Prenatal Imaging Features and Postnatal Factors Associated with Gastrointestinal Morbidity in Congenital Diaphragmatic Hernia

Abstract

<b><i>Background:</i></b> To perform a comprehensive assessment of postnatal gastrointestinal (GI) morbidity and determine the prenatal imaging features and postnatal factors associated with its development in patients with congenital diaphragmatic hernia (CDH). <b><i>Materials and Methods:</i></b> A retrospective review was conducted of all infants evaluated for CDH at a quaternary fetal center from February 2004 to May 2017. Prenatal imaging features and postnatal variables were analyzed. GI morbidity was the primary outcome. The Mann-Whitney U test, the Kruskal-Wallis test with Dunnett’s T3 post hoc analysis and logistic regression, and the χ<sup>2</sup> test were performed when appropriate. <b><i>Results:</i></b> We evaluated 256 infants; 191 (75%) underwent CDH repair and had at least 6 months of follow-up. Of this cohort, 60% had gastroesophageal reflux disease (GERD), 13% had gastroparesis, 32% received a gastrostomy tube (G-tube), and 17% needed a fundoplication. Large defect, patch repair, extracorporeal membrane oxygenation (ECMO), and prolonged use of mechanical ventilation were significantly associated with having GERD, gastroparesis, G-tube placement, and fundoplication (<i>p</i> < 0.05). Fetuses with stomach grades 3 and 4 were most likely to have GERD, a G-tube, and a long-term need for supplemental nutrition than fetuses with stomach grades 1 and 2 (<i>p</i> < 0.05). <b><i>Conclusion:</i></b> Survivors of CDH with large defects, prolonged use of mechanical ventilation, or that have received ECMO may be at an increased risk for having GERD, gastroparesis, and major GI surgery. Marked stomach displacement on prenatal imaging is significantly associated with GI morbidity in left-sided CDH.

Prenatal stomach position predicts gastrointestinal morbidity at 2 years in fetuses with left‐sided congenital diaphragmatic hernia

“…the incidence of GERD (defined by upper gastrointestinal tract endoscopy and esophageal pH‐metry) at 1 year of age was 46% in 26 CDH survivors, half of whom had no significant symptoms. Verla et al 26 . found an association of a large defect, patch repair and use of ECMO with GERD, gastrostomy tube placement and fundoplication.…”

“…In the study by Koivusalo et al 8 , the incidence of GERD (defined by upper gastrointestinal tract endoscopy and esophageal pH-metry) at 1 year of age was 46% in 26 CDH survivors, half of whom had no significant symptoms. Verla et al 26 found an association of a large defect, patch repair and use of ECMO with GERD, gastrostomy tube placement and fundoplication. They also found an association between stomach displacement on prenatal imaging and GIM at 6 months of age in cases of left-sided CDH.…”

A Challenging Case of Congenital Diaphragmatic Hernia Managed Successfully: A Case Report

“…[5] Verla et al, pointed several possible factors for GER; slow pulmonary expansion of the affected side, size of defect, malposition of the stomach, use of mechanical ventilation, or extracorporeal membrane oxygenator. [6] Marseglia et al, proposed increased intra-abdominal pressure after closure of the abdominal defect, motility disturbance of the upper gastrointestinal tract, or damage of esophageal peristaltic pump, as possible causes of GERD in cases of CDH. [7] There was a correlation between GER and early detection of CDH in prenatal studies and the presence of polyhydramnios.…”

Unsolved problems in CDH follow-up

“…Verla observed that larger defects and intrathoracic stomach displacement on prenatal MRI were significantly associated with the diagnosis of GERD, but an intrathoracic liver was not. On the other hand, these variables were not associated with the need of anti-reflux surgery ( 55 ). Cordier et al found that stomach position on prenatal ultrasound was independently associated with GER.…”

“…Several post-natal factors are associated with an increased risk of GER, including right-sided CDH, management with non-conventional mechanical ventilation such as high frequency oscillatory ventilation, need for nitric oxide (NO) and ECMO, the need for patch closure and liver within the chest ( 55 , 58 ). On multiple variable analysis, however, Diamond et colleagues demonstrated that only liver in the chest and patch repair were significant predictors of GER.…”