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Reverse, innervated latissimus dorsi flap reconstruction of congenital diaphragmatic absence
1Department of Surgery, University of Texas Southwestern Medical School, USA.
Insights
Congenital diaphragmatic absence repair using reverse latissimus dorsi flaps shows promising results in young children. This innovative technique aims to restore diaphragmatic function and improve long-term pulmonary outcomes.
Area of Science:
- Pediatric Surgery
- Thoracic Surgery
- Neonatal Care
Background:
- Congenital diaphragmatic absence (CDH) historically has high mortality, often due to fetal circulation patterns.
- Advances like extracorporeal membrane oxygenation (ECMO) improve survival but lead to challenges with chest wall growth.
- Gore-Tex patches used for initial repair can detach, causing recurrent herniation and pulmonary compromise.
Purpose of the Study:
- To evaluate the efficacy of reverse latissimus dorsi flap reconstruction for recurrent congenital diaphragmatic absence.
- To assess the restoration of diaphragmatic function and pulmonary development in pediatric patients.
Main Methods:
- Surgical reconstruction using a reverse latissimus dorsi flap.
- Anastomosis of the thoracodorsal nerve to the phrenic nerve.
- Study included five children aged 5-11 months with follow-up from 22-50 months.
Main Results:
- Three patients demonstrated physiologic neodiaphragmatic motion.
- Two patients showed stable absence of paradoxical motion.
- No surgical complications were reported in the series.
Conclusions:
- Reverse latissimus dorsi flap reconstruction is a viable option for severe congenital diaphragmatic absence with recurrent herniation.
- The procedure shows encouraging early results for restoring diaphragmatic function and improving pulmonary status.
- Long-term follow-up is necessary to confirm sustained benefits and eventual patient outcomes.
Abstract:
Children with congenital diaphragmatic absence have experienced a high mortality rate regardless of early intervention due to regression to fetal circulation patterns. Advances in neonatal care, particularly extracorporeal membrane oxygenation, have led to the survival of children who previously would not have lived. With growth, the Gore-Tex patch used for emergency repair in severe cases pulls away from the rib periosteum as a result of the expansile growth of the chest wall and the indistensibility of the patch. Recurrent herniation of abdominal contents ensues, slowly restricting pulmonary function and development. When pulmonary function is significantly impaired, we perform a reverse latissimus dorsi flap reconstruction with anastomosis of the thoracodorsal nerve to the phrenic nerve. Our series includes five children aged 5 to 11 months. Follow-up ranges from 22 to 50 months. Three children have proven physiologic neodiaphragmatic motion. The other two are doing well with stable absence of paradoxical motion. There have been no complications. Long-term follow-up will be required to determine their eventual fate. The prognosis is encouraging.