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Eur J Pediatr Surg 2021; 31(05): 396-406
DOI: 10.1055/s-0040-1716882
Original Article

Diaphragmatic Hernia following Pediatric Liver Transplantation: An Underappreciated Complication Prone to Recur

Lea Sibylle Waldron
1   Department of Pediatric Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
2   Department of Pediatrics, Hospital of the Philipps-University Marburg, Marburg, Germany
,
Miriam Cortes Cerisuelo
3   Liver Transplant Surgery, Institute of Liver Studies, King's College Hospital, National Health Service Foundation Trust, London, United Kingdom
,
Denise Lo
4   Emory Transplant Center, Emory University, Atlanta, United States
,
Blayne Amir Sayed
5   Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
,
Hector Vilca-Melendez
3   Liver Transplant Surgery, Institute of Liver Studies, King's College Hospital, National Health Service Foundation Trust, London, United Kingdom
,
Joseph Magliocca
4   Emory Transplant Center, Emory University, Atlanta, United States
,
Eberhard Lurz
6   Division of Pediatric Gastroenterology, Hepatology and Nutrition, Dr. von Hauner Children’s Hospital, Ludwig-Maximillians-University, Munich, Germany
,
Ulrich Baumann
7   Department of Pediatric Gastroenterology, Hannover Medical School, Hannover, Germany
8   Institute for Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
,
Florian W. R. Vondran
9   Department for General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
,
Nicolas Richter
9   Department for General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
,
Dietrich von Schweinitz
10   Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, Ludwig-Maximillians-University, Munich, Germany
,
Markus Guba
11   Department of General, Visceral and Transplant Surgery, University Hospital, Ludwig-Maximilians-University, Munich, Germany
,
Oliver J. Muensterer 
1   Department of Pediatric Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
10   Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, Ludwig-Maximillians-University, Munich, Germany
,
Michael Berger
10   Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, Ludwig-Maximillians-University, Munich, Germany
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Abstract

Introduction Postoperative diaphragmatic hernia (DH) is a rare but potentially life-threatening complication following pediatric liver transplantation (LT). In the current literature, a total of 49 such hernias have been reported in 17 case series. We present eight additional cases, three of which reoccurred after surgical correction, and review the current literature with a focus on recurrence.

Materials and Methods The study sample included children (<18 years of age) who underwent LT between June 2013 and June 2020 at five large transplant centers and who subsequently presented with DH. During the study period, a total of 907 LT was performed. Eight DH were recognized, and risk factors were analyzed.

Results For the eight children with DH, the mean age at LT was 28.0 (5–132) months. All patients with a DH received left lateral segment split grafts except one, who received a full left lobe. The mean weight at time of LT was 11.8 (6.6–34) kg. Two patients had a primary abdominal muscle closure, and six had a temporary silastic mesh closure. All eight children presented with a right posterolateral DH. The small bowel was herniated in the majority of cases. Symptoms reported included nausea, vomiting, and respiratory distress. Two patients were asymptomatic, and discovery was incidental. All patients underwent prompt primary surgical repair. Three DH hernias (37.5%) recurred despite successful surgical correction.

Conclusion DH following liver transplant with technical variant grafts may be underreported and is prone to recur despite surgical correction. A better understanding of the pathophysiology and more thorough reporting may help increase awareness. Early detection and prompt surgical management are the cornerstones of a successful outcome.

