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CASE REPORT TYAGI ET AL INTRAPERICARDIAL DIAPHRAGMATIC HERNIA REPAIR
Ann Thorac Surg 2014;97:332–3
References 1. Ohde Y, Nakagawa K, Okumura T, Kondo H. Spontaneous pulmonary torsion secondary to pseudo-Meigs’ syndrome. Interact Cardiovasc Thorac Surg 2005;4:59–60. 2. Shorr RM, Rodriguez A. Spontaneous pulmonary torsion. Chest 1987;91:927–8. 3. Moser ES Jr, Proto AV. Lung torsion: case report and literature review. Radiology 1987;162:639–43. 4. Trotter MC, McFadden PM, Ochsner JL. Spontaneous torsion of the right lung: a case report. Am Surg 1995;61:306–9. 5. Felson B. Lung torsion: radiographic findings in nine cases. Radiology 1987;162:631–8. 6. Raynaud C, Lenoir S, Caliandro R, Raffenne L, Validire P, Gossot D. Spontaneous middle lobe torsion secondary to pleural effusion. Chest 2009;136:281–3. 7. Fogarty JP, Dudek G. An unusual case of lung torsion. Chest 1995;108:575–8. 8. Hendriks J, Van Schil P, De Backer W, Hauben E, Vanmaele R, Van Marck E. Massive cerebral infarction after completion pneumonectomy for pulmonary torsion. Thorax 1994;49:1274–5.
FEATURE ARTICLES
Laparoscopic Repair of an Intrapericardial Diaphragmatic Hernia Sam Tyagi, MD, Justin Steele, MD, Byron Patton, MD, Shinichi Fukuhara, MD, Avram Cooperman, MD, and Michael Wayne, MD Beth Israel Medical Center, Department of Surgery, Albert Einstein College of Medicine, New York, New York
An isolated intrapericardial diaphragmatic hernia is very rare. Only 15 cases have been reported, 2 of which are in adults. The defect in the anterior diaphragm allows abdominal contents to enter the pericardial cavity. We report the 16th case—the third in an adult—and its laparoscopic repair. (Ann Thorac Surg 2014;97:332–3) Ó 2014 by The Society of Thoracic Surgeons
Fig 1. Coronal computed tomography image displaying the transverse colon in the thorax.
and laboratory tests were normal. An anterior diaphragmatic hernia containing omentum and transverse colon was reported on computed tomography scan (Fig 1). A presumed diagnosis of a Morgagni hernia was made and surgery advised. At laparoscopy, a 4 6 cm central diaphragmatic defect open to the pericardium, containing omentum and transverse colon without hernia sac, was encountered. The colon was easily reduced, and the omentum was freed with a harmonic scalpel (Ethicon Endo-Surgery, a subsidiary of Johnson & Johnson, Somerville, NJ [Fig 2]). The defect was closed with a 10 15 cm Gore-Tex (WL Gore & Assoc, Flagstaff, AZ) mesh (Fig 3) and fixed with a spiral tacker. The postoperative chest radiograph had no pneumomediastinum or pneumothorax. There were no postoperative complications, and the patient was discharged 2 days later. He remains asymptomatic at
C
ongenital diaphragmatic defects and hernias are uncommon and are estimated to occur once in every 2,200 births. Eighty percent involve a posterolateral defect. One percent to 6% of congenital diaphragmatic hernias involve the anterior diaphragm and usually present in the neonatal period [1, 2]. An isolated, anterior diaphragmatic hernia in an otherwise healthy adult has been reported only twice previously. We report the third case in an adult. A 36-year-old healthy male police officer presented to the emergency department with a 5-week history of epigastric discomfort, treated as gastritis. The pain intensified and persisted in the 24 hours before evaluation. Physical examination revealed epigastric guarding, Accepted for publication April 22, 2013. Address correspondence to Dr Tyagi, Beth Israel Medical Center, Department of Surgery, Albert Einstein College of Medicine, 1st Ave and 16th St, New York, NY 10003; e-mail:
[email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 2. Diaphragmatic defect with abdominal contents reduced. Myocardium of the heart is visible through the defect. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.04.127
Ann Thorac Surg 2014;97:333–5
CASE REPORT AL-AYOUBI ET AL PULMONARY NEUROENDOCRINE HYPERPLASIA
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2. Paci M, de Franco S, Della Valle E, et al. Septum transversum diaphragmatic hernia in an adult. J Thorac Cardiovasc Surg 2005;129:444–5. 3. Clavert JM, De Geeter B, Bientz J, Sauvage P, Buck P. Abdomino-pericardial hernia as a result of an anomaly of the septum transversum. Apropos of a case in a newborn infant. Chir Pediatr 1983;24:137–9. 4. Cantrell JR, Haller JA, Ravitch MM. A syndrome of congenital defects involving the abdominal wall, sternum, diaphragm, pericardium and heart. Surg Gynecol Obstet 1958;107:602–14. 5. Meng R, Straus A, Milloy F, et al. Intrapericardial diaphragmatic hernia in adults. Ann Surg 1979;189:359–66. 6. Jagad RB, Kamani P. Central diaphragmatic hernia in an adult: a rare presentation. Hernia 2012;16:607–9.
