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Pleural effusion requiring drainage in congenital diaphragmatic hernia: incidence, aetiology and treatment
G Casaccia1, F Crescenzi, S Palamides
1Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Pediatric Hospital, Rome, Italy. germanacasaccia@hotmail.com
Insights
In congenital diaphragmatic hernia (CDH) repair, avoiding chest tubes prevents lung injury. However, pleural effusion (PE) requiring drainage occurred in 30% of cases, particularly after patch repair, necessitating prompt intervention.
Area of Science:
- Pediatric Surgery
- Thoracic Surgery
- Neonatal Medicine
Background:
- Congenital diaphragmatic hernia (CDH) repair traditionally involves chest tube insertion, posing a risk of lung overexpansion and pneumothorax in hypoplastic lungs.
- A shift away from routine chest tube insertion at CDH repair was implemented to mitigate these risks.
Purpose of the Study:
- To determine the incidence of postoperative pleural effusion (PE) requiring drainage in CDH patients treated without intraoperative chest tubes.
- To assess if patch repair for CDH is associated with an increased incidence of PE.
- To investigate the etiology and treatment of PE in this cohort.
Main Methods:
- Retrospective review of high-risk CDH cases operated on between 1998 and 2004, with no chest tube inserted during repair.
- Postoperative chest drainage was performed only if cardiopulmonary distress due to PE occurred.
- Statistical comparison (chi-squared and Student's t-tests) between patients with and without patch repair, analyzing various clinical factors.
Main Results:
- Out of 76 CDH patients, 23 (30%) underwent patch repair. Pleural effusion (PE) occurred in 22 patients (29%), with chylothorax in 68% of these cases.
- Patients with patch repair had significantly lower birth weight and a higher incidence of PE compared to those without patch repair.
- All patients requiring pleural drainage showed improvement in ventilatory and respiratory parameters.
Conclusions:
- The incidence of postoperative PE requiring drainage in CDH is significant (30%), and notably higher in patients who received patch repair.
- While avoiding intraoperative chest tubes is beneficial, vigilant monitoring for PE is crucial, especially in patch repair cases.
- Prompt chest tube drainage for PE-induced cardiopulmonary distress is warranted to improve outcomes and potentially reduce mortality.
Abstract:
In congenital diaphragmatic hernia (CDH), chest tube insertion at repair could determine rapid overexpansion of hypoplastic lungs, increasing the risk of pneumothorax. Therefore, in our institution no drainage tube at CDH repair was inserted after 1997. Afterwards several patients needed chest drainage for cardiopulmonary distress due to pleural effusion (PE) during the postoperative course. The aims of this study are to establish the incidence of PE requiring drainage for cardiopulmonary distress during postoperative course in CDH and to assess its eventual increase in patients with patch repair. Furthermore, the aetiology and treatment of PE are highlighted. Records of high-risk CDH operated on from 1998 to 2004 were reviewed. No chest tube was inserted at repair. Drainage was accomplished postoperatively if a cardiopulmonary distress due to PE occurred. Groups with and without patch were compared on gender, gestational age, birth weight, side of hernia, PE, hernial sac, central venous line and venous thrombosis, using the chi(2) and Student's t tests. Overall mortality rate was recorded. Out of 76 patients, 23 (30%) required patch repair. The PE occurred in 22 out of 76 patients, and in 68% of cases a chylothorax resulted. Birth weight was significantly lower, and the PE rate was significantly higher in patients with patch. Pleural drainage yielded improvement of ventilatory and respiratory parameters in all cases. Overall mortality rate was 16 and 23% in patients that required chest drain. The incidence of PE was 30% in CDH and significantly higher in patients with patch. The increased mortality rate in patients with PE causing cardiopulmonary distress warrants chest tube drainage before instability occurs.
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