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

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.

Successful Surgical Repair of Left-Sided Diaphragmatic Hernia after Adult Orthotopic Liver Transplantation: Case Report

“…Postoperative delayed DH is a rare and exceptional event after adult OLT, but it could be potentially life-threatening complication, especially in the absence of early diagnosis and appropriate surgical treatment. Waldron et al to this day reported about 57 cases (including their own 8 cases) of DH mainly with right-sided herniation following pediatric liver transplantation [12]. In the current literature we found only 4 reported cases of left-sided DH after the adult OLT with herniation of the stomach into the thorax [2,3].…”

“…Diaphragmatic hernias (DHs) are a rare and unusual surgical complication after adult and pediatric liver transplant [1][2][3][4][5][6][7][8][9][10][11][12][13]. Until today nearly 60 cases of diaphragmatic herniation following liver transplants, being more frequent in child transplants, were reported in English literature [12]. Review of available literature identified only four reported cases of left diaphragmatic herniation with the stomach.…”

Acquired diaphragmatic hernia after hepatectomy and liver transplantation in adults and children: A case series and literature review

“…In children who developed DH, most of them were small, young, and cirrhotic with impaired coagulation profile and nutritional status when they underwent LT. Table 3 summarizes most relevant publications on 56 children who developed ADH after LT [ 4 , 8 , 9 , 11 , 12 , 21 - 26 ]. Their median age and weight were 0.75 to 4 years and 5.5 to 17.6 kg, respectively.…”

“…Nevertheless, in a study of case-matched control group without ADH, Karakas et al [ 11 ] were unable to determine any risk factor responsible for the occurrence of ADH. Up to now, 77 cases (including ours) of ADH after pediatric LT have been identified in 21 articles from the literature [ 4 , 8 , 9 , 11 , 12 , 21 - 36 ].…”

“…In the literature, a few low case series have been reported. Its incidence is estimated to be between 0.74% and 2.9% [ 1 - 12 ]. Main descriptions of ADH concern liver resection for tumours, living donor hepatic donation in adult patients, and partial liver graft transplantation in children.…”