RESUMO
Diaphragmatic hernia in adults is mostly post-traumatic in origin, and rarely congenital. In both situations, the right side is less commonly involved due to the protection offered by the liver and earlier closure of the right pleuroperitoneal canal. A congenital diaphragmatic hernia may present in adulthood with multi-visceral contents, of which the liver is an extremely rare content, mentioned only in a few previous reports. A herniated liver may mimic a pulmonary tumor and may be completely atrophic due to sustained compression of the venous outflow. Careful operative planning is essential to identify and reduce the liver, along with other contents. We are reporting two adults with a congenital diaphragmatic hernia, with multi-visceral contents and an atrophied liver. The first patient was a 28-year-old man with a remote history of trauma found to have a large right diaphragmatic hernia on imaging. The right liver was completely atrophied due to right hepatic venous compression, while the left liver underwent massive hypertrophy and rotation of the left portal axis. Exploratory laparotomy and reduction of contents, along with mesh repair, were accomplished with satisfactory results. The second patient was a 26-year-old man with Down's syndrome detected to have multiple bowel loops in the right thorax on imaging. At laparoscopy, a Larrey's type of Morgagni hernia with a right paramedian defect was found. The left liver was atrophied into a leaf-like appendage due to possible portal obliteration and was dissected away from the diaphragm edge. Appropriate mesh repair was completed by a minimally invasive technique.
RESUMO
Introduction Lymphatic complications (LC) are common (up to 33%) and troublesome after renal transplantation. Different studies have established varying medical and surgical risk factors, mostly by retrospective analysis on deceased donor renal transplants (DDRTs). The end-point is mostly lymphocele, with few reports documenting the equally important lymphorrhea. Methods In our prospective analytical study done over three years, most were living donor renal transplant (LDRT) pairs by a single team. The primary outcome measure was lymphocele and/or prolonged drainage for more than 15 days, with a six-month follow-up. The variables recorded were age, gender, hemodialysis duration, etiology, relationship, human leucocyte antigen (HLA) mismatch, induction regimen, acute rejection, warm ischemia time (WIT), and delayed graft function (DGF). Univariate analysis was by chi-square and t-tests as applicable, while logistic regression (both simultaneous and forward stepwise) was used for risk factor prediction. Results Eligible cases were 150, with 145 (97%) LDRT pairs. Donors were mostly female (122/150; 81%) with mean age (~43 years) higher than recipient age (~33 years). The common etiologies were diabetes (31%), hypertension (23%), and IgA nephropathy (11%). Most donors were mothers (37%) and wives (31%), and 28% of LDRT pairs had HLA mismatch >3. Mean duration of hemodialysis was about 18 months, and mean WIT was 52 minutes. Both DGF (B coefficient= -1.69, p<0.000) and WIT (B=-0.038, p=0.024) were significant predictors of the primary outcome, while drain removal before 15 days predicted lymphocele significantly (B=-2.4, p<0.000). Conclusions LDRT has specific risk factors for lymphatic complications, which may be related to extent of recipient vascular dissection, arterial anastomotic time, and early drain removal.
