|Year : 2016 | Volume
| Issue : 4 | Page : 175-177
Intragastric pressure: Useful indicator in the management of congenital diaphragmatic hernia
Kartik Chandra Mandal1, Pankaj Halder1, Shibsankar Barman2, Rajarshi Kumar2, Biswanath Mukhopadhyay3, Ram Mohan Shukla4
1 Department of Pediatric Surgery, Dr. B. C. Roy, PGIPS, Kolkata, West Bengal, India
2 Department of Pediatric Surgery, Nil Ratan Sircar Medical College and Hospital, Kolkata, West Bengal, India
3 Senior Consultant, Pediatric Surgery, Apollo Gleneagles Hospitals, Kolkata, West Bengal, India
4 Department of Pediatric Surgery, R D Gardi Medical College, Ujjain, Madhya Pradesh, India
|Date of Web Publication||19-Jul-2016|
Kartik Chandra Mandal
Department of Pediatric Surgery, Dr. B. C. Roy, PGIPS, 111, Narkeldanga Main Road, Kolkata 700 054, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aims: To assess the role of measuring of intragastric pressure (IGP) during closure of congenital diaphragmatic hernia. Materials and Methods: Thirty-two cases were included in the study (August 2008 to February 2014), and IGP has been measured intraoperatively during closure. Result: Patients were categorized in group A (15 patients), group B (14 patients) and group C (3 patients). In group C, IGP was more than 30 cm of water pressure and all of tehm required creation of ventral hernia and ventilator support. Conclusion: Measurement of IGP as an objective, noninvasive and simple method to evaluate intra-abdominal pressure and prevention of abdominal compartment syndrome and intraoperative IGP value determines the types of abdominal closure.
Keywords: Abdominal compartment syndrome, congenital diaphragmatic hernia, intragastric pressure, ventilation, ventral hernia
|How to cite this article:|
Mandal KC, Halder P, Barman S, Kumar R, Mukhopadhyay B, Shukla RM. Intragastric pressure: Useful indicator in the management of congenital diaphragmatic hernia. J Indian Assoc Pediatr Surg 2016;21:175-7
|How to cite this URL:|
Mandal KC, Halder P, Barman S, Kumar R, Mukhopadhyay B, Shukla RM. Intragastric pressure: Useful indicator in the management of congenital diaphragmatic hernia. J Indian Assoc Pediatr Surg [serial online] 2016 [cited 2020 Feb 19];21:175-7. Available from: http://www.jiaps.com/text.asp?2016/21/4/175/186547
| Introduction|| |
Congenital diaphragmatic hernia (CDH) is a defect in any part of diaphragm, commonly left posterolateral defect. The incidence of CDH is 1:2500.  After correction of pulmonary hypertension, surgical repair is the only option. Abdominal closure in CDH patient is difficult in some cases. Too tight abdominal closure may result in abdominal compartment syndrome (ACS) and may increase the duration of ventilatory support. Abdominal pressure can be measured indirectly by intravesical pressure, rectal pressure, and central venous pressure (CVP). Measuring intra-abdominal pressure (IAP) in abdominal wall defect (omphalocele, gastroschisis) helps during operation and postoperative outcome as well. Measurement of intragastric pressure (IGP) is an indirect method of IAP and also helps in managing abdominal wall defect and to improve outcome.  In this study, we retrospectively analyzed our data regarding peroperative IGP, mode of abdominal wall closure, and duration of ventilator support. IGP is also an indirect measure of IAP and it helps during operation and postoperative period to improve outcome in CDH patients.
| Materials and methods|| |
We have studied 32 patients in the period of 5½ years (August 2008 to January 2014) in a tertiary care center as shown in [Table 1]. A retrospective review of data regarding mode of delivery, type and requirement of ventilatory support, medical management given, operative findings, IGP measurement during operation, type of closure, and duration of postoperative ventilatory support was carried out. Antenatally diagnosed, uncorrected pulmonary hypertension and diaphragmatic defect other than left posterior diaphragm are excluded from our study. Two cases are included in the study with left-sided recurrent CDH with intestinal obstruction.