follow-up, and computed tomography done at 11 months postoperatively showed an intact repair.
Comment The diaphragm is formed by fusion of four structures: the pleuroperitoneal membranes; the septum transversum; the dorsal mesentery of the esophagus; and the lateral body walls [5]. Eighty percent of congenital defects involve the posterolateral diaphragm (Bochdaleks gap). One percent to 6% of congenital defects are anterior and caused by failure of fusion of the septum transversum to form the pars sternalis portion of the diaphragm [3]. This specific entity has been described in Cantrell’s pentalogy of defects of the sternum, abdominal wall, pericardium, anterior diaphragm, and congenital heart disease (most commonly as tetralogy of Fallot) [2, 4]. Most hernias are discovered during maternal sonography or in the neonatal period owing to cardiorespiratory distress, often as a result of coexisting malformations. That explains the neonatal mortality rate of 40% to 50% [1–3, 6]. Our case is the 16th report of an isolated intrapericardial diaphragmatic hernia, and the third in an adult. Both open and laparoscopic techniques have been utilized in treatment but today the laparoscopic approach is preferred. For large defects, mesh repair that covers 2.5 cm to 3 cm beyond the defect should be effective. The lessons to be learned are anterior congenital diaphragmatic hernias (1) result from failed development of the septum transversum of the pars sternalis of the anterior diaphragm; (2) may be initially asymptomatic and not present until later in life owing to incarceration; and (3) should be approached laparoscopically.
Adnan M. Al-Ayoubi, MD, Jonathan S. Ralston, MD, S. Russ Richardson, BS, and Chadrick E. Denlinger, MD Divisions of Cardiothoracic Surgery and Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina
Diffuse pulmonary neuroendocrine cell hyperplasia (DIPNECH) is characterized by a diffuse hypertrophy of neuroendocrine cells along the distal bronchioles. This condition is characterized by obstructive lung physiology and the development of small carcinoid tumors. We present a case of DIPNECH in a patient undergoing surgery for a primary lung adenocarcinoma. Interestingly, the chest wall also demonstrated involvement of DIPNECH indicated by the presence of small carcinoid tumors. The absence of any lung carcinoid tumor greater than 5 mm and the absence of lymph node metastases render the chest wall involvement unlikely to represent metastatic disease. (Ann Thorac Surg 2014;97:333–5) Ó 2014 by The Society of Thoracic Surgeons
P
ulmonary carcinoid tumors represent 1% to 2% of all lung malignancies and are pathologically classified as typical or atypical, depending on the degree of mitotic activity and the presence or absence of tumor necrosis. A recently described condition on the same spectrum of disease is diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH), which principally involves the distal airways and frequently is associated with numerous tiny carcinoid tumorlets, which are defined as lesions less than 5 mm. We present a case of a patient who underwent surgical resection of a primary lung adenocarcinoma who was incidentally found to have DIPNECH. Interestingly, the
References 1. Jain V, Choudhury S, Chadha R, Puri A. Intrapericardial diaphragmatic hernia: a rare type of congenital diaphragmatic hernia. J Pediatr Surg 2011;46:E29–31. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Accepted for publication April 29, 2013. Address correspondence to Dr Denlinger, 25 Courtenay Dr, Ste 7018, Charleston, SC 29425; e-mail:
[email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.04.139
FEATURE ARTICLES
Fig 3. Gore-Tex (WL Gore & Assoc, Flagstaff, AZ) mesh covering the defect.
Diffuse Pulmonary Neuroendocrine Cell Hyperplasia Involving the Chest Wall