Keywords

pediatric liver transplantation - diaphragmatic hernia - liver surgery


Publication History

Received: 06 March 2020

Accepted: 16 August 2020

Article published online:
13 November 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Imanieh MH, Erjaee A, Dehghani SM, Bahador A, Malek-Hosseini SA. Early postoperative complications of pediatric liver transplantation. Indian Pediatr 2009; 46 (12) 1088-1090
    PubMedGoogle Scholar
  • 2 Laurence JM, Sapisochin G, DeAngelis M. et al. Biliary complications in pediatric liver transplantation: incidence and management over a decade. Liver Transpl 2015; 21 (08) 1082-1090
    CrossrefPubMedGoogle Scholar
  • 3 Dehghani SM, Bahador A, Gholami S. et al. Pediatric liver transplantation in Iran: evaluation of the first 50 cases. Pediatr Transplant 2007; 11 (03) 256-260
    CrossrefPubMedGoogle Scholar
  • 4 Cortes M, Tapuria N, Khorsandi SE. et al. Diaphragmatic hernia after liver transplantation in children: case series and review of the literature. Liver Transpl 2014; 20 (12) 1429-1435
    PubMedGoogle Scholar
  • 5 Earl TM, Wellen JR, Anderson CD. et al. Small bowel obstruction after pediatric liver transplantation: the unusual is the usual. J Am Coll Surg 2011; 212 (01) 62-67
    CrossrefPubMedGoogle Scholar
  • 6 Cramm SL, Waits SA, Englesbe MJ. et al. Failure to rescue as a quality improvement approach in transplantation: a first effort to evaluate this tool in pediatric liver transplantation. Transplantation 2016; 100 (04) 801-807
    CrossrefPubMedGoogle Scholar
  • 7 Emamaullee JA, Nekrasov V, Gilmour S. et al. Case series and systematic review of acquired diaphragmatic hernia after liver transplantation. Pediatr Transplant 2018; 22 (08) e13296
    CrossrefPubMedGoogle Scholar
  • 8 Moon S-B, Jung S-M, Kwon C-H. et al. Posteromedial diaphragmatic hernia following pediatric liver transplantation. Pediatr Transplant 2012; 16 (04) E106-E109
    CrossrefPubMedGoogle Scholar
  • 9 Leal AJG, Tannuri ACA, Belon AR. et al. Effects of ischemic preconditioning in a pig model of large-for-size liver transplantation. Clinics (São Paulo) 2015; 70 (02) 126-135
    CrossrefPubMedGoogle Scholar
  • 10 Yazdani M, Park E, Udayasankar U. Postsurgical diaphragmatic herniation: a rare delayed complication of pediatric intraabdominal surgery. J Pediatr Surg 2016; 51 (02) 333-335
    CrossrefPubMedGoogle Scholar
  • 11 Yeung F, Chung PHY, Wong KKY, Tam PKH. Iatrogenic diaphragmatic hernia in paediatric patients. Pediatr Surg Int 2015; 31 (06) 589-592
    CrossrefPubMedGoogle Scholar
  • 12 Okajima H, Hayashida S, Iwasaki H. et al. Bowel obstruction due to diaphragmatic hernia in an elder child after pediatric liver transplantation. Pediatr Transplant 2007; 11 (03) 324-326
    CrossrefPubMedGoogle Scholar
  • 13 Dökümcü Z, Divarcı E, Erdener A, Sözbilen M, Ergün O. Acquired right diaphragmatic hernia following pediatric living donor orthotopic liver transplantation. Pediatr Transplant 2015; 19 (06) E149-E151
    CrossrefPubMedGoogle Scholar
  • 14 McCabe AJ, Orr JD, Sharif K, De Ville de Goyet J. Right-sided diaphragmatic hernia in infants after liver transplantation. J Pediatr Surg 2005; 40 (07) 1181-1184
    CrossrefPubMedGoogle Scholar
  • 15 Lee S, Seo J-M, Younes AE, Oh C-Y, Lee S-K. Thoracoscopic approach for repair of diaphragmatic hernia occurring after pediatric liver transplant. Medicine (Baltimore) 2015; 94 (33) e1376
    CrossrefPubMedGoogle Scholar
  • 16 Englert C, Helmke K, Richter A. et al. Diaphragmatic hernia resulting in enterothorax following pediatric liver transplantation: a rare complication. Transplantation 2006; 82 (04) 574-576
    CrossrefPubMedGoogle Scholar
  • 17 Kazimi M, Ibis C, Alper I. et al. Right-sided diaphragmatic hernia after orthotopic liver transplantation: report of two cases. Pediatr Transplant 2010; 14 (05) e62-e64
    CrossrefPubMedGoogle Scholar
  • 18 Shigeta T, Sakamoto S, Kanazawa H. et al. Diaphragmatic hernia in infants following living donor liver transplantation: report of three cases and a review of the literature. Pediatr Transplant 2012; 16 (05) 496-500
    CrossrefPubMedGoogle Scholar
  • 19 Lam H-D, Mejia J, Soltys KA, Sindhi R, Mazariegos G, Bond G. Right diaphragmatic hernia after liver transplant in pediatrics: a case report and review of the literature. Pediatr Transplant 2013; 17 (03) E77-E80
    CrossrefPubMedGoogle Scholar
  • 20 Wang K, Gao W, Ma N. et al. Acquired diaphragmatic hernia in pediatrics after living donor liver transplantation: three cases report and review of literature. Medicine (Baltimore) 2018; 97 (15) e0346
    CrossrefPubMedGoogle Scholar
  • 21 Okur MH, Yankol Y, Mecit N. et al. Diaphragmatic hernia after liver transplant in children: report of 2 cases. Exp Clin Transplant 2018; 16 (03) 337-339
    PubMedGoogle Scholar
  • 22 Lurz E, Patel H, Frimpong RG. et al. Sarcopenia in children with end-stage liver disease. J Pediatr Gastroenterol Nutr 2018; 66 (02) 222-226
    CrossrefPubMedGoogle Scholar
  • 23 Lurz E, Quammie C, Englesbe M. et al. Frailty in children with liver disease: a prospective multicenter study. J Pediatr 2018; 194: 109-115
    CrossrefPubMedGoogle Scholar
  • 24 Kirnap M, Akdur A, Ozcay F, Soy E, Coskun M, Moray G, Haberal M. Diaphragmatic hernia after pediatric liver transplant. Exp Clin Transplant 2015; 13 (05) 471-474
    PubMedGoogle Scholar