Diaphragmatic hernias after pediatric liver transplantation: Experience of a high‐volume transplant center

Abstract

Diaphragmatic hernias (DHs) are rare complications after pediatric liver transplantation (PLT). It is now widely accepted that DHs after liver transplantation (LT) is a pediatric related condition. PLTs (under of age 18) performed between January 2013 and June 2019 at Malatya Inonu University Institute of Liver Transplantation were retrospectively scanned. Study group consisting DHs and a control group were compared. Among 280 PLTs, 8 of them were complicated with DHs (%2.9). Median age of the patients with DH was 3.0 (0.8‐9.5) years. Median graft recipient weight ratio was 2.5 (0.9‐4.4). Five patients were below 5th percentiles in terms of pediatric weight growth chart at the time of LT. Also, 6 patients were below 5th percentiles in terms of pediatric height growth chart. There was no statistical difference between study and control groups. There are many risk factors mentioned in literature that may be primarily responsible for DHs after PLT. These factors are left lobe and large‐for‐size grafts, malnutrition, trauma or diathermy of diaphragmatic nerve and vessels and immunosuppressants. In our study, we could not specify any reason that differs in DHs. In our aspect, narrow diaphragma and thorax are exposed to high intra‐abdominal pressure from abdomen. Large‐for‐size grafts, which are specific to children, also may contribute to this affect. Excessive diathermy and trauma to diaphragmatic collaterals may aggravate the risk of DH. More patients are needed to make an exact conclusion, in order to evaluate with comparable study on this aspect.

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.…”

“…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.…”

Pediatric Thoracoscopic Repair of Diaphragmatic Herniation Following Liver Transplantation

“…Another disadvantage of thoracoscopy is that it may offer some technical limitations, such as the mobilization of the posterior muscular rim [9]. There are very few described cases of LTDH managed by thoracoscopy in the literature [1,2,4]. Furthermore, among nearly 50 cases published about LTDH, only 3 were approached by thoracoscopy [2,4,5,10].…”

“…Earlier, surgeries under the abdominal approach threw several challenges such as less clear planes and more adhesions, making it more difficult to access the diaphragm clearly and increasing the risk of iatrogenic injury. Furthermore, steroids and other immunosuppressive therapies have been associated with impaired wound healing, which poses a greater risk of incisional hernias [4,5]. Thus, MITs improve cosmetic results and probably reduce the incidence of incisional hernias.…”

“…Pediatric liver transplantation (LT) is a life-saving procedure. However, factors such as low weight and poor medical standing put children at the forefront of post-LT diaphragmatic hernia (LTDH), with an incidence of 0.75-3.2% [1][2][3][4][5].…”