“Hernia diafragmática en recién nacido”

Abstract

Congenital diaphragmatic hernia is a pathology caused by a defect in the pleuroperitoneal membrane (diaphragm) in which it allows the displacement of abdominal contents through a defect in the diaphragm (1, 2). The herniated viscera (stomach, small intestine, spleen, liver) exert on the lungs a compression that leads to pulmonary hypoplasia, which is the main cause of neonatal death, around 40% (3,4). This severe malformation can originate in the embryonic or fetal stage, with a frequency of 1 in every 5000 live births (1, 2, 4 ). It is described that between 75 and 85% of the cases the defect is found in the posterolateral pleuroperitoneal membrane known as Bockdalec's hernia being the most frequent and predominantly on the left side in 80% of cases (3). Lev- Chelouche and Cols describe in turn that Bochadalek hernia is diagnosed in newborns due to its distinctly respiratory complication (pulmonary hypoplasia) as well as other musculoskeletal, urogenital or cerebral malformations, and it is rarely associated with ocular defects affecting around of 1%, congenital ocular malformations consist mainly of anophthalmia and microphthalmia, colobomas. The congenital cataract as well as the main complication is intestinal rotation (4). On the other hand, the Morgagni hernia represents 5 to 10% of the cases and is caused by a ventral and parasternal defect and is more prevalent on the right 5 since it is a defect between the costal and sternal ligaments of the diaphragm in consequence of an abnormal development of the diaphragmatic tendon (6). The diagnosis is made with a prenatal ultrasound examination in which the abdominal viscera within the thorax is observed in the case that the right hernia is a bit difficult to diagnose by the similarity of the liver and fetal lung. Fetal magnetic resonance is currently used, which makes it possible to specify the degree of fetal hypoplasia and the position of solid viscera such as the liver (7). The management is performed with the use of oxygenation with extracorporeal membrane but not very effective, in some patients does not apply any effect, also with the use of nitric oxide and surfactant (8). Another option and the most appropriate is the surgical form in utero with the placement of PLUG or intratracheal balloon in order to induce compensatory pulmonary hyperplasia. In addition to surgery after birth by placing the organs in the abdominal region. and surgical treatment that was previously considered an emergency but the results were not feasible since patients continued with respiratory symptoms for this reason surgery has been considered after hemodynamic stability and preoperative ventilation although this hypothesis is controversial since a meta-analysis in which randomized trials of The Cochrane Collaboration Handbook that compared a strategy of late versus early surgical correction of HDC. The blinding of the investigators with respect to the groups after the assignment was very unlikely and was not required. Follow-up of a minimum of 80% of patients was required. We excluded studies that used convenience allocation or the preference of the investigator and studies that used historical controls, assigned infants who developed signs and symptoms such as respiratory distress attributable to HDC within the first 12 hours. Mortality was assessed differently in the two studies; Nio evaluated deaths before discharge (which took place at one to two months of age for most children) and Hunt evaluated deaths at six months of age. In the de la Hunt study, 43% of the late surgical group and 54% of the early surgical group had died at six months (RR for death with late surgery 0.80, 95% CI 0.46; 1.39, RD: -0.11, 95% CI: -0.38, 0.16). In the Nio study, death before discharge occurred almost as often with late and early surgical intervention (RR for death with late surgery 1,11, 95% CI 0.32, 3.81, DR 0 , 03, 95% CI: -0.29, 0.35), so there is no evidence that early or late surgery has real benefit (8). The surgical technique consists in the placement of the herniated organs in the abdominal cavity and the suture of the orifices. If the hernia is very large, a silicone elastomer plate or polytetrafluoroethylene is used to close the hernial orifice (9).