and analyzed. Systematic review and meta-analysis of related studies was undertaken. Data are reported as median (range).

Results: Eighty-nine cases were identified in thoracic (Congenital = 5, Acquired = 84) and 13 (Congenital = 10, Acquired = 3) in abdominal group aged 5.88 (0.36-184.44) and 10.0 (0.12-181.8) months. Improvement in diaphragm level post-DP was significantly higher in abdominal [2(0-4)] than chest [1.5(0-5)] group (p = 0.04). On Cox regression analysis, there was a non-significant trend to a longer time to extubation in the chest group (Hazard ratio (HR) = 0.539[0.208-1.395], p = 0.203). Patients operated transthoracically left intensive care unit after a significantly longer time (HR = 0.339[0.119-0.966], p = 0.043). Patients operated transabdominally tended to be fed later, although this was not significant (HR = 1.801[0.762-4.253], p = 0.043). On Kaplan-Meier analysis, there was a non-significant trend to a lower rate of recurrence in the abdominal group (HR = 0.3196[0.061-1.675], p = 0.1876). In the meta-analysis including three published studies as well as our data (total n = 181, Thoracic = 139, Abdominal = 42), no difference was found in the incidence of recurrence amongst the 2 groups (RD = -0.04, 95%CI = -0.25, 0.18, p = 0.74).

Conclusion: This is one of the largest reports on outcomes of children undergoing DP for DE. There is no significant difference in recurrence rate, even though all recurrences in our series (15.7%) were in the acquired cases operated using a thoracic approach.

Type of study: Treatment Retrospective Comparative Study.

Level of evidence: Level III.

Keywords: Diaphragmatic eventration; Laparoscopy; Laparotomy; Plication; Thoracoscopy; Thoracotomy.

MeSH terms

Abdomen / surgery*
Adolescent
Child
Child, Preschool
Diaphragm / surgery*
Diaphragmatic Eventration / epidemiology
Diaphragmatic Eventration / surgery*
Humans
Infant
Infant, Newborn
Recurrence
Retrospective Studies
Thoracic Surgical Procedures* / adverse effects
Thoracic Surgical Procedures* / methods
Thoracic Surgical Procedures* / statistics & numerical data
Treatment Outcome