Age ranged from 1 day to 3.6 years (Mean - 1.8 years) and body weight ranged from 2 kg to 7 kg (Mean - 4.5 kg). Patients who were stable on admission or stabilized with pharmacotherapy and conventional ventilation are selected for operation. Clinically and radiologically confirmed left-sided CDH patients are included in the study. All patients were explored through left subcostal incision. After correction of diaphragmatic defect and malrotation of gut, position of intragastric tube was confirmed. Stomach was completely emptied of its content. Nozzle of 10 cc syringe was fitted in outer end of the nasogastric tube and holds it up. Peritoneum was closed. Normal saline was slowly instilled in the syringe, already connected with the nasogastric tube. Height of saline column was measured in cm at the midaxillary line upward. IAP was measured by measuring IGP by noting height of the saline column in nasogastric tube [Figure 1].
| Results and analysis|| |
A retrospective review of data in 32 patients was analyzed. Patients in neonatal age either stable or stabilized with pharmacotherapy and conventional ventilation and postneonatal patients were included in the study. After closure of peritoneum, IAP was assessed by measuring IGP. Patients were categorized into three groups.
- Group A: IGP <20 cm of H 2 O
- Group B: IGP 20-30 cm of H 2 O
- Group C: IGP >30 cm of H 2 O.
Fifteen patients in Group A, 14 in Group B, and 3 in Group C were included in the study [Chart 1 [Additional file 1]].
Total 15 of 32 patients were included in Group A where abdomen was closed in layers and recovered from anesthesia well and they did not require ventilator support. Postoperative period was uneventful. They were discharged in 3-5 days.
Total 14 of 32 patients were included in Group B where abdomen was closed in layers. However, postoperatively, patients required ventilator support for 2-7 days (Mean = 4.5 days). In this group of patients, ventral hernia was not created. However, ventilatory support was required for variable period [Chart 2 [Additional file 2]].
In Group C, all three patients required ventral hernia creation and prolonged ventilator support.
In this group, IGP was >30 cm of water pressure.
| Discussion|| |
CDH is due to developmental abnormality of diaphragm. The extent of defect and contents are variable. Survival of patient depends on severity of pulmonary hypertension. Properly corrected pulmonary hypertension and timely repair of diaphragmatic defect give good results. There are various determining factors of outcome in CDH. Here, we studied one such factor which may determine the type of abdominal wall closure and outcome in CDH patients. Abdominal pressure is increased after repair of diaphragmatic defect and closure of abdomen. Increased abdominal pressure may ultimately lead to ACS. The term "ACS" represents the pathophysiological consequences of a raised IAP, including effects on lung compliance and ventilation, a critical reduction in the perfusion of the intra-abdominal organs, leading to oliguria, renal impairment.  The homogeneous transmission of IAP can be estimated through urinary bladder, rectum, or stomach. , Abraham et al. have shown the use of measuring intravesical pressure as a prognostic marker in CDH.  There are other various indirect methods of measurement of IAP such as CVP and peak inspiratory pressure. Each of the methods has its own advantages and disadvantages. CVP measurement is an invasive procedure and has potential risk for infection and thrombosis. Intravesical pressure has some disadvantages too, such as urinary tract infection, bleeding, and delayed stricture formation. IGP is commonly employed as a surrogate measure in respiratory research. However, evidence for relationship between IGP and IAP is conflicting.  IGP is a very simple and noninvasive technique reflecting IAP, which can be used as a guideline to determine whether to do a primary abdominal closure or to create a ventral hernia. Peroperative IGP measurement helped us take decision about requirement of postoperative ventilatory support and its duration. IGP was measured with the help of a specially designed catheter attached with a measuring scale. In our study, we measured IGP by measuring the height of water column in centimeter scale. Due to nonavailability of intragastric catheter, we used nasogastric tube as intragastric catheter. An elevation of pressure >30 mmHg (32-39 cm H 2 O) within the abdominal cavity will result in compromise of perfusion of visceral organs. ,, There are studies to measure IAP in critically ill children.  We are aware that there is sudden increase in IAP after repair of CDH  and may need creation of ventral hernia and delayed fascial closure. 
| Conclusion|| |
In our study, we found that IGP > 30 mm of water need creation of ventral hernia and prolonged ventilatory support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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