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Thoracic versus abdominal approach to correct diaphragmatic eventration in children
Alisha Gupta1, Martin Sidler2, Daan van Poll1
1Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children NHS trust, London, UK.
Insights
Diaphragm plication (DP) for diaphragm eventration (DE) in children shows no significant difference in recurrence rates between thoracic and abdominal approaches. However, acquired cases treated with the thoracic approach had all recurrences in this study.
Area of Science:
- Pediatric Surgery
- Thoracic Surgery
- Gastrointestinal Surgery
Background:
- Diaphragm plication (DP) is a surgical procedure to correct diaphragm eventration (DE).
- Surgical approaches include thoracic and abdominal routes.
- Comparative outcome data between these approaches are limited, especially in pediatric populations.
Purpose of the Study:
- To compare the outcomes of pediatric patients undergoing diaphragm plication (DP) for diaphragm eventration (DE) using thoracic versus abdominal approaches.
- To analyze surgical outcomes based on a single-center retrospective study and a systematic literature review.
Main Methods:
- Retrospective analysis of children (<16 years) who underwent DP between 2004-2018.
- Systematic review and meta-analysis of relevant published studies.
- Comparison of diaphragm level improvement, time to extubation, intensive care unit (ICU) stay, feeding, and recurrence rates.
Main Results:
- A higher improvement in diaphragm level was observed in the abdominal group (p=0.04).
- Transthoracic operations were associated with a significantly longer time to leave the ICU (p=0.043).
- Meta-analysis (n=181) showed no significant difference in recurrence rates between thoracic and abdominal approaches (p=0.74).
Conclusions:
- Diaphragm plication for diaphragm eventration in children can be performed via thoracic or abdominal routes with comparable recurrence rates.
- While not statistically significant, acquired cases treated with the thoracic approach showed all recurrences in this series.
- Further research may clarify optimal approach selection based on specific patient factors.
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.
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